The People's Perspective on Medicine

Cough Remedy Plus Antidepressant Spark Scary Serotonin Syndrome!

Drug interactions are more common than most people realize. Even something as seemingly safe as an OTC cough medicine can trigger scary serotonin syndrome.

Chances are good that you’ve heard of serotonin. It is a neurotransmitter in the brain that has been linked to mood. Fluoxetine (Prozac) and its antidepressant chemical cousins (citalopram or Celexa, escitalopram or Lexapro, paroxetine or Paxil and sertraline or Zoloft) are known as SSRIs (selective serotonin reuptake inhibitors). Serotonin plays a crucial role throughout the body. It is mostly located in specialized cells in the digestive tract. Serotonin is also found in blood cells called platelets. Certain drug combinations can trigger a scary serotonin syndrome. As this mother reports, even a seemingly simple OTC cough remedy could contribute to this reaction.

Mother Shares Scary Serotonin Syndrome Story:

Q. Several years ago, my daughter was on a low dose of escitalopram (Lexapro). Once when she had a cough, I gave her a generic version of Robitussin DM just before she left for school. Within minutes, she began acting confused and had difficulty walking.

I remembered reading about serotonin syndrome, so my husband and I took her to an urgent care center. At first the doctor there told us our daughter was fine. Before we left, however, she came back and told us that our daughter had symptoms of serotonin syndrome and that we should get to the hospital ASAP. The doctor in the ER said she would watch our daughter for several hours to see what would develop. Luckily, she recovered without incident.

All in all, it was a lesson learned that I’ll never forget. I’ll ALWAYS inquire about possible drug interactions from now on.

Symptoms of Serotonin Syndrome:

A. Serotonin syndrome occurs when levels of the neurotransmitter serotonin rise dangerously. Symptoms may include the confusion and gait disturbance you noted in your daughter. Shivering, restlessness, sweating, tremors, muscle twitches, elevated temperature, diarrhea or vomiting are other signs of a scary serotonin syndrome attack. Blood pressure and heart rate may also rise. This can become a life-threatening situation.

Dextromethorphan and Serotonin Syndrome:

Many people don’t realize that something as simple as an over-the-counter cough medicine containing dextromethorphan (DM) could cause a problem as serious as serotonin syndrome. The DM in the cough medicine apparently interacted with your daughter’s antidepressant, escitalopram.

This isn’t the first time we’ve heard of Lexapro interacting with dextromethorphan. Here is a link to a somewhat similar scary serotonin syndrome story.

The interaction of escitalopram and dextromethorphan has been reported in the medical literature. Here is a documented case of scary serotonin syndrome leading to hospitalization (BMJ Case Reports, Aug. 7, 2017):

“A 63-year-old woman, presented to the emergency department (ED) with altered mental status. Approximately 1.5 hours prior to arrival, the patient was found unresponsive in bed by her husband, who had then called emergency medical services (EMS).

“On further inquiry of the patient’s husband, the patient had been sick over the past 2 weeks with cold-like symptoms, non-productive cough, chest discomfort but no fever or chills. The patient was maintained on long-standing escitalopram for her depression. She had consulted her primary care physician and was given cough syrup containing dextromethorphan-promethazine. After 5 days, there was reported loss of appetite, sleep talking and poor sleep. Two days prior to ED admission, there was note of possible auditory and visual hallucinations. Over 2 weeks, she progressively had cognitive decline, described as ‘not her usual self’ and acting slower than usual.

“On arrival in the ED in the evening, she was briefly awake but restless with twitching of her upper extremities.”

The doctors eliminated both the escitalopram and dextromethorphan. She received extra oxygen and IV fluids. By the next morning she had stabilized. They end their article:

“In conclusion, serotonin syndrome frequency and severity increases with drug interactions of medications such as SSRI and over-the-counter medications such as dextromethorphan. Review of medication interactions is important to prevent serotonin syndrome, and recognition through examination and review of medications is key to preventing further complications.”

Nyquil and Sertraline:

Do you read the label of OTC cold and cough medicine? Would you know what the ingredients are if you did? Here is the ingredient list for Nyquil:

“Active Ingredients (in each 30 mL)

Acetaminophen 650 mg (Pain reliever/fever reducer)

Dextromethorphan HBr 20 mg (Cough suppressant)

Doxylamine succinate 12.5 mg (Antihistamine)

Phenylephrine HCl 10 mg (Nasal decongestant)

“Inactive Ingredients

alcohol, citric acid, D&C Yellow No. 10, FD&C Yellow No. 6, FD&C Green No. 3, flavor, glycerin, propylene glycol, purified water, saccharin sodium, sodium benzoate, sodium chloride, sodium citrate, sorbitol, sucralose”

Here is a reported interaction between the antidepressant sertraline and the ingredients in Nyquil (The Primary Care Companion for CNS Disorders, online, Dec. 27, 2012).

“Mr A, a 46-year-old thinly built man, had received sertraline 100 mg/d for depression for 2 years… After he developed cough, congestion, and insomnia, he called his primary care physician for an appointment. The physician’s office recommended his taking over-the-counter (OTC) medications for congestion until he was to be seen the following day. Thus, he started taking OTC NyQuil containing dextromethorphan; in 1 night, he drank 240 mL [8 oz] of the liquid.

