Life-threatening serotonin toxicity due to a citalopram-fluconazole drug interaction: case reports and discussion Journal Article


Authors: Levin, T. T.; Cortes-Ladino, A.; Weiss, M.; Palomba, M. L.
Article Title: Life-threatening serotonin toxicity due to a citalopram-fluconazole drug interaction: case reports and discussion
Abstract: Objective: To discuss two cases of life-threatening serotonin toxicity due to a drug interaction between citalopram and fluconazole and to review the pertinent literature. Methods: A Medline search without date limitation was conducted using the terms serotonin syndrome, serotonin toxicity, fluconazole and citalopram. Results and Discussion: Fluconazole inhibits CYP2C19. Citalopram is a substrate for 2C19 and inhibition of its metabolism may result in serotonin toxicity. Serotonin toxicity in oncology patients may not present with the classic constellation of signs typically described in the literature. Delirium may be the only presenting feature. Current level of evidence for treatment of serotonin toxicity is level 4 or 5 (case series and expert opinion). Nevertheless, there is a strong theoretical basis for treating serotonin toxicity in medical patients with a 5H2A blocker such as cyproheptadine. Conclusions: Consultation-liaison psychiatrists and oncologists should be aware of this preventable and underrecognized interaction. Citalopram should be stopped or substituted prior to the concurrent administration of fluconazole, and in the event of toxicity, treatment with cyproheptadine has a favorable risk-benefit ratio despite a lack of randomized controlled data to support its use. © 2008 Elsevier Inc. All rights reserved.
Keywords: adult; treatment response; aged; middle aged; antibiotic agent; case report; drug withdrawal; nonhuman; antineoplastic agent; methylene blue; imatinib; drug inhibition; unindexed drug; low drug dose; enzyme inhibition; lorazepam; olanzapine; delirium; antifungal agent; enzyme substrate; information retrieval; drug fever; confusion; depression; severity of illness index; proton pump inhibitor; neuroleptic agent; medline; antilipemic agent; disease duration; antivirus agent; seizure; drug metabolism; aryl hydrocarbon hydroxylases; clarithromycin; somnolence; venlafaxine; citalopram; clonazepam; serotonin syndrome; electroencephalogram; fluconazole; antifungal agents; drug interactions; depressive disorder; phenytoin; analgesic agent; narcotic agent; drug interaction; fluvoxamine; carcinoid syndrome; disorientation; trazodone; anesthetic agent; buspirone; cyproheptadine; ritonavir; serotonin toxicity; anorexigenic agent; cardiovascular agent; delavirdine; isoniazid; ketanserin; nefazodone; long term memory; perseveration; short term memory; serotonin antagonists; serotonin uptake inhibitors
Journal Title: General Hospital Psychiatry
Volume: 30
Issue: 4
ISSN: 0163-8343
Publisher: Elsevier Science, Inc.  
Date Published: 2008-07-01
Start Page: 372
End Page: 377
Language: English
DOI: 10.1016/j.genhosppsych.2008.03.008
PUBMED: 18585543
PROVIDER: scopus
DOI/URL:
Notes: --- - "Cited By (since 1996): 3" - "Export Date: 17 November 2011" - "CODEN: GHPSD" - "Source: Scopus"
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MSK Authors
  1. Maria Lia Palomba
    128 Palomba
  2. Tomer T Levin
    58 Levin
  3. Mark Weiss
    80 Weiss