Eletriptan interaction
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First report of an interaction with concomitant fluoxetine and hypericum leading to serotonin syndrome and rhabdomyolysis: case report A 28-year-old woman developed serotonin syndrome and rhabdomyolysis during treatment with concomitant eletriptan, fluoxetine and hypericum. The woman had a history of migraine attacks since adolescence and had experienced four episodes of 1–2 days duration each month; she had received eletriptan 40 mg/day at the start of an attack. She was hospitalised because of sudden head deviation and loss of consciousness. At the time of admission, she had received eletriptan 3–4 times a month over the previous 6 months [dosage not clearly stated], and had taken 40 mg/day in the previous 3 days for recurrent migraine. She had also received fluoxetine 60 mg/day for an eating disorder for the past year, and self-prescribed hypericum [St John’s Wort; dosage and therapeutic indication not stated] for a month. She had a seizure with tonic-clonic convulsions and subsequent confusion in the emergency room. A CT brain scan showed an absence of brain focal lesions. The woman received IV lorazepam. Examination showed mental slowness and subtle postural tremor of her fingers. Her temperature was 37.5°C. Blood tests revealed a mild increase in her myoglobin level and a modest increase in her D-dimer level. Her fluoxetine dosage was decreased to 20 mg/day, hypericum was stopped, and eletriptan 40 mg/day was continued. She experienced diffuse myalgias that deteriorated a few days later. Acute rhabdomyolysis indices were apparent: she had a creatine kinase level of 13.660 U/L, an aldolase level of 80 U/L and a myoglobin level of 965 µg/L. Her serum aminotransferase and D-dimer levels were also increased. Despite hydration therapy, she had transient mild acute renal failure. Eletriptan and fluoxetine were then stopped. No signs of myopathy were apparent on electromyography. At discharge 10 days later, her blood test results were normal and she did not have any myalgias. Author comment: "In this case the combination of hypericum and fluoxetine probably predisposed the patient to develop serotonin syndrome precipitated by subsequent use of eletriptan. . .[I]t is conceivable that the concomitant use of hypericum with [serotonin reuptake inhibitors] and triptans precipitated the condition by potentiating the pharmacodynamic interaction of serotonin neurotransmission." Bonetto N, et al. Serotonin syndrome and rhabdomyolysis induced by concomitant use of triptans, fluoxetine and hypericum. Cephalalgia 27: 1421-1423, No. 12, Dec 801091706 2007 - Italy
» Editorial comment: A search of AdisBase and Medline did not reveal any previous case reports of an interaction between eletriptan, fluoxetine and hypericum. The WHO Adverse Drug Reactions database did not contain any reports involving the concomitant use of eletriptan, fluoxetine and hypericum.
0114-9954/10/1173-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 13 Oct 2007 No. 1173
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