Symptoms of a Zoloft Overdose

Serotonin Syndrome after Sertraline Overdose in a Child: A Case Report

Symptoms of a Zoloft Overdose

Serotonin syndrome is a potentially life-threatening drug effect. It may be misdiagnosed because it has mostly been reported in adults. Case Report.

An 8-year-old girl with behavioral problems and medicated with risperidone and sertraline was admitted in the emergency department after she had taken voluntarily 1500 mg of sertraline (50 mg/kg). At admission, she had marked agitation, visual hallucinations, diaphoresis, flushing, and tremor. She had fever and periods of hypertension.

She also showed generalized rigidity and involuntary movements. She was treated with fluids and iv diazepam, midazolam, clemastine, and biperiden.

As the patient presented a severe insomnia and a progressive rhabdomyolysis, she was transferred to pediatric intensive care unit (ICU), where she was under treatment with cyproheptadine, mechanical ventilation, and muscular paralysis for 11 days. She was discharged from hospital a few days later with no neurological sequelae.

Conclusions. Serotonin syndrome is still not well recognized by physicians. In our patient, the diagnosis was made early due to the history of overdose with serotonin reuptake inhibitors and the triad of mental, neurological, and autonomic signs. Parents must be educated to prevent children from having free access to drugs, avoiding self-medication or overdose.

1. Introduction

In the past years, the use of psychiatric drugs serotonin reuptake inhibitors (SSRIs) has increased among children and adolescents [1].

Serotonin syndrome (SS) is a potentially life-threatening drug effect from the use of SSRIs as well as other drugs monoamine oxidase inhibitors (MAOIs), tricycle antidepressants, over-the-counter cough medicines, antibiotics, antiemetics, drugs of abuse, and herbal products [2]. Clinical manifestations are nonspecific.

It is often described as a clinical triad of mental-status changes, neuromuscular abnormalities, and autonomic dysfunction, although these symptoms may not be all present in the same patient and at the same time [2–4].

The SS in children may be misdiagnosed because it has mostly been reported in adults. However, the incidence of this condition in children has increased and it is important to recognize the clinical manifestations [2]. The authors report the case of SS in an 8-year-old child resulting in pediatric intensive care unit (ICU) admission following an overdose of SSRIs.

2. Case Presentation

An 8-year-old girl with behavioral problems was prescribed oral risperidone (1 mg per day) since the age of 6 and sertraline (25 mg/day) 1 month before. She was admitted in a pediatric emergency department at 4 am after she was found by her caregivers in a confusional state.

Five hours before admission she had voluntarily taken 30 pills of sertraline, 1500 mg (50 mg/kg) because she had insomnia. When she arrived at the hospital, she had a marked agitation with visual hallucinations, normal pupils, diaphoresis, flushing, hypersalivation, tremor, and a strange behavior as if she was afraid of something. Her vital signs included an axillary temperature of 38.

3°C, pulse of 160 beats per min (bpm), periods of hypertension (maximum of 150/96 mmHg), and polypnea with peripheral oxygen saturation of 96%. She also presented generalized rigidity with hyperreflexia and involuntary movements myoclonus in both hands. A peripheral intravenous (iv) access was established and she was given fluids and a first dose of oral diazepam (10 mg).

A venous blood gas demonstrated a pH of 7.46 with a pCO2 of 33 mmHg and bicarbonate of 25 mmol/L. The blood cell count was 12.03 × 103/uL with 5.3% neutrophils and 26.6% lymphocytes. She had also normal renal and hepatic function with serum urea (BUN) 36 mg/dL, creatinine 0.59 mg/dL, alanine aminotransferase (ALT) 11 U/L, and aspartate aminotransferase (AST) 37 U/L.

The urine toxicology excluded toxic intake. She was prescribed iv diazepam every 4 hours. Because there was no clinical improvement, she was then prescribed iv midazolam, clemastine, and biperiden. However, the clinical condition progressed with dystonic and athetotic movements of all four extremitites.

