How many medications are you on for fibromyalgia and chronic fatigue syndrome? How many of them have similar effects on your brain chemistry? If it's more than 1, you could be at risk of developing serotonin syndrome -- a potentially fatal complication of serotonin-boosting drugs.
Anyone on these drugs, and certain supplements as well, should know the symptoms. Here's an example of why, from a reader who probably saved her own life by recognizing the symptoms:
"I have had the dual problem of fibro and chronic migraines. So, for awhile, the docs were trying everything under the sun to try to at least control the migraines. Many of the drugs were either SSRIs or interacted synergistically with SSRIs. ... Anyhow, at one time I was on an SSRI for depression, tramadol for pain, and a series of other meds attempting to control the migraines. The migraines got worse. Then I started having worsening cardiac palpitations. So, of course, I had a work-up and they put me on something to control the rhythm.
That was when I really got into trouble. I was dizzy, I passed out and had other side effects from all the meds. I happened onto an article about serotonin toxicity and the symptoms matched almost perfectly with what was going on. So, I stopped the SSRI related drugs and the palpitations diminished so I was able to stop the cardiac drug. The electrical zaps stopped and I generally felt better.
I still have fibro and the migraines but I just live with it. They insisted I go back on an SSRI antidepressant. I just stopped it again because the cardiac rhythm problems returned. ...
The worst of it was, my doctor never even thought about serotonin toxicity until I told him what I had read and that my symptoms vastly improved with stopping it. He would have ignored me even then I am sure but it is hard to totally ignore a former ICU nurse with a masters degree on these things." ~Lois
What can you do to avoid serotonin syndrome? First, research your medications and know how they work. Here are some resources for that:
Your doctor may or may not know about serotonin syndrome or the drugs that put you at risk -- they're not the experts on medications. To ensure your safety, you should talk to your pharmacist. Those folks do a lot more than count pills; they're doctors specializing in the effects of medicine, so they're the best resource around when it comes to this kind of problem. It's their job to give you guidance, so don't hesitate to ask questions when you're in the pharmacy, or to call them if you have questions.
If you do opt for taking a combination of drugs that puts you at risk (one alone is considered safe), be sure you know the symptoms of serotonin syndrome. My suggestion is to print them out and put them on your fridge, so you and everyone in your household has the list readily available. Give the list to a co-worker or 2, in case something happens while you're at work. The earlier you catch serotonin syndrome, the better.
You'll find a symptom list, as well as types of drugs and supplements that can contribute to toxicity, here:
Have you had a problem with serotonin syndrome? Has your doctor or pharmacist warned you about it? Leave your comments below!
Learn more or join the conversation!
NEWSLETTER | FORUM | BIO | TWITTER | FACEBOOK
Photo © David De Lossy/Getty Images
Check with your pharmacist and doctor, but you might try switching to gabapentin for pain. It’s directed toward neuropathological pain as is lyrica so it may not have any affect on your migraines.
As for your migraines I assume you are using the usual dietary restrictions.
I had just read a few minutes ago that I shouldn’t be taking Savella & Dexedrine together because they both increase Serotonin! My Dr. is on vaca. all this mo., but after reading the symptoms I think I am fine. Thanks for all of your hard work & invaluable info., Adrienne — It is greatly appreciated!
Thank you for this important alert. I don’t use medication myself. I use diet and avoidance of toxic chemicals and fragrance to keep symptoms at bay.
Thanks for calling attention to this — but I disagree about talking to a pharmamcist rather than your own doctor. Your doctor is the one prescribing the medications and SHOULD be aware of any potential side effects when paired with other meds.
My doctors had a disagreement over seratonin syndrome. My rhematologist wanted to bump up my tramadol to cut down on other painkillers but my primary care physician said no because of the potential risk of seratonin syndrome. So I remain on a lower dose and still take added pain meds, but both doctors were aware of the issue and took opposite sides.
In the end the patient has to understand the issues and make decisions for themselves.
Good info to have.
I disagree with a previous comment and think that a pharmacist is actually an excellent way to be certain that your meds are not contraindicated in any situation.
