Which analgesic agent would a nurse avoid to help prevent Serotonin syndrome with a patient who takes sertraline?

Open Resources for Nursing (Open RN)

Antidepressants are used to treat depression and other mental health disorders, as well as other medical conditions such as migraine headaches, chronic pain, and premenstrual syndrome. Antidepressants increase levels of neurotransmitters in the CNS, including serotonin (5-HT), dopamine, and norepinephrine. Treatment is based on the belief that alterations in the levels of these neurotransmitters are responsible for causing depression.[1]

This module will discuss four classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). These medications are compared in Table 8.7.

TCAs and MAOIs are referred to as first-generation antidepressants because they were first marketed in the 1950s. SSRIs, SNRIs, and other miscellaneous medications such as bupropion are called second-generation antidepressants and are popular because of fewer side effects like sedation, hypotension, anticholinergic effects, or cardiotoxicity.[2]

Safety warnings (Black Box) are in place for all classes of antidepressants used with children, adolescents, and young adults for a higher risk of suicide. All clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.

For more information on different types of anti-depressants, watch this video.

Pharmacology – Antidepressants, SSRI, MAIO, TCA, SNRIs by Simple Nursing, is licensed under a Standard YouTube license

Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) were one of the original first-generation antidepressants. Due to the popularity of SSRIs and SNRIs, TCAs are now more commonly used to treat neuropathic pain and insomnia.

Mechanism of Action

TCAs tend to have sedative and anticholinergic effects. They act by inhibiting presynaptic reuptake of NE and 5-HT into nerves. The choice of TCA depends on individual response and tolerance to the drug.

Indications for Use

TCAs are used to treat depression, chronic neuropathic pain, and insomnia.

Nursing Considerations Across the Lifespan

TCAs are often administered at bedtime due to sedating effects and are contraindicated with MAOIs.

Geriatric clients are particularly sensitive to the anticholinergic side effects of tricyclic antidepressants. Peripheral anticholinergic effects include tachycardia, urinary retention, constipation, dry mouth, blurred vision, and exacerbation of narrow-angle glaucoma. Central nervous system anticholinergic effects include cognitive impairment, psychomotor slowing, confusion, sedation, and delirium. Elderly clients taking amitriptyline may be at increased risk for falls. Elderly clients should be started on low doses of amitriptyline and observed closely.

After prolonged administration, abrupt cessation of treatment may produce nausea, headache, and malaise. The dose should be gradually tapered, but transient symptoms may still occur.

TCAs should not be used in children and those who are pregnant or lactating.

Adverse/Side Effects

Adverse effects of TCAs are a result of their blockade effects on various receptors, often resulting in anticholinergic adverse effects such as constipation, urinary retention, and drowsiness. Blockage of adrenergic and dopaminergic receptors can cause cardiac conduction disturbances and hypotension. Histaminergic blockage can cause sedation, and serotonergic blockade can alter the seizure threshold and cause sexual dysfunction.

Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.

TCAs are contraindicated as follows:

• Myocardial infarction.
• Concurrent use of MAOIs.
• Pregnancy, lactation.
• Preexisting cardiovascular disorders.
• Angle-closure glaucoma, urinary retention, prostate hypertrophy, GI or GU surgery.
• History of seizures.
• Hepatorenal diseases.

There are also several drug interactions such as cimetidine, fluoxetine, ranitidine: increased therapeutic and adverse effects of TCAs. Usage with oral anticoagulants can increase serum levels of anticoagulants and increase the risk of bleeding. TCAs should not be used concurrently with MAOIs, which increases the risk for a severe hyperpyretic crisis. [3]

Overdosage

Death may occur from overdosage with this class of drugs. Multiple drug ingestion (including alcohol) is common in deliberate tricyclic antidepressant overdose. If an overdose occurs, consult with a Poison Information Center (1-800-567-8911).

