Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management

Clinical Toxicology

Volumn 45, Issue 4, 2007, Pages 315-332

  Nelson, Lewis S ^a   Erdman, Andrew R ^a   Booze, Lisa L ^a   Cobaugh, Daniel J ^a   Chyka, Peter A ^a   Woolf, Alan D ^a   Scharman, Elizabeth J ^a   Wax, Paul M ^a   Manoguerra, Anthony S ^a   Christianson, Gwenn ^a   Caravati, E Martin ^a   Troutman, William G ^a  

^a American Association of Poison Control Centers   (United States)

Author keywords

Poison control centers standards; Practice guidelines; Serotonin uptake inhibitors poisoning

Indexed keywords

ACTIVATED CARBON; ANTICONVULSIVE AGENT; BENZODIAZEPINE; BENZODIAZEPINE DERIVATIVE; BICARBONATE; CITALOPRAM; ESCITALOPRAM; FLUOXETINE; FLUVOXAMINE; FLUVOXAMINE MALEATE; GLUCOSE; INFUSION FLUID; IPECAC; OXYGEN; PAROXETINE; SEROTONIN UPTAKE INHIBITOR; SERTRALINE;

ANTIBIOTIC THERAPY; ARTIFICIAL VENTILATION; CASE MANAGEMENT; CLINICAL TRIAL; CONSENSUAL VALIDITY; CONSENSUS DEVELOPMENT; DIAPHORESIS; DRUG INTOXICATION; DRUG MEGADOSE; DRUG OVERDOSE; EMERGENCY CARE; EMERGENCY HEALTH SERVICE; EVIDENCE BASED MEDICINE; HEALTH CARE COST; HOSPITAL MANAGEMENT; HOSPITAL SUBDIVISIONS AND COMPONENTS; HUMAN; HYPERTHERMIA; MEDICAL DECISION MAKING; MEDICAL EXAMINATION; MYDRIASIS; OBSESSIVE COMPULSIVE DISORDER; OXYGEN THERAPY; PATIENT CARE; PATIENT REFERRAL; PATIENT TRANSPORT; POISON CENTER; PRACTICE GUIDELINE; RESUSCITATION; REVIEW; SEIZURE; SEROTONIN SYNDROME; SINGLE DRUG DOSE; SLEEP PATTERN; SOMNOLENCE; STOMACH LAVAGE; SUICIDAL IDEATION; SYSTEMATIC REVIEW; UNITED STATES; VOMITING;

ADULT; AGE FACTORS; AMBULATORY CARE; CHILD, PRESCHOOL; EMERGENCY MEDICAL SERVICES; EVIDENCE-BASED MEDICINE; HUMANS; OVERDOSE; SEROTONIN SYNDROME; SEROTONIN UPTAKE INHIBITORS; SUICIDE; SUICIDE, ATTEMPTED; TERMINOLOGY; TRIAGE;

EID: 34248159974     PISSN: 15563650     EISSN: 15569519     Source Type: Journal    
DOI: 10.1080/15563650701285289     Document Type: Review

References (107)