Many people don’t have a primary physician and see multiple GP’s or specialists or both. And I have personally seen situations where either have not been aware what the other have prescribed. They SHOULD be – but they were not. I was prescribed something by a specialist that should not be taken with another medication that had been prescribed by my GP and it was the pharmacist that said to me, ‘Are you still taking ____?’ And he advised me that it may not be recommended that I take the meds I’d been described and asked me to phone the doctor before I started taking them. And I am very glad that I use the same pharmacy and that they keep a record of what medication I’ve collected and when so that if there’s an oversight somewhere – it will be found before I end up in the hospital with a bad reaction.
I had a couple short bouts with seratonin syndome, at least that’s what the nurse thought it was, when I was in a pain cllinic program. They had upped my tramadol significantly (Dr said I was only patient he ever told take MORE pain relievers) and I was on antidepressants – Wellbutrin the first time (which shouldn’t have reacted) then Zoloft which would. This is a roundabout way of saying even the best specialists some times have no idea an nobody warned me about it, I had no idea what it was. They even had 2 pharmacological interns go over my meds and nobody caught that upping the tramadol would be so bad. Glad to hear the news is out there now, when it happened to me it was still not mentioned much (believe me, I mentioned it after that!!)
Effexor Xr caused increased heart palpitations when I was taking it. I had many expensive tests, including invasive heart procedures, to determine the cause of the palpitations,all the while remaining on Effexor XR(aka Side-effexor) GRRR.
I’ve been fighting Serotonin Syndrome for years. Most doctors won’t believe me when I tell them I have it – but when I go down the list of meds, I’ve had reactions to every single one of them I’ve taken. With every reaction, my sensitivity grows stronger, my symptoms get worse.
It’s not just prescription medications…even Robutussin can affect you if you have this sensitivity. You have to be very defensive when it comes to meds – I don’t take a new med unless I’ve researched it myself. Even foods high in serotonin such as sunflower seeds or pumpkin seeds have triggered symptoms in my case.
I’ve experienced seratonin syndrome several times now. The first time was when I was prescribed Ultram or Ultracet by my GP to try in order to get me off of Norco. BUT no one told me NOT to take it around the same time as the muscle relaxant, narcotic pain meds, anti-depressant, etc. NO ONE! I went through hell and didnt know what was happening to me. Somewhere I wrote down all what I was experiencing – it felt like hallucinations and being very, very stoned and laid back, yet feeling very restless. It also felt like my eyes were jerking left and right on me when I was trying to see straight – very weird! I thought I was going to die. At one point I did call the pharmacist and he was such a jerk when I tried to explain to him what I was going through – he yelled at me that “I waited until NOW to call? You should be calling your dr but its after 5pm so they are probably gone”. What a dick! He told me not to take anymore of the Ultram or Ultracet, cant remember which one it was, and to call the dr in the morning. The next day I talked to the nurse and then I went into the pharmacy and talked to a different pharmacist who actually filled the prescription. I point-blank asked her why didnt she or anyone else tell me about the warnings of taking the drugs around the same time. She actually got tears in her eyes when I described what I went through and told me normally the computer screen will display a warning that they have to bypass in order to fill the drug. I think they just got lazy and probably see the warnings all the time and just click on by it without thinking of doing a patient consult. The jerk that yelled at me was new to the pharmacy, actually he was the new manager, and I had not met him yet. Since I take anywhere from 15 to 20 prescriptions a month I am usually in the pharmacy every other day to drop off or pick up prescriptions. To this day I try to avoid this pharmacist as he has proved to be very unhelpful and unusefull when it comes to giving guidance for a drug and he in fact defers me to my doctor for questions. I keep all of my meds in a spreadsheet with the amount I take and when I take them. I also recently had a problem with one specialist for arthritis wanting me to start Plaquenil (anti-malaria drug to supress immune system) while I was getting immunotherapy shots from another specialists!! One wants to suppress my immune system and the other is trying to boost my immune system. Luckily I did not start taking the drug and instead read up on it – when I found out it suppresses the immune system I got really ticked off! My medications are listed in black and white and this lady still screwed up!!
