Sertraline Dose Increase Protocol
When increasing sertraline dosage, start with the smallest available increments and increase at intervals of no less than 1 week, with dose adjustments ranging from 50-200 mg/day based on clinical response and tolerability. 1
Initial Dosing and Standard Titration
- The standard starting dose for sertraline is 50 mg once daily for most indications, though 25 mg daily may be used initially in some cases (such as panic disorder, PTSD, and social anxiety disorder) 1
- For most patients, 50 mg/day is considered the usually effective therapeutic dose with optimal balance of efficacy and tolerability 2
- Sertraline can be administered at any time of day, either morning or evening, as a single daily dose 1, 2
- The elimination half-life of sertraline is approximately 24 hours, which is why dose changes should not occur at intervals of less than 1 week 1, 3
Dose Increase Protocol
- For patients not responding adequately to the initial dose, increase sertraline in 50 mg/day increments 1
- Allow at least 1 week between dose increases to reach steady state plasma concentrations 1, 4
- The maximum recommended dose is 200 mg/day 1
- Dose increases should be based on clinical response and tolerability assessment at each step 4
Special Considerations
- Unlike some other SSRIs, sertraline generally does not require dose adjustments for elderly patients based solely on age 2, 5
- When increasing the dose, monitor for side effects including nausea, dry mouth, drowsiness, reduced libido, headache, insomnia, and dizziness 6, 7
- A discontinuation syndrome can occur with missed doses or abrupt cessation, particularly with sertraline which has a shorter half-life than fluoxetine 4, 6
- Caution should be exercised when combining sertraline with other serotonergic medications due to risk of serotonin syndrome 4
Clinical Pearls
- Research suggests that continuing treatment at 100 mg/day for at least 8 weeks may be beneficial before considering alternative strategies for non-responders 8
- Interestingly, one study found that increasing sertraline to 200 mg/day in non-responders resulted in a lower response rate (56%) compared to maintaining 100 mg/day (70%) 8
- Sertraline has a relatively favorable drug interaction profile compared to other SSRIs due to less effect on CYP450 isoenzymes 6, 7
- For mild to moderate anxiety presentations, a conservative approach involves increasing the dose in the smallest available increments at 1-2 week intervals 4
- For more severe presentations, faster up-titration may be indicated as tolerated, though higher doses can be associated with more adverse effects 4
Monitoring During Dose Increases
- Assess for common side effects that may increase with higher doses, particularly gastrointestinal symptoms and sexual dysfunction 6, 5
- Monitor for signs of serotonin syndrome when increasing doses, especially if the patient is on other serotonergic medications 4
- Systematic assessment of treatment response using standardized symptom rating scales can be helpful when evaluating the need for dose increases 4
- The therapeutic plasma concentration range for sertraline is 10-50 ng/mL, though routine plasma level monitoring is not typically required 6