1
|
Prakash S, Shah CS, Prakash A. Serotonin syndrome controversies: A need for consensus. World J Crit Care Med 2024; 13:94707. [DOI: 10.5492/wjccm.v13.i2.94707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/26/2024] [Accepted: 05/11/2024] [Indexed: 06/03/2024] Open
Abstract
Serotonin syndrome (SS) is a drug-induced clinical syndrome resulting from increased serotonergic activity in the central nervous system. Although more than seven decades have passed since the first description of SS, it is still an enigma in terms of terminology, clinical features, etiology, pathophysiology, diagnostic criteria, and therapeutic measures. The majority of SS cases have previously been reported by toxicology or psychiatry centers, particularly in people with mental illness. However, serotonergic medications are used for a variety of conditions other than mental illness. Serotonergic properties have been discovered in several new drugs, including over-the-counter medications. These days, cases are reported in non-toxicology centers, such as perioperative settings, neurology clinics, cardiology settings, gynecology settings, and pediatric clinics. Overdoses or poisonings of serotonergic agents constituted the majority of the cases observed in toxicology or psychiatry centers. Overdose or poisoning of serotonergic drugs is uncommon in other clinical settings. Patients may develop SS at therapeutic dosages. Moreover, these patients may continue to use serotonergic medications even if they develop mild to moderate SS due to several reasons. Thus, the clinical presentation (onset, severity, and clinical features) in such instances may not exactly match what toxicologists or psychiatrists observe in their respective settings. They produce considerable diversity in many aspects of SS. However, other experts discount these new developments in SS. Since SS is a potentially lethal illness, consensus is required on several concerns related to SS.
Collapse
Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara 391760, Gujarāt, India
| | - Chetsi S Shah
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara 391760, Gujarāt, India
| | - Anurag Prakash
- Medicine, Parul Institute of Medical Sciences and Research Centre, Parul University Waghodia, Vadodara 391760, India
| |
Collapse
|
2
|
Huang J, Edrees H, Lee G. A Case Series on Serotonin Syndrome from Concomitant use of linezolid With Methadone, Buprenorphine, and/or Dextroamphetamine. J Pharm Pract 2024; 37:780-785. [PMID: 37295073 DOI: 10.1177/08971900231182772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Background and Objectives: The risk of serotonin syndrome (SS), especially when linezolid is used concomitantly with methadone, buprenorphine, and/or dextroamphetamine, remains widely unstudied and may limit the options for antimicrobial therapy in these patient populations. Methods: We reviewed all adult encounters on linezolid with concomitant methadone, buprenorphine, and/or dextroamphetamine from April 2016 to June 2022. The primary outcomes included characterizing prescribing preferences and prevalence of confirmed and possible serotonin syndrome using ICD-10 diagnosis codes, cyproheptadine administration, and electronic medical record chart review using the Hunter Serotonin Toxicity Criteria. Results: Overall, 194 encounters were evaluated. 16.5%, 17.8%, and 7.1% were on high dose methadone, buprenorphine, and dextroamphetamine, respectively. Mean duration of overlap with linezolid was 4.6, 3.3, and 7 days respectively. One confirmed and two possible cases of serotonin syndrome were identified. Conclusion: Linezolid may be considered in patients who are concomitantly on methadone, buprenorphine, and/or dextroamphetamine. In our analysis of 194 encounters, one definitive case and two possible cases of SS were identified. Additional real-world studies are necessary to identify if exposure and/or duration may be correlated with an increased risk of serotonin syndrome.
Collapse
Affiliation(s)
- Joanne Huang
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
- Department of Pharmacy, UW Medicine, Valley Medical Center, Renton, WA, USA
| | - Heba Edrees
- Division of General and Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Grace Lee
- Department of Pharmacy, UW Medicine, Seattle, WA, USA
| |
Collapse
|
3
|
Burch R. Acute Treatment of Migraine. Continuum (Minneap Minn) 2024; 30:344-363. [PMID: 38568487 DOI: 10.1212/con.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE Most patients with migraine require acute treatment for at least some attacks. This article reviews the approach to the acute treatment of migraine, migraine-specific and nonspecific treatment options, rescue treatment and options for management in the emergency department and inpatient settings, and treatment during pregnancy and lactation. LATEST DEVELOPMENTS Triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs have historically been the main acute treatments for migraine. The development of new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), expands available options. These new treatments have not been associated with vasospasm or increased cardiovascular risk, therefore allowing migraine-specific acute treatment for the more than 20% of adults with migraine who are at increased risk of cardiovascular events. Neuromodulation offers a nonpharmacologic option for acute treatment, with the strongest evidence for remote electrical neuromodulation. ESSENTIAL POINTS The number of available migraine treatments continues to expand, although triptans are still the mainstay of migraine-specific acute treatment. There is no one-size-fits-all acute treatment and multiple treatment trials are sometimes necessary to determine the optimal regimen for patients. Switching within and between classes, using the maximum allowed dose, using combination therapy, and counseling patients to treat early are all strategies that may improve patient response to acute treatment.
Collapse
|
4
|
Mansuri Z, Adnan M, Shah B, Trivedi C, Vadukapuram R, Patel S, Yadav G, Srinivas S, Ansari M, Makani R, Baweja R, Reddy A. Serotonin Syndrome With the Concomitant Use of Triptans and SSRIs/Serotonergic Medications: Is It Time to Revisit FDA Warning? J Clin Psychopharmacol 2024; 44:199-200. [PMID: 38227629 DOI: 10.1097/jcp.0000000000001812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
|
5
|
Hervik JA, Vika KS, Stub T. Transcranial direct current stimulation for chronic headaches, a randomized, controlled trial. FRONTIERS IN PAIN RESEARCH 2024; 5:1353987. [PMID: 38476353 PMCID: PMC10927820 DOI: 10.3389/fpain.2024.1353987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/15/2024] [Indexed: 03/14/2024] Open
Abstract
Background and objectives Chronic headaches are a frequent cause of pain and disability. The purpose of this randomized trial was to examine whether transcranial direct current stimulation (tDCS) applied to the primary motor cortex, reduces pain and increases daily function in individuals suffering from primary chronic headache. Materials and methods A prospective, randomized, controlled trial, where participants and assessors were blinded, investigated the effect of active tDCS vs. sham tDCS in chronic headache sufferers. Forty subjects between 18 and 70 years of age, with a diagnosis of primary chronic headache were randomized to either active tDCS or sham tDCS treatment groups. All patients received eight treatments over four consecutive weeks. Anodal stimulation (2 mA) directed at the primary motor cortex (M1), was applied for 30 min in the active tDCS group. Participants in the sham tDCS group received 30 s of M1 stimulation at the start and end of the 30-minute procedure; for the remaining 29 min, they did not receive any stimulation. Outcome measures based on data collected at baseline, after eight treatments and three months later included changes in daily function, pain levels, and medication. Results Significant improvements in both daily function and pain levels were observed in participants treated with active tDCS, compared to sham tDCS. Effects lasted up to 12 weeks post-treatment. Medication use remained unchanged in both groups throughout the trial with no serious adverse effects reported. Conclusion These results suggest that tDCS has the potential to improve daily function and reduce pain in patients suffering from chronic headaches. Larger randomized, controlled trials are needed to confirm these findings. Trial registration The study was approved by the local ethics committee (2018/2514) and by the Norwegian Centre for Research Data (54483).
