Major
Escitalopram × Tramadol
Selective serotonin reuptake inhibitors (SSRIs)×Other opioids
Mechanism
Escitalopram (SSRI) raises synaptic serotonin; tramadol blocks serotonin and norepinephrine reuptake. Combined action sharply amplifies serotonergic transmission – serotonin syndrome risk.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia, dilated pupils. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
Avoid the combination. For analgesia on escitalopram, use paracetamol, an NSAID, or morphine/oxycodone. For neuropathic pain, gabapentin or pregabalin.