The patient was not able to sleep during 48 hours and presented progressive elevation of creatine kinase (CK) at a maximum of 316 U/L. After 36 hours, the patient was sedated, submitted to muscle paralysis, and transferred to the pediatric ICU.

During the admission in ICU, due to the severity of clinical condition she was under treatment with cyproheptadine (a nonspecific serotonin antagonist) during 5 days. She was also prescribed iv midazolam, morphine, and vecuronium. For the hypertension, she was prescribed propranolol until day 10.

The patient presented rhabdomyolysis with a CK maximum of 843 U/L and myoglobin of 170 μg/mL at day 7, for which she was treated with fluids, furosemide, and bicarbonate perfusion until day 11. The renal and hepatic functions were always normal, but at day 8 the serum chemistry revealed an elevation of transaminases (AST 1091 U/L and ALT 452 U/L) with no signs of cholestasis.

Mechanical ventilation and muscular paralysis were necessary for 11 days. After extubation, she had low muscle strength and periods of mental confusion; the vital signs were stable. She was transferred back to the pediatric department and a few days later she was discharged from hospital with a normal neurological examination, without antidepressants.

At the present time, two years after this episode she is under treatment with risperidone for behavioral problems and she has no neurological sequelae.

3. Discussion

Serotonin (5-HT) is a neurotransmitter produced in presynaptic neurons from L-tryptophan. The concentration of serotonin available at postsynaptic receptors is regulated by a combination of feedback loops, reuptake mechanisms, and metabolism [2].

Serotonin receptors are divided into 7 types: 5-HT1 through 5-HT7. The receptors are located in the central nervous system where they are involved in behavior, mood, sleep-wakefulness cycles, muscular tone, nociception, and thermoregulation [2, 5].

The receptors located in the periphery are involved in the regulation of gastrointestinal mobility and vascular tone [2].

SS is a predictable consequence of overstimulation of serotonin receptors, although the exact pathophysiology is not very well known [4]. The incidence of SS reflects the increasing number of serotonergic agents used in pediatric and adult population [2].

The syndrome has an estimated incidence of 14 to 16% of people who overdose on SSRIs [6]. Although severe cases have been reported with an overdose of a single drug, they more often occur with a combination of two or more serotonergic drugs, even if they are used at therapeutic dose [7].

Because most cases are reported in adults and the variability of clinical manifestations, the syndrome may be misdiagnosed in children [2, 4].

SS is characterized by a triad of mental, autonomic, and neurological disorders that usually begins suddenly less than 24 hours after the beginning of treatment or overdose [2, 4, 5, 8, 9].

Mild cases present with mydriasis, diaphoresis, tachycardia, tremor, clonus, and hyperreflexia, typically more prominent in the lower extremities [5, 8]. Moderate cases may also present gastrointestinal symptoms, fever, and rhabdomyolysis.

Neurological symptoms such as altered mental status, insomnia, and agitation are also common [5]. Severe cases may present with profound hypertension and tachycardia, high fever, seizures, and delirium and proceed to coma [8]. In 2003, Dunkley et al.

[10] published the Hunter Serotonin Toxicity Criteria, which are more sensitive and specific than Sternbach’s criteria.

In the presence of a serotonergic agent, there must coexist spontaneous clonus, inducible clonus, and agitation or diaphoresis; ocular clonus and agitation or diaphoresis; tremor, and hyperreflexia; hypertonicity and temperature > 38°C; and ocular clonus or inducible clonus. Only the following variables are required for accurately predicting serotonin toxicity: clonus, agitation, diaphoresis, tremor, and hyperreflexia.

There are no laboratory tests that confirm or exclude the diagnosis of SS. To reach the diagnosis, a history of use of serotonergic agent, clinical manifestations, and the exclusion of other conditions are required [2, 5].

In patients with confusion and neurological symptoms, it is important to make the differential diagnosis with other conditions, such as the neuroleptic malignant syndrome, dystonic reactions, carcinoid syndrome, and encephalitis. There are many clinical features shared by these conditions, but clonus, hyperreflexia, and flushing are the most specific signs for SS [7, 9].