Collapse
Affiliation(s)
- Jill Angela Hervik
- Department of Anaesthesiology, Vestfold Hospital Trust, Tonsberg, Norway
| | - Karl Solbue Vika
- Department of School and Nursery, NIFU Nordic Institute for Studies in Innovation, Research and Education, Oslo, Norway
| | - Trine Stub
- Department of Community Medicine, National Research Center in Complementary and Alternative Medicine, NAFKAM, UiT The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
6
|
Elashmony SM, Sheikh BW, Brashi RA, Almalki Z, Alharthi A, Alghuraybi S, Bakhshwaen S, Alsharif MH. Knowledge, Attitude, and Practice of Saudi Medical, Nursing, and Pharmacy Students and Interns Regarding Antidepressant Drugs and Drug-Induced Serotonin Syndrome. Cureus 2023; 15:e51335. [PMID: 38161564 PMCID: PMC10757576 DOI: 10.7759/cureus.51335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 01/03/2024] Open
Abstract
Background and aim Antidepressant drugs are commonly used to treat depressive disorders and anxiety. However, they can cause side effects, including drug-induced serotonin syndrome, which is a potentially life-threatening condition. It is essential to understand the level of knowledge of healthcare professionals who are likely to prescribe and administer these medications. This article aims to assess the knowledge of Saudi medical, nursing, and pharmacy students and interns regarding antidepressant drugs and drug-induced serotonin syndrome. Methods A cross-sectional survey was conducted among medical, nursing, and pharmacy students and interns in Saudi Arabia. A self-administered questionnaire was used to collect data from participants. The questionnaire consisted of three sections: demographic information, knowledge about antidepressants, and knowledge about serotonin syndrome. Results A total of 425 participants were included in the study. The median knowledge score for antidepressants and serotonin syndrome was moderate to good, with median scores of 18 out of 23 (IQR: 16-20) and eight out of 12 (IQR: 6-10), respectively. However, more than half of the participants had sufficient knowledge about these topics, with only 227 (53.4%) and 264 (62.1%) having sufficient knowledge about antidepressants and serotonin syndrome, respectively. Regarding serotonin syndrome, males had a significantly higher proportion of sufficient knowledge compared to females, 86 (70.5%) out of 122 vs. 178 (58.7%) out of 303 (p=0.024), respectively. Medical students/interns had a significantly higher proportion of sufficient knowledge about antidepressants compared to nursing students/interns. According to the academic year, interns had the highest proportion of sufficient knowledge. Conclusion The current study revealed that Saudi medical, nursing, and pharmacy students and interns had moderate to good levels of knowledge about antidepressants and serotonin syndrome. The participating students had slightly better knowledge about serotonin syndrome in comparison to knowledge about antidepressants. Further research is needed to identify the causes of the knowledge gap and develop targeted interventions to address these causes. Educational efforts to ensure the safe and effective use of antidepressants are needed.
Collapse
Affiliation(s)
- Sahar M Elashmony
- Pharmacology and Toxicology, Umm Al-Qura University, College of Medicine, Al-Qunfudah, SAU
- Medical Pharmacology Department, Cairo University, College of Medicine, Cairo, EGY
| | | | - Rafal A Brashi
- College of Pharmacy, Umm Al-Qura University, Makkah, SAU
| | - Ziyad Almalki
- College of Medicine, King Abdulaziz University, Faculty of Medicine, Rabigh, SAU
| | | | | | - Saja Bakhshwaen
- College of Medicine and Surgery, Batterjee Medical College, Jeddah, SAU
| | | |
Collapse
|
7
|
Cortel-LeBlanc MA, Orr SL, Dunn M, James D, Cortel-LeBlanc A. Managing and Preventing Migraine in the Emergency Department: A Review. Ann Emerg Med 2023; 82:732-751. [PMID: 37436346 DOI: 10.1016/j.annemergmed.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/13/2023]
Abstract
Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.
Collapse
Affiliation(s)
- Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada.
| | - Serena L Orr
- Departments of Pediatrics, Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Maeghan Dunn
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Daniel James
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada; 360 Concussion Care, Ottawa, ON, Canada; Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, ON, Canada
| |
Collapse
|
8
|
Wu J, Yu J, Qu K, Yin J, Zhu C, Liu X. Serotonin syndrome caused by a CYP2C19-mediated interaction between low-dose escitalopram and clopidogrel: a case report. Front Psychiatry 2023; 14:1257984. [PMID: 37886119 PMCID: PMC10598681 DOI: 10.3389/fpsyt.2023.1257984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/14/2023] [Indexed: 10/28/2023] Open
Abstract
Background Serotonin syndrome has been recognized as a serious adverse reaction to antidepressants and is characterized by sudden or severe autonomic nerve dysfunction and neuromuscular symptoms. Without an accurate diagnosis and prompt treatment, serotonin syndrome progresses rapidly and can be life-threatening. It is usually related to the dose of 5-hydroxytryptamine drugs, and the dose is the basis for diagnosis. Therefore, serotonin syndrome induced by low-dose antidepressants rarely occurs, and clinicians are more likely to misdiagnose patients who take low-dose antidepressants with similar symptoms. Here, we present a case study of serotonin syndrome caused by a relatively low dose of escitalopram, which is not common in past references. Case summary The patient was a 74-year-old Asian woman with a 42-year history of schizophrenia. After 6 weeks of antidepressant treatment, our patient presented with characteristic myoclonus in the lower limbs and closed eyes with fluttering. Initially, she was misdiagnosed with neuroleptic malignant syndrome (NMS) due to antipsychotic medication and was treated accordingly, even with discontinuation of clozapine. However, her symptoms persisted, and then therapeutic drug monitoring was initiated with the involvement of a clinical pharmacist. Eventually, she was diagnosed with serotonin syndrome due to escitalopram levels reaching the warning level. Subsequently, the patient's treatment was modified, and her clinical outcome was satisfactory without any other serious adverse reactions. Gene detection was also performed, and a cytochrome P450 enzyme (CYP) 2C19-mediated interaction between low-dose escitalopram and clopidogrel seems to be a possible mechanism. Conclusion Data on this is extremely scarce, and to the best of our knowledge, serotonin syndrome caused by low-dose antidepressants has not yet been discussed to any great extent in the literature. Our case provides more clinical experience in the treatment of serotonin syndrome.
