From the Guidelines
Sertraline generally does not significantly prolong the QTc interval at standard therapeutic doses. It is considered one of the safer selective serotonin reuptake inhibitors (SSRIs) regarding cardiac effects. While very high doses or overdoses of sertraline might theoretically affect cardiac conduction, clinical evidence suggests minimal QTc prolongation risk with normal dosing, as noted in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. This makes sertraline a preferred antidepressant option for patients with cardiac concerns or those taking other medications that might affect QTc. However, caution is still warranted in patients with pre-existing QTc prolongation, electrolyte abnormalities (especially hypokalemia or hypomagnesemia), or those taking multiple QTc-prolonging medications. In these high-risk patients, baseline and follow-up ECG monitoring may be appropriate when starting sertraline, as recommended in the proposal for clinical management of arrhythmia induced by psychotropic medications 1. The relative cardiac safety of sertraline stems from its pharmacological profile, which shows minimal interaction with cardiac ion channels compared to some other psychotropic medications.
Some key points to consider when prescribing sertraline include:
- Starting with a low dose and gradually increasing as needed and tolerated
- Monitoring for symptoms of serotonin syndrome, especially when combining sertraline with other serotonergic drugs
- Avoiding concomitant use with monoamine oxidase inhibitors (MAOIs) due to the increased risk of serotonin syndrome
- Being cautious when prescribing sertraline to patients with a history of QTc prolongation or those taking other medications that may affect QTc, as recommended in the clinical practice guideline 1 and the proposal for clinical management of arrhythmia induced by psychotropic medications 1.
Overall, sertraline is a relatively safe option for patients with anxiety disorders, but it is essential to carefully evaluate each patient's individual risk factors and monitor them closely when starting treatment, as suggested by the clinical practice guideline 1 and the proposal for clinical management of arrhythmia induced by psychotropic medications 1.
From the FDA Drug Label
Other important adverse events reported with sertraline hydrochloride overdose (single or multiple drugs) include ... QT-interval prolongation, ...
Sertraline can prolong QTc in the context of an overdose, as indicated by reports of QT-interval prolongation.
- This is based on post-marketing experience with the drug.
- The exact circumstances under which this occurs are not specified in the label. 2
From the Research
QT Prolongation and Sertraline
- Sertraline is a selective serotonin reuptake inhibitor (SSRI) that has been studied for its potential to prolong the QT interval, a measure of the heart's electrical activity 3, 4, 5, 6.
- A study published in 2013 found that sertraline, at traditional doses, did not demonstrate clinically significant increases in QTc in the majority of studies, although case reports still linked it with QTc prolongation 3.
- Another study published in 2022 found that sertraline had a comparable safety profile to other SSRIs, with no increased risk of QT prolongation, but recommended screening ECGs and monitoring for patients with high-risk factors for arrhythmias 4.
- A thorough QT study published in 2020 found that sertraline at a supratherapeutic dose of 400 mg/day did prolong the QT interval, with the upper bound of the 90% confidence interval exceeding the predefined 10-millisecond significance threshold at one time point 5.
- A comprehensive review published in 2020 found that all antidepressants, including SSRIs like sertraline, should be used with caution and monitoring for QT prolongation, as they can increase the risk of cardiovascular mortality 6.
Risk Factors and Monitoring
- Patient-specific risk factors, such as age, sex, and electrolyte imbalances, should be considered when prescribing sertraline, and close monitoring of the QT interval is recommended 4, 7.
- Screening ECGs and genotyping for serotonin transporter/receptor variations may be necessary for patients with high-risk factors for arrhythmias 4.
- Reducing the medication dosage or discontinuing it altogether may be necessary if QT prolongation occurs, and selective beta blockers may be employed in some cases 7.