Fast Five Quiz: Serotonin Syndrome

Richard H. Sinert, DO


June 04, 2021

When serotonin toxicity is suspected, the most important initial step is to remove the offending agent. The best-known serotoninergic agents are antidepressants, as follows:

  • Monoamine oxidase (MAO) inhibitors, such as MAO-A inhibitors (isocarboxazid, phenelzine, tranylcypromine) or MAO-B inhibitors (rasagiline, safinamide, selegiline)

  • Tricyclic antidepressants, such as amitriptyline, amoxapine, clomipramine, cyclobenzaprine, desipramine, doxepin, imipramine, nortriptyline, protriptyline, and trimipramine

  • SSRIs, such as citalopram, escitalopram, fluoxetine, paroxetine, fluvoxamine, sertraline, and vortioxetine

  • Serotonin-norepinephrine reuptake inhibitors, such as desvenlafaxine, duloxetine, levomilnacipran, milnacipran, venlafaxine

  • Bupropion

Many other pharmaceuticals are potential offending agents, including:

  • Opioids, such as fentanyl, meperidine, oxycodone, hydrocodone, and tramadol

  • 5-hydroxytryptamine (5-HT) (ie, serotonin) antagonists, such as ondansetron, granisetron, dolasetron, and palonosetron

  • Triptans, such as sumatriptan, eletriptan, frovatriptan, and rizatriptan

  • Stimulants, such as amphetamine, dexmethylphenidate, dextroamphetamine, diethylpropion, lisdexamfetamine, and methylphenidate

  • Metoclopramide

  • Trazodone

  • Mirtazapine

  • Methylene blue

  • Linezolid

Antipsychotics (eg, olanzapine, risperidone, and quetiapine) and antibiotics (eg, linezolid) are also often implicated. In addition, recreational drugs (eg, 3,4-methylenedioxy-methamphetamine [MDMA; ecstasy], bath salts) and over-the-counter drugs (eg, St John's wort) have been associated with serotonin syndrome. Patients taking high doses of a serotoninergic drug are particularly vulnerable.

Read more about drugs involved with serotonin syndrome.


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