THE SEROTONIN SYNDROME-ASSOCIATED WITH PAROXETINE, AN OVER-THE-COUNTER COLD REMEDY, AND VASCULAR-DISEASE

There is a new, potentially fatal disorder that is infrequently report ed. The apparent rareness may be because of a lack of recognition of t he syndrome or its predisposing factors. Fluoxetine (Prozac, Dista Pro ducts Co, Division of Eli Lilly Co, Indianapolis, IN), sertraline (Zol oft, Roerig Division, Pfizer Inc, New York, NY), and paroxetine (Paxil , SmithKline Beecham Pharmaceuticals, Philadelphia, PA) belong to a ne w class of antidepressant medication: the serotonin reuptake-inhibitor s (SRIs). The relative safety profile of the SRIs has led to their wid espread use. However, a syndrome of excessive serotonergic activity, t he ''serotonin syndrome'' (SS), has recently been recognized. It is ch aracterized by changes in mental status, hypertension, restlessness, m yoclonus, hyperreflexia, diaphoresis, shivering, and tremor. A high in dex of suspicion is required to make the diagnosis in these acutely il l patients. The most common agents implicated in SS are the monoamine oxidase inhibitors in combination with L-tryptophan or fluoxetine. A c ase of a patient with significant peripheral vascular disease who deve loped SS while taking paroxetine and an over-the-counter cold medicine is reported. There have been no prior reports of this interaction. Di scontinuation of the offending agents, sedation, and supportive care a re the mainstays of treatment. The interactions of serotonin with plat elets and vascular endothelium are also discussed.