What is the recommended algorithm for discontinuing sertraline (Selective Serotonin Reuptake Inhibitor - SSRI)?

Sertraline Discontinuation Algorithm

Sertraline should be gradually tapered over a period of 10-14 days to minimize withdrawal symptoms, with slower tapering needed for patients on higher doses or longer treatment durations. 1, 2

Rationale for Gradual Tapering

Abrupt discontinuation of sertraline can lead to significant withdrawal symptoms due to its relatively short half-life compared to other SSRIs like fluoxetine. These symptoms can include:

• Somatic symptoms: Dizziness, light-headedness, nausea, vomiting, fatigue, myalgia, flu-like symptoms, sensory disturbances, and sleep disturbances 2
• Psychological symptoms: Anxiety, agitation, crying spells, and irritability 2
• Cardiovascular effects: Orthostatic hypotension has been reported with sertraline withdrawal 3

Recommended Tapering Protocol

Standard Tapering Schedule

1. For patients on 50mg daily (standard dose):

   • Week 1: Reduce to 25mg daily
   • Week 2: Reduce to 25mg every other day
   • Week 3: Discontinue completely

2. For patients on 100mg daily:

   • Week 1: Reduce to 75mg daily
   • Week 2: Reduce to 50mg daily
   • Week 3: Reduce to 25mg daily
   • Week 4: Reduce to 25mg every other day
   • Week 5: Discontinue completely

3. For patients on 150-200mg daily:

   • Use smaller decrements (25-50mg) at 1-2 week intervals
   • Extend the tapering period to 6-8 weeks or longer

Special Considerations

• Long-term users (>1 year): Consider more gradual tapering with smaller decrements and longer intervals between dose reductions 2
• Elderly patients: Start with lower doses and taper more gradually due to increased risk of side effects 1
• History of withdrawal symptoms: Use a more extended tapering schedule with smaller decrements

Monitoring During Discontinuation

1. Regular assessment for emergence of withdrawal symptoms
2. If severe symptoms occur: Return to the previous dose and slow the rate of taper 2
3. Monitor for depression relapse: Patients who discontinue antidepressants have a significantly higher risk of relapse (56% vs 39% for those who continue) 4

Managing Withdrawal Symptoms

• Mild symptoms: Reassurance that symptoms are usually transient 2
• Moderate symptoms: Slow the rate of taper further
• Severe symptoms: Return to the previous effective dose and restart tapering at a slower rate 2

Important Cautions

• Adherence challenges: Only 52% of patients successfully adhere to discontinuation protocols 4
• Misdiagnosis risk: Withdrawal symptoms may be mistaken for physical illness or depression relapse 2
• Relapse risk: Patients should be informed about the increased risk of depression relapse after discontinuation 4

Special Populations

• Adolescents: Follow the same gradual tapering principles, but start from lower doses (typically 25-50mg) 5
• Patients with cardiovascular issues: Monitor for orthostatic hypotension during the tapering process 3

Remember that withdrawal symptoms are generally mild and self-limiting but can be distressing enough to impact daily functioning. The key to successful discontinuation is a gradual, patient-specific approach with appropriate monitoring and support.