There are no guidelines or consensus for diagnosis or treatment of this syndrome. The management of patients with SS relies on early recognition, the removal of the precipitating drugs, and supportive care, including external cooling, antihypertensive drugs, muscular paralysis, and sedation [4, 8, 9].

Benzodiazepines are the most important drug in the management of the majority of cases. They have been advocated as treatment for this syndrome due to its nonspecific inhibitory effects on serotonergic transmission [4, 9, 11]. The intensity of therapy depends on the severity of illness.

Severe cases with hyperthermia should receive supportive care, benzodiazepines, and immediate sedation with neuromuscular paralysis [2]. Control of hyperthermia should be attempted with benzodiazepines and muscular paralysis induced by nondepolarizing agents as vecuronium, followed by mechanical ventilation.

There is no rule for antipyretic agents because the hyperthermia is due to excessive muscular activity and not to hypothalamic dysfunction. Hypertension and tachycardia should be treated with short-acting agents as nitroprusside [2].

Propranolol should be avoided because it might cause shock in patients with autonomic instability. However, our patient was treated with this drug with good response and no side effects.

Cyproheptadine is an antihistamine with non-specific antagonism properties at 5-HT1 and 5-HT2 receptors [2, 9–12]. The treatment of SS is experience, since clinical trials are not available [3]. Graudins reported 5 cases of SS with mild-to-moderate features that were treated with one single dose of cyproheptadine, all with good outcomes [11].

Other reports present cyproheptadine as an important drug for the management of this syndrome, especially in mild-to-moderate cases, with no adverse effects [13, 14]. Cyproheptadine is only available as an oral preparation. Pediatric dosing advice has been published with a recommended dose of 0.25 mg/kg/day, every 2 hours until symptoms improvement [2, 3, 8, 11].

In our patient, cyproheptadine was maintained for 5 days and mechanical ventilation and muscular paralysis were necessary for 11 days. In some cases, chlorpromazine has been reported to be effective in the management of serotonin syndrome [15].

However, it should be carefully managed since the drug can cause hypotension, dystonic reactions, and a neuroleptic syndrome [2, 11].

In conclusion, SS is still not well recognized by physicians. In our patient, the diagnosis was made early due to the history of overdose with SSRIs and the triad of mental, neurological, and autonomic signs. Cessation of serotonergic medication and supportive care remain the mainstay of therapy.

Muscular paralysis and mechanical ventilation may be necessary to prevent renal and hepatic failure due to rhabdomyolysis. Cyproheptadine should be considered in mild-to-severe cases, although patients’ outcome is still not known.

Parents must be educated to prevent children from having free access to drugs, avoiding self-medication or overdose.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Copyright © 2013 Joana Grenha et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Источник: https://www.hindawi.com/journals/cripe/2013/897902/

Sertraline Overdose: Signs, Symptoms, and Precautions

Symptoms of a Zoloft Overdose

Sertraline hydrochloride is a generic prescription antidepressant medication that is also sold under the brand name Zoloft. 

The medication is a commonly prescribed antidepressant in the United States, and it is approved by the Food and Drug Administration (FDA) for the treatment of common mental health conditions obsessive-compulsive disorder (OCD), social anxiety disorder, panic disorder, panic attacks, post-traumatic stress disorder (PTSD), major depressive disorder, and premenstrual dysphoric disorder. Clinical trials have shown that sertraline is effective in reducing depression in patients with Alzheimer's disease. 

Although sertraline is generally considered a safe medication, overdosing on the drug is possible. Be on the lookout for the following signs and symptoms of sertraline overdose.

Signs and Symptoms of Sertraline Overdose

Antidepressant drugs sertraline can cause a potentially serious overdose, but few people are aware of the risk of overdose that is associated with these medications. 

Sertraline may cause overdose symptoms that are similar to those of other selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), but the presentation of these symptoms can vary from person to person depending on which drug is consumed and which substances, if any, the medication has been combined with. 

