OBJECT DRUGS

Opioid Analgesics (Serotonergic):

• Alfentanil (Alfenta)
• Fentanyl (Sublimaze, etc.)
• Meperidine (Demerol)
• Tramadol (Ultram, etc.)

PRECIPITANT DRUGS

SSRI and SNRI:

• Citalopram (Celexa)
• Clomipramine (Anafranil)
• Desvenlafaxine (Pristiq, etc.)
• Duloxetine (Cymbalta)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac, etc.)
• Fluvoxamine (Luvox, etc.)
• Imipramine (Tofranil, etc.)
• Milnacipran (Savella)
• Paroxetine (Paxil, etc.)
• Sertraline (Zoloft)
• Venlafaxine (Effexor)

Comment:

There have been a number of cases of serotonin syndrome following the combined used of serotonergic analgesics such as meperidine or tramadol with selective serotonin reuptake inhibitors (SSRI) or selective serotonin-norepinephrine reuptake inhibitors (SNRI). One case of fatal serotonin syndrome was reported in a patient on amitriptyline following the addition of tramadol. Limited evidence suggests that fentanyl may also exhibit additive serotonergic effects with other serotonergic drugs, but more evidence is needed.

Class 3: Assess Risk & Take Action if Necessary

• Consider Alternative:
• Opioid Analgesic: In patients taking an SSRI or SNRI consider using an alternative to meperidine or tramadol.
• Antidepressant: If a tricyclic antidepressant (TCA) is given to patients on meperidine or tramadol, use a TCA other than clomipramine or imipramine. Avoiding amitriptyline, doxepin and desipramine would also be prudent.
• Monitor: If the combination is used monitor for evidence of serotonin syndrome (myoclonus, rigidity, tremor, fever, sweating, seizures, confusion, agitation, incoordination, and coma).