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Douglas S. Paauw, MD<\/p>\nHow Much Do You Know About SSRI Side Effects?Douglas S. Paauw, MD<\/p>\n
A 45-year-old woman presents with increasing tremor in her arms and a new tremor in her legs. These have been present for the past 3 weeks. She was in a motor vehicle accident 6 weeks ago and sustained a neck injury as well as increased fear, anxiety, and insomnia<\/a> since the accident. Her exam shows a postural tremor which is mild. Current medications: sertraline<\/a>, zolpidem, tramadol<\/a>, and naproxen<\/a>.<\/p>\n Which medication is the most likely cause of the tremors?\u00a0 The likely cause of her tremor is sertraline, a selective serotonin reuptake inhibitor (SSRI). It is possible the patient has serotonin syndrome<\/a> with the combination of sertraline and tramadol. Tremors are almost always present with serotonin syndrome. SSRIs can cause tremors separate from serotonin syndrome. The tremor<\/a> is usually postural and resolves with discontinuation of the medication. In one case series of fluoxetine-induced tremor<\/a>, it lasted for months after discontinuation.<\/p>\n Hyponatremia<\/p>\n Another important, underappreciated side effect of SSRIs is hyponatremia<\/a>. SSRI use is more common in patients who are admitted with severe (Na hyponatremia. A meta-analysis of 39 studies looking at antidepressant exposure risk and development of hyponatremia found the highest risk being in patients exposed to serotonin-norepinephrine<\/a> reuptake inhibitors (7.44%) and SSRIs (5.59%); mirtazapine<\/a> was much less likely to be associated with hyponatremia (1%). Hyponatremia due to SSRIs is elevated<\/a> in elderly patients and women. Simultaneous use of diuretics<\/a> and angiotensin converting enzyme inhibitors further increases the risk of hyponatremia in patients who use SSRIs.<\/p>\n Yawning<\/p>\n Yawning is an interesting side effect of SSRIs. In a case report by Sinha and colleagues, a patient developed frequent yawning<\/a> (5 times every 15 minutes) when her escitalopram<\/a> dose was increased from 5 mg to 15 mg. Roncero et al described a case of yawning in a patient on escitalopram that resolved when the dose of escitalopram<\/a> was reduced. In a review of drug-induced yawning<\/a>, SSRIs as a class were most frequently involved, and sertraline, fluoxetine<\/a>, and paroxetine<\/a> were implicated.<\/p>\n Bleeding Risk<\/p>\n
\u2003A) Sertraline\u00a0
\u2003B) Zolpidem\u00a0
\u2003C) Tramadol\u00a0
\u2003D) Naproxen<\/p>\n