I sufferred this syndrome to a degree several years ago. I was taking Prozac and trazadone. no narcs. I had a hard time going up and down stairs ..felt confused..more than normal and I felt like I was getting parkinson’s or MS. I had surgery at Baylor for leaking breast implants. I asked the dr should i stop meds 2-3 weeks before the surgery. I did that in the ’80’s for endometrious. I have always had surgery and went back to work ASAP. After Baylor, Ihad such weird symptoms. I did not understand. I found one website that said you need to be off trazadone several..3…to me. They do not know how it reacts with surgery. I can tell you what or how it reacts. I was confused, Shaking and could not find my way around town. All the while I am taking my meds. My new obgyn put a name to what i had gone thru. I even went to my pharmacy to see if anything was not normal. I lost a job . It was devastating. Now , I am fine, but before any surgery, I quit taking Prozac and I quit with the trazadone. Please cross referance the drugs . I hate to take meds, but I have to work and do feel better. Anyting ovr thecounter or a new med is rxd , I get on my puter and cross referance.
Adrienne, I am so glad you brought this up. I missed a week or so a couple of years ago because I was so stoned (2 Tramadol twice daily, 40 mg. Prozac) I couldn’t believe it. The hallucinations were interesting sometimes but I don’t want to do that again.
I am blessed with a son who is a pharmacy technician and a good pharmacist (the one my son works with). They watch what I take and are quick to point out any problem.
It’s hard for us to keep an eye on what’s good and what is not but I feel that reading columns like this one and reading as much as I can about fibro has been very good for me. Like the comment “You can never be too thin or too rich”, you can’t be too informed about this disease (when will they finally admit it IS a disease). I sometimes think there are many doctors (mostly male) who, when a patient complains about her meds, gives her a figurative pat on the head and says ‘there, there’ — and does nothing else because she isn’t really sick since fibro isn’t a REAL disease.
I have fibromyalgia and unrelated problems. My primary care doctor is well aware of seratonin syndrome. It meant dumping tramadol.
Was on Elavil and was having some issues with heart palpitations. The pain specialist told me just give it more time and added Celexa. Within 48 hours was in the ER with Serotonin Syndrome. Heart rate 150-160 bpm, 170/110 bp, electric shocks down my extremeties that would make them randomly jerk, anxiety attacks, headache, weakness, fatigue, diarrhea and agitation. The triage nurse was incredibly rude and thought I was a middle-age woman having an anxiety attack until she hooked me up to the monitors. Dr.’s in the ER first thought medication induced thyroid storm until they got my lab values back, then they thought a pulmonary emboli because I had a right shift in the axis of my EKG and am on hormone replacement therapy. Toxicology saw me in the ER and they thought cholinergice syndrome. Finally, I said to the resident why hasn’t anyone thought of Serotonin Syndrome. I suggested this because I had been doing some reading because of the heart palpitations due to the Elavil. Guess what, next day when I was discharged, diagnosis was Serotonin Syndrome. Took over a month before I was no longer tachycardiac and now I am even more sensitive to meds. This was an absolutely awful experience and wish this on no one.
This is all very new information for me. I live in Australia and have had CFS and severe fibromyalgia for 28 years. I have always used alternative therapies such as reflexology, kinesiology, acupuncture, thought field therapy and hypnotherapy as I wanted to not put any drugs into my being. After surgery last year, my pain levels increased to a point where the pain was unbearable. My doctor tried me on a number of the drugs you are all discussing and the side effects were absolutely horrendous. I now realise that the symptoms I was manifesting were as you have described. I have decided to go back to my alternative therapies and deal with the pain this way. We are a long way behind you in America. Thank you for sharing with us.
I have been taking Topamax (100 mg) at night for the prevention of migraines…It has been a blessing…I used to have to go to the hospital my migraines were so bad, now I have maybe one or two a year! But you do have to be careful not to take it with certain other medicines…Cymbalta is one you cannot take it with….I always look it up myself….I know of so many other people that are on the Topamax and it has helped them too……
I am not a doctor or in any way related to the medical profession and do not portray to be and the information herein, is a guideline for the possibility of you feeling better if you were to try any of these vitamin’s after speaking to your doctor and finding out if it is OK as some vitamins can interfere with prescribed medication’s in an adverse way. CHECK WITH YOUR DOCTOR BEFORE TAKING ANY NEW VITAMIN’S OR DRUGS.
