Major
fluvoxamine × Tramadol
SSRI×Other opioids
Mechanism
SSRI (fluvoxamine) + tramadol – serotonin syndrome. Tramadol also lowers seizure threshold.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia. Autonomic features: sweating, tachycardia, hypertension, fever. First signs appear within hours of co-administration.
Management
Avoid the combination. For analgesia on fluvoxamine, use paracetamol, an NSAID, or morphine/oxycodone. For neuropathic pain, gabapentin or pregabalin.