A neurologist may also be important for ongoing care. If suspected by a triage nurse in an emergency setting, it is important that the emergency medicine physician immediately begin supportive treatment. Coordinating with the intensivist and ICU nursing staff may also be required as treatment may require immediate sedation and intubation. Serotonin syndrome is important to keep in mind due to the widespread use of SSRIs. This interprofessional approach to SSRI therapy will lead to better patient outcomes with fewer adverse events. Therefore, it is essential to have accurate medication reconciliation by the entire interprofessional team, including clinicians, pharmacists, nursing staff, and other health professionals. They are used to treat numerous conditions and may be used in many settings, not just in primary care or psychiatry. Patients may be on these medications for the long term. SSRIs are currently some of the most commonly prescribed medications. Cyproheptadine has shown some success in several small studies and case reports for patients who do not respond to initial treatment. There is no definitive treatment for serotonin syndrome aside from discontinuing the offending agent, supportive measures, and benzodiazepines for agitation. Serotonin syndrome also has a rapid onset and resolution. In general, serotonin syndrome is distinguishable by taking a thorough history. This is especially important to keep in mind since commonly prescribed psychiatric medications can cause both serotonin syndrome and neuroleptic malignant syndrome. Serotonin syndrome may present similarly to neuroleptic malignant syndrome and malignant hyperthermia. Findings may include agitation, tachycardia, hypertension, hyperthermia, hyperreflexia, tremor, nausea, vomiting, and clonus. Serotonin syndrome is characterized by mental status changes, autonomic dysfunction, and dystonias. It can result from overdosing on SSRIs or from combining multiple medications that increase serotonin levels. Serotonin syndrome is a life-threatening consequence of increased serotonergic activity. Citalopram and escitalopram have an increased risk of cardiotoxicity due to QT prolongation, which can progress to serious arrhythmias such as Torsades. SSRI overdose is relatively infrequent due to their increased safety profile and tolerability compared to other classes of antidepressants. SSRI overdoses are rarely fatal and usually do not have serious consequences. Out of all the SSRIs, citalopram and escitalopram are more likely to cause overdose due to differences in their structures. Fluoxetine and fluvoxamine are inhibitors of CYP2C19. Fluoxetine, paroxetine, sertraline, citalopram, and escitalopram are inhibitors of CYP2D6. SSRIs are metabolized by and have effects on the cytochrome P450 system. Although infrequent, as with all medications that increase serotonin activity, it is important to be aware of the risk of serotonin syndrome, particularly when prescribing multiple medications that may have serotonergic effects. Coagulopathy also correlates with SSRI use. Citalopram has correlations with a longer QT duration than the other medications in this class. SSRIs also have the potential to prolong the QT interval, which can lead to fatal arrhythmia, torsade de pointes. Common side effects from SSRIs include sexual dysfunction, sleep disturbances, weight changes, anxiety, dizziness, xerostomia, headache, and gastrointestinal distress. The risk and benefits of initiating SSRI therapy on acutely suicidal patients must be weighed, keeping in mind that depression itself is a large risk factor for suicidality and requires treatment. In 2004, the FDA issued a black box warning for SSRIs and other antidepressant medications due to a possible increased risk of suicidality among pediatric and young adult (up to age 25) populations. Although relatively safer due to their selectiveness for serotonin, SSRIs are not without risks. Increased tolerability compared to other classes of medications make SSRIs first-line options for their indicated uses. This characteristic leads to fewer complaints of side effects such as xerostomia, sedation, constipation, urinary retention, and cognitive impairments. SSRIs have little or no effect on dopamine, norepinephrine, histamine, or acetylcholine (except for paroxetine). The popularity and widespread use of SSRIs is due in part to their relatively fewer side effects than prior commonly used antidepressants such as TCAs and MAOIs.
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