Rare Case of Serotonin Syndrome With Therapeutic Doses of Paroxetine

Abstract

Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) and anxiolytic that is approved to treat numerous mood disorders. Serotonin syndrome, defined as a triad of mental status changes, autonomic instability, and neuromuscular abnormalities, is a potentially life-threatening complication of administering such serotonin-modifying drugs. Most cases of serotonin syndrome that have occurred with paroxetine administration are due to inadvertent drug interactions, most notably between SSRIs and monamine oxidase inhibitors, or intentional overdoses. The authors present the case of an 80-year-old woman who presented with serotonin syndrome while on a therapeutic dose of paroxetine. Paroxetine was stopped, and aggressive hydration with fluids and treatment with cyproheptadine was followed by remarkable improvement and return to baseline status in 4 days. This case illustrates the importance for physicians to have a heightened sense of suspicion of the serotonin syndrome in any patient known to be on serotonin-modifying agents presenting with altered sensorium and cholinergic symptoms. Consequently, they will be able to start timely treatment without subjecting the patient to unnecessary and potentially harmful tests.

Psychedelics in Psychiatry: Neuroplastic, Immunomodulatory, and Neurotransmitter Mechanisms

“…Several approved serotonergic psychiatric drugs, including SSRIs, have been associated with serotonin syndrome, both at clinical doses and after accidental or voluntary overdose (Graudins et al, 1998;Kinzie and Meltzer-Brody, 2005;Paruchuri et al, 2006). A major concern revolves around the ingestion of serotonergic psychedelics by patients who medicate with SSRIs, a combination which can result in serotonin syndrome due to synergistic effects of SSRIs and serotonergic psychedelics or other compounds with MAOI activity such as Peganum harmala (Syrian rue) (Bakim et al, 2012).…”

A Case Report of Serotonin Syndrome in a Patient on Selective Serotonin Reuptake Inhibitor (SSRI) Monotherapy

“…To date, only 5 cases of serotonin syndrome have been reported in patients using SSRI monotherapy at recommended therapeutic doses. [7][8][9][10][11] Serotonin syndrome is largely underdiagnosed due to its variable onset, nonspecific symptoms, evolving diagnostic criteria, and lack of awareness among prescribers. 14,15 Consequently, an estimated 85% of physicians fail to recognize serotonin syndrome.…”

“…5,6 To date, only 5 cases have described the occurrence of serotonin syndrome with therapeutic doses of an SSRI when prescribed as monotherapy. [7][8][9][10][11] Of the 5 case reports identified, 2 involved young males 12 years of age, 2 involved males between 40 and 60 years of age, and the other involved an 80-year-old female (Table 1). We describe a case of serotonin syndrome in a 21-year-old female taking therapeutic doses of paroxetine.…”

Recognition and mangement of serotonin syndrome

“…Serotonin syndrome has been in observed in children, adults and the elderly. 17,18 Theoretically, any patient taking a serotonergic agent may potentially develop serotonin syndrome; however ,prescribers should be particularly vigilant in any patient taking more than one serotonergic agent, for psychiatric conditions or otherwise. Buckley et al (2014) 3 emphasise that severe serotonin syndrome is generally seen only in the context of ingestion of multiple serotonergic agents, the most common cause being the combining of an MAOI with one or more other serotonergic drug.…”