Serotonin toxicity involving MDMA (ecstasy) and moclobemide

Combining MDMA (ecstasy) with moclobemide, a reversible MAO-A inhibitor, can cause fatal serotonin toxicity. Four deaths in Australia are reported where this drug interaction led to symptoms including hyperthermia, hyperkalemia, profuse sweating, twitching, and shaking. Two cases had moclobemide concentrations consistent with prescribed doses, while two had higher, toxic levels. Three of the four individuals had some form of heart disease. Despite known risks, few fatalities from this combination have been documented.

Study at a glance

Abstract

The use of MDMA (ecstasy) in Australia is a widespread and growing problem, promoting acute toxicity and disease which can lead to premature death in users. We report four cases of fatal serotonin toxicity caused by the combination of MDMA and moclobemide, a reversible MAO-A inhibitor with potent serotonergic activity. Despite the highly reported toxicity of this drug combination, there are very few reports of fatalities attributed to a MDMA and moclobemide interaction. Pathology and toxicology reports, initial police reports and coroners' findings were examined to determine the circumstances of the deaths. Symptoms of some of the four cases as reported by paramedics and medical staff included hyperthermia, hyperkalemia, profuse sweating, twitching and shaking. Two cases involved moclobemide concentrations consistent with common prescribed doses, while the other two cases involved much higher concentrations often associated with toxicity. Three of these cases presented with some form of heart disease.