Management of Serotonin Syndrome and Neuroleptic Malignant Syndrome

Opinion statement

Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) can present similarly and range in severity from mild to life-threatening. Although they are easily misdiagnosed, each is distinct clinically and pathophysiologically. It is important to distinguish between the two, as therapeutic options differ. An accurate and thorough medication history plus knowledge of the various clinical presentations of both syndromes are the first steps in management. After this, removing the offending agents and aggressive supportive care are crucial. This includes controlling muscle rigidity and hyperthermia, providing cardiovascular support, and alleviating agitation. In severe cases, paralysis, sedation, and intubation are required. Agents to reverse either surplus serotonergic activity or dopamine blockage can be useful. However, the diagnosis must be clear, as use of these agents in the incorrect syndrome can worsen symptoms. In pharmacologically refractory cases of NMS, electroconvulsive therapy should be pursued.