Epileptic seizure due to drug interaction between sertraline and methylphenidate

Peña Guerrero, Patricia; Magro Fernández, Carolina; Durán Ferreras, Eduardo

doi:10.1016/j.medcle.2016.12.049

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There are drugs, such as the antidepressants, which may favour the onset of epileptic episodes as the seizure threshold is lowered.We report the case of a 14-year-old male, with no history of interest except for attention deficit-hyperactivity disorder under treatment for some years with methylphenidate (MPH) 54mg/day, and, just during the last 15 days, receiving sertraline (SRT) solution 10mg/day for depressive symptoms. The patient was admitted for a generalised tonic–clonic seizure without tongue biting, followed by drowsiness and postepileptic amnesia. It was the first seizure with these characteristics. The examination was normal, as well as a complete lab test, X-ray, electrocardiogram, electroencephalogram (EEG) and cranial CT scan. Suspecting that the SRT was the cause of the seizure, its administration was suspended since that moment.The use of antidepressants may trigger the onset of epileptic seizures, particularly in patients with a history of epilepsy, the elderly, those taking high doses of antidepressants or those with neurological injuries, among others.<a class="elsevierStyleCrossRef" href="#bib0030">1</a>SRT is a selective serotonin reuptake inhibitor, a first-choice drug in the treatment of various disorders (depression, dysthymic and obsessive-compulsive disorder), as it presents the best evidence and the best risk/benefit balance, and is considered an antidepressant with a low epileptogenic risk. Others, such as duloxetine, bupropion or venlafaxine, have a medium or medium–high risk.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> Even SRT could help control seizures by inhibiting (reducing the permeability of the presynaptic sodium channels) secretion of proinflammatory cytokines (IL-1β and TNF-α), which increase in both epilepsy and depression. Even though it reduces brain excitability,<a class="elsevierStyleCrossRef" href="#bib0035">2</a> at high doses, by co-activation of serotonergic brain receptors, it can induce an increase in seizure frequency in epileptic patients.<a class="elsevierStyleCrossRefs" href="#bib0030">1,3</a>Besides, 3 cases of epileptic seizures have also been published in which, like in the case of our patient, SRT was combined with MPH. They were analysed in 2008.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> MPH is a mild stimulant of the central nervous system, as it blocks the presynaptic reuptake of norepinephrine and dopamine, with its consequent release into the extraneuronal space. It may lower the seizure threshold in epileptic patients and even in those without previous history of epileptic seizures or EEG abnormalities, as in the case of our patient. The cases found in the literature review conducted on the epileptogenic synergistic effect of MPH and SRT have been very rare. McGlohn and Bostwick were the first to report, in 1995, the appearance of seizures after administration of MPH in a 61-year-old man already receiving treatment with SRT. Two years later, Feeney and Klykyl described the onset of seizures after the introduction of SRT in a 13-year-old already under treatment with MPH for years; and finally, in 2008, Schertz and Steinberg<a class="elsevierStyleCrossRef" href="#bib0045">4</a> described another case in a 12-year-old adolescent. Neither our patient nor any of the other patients had another epileptic seizure after the withdrawal of SRT.According to the Drug Interaction Probability Scale of Horn et al.,<a class="elsevierStyleCrossRef" href="#bib0050">5</a> which uses different questions about potential interactions and pharmacological properties, there would be a probable interaction. Therefore, we believe that taking MPH with SRT contributed decisively to our patient experiencing the seizure, even though the antidepressant dose was not high, and, therefore, we submitted the corresponding notification of suspected adverse reaction to the Andalusian Center of Pharmacovigilance. By way of conclusion, we can say that SRT has two different interactions regarding epilepsy; although it is considered a safe drug in patients with this condition, there is a risk (even though low) of triggering the onset of seizures, especially if it is administered in conjunction with other drugs such as MPH. Therefore, it must be used at the lowest possible dose, and if a patient taking SRT has an epileptic seizure, this drug should be considered as responsible, even when administered at usual doses." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Peña Guerrero P, Magro Fernández C, Durán Ferreras E. Crisis comicial por la interacción sertralina-metilfenidato. Med Clin (Barc). 2016;147:568." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antidepresivos en epilepsia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B. 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Aldana" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0111665" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2014" "volumen" => "9" "paginaInicial" => "e111665" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25364907" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seizure with sertraline: is there a risk?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Sarkar" 1 => "S. Gangadhar" 2 => "E. Subramaniam" 3 => "S.K. Praharaj" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Neuropsychiatry Clin Neurosci" "fecha" => "2014" "volumen" => "26" "paginaInicial" => "27" "paginaFinal" => "32" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seizures induced by the combination treatment of methylphenidate and sertraline" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Schertz" 1 => "T. Steinberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/cap.2007.0141" "Revista" => array:6 [ "tituloSerie" => "J Child Adolesc Psychopharmacol" "fecha" => "2008" "volumen" => "18" "paginaInicial" => "301" "paginaFinal" => "303" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18582188" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proposal for a new tool to evaluate drug interaction cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.R. Horn" 1 => "P.D. Hansten" 2 => "L.N. Chan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1345/aph.1H423" "Revista" => array:6 [ "tituloSerie" => "Ann Pharmacother" "fecha" => "2007" "volumen" => "41" "paginaInicial" => "674" "paginaFinal" => "680" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17389673" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014700000012/v1_201702040025/S2387020616307999/v1_201702040025/en/main.assets" "Apartado" => array:4 [ "identificador" => "46463" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014700000012/v1_201702040025/S2387020616307999/v1_201702040025/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616307999?idApp=UINPBA00004N"]

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Vol. 147. Issue 12.

Pages 568 (December 2016)

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