1. Watson WA, Litovitz TL, Rodgers GC, Klein-Schwartz W, Reid N, Youniss J, Flanagan A, Wruk KM. 2004 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2005; 23:589-666.
2. Toxic Exposure Surveillance System (TESS). American Association of Poison Control Centers 2000-2005.
3. Miller TR, Lestina DC. Costs of poisoning in the United States and savings from poison control centers: a benefit-cost analysis. Ann Emerg Med 1997; 29:239-245.
4. Klasco RK, ed. Poisindex system. Greenwood Village (CO): Thomson Micromedex; edition expires March 2004.
5. Mosby's Drug Consult 2005. Philadelphia: Elsevier; 2005.
6. Stork CM. Serotonin reuptake inhibitors and atypical antidepressants. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, eds. Goldfrank's Toxicologic Emergencies. 7th ed. New York: McGraw-Hill; 2002. p. 865-874.
7. Whyte IM, Dawson AH, Buckley NA. Relative toxicity of venlafaxine and selective serotonin reuptake inhibitors in overdose compared to tricyclic antidepressants. QJM 2003; 96:369-374.
8. Grundemar L, Wohlfart B, Lagerstedt C, Bengtsson F, Eklundh G. Symptoms and signs of severe citalopram overdose. Lancet 1997; 349:1602.
9. Ho R, Norman RF, van Veen MM, Anderson IB. A 3-year review of citalopram and escitalopram ingestions. [abstract]. J Toxicol Clin Toxicol 2004; 42:746.
10. Kelly CA, Dhaun N, Laing WJ, Strachan FE, Good AM, Bateman DN. Comparative toxicity of citalopram and the newer antidepressants after overdose. J Toxicol Clin Toxicol 2004; 42:67-71.
11. Öström, Eriksson A, Thorson J, Spigset O. Fatal overdose with citalopram. Lancet 1996; 348:339-340.
12. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112-1120.
13. http://www.fda.gov/medwatch/safety/2005/safety05.htm#Paxil3
14. Gentile S. SSRIs in pregnancy and lactation: emphasis on neurodevelopmental outcome. CNS Drugs 2005; 19:623-633.
15. Malm H, Klaukka T, Neuvonen PJ. Risks associated with selective serotonin reuptake inhibitors in pregnancy. Obstet Gynecol 2005; 106:1289-1296.
16. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999; 281:1900-1905.
17. Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM. Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization. Ann Intern Med 2003; 139:493-498.
18. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL. CDC Growth Charts: United States. Advance Data from Vital and Health Statistics; No. 314. Hyattsville, MD: National Center for Health Statistics, 2000.
19. Benowitz NL. Antidepressants, general (noncyclic). In: Olson KR, ed. Poisoning & drug overdose. 4th ed. New York: McGraw Hill; 2004. p. 88-90.
20. Brent J. Serotonin reuptake inhibitors, newer antidepressants, and the serotonin syndrome. In: Ford MD, Delaney KA, Ling LJ, Erickson T, eds. Clinical Toxicology. Philadelphia: WB Saunders; 2001. p. 522-531.
21. Pentel PR, Keyler DE, Haddad LM. Tricyclic antidepressants and selective serotonin reuptake inhibitors. In: Haddad LM, Shannon MW, Winchester JF, eds. Clinical Management of Poisoning and Drug Overdose. 3rd ed. Philadelphia: WB Saunders; 1998. p. 437-451.
22. Whyte, IM. Serotonin uptake inhibitors. In: Dart RC, ed. Medical Toxicology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 843-851.
23. Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics 17th ed. Philadelphia: WB Saunders; 2004.
24. Lee C, Robertson J, Shilkofski N. Drug doses. In: Robertson J, Shilkofski N, eds. The Harriet Lane Handbook: a Manual for Pediatric House Officers / the Harriet Lane Service, Children's Medical and Surgical Center of the Johns Hopkins Hospital. Philadelphia: Elsevier Mosby; 2005.
25. http://www.fda.gov/cder/drug/antidepressants/SSRIPHA200410.htm
26. Isbister GK, Dawson A, Whyte IM. Citalopram overdose, serotonin toxicity, or neuroleptic malignant syndrome? Can J Psychiatry 2001; 46:657-659.
27. Wijnands-Kleukers APG, Zoelen G van, Dries I de, Muelenbelt J. A prospective study on intoxications with citalopram [abstract]. J Toxicol Clin Toxicol 2002; 40:274-275.