“The next day, Mr A presented to the emergency department with confusion, shivering, agitation, fever, diaphoresis [sweating], stupor, hyperreflexia, and diarrhea. Examination found tachycardia [rapid heart beat] with pulse of 110 bpm, blood pressure of 155/89 mm Hg, tachypnea [rapid breathing] (24 breaths/min), and hyperthermia [fever] (39.0°C). Mydriasis [dilated pupils] and hyperactive bowel sounds were appreciated. Neurologic examination was positive for hyperreflexia (which was greater in the lower than in the upper extremities), tremor, and rigidity.”

The physicians diagnosed serotonin syndrome based on this man’s symptoms. They gave him diazepam (Valium), IV fluids and he gradually got better over two days. The authors cautioned:

“Patients taking SSRIs should be warned about the increased chances of serotonin syndrome when also taking over-the-counter medications containing dextromethorphan. Once recognized, serotonin syndrome should be aggressively treated and offending agents should be removed.”

Other Combos that Can Trigger Scary Serotonin Syndrome

Many antidepressants affect serotonin levels. Fluoxetine (Prozac) or sertraline (Zoloft) may also trigger serotonin syndrome, particularly if combined with another medication such as a triptan for migraine treatment, tramadol for pain or the antibiotic linezolid.

Diagnosing Serotonin Syndrome is NOT A Slam Dunk

The physicians writing in BMJ Case Reports note that:

“Clinically, serotonin syndrome has a broad range of presentations that often result in under diagnosis. Mild cases may result from therapeutic doses, and the patient may or may not be symptomatic. Moderate cases present with more autonomic and neurological dysfunction. Severe cases generally present with worsening vital signs, rigidity, hyperthermia and the potential for multiorgan failure.”

Serotonin syndrome is personal for my family. An avoidable drug interaction led to serotonin syndrome for my mother. The devastating reaction set off a cascade of events that led to my mother’s death the next morning. This occurred in one of the best hospitals in the U.S. The attending physician had never heard of serotonin syndrome.

You can read the details of this deadly drug interaction in our book, Top Screwups. We have included a section about preventing dangerous drug interactions. It is available in libraries or online at our bookstore.

We hope your family will never experience a dangerous drug interaction. Always trust but verify! Do your homework to make sure a loved one does not receive medicines that could be incompatible. That includes over-the-counter cough medicine like dextromethorphan.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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Valuable information. What can we do immediately – before or as we call for help – to alleviate the dangerous symptoms ?

This is really interesting to me. My daughter was prescribed anti-depressants a couple of years ago and they have really helped her. When discussing this with her psychiatrist, I was told that used according to directions, an occasional use of cough meds were usually safe and that negative side effects were very rare.

First I want to thank you for posting this and letting people know! Many of the fibromyalgia members of my support group think I am nuts about talking about serotonin syndrome, but once you start having the side effects of brain zaps, of squeed vision, dizziness, slurred speech, not to mention temperature problems, with hyper sweating, sadly, you’re off to the races with serotonin syndrome.

Doctors are pretty cavalier when it comes to Serotonin Syndrome (which I have had twice), and it is no joke. People die from it! In my case, it came from experimentally having doctors add drugs (sleep meds, anti-nausea meds, and pain medications, not to mention Proton Pump Inhibitors) without bothering to look at the rest of my med sheet which contained numerous over the counter meds that also cause serotonin increase (like cough medicine, Benedryl, Sudafed, and don’t get me started on phyto MAOI (natural herbs) like Turmeric, and this list is huge) and once you’ve had serotonin syndrome, you have to be very, very careful to not go there again. This means thinking twice before even drinking an herbal tea and not using “golden milk” for health purposes because it can be dangerous for us!

Both Serotonin attacks gave me seizures, 104.6-degree temperatures, nausea, vomiting and core dumping that were serious. I have cerebral palsy on top of Fibromyalgia, and the reality is doctors do not know enough either about secondary OTC drugs that can increase serotonin (like cough syrups, etc) so therefore, they don’t even consider it when they are dispensing other serotonin drugs such as sleep meds, etc. AND they NEED to.

This is very scary. My husband is on Prozac and will just swig Niguel any time he has a cough or cold.

After switching to a generic version of Zoloft and no longer experiencing relief from symptoms of major depression, my PCP began experimenting by adding various drugs to the Rx for sertraline without positive effect. Within 3 days of adding a generic form of Wellbutrin to the mix, I began experiencing physical and mental problems including visual hallucinations.

I quit taking the buproprion and called a friend who offered to drive me to the hospital but on the way I experienced a grand mal seizure. I was diagnosed with serotonin syndrome at the hospital and quit taking all antidepressant meds from that time forward. My PCP decided I was *noncompliant* with her prescription recommendations. She is no longer my PCP. While I continue to be plagued with the symptoms of major depression, I have not experienced any further symptoms of serotonin syndrome — including the visual hallucinations and seizures which were obviously due to the drugs I was prescribed so carelessly by my physician. And we pay dearly for this kind of *care*…

Thanks!! Extremely useful to bring this kind of stories, with or without a known mechanism.
Serependity had often caused big changes in our world.
Wine is made from raisins…….some common denominator??

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