Collapse
Affiliation(s)
- Jianhong Wu
- The Affiliated Mental Health Center, Jiangnan University, Wuxi, China
- Wuxi Central Rehabilitation Hospital, Wuxi, Jiangsu, China
| | - Jiao Yu
- The Affiliated Mental Health Center, Jiangnan University, Wuxi, China
- Wuxi Central Rehabilitation Hospital, Wuxi, Jiangsu, China
| | - Kankan Qu
- The Affiliated Mental Health Center, Jiangnan University, Wuxi, China
- Wuxi Central Rehabilitation Hospital, Wuxi, Jiangsu, China
| | - Jiajun Yin
- The Affiliated Mental Health Center, Jiangnan University, Wuxi, China
- Wuxi Central Rehabilitation Hospital, Wuxi, Jiangsu, China
| | - Chunming Zhu
- The Affiliated Mental Health Center, Jiangnan University, Wuxi, China
- Wuxi Central Rehabilitation Hospital, Wuxi, Jiangsu, China
| | - Xiaowei Liu
- The Affiliated Mental Health Center, Jiangnan University, Wuxi, China
- Wuxi Central Rehabilitation Hospital, Wuxi, Jiangsu, China
| |
Collapse
|
9
|
George A, Minen MT. Episodic Migraine and Psychiatric Comorbidity: A Narrative Review of the Literature. Curr Pain Headache Rep 2023; 27:461-469. [PMID: 37382869 DOI: 10.1007/s11916-023-01123-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE OF REVIEW We evaluate the evolving evidence of psychiatric comorbidities associated with episodic migraine. Utilizing recent research publications, we aim to assess traditional treatment option considerations and discuss recent and evolving non-pharmacologic treatment progress for episodic migraine and related psychiatric conditions. RECENT FINDINGS Recent findings indicate that episodic migraine is strongly linked to comorbid depression, anxiety, posttraumatic stress disorder, and sleep disorders. Not only do patients with episodic migraine have higher rates of psychiatric comorbidity, but a higher number of headache days reported is also strongly linked to an increased risk of developing a psychiatric disorder, indicating there may be a link between frequency and psychiatric comorbidity and that patients with high-frequency episodic migraine should be assessed for psychiatric comorbidity. Few migraine preventive medications have examined the effect of the medication on both migraine and psychiatric comorbidity though we discuss what has been reported in the literature. Non-pharmacologic-based treatments including behavioral therapies and mind-body interventions previously developed for psychiatric conditions, e.g., mindfulness-based CBT (MBCT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) therapy, have promising results for patients diagnosed with episodic migraine and may therefore be useful in treating migraine and comorbid psychiatric conditions. Psychiatric comorbidity may affect the efficacy of the treatment of episodic migraine. Thus, we must assess for psychiatric comorbidities to inform better treatment plans for patients. Providing patients with episodic migraine with alternate modalities of treatment may help to improve patient-centered care and increase patients' sense of self-efficacy.
Collapse
Affiliation(s)
- Alexis George
- Department of Neurology, NYU Langone Health, 222 East 41st Street, New York, NY, 10017, USA
| | - Mia T Minen
- Department of Neurology, NYU Langone Health, 222 East 41st Street, New York, NY, 10017, USA.
| |
Collapse
|
10
|
Peng KP, Burish MJ. Management of cluster headache: Treatments and their mechanisms. Cephalalgia 2023; 43:3331024231196808. [PMID: 37652457 DOI: 10.1177/03331024231196808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND The management of cluster headache is similar to that of other primary headache disorders and can be broadly divided into acute and preventive treatments. Acute treatments for cluster headache are primarily delivered via rapid, non-oral routes (such as inhalation, nasal, or subcutaneous) while preventives include a variety of unrelated treatments such as corticosteroids, verapamil, and galcanezumab. Neuromodulation is becoming an increasingly popular option, both non-invasively such as vagus nerve stimulation when medical treatment is contraindicated or side effects are intolerable, and invasively such as occipital nerve stimulation when medical treatment is ineffective. Clinically, this collection of treatment types provides a range of options for the informed clinician. Scientifically, this collection provides important insights into disease mechanisms. METHODS Two authors performed independent narrative reviews of the literature on guideline recommendations, clinical trials, real-world data, and mechanistic studies. RESULTS Cluster headache is treated with acute treatments, bridge treatments, and preventive treatments. Common first-line treatments include subcutaneous sumatriptan and high-flow oxygen as acute treatments, corticosteroids (oral or suboccipital injections) as bridge treatments, and verapamil as a preventive treatment. Some newer acute (non-invasive vagus nerve stimulation) and preventive (galcanezumab) treatments have excellent clinical trial data for episodic cluster headache, while other newer treatments (occipital nerve stimulation) have been specifically tested in treatment-refractory chronic cluster headache. Most treatments are suspected to act on the trigeminovascular system, the autonomic system, or the hypothalamus. CONCLUSIONS The first-line treatments have not changed in recent years, but new treatments have provided additional options for patients.
Collapse
Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark J Burish
- Department of Neurosurgery, UTHealth Houston, Houston, Texas, USA
| |
Collapse
|
11
|
Pelzer N, de Boer I, van den Maagdenberg AMJM, Terwindt GM. Neurological and psychiatric comorbidities of migraine: Concepts and future perspectives. Cephalalgia 2023; 43:3331024231180564. [PMID: 37293935 DOI: 10.1177/03331024231180564] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND This narrative review aims to discuss several common neurological and psychiatric disorders that show comorbidity with migraine. Not only can we gain pathophysiological insights by studying these disorders, comorbidities also have important implications for treating migraine patients in clinical practice. METHODS A literature search on PubMed and Embase was conducted with the keywords "comorbidity", "migraine disorders", "migraine with aura", "migraine without aura", "depression", "depressive disorders", "epilepsy", "stroke", "patent foramen ovale", "sleep wake disorders", "restless legs syndrome", "genetics", "therapeutics". RESULTS Several common neurological and psychiatric disorders show comorbidity with migraine. Major depression and migraine show bidirectional causality and have shared genetic factors. Dysregulation of both hypothalamic and thalamic pathways have been implicated as a possibly cause. The increased risk of ischaemic stroke in migraine likely involves spreading depolarizations. Epilepsy is not only bidirectionally related to migraine, but is also co-occurring in monogenic migraine syndromes. Neuronal hyperexcitability is an important overlapping mechanism between these conditions. Hypothalamic dysfunction is suggested as the underlying mechanism for comorbidity between sleep disorders and migraine and might explain altered circadian timing in migraine. CONCLUSION These comorbid conditions in migraine with distinct pathophysiological mechanisms have important implications for best treatment choices and may provide clues for future approaches.
Collapse
Affiliation(s)
- Nadine Pelzer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arn M J M van den Maagdenberg
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
12
|
Begasse de Dhaem O, Takizawa T, Dodick DW. Long-term open-label and real-world studies of lasmiditan, ubrogepant, and rimegepant for the acute treatment of migraine attacks. Cephalalgia 2023; 43:3331024221137092. [PMID: 36739505 DOI: 10.1177/03331024221137092] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Long-term data helps assess the consistency of efficacy, tolerability, and safety of acute treatment over repeated use for different attacks. Real-world studies help assess tolerability, safety, and efficacy in patients with possibly refractory chronic migraine, more comorbidities, other diseases such as cardiovascular diseases, and polypharmacy. METHODS This is a narrative review of the long-term open-label and real-world studies of lasmiditan, ubrogepant, and rimegepant for the acute treatment of migraine. Both manuscripts and abstracts were reviewed. RESULTS The efficacy and tolerability of lasmiditan, ubrogepant, and rimegepant are maintained over time. No significant cardiovascular adverse events were thought to be related to any of these medications. The rare instances of palpitations and/or tachycardia occurred within 48 hours of lasmiditan. One participant with a history of supraventricular tachycardia had sinus tachycardia thought to be related to ubrogepant which did not recur despite continued use. One case of thrombocytopenia and two cases of increased aspartate aminotransferase and alanine transaminase were thought to be possibly related, but the alanine transaminase and aspartate aminotransferase levels normalized despite continued use of ubrogepant. A case of first-degree atrioventricular block was considered possibly related to rimegepant. Acute use of rimegepant was associated with a decrease in monthly migraine days over time. The three medications were associated with improvement in function and/or productivity. CONCLUSION Long-term and real-world data of tolerability, safety and efficacy of lasmiditan, ubrogepant, and rimegepant is thus far consistent with prior studies, but more longitudinal data that clarifies long-term safety as well as consistency and predictors of response is needed.
