The Tipping Point. Brita Roy, MD MPH MS F. Stanford Massie Jr., MD

Transcription

1 The Tipping Point Brita Roy, MD MPH MS F. Stanford Massie Jr., MD

2 Learning Objectives 1. To recognize an important cause of fever, somnolence, and rigidity. 2. To appreciate the dangers of polypharmacy.

3 History of Present Illness 39-year-old white woman Chief complaint: Fever, somnolence Initiated methadone treatment for chronic pelvic pain TMP/SMX Urinary tract infection symptoms Anxious Increased somnolence and confusion Fever, tremors, and altered mental status 4-days prior 3-days prior 2-days prior 1-day prior Emergency Department

4 Past Medical History Chronic pelvic pain Hypothyroidism Diabetes mellitus Anxiety Depression Migraine headaches

5 Medications Levothyroxine Metformin Pravastatin Zonisamide Citalopram Buspirone Quetiapine Amitryptiline Meclizine Promethazine Prochlorperazine Gabapentin TMP/SMX Methadone

6 Physical Exam T F HR122/min R 27/min BP 92/63mmHg Gen: Somnolent, profusely diaphoretic, speech unintelligible HEENT: Pupils dilated (reactive), no papilledema CV: Tachycardic, no murmurs GI: Soft, non-distended, hypoactive bowel sounds Neuro: Rigid in all extremities, spontaneous tremors, inducible clonus, hyperreflexic

7 Testing Laboratory: < LFTs: normal UDS: + methadone > < N, 6L, 6M, 1B CPK: 567 IU/L U/A: + LE, + Nitrite CT Head: normal

8 Assessment 39 year-old woman with: Fever and SIRS Somnolence Recent symptoms of urinary tract infection Urosepsis Rigidity Clonus Recent initiation of methadone

9 Differential Diagnosis Fever, somnolence, and rigidity Infection (SIRS/sepsis) Encephalitis Non-convulsive seizures Malignant hyperthermia Neuroleptic malignant syndrome Acute baclofen withdrawal Anticholinergic toxicity Serotonin syndrome

10 Serotonin Syndrome Hunter Serotonin Toxicity Criteria: 1 of the following after exposure to serotonergic agent Spontaneous clonus Inducible clonus with agitation or diaphoresis Ocular clonus with agitation or diaphoresis Tremor and hyperreflexia Hypertonia, T >100.4 F, ocular or inducible clonus Sensitivity 84%, specificity 97% QJM. 2003;96(9):635-42

11 Serotonin Syndrome Hunter Serotonin Toxicity Criteria: 1 of the following after exposure to serotonergic agent Spontaneous clonus Inducible clonus with agitation or diaphoresis Ocular clonus with agitation or diaphoresis Tremor and hyperreflexia Hypertonia, T >100.4 F, ocular or inducible clonus Sensitivity 84%, specificity 97% QJM. 2003;96(9):635-42

12 Serotonin Syndrome Other findings Elevated white blood cell count Elevated creatine phosphokinase Elevated transaminases Metabolic acidosis Serum serotonin levels do not correlate with clinical findings

13 Serotonin Syndrome Other findings Elevated white blood cell count Elevated creatine phosphokinase Elevated transaminases Metabolic acidosis Serum serotonin levels do not correlate with clinical findings

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15 Cause of Serotonin Syndrome Drugs acting on receptor Amphetamines Antipsychotics Antiemetics Anti-migraines Linezolid Increase 5HT availability Monoamine oxidase inhibitors (MAOIs) Selective serotonin reuptake inhibitors (SSRI) Synthetic opioids Methadone Tramadol Dextromethorphan

16 Medications Levothyroxine Metformin Pravastatin Zonisamide Citalopram Buspirone Quetiapine Amitryptiline Meclizine Promethazine Prochlorperazine Gabapentin

17 Medications Levothyroxine Metformin Pravastatin Zonisamide Citalopram Buspirone Quetiapine Amitryptiline Meclizine Promethazine Prochlorperazine Gabapentin

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19 The Tipping Point Prochlorperazine Promethazine Zonisamide Amytriptiline Quetiapine Citalopram Buspirone

20 The Tipping Point Methadone Prochlorperazine Promethazine Zonisamide Amytriptiline Quetiapine Citalopram Buspirone

21 The Tipping Point Methadone Prochlorperazine Promethazine Zonisamide Amytriptiline Quetiapine Citalopram Buspirone

22 Treatment If untreated, serotonin syndrome rapidly progresses to multiorgan failure High mortality rate 1. Removal of all offending agents 2. Supportive care 3. Benzodiazepines 4. Cyproheptadine - serotonin 2A antagonist

23 Our Patient Intravenous fluids Empiric antibiotics Held methadone, promethazine, prochlorperazine, SSRI, buspirone, zonisamide, quetiapine, and amytriptiline Benzodiazepines

24 Prevention AVOID POLYPHARMACY!

25 Conclusions Recognize serotonin syndrome in patients presenting with fever, somnolence and rigidity. Synthetic opioids can contribute to serotonin syndrome. Polypharmacy can be lethal.

26 THANK YOU! QUESTIONS?