Advising patients on serotonin syndrome in General Practice

We were very interested in the review of serotonin syndrome management by Chiew et al.¹ It highlighted the importance of early symptom recognition in reducing severity progression.

Given that the majority of prescribing practices occur in primary care, we recently conducted an audit (April 2024) at a large General Practice in the United Kingdom. The audit aimed to determine whether the potential risk of serotonin syndrome was communicated to at-risk patients and, if so, the nature of the advice provided. We performed a search of the practice's electronic patient records to identify patients who were currently co-prescribed two or more medications known to increase the risk of serotonin syndrome. The medications of interest included selective serotonin reuptake inhibitors, serotonergic-noradrenergic reuptake inhibitors, triptans and opioids. A subsequent review of individual patient notes was conducted to identify any documentation pertaining to serotonin syndrome counselling.

From the total practice population of 15 328 patients, 148 individuals were identified through the search. Of these, only 36 patients (24%) had documented evidence of receiving specific safety netting advice regarding serotonin syndrome. Among these, 5 patients were informed solely of the risk of the condition, 18 were additionally warned about the potential signs and symptoms and 13 were advised on appropriate actions to take if they experienced these symptoms.

We acknowledge that this audit is limited by its reliance on clinical documentation, which may not fully capture all discussions that occurred during consultations. However, from a medico-legal perspective, the absence of documentation generally implies that the discussion did not take place. Therefore, this audit underscores the need to enhance medication counselling practices, particularly concerning higher risk drug combinations, to ensure that patients are adequately informed about the possible signs and symptoms of serotonin syndrome and the importance of seeking urgent medical attention.

As a result of this audit, we recommend the implementation of educational interventions to raise clinician awareness of this complication. Additionally, integrating alerts into the patient record system may help remind clinicians of the key areas to discuss and document during consultations. A follow-up audit is planned to evaluate the effectiveness of these interventions.