quetiapine-fumarate and Serotonin-Syndrome

Topics: Antipsychotic Agents; Cardiac Surgical Procedures; Female; Humans; Methylene Blue; Middle Aged; Paroxetine; Postoperative Complications; Quetiapine Fumarate; Selective Serotonin Reuptake Inhibitors; Serotonin Syndrome

BACKGROUND Serotonin toxicity, often referred to as 'serotonin syndrome,' is a drug-induced condition due to excess serotonin released from brain synapses, resulting in symptoms that may be autonomic, neuromuscular, and/or cognitive in nature. Most cases involve more than 1 of the following drug regimens: monoamine oxidase inhibitors (MAOIs), serotonin releasers, selective serotonin reuptake inhibitors (SSRIs), or serotonin-norepinephrine reuptake inhibitors (SNRIs). This report is of a 70-year-old woman who presented with confusion and muscle spasms due to serotonin toxicity associated with paroxetine and quetiapine treatment. CASE REPORT An elderly woman with dementia presented to the Emergency Department with fever, altered mental status, labile blood pressures, and inducible clonus. No known medication dosage increases had been made, nor had any new serotonergic agents been added to the patient's drug regimen. She underwent a thorough workup in the Emergency Department and later during her hospitalization. A presumptive diagnosis of serotonin toxicity was made early on during her stay, with the etiology attributed to use of paroxetine and quetiapine. Clinical improvement was observed after benzodiazepine administration, discontinuation of offending agents, and a brief cyproheptadine course. The patient survived her hospital stay and was ultimately discharged to hospice care with a return to her baseline level of functioning. CONCLUSIONS Diagnosing serotonin toxicity requires a high degree of clinical suspicion and can occur in the absence of increased dosage of existing, or initiation of new, serotonergic agents.

Topics: Aged; Female; Humans; Paroxetine; Quetiapine Fumarate; Selective Serotonin Reuptake Inhibitors; Serotonin; Serotonin Syndrome; Spasm

A retrospective analysis was followed on 20 case reports covering the possible correlation between the atypical antipsychotic, quetiapine, and neuroleptic malignant syndrome (NMS), determined by the study of 7 different NMS criteria guidelines. A great majority (19) of the case studies did not meet the requirements of all 7 guidelines, frequently due to unreported information. Nor was quetiapine proven to be the sole cause of the possible NMS in the two age groups investigated. Only one case was found to have no other medication or medical conditions confounding the relationship of quetiapine and NMS symptoms, and that case was in the context of a significant quetiapine overdose. The other 19 cases demonstrated the difficulty of identifying the cause of NMS when polypharmacy and other medical conditions are involved. The authors note the need for caution in deciding both the presence of NMS and the causal factors of the symptoms.

Topics: Adult; Age Factors; Antiparkinson Agents; Antipsychotic Agents; Diagnosis, Differential; Diagnostic and Statistical Manual of Mental Disorders; Dibenzothiazepines; Dose-Response Relationship, Drug; Fever; Guideline Adherence; Humans; Mental Disorders; Middle Aged; Muscle Rigidity; Neuroleptic Malignant Syndrome; Practice Guidelines as Topic; Quetiapine Fumarate; Retrospective Studies; Selective Serotonin Reuptake Inhibitors; Serotonin Syndrome; Young Adult

Topics: Antidepressive Agents, Tricyclic; Antipsychotic Agents; Dibenzothiazepines; Drug Therapy, Combination; Fatal Outcome; Female; Haloperidol; Humans; Mianserin; Middle Aged; Mirtazapine; Neuroleptic Malignant Syndrome; Quetiapine Fumarate; Risk Factors; Serotonin Syndrome

To evaluate the use of urine dopamine and catecholamine concentrations as diagnostic aids in a patient with neuroleptic malignant syndrome (NMS) in the emergency department setting.. A 61-year-old female on multiple medications, including several antipsychotics, rapidly deteriorated, with fever, lead-pipe rigidity, and decreased level of consciousness. The patient died 20 days after initial presentation to an emergency department. The Naranjo probability scale indicated probable causality for NMS due to quetiapine, haloperidol, and risperidone in this patient, whereas the Naranjo scale assigned only possible causality for serotonin syndrome developing with serotonergic agents. Laboratory investigations of blood and urine revealed elevations in dopamine, metanephrines, and epinephrines, as well as trazodone and risperidone. Serotonin metabolites were not elevated.. NMS is a rare and potentially severe adverse effect associated with the use of antipsychotic medications. It is mainly characterized by hyperthermia, altered mental state, hemodynamic dysregulation, elevated serum creatine kinase, and rigors. It has been associated with multisystem organ failure potentially leading to rhabdomyolysis, acute respiratory distress syndrome, and disseminated intravascular coagulation. The prevalence of this syndrome is associated with the use of neuroleptics. Serotonin syndrome is another adverse drug reaction leading to NMS associated with elevated serotonin. It occurs when multiple serotonergic medications are ingested and is associated with rapid onset of altered mental status, myoclonus, and autonomic instability. Differentiating between NMS and serotonin syndrome can be challenging because of their similar clinical presentation. This case highlights the importance of a diagnostic aid being available to help distinguish between the 2 syndromes.. We propose that laboratory findings that include dopamine and serotonin metabolites can be used as adjuncts to clinical and prescription histories in the diagnosis of NMS. The use of urinary catecholamine as a diagnostic aid in NMS needs further evaluation.

