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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 3 of 3. This is the beginning of the thread.
Posted by laima on February 28, 2007, at 8:37:17
I thought this was an interesting and comprehensive overview on a topic which most of us would do well to be very informed about. Most surprising is that apparently a large percentage of doctors are unaware of or not good at recognizing the syndrome!http://www.nytimes.com/2007/02/27/health/27brody.html?ref=health
February 27, 2007
Personal Health
A Mix of Medicines That Can Be LethalBy JANE E. BRODY
The death of Libby Zion, an 18-year-old college student, in a New York hospital on March 5, 1984, led to a highly publicized court battle and created a cause célèbre over the lack of supervision of inexperienced and overworked young doctors. But only much later did experts zero in on the preventable disorder that apparently led to Ms. Zion’s death: a form of drug poisoning called serotonin syndrome.Ms. Zion, who went to the hospital with a fever of 103.5, had been taking a prescribed antidepressant, phenelzine (Nardil). The combination of phenelzine and the narcotic painkiller meperidine (Demerol) given to her at the hospital could raise the level of circulating serotonin to dangerous levels. When she became agitated, a symptom of serotonin toxicity, and tried to pull out her intravenous tubes, she was restrained, and the resulting muscular tension is believed to have sent her fever soaring to lethal heights.
Now, with the enormous rise in the use of serotonin-enhancing antidepressants, often taken in combination with other drugs that also raise serotonin levels, emergency medicine specialists are trying to educate doctors and patients about this not-so-rare and potentially life-threatening disorder. In March 2005, two such specialists, Dr. Edward W. Boyer and Dr. Michael Shannon of Children’s Hospital Boston, noted that more than 85 percent of doctors were “unaware of the serotonin syndrome as a clinical diagnosis.”
In their review in The New England Journal of Medicine, Dr. Boyer and Dr. Shannon cited a report based on calls to poison control centers around the country in 2002 showing 7,349 cases of serotonin toxicity and 93 deaths. (In 2005, the last year for which statistics are available, 118 deaths were reported.)
The experts fear that failure to recognize serotonin syndrome in its mild or early stages can result in improper treatment and an abrupt worsening of the condition, leading to severe illness or death. Even more important, in hopes of preventing it, they want doctors — and patients — to know just what drugs and drug combinations can cause serotonin poisoning.
A Diagnostic Challenge
Serotonin syndrome was first described in medical literature in 1959 in a patient with tuberculosis who was treated with meperidine. But it wasn’t given its current name until 1982.
Recognizing the early signs is tricky because it has varying symptoms that can be easily confused with less serious conditions, including tremor, diarrhea, high blood pressure, anxiety and agitation. The examining physician may regard early symptoms as inconsequential and may not think to relate them to drug therapy, Dr. Boyer and Dr. Shannon noted.
In its classic form, serotonin syndrome involves three categories of symptoms:
¶Cognitive-behavioral symptoms like confusion, disorientation, agitation, irritability, unresponsiveness and anxiety.
¶Neuromuscular symptoms like muscle spasms, exaggerated reflexes, muscular rigidity, tremors, loss of coordination and shivering.
¶Autonomic nervous system symptoms like fever, profuse sweating, rapid heart rate, raised blood pressure and dilated pupils.
Widespread ignorance of the syndrome is another diagnostic impediment. But even when doctors know about it, the strict diagnostic criteria may rule out “what are now recognized as mild, early or subacute stages of the disorder,” Dr. Boyer and Dr. Shannon wrote.
Perhaps adding to the diagnostic challenge is the fact that a huge number of drugs — prescription, over the counter, recreational and herbal — can trigger the syndrome. In addition to selective serotonin reuptake inhibitors like Zoloft, Prozac and Paxil and serotonin/norepinephrine reuptake inhibitors like Effexor, the list includes tricyclic antidepressants and MAOIs (for monoamine oxidase inhibitors); narcotic painkillers like fentanyl and tramadol; over-the-counter cough and cold remedies containing dextromethorphan; the anticonvulsant valproate; triptans like Imitrex used to treat and prevent migraines; the antibiotic Zyvox (linezolide); antinausea drugs; the anti-Parkinson’s drug L-dopa; the weight-loss drug Meridia (sibutramine); lithium; the dietary supplements tryptophan, St. John’s wort and ginseng; and several drugs of abuse, including ecstasy, LSD, amphetamines, the hallucinogens foxy methoxy and Syrian rue.
Although serotonin poisoning can be caused by an antidepressant overdose, it more often results from a combination of an S.S.R.I. or MAOI with another serotonin-raising substance. Patients at particular risk, some experts say, are those taking combinations of antidepressant and antipsychotic drugs sometimes prescribed to treat resistant depression. All it may take is a small dose of another serotonin-inducing drug to cause the syndrome.
One patient, a 45-year-old Bostonian, had been taking four drugs to treat depression when he had surgery on an ankle last December. He developed several classic signs of serotonin syndrome while in the recovery room, where he had been given fentanyl when the anesthetic wore off.
As described by his wife, he suddenly developed tremors and violent shaking and started cracking his teeth. He was moved to the intensive care unit, where he thrashed and flailed, was oblivious to those around him, and had to be restrained to keep from pulling out his tubes. Two weeks later, he was still in intensive care and still very confused, despite being taken off all medications that could have caused his symptoms.
