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A Mix of Medicines That Can Be Lethal
NY Times ^ | February 27, 2007 | JANE E. BRODY

Posted on 03/03/2007 8:37:14 PM PST by neverdem

The death of Libby Zion, an 18-year-old college student, in a New York hospital on March 5, 1984, led to a highly publicized court battle and created a cause célèbre over the lack of supervision of inexperienced and overworked young doctors. But only much later did experts zero in on the preventable disorder that apparently led to Ms. Zion’s death: a form of drug poisoning called serotonin syndrome.

--snip--

In its classic form, serotonin syndrome involves three categories of symptoms:

¶Cognitive-behavioral symptoms like confusion, disorientation, agitation, irritability, unresponsiveness and anxiety.

--snip--

Perhaps adding to the diagnostic challenge is the fact that a huge number of drugs — prescription, over the counter, recreational and herbal — can trigger the syndrome. In addition to selective serotonin reuptake inhibitors like Zoloft, Prozac and Paxil and serotonin/norepinephrine reuptake inhibitors like Effexor, the list includes tricyclic antidepressants and MAOIs (for monoamine oxidase inhibitors); narcotic painkillers like fentanyl and tramadol; over-the-counter cough and cold remedies containing dextromethorphan; the anticonvulsant valproate; triptans like Imitrex used to treat and prevent migraines; the antibiotic Zyvox (linezolide); antinausea drugs; the anti-Parkinson’s drug L-dopa; the weight-loss drug Meridia (sibutramine); lithium; the dietary supplements tryptophan, St. John’s wort and ginseng; and several drugs of abuse, including ecstasy, LSD, amphetamines, the hallucinogens foxy methoxy and Syrian rue.

Although serotonin poisoning can be caused by an antidepressant overdose, it more often results from a combination of an S.S.R.I. or MAOI with another serotonin-raising substance. Patients at particular risk, some experts say, are those taking combinations of antidepressant and antipsychotic drugs sometimes prescribed to...

--snip--

Most important to preventing the syndrome is for patients to give each of their doctors a complete list of drugs they regularly take — including prescriptions, over-the-counter medication, dietary supplements and recreational drugs — before a doctor prescribes something new.

(Excerpt) Read more at nytimes.com ...


TOPICS: Culture/Society; Extended News; News/Current Events
KEYWORDS: antidepressants; health; medicine; mentalhealth; psychiatrists; psychiatry; psychotherapy; serotonin; serotoninsyndrome
ANTIDEPRESSANT CASUALTIES
1 posted on 03/03/2007 8:37:18 PM PST by neverdem
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To: neverdem

Serotonin syndrome might have a genetic link...


2 posted on 03/03/2007 8:38:26 PM PST by TASMANIANRED (No stinking peanut butter.)
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To: neverdem
ACETAMINOPHEN CASUALTIES
3 posted on 03/03/2007 8:52:52 PM PST by the808bass
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To: the808bass

Session Cookie Error


4 posted on 03/03/2007 8:56:30 PM PST by neverdem (May you be in heaven a half hour before the devil knows that you're dead.)
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To: neverdem

What's the point here. People have side effects from all kinds of medications.


5 posted on 03/03/2007 9:12:29 PM PST by USMCWife6869 (Godspeed Sand Sharks.)
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To: TASMANIANRED
Serotonin syndrome might have a genetic link...

Although the thrust of this article seems to be drug - drug interactions, I wouldn't doubt a genetic predisposition. Enter serotonin syndrome and (CYP2D6 or cytochrome P450) into PubMed's query box. A lot of school shootings, maybe most, were done by kids on SSRIs. If their defense was up to snuf, they would be tested for this genetic variation for trial, appeal or parole board.

6 posted on 03/03/2007 9:26:14 PM PST by neverdem (May you be in heaven a half hour before the devil knows that you're dead.)
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To: USMCWife6869
What's the point here. People have side effects from all kinds of medications.

These are preventable side effects. A serotonin storm can kill you. Your doctor and pharmacist must know all the medicine both prescription and over the counter that you are taking. Our new drug interaction software will catch these interactions. Use one doctor and one pharmacist!!!!!!!!!

