Spies Petra E, Pot J L W Hans, Willems Roel P J, Bos Jacqueline M, Kramers Cornelis
Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.
Meander Medical Centre, Amersfoort, The Netherlands.
Eur J Hosp Pharm. 2017 Mar;24(2):124-127. doi: 10.1136/ejhpharm-2015-000838. Epub 2016 Mar 23.
The combination of a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) with tramadol can result in serotonin syndrome, characterised by neuromuscular and autonomic nervous system excitation and altered mental state. The incidence of serotonin syndrome with this combination of drugs is low, and the serotonin syndrome is generally mild or moderate in form, but can be life threatening and is more easily prevented than treated. We aimed to investigate whether prescribers in a general hospital were aware of this risk and if it influenced their prescriptions.
A questionnaire was sent to 194 physicians in a general teaching hospital with over 650 beds in The Netherlands. The questionnaire presented four cases, two of whom used an SSRI or SNRI among other medications, and asked the respondents to prescribe an opioid in each case. The respondents were not aware of the focus of our research. Actual prescription rates of tramadol in admitted patients who did or did not use an SSRI or SNRI were assessed using the hospital pharmacy database.
Based on the questionnaire, respondents prescribed tramadol equally in patients with or without concomitant use of SSRIs/SNRIs. About one-third of respondents who prescribed tramadol indicated they were aware of the potential interaction with SSRIs/SNRIs. About one-fifth deliberately avoided tramadol because a potential interaction with SSRIs/SNRIs was identified. However, there was no difference in actual tramadol prescriptions, as recorded in the hospital pharmacy database: 23.8% of SSRI/SNRI users received tramadol versus 24.6% of non-SSRI/SNRI-users (calculated OR 0.96; 95% CI 0.78 to 1.17).
In total, 20-30% of prescribers in a general hospital were aware of the potential interaction between tramadol and SSRIs or SNRIs, yet this did not translate to a difference in tramadol prescriptions between SSRI/SNRI users and non-users, as documented in the hospital pharmacy database. A physician's decision to prescribe tramadol to SSRI/SNRI users may be guided by a comprehensive individual benefit-risk assessment; expected benefits of tramadol may outweigh the small risk of serotonin syndrome. In order to increase awareness of the potential risk of a serotonin syndrome, hospital pharmacies may play an important role in signalling the potential interaction and providing information on the benefits and risks of tramadol and alternative analgesics in the presence of SSRIs or SNRIs.
选择性5-羟色胺再摄取抑制剂（SSRI）或5-羟色胺-去甲肾上腺素再摄取抑制剂（SNRI）与曲马多联合使用可导致5-羟色胺综合征，其特征为神经肌肉和自主神经系统兴奋以及精神状态改变。这种联合用药导致5-羟色胺综合征的发生率较低，且该综合征通常为轻或中度，但可能危及生命，且预防比治疗更容易。我们旨在调查一家综合医院的开处方者是否意识到这种风险以及它是否会影响他们的处方。
向荷兰一家拥有650多张床位的综合教学医院的194名医生发送了一份问卷。问卷给出了四个病例，其中两个病例在使用其他药物的同时还使用了SSRI或SNRI，并要求受访者在每个病例中开出一种阿片类药物。受访者并不知晓我们的研究重点。使用医院药房数据库评估使用或未使用SSRI或SNRI的住院患者中曲马多的实际处方率。
根据问卷，受访者在同时使用或未同时使用SSRI/SNRI的患者中开具曲马多的情况相同。约三分之一开具曲马多的受访者表示他们知晓与SSRI/SNRI的潜在相互作用。约五分之一的受访者因发现与SSRI/SNRI存在潜在相互作用而刻意避免使用曲马多。然而，医院药房数据库记录的曲马多实际处方情况并无差异：23.8%的SSRI/SNRI使用者接受了曲马多治疗，而非SSRI/SNRI使用者的这一比例为24.6%（计算得出的比值比为0.96；95%置信区间为0.78至1.17）。
总体而言，一家综合医院中有20% - 30%的开处方者知晓曲马多与SSRI或SNRI之间的潜在相互作用，但正如医院药房数据库所记录的那样，这并未导致SSRI/SNRI使用者和非使用者在曲马多处方上出现差异。医生决定给SSRI/SNRI使用者开具曲马多可能是基于全面的个体获益-风险评估；曲马多的预期获益可能超过5-羟色胺综合征的微小风险。为了提高对5-羟色胺综合征潜在风险的认识，医院药房在提示潜在相互作用以及提供曲马多和在存在SSRI或SNRI时替代镇痛药的获益和风险信息方面可能发挥重要作用。