Common signs of a sertraline overdose include:

  • Agitation
  • Dizziness
  • Nausea 
  • Vomiting
  • Shakiness
  • Confusion
  • Fever
  • Rapid heartbeat
  • Drowsiness or somnolence

Of these common symptoms, studies have shown that the most ly symptoms of sertraline overdose are tremors, lethargy, and nausea, while agitation, confusion, and lethargy are less common. 

As a sertraline overdose escalates, more severe side effects can occur, some of which can be dangerous and even life-threatening. 

Severe adverse effects of a sertraline overdose include:

  • Higher or lower blood pressure than normal
  • Delirium
  • Heart problems
  • Mania
  • Fainting
  • Hallucinations
  • Inflammation of the pancreas
  • Seizures
  • Stupor

When intentionally taken in large amounts, sertraline is ly to cause a severe overdose that may include symptoms of increased heart rate (tachycardia), slowed heart rate (bradycardia), high blood pressure (hypertension), QT prolongation, tremors, confusion, agitation, vomiting, and hyperthermia (fever). Sertraline-related tachycardia can cause an uncommon but potentially lethal polymorphic ventricular tachycardia called torsades de pointes (TdP). Case reports have also shown that SSRI-induced rhabdomyolysis is possible with prolonged use of sertraline.

Another potentially serious and life-threatening symptom of sertraline overdose is the development of a condition called serotonin syndrome (toxicity). Serotonin syndrome occurs when levels of the neurotransmitter in the body become elevated past safe levels. 

Signs and symptoms of serotonin syndrome include:

  • Nausea
  • Convulsions
  • Confusion
  • Stomach cramps
  • Vomiting
  • Diarrhea
  • Irregular heart beat
  • Anxiety
  • Changes in blood pressure
  • Coma 
  • Death

Sertraline Overdose Precautions

The best way to avoid the dangerous symptoms associated with a sertraline overdose is to stop the overdose from occurring in the first place. Sertraline should only be taken by people who have a prescription for the medication, as the drug can cause dangerous drug interactions, and it should only be taken exactly as directed by your doctor or healthcare provider.

If you suspect that you or someone you love is experiencing a sertraline overdose, get medical help immediately. The condition is best treated when caught early, so it’s recommended that you head to the emergency room, if possible. Otherwise, call your local Poison Control center to receive advice on how to proceed. 

A recent sertraline overdose can sometimes be treated by pumping the stomach of the person who has overdosed or by using activated charcoal, which absorbs any remnants of the medication in the stomach.

However, if not caught quickly, the overdose will have to run its course.

People experiencing a sertraline overdose should have their vital signs monitored, and any symptoms that arise should be treated immediately. 

Fatal sertraline overdose is rare, but it most commonly occurs when a patient combines sertraline with other medications, drugs, or alcohol.

Sertraline should not be combined with other medications or substances that influence the amount of serotonin in the brain, including monoamine oxidase inhibitors (MAOIs), other SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs) venlafaxine, and other types of antidepressants including benzodiazepines diazepam and tricyclic antidepressants such as amitriptyline. 

Summary

Sertraline overdose can occur when a patient ingests more of the medication than recommended or when the drug is combined with other medications, drugs, or alcohol. The most common symptoms of sertraline overdose include agitation, dizziness, nausea, vomiting, shakiness, confusion, fever, rapid heartbeat, and sleepiness. 

While fatal overdoses are uncommon, they are more ly to occur when a patient combines sertraline with other substances. Patients should use sertraline only as prescribed by a pharmacology or psychiatry professional in order to prevent overdose, and they should seek medical treatment immediately if an overdose is suspected.

Sources: 

https://pubmed.ncbi.nlm.nih.gov/8808373/ 

https://www.healthline.com/health/can-you-overdose-on-antidepressants 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662142/ 

Источник: https://www.usarx.com/drug/sertraline-hydrochloride/sertraline-overdose

Zoloft (Sertraline) Overdose: What Are The Symptoms & How To Treat It?

