Selective Serotonin Reuptake Inhibitor Toxicity

Prioritize airway protection, oxygenation, temperature control, circulation, and seizure treatment in any patient with depressed consciousness, hyperthermia, marked agitation, rigidity, or dysrhythmia. SSRI poisoning is often limited to nausea, vomiting, or drowsiness, but serotonin syndrome, seizures, and QT prolongation occur in a minority; ICU admission and death are uncommon overall. ScienceDirectScienceDirectClinical toxicity and management of selective serotonin reuptake inhibitor (SSRI) poisoning: a comprehensive review

Establish whether exposure is isolated or mixed. Severe serotonin toxicity is more likely with serotonergic polypharmacy, including another antidepressant, monoamine oxidase inhibitor, certain opioids, triptan, over-the-counter cough/cold product, antiemetic, or drug of abuse. Concomitant MAOI exposure is particularly concerning because serious and sometimes fatal reactions with hyperthermia, rigidity, myoclonus, autonomic instability, delirium, coma, and rapid vital-sign fluctuations have been reported. dailymed nlm nih+3dailymed nlm nihCITALOPRAM TABLETS USP474047414742Rx onlydailymed nlm nih[PDF] ESCITALOPRAM - DailyMedNatureSerotonin Toxicity and Clinical Management | Toxicology | Pharmacology and Pharmaceutical Sciences | Health sciences | Topics | Nature IndexWileySerotonin Syndrome after Sertraline Overdose in a Child: A Case Report - Grenha - 2013 - Case Reports in Pediatrics - Wiley Online Library

Obtain the home medication list, refill history when available, pill counts, formulation, time of ingestion, intentionality, and all co-ingestants. Escitalopram and citalopram warrant particular cardiac attention because both are associated with QTc prolongation; escitalopram labeling also reports delayed seizures, altered mental status, QRS/QTc prolongation, wide-complex tachyarrhythmias, and torsade de pointes in overdose. dailymed nlm nih+2dailymed nlm nih[PDF] LEXAPRO - DailyMeddailymed nlm nihThese highlights do not include all the information needed to use ESCITALOPRAM TABLETS safely and effectively. See full prescribing information for ESCITALOPRAM TABLETS. ESCITALOPRAM tablets, for oral use Initial U.S. Approval: 2002PubMedSelective Serotonin Reuptake Inhibitor Toxicity - StatPearls - NCBI Bookshelf

Perform a focused neurologic examination before sedation when feasible: assess ocular and lower-extremity clonus, deep-tendon reflexes, tremor, tone, coordination, mental status, pupils, diaphoresis, bowel activity, and temperature. Serotonin toxicity is a clinical diagnosis requiring serotonergic exposure or overdose plus compatible neuromuscular excitation, autonomic stimulation, and altered consciousness; generalized clonus is a particularly discriminating finding, and neuromuscular signs may be most evident in the legs. PubMedPubMedSelective Serotonin Reuptake Inhibitor Toxicity - StatPearls - NCBI Bookshelf

Use the Hunter serotonin-toxicity framework rather than relying on nonspecific symptoms alone. In the setting of serotonergic exposure, diagnostic constellations include spontaneous clonus; inducible clonus plus agitation or diaphoresis; ocular clonus plus agitation or diaphoresis; tremor plus hyperreflexia; or hypertonia plus temperature above 38°C with ocular or inducible clonus. PubMed+1PubMedThe pharmacokinetics of sertraline in overdose and the effect of activated charcoalPubMedSelective Serotonin Reuptake Inhibitor Toxicity - StatPearls - NCBI Bookshelf

Differentiate serotonin toxicity from neuroleptic malignant syndrome–like reactions by medication history and neuromuscular pattern. SSRI labeling recognizes that severe serotonin syndrome can resemble neuroleptic malignant syndrome, including hyperthermia, rigidity, autonomic instability, and altered mental status; clonus and hyperreflexia support serotonergic toxicity and should redirect treatment toward serotonergic drug cessation and sedation. dailymed nlm nih+2dailymed nlm nihCITALOPRAM TABLETS USP474047414742Rx onlydailymed nlm nih[PDF] ESCITALOPRAM - DailyMedPubMedSelective Serotonin Reuptake Inhibitor Toxicity - StatPearls - NCBI Bookshelf

Do not attribute coma, marked acidosis, persistent seizure, conduction abnormality, or disproportionate hypotension to an uncomplicated isolated SSRI exposure without reassessing for co-ingestants or alternative diagnoses. Escitalopram overdose labeling specifically notes that hypotension may occur, particularly with co-ingestants including alcohol. dailymed nlm nih+1dailymed nlm nih[PDF] LEXAPRO - DailyMeddailymed nlm nihThese highlights do not include all the information needed to use ESCITALOPRAM TABLETS safely and effectively. See full prescribing information for ESCITALOPRAM TABLETS. ESCITALOPRAM tablets, for oral use Initial U.S. Approval: 2002

