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Sertraline

Brands and Forms

  • Zoloft
    • tablet: 25mg scored, 50mg scored, 100mg
  • Lustral
  • Serlain

Uses of Sertraline

Sertraline is commonly used for treating Depressive Disorders (including Major Depressive Disorder, Dysthymia, and Premenstrual Dysphoric Disorder) and Anxiety Disorders (including Panic Disorder, Generalized Anxiety Disorder, Social Phobia, PTSD, and Obsessive-Compulsive Disorder).

It can also be used for treating Bulimia Nervosa, Binge-Eating Disorder, Hypochondriasis, Body Dysmorphic Disorder, Trichotillomania, Depression in Bipolar Disorder, and impulsive behaviors associated with Borderline Personality Disorder and Dementia.

How Sertraline Works

Sertraline is an SSRI antidepressant. It blocks serotonin reuptake at the serotonin transporter, and thus boosts serotonin actions in the central nervous system. Sertraline also desensitizes serotonin 1a autoreceptors, and has antagonist properties at the dopamine reuptake transporter that can help to increase dopamine neurotransmission.

Cautions when Using Sertraline

Sertraline can induce Manic or Mixed Episodes and Rapid Cycling in people with Bipolar Disorder.

Children and adolescents who use antidepressants like Sertraline may develop self-injurious or suicidal behaviors (for more information, see here).

Use with caution in people with a known seizure disorder, and in those who are taking anticoagulant (blood thinning) medication.

Long-term use of SSRI antidepressants like Sertraline has been associated with increased risk of osteoporosis and bone fractures in individuals over age 50.

Dangerous heart arrhythmias could occur if Sertraline is combined with Thioridazine or Pimozide.

Sertraline should not be used during or within 14 days following the administration of an MAOI, because a hypertensive crisis may result.

Dosing of Sertraline

The usual therapeutic range of Sertraline is 50-200mg/day; higher doses of up to 400mg/day may be required for Obsessive-Compulsive Disorder. It can be given once daily, usually in the morning.

Sertraline can be started at 25mg/day for the first week, then increased to 50mg/day. At that point, it is common practice to wait about 4 weeks for therapeutic effects to take place before deciding to increase the dose. Dose increases are usually done in 50mg increments at 2-week intervals to allow time for therapeutic effects to appear.

When wanting to stop this medication, the dose should be decreased gradually over a period of 6-8 weeks. A sudden cessation of the medication can result in an SSRI discontinuation syndrome.

Onset of action

Therapeutic effects are not expected before 2-4 weeks at a dose of 50mg/day. If no significant effects are seen after 6-8 weeks of use, including at least 2 weeks at a dose above 100mg/day, then the medication may not work at all.

Kidney impairment

No dose adjustment required.

Liver impairment

Reduce dose by about half, or give less frequently.

Side-effects of Sertraline

Below is a list of most of the reported side-effects of Sertraline. Most of these side-effects occur in only a minority of individuals, and many also resolve with time while the medication is continued.

Cardiovascular: hot flushes; postural hypotension; hypertension; fainting; tachycardia; palpitations; chest pain; bradycardia; cardiac arrhythmias (rare).

Central Nervous System: headache; insomnia; dizziness; tremor; fatigue; tingling sensations; diminished sensation; twitching; confusion; somnolence; decreased libido; vertigo; apathy; hypokinesia/hyperkinesia; abnormal dreams; weakness; hypertonia; malaise; extrapyramidal symptoms (rare); seizures (very rare); serotonin syndrome (very rare).

Dermatologic: excessive sweating; itchiness; acne; rash; hair loss (rare).

Endocrine/Metabolic: weight loss; weight gain; elevated prolactin (very rare); SIADH (very rare).

Eyes, Ears, Nose and Throat: abnormal vision; ringing in the ears; pharyngitis; nose bleeds.

Gastrointestinal: nausea; diarrhea; dry mouth; loss of appetite; vomiting; constipation; abdominal pain; dyspepsia; gastroenteritis; tooth caries; dysphagia; increased appetite; pancreatitis (very rare); hepatits (very rare).

