View Full Version : serotonin syndrome
I'm taking low doses of citalopram (10mg) and mirtazapine (7.5mg). My obgyn has just prescribed tramadol 50mg tid. Pharmacist was reluctant for me to walk off with it and wanted me to speak to my doctor first (have left a message), especially as I've never taken an opioid before. I am in a shit tonne of pain, but am now scared to take it. The pharmacist said it makes no difference that the ADs are at a low dose, the potential is still the same. Not really asking for advice, just wondering if others have been in the same boat. (NSAIDs aren't touching the pain, hence the prescription)
nomorepanic
02-12-19, 23:46
They do need to be careful with tramadol
Doubt you'd get 'serotonin syndrome' but tramadol in conjunction with SSRIs can increase risk of seizures, which is why you have to exercise caution.
See what your GP advises.
Thanks, guys. That doesn't sound like fun. Am going to hold off for now, at least until I speak to the doctor.
You might see some pretty colors, Mel ;)
Is Tramadol XR or the normal stuff? 50mg of normal stuff won't do nothing bad, yous can take but don't expect it to give you pain relief for more than s few hours. You'll get constipation too
You might see some pretty colors, Mel ;)
Ha!Ha!Ha! (Lucy in the Sky with Diamonds)X.:roflmao:
You might see some pretty colors, Mel ;)
Hi Vee :roflmao:
MyNameIsTerry
03-12-19, 02:46
It's a risk just as adding other agents that affect serotogenic drugs is but it's not a do not do as it's left to the doctor to monitor the patient. But the pharmacist is being cautious and considering you haven't mentioned whether your doctor will be monitoring you this is no bad thing as some doctors don't understand interactions in my experience.
Has your doctor told you what to look out for? Are you having a fairly quick follow up appointment? If not, perhaps the pharmacist has concerns over what GP's are doing and being cautious? I've seen GP's at my surgery write a prescription only for the patient to be refused at the pharmacy due to interactions before and I know some GP's at my surgery struggle with the basics of what antidepressants cause in terms of side effect and how to use them properly.
Hi Terry. Different prescribing doctors. My GP did the citalopram and mirtazapine. The gyno did the tramadol. It did come up that I was taking an SSRI, but not in the context of the pain management conversation. It just occurred to me to ask the pharmacist about interactions as I've never taken an opioid before, and was vaguely aware of serotonin syndrome. I thought he'd just say I was on such small doses, it would be fine. I was surprised by his reaction
Hi Mel! :welcome:
So I'm on escitalopram 20 mg daily and I've take vicodin with it, when I had some bad back pain. I'm okay...I think LOL
Good to know. I really thought I was just being my usual overcautious self, but the pharmacist was more worried that I was :unsure:
Hey Melfishy
Is it a young pharmie? This serotonin syndrome is a favourite Doc Google gig but as Panic Ian will tell yous, most real docs never come across it in their life.
I've taken ADs anti-psycho benzos and Tramadol 150mg together and felt pleasantly spaced out
The gig with Tramadol us that you'd got XR and normal gear
One 50mg XR will zap pain all day
The normal stuff one 50mg will work 6 hours tops
It's addictive but if yous take max one week then stop at least 2 days then yous can restart safely but best taken only when pain real bad.
I'm sure your doc wouldn't have given yous if it was dangerous
Thanks, lebonvin, for the tips. That eases my mind a little.
One time my pharmacist freaked out over escitalopram and my taking a cough syrup with dextromin something in it. Called the doc, and she said it was fine. Sure enough I took both together and no problems.
MyNameIsTerry
03-12-19, 07:59
Hi Mel,
My experiences differ as I've found GP's know little more about antidepressants than mt postman does. The pharmacists are the go-to guys.
Also worth remembering that when were hear about SS it's always how it's awful but the reality is it can be mild too. There are many people on here who take meds that could cause it (on multiple antidepressants) but I can't think of more than 2 threads where it ever looked possible and one of those was quite clearly a really stupid GP who hadn't followd prescribing guidelines with any of the meds.
In my opinion it's a bit irresponsible of the gyno if yhey haven't asked you to have your GP monitoring and made you aware of any signs to look out for. So, talking to your GP is not a bad thing anyway as they can provide reassurance via monitoring if needed as they normally do as meds are adjusted anyway.
But I would still look at it as a cautious approach as opposed to a massive no no because they wouldn't have dispensed it knowing they would be liable as the ones that make the final checks. So often you can look on a drugs database and see a major warning but people are commonly on them long term with little monitoring. It's just a flag to the doctor to ensure they agree it's worth it and take any precautionary steps.
Hey Me
The gig with Tramadol is that it does more than just zap pain. It completely zaps anxiety and elevates mood so yous feel real good. That's what makes it hard for some folk to quit. Same with all opioids but Tramadol is about one quarter the strength of oxy and morphine and the real hard stuff so no need to be alarmed.