The first thing you need to do is dump the male doctor’s when at all possible. Many think women’s symptoms are a joke or just in your head or all depression. I complained for years and was told for the first ten of them that I did not have Hypothyroid, I do. For 20 years that I did not have Fibromyalgia, I do. That I did not have GERD, I do, did not have Dysphasia, I do and so many other illnesses that I do have. None of the doctor’s for the 35 years of complaining and being told there is nothing wrong with me ever got it that I was not making it up and that I was genuinely sick from it all.
Hypothyroid can cause all kinds of issues for you if not corrected early on. Using all natural Armour Thyroid works the best for this as the synthetics do not give you both T3 and T4 which you need and for some of us the synthetics just do not work as well as the Armour does and it is like night and day with how much better you feel. You probably will never be like before having hypothyroid, but you will be better than after and on synthetics.
Fibromyalgia is also a side effect of Hypothyroid from what I have read on the net due to it is caused by the immune system as far as it can be told scientifically at this time.
Migraines also fall under the “Hypothyroid” causes. My Neurologist put me on Zonisimide starting with the lowest dose and adjusting upward from there and for the break thru one’s a heavier only as needed medication. This Zonisimide is a God send for the daily headaches and migraines I suffer from. Magnesium and Riboflavin (a B vitamin) get depleted when you start/are in menopause so it is important to get enough of these as they can cause headaches as can a deficiency in Iron. Iron deficiency can make you itchy, have raw spot(s) on your tongue and be tired and lethargic.
What I have discovered, and therefore, do better than others I know who have similar or the same symptoms is to take lots of targeted vitamins. My take on being ill is this- what you eat for your daily diet takes care of your daily functioning, but is not doing anything for the repairing your body so desperately needs to heal itself of the ill effects of your illness(es). I found taking targeted to the symptom vitamin’s have made a difference like night and day.
There is a product on the market for bodybuilders called Six Star -Muscle Building Whey Protein Shake that works quite well for Fibromyalgia and the aches and pains that come with it. I buy it at WalMart, they are the cheapest, but have continually upped the price over the last 6 months on a regular basis and not by cents, but by dollars. Is it still worth it? Yes! When you find something that helps at all with no side effects it is worth it. Don’t worry about it making you muscular, it will not unless you do all the working out that is required to build muscle. I use it to repair my body of all the illness causing aches, pains, and ill effects from having illnesses. For the first time in 35 years my eye doctor told me my eyes got better. I must be doing something right and am on the right track is how I feel. I mix the whey protein into a cup of cold milk, stir to mix as well as possible and then I pour hot water into that and stir. Let set for 30 seconds and stir again and most of the mix to all will be dissolved and ready to drink unless too hot, if so let cool a bit. This will also help you to sleep by drinking warmed milk. Taking the whey protein at night works as an anabolic action, repairing your body while you sleep which is what sleep is supposed to do in the first place, be restorative. That I know anabolic means to repair and that is also, why you won’t build muscle. I have many people now using this due to how much it has helped me and they also use it if they are going to go for a walk, do a workout, yard work, housework, or do any kind of work that stresses the muscles or will easily fatigue them/you. They all feel the difference when they use it and when they do not.
Kelp or also known as Sea Kelp sold at vitamin shops and WalMart works to help your thyroid work more efficiently. It helps with all body functions as your thyroid regulates every part of the body. I take one in the morning and one at bedtime and yes, I take my thyroid medication still of Armour thyroid. I tried going without the Kelp and did not do as well. It is only $4.99 for 200 pills. A great bargain for something that helps.
For the arthritis pains- Cod Liver Oil gel caps from WalMart work well and I no longer have the creaks and cracks in my joints as this helps to lubricate them and a bit less of the painful joints to go with it.
I take one Potassium pill at bedtime from WalMart and no more heart racing and feeling fluttery.
Be aware that if you are going through menopause or in it you end up losing some of what you had prior to and sometimes you just need supplements to feel a bit like your old self. Also, none of this happens over night, just like with any other medications you take it takes four to six weeks for most to feel any effect(s) so don’t give up too early.
Gastro problems are also associated with the thyroid and for that I take a MultiEnzyme with 1,000,000 Probiotics in it at bedtime and with breakfast to help regulate the digestive system. Think about it. How can you feel well if your digestive system is off track? Do you go from constipation to diarrhea to not going at all for a day or more? Well when your intestines that break down your foods are not working properly you get the symptoms above, improper nutrition, and weight gain for some, also. When you eat and your foods break down it sends off what you need to have oxygenated blood for your whole body, vitamin breakdown for cell growth and nerves and on and on. You can find all of this on the web if you do your research.
