What are the potential side effects of sertraline (Zoloft)?

Sertraline (Zoloft) Side Effects

Sertraline commonly causes side effects including sexual dysfunction, gastrointestinal disturbances (nausea, diarrhea), insomnia, drowsiness, dizziness, headache, and dry mouth, with approximately 63% of patients experiencing at least one side effect during treatment. 1

Common Side Effects

Gastrointestinal Effects

• Nausea and vomiting: Among the most common reasons for discontinuation 2
• Diarrhea: Sertraline has a higher rate of diarrhea compared to other antidepressants including bupropion, citalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, and venlafaxine 2
• Indigestion/digestive issues 3

Neurological and Psychiatric Effects

• Drowsiness/fatigue: Common and may affect daily functioning 3
• Insomnia and sleep disturbances: May require timing adjustment of medication 1
• Dizziness: Can affect balance and coordination 3
• Headache: Frequently reported 3
• Tremor or shaking: May be noticeable particularly in the hands 3
• Yawning: Listed as a frequent side effect 3

Sexual Dysfunction

• Male sexual dysfunction: Including ejaculation failure/delay 3, 4
• Female sexual dysfunction: Including decreased libido 3
• Persistence: 83% of patients still experience sexual side effects at 3 months 1

Other Common Side Effects

• Increased sweating: Frequently reported 3
• Dry mouth: Common but usually mild 3
• Anxiety or agitation: May occur especially during initial treatment 3

Serious Side Effects

Psychiatric Effects

• Suicidal ideation: Particularly in young patients up to 24 years old 1
• Serotonin syndrome: Characterized by high fever, uncontrolled muscle spasms, stiff muscles, rapid changes in heart rate or blood pressure, confusion, and loss of consciousness 3
• Emotional lability, aggression, or worsening depression: Requires immediate medical attention 3

Cardiovascular Effects

• Torsade de Pointes arrhythmias: Rare but serious 3
• Reversible cerebral vasoconstriction syndrome: Rare complication 3

Endocrine and Metabolic Effects

• Small mean increases in total cholesterol (approximately 3%) 3
• Small mean increases in triglycerides (approximately 5%) 3
• Small mean decrease in serum uric acid (approximately 7%) 3
• Hyponatremia: Can occur especially in elderly patients 2
• Hyperprolactinemia and galactorrhea: Rare but reported 3

Hepatic Effects

• Elevated liver enzymes: Occurs in approximately 0.8% of patients, usually within first 1-9 weeks of treatment 3
• Severe liver events: Including hepatitis, jaundice, and in rare cases, liver failure 3

Hematologic Effects

• Blood disorders: Rare reports of agranulocytosis, aplastic anemia, leukopenia, and thrombocytopenia 3

Dermatologic Effects

• Severe skin reactions: Potentially fatal conditions such as Stevens-Johnson syndrome 3
• Photosensitivity: Increased sensitivity to sunlight 3

Managing Side Effects

For Sexual Dysfunction

• Consider dose reduction
• Drug holidays (temporary discontinuation)
• Switching to medications with fewer sexual side effects (mirtazapine, duloxetine, venlafaxine, or bupropion) 1

For Gastrointestinal Effects

• Take medication with food
• Gradual dose titration
• Temporary use of antacids 1

For Sleep Disturbances

• Morning dosing for insomnia
• Bedtime dosing for drowsiness 1

Special Considerations

Discontinuation

• Withdrawal syndrome: Avoid abrupt discontinuation to prevent withdrawal symptoms including anxiety, headache, nausea, fatigue, and low mood 1
• Tapering: Gradually reduce dose over several weeks

Drug Interactions

• MAOIs: Avoid concomitant use due to risk of serotonin syndrome 1
• Medications metabolized by CYP2D6: Exercise caution 1
• Tamoxifen: May reduce tamoxifen's efficacy 1
• Blood thinners: May increase bleeding risk 3

Monitoring Recommendations

• More frequent monitoring in the first few weeks of treatment, especially in young patients
• Regular assessment of suicidal ideation
• Monitoring for signs of serotonin syndrome
• Liver function tests if symptoms of liver dysfunction develop

Sertraline has a generally favorable safety profile compared to older antidepressants like tricyclics, with minimal anticholinergic activity and cardiovascular effects 4. However, the side effect profile should be carefully considered when initiating treatment, especially in vulnerable populations such as the elderly, adolescents, and those with pre-existing conditions.