Symptoms of a Zoloft Overdose

Zoloft is a highly effective SSRI antidepressant that also carries a significant risk of OD. This risk is further increased for people who use sertraline without proper medical guidance. According to the information published in Harvard Health Publishing, the amount of U.S.

citizens taking antidepressants is close to 10%, with Sertraline being in the leading positions among prescribed antidepressants. It’s prudent to know how to spot signs of Zoloft overdose in oneself or loved ones to prevent any complications.

Read along to determine how sertraline overdose occurs, the associated signs and symptoms, and the corresponding treatment options available.

Who is at Greater Risk of Overdose On Zoloft?

Different disorders associated with depression are treated with Zoloft, but there are a few common factors that can lead to OD on this antidepressant.

They include the following:

  • The rate of metabolism of each individual
  • The person’s weight
  • Age
  • Any pre-existing health conditions or diseases that the individual might be suffering from
  • It’s combination with other medicines and drugs
  • Exceeding the prescribed dosage

Some of these above-mentioned factors that can increase the complications and risks are further discussed below.

Drug Combinations May Increase Overdosing Risk

The clinical study provided by Dr. Lau and Dr. Zane Horowitz found out that OD is frequently caused when Sertraline is used with alcohol.

the number of cases being studied and their corresponding symptoms, it was concluded that an OD occurred because of taking this medication with some other drugs and/or alcohol.

Findings from the study in various control centers across the U.S. showed the mean age of patients who had overdosed on sertraline was 35.3 years.

Zoloft overdose, in most cases, is non-fatal, and this was observed in the study as well. Some of the patients had OD on the medicine alone, whereas others had combined it with other medication or alcohol. The amount of this medicine ingested in the patients ranged from 50 mg to 8000 mg.

How Many MG Does It Take to OD?

the research about SSRI medication, death from Zoloft overdose has been known to occur from ingesting as low as 750 mg (fifteen 50mg pills).

The risk of toxicity and death increases manifold when a high dose of this medicine is combined with other medications and alcohol.

Whether OD occurred because of higher ingestion of pills or through its interactions with drugs or alcohol, it should be managed at a health facility by professional care providers.

Sertraline Overdose Symptoms

A study about a massive OD on Zoloft drug showed that serotonin syndrome was caused by the ingestion of a high dose of the drug alone. Patients showed symptoms confusion, agitation, myoclonus, hyperreflexia, fever, and creatine kinase elevation.

According to the FDA, the most common Zoloft overdose symptoms include:

  • Agitation
  • Confusion
  • Nausea
  • Vomiting
  • Fever
  • Dizziness
  • Sweating
  • Flushing
  • Tremors
  • Irregular heartbeat
  • Drowsiness or Somnolence (Excessive sleepiness)

There can be some severe Zoloft overdose symptoms as well, including:

  • High or low blood pressure
  • Bradycardia (slowed heart rate)
  • Delirium
  • Hallucinations
  • Fainting spells
  • Serotonin syndrome
  • Heart issues
  • Pancreatic inflammation
  • Panic attacks
  • Paranoia
  • Convulsions
  • Seizures
  • Stupor
  • Coma
  • Mania
  • Syncope
  • QT-interval prolongation
  • Bundle-branch block
  • Torsade de Pointes

Some of these above-mentioned symptoms are further described below.

Somnolence Or Excessive Sleepiness

Somnolence or excessive sleepiness is one of the most common sertraline overdose symptoms. This behavioral effect is particularly prevalent when the OD occurs in the backdrop of concurrent benzodiazepine ingestion.

Tachycardia or A Fast Heartbeat

Tachycardia occurs as a manifestation of the autonomic instability that occurs due to high amounts of sertraline and its metabolites in blood. These increased levels lead to an elevation of serotonin in the brain, thereby affecting the autonomic nervous system.