Menopause and Hypothyroid can deplete your B vitamin’s so taking a B-Complex vitamin in the morning will do wonders for your nerves and for your memory, as these can be affected by both conditions and some med’s deplete your vitamin’s in spite of doc’s who tell you it is inconclusive. You will know when you see the side effects that are listed on the http://www.cdc.gov and http://www.health.gov sites. These are gov sites full of health information. Doc’s do not usually use the regular websites we use for health info. They may be more apt to listen or take into consideration what you say if you bring a print out from one or both of the gov sites as from what I know that is where they get most of their information in the first place. These are our health regulatory offices.
Vitamin C is super important in the building of collagen and fighting illness. It replenishes the system with new tissue growth and I found taking it for the past few years that I do not get sick like I used to, it is now once or twice a year if that and no where near as severe. Is also known to help lower cholesteral and so does Oat Meal.
Get the Pneumonia shot just as you would the flu shot when you have illnesses. I go once every five years. It is good for five years and I no longer get bronchitis and pneumonia from having a weakened immune system from all these illnesses.
Many doctor’s refuse to see that a medicine or medicines are making you sick and assume that because you have taken it for months that it can’t be the culprit. What they sometimes leave out is that in the meantime they gave this or that other medicine and the two or more do not mesh and you get to be the bearer of the side effects they refuse to acknowledge. Been there too many times where they refuse to listen. I do not know if it is because they truly do not think so or if they think they will be sued, or if they are just that ignorant to the side effects. You know you best and if you had no symptoms or a new one pops up after starting a new med or being on a new one for a short-medium period of time it is time to suspect the new or last med. This has saved me more times than I can count now, because my doc wouldn’t listen and thought it a new symptom and gave a new med. I don’t want more meds to cover for what the one’s I am on are doing to me. I want less and have found that via my own vitamin regimen. You can too if you do trial and error with them. Also some are best taken at night/bedtime and some at breakfast and some are best not taken together. You do not take calcium when you take iron for instance as the calcium blocks the iron absorption. Do not take Calcium within four hours of taking you Armour Thyroid. Does this hold true for the synthetic, not sure, ask the pharmacist?
Be aware that too many meds tax the liver, cause it to work over time, and therefore breaks it down due to toxicity overload of too many meds in the system for it to filter. Check the web for drug toxicity effects and see what you find. Many times to get the full picture you have to read more than one site as some explain better than others and cross reference some of the words within what you read on using search engine such as Google for the particular word or words to fully understand.
Having trouble sleeping and just refuse to take meds or more for it, go to WalMart and get Melatonin 3mg. and take one at bedtime. It works great for those of us who have Fibromyalgia and insomnia due to it and or Arthritis. Both illnesses that help to keep us awake at night. Have a glass of warm milk with it and sleep even better.
Calcium is important and make sure it contains D vitamin as well. Calcium is needed for bone growth, your teeth, hair and nails. And more, do read to be better informed on how it all affects and effects your health by not getting what you need.
D vitamin works to help combat depression which also comes along with Hypothyroid, Fibromyalgia, and loss of bone mass. D helps calcium to be absorbed into your system and become usable to build bones and more, as I understand it.
There are other vitamin’s and you have to figure out what does and does not work for you by targeting and which work better together for you and which don’t. Read the bottle for what it states it helps. Also, paying more does not make it work any better which is why I use mostly WalMart for the pricing and Dollar Tree for the B-Complex and Omega 3’s. Try taking one vitamin for a week and then add the next and see if they mix well for you and then add another a week later and keep going from there. The exception is the one’s you have to take at night or bedtime when you will not be going out or driving and that is any one of them that makes you sleep or drowsy. This is very important to pay attention to what the bottle says it can do to affect you in good or bad ways if any.
I am not a doctor or in any way related to the medical profession and do not portray to be and the information herein, is a guideline for the possibility of you feeling better if you were to try any of these vitamin’s after speaking to your doctor and finding out if it is OK as some vitamins can interfere with prescribed medication’s in an adverse way. CHECK WITH YOUR DOCTOR BEFORE TAKING ANY NEW VITAMIN’S OR DRUGS.
