Methylthioninium-chloride/venlafaxine interaction
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Serotonin syndrome: case report A 29-year-old man developed serotonin syndrome during concomitant administration of methylthioninium-chloride and venlafaxine. The man had a history of stage IIB right femoral fibrosarcoma and had received neoadjuvant cisplatin and doxorubicin for it. He also underwent type 2 hemipelvectomy and iliofemoral fusion with fibula. He then received adjuvant ifosfamide chemotherapy and his first cycle was complicated by visual hallucinations and mild confusion, which were attributed to IIE. He was then started on methylthioninium-chloride [methylene blue] and the symptoms subsided. After 3 weeks, he was admitted for his second cycle of ifosfamide. Upon admission, he was receiving venlafaxine extended release 75 mg/day for depression and morphine for pain control. His chemotherapy regimen included ifosfamide along with concomitant metoclopramide, dexamethasone, esomeprazole and ondansetron. Due to his history of IIE, he was started on prophylactic treatment with IV methylthioninium-chloride 50 mg every 6 hours and thiamine. On the second day of hospitalisation, developed a rapid deterioration in mental status. Initially, he was found confused and then he became unresponsive to physical and verbal stimuli. Additionally, he developed sinus tachycardia, severe muscle rigidity of all extremities, fixed/dilated pupils and profuse diaphoresis. Thus, a diagnosis was confirmed with serotonin syndrome [duration of treatments to reaction onset not stated]. He stopped receiving ifosfamide and further received methylthioninium-chloride dosing for presumptive IIE. He received levetiracetam and lorazepam for presumptive seizures. However, his clinical status did not improve and became febrile. He was intubated and shifted to ICU. An electroencephalogram showed no evidence of epileptiform activity and Brain CT was unremarkable. Blood cultures were also negative. After ruling out of additional causes, the pharmacist recognised the temporal relationship between methylthioninium-chloride and venlafaxine combination. The man stopped receiving methylthioninium-chloride and venlafaxine, and was started on cyproheptadine. Subsequently, his clinical condition improved and he was extubated within 48 hours of starting original symptoms. Eventually, he was discharged on day 8 of hospitalisation without any further complications. The Naranjo scale score for this event was 7, listing it as probably secondary to the methylthioninium-chloride. Additionally, this case also fulfilled the Hunter’s Serotonin Toxicity Criteria for event probability. Gilbert B, et al. A Case of Serotonin Syndrome Caused by the Concomitant Utilization of Methylene Blue and Venlafaxine in an Oncological Patient. Journal of Pharmacy 803517623 Practice 33: 705-707, No. 5, 23 Jun 2019. Available from: URL: http://doi.org/10.1177/0897190019850706
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Reactions 28 Nov 2020 No. 1832
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