I actually think your doc done good to give it to yous coz I'm sure many wouldn't
panic_down_under
03-12-19, 11:47
Pharmacist was reluctant for me to walk off with it and wanted me to speak to my doctor first (have left a message), especially as I've never taken an opioid before.
Tramadol is a serotonin reuptake inhibitor so the pharmacist's computer would have flagged the serotonin syndrome potential with citalopram. It could have been a real issue had you been taking a MAOI class AD, but with SRI+SRI combinations dose is the main determinant and serious issues even at typical therapeutic doses are rare. That said, the obgyn probably should have inquired further before prescribing and it's probably prudent to select a non SRI opiate if a serotonergic AD is being taken just on principle.
So I'm on escitalopram 20 mg daily and I've take vicodin with it, when I had some bad back pain.
Not all opiates are risky, at least not in regard to SS. Buprenorphine, codeine, hydrocodone, morphine, oxycodone and pentazocine are not an issue. It's mostly the synthetic opiates dextromethorphan (which is also in some otc cough suppressants though whether the dose is high enough may be debatable), d-propoxyphene, fentanyl, methadone, pethidine (aka meperidine) and tramadol which may be of concern in some cases.
I'm okay...I think LOL
Hmmm. You might say that, Vee, but I couldn't possibly comment! :whistles:
Thanks, Panic. Was hoping you'd chime in. Thing is, it *wasn't* flagged at my pharmacy like it should have been. I asked to speak to a pharmacist and that's when the freakout occurred. I'm trying to manage the pain with NSAIDS, but for about seven days a month even at max dose, they don't touch it. Should I be asking for a different pain med from the gyno, even though I am only on baby doses of the two ADs? I don't think the serotonergic effects even kick in until 30 of 40mg for the mirt. Not sure about 10mg of citalopram, though that's not a therapeutic dose either
Thanks, Panic. Was hoping you'd chime in. Thing is, it *wasn't* flagged at my pharmacy like it should have been. I asked to speak to a pharmacist and that's when the freakout occurred. I'm trying to manage the pain with NSAIDS, but for about seven days a month even at max dose, they don't touch it. Should I be asking for a different pain med from the gyno, even though I am only on baby doses of the two ADs? I don't think the serotonergic effects even kick in until 30 of 40mg for the mirt. Not sure about 10mg of citalopram, though that's not a therapeutic dose either
I doubt there will be a problem with the low dose of Cit you're on - and Mirt is unlikely to be "serotonergic" at ANY dose.
Take the med - cautiously - and deal with the pain issue as you're clearly suffering.
If, however, anything untoward transpires, sue your prescribing doc :D
Thanks, Panic. Was hoping you'd chime in. Thing is, it *wasn't* flagged at my pharmacy like it should have been. I asked to speak to a pharmacist and that's when the freakout occurred.
Yous a nauggty lady for distorting the truth lol
You done a Doc Google n'est-ce pas? Doc Google ain't your friend. Doc Google delight in spreading fear and panic
I done a Doc Google the other day but specific asking if leg pain can be caused by ba CK problem. All I wanted was yes or no answer. Doc Google told me I had degenerate disc disease or sciatica both what made me feel worse. Far better come straight here and ask for experience of the good folk.
Enjoy your Tramadol hit. Expect a bit of constipation the next day. Your on so little of the other gear that a bad reaction is impossible
Charlie
Huh? No, I asked the pharmacist about it, expecting to be reassured. He was the one who freaked and didn't want to give it me
I say if you don't like the tramadol...share ;)
MyNameIsTerry
04-12-19, 05:48
What's the worst that can happen? :winks:
https://media.giphy.com/media/ZNwEBSCs08gx2/giphy.gif
I say if you don't like the tramadol...share ;)
1 for you,1 for me :roflmao:
1 for you,1 for me :roflmao:
Exactly! :yahoo:
And maybe one more for me for coming up with the idea... ;)
One for you
Two for you
One two three for me 👿
We will share evenly.
3 packets each.:yesyes:
I was thinking in terms of crates 😄
panic_down_under
04-12-19, 10:09
I don't think the serotonergic effects even kick in until 30 of 40mg for the mirt.
Mirtazapine serotonin activity is so low even at maximum doses that it is, in the words of one of the two doctors who know most about SS, about as likely to trigger it as a vitamin C tablet is (PDF (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550296/pdf/13181_2010_Article_84.pdf)). Plus, mirtazapine is a serotonin 5-HT2a receptor antagonist (blocker) which can prevent (https://www.ncbi.nlm.nih.gov/pubmed/20655983) the body temperature spike which does the damage in SS although in humans the recommended treatments (http://www.psychotropical.com/treatment-of-serotonin-toxicity) are the more potent 5-HT2a antagonists cyproheptadine and chlorpromazine.
