Serotonin syndrome

Serotonin syndrome occurs when the level of a chemical in the brain, called serotonin, gets too high. It is a known adverse reaction associated with the use of some medicines, or herbal supplements.

Key points

  1. Serotonin is a chemical that is produced in the body, and is needed for the nerve cells and brain to function. 
  2. Serotonin syndrome occurs when the level of serotonin in the brain gets too high. This may be caused by the use of some medicines, or herbal supplements.
  3. Symptoms of serotonin syndrome can range from mild (shivering and diarrhoea) to severe (muscle rigidity, fever and seizures). 
  4. Milder forms of serotonin syndrome may go away within a few days of stopping the medicines that caused the symptoms. 
  5. Severe serotonin syndrome needs hospital admission and can be fatal if not treated.

Causes of serotonin syndrome

Serotonin syndrome is a known adverse reaction associated with the use of some medicines, or herbal supplements.

The following are examples of medicines and herbal supplements known to increase serotonin levels: 

  • Selective Serotonin Reuptake Inhibitors (SSRIs) such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline.
  • Tricyclic Antidepressants (TCAs) such as amitriptyline, imipramine, clomipramine, nortriptyline.
  • Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs) such as venlafaxine, duloxetine.
  • Atypical Antidepressants such as mirtazipine.
  • Monoamine Oxidase Inhibitors (MAOIs) such as moclobemide, phenelzine, tranylcypromine.
  • Opioid Analgesics (pain medication) such as pethidine, fentanyl, tramadol.
  • Migraine medication such as sumitriptan, rizatriptan, zolmitriptan.
  • Nausea medication such as ondansetron, granisetron.
  • Cough suppressants such as dextromethorphan.
  • Herbal Products such as St John's Wort.

Some people are more sensitive to these medicines and supplements that cause serotonin syndrome than are others, but the condition can occur in anyone.

You are at increased risk of serotonin syndrome if:

  • You recently started taking or increased the dose of a medicine known to increase serotonin levels.
  • You take more than one medicine known to increase serotonin levels.
  • You take herbal supplements known to increase serotonin levels.
  • You use an illicit drug known to increase serotonin levels.

Symptoms of serotonin syndrome

Serotonin syndrome symptoms usually occur within hours to days of taking the medicine or increasing the dose of a medicine you are already taking. Signs and symptoms include:

  • feeling agitated or restlessness
  • confusion
  • fast heart rate or irregular heart beat
  • loss of muscle coordination or twitching muscles
  • muscle rigidity
  • heavy sweating
  • diarrhoea
  • headache
  • shivering
  • goose bumps
  • high fever
  • seizures (or fits)
  • unconsciousness

Prevention of serotonin syndrome

Taking more than one medication known to increase serotonin levels increases your risk of serotonin syndrome. Talk to your doctor about possible risks.

  • Don't stop taking any such medications on your own.
  • If your doctor prescribes a new medication, make sure he or she knows about all the other medications you're taking, especially if you receive prescriptions from more than one doctor.
  • If you and your doctor decide the benefits of combining certain drugs that affect serotonin levels outweigh the risks, be alert to the possibility of serotonin syndrome.

Treatment of serotonin syndrome

The treatment of serotonin syndrome depends on the severity of your symptoms.

  • If your symptoms are mild, a visit to the doctor and stopping the medication causing the problem may be enough. In the milder forms, the symptoms of serotonin syndrome usually go away within 24 to 72 hours of stopping medications that increase serotonin.
  • If you have symptoms that concern your doctor, you may need to go to the hospital. Your doctor may have you stay in the hospital for several hours to make sure your symptoms are improving.
  • If you have severe serotonin syndrome, you'll need intensive treatment in a hospital.

Learn more

The following links provide further information on serotonin syndrome.
Be aware that websites from other countries may contain information that differs from New Zealand recommendations.

Serotonin syndrome Medsafe, New Zealand 
Serotonin Syndrome Patient Info, UK

References

Advice about serotonin syndrome Medsafe New Zealand July 2015

Credits: Sandra Ponen, Pharmacist. Reviewed By: Dr J Bycroft. Health Navigator NZ Last reviewed: 29 Aug 2015