Serotonin Syndrome


Article Author:
Leslie Simon


Article Editor:
Michael Keenaghan


Editors In Chief:
Lauren Camaione


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/4/2019 6:16:03 PM

Introduction

Serotonin syndrome is a potentially life-threatening condition precipitated by the use of serotonergic drugs. It may be a consequence of therapeutic medication use, accidental interactions between medications or recreational drugs, or intentional overdose. Symptoms can range from mild to fatal and classically include altered mental status, autonomic dysfunction, and neuromuscular excitation. Several criteria exist for making this clinical diagnosis, but the Hunter criteria are generally accepted as the most accurate. The diagnosis can be made in patients with a history of exposure to a serotonergic drug plus one or more of the following: spontaneous clonus, inducible clonus with agitation and diaphoresis, ocular clonus with agitation and diaphoresis, tremor and hyperreflexia, hypertonia, temperature over 38 C with ocular or inducible clonus. Management consists of immediate discontinuation of serotonergic agents, hydration, and supportive care to manage blood pressure, hyperpyrexia, and respiratory and cardiac complications. Sedation is best facilitated with benzodiazepines. Refractory cases may respond to the antidote, cyproheptadine, which must be given orally or via gastric tube. The effectiveness of cyproheptadine is unproven, but multiple case reports support its use in patients who do not respond to sedation and supportive care.[1][2][3]

Etiology

Serotonin syndrome may occur as a consequence of therapeutic medication use, drug interactions, or intentional overdose. Multiple drugs may precipitate serotonin toxicity by a variety of mechanisms. SSRIs such as citalopram, escitalopram, fluoxetine, fluoxetine, paroxetine, and sertraline impair reuptake of serotonin from the synaptic cleft into the presynaptic neuron. Many other drugs also impair serotonin reuptake including meperidine, tramadol, pentazocine, metoclopramide, valproate, carbamazepine, dextromethorphan, and cyclobenzaprine. Serotonin modulators, such as trazodone, and dopamine-norepinephrine reuptake inhibitors, such as bupropion, also impair serotonin reuptake. Tri-cyclic antidepressants and St. John’s wort, a popular supplement, also inhibit serotonin reuptake. Monoamine oxidase inhibitors (MAOIs) inhibit serotonin metabolism and tend to produce the most severe and prolonged cases. MAOIs include phenelzine, tranylcypromine, isocarboxazid, selegiline, the antibiotic, linezolid, and methylene blue. Direct serotonin agonists include buspirone, ergot derivatives, fentanyl and lysergic acid diethylamide (LSD). Tryptophan, as a supplement or dietary source, increases serotonin formation and can be particularly dangerous in patients on other serotonergic drugs, especially MAOIs. Amphetamines, cocaine, MDMA (Ecstacy) and levodopa all increase serotonin release. Cocaine and MDMA also inhibit serotonin reuptake. Serotonin syndrome is often precipitated by the addition of one or more of these medications in patients who were previously stable on a serotonergic agent. Since there are so many drugs that may cause serotonin syndrome, it is important for providers to take a careful medication history when adding new medications.[4][5][6][7]

Epidemiology

The true incidence of serotonin syndrome is unknown, most likely because mild cases are frequently overlooked or dismissed. Even more serious cases may frequently be attributed to other causes. There is no confirmatory test or specific laboratory findings, and the syndrome has a broad spectrum of severity ranging from barely perceptible to lethal. Serotonin syndrome occurs in all age groups, and incidence is increasing with the increased use of serotonergic agents. SSRIs are the most common class of medications implicated in serotonin syndrome due to widespread use.

Pathophysiology

Serotonin, or 5-hydroxytryptamine (5-HT), is a monoamine neurotransmitter that is biochemically derived from tryptophan. Serotonin is found primarily in the gastrointestinal tract, the central nervous system and in platelets. It is metabolized by monoamine oxidase in the liver. Serotonin modulates attention, mood, appetite, and sleep as well as some cognitive functions, making serotonin modulation a common mechanism of action for many antidepressants. Serotonin also modulates thermoregulation and promotes platelet aggregation, uterine contraction, bronchoconstriction, vasoconstriction, and gastrointestinal motility. Stimulation of the postsynaptic 5-HT1A and 5-HT2A receptors from a single or combination of drugs produces serotonin syndrome.[8][9]