Regarding you Primary Care Physician (PCP) doctor not knowing what other doctor’s have prescribed to you and then it causes an adverse action for some, do like I do and have all doctor’s who treat you to send a report back to your Primary Care Physician -doctor and you can avoid this. You will have to sign a release of information and you should do this for your Optometrist, especially if you have Diabetes. Many times your eye doctor can and does find health issues before a PCP and will report back to your PCP so they can work together and not have one doing this and the other doing that and neither is the wiser for it, but you may end up paying the consequences of it all.
Much of your care is due to what you push for and don’t ever allow anyone to tell you that you do not know what you are talking about or that you have nothing wrong when you know you do. It is your job to push till you find the one doctor who listens and finds what just may save your life some day. You are your own best advocate and never give up altogether even if you take time-outs and regroup for another round of lets find a doctor who cares enough to listen. It took me 34 years in total to finally get the answers for what I complained of starting 34 years ago and was told all was normal when I knew it was not and did not feel well for all those years. I am doing better than I was even though not better altogether and most likely never will be due to how long it took for them to find all the problems they dismissed years before and who knows what damage was done by it, but I do get more done than I used to and any time I can do more than I did in the past I will take it because each step of progress is better than none at all.
Don’t forget doctor’s are not miracle workers and can only do within their scope what they are taught and what they are taught is drug therapy and as far as I am concerned drug therapy is like putting a lid on a pan of rotting food, but the stench continues on for a long time while never taking care of the underlying cause. That is my reason for turning to vitamin’s and I am better for it and do not have the severe depression I used to. I was never truly had depression so it makes sense that their med’s caused more problems than it helped. You can’t expect a med to work if you do not have what it is prescribed for. If you find your depression med’s or what they give you do not work, don’t be surprised if it is due to you do not have real depression, but depression as a side effect to all your pain from your health issues and that is called secondary depression due to pain caused by the illnesses which is not true depression and why for me throughout all the years the depression meds made me worse instead of better and all the weight gain just is not worth it. I take only what I need to at this point and the rest is eat well and vitamin’s for the much needed benefit of healing what the food I eat does not or cannot provide. Another reason food does not do all is that if food of the past had 100 % of its vitamin value it is known today that it does not so some of what you eat may only have 60% vitamin value and then when you cook it that drops it even more so that if you have health issue’s and do not take vitamin’s you never get the vitamin’s from your food needed to heal and compound that with a bad digestive system and you are well on your way to being sick and not getting better. Each plays its part in the effects of the health chain.
I hope this is of help to some of you and I wish you all, all the best in your journey of healing and getting better, if nothing else.
I am not a doctor or in any way related to the medical profession and do not portray to be and the information herein, is a guideline for the possibility of you feeling better if you were to try any of these vitamin’s after speaking to your doctor and finding out if it is OK as some vitamins can interfere with prescribed medication’s in an adverse way. CHECK WITH YOUR DOCTOR BEFORE TAKING ANY NEW VITAMIN’S OR DRUGS
In response to V’s long post that we should check with our doctor before taking new vitamins and/or drugs…that’s all well and good if one’s doctor is aware of serotonin syndrome. If not, then the exercise is pointless. I’m on Lexapro for depression; I also have fibro, as well as myofascial pain syndrome. I take no drugs for pain managment, choosing to use massage, yoga, exercise, meditation and diet to control the pain. However, a few months ago, I was not sleeping well, so the doc told me to take L-tryptophan. Having already had one bout of serotonin syndrome in the 90’s, I quizzed her about the safety of taking L-tryptophan with with an SSRI. She assured me there was no problem. Well, guess what folks! I’ve not had full blown serotonin syndrome this time-thank God–however, I’ve had a horrendous headache for four months, the trigger points never relax, I’m not sleeping, I’m irritable, am hallucinating…well you get the picture. And you can bet that my doc and I are going to have a chat about this real soon. The bottom line is that YOU have to know your medications, interactions, and side effects. The doctors don’t know this and the pharmacist may be too busy or too much of an ass to talk you. Your health is ultimately your responsibility.
