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Prozac (fluoxetine)

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Prozac may cause muscle twitching.

This drug may also cause the following symptoms that are related to muscle twitching:

Medical Source Information
Yellow highlights indicate symptoms related to muscle twitching.

The development of a potentially life-threatening serotonin syndrome or neuroleptic malignant syndrome (NMS)-like reactions have been reported with SNRIs and SSRIs alone, including fluoxetine, but particularly with concomitant use of serotonergic drugs (including triptans) with drugs which impair metabolism of serotonin (including MAOIs), or with antipsychotics or other dopamine antagonists. Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination) and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Serotonin syndrome, in its most severe form can resemble neuroleptic malignant syndrome, which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and mental status changes. Patients should be monitored for the emergence of serotonin syndrome or NMS-like signs and symptoms.

Other side effects include a withdrawal-type reaction. In one retrospective chart review of 352 patients who were supervised during tapering and discontinuation from serotonin reuptake inhibitor therapy, dizziness, lethargy, paresthesia, nausea, vivid dreams, irritability, and lowered mood were the most common symptoms reported. Patients with at least on qualitatively new symptom were defined in the fluoxetine group at a rate of 1.5%.

Nervous system side effects including headache, anxiety, nervousness, insomnia, drowsiness, sedation, tremor, dizziness, jitteriness, and fatigue have all been reported. The reported incidence of each of these effects ranges between 4% and 20% of treated patients. Cases of akathisia, neuromuscular twitching, tics, myoclonus, migraines, sleep abnormalities, dyskinesia, acute dystonic reactions, worsening of Parkinson's disease, seizures, stuttering, paresthesias, and cognitive dysfunction have also been reported.

Cases of the neuroleptic malignant syndrome occurring in patients started on fluoxetine have been reported. One retrospective study of 23 outpatients with Parkinson's disease treated with 40 mg of fluoxetine a day reported that three patients experienced worsening of parkinsonism, two patients experienced improvement of parkinsonism, and 18 patients experienced no change. Another small study reported a series of four patients who experienced worsening of parkinsonism during treatment with fluoxetine. A number of case reports have implicated fluoxetine in causing seizures. The manufacturer reports that, during premarketing testing, 12 out of 6000 patients experienced convulsions. A case of dose-dependent exacerbation of preexisting, mild restless legs syndrome (which ultimately required discontinuation of fluoxetine) has been reported. Nearly all selective serotonin reuptake inhibitors, mixed serotonin/norepinephrine reuptake inhibitors, and tricyclic antidepressants cause sleep abnormalities to some extent. These antidepressants have marked dose-dependent effects on rapid eye movement (REM) sleep, causing reductions in the overall amount of REM sleep over the night and delays the first entry into REM sleep (increased REM sleep onset latency (ROL)), both in healthy subjects and depressed patients. The antidepressants that increase serotonin function appear to have the greatest effect on REM sleep. The reduction in REM sleep is greatest early in treatment, but gradually returns towards baseline during long-term therapy; however, ROL remains long. Following discontinuation of therapy the amount of REM sleep tends to rebound. Some of these drugs (i.e., bupropion, mirtazapine, nefazodone, trazodone, trimipramine) appear to have a modest or minimal effect on REM sleep.

Side Effects to Watch
Watch closely for the following side effects and notify your physician immediately should any of these develop:

Abnormal heart rate, fluttering in the chest, weakness, faintness, dizziness or loss of consciousness (signs of a serious condition called "torsade de pointe or QT prolongation" in which irregular heartbeats occur)
Abnormal bruising or signs of bleeding such as bleeding from the gums, nose, digestive tract, vagina (females), faintness, dizziness, loss of consciousness, or rash (signs of problems with blood clot formation)

Lab and Diagnostic Tests
If certain symptoms develop, ask your physician whether you need the following lab tests or other diagnostic tests (if you've not already had them):

