Is angioedema reported for Seroxat (paroxetine), Remeron (mirtazapine) or Zoloft (sertraline)?/nA 5

Fråga: Is angioedema reported for Seroxat (paroxetine), Remeron (mirtazapine) or Zoloft (sertraline)? A 57-year-old woman has been bothered by recurrent swelling of the throat and tongue during the past one and a half year. She started antidepressive therapy with paroxetine about four years ago. Two years ago she switched to mirtazapine and has the past four months been taking sertraline instead.

Sammanfattning: Angioedema seems to be a rare, but still reported adverse effect for paroxetine, sertraline and mirtazapine.

Svar: There have been rare reports of angioedema and tongue swelling during paroxetine therapy. One case report concerns a woman experiencing swelling of the tongue and throat six hours after her first dose of paroxetine, which made it difficult to swallow (1). All symptoms disappeared, without treatment, after discontinuation of the drug. This implies that she had an allergic reaction to the drug, which resulted in angioedema.

Similar effects have been reported with other SSRI:s (selective serotonin uptake inhibitors). One case report regards a man who has taken an overdose of sertraline and trazodone (2). In combination with other effects he had the sensation of an enlarged tongue, which was confirmed after physical examination. The day after the patient´s tongue was protruding and it was moving involuntarily. Later he had trouble breathing and was inable to swallow. The enlarged tongue was concluded to be angioedema. Similar symptoms have also been reported for fluoxetine (1,2).

In the Swedish Catalogue of Approved Medical Products (FASS) facial edema is an adverse effect that appears in 0.1-1 percent of patients taking paroxetine (3). Angioedemas are reported as a rare adverse effect for both paroxetine and sertraline and edemas are reported as a rare effect for mirtazapine (3). In the files of SADRAC (the Swedish Adverse Drug Reactions Advisory Committee) 12 reports out of 2126 total cases concern angioedema for selective serotonin uptake inhibitors (4). Paroxetine has four cases reported and one of these was an oedematous swelling of the tongue. For sertraline there is only one report of angioedema, which concerns eyelid edema and an itching rash in the face. There are six reports of angioedema and an additional report of tongue edema (of a total of 304 reports) for mirtazapine.

All of the mentioned case reports concern immediate reactions to the drugs. However, in the present case, the woman had experienced these symptoms for a long time and the cause of the reaction is probably not due to the drugs. Paroxetine was taken before the symptoms appeared, and can therefore be totally excluded from the discussion.