Tremors or Shakiness

Tremors result from the altered neuromuscular activity that occurs from increased sertraline activity in the brain. This affects serotonin reuptake in the brain, altering the peripheral nervous system functions, consequently disrupting the body’s neuromuscular activity.

Dizziness

Dizziness is yet another manifestation of the autonomic disturbances that are associated with an overdose on Zoloft. It may be accompanied by excessive sweating and flushing.

Agitation

Agitation occurs due to overstimulation of the 5HT serotonin receptors in the brain, which causes disturbances in a person’s mental status.

Nausea and Vomiting

Nausea and vomiting are part of the gastrointestinal disturbances caused by too much sertraline in the body. Clinically, these two symptoms seem to be self-limiting and may occur as the body tries to expel the offending ingested medication.

Treatment Of Overdosing On Zoloft

Whenever overdose symptoms are suspected, it is better to seek medical help to minimize Zoloft adverse effects immediately. Some of the steps that should be taken are discussed below:

First Aid at Home

The following are first aid and management steps at initial contact with a person who has overdosed on SSRIs:

  • Call 911 and seek help if the person appears to be in great distress.
  • Do not leave the person’s side; keep talking to them calmly and reassure them that they will recover.
  • If the person is agitated, enlist a close friend or family’s help calm that person down.

What Information to Give to the Doctor?

The following information should be carefully gathered and given to the doctor to aid in OD treatment:

  • The amount of medication ingested
  • The time when the medicine was taken
  • Any other drugs that the person might have also taken
  • Information if the person had also taken alcohol
  • If there are any drug prescription containers, bring them to the hospital

Treatment in a Medical Center

Zoloft overdose is often treated in the emergency department. In most cases, sertraline levels in the blood are not routinely measured since getting these lab values might be costly and time-consuming.

Instead, the physician will try to estimate the ingested amount from the patient’s history or the person accompanying them.

An estimate of the ingested medicine amount may also be made by counting the number of pills missing from the patient’s prescription bottle.

Most symptoms of mild to moderate OD resolve on their own as the drug gets metabolized and eliminated from the body. Most patients with mild to moderate overload, therefore, do not require any specific treatment. They are managed through reassurance and careful observation of their vitals by a medical professional.

The definitive treatment for severe SSRI OD involves gastric decontamination with charcoal or lavage. the study about sertraline overdose and the effects of activated charcoal, it was concluded that the use of a single dose of activated charcoal shows positive results.

Hospital admission may also be advised if the doctor feels a need to observe the patient further. The patient may also be referred to a psychiatric hospital for further follow-up and treatment.

Significant antidepressant ingestion and OD may also be reported to the relevant poison control centers.

Is There Any Antidote to Overdosing On Zoloft?

A specific antidote for sertraline is yet to be found.

In most cases, medical professionals will monitor the heart rate, blood pressure, breathing, and other vital signs of the patient to treat any problem immediately if it arises.

Once the drug leaves the body after a day, the patient makes a full recovery. Thankfully overdose on Zoloft isn’t life-threatening in most cases, and most of the deaths associated with its OD are due to co-ingestion with alcohol or other drugs.

It is highly recommended that all suspected cases of Zoloft abuse are reported to the nearest addiction treatment facilities at once.

This will ensure that even after the patient has recovered from the OD, he can get further treatment of the disorder, being informed about how to prevent a similar situation from happening again, whether it was because of any accidental increase in dose intake, its interaction with other drugs, large dosage the underlying cause needs to be addressed and treated to prevent similar situations in the future.

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Published on: October 4th, 2018

Updated on: December 18th, 2020

Nena Messina is a specialist in drug-related domestic violence. She devoted her life to the study of the connection between crime, mental health, and substance abuse. Apart from her work as management at addiction center, Nena regularly takes part in the educational program as a lecturer.

8 years of nursing experience in wide variety of behavioral and addition settings that include adult inpatient and outpatient mental health services with substance use disorders, and geriatric long-term care and hospice care.  He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture.

Источник: https://addictionresource.com/drugs/zoloft/overdose/

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