Not sure about 10mg of citalopram, though that's not a therapeutic dose either
While it is more likely to have an effect than mirtazapine, even so you're unlikely to notice anything untoward.
panic_down_under
04-12-19, 10:15
You can all have my share. The only thing I get from opiates is nausea and vomit over my shoes? Worse than sea-sickness. :weep:
MyNameIsTerry
04-12-19, 15:11
You can all have my share. The only thing I get from opiates is nausea and vomit over my shoes? Worse than sea-sickness. :weep:
My mum found the same, Ian. She was given them for back pain not too long ago as the codeine wasnt doing much at the time. She took one and gave them back.
Cannabis used to do that to me. Hated the stuff.
I call dibs on Ian's share! ;)
I call dibs on Ian's share! ;)
Don't be so greedy, Miss Vee :lac:
Crimbo is a time for giving so hand them over for safe keeping :shades:
Oh, imagine that! An agent trying to "mishandle" my goods. Can't say I'm surprised ;) Bureaucracies :lac:
Oh, imagine that! An agent trying to "mishandle" my goods. Can't say I'm surprised ;) Bureaucracies :lac:
Do you mean an agent manhandling your goods...?
Utter depravity I say! :lac:
MyNameIsTerry
05-12-19, 02:05
Don't be so greedy, Miss Vee :lac:
Crimbo is a time for giving so hand them over for safe keeping :shades:
Exactly! Customs won't be checking inside any Christmas turkeys being sent over https://yoursmiles.org/msmile/animal/m0224.gif (https://yoursmiles.org/m-animal.php?page=2):yesyes:
You know, KK has "manhandled" a lot of my stuff... I think he has a thing for Jewish girls ;)
Terry says one should not discriminate and manhandle ANY girl, given the opportunity :wacko:
I'm still not sure about him advising on such matters :shrug:
MyNameIsTerry
05-12-19, 02:32
Absolutely! I'm all for equality :roflmao:
Is "manhandling" what some blokes can't resist doing in the trouser dept when they are "manspreading"? :ohmy::blush:
Absolutely! I'm all for equality :roflmao:
Is "manhandling" what some blokes can't resist doing in the trouser dept when they are "manspreading"? :ohmy::blush:
Or when they're "mansplaining" I believe :D
Now I see where KK gets his bad influence from...Terry. Terry tried to put his matzoh balls in my knish ;)
MyNameIsTerry
05-12-19, 02:49
I didn't even know what a knish was until Vee showed me :whistles:
It's funny that we men have the term mansplaining. I think it must come from the fact women tend to be 'splaining all the time to us so it's too common to count whereas we deserve some special acknowledgement when we come up with a point! Like the little boy running in to tell his mother he's just done something cool to get a pat on the head :yesyes:
And the first thing you asked me was if you could put matzoh balls in it, Terry ;)
I think it's funny that a bunch of annoying things start with "men"... menstruation, menstrual cycle, mental, menopause, menace, meningitis...
Mirtazapine serotonin activity is so low even at maximum doses that it is, in the words of one of the two doctors who know most about SS, about as likely to trigger it as a vitamin C tablet is (PDF (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3550296/pdf/13181_2010_Article_84.pdf)). Plus, mirtazapine is a serotonin 5-HT2a receptor antagonist (blocker) which can prevent (https://www.ncbi.nlm.nih.gov/pubmed/20655983) the body temperature spike which does the damage in SS although in humans the recommended treatments (http://www.psychotropical.com/treatment-of-serotonin-toxicity) are the more potent 5-HT2a antagonists cyproheptadine and chlorpromazine.
While it is more likely to have an effect than mirtazapine, even so you're unlikely to notice anything untoward.
Thanks, Ian! My gyno said just take it and watch out for a fever or diarrhea etc :shrug: I'm only going to take it when the pain hits a 10 (and it does, apparently it's comparable to labour pains)
panic_down_under
06-12-19, 22:09
My gyno said just take it and watch out for a fever or diarrhea etc :shrug:
Diarrhoea isn't a reliable indicator of serotonin syndrome as it is a common AD side-effect. Fever can be as the danger of SS is a large spike in temperature, but other symptoms usually occur earlier. The Hunter Serotonin Toxicity Criteria (PDF (https://www.semanticscholar.org/paper/The-Hunter-Serotonin-Toxicity-Criteria%3A-simple-and-Dunkley-Isbister/f7dc4ab4a707581395716cfa64b595be5961f700)) requires at least 3 of the following to be present: Mental status changes (confusion, hypomania), Agitation, Myoclonus, Hyper reflexia, Diaphoresis, Shivering, Tremor, Diarrhoea, Uncoordination and Fever.
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