Selective serotonin reuptake inhibitor toxicity

Background

  • Most serious adverse effect is potential to produce serotonin syndrome
    • However, serotonin syndrome unlikely to occur unless co-ingested with other serotonergic drug classes (MAOIs, SNRI, TCAs, amphetamines, opiates)
  • Pure overdoses are generally benign (mortality uncommon). Associated with less toxicity than tricyclic antidepressants.
  • 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)
  • 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

Differential Diagnosis

Anticholinergic toxicity Causes

Evaluation

Workup

Diagnosis

Management

  • Treatment is mostly supportive. Consult poison control for guidance, if needed.
  • 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 with 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

Medication Dosing

Magnesium sulfate 2g IV IV

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.
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