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Re: Serotonin Syndrome » stjames

Posted by Elizabeth on May 16, 2001, at 12:54:25

In reply to Re: Seratonin Syndrome, posted by stjames on May 14, 2001, at 18:31:42

> As sal quoted the Archives of Family Medicine I would trust this source over your lay opinion.

Ordinarily I would too. However, (1) it's a family medicine journal, not a psychiatric one; and, more importantly, (2) while the symptoms described are among those *associated* with the serotonin syndrome, the description was *very* generic (not including any specific symptoms of CSS) and did not sound severe enough to warrant a diagnosis of serotonin syndrome (which is generally considered to be a life-threatening emergency). Unless there were other symptoms present I would say the diagnosis was questionable at best; it sounds more like generalised activation caused or exacerbated by phentermine. The absence of changes in state of consciousness, tremor, fever, dilated pupils, manic symptoms, perceptual changes, vomiting, diarrhea, myoclonus, hyperreflexia, high/low/labile blood pressure, and other characteristic signs and symptoms of makes me skeptical of the diagnosis of serotonin syndrome (which is kind of a foggy diagnosis anyway -- a common annoyance in psychiatry < g >).

I've had CSS three times in my life (this is what happens when you go through *all* the monoaminergic antidepressants and various combinations). It landed me in the hospital each time and twice included frank delirium, as well as tremor (chattering teeth are particularly common and specific), myoclonus, rapidly fluctuating blood pressure, fever, confusion, vomiting, and dilated pupils (a sign that I believe would pretty much *have* to be present in true CSS). It goes well beyond straightforward psychomotor (or even autonomic) agitation.

I would be interested in hearing the definition or description of CSS given by Goldberg, as it may be broader than the one I was taught. It would be interesting to read the letter by Bostwick and Brown (which may or may not refer to CSS; the title doesn't specify what the "toxic reaction" was) as well.

The *peripheral* toxic reactions to "phen-fen" -- primary pulmonary hypertension and heart valve damage -- have nothing to do with the *central* serotonin syndrome that is most often associated with combinations of multiple serotonergic drugs (in most of the serious cases, a MAOI was involved). Furthermore, the "phen-fen" reactions actually believed to have no relationship to the (amphetamine-like) stimulant phentermine and were only discovered due to the widespread use of d-fenfluramine, or Redux (alone, not combined with phentermine), in the few months that it was on the market. The reaction in question is associated only with serotonin-releasing drugs (like fenfluramine, which acts like amphetamine, except on serotonin rather than on catecholamines), not with pure reuptake inhibitors (e.g., Prozac).

The odds of a serious adverse interaction between Prozac and phentermine are extremely low, but as noted, when adding a second drug, one should be especially cautious with dosing and watch for possible adverse reactions.

-elizabeth


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poster:Elizabeth thread:62569
URL: http://www.dr-bob.org/babble/20010515/msgs/63230.html