7 posted on 03/03/2007 9:26:18 PM PST by cpdiii (Pharmacist, Pilot, Geologist, Oil Field Trash and proud of it.)
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To: neverdem
Paging John Edwards-- white courtesy phone....
8 posted on 03/03/2007 9:34:35 PM PST by hatfieldmccoy (Satan has a new name and it is Islam)
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To: USMCWife6869
What's the point here. People have side effects from all kinds of medications.

"In March 2005, two such specialists, Dr. Edward W. Boyer and Dr. Michael Shannon of Children’s Hospital Boston, noted that more than 85 percent of doctors were 'unaware of the serotonin syndrome as a clinical diagnosis.'"

IMHO, adverse drug - drug interactions is another.

9 posted on 03/03/2007 9:35:05 PM PST by neverdem (May you be in heaven a half hour before the devil knows that you're dead.)
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To: neverdem

Was Corona w/ Bacardi's Limon on the list?


10 posted on 03/03/2007 9:40:29 PM PST by MHGinTN (If you've had life support. Promote life support for others.)
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To: neverdem
A lot of school shootings, maybe most, were done by kids on SSRIs.

I'd be interested in seeing the hard numbers, but then again, if they didn't have "problems", they probably wouldn't be on the meds.

Did the SSRIs affect the behavior? Without, would a lonely suicide be the course of action, or did the SSRIs change the course action that to that of TROP practitioner?

I just hate to see beneficial drugs be maligned and/or taken off the market because the wrong people got them.

That's not to say that better qualifying criteria can't be put in place.

11 posted on 03/03/2007 10:03:35 PM PST by Calvin Locke
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To: neverdem

I've seen it happen with first dose on a medication...

Drug interactions most certainly can cause it as well.


12 posted on 03/03/2007 10:05:40 PM PST by TASMANIANRED (No stinking peanut butter.)
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To: neverdem
Here's an unadulterated link (I hope)

http://www3.interscience.wiley.com/cgi-bin/abstract/112149032/ABSTRACT

Hope that works

13 posted on 03/03/2007 10:06:34 PM PST by the808bass
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To: MHGinTN
Was Corona w/ Bacardi's Limon on the list?

Only in conjunction with espresso martinis. I know that combo is personally toxic for me.

14 posted on 03/03/2007 10:07:36 PM PST by the808bass
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To: cpdiii
These are preventable side effects. A serotonin storm can kill you.

Are you saying that we know which serotonin-affecting drugs will cause serotonin storm in combination? Or that they all could? Or that one patient should never be on multiple serotonin-affecting agents? I'm not trying to be smart. Just curious. I thought many psychiatrists just piled on SSRI after SSRI, etc

15 posted on 03/03/2007 10:10:52 PM PST by the808bass
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To: TASMANIANRED

The case of Libby Zion was straightforward. She did not tell the attending physician she had been taking drugs. As Dr. House would say...the first rule of medicine is that the patient always lies.

Libby's father had the power of the press behind him and that's the only reason it became a huge story. He did not want to face the fact his daughter was not the perfect little girl he thought she was. And that's the truth.


16 posted on 03/03/2007 10:12:24 PM PST by Hildy (RINO=RUDY IS NUMBER ONE)
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To: Hildy

You got that right.

Medical Mantra: Look for the lie.


17 posted on 03/03/2007 10:14:11 PM PST by TASMANIANRED (No stinking peanut butter.)
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To: Calvin Locke
I'm not schizophrenic! And neither am I!
18 posted on 03/03/2007 10:20:39 PM PST by Wally_Kalbacken (Seldom right but never in doubt)
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To: the808bass
Only in conjunction with espresso martinis. I know that combo is personally toxic for me.

My God. I feel queasy just reading that.

19 posted on 03/03/2007 11:10:19 PM PST by A_perfect_lady
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To: cpdiii
A serotonin storm can kill you.

What about a severe LACK of serotonin, especially in the presence of SSRIs?