Topics: Antipsychotic Agents; Catecholamines; Diagnosis, Differential; Dibenzothiazepines; Dopamine; Female; Haloperidol; Humans; Middle Aged; Neuroleptic Malignant Syndrome; Quetiapine Fumarate; Risperidone; Serotonin; Serotonin Syndrome

We report two cases of serotonin syndrome in elderly patients during treatment of psychotic depression with atypical antipsychotics and antidepressants. The first case is a 69-year-old man who was admitted for depression with psychosis and treated with trazodone, risperidone, and sertraline. Subsequently, he developed myoclonus, tremor, cogwheel rigidity, and diaphoresis. The second case is a 72-year-old female initially admitted to a medical inpatient unit for a change in mental status that presented as increased confusion, lethargy, slurred speech, and a fever of 101.5 degrees. She had been on phenelzine and quetiapine. In both cases, all symptoms resolved within 24 hours of the psychotropics being stopped. In both cases, we believe that serotonin syndrome was produced by a combination of an antidepressant and an atypical antipsychotic. There have been several case reports of serotonin syndrome from similar combinations of antidepressant and atypical antipsychotic treatment. Clinicians treating elderly patients with a combination of serotonergic antidepressants and atypical antipsychotics for psychotic depression should be aware of the potential for serotonin syndrome.

Topics: Affective Disorders, Psychotic; Aged; Antidepressive Agents; Antipsychotic Agents; Dibenzothiazepines; Dose-Response Relationship, Drug; Drug Interactions; Drug Therapy, Combination; Female; Humans; Male; Quetiapine Fumarate; Risperidone; Serotonin Syndrome

The use of atypical antipsychotic medication is increasing, with an increase in reported side-effects. The first reported case of quetiapine and citalopram-associated serotonin syndrome is discussed with reference to a Medline, Embase, and PsycINFO literature search. The putative aetiological mechanism is supersensitivity of 5-HT(1A) receptors (quetiapine) within an environment of increased synaptic available serotonin (citalopram). The symptom profile of serotonin syndrome overlaps with neuroleptic malignant syndrome, but can be reliably differentiated using a time and toxicity scale.

Topics: Adult; Alprazolam; Anti-Anxiety Agents; Antipsychotic Agents; Bipolar Disorder; Citalopram; Dibenzothiazepines; Drug Therapy, Combination; Female; Humans; Quetiapine Fumarate; Risperidone; Selective Serotonin Reuptake Inhibitors; Serotonin Antagonists; Serotonin Syndrome; Treatment Outcome

To report a case of quetiapine/venlafaxine intoxication associated with multiple complications and to review their possible relationship with these 2 drugs.. A 53-year-old white man was admitted to the hospital for loss of consciousness secondary to voluntary intoxication with venlafaxine and quetiapine. Several complications were attributable to this intoxication including seizures, prolonged coma, respiratory depression, neuroleptic malignant syndrome, prolonged QRS and QTc intervals, and a possible venlafaxine withdrawal syndrome.. Quetiapine could be responsible for the neuroleptic malignant syndrome presented in this case. Moreover, venlafaxine intoxication, fever, autonomic instability, and myoclonus presented serotonin syndrome as a differential diagnosis. Potential causes of seizures and prolongation of the QRS and QTc intervals are reviewed. Finally, prolonged coma and late venlafaxine withdrawal are discussed with regard to the pharmacodynamics and pharmacokinetics of drug elimination in the context of intoxication.. Clinicians should be aware of possible complications following intoxication with atypical antipsychotics and anti-depressants, including protracted altered mental status.

Topics: Coma; Cyclohexanols; Diagnosis, Differential; Dibenzothiazepines; Drug Overdose; Electrocardiography; Humans; Male; Middle Aged; Neuroleptic Malignant Syndrome; Quetiapine Fumarate; Respiratory Insufficiency; Seizures; Serotonin Agents; Serotonin Syndrome; Substance Withdrawal Syndrome; Venlafaxine Hydrochloride