Do you need to taper off sertraline (Selective Serotonin Reuptake Inhibitor) to start an SNRI (Serotonin-Norepinephrine Reuptake Inhibitor)?

Switching from Sertraline to an SNRI: Tapering Protocol

Yes, you should gradually taper off sertraline before starting an SNRI to minimize withdrawal symptoms and avoid potential serotonin syndrome. 1, 2

Rationale for Tapering

Sertraline (an SSRI) requires a careful discontinuation plan to avoid withdrawal symptoms that can include:

• Physical symptoms: dizziness, light-headedness, nausea, headache, tremor, sensory disturbances
• Psychological symptoms: anxiety, irritability, mood changes, insomnia
• Discontinuation syndrome: electric shock-like sensations, flu-like symptoms 2, 3

The FDA label for sertraline specifically recommends "a gradual reduction in the dose rather than abrupt cessation" whenever possible 2.

Tapering Protocol for Sertraline

1. Initial Assessment

   • Review current sertraline dose
   • Identify risk factors for difficult discontinuation:
     • History of withdrawal symptoms with missed doses
     • Previous unsuccessful discontinuation attempts
     • Higher doses of sertraline 4

2. Tapering Schedule

   • For standard risk patients:

     • Reduce by approximately 25% of the original dose every 1-2 weeks 1
     • Example: 100mg → 75mg → 50mg → 25mg → stop

   • For high-risk patients or those on long-term therapy:

     • Consider slower hyperbolic tapering (reducing by smaller percentages as the dose gets lower) 3
     • May need to extend taper over several months 3

3. Monitoring During Taper

   • Watch for emergence of withdrawal symptoms
   • If symptoms occur, slow the taper or temporarily return to previous dose 1
   • Continue the taper only when symptoms have resolved

Starting the SNRI

1. Timing

   • Complete the sertraline taper before starting the SNRI
   • Allow at least 24 hours after the last dose of sertraline before starting the SNRI 2

2. SNRI Initiation

   • Start with the lowest available dose of the chosen SNRI
   • Titrate slowly upward according to response and tolerability 1

Important Precautions

• Avoid abrupt discontinuation: Research shows significantly more discontinuation symptoms with abrupt discontinuation (12.0 symptoms) versus tapering (5.9 symptoms) 5

• Contraindications: Never combine sertraline with MAOIs due to risk of serotonin syndrome 2

• Special populations:

  • Patients with liver impairment may need slower tapering 2
  • Young adults (under 24) require closer monitoring for suicidal ideation during medication changes 6

Potential Complications

• Serotonin syndrome: Risk increases with overlapping serotonergic medications; symptoms include mental status changes, autonomic instability, neuromuscular symptoms 2

• Mistaking withdrawal for relapse: Discontinuation symptoms can be misinterpreted as return of the original condition, leading to unnecessary long-term medication 3

• Discontinuation failure: Some patients may require multiple attempts with increasingly gradual tapers 7

By following a structured tapering protocol when switching from sertraline to an SNRI, you can minimize adverse effects and ensure a smoother transition between medications while prioritizing patient safety and comfort.