History and Physical

Serotonin syndrome is diagnosed clinically and requires a thorough review of medications and a careful physical exam. Symptoms tend to develop rapidly after exposure to the precipitating drug: 30% within one hour, 60% within 6 hours, and nearly all patients with toxicity developing symptoms within 24 hours of exposure. The spectrum may range from barely perceptible tremor to life-threatening hyperthermia and shock. Signs and symptoms include agitation, anxiety, restless, disorientation, diaphoresis, hyperthermia, tachycardia, nausea, vomiting, tremor, muscle rigidity, hyperreflexia, myoclonus, dilated pupils, ocular clonus, dry mucous membranes, flushed skin, increased bowel sounds, and a bilateral Babinski sign. Clonus and hyperreflexia are particularly common. Neuromuscular findings tend to be more pronounced in the lower extremities. As compared to the neuroleptic malignant syndrome, patients with serotonin syndrome are more likely to have associated gastrointestinal symptoms and clonus.

Several criteria exist for making the diagnosis: Sternbach, Radomski, and Hunter. The Hunter test is accepted as the most accurate, but the criteria were designed specifically for patients with SSRI overdose, not serotonin syndrome from other agents; therefore, it may not reveal the disease in patients with minor symptoms.[10][11]

Hunter Criteria

  1. History of exposure to a serotonergic drug
  2. Plus one or more of the following:
  • spontaneous clonus
  • inducible clonus with agitation and diaphoresis
  • ocular clonus with agitation and diaphoresis
  • tremor and hyperreflexia
  • hypertonia
  • temperature over 38 C with ocular or inducible clonus

Evaluation

The following tests may be useful in assessing patients with serotonin syndrome and narrowing the differential diagnosis: complete blood count, electrolytes, creatinine and BUN, creatine phosphokinase, hepatic transaminases, coagulation studies, urinalysis, drug screen, neuroimaging, and lumbar puncture. No laboratory test confirms the diagnosis, but patients may have leukocytosis, elevated creatine phosphokinase, and decreased serum bicarbonate concentration. Patients may develop labile blood pressure, heart rate and cardiac dysrhythmias, disseminated intravascular coagulation, rhabdomyolysis, renal failure, metabolic acidosis, myoglobinuria, and respiratory failure.

Treatment / Management

Most cases of serotonin syndrome are mild and will resolve with removal of the offending drug alone. After stopping all serotonergic drugs, management is largely supportive and aimed at preventing complications. Patients frequently require sedation, which is best facilitated with benzodiazepines. Antipsychotics should be avoided because of their anticholinergic properties, which may inhibit sweating and heat dissipation. Vital signs should be normalized with intravenous (IV) fluids and cooling measures. Antipyretics such as acetaminophen are ineffective because increased muscular activity causes the hyperthermia in serotonin syndrome. Severe hyperthermia may require sedation, paralysis, and intubation for mechanical ventilation. Autonomic instability may require antihypertensive agents or vasopressors, depending on presentation, and may be quite labile and difficult to manage.  Short-acting agents such as esmolol are recommended if antihypertensive are required. Most cases with hypotension can be managed with IV fluids alone, but in refractory cases, direct-acting sympathomimetics such as phenylephrine, norepinephrine, and epinephrine are preferable.

Cyproheptadine is a histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-Ht2A antagonistic properties. While strong evidence to support its use is lacking, it is widely used as an antidote for serotonin syndrome. Side effects may include sedation, which may be desirable, and hypotension, which in most cases will respond to IV fluids. The usual starting dose is 12 mg, followed by an additional 2 mg every two hours as long as symptoms persist. As the patient improves, cyproheptadine is usually continued at a dose of 8 mg every 6 hours until symptoms resolve.

Patients with abnormal vital signs require admission to a monitored setting, and severe cases warrant intensive care unit care.

Differential Diagnosis

Mild cases of serotonin syndrome, with subtle symptoms such as tremor or restlessness, are often overlooked completely or attributed to anxiety or the underlying psychiatric condition. When gastrointestinal symptoms are present, symptoms often are attributed to food poisoning or the flu. Serious cases share many common features with the neuroleptic malignant syndrome, malignant hyperthermia, anticholinergic toxicity, sympathomimetic toxicity, or infectious causes such as meningitis or encephalitis. A careful medication history and diagnostic testing will help delimitate the cause.

