SEROTONIN SYNDROME

- Life threatening condition caused by elevated serotonin conc.

- Can occur in context of initiation or dose increase of serotonergic agent, inadvertent interactions
between serotonergic medications, overdose of serotonergic medications or use of recreational drugs
- Specific agents: antidepressants, mood stabilisers, analgesics, 5-HT1 agonists (e.g. triptans), CNS
stimulants, hallucinogens, St John’s Wort
Signs/symptoms
- Psychiatric/neurological: agitation, confusion, coma, death
- Neuromuscualr: ataxia, hyperreflexia (usually lower limb), myoclonus, rigidity, tremors
- Autonomic: GI upset (nausea, diarrhoea), hyper/hypotension, hyperthermia,mydriasis, tachycardia
Comparison between serotonin syndrome and NMS
Feature Serotonin syndrome Neuroleptic malignant
syndrome
Associated agent Serotonin agent Antipsychotic medication
Mechanism Serotonin excess Dopamine antagonism
Symptom onset Minutes to hours Days to weeks
Symptom resolution <24 hours 5-14 days
Muscle rigidity Less severe More severe
Activity Hyperkinesia Bradykinesia
Myoclonus and seizure Common Rare
Rhabdomyolysis Rare Common
Elevated transaminases Rare Common

Management
- Severe symptoms – immediate transfer to ED for supportive treatment and acute management
- Overdose – gastric lavage a/o activated charcoal
Biological
- Discontinue any serotonergic
- BZD – relieve muscular symptoms
- Serotonin receptor antagonists (e.g. cyprotheptadine)
- Beta-blockers – propranolol and pindolol
Course and prognosis
- Resolve without sequelae within 24-36 hours with adequate supportive measures
- Restart serotonergic agents slowly and @ low doses and consider using serotonergic agents from a
different class