# A 45-year-old client takes duloxetine 60 mg daily for diabetic peripheral neuropathy and is now prescribed sumatriptan for new migraines, plus an over-the-counter cold remedy containing dextromethorphan. Which adverse outcome does the nurse counsel the client to recognize?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375213&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 45-year-old client takes duloxetine 60 mg daily for diabetic peripheral neuropathy and is now prescribed sumatriptan for new migraines, plus an over-the-counter cold remedy containing dextromethorphan. Which adverse outcome does the nurse counsel the client to recognize?

## Option

1. Neuroleptic malignant syndrome — muscle rigidity, hyperthermia, autonomic instability, altered mental status, and elevated creatine kinase — which can occur within hours of exposure to dopamine antagonists and is an emergency requiring discontinuation of offending agents, aggressive cooling, and possibly dantrolene or bromocriptine.
2. Hypertensive crisis — severe headache, blurred vision, anxiety, chest pain, epistaxis, and possible signs of end-organ damage such as acute kidney injury or pulmonary edema — which can occur within hours of combining vasoconstrictive drugs and is an emergency requiring immediate blood pressure reduction with intravenous antihypertensives and continuous monitoring.
3. Anticholinergic toxicity — dry mucous membranes, mydriasis, urinary retention, decreased bowel sounds, flushed skin, hyperthermia, and altered mental status — which can occur from medications with antimuscarinic effects and is an emergency requiring discontinuation of the offending agents, supportive care, and possibly physostigmine in severe cases.
4. Serotonin syndrome — confusion, agitation, restlessness, hyperreflexia, clonus, tremor, sweating, hyperthermia, tachycardia, hypertension, GI symptoms, and ocular clonus — which can occur within hours of combining serotonergic agents and is an emergency requiring discontinuation of all serotonergic drugs, supportive care, and possibly cyproheptadine. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor (SNRI) and a first-line agent for diabetic peripheral neuropathy, fibromyalgia, chronic musculoskeletal pain, major depression, and generalized anxiety disorder. Combining duloxetine with other serotonergic agents — triptans (sumatriptan, rizatriptan), other SSRIs/SNRIs, MAOIs, tramadol, dextromethorphan, ondansetron, linezolid, methylene blue, St John wort, or recreational drugs like MDMA — increases the risk of serotonin syndrome. Clinical features include mental status changes, neuromuscular hyperactivity (hyperreflexia, clonus including ocular clonus, tremor, rigidity), and autonomic instability (hyperthermia, tachycardia, hypertension, diaphoresis, mydriasis, GI symptoms). Onset is often within hours and severity ranges from mild to lethal. Management: stop all serotonergic agents, supportive care including IV fluids and cooling, benzodiazepines for agitation, and in severe cases cyproheptadine. Other duloxetine teaching: gradual taper at discontinuation to avoid SNRI discontinuation syndrome, suicidal ideation FDA boxed warning especially under age 25, hepatic concern with alcohol, BP and heart rate monitoring, do not crush or chew capsules, take consistently. Dental, anemia, and hearing loss are not the priority risks here.

## In-depth explanation

Duloxetine + triptan + dextromethorphan = stacked serotonergic risk. Hyperreflexia with clonus is the hallmark exam finding for serotonin syndrome.

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