Client Teaching & Education: Due to the increased risk of suicidality with antidepressants, clients and their family members or caregivers should be instructed to immediately report any sudden changes in mood, behaviors, thoughts, or feelings. The potential side effects discussed above should be reviewed. [4],[5],[6]

Table 8.7 provides a closer look at this medication and compares TCAs with other classifications of antidepressants. 

Selective Serotonin Reuptake Inhibitor (SSRI)

Selective Serotonin Reuptake Inhibitors (SSRIs) are second-generation antidepressants and have fewer side effects than TCAs and MAOIs. Fluoxetine and citalopram are commonly used SSRIs.

Mechanism of Action

SSRIs inhibit the reuptake of serotonin.

Indications for Use

SSRIs are primarily used to treat depression but are also used to treat obsessive-compulsive disorder, bulimia, panic disorder, posttraumatic stress disorder, other forms of anxiety, premenstrual syndrome, and migraines.

Nursing Considerations Across the Lifespan

The onset of fluoxetine’s antidepressant effect develops slowly for up to 12 weeks.

Use caution in clients who are taking other CNS medications or who have liver dysfunction. This drug is contraindicated with MAOIs. Monitor for increased suicide ideation in all populations, as well as for the development of serotonin syndrome. Clients should avoid grapefruit juice due to its effect on the CYP3A4 enzyme that affects the bioavailability of the medication.

Adverse/Side Effects

Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.

The development of a potentially life-threatening serotonin syndrome or neuroleptic malignant syndrome (NMS)-like reactions has been reported with SNRIs and SSRIs, particularly with concomitant use of serotonergic drugs, drugs that impair the metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists. Symptoms of may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin syndrome, in its most severe form, can resemble (NMS), which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and mental status changes. Clients should be monitored for the emergence of serotonin syndrome or NMS-like signs and symptoms.[7]

Other side effects include rash; mania; seizures; decreased appetite and weight; increased bleeding associated with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation; hyponatremia; anxiety; and insomnia.

Abrupt discontinuation may cause several adverse effects, so a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. [8],[9],[10] 

Client Teaching & Education

Clients should be careful to take medications as directed. Abrupt discontinuation may cause anxiety, insomnia, and increased nervousness. Additionally, orthostatic blood pressure changes are common during medication therapy. Clients may also be increasingly drowsy or exhibit some confusion. Use of SSRI medications with alcohol or other CNS depressant drugs should be avoided.

Clients, family, and caregivers should monitor clients carefully for suicidality.  Other side effects include possible decreased libido, urinary retention, constipation, and increased photosensitivity.

Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants. 

A 32-year-old female visits the nurse practitioner with concerns about “feeling tired all the time,” “having difficulty concentrating,” “problems sleeping,” and “just generally feeling down.” The nurse practitioner prescribed fluoxetine.

The client tells the nurse, “One of my friends told me I have to be careful or I might get serotonin syndrome if I take medication.”

1. What places a client at risk for serotonin syndrome, and what symptoms should the nurse teach the client about this condition?

2. The nurse knows that anyone starting an antidepressant is at risk for suicidal thoughts. How should the nurse therapeutically discuss this potential adverse effect with the client?

3. What potential common side effects should the nurse discuss with the client?

The client states, “I can’t wait to feel better again. How soon will this medication work?”

4.  What is the nurse’s best response?

Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.

Serotonin Norepinephrine Reuptake Inhibitor (SNRI)

Venlafaxine is an example of a Serotonin Norepinephrine Reuptake Inhibitor (SNRI).

Mechanism of Action

Venlafaxine inhibits the reuptake of serotonin and norepinephrine, with weak inhibition of dopamine reuptake.

Indications for Use

SNRIs are indicated for the treatment of a major depressive disorder.

Nursing Considerations Across the Lifespan

SNRIs are contraindicated with MAOIs or within 14 days of use of an MAOI. Dosage adjustment is required for use in clients with renal and/or liver disease. Elderly clients are at greater risk for developing hyponatremia. Use with caution with other serotonin medications.