Monitor serotonin
Blood tests to assess normal clotting - in people who develop signs of bleeding such as abnormal bruising or signs of bleeding including bleeding from the gums, nose, digestive tract, vagina (females), faintness, dizziness, loss of consciousness, or rash
EKG - if abnormal heartbeats (rapid slow or irregular) develop
Platelet counts - should be monitored

References

Extrapyramidal symptoms upon discontinuation of fluoxetine. Stoukides JA, Stoukides CA Am J Psychiatry 1991;148:1263.
Reversible intermittent rhythmic myoclonus with fluoxetine in presumed pick's disease. Lauterbach EC Mov Disord 1994;9:343-6.
Migraine with typical aura associated with fluoxetine therapy: case report. Larson EW J Clin Psychiatry 1993;54:235-6.
Grand mal seizures associated with the use of fluoxetine. Levine R, Kenin M, Hoffman JS, Dayknepple E J Clin Psychopharmacol 1994;14:145-6.
Adverse reaction to high-dose fluoxetine. Lavin MR, Mendelowitz A, Block SH J Clin Psychopharmacol 1993;13:452-3.
Fluoxetine-associated dystonia. Dave M Am J Psychiatry 1994;151:149.
Fluoxetine and neuroleptic malignant syndrome. Halman M, Goldbloom DS Biol Psychiatry 1990;28:518-21.
Increase of Parkinson disability after fluoxetine medication. Steur EN Neurology 1993;43:211-3.
Obsessive-compulsive disorder, fluoxetine, and buspirone. Sternlicht HC Am J Psychiatry 1993;150:526.
Tardive dyskinesia associated with fluoxetine. Dubovsky SL, Thomas M Psychiatr Serv 1996;47:991-3.
Efficacy and safety of second-generation antidepressants in the treatment of major depressive disorder. Hansen RA, Gartlehner G, Lohr KN, Gaynes BN, Carey TS Ann Intern Med 2005;143:415-26.
Adverse events in PTSD patients taking fluoxetine. Marshall RD, Printz D, Cardenas D, Abbate L, Liebowitz MR Am J Psychiatry 1995;152:1238-9.
Akathisia causing suicide attempts in patients taking fluoxetine (Prozac). Tueth MJ J Emerg Med 1993;11:336-7.
Does fluoxetine exacerbate Parkinson's disease? Caley CF, Friedman JH J Clin Psychiatry 1992;53:278-82.
Fluoxetine-induced stuttering. Guthrie S, Grunhaus L J Clin Psychiatry 1990;51:85.
Cognitive dysfunction associated with fluoxetine. Mirow S Am J Psychiatry 1991;148:948-9.
Persistent dyskinesia in a patient receiving fluoxetine. Budman CL, Bruun RD Am J Psychiatry 1991;148:1403.
Fluoxetine-associated paresthesias and alopecia in a woman who tolerated sertraline. Bhatara VS, Gupta S, Freeman JW J Clin Psychiatry 1996;57:227.
Eye tics and subjective hearing impairment during fluoxetine therapy. Cunningham M, Cunningham K, Lydiard RB Am J Psychiatry 1990;147:947-8.
Product Information. Prozac (fluoxetine). Anonymous Dista Products Company, Indianapolis, IN. PROD;
Fluoxetine induced dyskinesia. Mander A, Mccausland M, Workman B, Flamer H, Christophidis N Aust N Z J Psychiatry 1994;28:328-30.
Fluoxetine-induced seizures. Hargrave R, Martinez D, Bernstein AJ Psychosomatics 1992;33:236-9.
A case report of paradoxical sedation with fluoxetine therapy. Gupta S, Rajaprabhakaran R J Clin Psychiatry 1994;55:118.
Fluoxetine and extrapyramidal side effects. Anonymous Am J Psychiatry 1989;146:1352-3.
Status epilepticus secondary to fluoxetine. Madi L, Obrien AAJ, Fennell J Postgrad Med J 1994;70:383-4.
Fluoxetine and extrapyramidal side effects. Coulter DM, Pillans PI Am J Psychiatry 1995;152:122-5.

Multum version: 154.0 (Jun 16, 2010)

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