Serotonin syndrome controversies: A need for consensus

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.

Keywords: Serotonin; Serotonin syndrome; Serotonin toxicity; Selective serotonin reuptake inhibitors; Antidepressants; Cyproheptadine

Core Tip: Many recent papers have highlighted new developments in serotonin syndrome (SS). New clinical findings and clinical scenarios have emerged. Cases are now being reported from non-psychiatric and non-toxicological centers. SS can occur at therapeutic and stable doses. They create considerable diversity in various aspects of SS. Some experts, meanwhile, dismiss these recent advancements in SS. Because SS is a potentially fatal illness, there must be agreement on various issues of SS.