A 58-year-old woman comes to the office with new-onset low back pain. The patient was helping her friend move yesterday and strained her back. She does not drink alcohol or use illicit substances. Medical history includes hypertension and major depressive disorder currently treated with captopril and citalopram. A short course of medication is prescribed, and the patient is asked to monitor for development of diaphoresis, restlessness, tremors, and diarrhea. The patient was most likely prescribed which of the following medications?

Question

A 58-year-old woman comes to the office with new-onset low back pain.  The patient was helping her friend move yesterday and strained her back.  She does not drink alcohol or use illicit substances.  Medical history includes hypertension and major depressive disorder currently treated with captopril and citalopram.  A short course of medication is prescribed, and the patient is asked to monitor for development of diaphoresis, restlessness, tremors, and diarrhea.  The patient was most likely prescribed which of the following medications?

Quizplus · Accepted Answer

11ec160b_3c59_9e27_9249_d13f0a18923d_MD0001_00 The symptom constellation of diaphoresis, restlessness, tremors, and diarrhea is characteristic of serotonin syndrome, a potentially dangerous condition that results from excess serotonergic activity in the CNS. This patient is currently taking the selective serotonin reuptake inhibitor (SSRI) citalopram and was likely prescribed tramadol, an opioid analgesic that also has serotonergic activity. Tramadol acts as a mu opioid receptor agonist and serotonin and norepinephrine reuptake inhibitor and, in combination with an SSRI, can potentially cause serotonin syndrome. Onset of serotonin syndrome typically occurs within the first 24 hours after a change in dose or initiation of a serotonergic medication, and typically presents with the classic triad of mental status changes, autonomic instability, and neuromuscular hyperactivity. In addition, stimulation of serotonin receptors in the gut commonly results in gastrointestinal symptoms (eg, diarrhea) and hyperactive bowel sounds. Patients taking SSRIs should be cautioned about the risk of serotonin syndrome when a medication with serotonergic activity is added. Tramadol (or other causative agent) should be discontinued promptly if serotonin syndrome occurs. (Choice A) Baclofen, a selective agonist of the GABA B receptor, works as a skeletal muscle relaxant by inhibiting reflexes at the spinal cord level. Its common adverse effects include sedation and dizziness. (Choices B and D) Celecoxib and naproxen are nonsteroidal anti-inflammatory drugs commonly used as initial therapy for acute low back pain. Celecoxib is a selective inhibitor of cyclooxygenase-2 (COX-2), whereas naproxen is a nonselective inhibitor of COX-1 and COX-2. Neither drug is associated with serotonin syndrome. (Choice C) Diazepam is a benzodiazepine that works by binding to GABAA receptors. Benzodiazepines have sedative, anxiolytic, anticonvulsive, and muscle-relaxing properties; adverse effects include impairment of psychomotor performance, amnesia, and dependence. Educational objective: Coadministration of tramadol with serotonergic medications such as selective serotonin reuptake inhibitors increases the risk of serotonin syndrome, which presents with the characteristic triad of mental status changes (agitation, confusion), autonomic instability (hyperthermia, diaphoresis), and neuromuscular hyperactivity (tremor, myoclonus). __________ References: Tramadol, pharmacology, side effects, and serotonin syndrome: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26218943)

A 58-Year-Old Woman Comes to the Office with New-Onset Low