20 posted on 03/03/2007 11:12:35 PM PST by FreeKeys (Even if McCain says he'd nominate justices who'd overturn McCain-Feingold, would you believe him?)
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To: A_perfect_lady
I feel queasy just reading that.

It all comes out in the wash.

21 posted on 03/03/2007 11:16:36 PM PST by the808bass
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To: neverdem
As Anthon Chekhov [a physician} wrote:
"-You gave her a laxative, then a fixative, then a laxative again - and she could not stand it and died.
- In medicine one cannot do without it"
22 posted on 03/04/2007 2:16:33 AM PST by GSlob
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To: Hildy

"Libby's father had the power of the press behind him and that's the only reason it became a huge story. He did not want to face the fact his daughter was not the perfect little girl he thought she was. And that's the truth."

As I understand this story, the cause of death seems to be complications of an interaction between Libby Zion's legally prescribed antidepressant Nardil and the narcotic painkiller Demerol that was given to her at the hospital. I see no mention of the ingestion of any other drugs. If she was asked, I don't know why this young woman did not tell the doctor at the hospital that she was taking Nardil. Maybe she wasn't thinking straight due to her illness and fever, or maybe she was taking more than the prescribed dosage and didn't want to admit it. The thrust of the article seems to be that doctors need to be made more aware of the manifestations of this syndrome. Of course, if they are conscious and cognizant, the patient has to do his part by being honest with the doctor.


23 posted on 03/04/2007 3:26:30 AM PST by Mila (i)
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To: Calvin Locke
A lot of school shootings, maybe most, were done by kids on SSRIs.

Sorry, but I am sick of allowing people to "excuse" criminal behavior just because they were taking a certain medication at the time of the crime.

The kid that is on Riddlin may be a miscreant, but he/she still knows the difference between right and wrong. When decisions reach criminal perportions, he/she should be held accountable. I don't care how badly the brain nuerons are misfiring, there is still a comprehension of choices and consequenses.

24 posted on 03/04/2007 3:45:11 AM PST by REPANDPROUDOFIT
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To: Mila

If you really want to know what happened, here it is. An older Doc once told me, "We have checks in place in medicine and bad things can't happen without multiple mistakes being made. Even so it happens and when it does it isn't 'One persons fault' but multiple failures." In this case the intern told the nurse over the phone to give the agitated patient more Demerol to calm her down. There are at least two mistakes here. 1) the intern should have known better than to give the oder 2) the nurse should have known better than to give the medicine to the patient. The intern probably should have gone to evaluate the patient. The ER probably should have insisted on a patient that was that ill go to a Unit bed instead of the floor and the ER doc should have known better than to start this mess by giving Demerol for agitation. The upper level resident should have been keeping a closer eye on an intern that was this clueless. The charge nurse should have been keeping a closer eye on a nurse that was his clueless. I could just go on and on here but I think you get the point.


25 posted on 03/04/2007 4:03:12 AM PST by wastoute
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To: REPANDPROUDOFIT
When decisions reach criminal perportions, he/she should be held accountable.

I don't disagree with that view.

26 posted on 03/04/2007 4:34:13 AM PST by Calvin Locke
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To: MHGinTN

alcohol should be on the list- the interaction of alcohol with many other medications (prescriobed or not) can be lethal.


27 posted on 03/04/2007 5:50:08 AM PST by silverleaf (Fasten your seat belts- it's going to be a BUMPY ride.)
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To: neverdem

TEEN SUICIDE INCREASE - ANTIDEPRESSANT ALARMIST CASUALTIES

http://abcnews.go.com/Health/Depression/story?id=2850783&page=1


28 posted on 03/04/2007 5:57:26 AM PST by silverleaf (Fasten your seat belts- it's going to be a BUMPY ride.)
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To: silverleaf

(see my post 24) It is truly a tragedy that teens are deciding in greater numbers to take their own lives. But I can't be overly sympathetic about the reduction in availabilty of antidepressants being to blame. I am a strong believer in personal responsibility. Isn't it possible that the increased suicide rate is due to a culture that fails to imbue respect for human life. Rap songs, movies, video games etc. embrace the concepts of murder, torture, abuse. Self sacrifice has been replaced by the overly hyped necessity - "healthy self esteem". The current culture wants kids to acheive good self esteem thru osmosis or by decree from our education systems, as if it can be poured into them. Our parents taught us to be responsible adults and they did it the old fashioned way, by example. They worked hard and made sacrifices to benefit others. Many kids today just assume that they will all of a sudden be grown up, self satisfied, well rounded individuals. After all, they have been taught that everything is "Fair" and nothing unfair should ever happen to them.