Collapse
Affiliation(s)
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Phoenix, AZ, USA.,Atria Institute, New York, NY, USA
| |
Collapse
|
13
|
Hyeraci G, Gini R, Bezin J, Iannone LF, Benemei S, Lupi C, De Cesaris F, Geppetti P, Roberto G. Utilization patterns, cardiovascular risk, and concomitant serotoninergic medications among triptan users between 2008 and 2018: A gender analysis in one Italian region, Tuscany. Headache 2023; 63:222-232. [PMID: 36705316 DOI: 10.1111/head.14463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe the pattern of triptan use by gender in Tuscany, Italy, focusing on special user populations in which evidence on triptan safety is still not conclusive. BACKGROUND Growing evidence supports the role of gender differences in migraine pathophysiology and treatment. However, gender impact on triptan real-word utilization has been poorly investigated. METHODS A retrospective, descriptive, cohort study was performed using the population-based Administrative Healthcare Database of Tuscany region (Italy). Subjects registered in the database on the January 1 of each year between 2008 and 2018 were identified. New users (NU) of triptans (ATC:N02CC*) were patients with one or more triptan dispensation during the year of interest and none in the past. Age, cardiovascular comorbidities representing an absolute or a possible contraindication to triptan utilization, concomitant serotonergic medications, and pattern of triptan use during 1-year follow-up were described by gender. RESULTS A total of 86,109 patients who received one or more triptan dispensing were identified. Of 64,672 NU (men = 17,039; women = 47,633), 10.2% (6823/64,672) were aged >65 years, who were mostly women (n = 4613). Among NU, men and women with absolute cardiovascular contraindications were 4.3% (740/17,039) and 2.1% (1022/47,633), respectively, while those concomitantly taking serotonergic medications were 17.2% (267/1549) and 21.9% (949/4330), respectively (949/4330). Regular users (two or more dispensing with ≥3 months between first and last observed dispensing) accounted for 26.4% of women (12,597/47,633) and 19.11% of men (3250/17,039); frequent users (≥15 dosage units/month during ≥3 consecutive months) were overall 0.1% (94/64,672) and 62.0% (58/94) of them concomitantly received serotonergic medications. CONCLUSION Considering gender differences in triptan use highlighted here, large scale observational studies are warranted to better define what populations are safe to use triptans and whether it is appropriate to tighten or relax certain recommendations on triptan use. In the meantime, any suspected adverse drug reaction observed in the special user populations highlighted in this study should be promptly reported.
Collapse
Affiliation(s)
- Giulia Hyeraci
- Agenzia regionale di sanità della Toscana (ARS), Florence, Italy
| | - Rosa Gini
- Agenzia regionale di sanità della Toscana (ARS), Florence, Italy
| | - Julien Bezin
- Clinical Pharmacology Unit, Univ. Bordeaux, INSERM, BPH, Team Pharmacoepidemiology, U1219, CHU de Bordeaux, Bordeaux, France
| | - Luigi Francesco Iannone
- Headache Centre, Careggi University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | - Silvia Benemei
- Headache Centre, Careggi University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | - Chiara Lupi
- Area Vasta Centro Ethics Committee Secretariat - Clinical Trial Unit for Phase 1 Trials, Careggi University Hospital, Florence, Italy
| | - Francesco De Cesaris
- Headache Centre, Careggi University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | - Pierangelo Geppetti
- Headache Centre, Careggi University Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | - Giuseppe Roberto
- Agenzia regionale di sanità della Toscana (ARS), Florence, Italy
| |
Collapse
|
14
|
Abstract
Migraine affects about 1 billion people worldwide, and up to 15% of adults in the United States have migraine attacks in any given year. Migraine is associated with substantial adverse socioeconomic and personal effects. It is the second leading cause of years lived with disability worldwide for all ages and the leading cause in women aged 15 to 49 years. Diagnostic uncertainty increases the likelihood of unnecessary investigations and suboptimal management. This article advises clinicians about diagnosing migraine, ruling out secondary headache disorders, developing acute and preventive treatment plans, and deciding when to refer the patient to a specialist.
Collapse
|
15
|
Holdridge A, Buczyner J, Aymat CC, Le A. Prevention of Migraine. Semin Neurol 2022; 42:558-570. [PMID: 36513096 DOI: 10.1055/s-0042-1758781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Migraine, a primary headache disorder is a chronic and complex neurological disease that affects millions of people worldwide, impacting their quality of life. It is one of the most common reasons why individuals seek the advice of their physician, and is one of the most common referrals seen in the offices of general neurologists and headache specialists. In the past decade, there has been robust research on not only the pathophysiology of migraine but in the efforts to treat and, importantly, prevent. The introduction of calcitonin gene related peptide antagonists (CGRP-A) have opened new doors for preventive treatment options. OnabotulinumtoxinA (BoNTA) has remained a staple in the treatment of chronic migraine with data emerging with combination therapy. Neurostimulation has offered additional nonpharmacologic approaches to migraine treatment. In addition to lifestyle and behavioral modifications, these have changed the landscape of migraine prevention.
Collapse
Affiliation(s)
- Ashley Holdridge
- Department of Neurology and Headache, Advocate Aurora HealthCare, Whitefish Bay, Wisconsin
| | - Jennifer Buczyner
- Department of Neurology, First Choice Neurology, Palm Beach Gardens, Florida
| | - Cristina Cabret Aymat
- Department of Neurology and Headache, Ochsner Health Center - Covington, Covington, Louisiana
| | - Ariel Le
- Department of Neurology, First Choice Neurology, Palm Beach Gardens, Florida
| |
Collapse
|
16
|
Spadaro A, Scott KR, Koyfman A, Long B. High risk and low prevalence diseases: Serotonin syndrome. Am J Emerg Med 2022; 61:90-97. [PMID: 36057215 DOI: 10.1016/j.ajem.2022.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/10/2022] [Accepted: 08/14/2022] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Serotonin syndrome is a rare, frequently misdiagnosed, serious condition with high morbidity. OBJECTIVE This review highlights the pearls and pitfalls of serotonin syndrome, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence. DISCUSSION Serotonin syndrome is a potentially deadly toxidrome marked by excess serotonin receptor activity or neurotransmission. Features of serotonin syndrome include 1) neuromuscular excitation such as tremor, hyperreflexia, and clonus; 2) autonomic dysfunction such as tachycardia, hypertension/hypotension, and hyperthermia; and 3) altered mental status such as agitation, delirium, and coma. Although serotonin syndrome may be more obvious in patients who have overdosed on serotonergic agents such as serotonin reuptake inhibitors (SSRIs), multiple other medications may also cause serotonin syndrome. Alternative diagnoses such as sepsis, neuroleptic malignant syndrome, and decompensated hyperthyroidism should be considered. The primary components of therapy include stopping the offending agent and supportive care, which focuses on agitation control, monitoring for and treating hyperthermia, and managing autonomic instability. CONCLUSIONS An understanding of serotonin syndrome can assist emergency clinicians in diagnosing and managing this disease.