Immediately discontinue all serotonergic agents when serotonin toxicity is suspected. Provide intravenous fluids as clinically indicated, active external cooling for hyperthermia, and short-acting benzodiazepines for agitation and neuromuscular hyperexcitability; benzodiazepines were used in 67% of reported serotonin-toxicity cases. Nature+1NatureSerotonin Toxicity and Clinical Management | Toxicology | Pharmacology and Pharmaceutical Sciences | Health sciences | Topics | Nature IndexWolters KluwerSerotonin Toxicity : Journal of Clinical Psychopharmacology

Escalate to ICU-level care for hyperthermia, escalating rigidity, recurrent seizure, impaired airway protection, ventilatory support, shock, clinically important ECG abnormalities, or progressive rhabdomyolysis. Severe serotonin toxicity can progress to seizures and multiorgan dysfunction, and a pediatric sertraline overdose case required mechanical ventilation and neuromuscular paralysis for severe illness with progressive rhabdomyolysis. Nature+1NatureSerotonin Toxicity and Clinical Management | Toxicology | Pharmacology and Pharmaceutical Sciences | Health sciences | Topics | Nature IndexWileySerotonin Syndrome after Sertraline Overdose in a Child: A Case Report - Grenha - 2013 - Case Reports in Pediatrics - Wiley Online Library

Cyproheptadine has been used as a nonspecific serotonin antagonist, but reported practice is variable: only 15.1% of patients in one 1,010-case series received it. Consider toxicology-guided use for persistent clinically significant serotonin toxicity despite drug cessation, sedation, and supportive measures rather than substituting it for resuscitation, cooling, or airway management. Wiley+1WileySerotonin Syndrome after Sertraline Overdose in a Child: A Case Report - Grenha - 2013 - Case Reports in Pediatrics - Wiley Online LibraryWolters KluwerSerotonin Toxicity : Journal of Clinical Psychopharmacology

Treat seizures promptly with benzodiazepines and monitor for recurrence because seizures may be delayed after escitalopram overdose. For QRS widening or right bundle branch block after escitalopram overdose, one reported case improved after sodium bicarbonate; persistent ECG abnormalities require continuous monitoring and toxicology-directed management. dailymed nlm nih+2dailymed nlm nih[PDF] LEXAPRO - DailyMeddailymed nlm nihThese highlights do not include all the information needed to use ESCITALOPRAM TABLETS safely and effectively. See full prescribing information for ESCITALOPRAM TABLETS. ESCITALOPRAM tablets, for oral use Initial U.S. Approval: 2002PubMed2023 ACMT Annual Scientific Meeting Abstracts – San Diego, CA - PMC

Maintain prolonged cardiac monitoring after escitalopram overdose because the labeling specifically recommends it for arrhythmia risk and reports delayed QRS/QTc prolongation, wide-complex tachyarrhythmias, and torsade de pointes. A normal initial ECG should therefore not override a clinically significant exposure history or evolving symptoms. dailymed nlm nih+1dailymed nlm nih[PDF] LEXAPRO - DailyMeddailymed nlm nihThese highlights do not include all the information needed to use ESCITALOPRAM TABLETS safely and effectively. See full prescribing information for ESCITALOPRAM TABLETS. ESCITALOPRAM tablets, for oral use Initial U.S. Approval: 2002

Admit patients with serotonin toxicity requiring repeated benzodiazepines, hyperthermia, seizure, altered consciousness, ECG abnormalities, or rising CK. In reported serotonin-toxicity cases, rhabdomyolysis occurred in 9.7%, seizures in 13.7%, dysrhythmias in 0.8%, and death in 0.1%; these figures describe a selected toxicology case series rather than risk for every SSRI exposure. Wolters KluwerWolters KluwerSerotonin Toxicity : Journal of Clinical Psychopharmacology

Before medical clearance after intentional ingestion, ensure that neurologic findings have resolved, temperature and vital signs are stable, ECG concerns have been addressed, and CK surveillance is complete when symptoms suggested muscle injury. Arrange psychiatric assessment and a medication-safety plan after the acute toxicologic risk has resolved. Intentional exposures predominated in the reported serotonin-toxicity cohort. Wolters Kluwer+1Wolters KluwerSerotonin Toxicity : Journal of Clinical PsychopharmacologyPubMedFluoxetine overdose in a teenager resulting in serotonin syndrome, seizure and delayed onset rhabdomyolysis - PMC