Genitourinary: sexual dysfunction (abnormal ejaculation, impotence, anorgasmia; see below on managing sexual side-effects), urinary frequency, irregular menses.

Hematologic: increases bleeding time (thins the blood); easy bruising; thrombocytopenia; thrombosis.

Muskuloskeletal: risk of osteoporosis and bone fractures with long-term use.

Psychiatric: anxiety; agitation; apathy; worsening depression; suicidal thoughts (overall, Sertraline use helps to lower risk of suicide); self-injurious behaviors among children and adolescents; can induce Manic or Mixed Episodes and Rapid Cycling in people with Bipolar Disorder.

Respiratory: sinusitis; increased cough; shortness of breath; rhinitis.

Common side-effects of Sertraline

Nausea, diarrhea, headache, insomnia, sweating, sexual dysfunction (less than 5%, see below on managing sexual side-effects). Most of these side-effects resolve after a few weeks.

Rare but serious side-effects of note of Sertraline

Children and adolescents who use antidepressants like Sertraline may develop self-injurious or suicidal behaviors (for more information, see here).

SSRI discontinuation syndrome

Individuals who suddenly stop using Sertraline after taking the medication at moderate or high doses over a significant period of time are at risk of developing a discontinuation syndrome, which can include the following symptoms: dizziness, electric shock-like sensations, sweating, nausea, insomnia, tremor, anxiety, restlessness, agitation, depressed mood, irritability, confusion, lethargy, and vertigo. These symptoms usually start anywhere from one day to one week after the medication was stopped, and can persists for days or even weeks.

This syndrome can be treated by restarting the medication at its prior dose. It can be prevented by decreasing the dose gradually over a period of 6-8 weeks when wanting to stop the medication. In rare cases, individuals may experience the discontinuation syndrome even when the medication is being tapered gradually; in such cases, an extremely slow and gradual taper will be necessary.

Managing sexual side-effects of Sertraline

The first step to manage this is to try to lower the dose of the Sertraline. If this is not possible, or is not an effective solution, then either Bupropion, or Sildenafil (Viagra) or Vardenafil (Levitra), can be added [ref]. (Sildenafil and Vardenafil can be effective for female sexual side-effects as well, including difficulty achieving orgasm [ref, ref]).

Bupropion and Mirtazepine are two antidepressants that tend to have very low rates of sexual side-effects.

Sertraline overdose

Diarrhea, somnolence, vomiting, tachycardia, nausea, fainting, dizziness, agitation, tremor, serotonin syndrome, bradycardia, bundle branch block, convulsions, delirium, hallucinations, hypertension, hypotension, manic reaction, pancreatitis, QTc prolongation, stupor, coma. Can be fatal when combined with other drugs or alcohol.

Sertraline and pregnancy

Category C: some animal studies show adverse effects at very high doses, but no controlled human studies have been done; should only be used in pregnancy if clearly needed and if benefits outweigh potential risks. For further information, see the section on treating Depression in pregnancy.

Medical Monitoring for Sertraline

None for healthy individuals.

Drug Interactions with Sertraline

  • Caution should be used when combining Sertraline with other medications that can increase bleeding time and reduce blood clotting, including Aspirin, NSAIDs, anti-platelet agents, Heparin and Coumadin.
  • Combination with other serotonergic medications, including SSRI antidepressants and triptans, could potentially precipitate a serotonin syndrome.
  • Dangerous heart arrhythmias could occur if Sertraline is combined with Thioridazine or Pimozide.
  • Sertraline should not be used during or within 14 days following the administration of an MAOI, because a hypertensive crisis may result.
  • Sertraline can increase blood concentrations of Carvedilol, Clozapine, Cyclosporin, Digoxin, Flecainide, Risperidone, Phenytoin, Propafenone, Warfarin, and Zolpidem.
  • Sertraline can lower blood concentrations of Bupropion.
  • Sertraline blood concentrations can be reduced by Carbamazepine.
  • Sertraline blood concentrations can be increased by Cimetidine.