28. Baker SD, Morgan DL. Fluoxetine exposures: are they safe for children? Am J Emerg Med 2004; 22:211-213.
29. Barbey JT, Roose SP. SSRI safety in overdose. J Clin Psychiatry 1998; 59 Suppl 15:42-48.
30. Spiller HA, Morse S, Muir C. Fluoxetine ingestion: a one year retrospective study. Vet Hum Toxicol 1990; 32:153-155.
31. Feierabend RH, Jr. Benign course in a child with a massive fluoxetine overdose. J Fam Pract 1995; 41:289-291.
32. Garnier R, Azoyan P, Chataigner D, Taboulet P, Dellattre D, Efthymiou ML. Acute fluvoxamine poisoning. J Int Med Res 1993; 21:197-208.
33. Fraser J, South M. Life-threatening fluvoxamine overdose in a 4-yearold child. Intensive Care Med 1999; 25:548.
34. Myers LB, Dean BS, Krenzelok EP. Paroxetine (Paxil): overdose assessment of a new selective serotonin reuptake inhibitor [abstract]. Vet Hum Toxicol 1994; 36:370.
35. Myers LB, Krenzelok EP. Paroxetine (Paxil) overdose: a pediatric focus. Vet Hum Toxicol 1997; 39:86-88.
36. Baker SD, Vincent CB, Morgan DL. Paroxetine exposures: five-year analysis of unintentional ingestions in the pediatric population reported to the Texas Poison Center Network. [abstract]. J Toxicol Clin Toxicol 2003; 41:712.
37. Klein-Schwartz W, Anderson B. Analysis of sertraline-only overdoses. Am J Emerg Med 1996; 14:456-458.
38. Myers LB, Dean BS, Krenzelok EP. A closer look: sertraline (Zoloft) and pediatric overdoses [abstract]. J Toxicol Clin Toxicol 1995; 33:551.
39. Lau GT, Horowitz BZ. Sertraline overdose. Acad Emerg Med 1996; 3:132-136.
40. Catalano G, Cooper DS, Catalano MC, Guttman JM. Pediatric sertraline overdose. Clin Neuropharmacol 1998; 21:59-61.
41. Pao M, Tipnis T. Serotonin syndrome after sertraline overdose in a 5-year-old girl. Arch Pediatr Adolesc Med 1997; 151:1064-1067.
42. Personne M, Persson H, Sjöberg E. Citalopram toxicity. Lancet 1997; 350:518-519.
43. Personne M, Sjöberg G, Persson H. Citalopram overdose-review of cases treated in Swedish hospitals. J Toxicol Clin Toxicol 1997; 35:237-240.
44. Aydin N, Anac E, Caykoylu A, Akcay F. Neuroleptic malignant syndrome due to citalopram overdose. Can J Psychiatry 2000; 45:941-942.
45. Catalano G, Catalano MC, Epstein MA, Tsambiras PE. QTc interval prolongation associated with citalopram overdose: a case report and literature review. Clin Neuropharmacol 2001; 24:158-162.
46. Cuenca PJ, Holt KR, Hoefle JD. Seizure secondary to citalopram overdose. J Emerg Med 2004; 26:177-181.
47. Engebretsen KM, Harris CR, Wood JE. Cardiotoxicity and late onset seizures with citalopram overdose. J Emerg Med 2003; 25:163-166.
48. Lepola U, Leinonen E, Koponen H. Serum drug levels and electroencephalographic findings after citalopram intoxication. Nord J Psychiatry 1996; 50:61-62.
49. Rothenhausler HB, Hoberl C, Ehrentrout S, Kapfhammer HP, Weber MM. Suicide attempt by pure citalopram overdose causing long-lasting severe sinus bradycardia, hypotension and syncope: successful therapy with a temporary pacemaker. Pharmacopsychiatry 2000; 33:150-152.
50. Snider RD. Case report: left bundle branch block-a rare complication of citalopram overdose. J S C Med Assoc 2001; 97:380-382.
51. Tarabar AF, Hoffman RS, Nelson LS. Citalopram overdose: late presentation of torsades de pointes (TDP) with cardiac arrest [abstract]. J Toxicol Clin Toxicol 2003; 41:676.
52. Penfornis C, Hueber-Paysant V, Souplet JP, Curtes JP, Caubet A. Fatal case of citalopram intoxication [abstract]. Vet Hum Toxicol 1998; 40:178.
53. Lindgren KN, Bangh SA, Ling L, Stremski E, Mueller C. Escitalopram, a review of adverse effects in overdose reported to select regional poison center [abstract]. J Toxicol Clin Toxicol 2003; 41:658.
54. Olsen DG, Dart RC, Robinett M. Severe serotonin syndrome from escitalopram overdose [abstract]. J Toxicol Clin Toxicol 2004; 42:744-745.