Yes I did have a long ongoing issue with Effexor and other drugs that boost serotoning or are metabilized via p450 pathway. Horrid effects that went on for years making me ill lost my job my home so this is important as doctors do NOT get it. Only getting off all drugs cold turkey did I save myself ct off effexor is not fun 3 years protracted withdrawal still going on.
I believe I had chronic serotonin syndrome before you laugh me off here read this.
Chronic Serotonin Syndrome Sings and Symptoms
Serotonin syndrome is an iatrogenic disorder induced by pharmacologic treatment with serotonergic agents that increase serotonin activity.4,7 It is thought to occur as a result of excess stimulationof the 5-hydroxytryptamine 1A (5-HT1A) receptor and possibly the 5-hydroxytryptamine 2 (5-HT2) receptor.8–11 Serotonin syndrome may result from an excess of synaptic serotonin following the use of serotonergic agents alone or in combination with other serotonin-enhancing drugs.6 In most cases, SS has a rapid onset, within minutes to hours, although it can occur over a period of days, weeks, or even months after the start of treatment with various SSRIs.4,12 The incidence of SS is, in large part, unknown. The variable and nonspecific nature of its presentation makes it difficult to diagnose; therefore, it has gone underreported.8 Signs and symptoms of SS may consist of mental status changes, with acute manifestations consisting of cognitive behavioral changes, neuromuscular excitability, autonomic instability, and pain.4,8 Serotonin syndrome also appears to be dose related, with the dose of the medication affecting both the likelihood of developing SS and the severity of the clinical presentation.4,12,13 Because the signs and symptoms may overlap those of other chronic pain syndromes, a diagnosis is made on clinical grounds.4
Serotonin syndrome is not detected by laboratory tests or diagnostic imaging. Sternbach14 has set forth diagnostic criteria for this syndrome:
1. At least 3 of the following clinical features should occur coincident with the addition of or increase in dosage of a known serotonergic agent: mental status changes (confusion, hypomania), agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, and fever.
2. Other etiologies (infections, metabolic disorders, and substance abuse or withdrawal) need to be excluded.
3. A neuroleptic agent should not have been started or increased in dosage prior to the onset of the signs and symptoms listed above.
Mason et el8 and Chechani15 also discussed pain as a symptom of SS. Because SS is diagnosed on the basis of symptoms and signs, some patients may experience mild symptoms for weeks before progressing to a more severe form of the syndrome.12 Therefore, the purposes of this report are to bring attention to some of the signs and symptoms of SS that may be overlooked if their onset is gradual and to promote the ability of physical therapists to identify such signs and symptoms in patients with SS
n carisoprodol, clonazepam, and gabapentin for INITIAL EVALUATION
The initial physical therapy visit consisted of a thorough evaluation by use of a systems approach as described in the Guide to Physical Therapist Practice.1 Two months prior to receiving the neurologist’s diagnosis of SS, the patient’s primary care physician (PCP) referred her for physical therapy with a diagnosis of fibromyalgia, identified by increasing pain and weakness. Her pain rating at the time of the initial evaluation was 8 of 10 and ranged from a low of 4 of 10 with rest to a high of 10 of 10 with increased activity on an 11-point (0–10) numeric pain scale, in which 0 represented “no pain” and 10 represented “the worst pain possible.”16,17 The numeric pain scale has been shown to have high test-retest reliability (intraclass correlation coefficient=.96) and a strong correlation (r=.85) with data collected using a visual analog scale.16 The patient reported that pain ranging from 4 of 10 to 10 of 10 was constant. There did not appear to be any relationship between time of day and intensity of pain, nor was there a specific pain pattern. The patient reported that pain increased with activity and did not diminish with any specific position. The application of a hot pack, however, did seem to provide a small amount of relief. The patient described her pain as throbbing throughout her extremities, with burning and a sense of tightness along the spine. With increased pain, she also had increased nausea, with or without vomiting. There were also signs of dizziness that did not appear to increase or decrease with the degree of pain. Prior to the initial evaluation, the patient had experienced many similar symptoms.
HISTORY OF COURSE OF SYMPTOM
Four years prior to diagnosis.
