Correct!
5. All of the above

Treatment for serotonin syndrome is largely supportive with removal of all serotonergic agents, sedation with benzodiazepines, and administration of serotonin antagonists (5). Cyproheptadine (Periactin) is most commonly used and is a histamine-1 receptor antagonist with non-specific 5-HT1A and 5-HT2A antagonistic properties. The patient should be carefully evaluated to assess the need to restart serotonergic agents upon resolution of symptoms. The patient’s escitalopram, ondansetron, and methylene blue were stopped and she was treated with cyproheptadine and lorazepam. She returned back to her baseline mental status within 48 hours.

References

  1. Cerny T, Castiglione M, Brunner K, Küpfer A, Martinelli G, Lind M. Ifosfamide by continuous infusion to prevent encephalopathy. Lancet. 1990 Jan 20;335(8682):175. [CrossRef] [PubMed]
  2. Kurowski V, Cerny T, Küpfer A, Wagner T. Metabolism and pharmacokinetics of oral and intravenous ifosfamide. J Cancer Res Clin Oncol. 1991;117 Suppl 4:S148-53. [CrossRef] [PubMed]
  3. Common terminology criteria for adverse events v4.3. Bethesda, MD. U.S. Department of Health and Human Services, National Institutes of Health. National Cancer Institute. 2010. https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf.
  4. Patel PN. Methylene blue for management of Ifosfamide-induced encephalopathy. Ann Pharmacother. 2006 Feb;40(2):299-303. [CrossRef] [PubMed]
  5. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20. [CrossRef] [PubMed]
  6. Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007 Nov;152(6):946-51. [CrossRef] [PubMed]
  7. Ng BK, Cameron AJ. The role of methylene blue in serotonin syndrome: a systematic review. Psychosomatics. 2010 May-Jun;51(3):194-200. [CrossRef] [PubMed]

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