55. Borys DJ, Setzer SC, Ling LJ, Reisdorf JJ, Day LC, Krenzelok EP. The effects of fluoxetine in the overdose patient. J Toxicol Clin Toxicol 1990; 28:331-340.
56. Cooper GL. The safety of fluoxetine - an update. Br J Psychiatry Suppl 1988:77-86.
57. Braitberg G, Curry SC. Seizure after isolated fluoxetine overdose. Ann Emerg Med 1995; 26:234-237.
58. Finnegan KT, Gabiola JM. Fluoxetine overdose. Am J Psychiatry 1988; 145:1604.
59. Graudins A, Vossler C, Wang R. Fluoxetine-induced cardiotoxicity with response to bicarbonate therapy. Am J Emerg Med 1997; 15:501-503.
60. Gross R, Dannon PN, Lepkifker E, Zohar J, Kotler M. Generalized seizures caused by fluoxetine overdose. Am J Emerg Med 1998; 16:328-329.
61. Grover J, Caravati EM. Right bundle branch block and delayed seizure associated with citalopram and fluoxetine ingestion [abstract]. J Toxicol Clin Toxicol 2001; 39:491.
62. Kim SW, Pentel PR. Flu-like symptoms associated with fluoxetine overdose: a case report. J Toxicol Clin Toxicol 1989; 27:389-393.
63. Kincaid RL, McMullin MM, Crookham SB, Rieders F. Report of a fluoxetine fatality. J Anal Toxicol 1990; 14:327-329.
64. Kious T, Wax P, Cobaugh D. Tramadol and fluoxetine induced serotonin syndrome with subsequent severe hyperpyrexia despite cyproheptadine [abstract]. J Toxicol Clin Toxicol 1999; 37:631-632.
65. Lherm T, Lottin F, Larbi D, Bray M, Legall C, Caen D. Torsade de pointes après intoxication monomedicamenteuse à la fluoxetine. Presse Med 2000; 29:306-307.
66. Moore JL, Rodriguez R. Toxicity of fluoxetine in overdose. Am J Psychiatry 1990; 147:1089.
67. Riddle MA, Brown N, Dzubinski D, Jetmalani AN, Law Y, Woolston JL. Fluoxetine overdose in an adolescent. J Am Acad Child Adolesc Psychiatry 1989; 28:587-588.
68. Henry JA. Overdose and safety with fluvoxamine. Int Clin Psychopharmacol 1991; 6 Suppl 3:41-45.
69. Martin AJ, Tebbs VM, Ashford JJ. Affective disorders in general practice. Treatment of 6000 patients with fluvoxamine. Pharmatherapeutica 1987; 5:40-49.
70. Amital D, Amital H, Gross R, Kindler S, Zohar J. Sinus bradycardia due to fluvoxamine overdose. Br J Psychiatry 1994; 165:553-554.
71. Banerjee AK. Recovery from prolonged cerebral depression after fluvoxamine overdose. Br Med J (Clin Res Ed) 1988; 296:1774.
72. Buchberger R, Wagner W. Fluvoxamine: safety profile in extensive post-marketing surveillance. Pharmacopsychiatry 2002; 35:101-108.
73. Chen Y, Barboteu M, Taboulet P, Le Gall JR. Convulsions et arrêt circulatoire lors d'une intoxication par la fluvoxamine et la paroxetine. Therapie 1998; 53:165-167.
74. Gill M, LoVecchio F, Selden B. Serotonin syndrome in a child after a single dose of fluvoxamine. Ann Emerg Med 1999; 33:457-459.
75. Hahn I, Blancaflor G, Hoffman RS, Howland MA, Nelson LS. Fluvoxamine overdose producing status epilepticus [abstract]. J Toxicol Clin Toxicol 2000; 38:573.
76. Langlois RP, Paquette D. Sustained bradycardia during fluvoxamine and buspirone intoxication. Can J Psychiatry 1994; 39:126-127.
77. Lebegue B. Survivable fluvoxamine overdose. Am J Psychiatry 1990; 147:1689.
78. Manet P, Hilpert F, Fouet P, Toledano D. Troubles du rythme ventriculaire lors d'une intoxication à la fluvoxamine. Therapie 1993; 48:62-63.
79. De Riu PL, Rosati G, Sotgiu S, Sechi G. Epileptic seizures after treatment with thiocolchicoside. Epilepsia 2001; 42:1084-1086.
80. Greb WH, Buscher G, Dierdorf HD, von Schrader HW, Wolf D. Ability of charcoal to prevent absorption of paroxetine. Acta Psychiatr Scand Suppl 1989; 350:156-157.
81. Lund J, Lomholt B, Fabricius J, Christensen JA, Bechgaard E. Paroxetine: pharmacokinetics, tolerance and depletion of blood 5-HT in man. Acta Pharmacol Toxicol (Copenh) 1979; 44:289-295.
82. Christensen O, Sorensen HA, Almdal TP. Bivirkninger ved behandling med selektive serotoningenoptagelseshaemmere. Hyponotrioemi pa grund af Schwartz-Bartters syndrome. Ugeskr Laeger 1996; 158:6920-6922.
