Q; All of the following could be the parts of Serotonin syndrome (SS) management except?
B) Inravenous cyproheptadine
C) Therapeutic Paralytics
E) Preferably avoiding antipyretics
There are two objectives to this question.
First, to highlight the vital importance of cyproheptadine in the management of SS. Although there are no robust studies available (Grade 1 recommendations) for the use of cyproheptadine, it is relatively a benign drug and should be used if benzodiazepines fail to control the symptoms of SS. It can quickly culminate into a fatal scenario. Cyproheptadine is a histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-HT2A antagonistic properties. Technically it acts as an antidote. It is available only as oral formulation, so if a patient is not coherent enough to take it orally, the first dose of 12 mg should be delivered via oro/nasogastric tube emergently, followed by regular interval till symptoms subside.
Second, antipyretics has no role in SS because hyperthermia is not due to an alteration in the hypothalamic temperature set point. It is due to high muscular activity, that's why paralysis may be required (choice C).
1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112.
2. Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine. J Emerg Med 1998; 16:615.
3. Baigel GD. Cyproheptadine and the treatment of an unconscious patient with the serotonin syndrome. Eur J Anaesthesiol 2003; 20:586.
4. McDaniel WW. Serotonin syndrome: early management with cyproheptadine. Ann Pharmacother 2001; 35:870.