Prognosis

Most cases of serotonin syndrome will resolve completely within 24 to 72 hours without sequelae if recognized and treated with removal of the precipitating agent and appropriate supportive care. Patients who are asymptomatic 6 to 8 hours following an overdose are unlikely to develop significant toxicity. SSRIs are rarely associated with death, even in overdose, when used alone. Most fatalities associated with SSRIs are due to co-ingestion with other drugs. Fatalities, when they occur, tend to happen within the first 24 hours and are more likely in patients on MAOIs than SSRIs.

Enhancing Healthcare Team Outcomes

Serotonin syndrome is best managed by a multidisciplinary team that includes the pharmacist. Since many cases are drug-related, the physician and pharmacist must be aware of potential drug interactions. Drug-induced serotonin syndrome is usually mild and will resolve spontaneously but it is best to prevent the disorder in the first place. Cases that are diagnosed and managed have a good outcome.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Serotonin Syndrome - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following statement about serotonin syndrome is correct?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient who is taking a monoamine oxidase inhibitor presents with muscle rigidity, myoclonus, hyperthermia, and cardiovascular collapse. Two days earlier she had been started on another drug. What drug was this patient most likely prescribed?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What drug is used in the treatment of serotonin syndrome?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old female arrives at the emergency department via ambulance. On exam, she is agitated and confused. Her blood pressure is 160/110 mmHg, heart rate 140 beats/min, and temperature 39C. She is diaphoretic, tremulous, and hyper-reflexive, but otherwise has a non-focal neurological exam. She is unable to give a detailed history. She has with her a bottle of phenelzine. Her friends report that she "wanted to celebrate her eighteenth birthday" with "something new." What other drug may she have taken to cause this presentation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 36-year-old female with migraines and anxiety presents to the emergency room with complaints of headaches, fever, and diarrhea. She is agitated, diaphoretic, and tachycardic, but normotensive. On neuro exam, she has hyper-reflexia without spasticity. Her CT head and MR brain are normal. A lumbar puncture is performed which reveals normal cerebrospinal fluid studies. Which of the following is most likely responsible for this patient's condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following clinical findings are not included in the Hunter criteria for the diagnosis of serotonin syndrome?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is used as an antidote for serotonin syndrome?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old female presents with confusion and agitation. Prescriptions for sumatriptan and phenelzine were discovered. An exam shows a temperature of 39 C, pulse 110 beats/min, blood pressure 150/100 mmHg, and respirations of 18. She was tremulous and hyper-reflexive without focal neurologic findings. Her friends report that she took a recreational drug. Which drug most likely caused this reaction?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 25-year-old female with depression and migraines presents to the emergency department with a headache, diarrhea, and fever. She was taking sumatriptan for her migraines. Recently, fluoxetine was added for her depression. Her blood pressure is normal but she is tachycardic, mildly agitated, and diaphoretic. Exam shows hyperreflexia but no rigidity and is otherwise normal. MRI of the brain is normal. What is the most probable diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A depressed patient was started on a drug known to inhibit catecholamine degradation. Recently she started another drug and required emergency admission because of the combined effect. Which of the following is most likely drug added?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Fluoxetine, an SSRI antidepressant, can interact with other drugs and produce serious side effects. Which of the following drugs can precipitate serotonin syndrome when given in combination with fluoxetine?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following characteristics helps distinguish serotonin syndrome from neuroleptic malignant syndrome (NMS)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old female develops a seizure in recovery after wisdom teeth extraction using general anesthesia. Initially, she became febrile and hemodynamically unstable. She was tachycardic, but there was little respiratory effort. She was intubated and given lorazepam. Anesthetics given included nitrous oxide, isoflurane, cisatracurium, and meperidine. The drug screen showed methamphetamine. Which of the following is mostly the cause of this presentation of serotonin syndrome?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 54-year-old patient with a history of depression on phenelzine had general anesthesia for an elective orthopedic procedure. She was given nitrous oxide, isoflurane, cisatracurium, and meperidine and had a seizure in recovery. A drug screen revealed the patient had methamphetamine in her system. She was diagnosed with serotonin syndrome. Which two drugs were most likely responsible for her condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the mortality of serotonin syndrome?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which biochemical hormone may be increased when a Selective serotonin reuptake inhibitor (SSRI) is combined with a mono amine oxidase inhibitor (MAOI)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 21-year-old female patient presents to the emergency department complaining of restlessness, chest pain, and overheating. Her heart rate is 170 BPM and her blood pressure is 180/100 mmHg. The patient takes oral contraceptives and recently began taking tranylcypromine, a monoamine oxidase inhibitor (MAOI), for depression and anxiety. After some gentle prodding, the patient admits to taking a friend's dextroamphetamine earlier that evening. She claims that she has taken comparable doses many times before, and has never experienced any negative effects. What could be the cause of this patient's condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient presents with a temperature of 40.1C, dilated pupils, and hyperreflexia. Her parents report that she took an overdose of an antidepressant medication. Which of the following symptoms would not be expected?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male arrives for surgery pre-op for a cholecystectomy. He has a past medical history of depression treated with psychotherapy and trazodone. He is given fentanyl before the procedure, and vital signs indicate autonomic instability. You suspect serotonin syndrome and must intervene. What is the first step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 40-year-old male with depression presents to the emergency department with hyperthermia, agitation, dilated pupils, tremor, hyperreflexia, muscle rigidity, and flushed skin. Bowel sounds were hyperactive on physical exam. His only prescription medication is fluoxetine. His wife, who is accompanying him stated he took another depression medication that his friend gave him this morning. His blood pressure is 160/100 mmHg, the temperature is 42 F, the pulse is 100/min, and respiratory rate is 16/min. Which of the following is the next step of management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient presents to the emergency department with his wife reporting that he does not feel good. The wife states that he has a history of depression for four years, and it has gotten worse over the last four weeks. They have seen a psychiatrist who has increased the medication dose, but she reports that it is not helping. She states his depression has gotten so bad over the last day that he cannot rest and is agitated. He has had two episodes of watery diarrhea since yesterday. On examination, the patient has a flushed face, dilated pupils, and mildly annoyed. His temperature is measured to be 38.2 C. His wife requests that her husband get help with his depression so that he can relax and get some rest. Which of the following is the next best step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Serotonin Syndrome - References

