Table 3.

Treatment of high blood pressure (>175 mmHg) in serotonin syndrome as reported in the literature 2004–2016.

Case	Highest BP	Substance	Dosage	Effect
Rapid therapeutic response (⩽ 24h)
1. Gnanadesigan et al.14	200/90	Lorazepam	i.v., dose n.s.	In less than a day BP returned to baseline
2. Monterrubio Villar and Cordoba Lopez23	220/100	Diazepam Nitroglycerine	n.s. Several puffs	Rapidly controlled
3. Ozkardesler et al.25	200/114	Morphine Diphenhydramine Dexamethasone	1 mg × 3 i.v. 20 mg i.v. 8 mg i.v.	135/90 after 2 h
4. Monte and Waksman22	177/80	Propofol Clorazepate Lorazepam	30 mg × 5 30 mg p.o. 24 mg i.v.	No effect of clorazepate and lorazepam; after propofol, normalization in 45 min
5. Monte et al.21	177/113	Lorazepam	Repetitive doses i.v.	Normal after 6 h
6. Rim and Gitlin26	180/100	Lorazepam	12 mg in two doses i.v.	Rapidly improved
7. Choudhury et al.13	200/100	Nitroglycerine Diazepam Cyproheptadine	1 µg/kg/min 5 mg i.v. 20 mg p.o.	Effect of nitroglycerine not disclosed, but improvement 4 h after diazepam/cyproheptadine; resolution after 30 h
8. Levine et al.18	249/145	Diltiazem	20 mg i.v. over 5 min.	BP decreased to 66/54 after 15 min; persistent hypotension, needed norepinephrine
9. Miller and Lovell20	234/196	Propofol Lorazepam	Continuous i.v. Multiple doses i.v.	150/85 (after intubation)
10. Gollapudy et al.15	180/80	Fentanyl Hydromorphone	100 µg 0.4 mg	Unresponsiveness and apnoea leading to intubation; BP 99/58 after 1 h
11. Wilson et al.30	Fluctuating between 180 and 90 systolic	Benzodiazepines Cyproheptadine	n.s. n.s.	Benzodiazepines without effect. 2 h after cyproheptadine BP swings less pronounced and finally stabilized
12. Beatty et al.9	200 systolic	Midazolam Esmolol Fentanyl Lorazepam Hydromorphone	2 mg over 5 min 50 mg over 15 min 50 µg × 2 1 mg 0.4 mg + 1 mg i.v. over 90 min	Hyperdynamic after esmolol; clinically worse after fentanyl; BP normal 2 h after monotherapy with hydromorphone
13. Ma et al.19	180/100	Midazolam Propofol	5 mg/h n.s.	No control of symptoms until propofol added
14. Moseson et al.24	Fluctuating BP with MAP 40, then systolic BP in the 200s and MAP >100	Metoprolol Nicardipine Cyproheptadine Benzodiazepines	10 mg i.v. initially i.v. drip initially One dose n.s.	MAP dropped again to 40 after metoprolol/nicardipine; needed epinephrine; normalization 24 h after cyproheptadine
15. Shah and Jain31	230/120	Cyproheptadine Midazolam	12 mg, followed by 2 mg every 2 h continuously	8 h after cyproheptadine; BP returned to normal
Slow or no therapeutic response (⩾24 h)
16. Brown12	177/111	Lorazepam Diphenhydramine	1 mg every 6 h 25 mg every 6 h	Decreased, but never resolved over 6 days; after 6 days of treatment effect of nitroglycerin on a BP of 159/105
17. Velez et al.27	188/103	Lorazepam Cyproheptadine	30 mg i.v. over 6 h 8 mg p.t., then 3 × 4 mg/24 h	No improvement; fluctuating BP over 2 days (112–211 systolic)
18. Bergeron et al.10	206/102	Bisoprolol Methotrimeprazine Olanzapine Ondansetron	5 mg daily 25 mg daily 12.5 mg daily 8 mg daily	On day 5 BP between 160/80 and 138/80
19. Inoue et al.16	202/86	Nicardipine	1.7 µg/kg/min in decreasing dose over 10 days	Gradual decrease in BP over 2 weeks
20. Isenberg et al.17	210/93	Lorazepam Midazolam Diphenhydramine Hydromorphone Cyproheptadine	8 mg in four doses 4 mg n.s. 2 mg i.v. 4 mg p.t.	No change with any treatment before cyproheptadine; effect of cyproheptadine on BP not reported
21. Young et al.29	210/120	Nitroglycerine	i.v.	No satisfying control of BP
22. Bosak et al.11	230/104	Midazolam Lorazepam Diazepam Phenobarbital Propofol Cyproheptadine Fentanyl	Various dosages Various dosages Initially 15 mg/kg, then n.s. 60–80 µg/kg/min 12 mg p.t. 175 µg/h	Badly controlled for 96 h under continuous fentanyl treatment with repetitive hypertensive episodes while sedation was weaned

BP measurements in mmHg.

BP, blood pressure; i.v., intravenously; MAP, mean arterial pressure; n.s., not specified; p.o., orally; p.t., via gastric tube.