The patient had been taking citalopram (20 mg per day) since 1998 for the treatment of depression that was related to abuse that she had experienced as a child. She began to experience symptoms approximately 2 years after starting citalopram. Because of dizziness, she was considered to have Ménière disease, an idiopathic syndrome of endolymphatic hydrops.18 The American Academy of Otolaryngology head and neck surgery criteria for Ménière disease are the triad of vertigo, hearing loss, and tinnitus.18
Two years prior to diagnosis.
The patient began to have gastrointestinal tract problems consisting of increased bouts of nausea and vomiting with a slow and gradual onset. She also began to experience headaches that were bifrontal, with throbbing pain and hypersensitivity to light and sound. She had pain in her left shoulder, along her spine, and in many of her joints. She also experienced left-side weakness, muscle tightness, fluctuating temperature, insomnia, restlessness, and nervousness.
One year prior to diagnosis.
The patient had little to no appetite, bouts of diarrhea, and a sense of fullness and urgency with urination. She also experienced left-side muscle aching and spasms that caused her to have difficulty ambulating and to need a straight cane. The patient began to have mental symptoms, such as confusion and decreased memory. She also had dilated pupils, vertigo, and dysarthria.
Six months prior to diagnosis.
The patient experienced intermittent fatigue, bouts of increased sweating, episodes of feeling very cold, and nightmares. Mental symptoms, including confusion and decreased memory, were worsening. She complained of increased pain throughout her spine, joints, and extremities as well as left-sided weakness of the upper and lower extremities. She had decreased sensation in the lateral aspects of both hands.
The diagnostic criteria set forth by Sternbach,14 combined with the patient’s history of taking an SSRI, suggested that the above symptoms were indeed relevant to SS.
PHYSICAL EXAMINATION
I performed a physical examination 2 months prior to the diagnosis of SS being made by her neurologist.
Vital signs.
Vital signs were not noted at the time of the initial visit.
Neurologic findings.
Deep tendon reflexes were grossly 2 in bilateral upper extremities (biceps, triceps, and brachioradialis). Patellar and Achilles tendon reflexes were unattainable bilaterally. Nystagmus of greater than 3 beats was observed bilaterally, along with increased dizziness with finger tracking. The patient had difficulty when she was asked to touch her finger to her nose and then to touch my finger. Sensation to light touch was within normal limits, except for hypersensitivity to very light touch in the entire right lower extremity.
Musculoskeletal findings.
Palpation revealed tenderness in a nonanatomic pattern throughout the patient’s extremities and body. These findings did not coincide with the criteria for fibromyalgia.3 Because of the patient’s increased pain level, a proper assessment of gross range of motion and strength (force-generating capacity) was not performed. The patient’s roommate reported that she spent much of the night “jumping” and having muscle spasms with jerking motions in all parts of her body. This problem severely limited her ability to sleep for more than 2 hours at a time.
Cardiovascular, endocrinologic, and integumentary findings.
There were no significant findings for the cardiovascular, endocrinologic, and integumentary systems.
Gastrointestinal tract findings.
The patient reported gastrointestinal tract symptoms (nausea, vomiting, and difficulty with bowel and bladder functions).
I do not have CFS, but did have serotonin syndrome post-op as a result of the pain meds the surgeons gave me (fentanyl and ultram- two known offenders.) Nausea, profuse sweating, tachycardia, fever, tremors and shivering, burning throughout my whole body,and delirium. Thought I was going to die when my heart rate hit 170, and those docs didn’t have a clue what was wrong with me, and didn’t treat it or even acknowledge it. My allergist diagnosed me OVER THE PHONE and requested the surgeon to call him, but the surgeon and neurologist both said serotonin syndrome “isn’t real”. Can you believe that? Lol Know the symptoms and proper treatment. You just might need to educate your doc in a crisis. Those docs sure as hell didn’t save my life….
I went thru this years ago. I was on Lexepro then they added Cymbata. At first it was just a lot of sweating and strange body jerking. Also a heart rate of 120. I would kick out or my arm would lash out. Then the electric shock feelings started. All thru this I am telling my doctors about it and they blew me off. The final straw for me was when I had a electric shock go from my spine to my head followed by a loud Bzzzzzz in my head. Scared me to death!!! I did not know then about Seritonin Syn. But I figured out that it all started around the time I started adding the cymbalta. I stopped taking the cymbalta that day and weened myself off of the anti-depressants. A year later I read about Serotonin Syndrome and thanked god I am alive.