83. Dunbar GC. An interim overview of the safety and tolerability of paroxetine. Acta Psychiatr Scand Suppl 1989; 350:135-137.
84. Gorman SE, Rice T, Simmons HF. Paroxetine overdose. Am J Emerg Med 1993; 11:682.
85. Graeme K, Curry S, Kunkel D. Delayed cardiotoxicity after haloperidol and paroxetine overdose [abstract]. J Toxicol Clin Toxicol 1999; 37:635.
86. Johnsen CR, Hoejlyng N. Hyponatremia following acute overdose with paroxetine. Int J Clin Pharmacol Ther 1998; 36:333-335.
87. Johnson R, Velez LI, Roth B. Paroxetine as a sole cause of serotonin syndrome: a massive overdose with documented serum paroxetine levels [abstract]. J Toxicol Clin Toxicol 2001; 39:491.
88. Robert P, Senard JM, Fabre M, Cabot C, Cathala B. Syndrome sétoninergique lors d'une intoxication aiguë aux antidépresseurs. Ann Fr Anesth Reanim 1996; 15:663-665.
89. Velez LI, Shepherd G, Roth BA, Benitez FL. Serotonin syndrome with elevated paroxetine concentrations. Ann Pharmacother 2004; 38:269-272.
90. Waksman JC, Heard K, Jolliff H, Daly FFS, Bogdan GM, Dart RC. Serotonin syndrome associated with the use of St. John's wort (Hypericum perforatum) and paroxetine. [abstract]. J Toxicol Clin Toxicol 2000; 38:521.
91. Mattila MJ, Saarialho-Kere U, Mattila M. Acute effects of sertraline, amitriptyline, and placebo on the psychomotor performance of healthy subjects over 50 years of age. J Clin Psychiatry 1988; 49 Suppl:52-58.
92. Brendel DH, Bodkin JA, Yang JM. Massive sertraline overdose. Ann Emerg Med 2000; 36:524-526.
93. Brown DF, Kerr HD. Sertraline overdose. Ann Pharmacother 1994; 28:1307.
94. Caracci G. Unsuccessful suicide attempt by sertraline overdose. Am J Psychiatry 1994; 151:147.
95. Kaminski CA, Robbins MS, Weibley RE. Sertraline intoxication in a child. Ann Emerg Med 1994; 23:1371-1374.
96. Lopez Gaston OD, Wierzbinsky S, Lopez Gaston RS, Resnik S, Pardomenico S, Jorge M. Sertralina. Efectos adversos por superposicion de manifestaciones de sindromes serotoninico y neuroléptico maligno. Medicina (B Aires) 2000; 60:241-244.
97. Meier K, Lam R. 4 gram sertraline (Zoloft® ) overdose resulting in delayed seizures [abstract]. J Toxicol Clin Toxicol 1998; 36:520-521.
98. Mordel A, Linden CH. Marked sinus tachycardia following sertraline overdose [abstract]. J Toxicol Clin Toxicol 1998; 36:521.
99. Vanberkum M, Thiel J, Leikin J, Segovia A. A fatality due to serotonin syndrome [abstract]. J Toxicol Clin Toxicol 1996; 34:539-540.
100. Laine K, Kivisto KT, Pelttari S, Neuvonen PJ. The effect of activated charcoal on the absorption of fluoxetine, with special reference to delayed charcoal administration. Pharmacol Toxicol 1996; 79:270-273.
101. Lapatto-Reiniluoto O, Kivisto KT, Neuvonen PJ. Effect of activated charcoal alone or given after gastric lavage in reducing the absorption of diazepam, ibuprofen and citalopram. Br J Clin Pharmacol 1999; 48:148-153.
102. Isbister GK, Dawson AH, Whyte IM. Feasibility of prehospital treatment with activated charcoal: who could we treat, who should we treat? Emerg Med J 2003; 20:375-378.
103. Phillips S, Brent J, Kulig K, Heiligenstein J, Birkett M. Fluoxetine versus tricyclic antidepressants: a prospective multicenter study of antidepressant drug overdoses. The Antidepressant Study Group. J Emerg Med 1997; 15:439-445.
104. Brucculeri M, Kaplan J, Lande L. Reversal of citalopram-induced junctional bradycardia with intravenous sodium bicarbonate. Pharmacotherapy 2005; 25:119-122.
105. Caravati EM. Unintentional acetaminophen ingestion in children and the potential for hepatotoxicity. J Toxicol Clin Toxicol 2000; 38:291-296.
106. Henry JA. Epidemiology and relative toxicity of antidepressant drugs in overdose. Drug Saf 1997; 16:374-390.
107. Isbister GK, Bowe SJ, Dawson A, Whyte IM. Relative toxicity of selective serotonin reuptake inhibitors (SSRIs) in overdose. J Toxicol Clin Toxicol 2004; 42:277-285.