29 posted on 03/04/2007 8:14:50 AM PST by REPANDPROUDOFIT
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To: REPANDPROUDOFIT; Calvin Locke

BTTT


30 posted on 03/04/2007 8:16:20 AM PST by REPANDPROUDOFIT
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To: Mila

Let's just say that story has been rewritten for history sake. However, Sid Zion did change the hours doctors had to stay on duty, and that was a fantastic thing.

Sid Zion was a broken man after his beloved daughter died.


31 posted on 03/04/2007 8:25:24 AM PST by Hildy (RINO=RUDY IS NUMBER ONE)
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To: REPANDPROUDOFIT; Calvin Locke
"A lot of school shootings, maybe most, were done by kids on SSRIs."

That was my statement, not Calvin Locke's.

As per the Times' article: "In its classic form, serotonin syndrome involves three categories of symptoms:"

¶Cognitive-behavioral symptoms like confusion, disorientation, agitation, irritability, unresponsiveness and anxiety.

¶Neuromuscular symptoms like muscle spasms, exaggerated reflexes, muscular rigidity, tremors, loss of coordination and shivering.

¶Autonomic nervous system symptoms like fever, profuse sweating, rapid heart rate, raised blood pressure and dilated pupils.

Sorry, but I am sick of allowing people to "excuse" criminal behavior just because they were taking a certain medication at the time of the crime.

Sorry, but if you don't want to accept the symptoms as described by the NY Times' writer, then enter (SSRI or serotonin syndrome) and (aggression or violence) into the query box at PubMed.

If you don't understand that drugs called selective serotonin reuptake inhibitors, SSRIs, e.g. Prozac, Zoloft, etc., can make people lose their minds, then why do you think the FDA recently demanded Black Box Warnings on them?

Look at the stories linked in comment# 1. You'll find that many of these kids were just started on a SSRI, or that their dose was recently increased.

I just hate to see beneficial drugs be maligned and/or taken off the market because the wrong people got them.

They are still on the market, but with the Black Box Warnings. IMHO, folks started on these meds need to be tested for genetic variations alluded to in comment# 6.

I personally treated a person who became so hemodynamically unstable, i.e. a seriously abnormal blood pressure and heart rate, on multiple psychiatric drugs that she was admitted to the ICU. I stopped the meds. Then I spoke to her shrink who insisted that she needed all of them.

One of the reasons I posted the article was because it stated that 85% of docs are ignorant of serotonin syndrome.

32 posted on 03/04/2007 11:41:36 AM PST by neverdem (May you be in heaven a half hour before the devil knows that you're dead.)
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To: silverleaf

Thanks for the link. If I was a kid today, I'd be suicidal.


33 posted on 03/04/2007 11:55:16 AM PST by neverdem (May you be in heaven a half hour before the devil knows that you're dead.)
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To: FreeKeys
What about a severe LACK of serotonin, especially in the presence of SSRIs?

I am not familiar with that syndrome. However, if this does exist the SSRIs would be helpfull. The mechanism of Serotonin Specific Reuptake Inhifitors SSRIs is to decrease the amount of serotonin that is taken back out of the synapse into the neuron. It does not change the total amount of serotonin in the body but keeps more in the synapse thus in effect increasing the amount of the neurotransmitter that is available to carry the signal across the synapse. The neurotransmitters in the synapse are constantly taken up into the neuron and recycled as needed into the synapse. This is how an electrical signal in the neuron "jumps" the gap between them. The serotonin will go from one neuron to the next neuron and this will cause an electrical signal to go down the second neuron.

