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Zorluk: OrtaPsychopharmacology and Psychological Therapies

A patient with well-controlled depression is evaluated during a same-day appointment for acute-onset agitation, sweating, and muscle spasms. The 45-year-old male states these symptoms began roughly 12 hours ago. His medical history includes major depressive disorder, for which he takes citalopram daily. Two days ago, he strained his lower back while moving heavy boxes and received a prescription from a local urgent care facility. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 162/94 mm Hg, and heart rate of 115/min. On physical examination, the patient appears visibly restless and diaphoretic. Neurological assessment reveals bilateral ocular clonus, generalized hyperreflexia, and sustained ankle clonus. Which of the following medications was most likely prescribed for this patient's back injury?

  1. TramadolCevap
  2. B
    Baclofen
  3. C
    Celecoxib
  4. D
    Hydrocodone
  5. E
    Methocarbamol

Cevap

Tramadol
Tramadol has a dual mechanism of action: it acts as a weak mu-opioid receptor agonist and also inhibits the presynaptic reuptake of serotonin and norepinephrine. When a patient already taking a selective serotonin reuptake inhibitor (SSRI) like citalopram is prescribed tramadol, the synergistic increase in intrasynaptic serotonin can precipitate serotonin syndrome. This toxidrome is classically characterized by the triad of autonomic hyperactivity (tachycardia, diaphoresis, hyperthermia), altered mental status (agitation), and distinct neuromuscular abnormalities (hyperreflexia, sustained clonus, and ocular clonus).

Adım Adım Çözüm

1
Analyze the patient's acute clinical presentation.
The patient exhibits autonomic instability (fever, tachycardia, hypertension, diaphoresis), altered mental status (agitation), and neuromuscular irritability (hyperreflexia, ocular and ankle clonus).
These findings form the classic clinical triad of serotonin syndrome.
2
Review the patient's baseline medications.
The patient takes citalopram, a selective serotonin reuptake inhibitor (SSRI).
SSRIs increase baseline serotonergic tone and are the most common foundation for serotonin syndrome when combined with other serotonergic drugs.
3
Evaluate the options for a precipitating agent.
Identify which of the listed medications prescribed for back pain possesses serotonergic properties.
An interacting serotonergic medication is required to trigger this acute toxicity.
4
Select the correct medication.
Tramadol is chosen because it inhibits serotonin reuptake in addition to its primary analgesic effects.
Adding tramadol to an SSRI leads to a synergistic and dangerous increase in synaptic serotonin, precipitating the observed crisis.

Anahtar Kavram

Serotonin syndrome is a potentially life-threatening condition characterized by autonomic hyperactivity, mental status changes, and neuromuscular excitability. It is often precipitated by combining an SSRI with other serotonergic medications, such as tramadol, MAOIs, or linezolid.
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Psychopharmacology and Psychological Therapies

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