Amitriptyline

Abstract

decided that she would continue the treatment prescribed after hospital discharge. S Amitriptyline Author comment: The dosage of starting treatment with amitriptyline is recommended at a dose of 25 mg in a single Serotonin syndrome: case report nightly dose, with dose increases of 25 mg every 3-7 days. A 63-year-old woman developed serotonin syndrome The sudden establishment of a dose of 75 mg of amitriptyline during treatment with amitriptyline for bipolar affective in this patient in a single daily intake could possibly have disorder; the woman received amitriptyline at a dose of 75mg, favoured the development of [serotonin syndrome]. instead of the recommended 25mg as a single nightly dose (medication error). Sanchez-Gayango A, et al. Serotoninergic amitriptyline. Psiquiatria Biologica 26: The woman presented to hospital due to worsening of her 113-115, No. 3, Sep-Dec 2019. Available from: URL: http://doi.org/10.1016/ j.psiq.2019.10.003 [Spanish; summarised from a translation] Spain 803441101 baseline depressive state. Her medical history was notable for long-term psychiatric monitoring for bipolar affective disorder. She had been receiving multiple neuroleptic medications, and she subsequently started receiving amitriptyline 75mg at breakfast [route not stated]. However, 2 days later, she was hospitalised due to cogwheel stiffness and distal flaps in her upper limbs. Ocular myoclonus and orolingual movement disorders compatible with dyskinesia were also noted. She was unable to stand or walk without support, stating it was accompanied by an oppressive thoracic sensation. During psychopathological examination, she was found to be conscious and oriented to person; however, she was disoriented to time and space. She collaborated with slight hypoprosexia. She exhibited mood swings with affective lability. A tendency to thought derailment with loss of the main theme was also noted, without registering alterations in features or content. Her speech was dysarthric with poor flow. Sensory perception, appetite and sleep were unaltered. Neurology evaluation assessed her to be oriented in space and person, with a good level of consciousness. She was able to nominate, repeat and obey linked commands without dysarthria. She was able to maintain normal external eye movements, without facial asymmetry or nystagmus. Symmetrical deep tendon reflexes and plantar flexion test were without dysmetria. All four extremities exhibited tremor and rigidity of postural and intentional predominance, low amplitude and moderate frequency. Lingual tremors were also noted. Emergency brain CT scan showed chronic left maxillary sinusitis. Altered parameters included creatine phosphokinase 1 890 U/L, AST 53 IU/L and CRP 16 mg/L. A subsequent analytical control demonstrated a decrease in creatine phosphokinase to 650 U/L and AST to 43 IU/L. CRP remained unaltered. Therefore, it was decided to shift the woman to the evolution room, discontinuing amitriptyline and all other psychopharmacological medications. During subsequent assessment, 18h following her first interview, she remained hypoprosexic, with a tendency towards derailment and loss of the main theme. She exhibited partial amnesia of the previous day’s occurrences, non sequitur, partial disorientation to space and time, and visual and auditory illusions. Sweating and oral dyskinesia persisted; however, nystagmus, cogwheel rigidity and distal tremor were not observed. The acute confusional picture secondary to drugs raised suspicions of serotonin syndrome secondary to amitriptyline. It was believed that the sudden establishment of amitriptyline 75mg, instead of the recommended 25mg as a single nightly dose, with subsequent dose increases of 25mg every 3–7 days, might have contributed to the development of serotonin syndrome. Therefore, she was admitted to Internal Medicine, with gradual introduction of psychotropic drugs, beginning with olanzapine. During her 5-day admission, psychopharmacological therapy was gradually reinstated, with improvement in her underlying condition. At the time of discharge, the tremors decreased, being limited to her upper limbs. She was able to walk. Her orofacial and lingual tremors resolved. She expressed herself with coherent speech. She was completely oriented. She was prescribed treatment with olanzapine and diazepam. During follow-up post discharge, she was found to have a good, regular physical appearance. She was calm and collaborative. She maintained a proper appetite, being well-hydrated, without any problems in her sleep pattern. She remained in a good mood and was able to carry out her basic activities of daily living; hence, it was 1