Adverse/Side Effects

Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.

SNRI medication may cause a sustained increase in blood pressure. Other side effects include serotonin syndrome, insomnia, anxiety, decreased appetite, weight loss, mania, hyponatremia, increased bleeding (especially with the concomitant use of fluoxetine and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation), elevated serum cholesterol, somnolence, and nausea. [11]

Client Teaching & Education

Clients should be careful to take medications as directed.  The dose should be tapered prior to discontinuation. Clients may also be increasingly drowsy or dizzy.  Use of SNRI medications with alcohol or other CNS depressant drugs should be avoided. Clients, family, and caregivers should monitor clients carefully for suicidality.

Table 8.7 provides a closer look at this medication and compares SSRIs with other classifications of antidepressants. 

Monoamine Oxidase inhibitors (MAOI)

Monoamine oxidase inhibitors (MAOIs) are first-generation antidepressants.  A significant disadvantage to MAOIs is their potential to cause a hypertensive crisis when taken with stimulant medications or foods containing tyramine.

Mechanism of Action

The mechanism of action of MAOIs is not fully understood but is presumed to be linked to the potentiation of monoamine neurotransmitter activity in the central nervous system resulting from its inhibition of the enzyme monoamine oxidase (MAO).[12] MAO inactivates norepinephrine, dopamine, epinephrine, and serotonin. By inhibiting MAO, the levels of these transmitters rise thus creating anti-depressive effects.[13]

Indications for Use

MAOIs are indicated for the treatment of major depressive disorder in adult clients who have not responded adequately to other antidepressants.

Nursing Considerations Across the Lifespan

Serious interactions with several medications, as well as foods and beverages containing tyramine, have been reported; check drug labeling before administering. Safety has not been established with the pediatric population. The elderly population is at increased risk for postural hypotension and serious adverse effects. Misuse and dependence have been reported. Withdrawal effects can continue for several weeks after discontinuation.

Adverse/Side Effects

Black Box Warnings are in place for all classes of antidepressants used with children, adolescents, and young adults for higher risk of suicide. Clients receiving antidepressants should be monitored for signs of worsening depression or changing behavior, especially when the medication is started or dosages are changed.

Use with caution due to the risks of hypertensive crisis, serotonin syndrome, and increased suicidality. is defined by severe hypertension (blood pressure greater than 180/120 mm Hg) with evidence of organ dysfunction. Symptoms may include occipital headache (which may radiate frontally), palpitations, neck stiffness or soreness, nausea or vomiting, sweating, dilated pupils, photophobia, shortness of breath, or confusion. Either tachycardia or bradycardia may be present and may be associated with constricting chest pain. Seizures may also occur. Intracranial bleeding, sometimes fatal, has been reported in association with the increase in blood pressure. See more information about serotonin syndrome in the “SSRI” section.

Other potential side effects include mania, , hepatotoxicity, seizures, hypoglycemia in diabetic clients, decreased appetite and weight loss, dizziness, headache, drowsiness, and restlessness. Clients should be advised it may impair their ability to operate machinery or drive. MAOIs should be discontinued if hepatotoxicity occurs.[14]

Client Teaching & Education

Clients should be careful to take medications as directed. It may take up to 4 weeks to see the effects of the drug. They should avoid abrupt cessation of therapy to avoid withdrawal symptoms. Clients should avoid alcohol, other CNS depressants, and tyramine-containing products for two weeks after therapy is discontinued.  Clients should be advised regarding the signs of hypertensive crisis and to immediately report headache, chest or throat tightness, and palpitations to the provider.

Now let’s take a closer look at a medication grid that compares these classifications of anti-depressants in Table 8.7a.[15],[16],[17] 

Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below.  Prototype or generic medication examples are also hyperlinked to a free resource at Daily Med. On the home page, enter the drug name in the search bar to read more about the medication.