Appendix 1 Case reports of serotonin syndrome following concomitant use of tramadol with SSRIs are outlined in the table below. No case reports of serotonin syndrome developing in patients taking concomitant tramadol and escitalopram or fluvoxamine were located. Patient Tramadol dose SSRI dose Other Symptoms Outcome Ref age & sex medicines Tramadol and citalopram 70 yrs, female 50mg daily added to Citalopram 10mg daily Unknown Tremor, restlessness, fever, confusion, Symptoms resolved following tramadol 11 therapy visual hallucinations discontinuation 78 yrs, female Unknown Citalopram dose & duration Full recovery after both drugs removed. 12 unknown 71 yrs, female unknown Citalopram dose unknown Codeine, Unknown. Findings at autopsy: pulmonary Death 13 diazepam, and cerebral oedema ibuprofen 62 yrs male 50mg tds added to Citalopram 40mg daily, Bupropion Three days after starting tramadol presented Symptoms resolved within 48 hours of 14 therapy 150mg bd to the Emergency department with tremors, admission to hospital diaphoresis and anxiety 44 yrs, female Tramadol 100mg Citalopram 40mg daily Paracetamol Altered mental status, random spontaneous Symptoms resolved over 4 days after 15 qds as needed jerky movements in the extremities, medications stopped. added to therapy a combination, generalised weakness and vomiting. week before event (possibly taken to excess no details) lisinopril – Tramadol and fluoxetine 31 yrs, female 200–400mg daily Fluoxetine 20mg daily Unknown Tremor of right hand spread to face Both fluoxetine and tramadol discontinued. 16 started four weeks Symptom improvement 7 days later. prior to symptom presentation 72 yrs, female 150mg daily started Fluoxetine 20mg daily Unknown Feeling nervous, pyrexic, piloerection, Physical symptoms resolved 3 days after 17 18 days prior to muscular contractions, agitated, euphoric, tramadol discontinuation, although mental symptom hyperactive, insomnia. state still affected. Fluoxetine treatment presentation stopped and antipsychotic treatment started. Symptoms resolved 2 weeks later.
Appendix 1 Case reports of serotonin syndrome following concomitant use of tramadol with SSRIs are outlined in the table below. No case reports of serotonin syndrome developing in patients taking concomitant tramadol and escitalopram or fluvoxamine were located. Patient age & sex Tramadol dose SSRI dose Other medicines Symptoms Outcome Ref Tramadol and citalopram 70 yrs, female 50mg daily added to therapy Citalopram 10mg daily Unknown Tremor, restlessness, fever, confusion, visual hallucinations Symptoms resolved following tramadol discontinuation 11 78 yrs, female Unknown Citalopram dose & duration unknown Full recovery after both drugs removed. 12 71 yrs, female unknown Citalopram dose unknown Codeine, diazepam, ibuprofen Unknown. Findings at autopsy: pulmonary and cerebral oedema Death 13 62 yrs male 50mg tds added to therapy Citalopram 40mg daily, Bupropion 150mg bd Three days after starting tramadol presented to the Emergency department with tremors, diaphoresis and anxiety Symptoms resolved within 48 hours of admission to hospital 14 44 yrs, female Tramadol 100mg qds as needed added to therapy a week before event (possibly taken to excess – no details) Citalopram 40mg daily combination, lisinopril Altered mental status, random spontaneous jerky movements in the extremities, generalised weakness and vomiting. Symptoms resolved over 4 days after medications stopped. 15 Tramadol and fluoxetine 31 yrs, female 200–400mg daily started four weeks prior to symptom presentation Fluoxetine 20mg daily Unknown Tremor of right hand spread to face Both fluoxetine and tramadol discontinued. Symptom improvement 7 days later. 16 72 yrs, female 150mg daily started 18 days prior to symptom presentation Fluoxetine 20mg daily Unknown Feeling nervous, pyrexic, piloerection, muscular contractions, agitated, euphoric, hyperactive, insomnia. Physical symptoms resolved 3 days after tramadol discontinuation, although mental state still affected. Fluoxetine treatment stopped and antipsychotic treatment started. Symptoms resolved 2 weeks later. 17 Paracetamol
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