Serotonin syndrome can occur at any age, including in the elderly, in newborns and even in dogs. Since 1998, the poison control center at the American Society for the Prevention of Cruelty to Animals has gotten more than a thousand reports of the ingestion of antidepressant medications by dogs, which can develop symptoms rapidly and die. The syndrome can also occur weeks after a serotonin-raising drug has been discontinued. Some drugs remain active in the body for weeks, and the MAOIs disable an enzyme involved in serotonin metabolism that does not recover until weeks after the drugs are stopped.
Prevention and Treatment
Most cases of serotonin syndrome are mild and resolved within 24 hours. But if the doctor fails to recognize them and prescribes either a larger dose of a serotonin enhancer or another serotonin-raising drug, the consequences can be rapid and severe.
Most important to preventing the syndrome is for patients to give each of their doctors a complete list of drugs they regularly take — including prescriptions, over-the-counter medication, dietary supplements and recreational drugs — before a doctor prescribes something new.
Indeed, if you are taking any of the drugs described above, you might ask whether a new prescription is safe. And when filling a new prescription, it’s not a bad idea to also ask the pharmacist whether the medication, or an over-the-counter remedy you are considering, is safe to combine with any other drugs you take.
Once the syndrome develops, the first step is to stop the offending drugs. It is crucial to seek immediate care, preferably in a hospital. Most cases require only treatment of symptoms like agitation, elevated blood pressure and body temperature, and a tincture of time.
More severe cases are treated with drugs that inhibit serotonin and chemical sedation. Dr. Boyer and Dr. Shannon cautioned against using physical restraints to control agitation because they could enforce isometric muscle contractions that cause a severe buildup of lactic acid and a life-threatening rise in body temperature.
Posted by stargazer on February 28, 2007, at 20:26:47
In reply to informative new article about seratonin syndrome, posted by laima on February 28, 2007, at 8:37:17
My father, who had Parkinson's Disease (PD) and was on L-Dopa medications (Sinemet), was admitted to the ER at Yale New Haven Hospital for a condition he developed while at a New Year's Eve party. He was unable to get up after sitting for a few hours, which is very common for someone with PD. The disease itself cause muscle rigidity and tremors and your ability to walk and move can vary from hour to hour...
He was taken to Yale and was given the drug Haldol since he was agitated on arrival and I believe may have had too much L-dopa (Sinemet) in his system before being brought to the hospital.
The drug Haldol, should never be given to someone with PD since the drugs that are taken for PD are used to increase dopamine in the brain. Haldol blocks dopamine and you NEVER want to block dopamine in a patient with PD.
So here at a well respected teaching and research hospital, the doctors who are treating my father are unfamiliar with the interaction of Haldol and Sinemet, the #1 PD medication. They have no suspicians of why he is getting more agitated and has devloped a high fever.
Fortunately for my father, I was there with him, I told the nurse he was "burning up" (they were oblivious)and I asked them to take his temperature. I also asked to speak with his doctor and asked them what medications he was given. I explained that he had PD, which they should have known anyway, and I told the docs I thought he might have NMS (Neuroleptic Malignant Syndrone)from being given the Haldol. When I said this their eyes almost popped out of their heads with confusion and concern. I was familiar with the interaction of Haldol and Sinemet from working in field of geriatric psychiatry and had seen NMS before and knew why it occurred.
Bottom line, the condition NMS (Neuroleptic Malignant syndrone) would have killed my father that night because the doctors were totally unaware of the intereaction of Haldol and Sinemet.
I'm sure many people have died from these types of reactions because of ill trained hosiptal personnel.
Hospitals are not safe places anymore and the medications are so complicated that many of these reactions will be missed when they occur. The only way to avoid something like this would be to wear a bracelet identifying your medications. At least you have a better chance of not receiving the wrong medications if you end up in the hospital and you cannot tell them the medications you are taking.
Else perhaps have a microchip implanted...
Posted by laima on March 4, 2007, at 7:31:05
In reply to My father had a similar reaction in the Yale ER, posted by stargazer on February 28, 2007, at 20:26:47
What a horrible story- thank god you were there.
Yes, I've heard it's good for hospital patients to have someone with them, not just for support, but to keep an eye on the actual care. Ie, question all the various nurses about what's that? What are you giving now? Why? And what's that...can I see? What time is the next dose supposed to be? Keep eye on the patient.
I had some severe something- a flu maybe? Not sure, but pretty vomity, I was very severlely dehydrated. Ended up in ER, they had to give me an IV with potassium and other stuff in it- and the IV wasn't working properly. It just didn't seem right, the fluid level in the bag didn't change even after an hour or two. Nurse just stuck it in, walked in and out of the room, all rushed--it was ER. I was too faint to protest much, and she assured me it was fine when I pointed out that it hadn't changed. Actually, mom noticed and was one to point it out. It was great when my dad showed up to join my mom, see what was going on, and not only was he able to examine the IV and determine excatly why and how it was deffectively set up, (due to hurry, no doubt), he had a booming voice and a way of "giving that nurse an education", showing her precisely what she did wrong, and he hovered while she adjusted it per his instructions. (He says he knows all about IVs from being a heart patient, and we all know he's just good with all kinds of gadgets.) Sure enough, the fluid in the bag started moving after that. Oh, dad can be embarressing at times, but thank goodness for him!
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