Collapse
Affiliation(s)
- Anthony Spadaro
- Department of Emergency Medicine, University of Pennsylvania Health System, Philadelphia, PA, United States.
| | - Kevin R Scott
- Department of Emergency Medicine, University of Pennsylvania Health System, Philadelphia, PA, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| |
Collapse
|
17
|
Asif N, Patel A, Vedantam D, Poman DS, Motwani L. Migraine With Comorbid Depression: Pathogenesis, Clinical Implications, and Treatment. Cureus 2022; 14:e25998. [PMID: 35865445 PMCID: PMC9290761 DOI: 10.7759/cureus.25998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/05/2022] Open
|
18
|
Orlova YY, Mehla S, Chua AL. Drug Safety in Episodic Migraine Management in Adults Part 1: Acute Treatments. Curr Pain Headache Rep 2022; 26:481-492. [PMID: 35536501 DOI: 10.1007/s11916-022-01057-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to aid in choosing safe options when assessing potential risks of acute migraine treatments based on known mechanisms of action and anticipated safety concerns. RECENT FINDINGS Part 1 highlights safety issues associated with commonly used medications to treat acute migraine attacks. Strategies to mitigate cardiovascular and gastrointestinal risks of nonsteroidal anti-inflammatory drugs, evaluation of cardiovascular risks of triptan and ergot alkaloids, and precautions with use of antiemetics and the novel drugs gepants and ditans are discussed to help practitioners in clinical decision-making. When available, we included recommendations from professional societies and data from pharmacovigilance systems. While guidelines on efficacy are available, one must also consider the possible risks and adverse effects of a drug when creating treatment plans.
Collapse
Affiliation(s)
- Yulia Y Orlova
- University of Florida, 1149 Newell Dr., L3-100, Gainesville, 32611, USA.
| | - Sandhya Mehla
- Ayer Neurosciences Institute, Hartford Health Care Medical Group, University of Connecticut School of Medicine, Norwich, CT, USA
| | - Abigail L Chua
- Geisinger Health Systems, 1000 E. Mountain Boulevard, Wilkes-Barre, PA, 18702, USA
| |
Collapse
|
19
|
Abstract
Migraine is a common, chronic, disorder that is typically characterized by recurrent disabling attacks of headache and accompanying symptoms, including aura. The aetiology is multifactorial with rare monogenic variants. Depression, epilepsy, stroke and myocardial infarction are comorbid diseases. Spreading depolarization probably causes aura and possibly also triggers trigeminal sensory activation, the underlying mechanism for the headache. Despite earlier beliefs, vasodilation is only a secondary phenomenon and vasoconstriction is not essential for antimigraine efficacy. Management includes analgesics or NSAIDs for mild attacks, and, for moderate or severe attacks, triptans or 5HT1B/1D receptor agonists. Because of cardiovascular safety concerns, unreliable efficacy and tolerability issues, use of ergots to abort attacks has nearly vanished in most countries. CGRP receptor antagonists (gepants) and lasmiditan, a selective 5HT1F receptor agonist, have emerged as effective acute treatments. Intramuscular onabotulinumtoxinA may be helpful in chronic migraine (migraine on ≥15 days per month) and monoclonal antibodies targeting CGRP or its receptor, as well as two gepants, have proven effective and well tolerated for the preventive treatment of migraine. Several neuromodulation modalities have been approved for acute and/or preventive migraine treatment. The emergence of new treatment targets and therapies illustrates the bright future for migraine management.
Collapse
|
20
|
Brennan BP, Schnabel J, Pope HG, Hudson JI. Antidepressant use and risk of intubation or death in hospitalized patients with COVID-19: A retrospective cohort study of clinical effectiveness. Front Psychiatry 2022; 13:951065. [PMID: 36186877 PMCID: PMC9520125 DOI: 10.3389/fpsyt.2022.951065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022] Open
Abstract
Initial controlled trials of the serotonergic antidepressant fluvoxamine showed promise for treatment of mild to moderate COVID-19 in outpatients, although more recent outpatient data have been less encouraging. Turning to studies of hospitalized patients, a retrospective cohort study by Hoertel and associates in 2021 found a markedly reduced risk of intubation or death among patients hospitalized with COVID-19 who were receiving serotonergic antidepressants at the time of admission vs. those not receiving antidepressants. In an attempt to replicate these latter findings, we performed a similarly designed study of 500 individuals hospitalized with COVID-19 in a large academic hospital system who were taking a serotonergic antidepressant at the time of admission compared with two groups (N = 573 and N = 593) not receiving an antidepressant. In analyses controlling for demographic and clinical variables, we found no significant difference in effect between the antidepressant group and either of the two comparison groups [hazard ratios (95% CI) for intubation or death 1.1 (0.83-1.5) and 1.1 (0.86-1.5); and for death alone 1.3 (0.93-1.8) and 1.1 (0.85-1.7)]. Examining the results of our study, along with those of Hoertel et al. and three additional retrospective cohort studies in inpatients published in the interim, the data permit only very limited conclusions, with the findings on the effect of serotonergic antidepressants ranging from a strongly protective effect to no effect. Although there are numerous threats to validity that might account for this wide range of findings, we could not identify any principal factor or set of factors that could clearly explain the differences.
