What is the treatment for Serotonin Syndrome?

From the Guidelines

The treatment of serotonin syndrome requires immediate discontinuation of all serotonergic medications and supportive care, with consideration of serotonin2A antagonists like cyproheptadine for severe cases. The management of serotonin syndrome involves a multi-faceted approach, including:

• Discontinuation of the precipitating agent
• Supportive care, such as treatment of agitation with benzodiazepines, amelioration of hyperthermia, and management of autonomic instability with IV fluids and other agents to address abnormal vital signs 1
• For severe cases, consideration of emergency sedation, neuromuscular paralysis, and intubation may be necessary, as well as the use of serotonin2A antagonists like cyproheptadine 1
• The dosage of cyproheptadine is typically 12 to 24 mg over 24 hours, starting with 12 mg, followed by 2 mg every 2 hours for continuing symptoms, and a maintenance dose of 8 mg every 6 hours, given orally 1
• It is essential to note that physical restraints may be detrimental, as they can exacerbate isometric contractions, worsen hyperthermia and lactic acidosis, and increase mortality 1
• The condition can rapidly progress to life-threatening complications, so early recognition and aggressive management in an ICU setting is crucial for severe cases, with a mortality rate of approximately 11% and significant morbidity associated with serotonin syndrome 1

From the FDA Drug Label

DOSAGE AND ADMINISTRATION DOSAGE SHOULD BE INDIVIDUALIZED ACCORDING TO THE NEEDS AND THE RESPONSE OF THE PATIENT.

CLINICAL PHARMACOLOGY Cyproheptadine is a serotonin and histamine antagonist with anticholinergic and sedative effects.

The treatment for Serotonin Syndrome is cyproheptadine (PO). The dosage should be individualized according to the needs and response of the patient, with a typical range of 4 mg to 20 mg a day for adults, and 2 mg to 16 mg a day for pediatric patients, as needed and as tolerated 2. Cyproheptadine acts as a serotonin antagonist, which can help alleviate the symptoms of serotonin syndrome 2.

From the Research

Treatment Overview

The treatment for Serotonin Syndrome involves several key components, including:

• Withdrawal of the offending agent(s) [(3,4,5,6)]
• Aggressive supportive care to treat hyperthermia and autonomic dysfunction [(3,4,6)]
• Administration of serotonin antagonists, such as cyproheptadine or chlorpromazine [(3,4,7,5)]
• Use of benzodiazepines to treat agitation and tremor [(4,6)]

Management of Mild and Severe Cases

• Mild cases of Serotonin Syndrome may be treated with withdrawal of the offending agent and supportive care [(3,4)]
• Moderate and severe cases require hospitalization and more aggressive treatment, including neuromuscular paralysis, sedation, and intubation [(3,4,6)]
• Patients with severe cases may require active cooling and other supportive measures 6

Use of Serotonin Antagonists

• Cyproheptadine is a commonly used serotonin antagonist for the treatment of Serotonin Syndrome [(3,4,7,5)]
• The dosing schedule for cyproheptadine may vary, but it is often administered in a loading dose followed by regular doses 7
• Other serotonin antagonists, such as chlorpromazine and olanzapine, have been explored but evidence is limited [(3,6)]