Selective serotonin reuptake inhibitor toxicity: Difference between revisions

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==Background==
==Background==
*Most serious adverse effect is potential to produce [[Serotonin Syndrome]]  
*Most serious adverse effect is potential to produce [[serotonin Syndrome]]  
*Fatalities are uncommon with pure overdoses
*Fatalities are uncommon with pure overdoses
*Selective serotonin reuptake inhibitors (SSRI) are the most commonly prescribed antidepressants in the United States<ref>Pirraglia PA, Stafford RS, Singer DE. Trends in Prescribing of Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressant Agents in Adult Primary Care. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):153-157. doi: 10.4088/pcc.v05n0402. PMID: 15213776; PMCID: PMC419384.</ref>
*Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa)
*Overdose is generally benign. Associated with less toxicity than tricyclic antidepressants
*Serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI,  TCAs, amphetamines, opiates)
*Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent QT prolongation and increase risk of torsades de pointes


==Clinical Features==
==Clinical Features==
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*[[Coma]] and [[seizures]] (rare)
*[[Coma]] and [[seizures]] (rare)


==Differential Diagnosis==
*[[Serotonin syndrome]]
{{Anticholinergic types}}
==Management==
*Supportive care
*No role for [[activated charcoal]] or gastric lavage
*[[Magnesium]] sulfate 2g IV if QTc > 500 msec
*IV [[benzodiazepines]] if agitation or seizures
==Disposition==
*Consider admission for patients who are tachycardic or lethargic 6hr after ingestion
*ECG before clearing a patient with citalopram ingestion
==See Also==
*[[Serotonin syndrome]]
*[[SNRI Toxicity]]
==References==
<references/>
[[Category:Toxicology]]
==Background==
*Selective serotonin reuptake inhibitors (SSRI) are the most commonly prescribed antidepressants in the United States<ref>Pirraglia PA, Stafford RS, Singer DE. Trends in Prescribing of Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressant Agents in Adult Primary Care. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):153-157. doi: 10.4088/pcc.v05n0402. PMID: 15213776; PMCID: PMC419384.</ref>
*Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa)
*Overdose is generally benign. Associated with less toxicity than tricyclic antidepressants
*Serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI,  TCAs, amphetamines, opiates)
*Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent QT prolongation and increase risk of torsades de pointes


==Clinical Features==
==Clinical Features==
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***Muscular rigidity
***Muscular rigidity
***Resting tremor
***Resting tremor
==Differential Diagnosis==
*[[Serotonin syndrome]]
{{Anticholinergic types}}


==Differential Diagnosis==
==Differential Diagnosis==
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*[[Rhabdomyolysis]]
*[[Rhabdomyolysis]]
*[[Tetanus]]
*[[Tetanus]]


==Evaluation==
==Evaluation==
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===Diagnosis===
===Diagnosis===
==Management==
*Supportive care
*No role for [[activated charcoal]] or gastric lavage
*[[Magnesium]] sulfate 2g IV if QTc > 500 msec
*IV [[benzodiazepines]] if agitation or seizures


==Management==
==Management==
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**Analgesics (fentanyl, tramadol, methadone)
**Analgesics (fentanyl, tramadol, methadone)
**Antibiotics (linezolid)
**Antibiotics (linezolid)


==Disposition==
==Disposition==
 
*Consider admission for patients who are tachycardic or lethargic 6hr after ingestion
*ECG before clearing a patient with citalopram ingestion


==See Also==
==See Also==
 
*[[Serotonin syndrome]]
*[[SNRI Toxicity]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<references/>
[[Category:Toxicology]]

Revision as of 20:04, 6 July 2022

Background

  • Most serious adverse effect is potential to produce serotonin Syndrome
  • Fatalities are uncommon with pure overdoses
  • Selective serotonin reuptake inhibitors (SSRI) are the most commonly prescribed antidepressants in the United States[1]
  • Examples include fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), escitalopram (Lexapro), and citalopram (Celexa)
  • Overdose is generally benign. Associated with less toxicity than tricyclic antidepressants
  • Serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates)
  • Citalopram (>600 mg) and escitalopram (>300mg) are unique, as they may cause dose dependent QT prolongation and increase risk of torsades de pointes

Clinical Features


Clinical Features

  • Symptoms
    • Nausea/vomiting
    • Agitation
    • Ataxia
    • Confusion
  • Signs
    • Altered mental status
    • Autonomic instability
      • Diaphoresis
      • Hyperthermia
      • Hypertension/hypotension
    • Neuromuscular hyperactivity
      • Hyperreflexia
      • Muscular rigidity
      • Resting tremor

Differential Diagnosis

Anticholinergic toxicity Causes


Differential Diagnosis


Evaluation

Workup

Diagnosis

Management

Management

  • Treatment is mostly supportive. Consult poison control for guidance
  • Administer activated charcoal if lethal amount ingested within 1-2 hours
  • Continuous cardiac monitoring required for citalopram (>600 mg) and escitalopram (>300mg) for at least 8 hours. If citalopram (>1000 mg) and escitalopram (>500 mg) has been ingested then monitor for 12-24 hours
  • Manage seizures w/ benzodiazepines
  • Manage hyperthermia
  • If suspecting Serotonin Syndrome, stop all serotonergic medication:
    • SSRIs
    • Anticonvulsants (valproate)
    • Antiemetics (ondansetron, metoclopramide)
    • Analgesics (fentanyl, tramadol, methadone)
    • Antibiotics (linezolid)


Disposition

  • Consider admission for patients who are tachycardic or lethargic 6hr after ingestion
  • ECG before clearing a patient with citalopram ingestion

See Also

External Links

References

  1. Pirraglia PA, Stafford RS, Singer DE. Trends in Prescribing of Selective Serotonin Reuptake Inhibitors and Other Newer Antidepressant Agents in Adult Primary Care. Prim Care Companion J Clin Psychiatry. 2003 Aug;5(4):153-157. doi: 10.4088/pcc.v05n0402. PMID: 15213776; PMCID: PMC419384.
  2. Dawson AH, Buckley NA. Pharmacological management of anticholinergic delirium – theory, evidence and practice. Br J Clin Pharmacol. 2015;81(3):516-24.