Collapse
Affiliation(s)
- Brian P Brennan
- Psychiatric Epidemiology Research Program and Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jiana Schnabel
- Psychiatric Epidemiology Research Program and Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, United States
| | - Harrison G Pope
- Psychiatric Epidemiology Research Program and Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - James I Hudson
- Psychiatric Epidemiology Research Program and Biological Psychiatry Laboratory, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
21
|
Chiew AL, Buckley NA. The serotonin toxidrome: shortfalls of current diagnostic criteria for related syndromes. Clin Toxicol (Phila) 2021; 60:143-158. [PMID: 34806513 DOI: 10.1080/15563650.2021.1993242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Serotonin syndrome (toxicity) describes adverse drug effects from toxic amounts of intra-synaptic central nervous system serotonin. A wide range of drugs have been implicated to cause serotonin toxicity, not all justifiably. The plausible agents all have a final common pathway resulting in a substantial increase in central nervous system serotonergic neurotransmission. Serotonin toxicity is characterized by neuromuscular excitation, mental status changes, and autonomic dysregulation. Signs and symptoms represent a spectrum of toxicity (mild to life-threatening) related to increasing serotonin concentrations. As there is no consensus on the threshold for "toxicity" or diagnostic criteria, the true incidence of serotonin toxicity is unknown. The incidence in overdose is easier to quantify and is reasonably common in serotonergic antidepressant overdoses. In a large case series of overdoses, moderate serotonin toxicity occurred in 14% of poisonings with a selective serotonin reuptake inhibitor. While half those ingesting a monoamine oxidase inhibitor in combination with a serotonergic agent in overdose exhibit at least moderately severe serotonin toxicity. In contrast, the incidence of serotonin toxicity in those on therapeutic serotonergic agents appears to be very low. OBJECTIVES To provide a narrative review of the current diagnostic criteria, utilizing case reports of fatalities to evaluate how many meet the various diagnostic criteria and propose practical solutions to resolve controversies in diagnosis. METHODS A review of serotonin toxicity diagnostic criteria in the English literature was completed by searching Embase and PubMed from January 1990 to July 2021 for the keywords "serotonin syndrome/toxicity" paired with "diagnostic criteria" or "diagnosis." Also, fatal cases of serotonin toxicity identified from a recent systematic review were independently examined to determine what diagnostic criteria were met and whether serotonin toxicity or another cause was most likely. REVIEW OF DIAGNOSIS CRITERIA Serotonin toxicity is a clinical diagnosis, four diagnostic criteria (Sternbach, Serotonin Syndrome Scale, Radomski, and Hunter) have been proposed. However, the Serotonin Syndrome Scale has not been validated in patients with serotonin toxicity and only utilized in those on a serotonergic agent. The remaining three criteria are utilized more widely but have undergone little refinement or validation. REVIEW OF FATAL CASES Shortfalls with diagnostic criteria can be illustrated by examining case fatalities. Of 55 fatal cases reviewed, 12 (22%) were unlikely to be serotonin toxicity. Sternbach and Radomski criteria were met by 25 (45%), 20 (36%) had insufficient data reported and 10 (18%) met an exclusion criterion. Few had sufficient information reported to determine whether Hunter Criteria were met, with only 13 (24%) documented as meeting the criteria, the remaining 42 (76%) had insufficient data. RESOLVING SHORTFALLS IN CURRENT DIAGNOSTIC CRITERIA As serotonin toxicity is a clinical diagnosis, issues arise when basing the diagnosis on symptom criteria alone, without considering whether the drug/s ingested increase central nervous system serotonin or whether there is an alternative diagnosis. This has resulted in case reports and government warnings for drugs that cannot plausibly cause significant serotonin toxicity (e.g., ondansetron and antipsychotics). We propose when assessing for a serotonin toxidrome, both the causative agent(s) and clinical scenario is considered to determine the likelihood of serotonin toxicity. Then the clinical features assessed, those with a moderate to high prior probability (e.g., serotonergic drug-drug interaction, overdose, recent initiation or increase in dose of serotonergic agent/s) could be diagnosed based on the Hunter criteria. However, those with a low probability (e.g., stable therapeutic doses of a serotonergic agent) require more specific and stringent criteria. Finally, we propose a minimum dataset for case reports/series of serotonin toxicity. CONCLUSIONS More complete and accurate reporting of serotonin toxicity cases is required in the future, to avoid further misleading associations that are physiologically implausible.
Collapse
Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Randwick, Australia.,NSW Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia.,Clinical Pharmacology and Toxicology Research Group, Biomedical Informatics and Digital Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
22
|
Gaul C, Förderreuther S. [Sumatriptan 3 mg subcutaneous : Clinical relevance of acute treatment of migraine despite dose reduction]. DER NERVENARZT 2021; 93:612-617. [PMID: 34557933 DOI: 10.1007/s00115-021-01189-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Triptans are a highly effective substance class in the acute treatment of migraine attacks. They contribute to a substantial improvement in the quality of life and help to reduce the socioeconomic burden of the disease. RESULTS Sumatriptan is the only triptan that is available for subcutaneous administration. It is primarily indicated in patients with the need for rapid relief or insufficient enteral resorption due to nausea and vomiting. In the treatment of migraine attacks with 6 mg subcutaneous sumatriptan the number needed to treat (NNT) is 2.3 for freedom from pain within 2 h and the NNT is 2.1 for pain relief within 2 h; however, the fast resorption of sumatriptan after subcutaneous administration induces more side effects than the oral route, for example dizziness, paresthesia or chest pressure sensation. CONCLUSION Clinical studies showed that reducing the subcutaneous dose to 3 mg in migraine treatment has significantly better tolerability with high response rates and freedom from pain within 2 h with 66.7% (3 mg) or 50% (6 mg).
Collapse
Affiliation(s)
- Charly Gaul
- Kopfschmerzzentrum Frankfurt, Dalbergstr. 2a, 65929, Frankfurt am Main, Deutschland.
| | | |
Collapse
|
23
|
Genetic polymorphisms in opioid metabolism. Aust Prescr 2021; 44:118. [PMID: 34421175 PMCID: PMC8377294 DOI: 10.18773/austprescr.2021.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
24
|
Jin G, Stokes P. Drug interaction between a selective serotonin reuptake inhibitor and a triptan leading to serotonin toxicity: a case report and review of the literature. J Med Case Rep 2021; 15:371. [PMID: 34304734 PMCID: PMC8311984 DOI: 10.1186/s13256-021-02946-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Serotonin toxicity is a known side effect of selective serotonin reuptake inhibitors and has previously also been described as a possible side effect of 5-hydroxytryptamine receptor agonist (triptan) medications. However, the literature is conflicted about the risk of developing serotonin toxicity as a result of drug interaction between selective serotonin reuptake inhibitors and triptans. Case presentation A 30-year-old Caucasian woman with a history of depression on regular fluvoxamine presented to the emergency department with right-sided facial and lower limb twitching. The patient had recently been prescribed sumatriptan for migraines and had taken her first ever dose shortly prior to the onset of symptoms. She was tachycardic, diaphoretic, and hypertonic on initial assessment with bilateral lower limb and ocular clonus. Electrocardiogram showed sinus tachycardia with QT interval under the treatment interval, and pathology and imaging findings were unremarkable. Her symptoms improved with supportive management and cyproheptadine. Conclusions This patient’s presentation fulfilled both Sternbach and Hunter criteria for serotonin toxicity, illustrating a potential case of serotonin toxicity as a result of drug interaction between a selective serotonin reuptake inhibitor and a triptan.
Collapse
Affiliation(s)
- Gilbert Jin
- Redcliffe Hospital, Anzac Avenue, Redcliffe, QLD, 4020, Australia.
| | - Philip Stokes
- Redcliffe Hospital, Anzac Avenue, Redcliffe, QLD, 4020, Australia
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW Migraine is a disabling disease of attacks of moderate to severe pain with associated symptoms. Every person with migraine requires treatment for acute attacks. Treatments can range from behavioral management and nonspecific medications to migraine-specific medications and neuromodulation. For many with migraine, having a combination of tools allows for effective treatment of all types of attacks. RECENT FINDINGS Over the past several years, four neuromodulation devices have been cleared by the US Food and Drug Administration (FDA) for treatment of acute migraine, and three medications with novel mechanisms of action have been FDA approved. They add to the arsenal available to people with migraine and focus on migraine-specific pathways to allow for precise care with fewer side effects. SUMMARY This article discusses acute migraine therapy, focusing on best-level evidence.
Collapse
|
26
|
Abstract
IMPORTANCE Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide. OBSERVATIONS Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo. CONCLUSIONS AND RELEVANCE Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.
