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8. Psychopharmacology > Serotonin Syndrome > Flashcards

Serotonin Syndrome Flashcards

1
Q

what is the triad of symptoms associated with serotonin syndrome

A

mental status changes

autonomic hyperactivity

neuromuscular changes (hyperreflexia and clonus)

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2
Q

why does serotonin syndrome occur

A

due to excess serotonin

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3
Q

what is the range of possible presentations of serotonin syndrome

A

can vary significantly

mild symptoms (tremor, diarrhea)–> delirium, neuromuscular rigidity and hyperthermia in life threatening cases

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4
Q

what is the incidence of serotonin syndrome

A

unknown–> mild cases not diagnosed or can be dismissed

more serious presentations can be confounded by other toxidromes

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5
Q

what % of people who overdose on SSRIs develop serotonin syndrome

A

14-16%

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6
Q

is serotonin syndrome rare

A

no –> has been identified in elderly, children and newborn infants

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7
Q

what class of antidepressants is strongly associated with severe cases of serotonin syndrome?

what other combinations of drugs increase this risk

A

MAOIs strong associated with severe cases of serotonin syndrome

especially when used in combo with:
meperidine
dextromethorphan
SSRIs
MDMA

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8
Q

how quickly does serotonin syndrome present/how fast is symptom onset

A

RAPID onset of symptoms–> within MINUTES after a change in medication or an overdose

approx 60% of patients with serotonin syndrome oresent within SIX HOURS after initial use of medication, an overdose or a change in dosing

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9
Q

how quickly does serotonin syndrome resolve after initiation of treatment

A

most resolve within 24 hours after initiation of treatment and discontinuation of serotonergic drugs–> symptoms may persist in meds with longer half life

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10
Q

does serotonin syndrome occur only with initiation of serotonergic agents

A

no–> both initiation AND withdrawal of serotonergic agents have been associated with serotonin syndrome

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11
Q

list classes of medications that have been associated with serotonin syndrome

A

SSRIs

other antidepressants

MAOIs

anticonvulsants

analgesics

antimigraine drugs

bariatric medications

antibiotics

drugs of abuse

dietary and herbal supplements

mood stabilizers

antiemetics

OTC cold and flu meds

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12
Q

list SSRIs associated with serotonin syndrome

A

sertraline
fluoxetine
fluvoxamine
paroxetine
citalopram

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13
Q

list other antidepressants associated with serotonin syndrome

A

trazodone
nefazodone
buspirone
clomipramine
venlafaxine

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14
Q

list MAOIs associated with serotonin syndrome

A

phenelzine
moclobemide
clorgiline
isocarboxazid

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15
Q

list anticonvulsants associated with serotonin syndrome

A

valproate

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16
Q

list analgesics associated with serotonin syndrome

A

meperidone
fentanyl
tramadol
pentazocine

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17
Q

list antiemetics associated with serotonin syndrome

A

ondansetron
metoclopramide

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18
Q

list antimigraine drugs associated with serotonin syndrome

A

sumatriptan (because is a 5TH1B/1D agonist)

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19
Q

list bariatric medications associated with serotonin syndrome

A

sibutramine

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20
Q

list antibiotics associated with serotonin syndrome

A

linezolid (MAOI)

ritonavir (inhibits CYP3A4)

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21
Q

list OTC cold and flu meds associated with serotonin syndrome

A

dextromethorphan

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22
Q

list drugs of abuse associated with serotonin syndrome

A

MDMA

LSD

“foxy methoxy”

Syrian rue (has MAOI components)

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23
Q

list dietary supplements associated with serotonin syndrome

A

tryptophan

st johns wort

ginseng

24
Q

list mood stabilizers associated with serotonin syndrome

A

lithium

25
Q

what might you find on neurological exam associated with serotonin syndrome

A

horizontal ocular clonus

intemrittent tremors

myoclonus

hyperreflexia

26
Q

what is the name of the criteria proposed for diagnosing serotonin syndrome

A

Hunter critieria

27
Q

what is a mnemonic to remember the hunter criteria

A

MOIST

Muscle rigidity + temp above 38 + either ocular or inducible clonus

Ocular clonus and either agitation or diaphoresis

Inducible clonus and either agitation or diaphoresis

Spontaneous clonus

Tremor and hyperreflexia

28
Q

what is the first decision point in the Hunter’s Decision rules?

A

is there spontaneous clonus? if yes, then there is serotonin syndrome

29
Q

what is the decision tree in the Hunter Decision rules?

