serotonin syndrome 2
TRANSCRIPT
Serotonin syndrome
SAMIR EL ANSARY
https://www.facebook.com/groups/1451610115129555/#!/groups/1451610115129555/
Wellcome in our new group ..... Dr.SAMIR EL ANSARY
Case: I just want to die
• 45yo male
• OD on paxil, gravol, ibuprofen tonight
• Smoked some crack
• Recent abstinence from EtOH
• Headache, fever X 1week
• HR125 sinus
• BP 165/105
• Temp 38.0
• RR20, sats 95%
• C/S normal
• Agitation
• Pupils 6 mm
• Hyperreflexic, clonus
• Tremulous
• Very diaphoretic
• Neck stiff
• No bowel sounds
Case Questions
• Is this serotonin syndrome?
• What is the differential dx?
• What tests should be done?
• What are the main treatments of serotonin syndrome?
• Is there any evidence for the use of cyproheptidine?
What is Serotonin?
• Neurotransmitter
• Mood, personality, sleep, sex, motor, temp, pain functions
• Very complex
• 14 receptors
• Excitatory and inhibitory functions
What is Serotonin Syndrome?
• Serotonin syndrome is a constellation of findings related to excessive stimulation of serotonin receptors and is manifested by cognitive, autonomic, and neuromuscular abnormalities
CAN you diagnosis serotonin syndrome?
CCOGNITIVE CHANGES:
Agitation, confusion, euphoria, insomnia, hypomania, hallucinations
AAUTONOMIC CHANGES:
Tachycardia, HTN, fever, diaphoresis, mydriasis, arrythmias, tachypnea
NNEUROMUSCULAR CHANGES:
Tremor, hyperreflexia, clonus, ataxia, incoordination, seizures
Sternbach’s Criteria
• Addition or increased dose of a known serotonergicagent
• At least three of the C.A.N. criteria
• Other etiologies excluded
– Withdrawl, sympathomimetics, anticholinergics, CNS infections, neuroleptic malignant syndrome
• No neuroleptics that have been started or increased prior to the onset of symptoms
What causes serotonin syndrome?
• SSRIs
• SNRIs
• MAOIs
• Cocaine
• Amphetamines
• LSD
• Lithium
• Wellbutrin
• And many more!!
How is Seritonin Syndrome Managed?
• Supportive Care
• Temperature control
• Benzodiazepines
• Fluids • Other therapies– Cyprohepatadine
– Beta – blockers
– Chlorpromazine
– Dantrolene
What is Cyproheptadine?
• Antihistamine with anticholinergic and antiserotonergic properties
• Blocks 5HT1a and 5HT2 receptors
• Used as antihistamine or for appetite stimulant in anorexia
• Recommended dosage: 4 mg po tid
• No intravenous formulation
Does Cyproheptadine work?
DRUG DEATHS
Cyproheptadine 5 mg/kg 5/5
Cyproheptadine 10 mg/kg 0/5
Dantrolene 20 mg/kg 6/6
Propranolol 10 mg/kg 5/5
Chlorpromazine 20 mg/kg 6/6
Chlorpromazine 40 mg/kg 0/5
Does Cyproheptadine work?
–Case report– Seritonin syndrome of moderate severity
– Symptoms subsided 30 min after a 4 mg po dose
– Dose repeated in 3hrs for recurrence of symptoms
Does Cyproheptadine work?
–Case report– Severe serotonin syndrome
– Cyproheptadine 8 mg po
– Level of consciousness promptly improved, hypertonia resolved, temperature normalized
Does Cyproheptadine work?
–Case report– Moderate serotonin syndrome
– Treated with cyproheptadine 8 mg po with no effect, repeat dose at 8 hours with no effect
– Chlorpromazine 50 mg im and symptoms improved steadily over next 2hrs
Does Cyproheptadine work?
• McDaniel. Ann Pharmacoltherapy 2001.
–Case series of 4 patients– All mild to moderate serotonin syndromes
– Dosing: 8 mg po and repeat q 8hr
– Responses seen within hours
– No serious side – effects noted (some anticholinergic effects)
Does Cyproheptadine work?
–Case series of 5 patients– Generally moderate severities
– Initial dose 4-8 mg po
– A few got subsequent doses of 4 mg
– Responses seen within 1-2 hours
– No serious complicated reported
Does Cyproheptadine work?
• May be
• VERY little literature• Appears effective
• Appears safe
• Probably not much down side to trying
? Other treatments for Serotonin Syndrome
• Chlorpromazine
• Propranolol
• Dantrolene
https://www.facebook.com/groups/1451610115129555/#!/groups/1451610115129555/
Wellcome in our new group ..... Dr.SAMIR EL ANSARY