Collapse
Affiliation(s)
- Matthew S Robbins
- Department of Neurology, Weill Cornell Medical College, New York, New York
| |
Collapse
|
27
|
O'Rourke MJ, Keshock MC, Boxhorn CE, Correll DJ, O'Glasser AY, Gazelka HM, Urman RD, Mauck K. Preoperative Management of Opioid and Nonopioid Analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2021; 96:1325-1341. [PMID: 33618850 DOI: 10.1016/j.mayocp.2020.06.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/15/2020] [Accepted: 06/29/2020] [Indexed: 01/31/2023]
Abstract
There is a lack of guidelines for preoperative dosing of opioid and nonopioid pain medications for surgical patients, which can lead to suboptimal preoperative pain control. The Society for Perioperative Assessment and Quality Improvement identified preoperative dosing of opioid and nonopioid analgesics as an area in which consensus could improve patient care. The aim of this guideline is to provide consensus that will allow perioperative physicians to make optimal recommendations regarding preoperative pain medication dosing. Six categories of pain medications were identified: opioid agonists, opioid antagonists, opioid agonist-antagonists, acetaminophen, muscle relaxants, and triptans/headache medications. We then used a Delphi survey technique to develop consensus recommendations for preoperative dosing of individual medications in each of these groups.
Collapse
Affiliation(s)
- Michael J O'Rourke
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL; Department of Anesthesia, Edward Hines Jr Veteran Affairs Hospital, Hines, IL.
| | - Maureen C Keshock
- Department of Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH
| | - Christine E Boxhorn
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Boston, MA
| | - Darin J Correll
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Avital Y O'Glasser
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
28
|
Caroff SN, Watson CB, Rosenberg H. Drug-induced Hyperthermic Syndromes in Psychiatry. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:1-11. [PMID: 33508784 PMCID: PMC7851465 DOI: 10.9758/cpn.2021.19.1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/02/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Hyperthermia, or extreme elevations in body temperature, can be life-threatening and may be caused by prescription drugs or illegal substances acting at a number of different levels of the neuraxis. Several psychotropic drug classes and combinations have been associated with a classic clinical syndrome of hyperthermia, skeletal muscle hypermetabolism, rigidity or rhabdomyolysis, autonomic dysfunction and altered mental status ranging from catatonic stupor to coma. It is critical for clinicians to have a high index of suspicion for these relatively uncommon drug-induced adverse effects and to become familiar with their management to prevent serious morbidity and mortality. Although these syndromes look alike, they are triggered by quite different mechanisms, and apart from the need to withdraw or restore potential triggering drugs and provide intensive medical care, specific treatments may vary. Clinical similarities have led to theoretical speculations about common mechanisms and shared genetic predispositions underlying these syndromes, suggesting that there may be a common “thermic stress syndrome” triggered in humans and animal models by a variety of pharmacological or environmental challenges.
Collapse
Affiliation(s)
- Stanley N Caroff
- Corporal Michael J. Crescenz VA Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | - Charles B Watson
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| | - Henry Rosenberg
- Malignant Hyperthermia Association of the United States, Sherburne, NY, USA
| |
Collapse
|
29
|
Chow R, Kozhevnikov D, Prsic EH. Serotonin Syndrome in Palliative Care #403. J Palliat Med 2020; 23:1678-1680. [PMID: 33306009 DOI: 10.1089/jpm.2020.0492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
30
|
Abstract
OBJECTIVE This review of serotonin syndrome or serotonin toxicity covers the years 2014 to 2019, including information on pathophysiology, etiology, and diagnosis, 3 criteria for diagnosing serotonin syndrome, and criteria for neuroleptic malignant syndrome. IMPORTANCE The review highlights the potential lethal combinations of commonly prescribed medications used to treat both veteran and nonveteran patients and includes the latest information on offending medications. CONCLUSIONS Prevention of serotonin toxicity includes informed clinicians, patient education, careful prescribing and monitoring, and avoidance of multidrug regimens.
Collapse
Affiliation(s)
- Cynthia Wright Talton
- is a Nurse Practitioner in the Outpatient Mental Health Clinic at the Veterans Affairs Medical Center in Salem, Virginia
| |
Collapse
|
31
|
Abstract
Migraine causes significant lost time from everyday activities. Addressing lifestyle triggers and comorbidities in patients with migraine is the first step of management Acute migraine treatments primarily manage the headache component and should be started as early as possible in the migraine attack Prophylaxis may be recommended if a patient is having three or more migraines a month or if their migraines are difficult to manage The choice of prophylactic drugs should be tailored to the individual’s potential for adverse effects, interactions and comorbidities
Collapse
|
32
|
|
33
|
Fugger G, Dold M, Bartova L, Mitschek MMM, Souery D, Mendlewicz J, Serretti A, Zohar J, Montgomery S, Fabbri C, Frey R, Kasper S. Clinical Correlates and Outcome of Major Depressive Disorder and Comorbid Migraine: A Report of the European Group for the Study of Resistant Depression. Int J Neuropsychopharmacol 2020; 23:571-577. [PMID: 32885810 PMCID: PMC7710912 DOI: 10.1093/ijnp/pyaa035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/22/2020] [Accepted: 05/14/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The present multicenter study aimed at defining the clinical profile of patients with major depressive disorder (MDD) and comorbid migraine. METHODS Demographic and clinical information for 1410 MDD patients with vs without concurrent migraine were compared by descriptive statistics, analyses of covariance, and binary logistic regression analyses. RESULTS The point prevalence rate for comorbid migraine was 13.5% for female and 6.2% for male patients. MDD + migraine patients were significantly younger, heavier, more likely female, of non-Caucasian origin, outpatient, and suffering from asthma. The presence of MDD + migraine resulted in a significantly higher functional disability. First-line antidepressant treatment strategy revealed a trend towards agomelatine. Second-generation antipsychotics were significantly less often administered for augmentation treatment in migraineurs. Overall, MDD + migraine patients tended to respond worse to their pharmacotherapy. CONCLUSION Treatment guidelines for comorbid depression and migraine are warranted to ensure optimal efficacy and avoid possible pitfalls in psychopharmacotherapy, including serotonin syndrome.
Collapse
Affiliation(s)
- Gernot Fugger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Markus Dold
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Lucie Bartova
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Marleen M M Mitschek
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Daniel Souery
- Université Libre de Bruxelles, Bruxelles, Belgium,Psy Pluriel Centre Européen de Psychologie Médicale, Bruxelles, Belgium
| | | | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Joseph Zohar
- Psychiatric Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | - Chiara Fabbri
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy,Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
| | - Richard Frey
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Siegfried Kasper
- Center for Brain Research, Medical University of Vienna, Vienna, Austria,Correspondence: Siegfried Kasper, MD, Medical University of Vienna, Center for Brain Research, Spitalgasse 4, A-1090 Vienna, Austria ()
| |
Collapse
|
34
|
Abstract
PURPOSE OF REVIEW This review describes the pharmacology of each antidepressant class as it applies to migraine prevention, summarizes the evidence base for each medication, and describes relevant side effects and clinical considerations. Use of antidepressants for migraine prevention in clinical practice is also discussed. RECENT FINDINGS Antidepressants are commonly used as migraine preventives. Amitriptyline has the best evidence for use in migraine prevention. Nortriptyline is an alternative in patients who may not tolerate amitriptyline. The sedating effect of TCAs can be beneficial for patients with comorbid insomnia. SNRIs including venlafaxine and duloxetine also have evidence for efficacy and may be the most effective treatments in patients with comorbid depression and migraine. SSRIs including fluoxetine are not effective for most patients. The side effect burden of antidepressants can be substantial. Patients should be particularly counseled about the possibility of a withdrawal effect from SNRIs. Antidepressants are an important option for preventive treatment of migraine. Further research on the efficacy and tolerability of SNRIs as migraine preventives is needed.