A

spontaneous clonus–>

inducible clonus + either agitation or diaphoresis–>

ocular clonus + either agitation or diaphoresis–>

tremor + hyperreflexia–>

hypertonia + temp above 38 + ocular or inducible clonus

*if any any point moving down that tree, all of the conditions are met at that level, then you suspect serotonin toxicity and act accordingly

30
Q

how is the neurotransmitter serotonin produced

A

produced by the decarboxylation and hydroxylation of l-tryptophan

31
Q

which serotonin receptor appears to be most implicated in the development of serotonin syndrome

A

5HT2A agonism

(though no single receptor appears to be solely responsible)

32
Q

other than serotonin receptors, what other types of receptors/neurotransmitters also appear to be implicated in serotonin syndrome

A

NMDA antagonists

GABA

33
Q

ddx serotonin syndrome

A

anticholinergic poisoning

malignant hyperthermia

NMS

34
Q

how do you distinguish serotonin syndrome from anticholinergic poisoning

A

anticholinergic toxicity presents with NORMAL reflexes and have normal toxidrome of mydriasis, hyperactive delirium, dry oral mucosa and skin, urinary retention, absence of bowel sounds (i.e dry as a bone)

SS–> hyepractive bowel sounds, clonus, hyperreflexia, tremor, diaphoresis, normal skin color (NOT dry as a bone)

35
Q

how do you distinguish malignant hyperthermia from serotonin syndrome

A

MH–> after exposure to inhalational anesthesia; skin mottled, cyanotic areas, hyporeflexia

SS–> hyperreflexia

36
Q

how do you distinguish NMS from serotonin syndrome

A

NMS generally evolves over several days

SS is more rapid onset and is generally hyperkinetic

37
Q

are benzos safe to use in serotonin syndrome

A

yes

38
Q

are antipsychotics (i.e olanzapine) safe to use in serotonin syndrome

A

yes, if indicated

39
Q

is bromocriptine safe to use in serotonin syndrome

A

no–> worsens serotonin syndrome due to dopamine and serotonin agonist properties

40
Q

is dantrolene safe to use in serotonin syndrome

A

no–> not indicated and may worsen outcomes or cause death

41
Q

is there a single lab investigation that can diagnose serotonin syndrome

A

no

can see:
metabolic acidosis
rhabdo
elevated AST
elevated Cr
renal failure
DIC

42
Q

what should you think if you see tremor, clonus, hyperreflexia or akathesia without other signs of EPS

A

?serotonin syndrome

43
Q

where is the clonus associated with serotonin syndrome usually most pronounced

A

lower extremities

44
Q

what is the single most important clinical finding suggestive of serotonin syndrome

A

clonus

45
Q

what is the most important sign to check for when assessing for serotonin syndrome

A

deep tendon reflexes hyperreflexia

46
Q

why should you avoid physical restraints in serotonin syndrome unless imminent emergency or risk of injury

A

may contribute to increased mortality by reinforcing ISOMETRIC muscle contractions that may cause severe LACTIC ACIDOSIS and HYPERTHERMIA

47
Q

what are the first steps in treating serotonin syndrome

A

immediately d/c triggering serotonergic agent

supportive care–> IV fluids, correct vitals

control autonomic instability, hyperthermia and agitation

48
Q

treatment of mild serotonin syndrome

A

supportive therapy

49
Q

treatment of moderate serotonin syndrome

A

aggressively correct all cardiorespiratory and thermal abnormalities

may benefit from admin of 5HT2A antagonists

50
Q

treatment of severe serotonin syndrome

A

all people with temp above 41.1 are severely ill

should receive supportive therapy + cardioresp and thermal correction + 5HT2A antagonist

PLUS

immediate sedation, neuromuscular paralysis and intubation

51
Q

how do you manage agitation in serotonin syndrome

A

with benzos

52
Q

why is management of agitation with benzos essential in management of all cases of serotonin syndrome

A

help blunt hyperadrenergic component of the syndrome

+ control the agitation

53
Q

list 3 medications that are considered 5HT2A antagonists

A

cyproheptadine

olanzapine

chlorpromazine

54
Q

what is cyproheptadine

A

a first generation antihistamine with anticholinergic, antiserotonergic and local anesthestic properties

55
Q

how do you dose cyproheptadine in the case of serotonin syndrome treatment

A

initial dose of 12mg followed by 2mg q2h if symptoms continue

maintenance dose of 8mg q6h recommended

typically 12-32 mg given over 24 hour period will bind to 85-95% of serotonin receptors

56
Q

what dose of olanzapine can be given in the case of treatment of serotonin syndrome

A

10mg IM/SL

57
Q

is there a role for antipyretic agents in the management of serotonin syndrome

A

no–> the increase in temp is due to increase in muscular activity and not alteration in hypothalamic temp set point

8. Psychopharmacology (21 decks)

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