References

Francescangeli J,Karamchandani K,Powell M,Bonavia A, The Serotonin Syndrome: From Molecular Mechanisms to Clinical Practice. International journal of molecular sciences. 2019 May 9;     [PubMed]
Duma SR,Fung VS, Drug-induced movement disorders. Australian prescriber. 2019 Apr;     [PubMed]
Srivastava A,Singh P,Gupta H,Kaur H,Kanojia N,Guin D,Sood M,Chadda RK,Yadav J,Vohora D,Saso L,Kukreti R, Systems Approach to Identify Common Genes and Pathways Associated with Response to Selective Serotonin Reuptake Inhibitors and Major Depression Risk. International journal of molecular sciences. 2019 Apr 23;     [PubMed]
Hudon Thibeault AA,Sanderson JT,Vaillancourt C, Serotonin-estrogen interactions: What can we learn from pregnancy? Biochimie. 2019 Jun;     [PubMed]
Ott M,Mannchen JK,Jamshidi F,Werneke U, Management of severe arterial hypertension associated with serotonin syndrome: a case report analysis based on systematic review techniques. Therapeutic advances in psychopharmacology. 2019;     [PubMed]
Le Mestre J,Duparc C,Reznik Y,Bonnet-Serrano F,Touraine P,Chabre O,Young J,Suzuki M,Sibony M,Gobet F,Stratakis CA,Raverot G,Bertherat J,Lefebvre H,Louiset E, Illicit upregulation of serotonin signaling pathway in adrenals of patients with high plasma or intraadrenal ACTH levels. The Journal of clinical endocrinology and metabolism. 2019 May 10;     [PubMed]
Hasani R,Sarma J,Kansal S, Serotonin Syndrome Induced by Combined Use of Sertraline and Linezolid. Anesthesia, essays and researches. 2019 Jan-Mar;     [PubMed]
Shelton RC, Serotonin and Norepinephrine Reuptake Inhibitors. Handbook of experimental pharmacology. 2019 Mar 6;     [PubMed]
Ram P,Penalver JL,Lo KBU,Rangaswami J,Pressman GS, Carcinoid Heart Disease: Review of Current Knowledge. Texas Heart Institute journal. 2019 Feb;     [PubMed]
Ronan GP,Ronan N,McGettigan S,Browne G, Serotonin syndrome unmasking thyrotoxicosis. BMJ case reports. 2019 Mar 7;     [PubMed]
Tormoehlen LM,Rusyniak DE, Neuroleptic malignant syndrome and serotonin syndrome. Handbook of clinical neurology. 2018;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pharmacy-Pediatric. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pharmacy-Pediatric, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pharmacy-Pediatric, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pharmacy-Pediatric. When it is time for the Pharmacy-Pediatric board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pharmacy-Pediatric.