Collapse
Affiliation(s)
- Rebecca Burch
- John R. Graham Headache Center, Brigham and Women's Hospital Department of Neurology, Harvard Medical School, 1153 Centre St Suite 4H, Boston, 02130, USA.
| |
Collapse
|
35
|
Abstract
Migraine and tension-type headache are highly prevalent. Migraine is associated with significant work- and family-related disability. Migraine is underdiagnosed; it reasonable to err on the side of migraine when choosing between primary headaches. Barriers to appropriate treatment of migraine include lack of access to providers, misdiagnosis, and acute and preventive therapies not being prescribed. Acute, rescue, and preventive treatment options are extensive, and new classes of treatments are either available or in development. This review addresses diagnostic challenges including recognizing migraine with aura. It also summarizes nonpharmacologic, acute, rescue, and preventive treatment options for migraine and treatment of tension-type headache.
Collapse
Affiliation(s)
- Rebecca Burch
- Department of Neurology, John R. Graham Headache Center, Brigham and Women's Hospital, Harvard Medical School, 1153 Centre Street, Suite 4H, Jamaica Plain, MA 02130, USA.
| |
Collapse
|
36
|
Why Do You Keep Telling Me That Drug-Drug Interactions Are Important in Psychopharmacology When I Do Not See Them in My Clinical Practice?: My Failure to Convince Clinicians. J Clin Psychopharmacol 2019; 39:1-4. [PMID: 30212396 DOI: 10.1097/jcp.0000000000000924] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
37
|
Abstract
Increasingly complex medication regimens for many comorbidities in patients for planned surgical and procedural interventions necessitate detailed preoperative evaluation of the pharmacologic therapy, including the indications, the specific drugs, and dosing amount and interval. The implications of continuing or withholding these agents in the perioperative period need to be elucidated, as well as the risks of interactions and side effects. A comprehensive plan of the management of the therapeutic agents should be devised during the preoperative visit, with input from all relevant specialists, and clearly communicated to the patients in a format that ensures their comprehension and consistent compliance.
Collapse
Affiliation(s)
- Zdravka Zafirova
- Section of Critical Care, Department of Cardiovascular Surgery, Mount Sinai Hospital System, 1 Gustave L. Levy Place, Mail Box 1028, New York, NY 10029, USA.
| | - Karina G Vázquez-Narváez
- Department of Anesthesiology and Perioperative Medicine, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Vaco de Quiroga #15, Col. Belisario Dominguez Sección XVI, Mexico City 14080, Mexico
| | - Delia Borunda
- Department of Anesthesiology and Perioperative Medicine, Centro de Desarrollo de Destrezas Medicas, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Vaco de Quiroga #15, Col. Belisario Dominguez Sección XVI, Mexico City 14080, Mexico
| |
Collapse
|
38
|
Is There Always a Right or Wrong?: Comments on the FDA Warnings About Triptans and the Serotonin Syndrome. J Clin Psychopharmacol 2018; 38:545-546. [PMID: 30303862 DOI: 10.1097/jcp.0000000000000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
39
|
Culbertson VL, Rahman SE, Bosen GC, Caylor ML, Echevarria MM, Xu D. Implications of Off-Target Serotoninergic Drug Activity: An Analysis of Serotonin Syndrome Reports Using a Systematic Bioinformatics Approach. Pharmacotherapy 2018; 38:888-898. [PMID: 29972695 PMCID: PMC6160353 DOI: 10.1002/phar.2163] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Study Objective Serotonergic adverse drug events (ADEs) are caused by enhanced intrasynaptic concentrations of 5‐hydroxytryptamine (5‐HT). No systematic process currently exists for evaluating cumulative 5‐HT and off‐target toxicity of serotonergic drugs. The primary study aim was to create a Serotonergic Expanded Bioactivity Matrix (SEBM) by using a molecular bioinformatics, polypharmacologic approach for assessment of the participation of individual 5‐HT drugs in serotonin syndrome (SS) reports. Data Sources Publicly available databases including the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS), ChEMBL, DrugBank, PubChem, and Kyoto Encyclopedia of Genes and Genomes (KEGG) were queried for computational and pharmacologic data. Design An in‐house bioinformatics TargetSearch program ( http://dxulab.org/software) was used to characterize 71 serotonergic drugs interacting at 13 serotonin receptor subtypes and serotonin reuptake transporter protein (SERT). In addition, off‐target interactions at norepinephrine transporter (NET), monoamine oxidase (MAO), and muscarinic receptors were included to define seven polypharmacological drug cohorts. Serotonin syndrome reports for each serotonergic drug were extracted from FAERS by using the Sternbach and Hunter criteria. Measurements and Main Results A proportional reporting adverse drug reaction (ADR) ratio (PRR) was calculated from each drug's total ADEs and SS case reports and aggregated by drug bioactivity cohorts. Triple‐receptor interactions had a disproportionately higher number of SS cases using both the Hunter criteria (mean PRR 1.72, 95% CI 1.05–2.39) and Sternbach (mean PRR 1.54, 95% CI 1.29–1.79). 5‐Hydroxytryptamine agonists were associated with a significantly lower proportion of SS cases using the Hunter and Sternbach criteria, respectively (mean PRR 0.49, 95% CI 0.17–0.81 and mean PRR 0.49, 95% CI 0.15–0.83). Drugs with disproportionately higher participation in SS vary considerably between the two diagnostic criteria. Conclusion The SEBM model suggests a possible polypharmacological role in SS. Although further research is needed, off‐target receptor activity may help explain differences in severity of toxicity and clinical presentation.
Collapse
Affiliation(s)
- Vaughn L Culbertson
- Kasiska Division of Health Sciences, Department of Pharmacy Practice, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Shaikh E Rahman
- Kasiska Division of Health Sciences, Department of Biomedical & Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Grayson C Bosen
- Kasiska Division of Health Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Matthew L Caylor
- Kasiska Division of Health Sciences, Department of Biomedical & Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Megan M Echevarria
- Kasiska Division of Health Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Dong Xu
- Kasiska Division of Health Sciences, Department of Biomedical & Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| |
Collapse
|
40
|
Opioid analgesic drugs and serotonin toxicity (syndrome): mechanisms, animal models, and links to clinical effects. Arch Toxicol 2018; 92:2457-2473. [DOI: 10.1007/s00204-018-2244-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 06/13/2018] [Indexed: 12/11/2022]
|
41
|
Diener HC. [Not Available]. MMW Fortschr Med 2018; 160:34. [PMID: 29943019 DOI: 10.1007/s15006-018-0697-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
|