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Myxedema Coma Associated with Combination Aripiprazole and Sertraline Therapy

Associate Professor of Pharmacy Practice, College of Pharmacy, Southwestern Oklahoma State University, Weatherford, OK

Erin C Callen, PharmD BCPS

Associate Professor of Pharmacy Practice, College of Pharmacy, Southwestern Oklahoma State University

Reprints: Dr. Church, Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, Pasteur Medical Building, Pharmacy Education, 1111 North Lee, Ste. 241, Oklahoma City, OK 73103, fax 405/601-1201, chelsea.church{at}swosu.edu

OBJECTIVE: To describe a case of myxedema coma (MC) associated with combination aripiprazole and sertraline therapy.

CASE SUMMARY: A 41-year-old male presented to the emergency department with confusion, right-sided numbness and tingling, slurred speech, dizziness, and facial edema. His blood pressure was 160/113 mm Hg, with a pulse of 56 beats/min and temperature of 35.4 °C. Initial abnormal laboratory values included creatine kinase (CK) 439 U/L; serum creatinine 1.6 mg/dL; aspartate aminotransferase 85 U/L; and alanine aminotransferase 35 U/L. Repeat cardiac markers revealed an elevated CK level of 3573 U/L with a CK-MB of 24 ng/mL. Thyroid function tests showed thyroid-stimulating hormone 126.4 µIU/mL and free thyroxine 0.29 ng/dL. Home medications of unknown duration were sertraline 200 mg and aripiprazole 20 mg daily. He was admitted to the intensive care unit and initially treated with intravenous levothyroxine and dexamethasone. By hospital day 4, the patient was clinically stable and discharged to home.

DISCUSSION: Myxedema coma, the most significant form of hypothyroidism (HT), is a rare but potentially fatal condition. The known precipitating causes of MC were ruled out in this patient, which left his home medications as the likely cause. Cases of HT caused by certain atypical antipsychotics and antidepressants are found in the literature, but none was reported with aripiprazole therapy. There are also no reported cases of sertraline or aripiprazole inducing MC. Use of the Naranjo probability scale indicates that the combination of aripiprazole and sertraline was a probable inducer of MC in this patient.

CONCLUSIONS: Due to the widespread use of psychotropic medications, clinicians should be reminded of the rare, yet life-threatening, occurrence of MC when treating patients, especially with combination therapies such as sertraline and aripiprazole.

Key Words: aripiprazole, myxedema coma, psychotropic drug, sertraline

Published Online, November 24, 2009. www.theannals.com, DOI 10.1345/aph.1M369