Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management

Figures & data

Table 1. Summary of therapeutic dosing for SSRIs

Drug	Starting daily therapeutic dose	Maximum daily therapeutic dose	Dosage forms
Citalopram	Adult: 20 mg	60 mg	10, 20, 40 mg tablets
			10 mg/5 mL oral solution
	Child: not available	Not available
Escitalopram	Adult: 10 mg	20 mg	5 mg, 10 mg, 20 mg, tablets
			5 mg/5 mL oral solution
	Child: not available	Not available
Fluoxetine	Adult: 20 mg	80 mg	10, 20, 40 capsules
			10 mg tablets
			90 mg weekly capsules
			20 mg/5 mL oral solution
	Child (6–18 yr): 10 mg	20 mg
Fluvoxamine	Adult: 50 mg	300 mg	25, 50, 100 mg tablets
	Child (8–17 yr): 25 mg	200 mg
	Child (<8 yr): not available	Not available
Paroxetine	Adult: 20 mg	60 mg	10, 20, 30, 40 mg tablets
			10 mg/5 mL oral suspension
			Paxil CR controlled-release tablets 12.5, 25, 37.5 mg
	Child: 10 mg	60 mg
Sertraline	Adult: 50 mg once daily	200 mg	25. 50. 100 mg tablets
			20 mg/mL oral concentrate
	Child (6–12 yr): 25 mg once daily	200 mg
	Child (<6 yr): not available	Not available

Table 2. Details of dose and time to onset associated with more than mild toxicity following acute SSRI overdose

Drug	Time to peak serum concentration	Lowest reported acute dose to produce more than mild toxicity	Longest reported delay in onset of toxicity after acute overdose
Citalopram	4 hr	Adult: 400 mg	<13 hr
		Child: NA	NA
Escitalopram	5 hr	Adult: 100 mg	NA
		Child: 100 mg	NA
Fluoxetine	6–8 hr	Adult: NA	NA
		Child: 100 mg	NA
Fluvoxamine	3.8 hr	Adult: 750 mg	NA
		Child: 400 mg	NA
Paroxetine	4.9–6.4 hr	Adult: 360 mg	6 hr
		Child: NA	NA
Sertraline	4.5–8.4 hr	Adult: 500 mg	3 hr
		Child: 400 mg	4 hr

*The table reflects cases that excluded co-ingestants and in which reasonable validation was present. Development of serotonin syndrome resulting from a drug interaction is also excluded.

^†Derived from prescribing information for the individual drugs.

Table

Grade of recommendation	Level of evidence	Description of study design
A	1a	Systematic review (with homogeneity) of randomized clinical trials
	1b	Individual randomized clinical trials (with narrow confidence interval)
	1c	All or none (all patients died before the drug became available, but some now survive on it; or when some patients died before the drug became available, but none now die on it.)
B	2a	Systematic review (with homogeneity) of cohort studies
	2b	Individual cohort study (including low quality randomized clinical trial)
	2c	“Outcomes” research
	3a	Systemic review (with homogeneity) of case-control studies
	3b	Individual case-control study
C	4	Case series, single case reports (and poor quality cohort and case control studies)
D	5	Expert opinion without explicit critical appraisal or based on physiology or bench research
Z	6	Abstracts

Table