A 34 week-gestation infant was delivered from a mother with bipolar disease and PTSD on a combination of venlafaxine 150 mg daily, bupropion hydrochloride 300 mg daily, quetiapine 200 mg daily, and gabapentin 1200 mg 3 times daily. What symptoms did the infant experience and what were the symptoms attributed to?
At the time of delivery, he was hypotonic, but, at ∼10 minutes of life, while in the delivery room, he was noted to have nonsuppressible spells of bilateral arm internal rotation with wrist flexion and bilateral leg extension, alternating with generalized hypotonia. He demonstrated sustained ankle clonus and significant hyperreflexia with bilateral knee extension elicited by a unilateral patellar stimulus. His movements were not associated with vital sign changes.
The symptoms were attributed to serotonin syndrome from in-utero pharmacologic interaction to venlafaxine, o-desmethylvenlafaxine, bupropion and quetiapine in the face of decreased neonatal CYP2D6, cytochrome P450 2C19, and CYP3A4 activity and decreased renal function, particularly if premature.
Brajcich MR, Palau MA, Messer RD, Murphy ME, Marks J. Why the Maternal Medication List Matters: Neonatal Toxicity From Combined Serotonergic Exposures. Pediatrics. 2021 Feb;147(2):e20192250. doi: 10.1542/peds.2019-2250. PMID: 33504611.
Submitted by: James Mowry, PharmD, DABAT