34 posted on 03/04/2007 12:54:09 PM PST by cpdiii (Pharmacist, Pilot, Geologist, Oil Field Trash and proud of it.)
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To: the808bass
Are you saying that we know which serotonin-affecting drugs will cause serotonin storm in combination? Or that they all could? Or that one patient should never be on multiple serotonin-affecting agents? I'm not trying to be smart. Just curious. I thought many psychiatrists just piled on SSRI after SSRI, etc

Yes we do know the majority of the combinations. However, when a new drug comes out and is given to the public we will almost always find some new side effect that was not discovered in the initial clinical trials. In my opinion the use of multiple SSRIs is not warranted. The normal procedure is to try one and if it does not work, stop that one and start the patient on a different SSRI. The anti depressants are very patient specific and it is not unusual to try several until the best one for a particular patient is found.

However, it is not uncommon for a patient to be on two different anti depressants at the same time and this is perfectly rational. The SSRIs can affect sleep and make it difficult. It is very common to give an SSRI in the morning and a non specific re uptake inhibitor at bedtime. The non specific ones will have a sedative side effect and make sleep much easier and also have good anti depressant activity.

35 posted on 03/04/2007 1:03:11 PM PST by cpdiii (Pharmacist, Pilot, Geologist, Oil Field Trash and proud of it.)
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To: Hildy
Let's just say that story has been rewritten for history sake. However, Sid Zion did change the hours doctors had to stay on duty, and that was a fantastic thing

Where I work (a teaching hospital) I have had residents call the pharmacy and ask the most basic of questions or something really stupid. These Residents are very smart and knowledgeable people. They just did not have enough sleep and could no longer think straight. Fortunately they are now on reasonable schedules and this is now a rare occurrence.

36 posted on 03/04/2007 1:08:30 PM PST by cpdiii (Pharmacist, Pilot, Geologist, Oil Field Trash and proud of it.)
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To: REPANDPROUDOFIT
"I am a strong believer in personal responsibility"

You have never suffered from a mental illness nor had close experience with a friend or loved one who did- have you? There are many studies about why people don't do what they SHOULD. Including being normally able to be cheerful and optimistic enough to get up and function every day. It is KILLER to some mentally ill people (including the clinically depressed) for society (or more devastating, their loved ones) to judge them as "weak" or weak-willed because they are unable to do so.

When one considers the intricacy of chemical processing by our brains and the effects on aspects of our emotions and personality, is it really so hard to believe that organic disorders exist and that medication can help?

Yet the idea that one must "tough it out" and function
according to willpower and logic instead of taking "the easy way out" via antidepressant's is strong. But not among those who have walked in those shoes or lived with someone who did.
37 posted on 03/04/2007 1:37:12 PM PST by silverleaf (Fasten your seat belts- it's going to be a BUMPY ride.)
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To: wastoute

Oh, what a scary set of events! I can't see how there is any way to protect yourself from something like this happening to you or a loved one. In situations like this we tend to put our complete faith in the medical professionals. The family of this young girl are probably constantly tortured by the "what ifs". If any one of the factors that you mentioned had been done differently, this person might still be alive. Tragic.


38 posted on 03/04/2007 3:27:36 PM PST by Mila (i)
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To: Hildy

"Sid Zion was a broken man after his beloved daughter died."

Poor man, any parent, or for that matter anyone, can empathize with his loss.


39 posted on 03/04/2007 3:31:05 PM PST by Mila (i)
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To: Mila

Yes. My father knew him.


40 posted on 03/04/2007 3:34:40 PM PST by Hildy (RINO=RUDY IS NUMBER ONE)
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To: Mila
My purpose wasn't to frighten. Hour after hour, day after day, "the system" works but occasionally things happen that shouldn't. It happens in any field. In a factory errors can be detected and bad products held in "QI" but in the hospital errors happen to people. If you try to decrease the amount of hours docs work you increase the number of "handoffs" which are also a big source of errors. If you decrease the workload you dilute the experience they need to learn.
41 posted on 03/06/2007 3:12:21 AM PST by wastoute
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