Skip to main content
SpringerLink
Log in

Fatal overdose with a combination of SNRIs venlafaxine and duloxetine

  • Case Report
  • Published:
Forensic Science, Medicine and Pathology Aims and scope Submit manuscript

Abstract

Drugs for the treatment of depressive disorders, including SNRIs (serotonin noradrenaline reuptake inhibitors) venlafaxine and duloxetine, are widely prescribed as they have a high therapeutic to toxicity ratio. In rare cases, adverse effects may be severe, usually due to iatrogenic, accidental or intentional self-overdose that cause the excessive accumulation of serotonin and noradrenaline in synaptic clefts. Lethal intoxication with a combination of venlafaxine and duloxetine (postmortem blood concentrations 24 mg/L and 0.97 mg/L, respectively) without co-ingested substances, comorbidities or injuries that could have an unknown contribution to a fatal outcome is presented for the first time in the following case report, with a comprehensive clinical history, and complete results of the performed analyses. The cause of death was a serotonin syndrome that progressed to death in approximately six hours and 15 min after the suicidal ingestion of venlafaxine and duloxetine. Despite the high therapeutic to toxicity ratio SNRIs, which are reserved for patients with severe forms of depressive disorders and a higher suicidal tendency, they should be cautiously prescribed and handed over in smaller packages to make them easier to follow, and thus avoid accumulation within the patient’s reach.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Pirraglia PA, Stafford RS, Singer DE. Trends in prescribing of selective serotonin reuptake inhibitors and other newer antidepressant agents in adult primary care. Prim Care Companion J Clin Psychiatry. 2003;5:153–7.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Moffat AC, Osselton MD, Widdop B, editors. Clarke’s analysis of drugs and poisons. 4th ed. London: Pharmaceutical Press; 2011.

    Google Scholar 

  3. Taylor D, Lenox-Smith A, Bradley A. A review of the suitability of duloxetine and venlafaxine for use in patients with depression in primary care with a focus on cardiovascular safety, suicide and mortality due to antidepressant overdose. Ther Adv Psychopharmacol. 2013;3:151–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Buccelli C, Vacchiano G, Niola M, Graziano V, Basilicata P, Silvestre A, et al. On an engaged case of cardiac arrhythmia following duloxetine intoxication. Rom J Leg Med. 2017;25:60–4.

    Article  Google Scholar 

  5. Gartlehner G, Hansen RA, Morgan LC, Thaler K, Lux LJ, Van Noord M, et al., editors. Second-generation antidepressants in the pharmacologic treatment of adult depression: an update of the 2007 comparative effectiveness review. Rockville (MD): AHRQ Comparative Effectiveness Reviews; 2011.

  6. Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The hunter serotonin toxicity criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96:635–42.

    Article  CAS  PubMed  Google Scholar 

  7. Gundogmus I, Ispir M, Bakkal O, Karagoz A, Maden O, Algul A, et al. Venlafaxine-induced prostatism: a case report. Psych Clin Psychopharmacol. 2017;27:197–8.

    Article  Google Scholar 

  8. Pilgrim JL, Gerostamoulos D, Drummer OH. The prevalence of duloxetine in medico-legal death investigation in Victoria, Australia (2009-2012). Forensic Sci Int. 2014;234:165–73.

    Article  CAS  PubMed  Google Scholar 

  9. Menchetti M, Gozzi BF, Saracino MA, Mercolini L, Petio C, Raggi MA. Non-fatal overdose of duloxetine in combination with other antidepressants and benzodiazepines. World J Biol Psychiatry. 2009;10:385–9.

    Article  PubMed  Google Scholar 

  10. Boyer E, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352:1112–20.

    Article  CAS  Google Scholar 

  11. Haddad PM, Dursun SM. Neurological complications of psychiatric drugs: clinical features and management. Hum Psychopharmacol. 2008;23:15–26.

    Article  PubMed  Google Scholar 

  12. Ellahi R. Serotonin syndrome: a spectrum of toxicity. BJPsych Advances. 2015;21:324–32.

    Article  Google Scholar 

  13. Mason PJ, Morris VA, Balcezak TJ. Serotonin syndrome. Presentation of 2 cases and review of the literature. Medicine (Baltimore). 2000;79:201–9.

    Article  CAS  Google Scholar 

  14. Launiainen T, Ojanperä I. Drug concentrations in post-mortem femoral blood compared with therapeutic concentrations in plasma. Drug Test Anal. 2014;6:308–16.

    Article  CAS  PubMed  Google Scholar 

  15. Anderson D, Reed S, Lintemoot J, Kegler S, DeQuintana S, Sandberg M, et al. A first look at duloxetine (Cymbalta) in a postmortem laboratory. J Anal Toxicol. 2006;30:576–80.

    Article  CAS  PubMed  Google Scholar 

  16. Paulzen M, Hiemke C, Grunder G. Plasma levels and cerebrospinal fluid penetration by duloxetine in a patient with a non-fatal overdose during a suicide attempt. Int J Neuropsychopharmacol. 2009;12:1431–2.

    Article  PubMed  Google Scholar 

  17. Höjer J, Hulting J, Salmonson H. Fatal cardiotoxicity induced by venlafaxine overdosage. Clin Toxicol (Phila). 2008;46:336–7.

    Article  CAS  Google Scholar 

  18. Flanagan RJ. Fatal toxicity of drugs used in psychiatry. Hum Psychopharmacol Clin Exp. 2008;23:Suppl 1:43–51.

    Google Scholar 

  19. Chan AN, Gunja N, Ryan CJ. A comparison of venlafaxine and SSRIs in deliberate self-poisoning. J Med Toxicol. 2010;6:116–21.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Institute of Forensic Medicine, Faculty of Medicine, University of Ljubljana, Korytkova 2, 1000, Ljubljana, Slovenia

    Armin Alibegović

  2. Intensive Care Unit, Division of Internal Medicine, Izola General Hospital, Polje 40, 6310, Izola, Slovenia

    Stojan Kariž

  3. Institute of Pathology, Faculty of Medicine, University of Ljubljana, Korytkova 2, 1000, Ljubljana, Slovenia

    Metka Volavšek

Authors
  1. Armin Alibegović
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stojan Kariž
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Metka Volavšek
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Armin Alibegović.

Ethics declarations

Ethical approval

No ethical approval was required.

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(PDF 344 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Alibegović, A., Kariž, S. & Volavšek, M. Fatal overdose with a combination of SNRIs venlafaxine and duloxetine. Forensic Sci Med Pathol 15, 258–261 (2019). https://doi.org/10.1007/s12024-019-00097-3

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12024-019-00097-3

Keywords

Search

Navigation