Restarting Sertraline (Zoloft) Dosing
When restarting sertraline after discontinuation, begin at 50 mg once daily for most indications (major depression, OCD), or 25 mg once daily for panic disorder, PTSD, and social anxiety disorder, with the same titration approach used for treatment-naive patients. 1
Initial Dosing Strategy Upon Restart
The FDA-approved approach for restarting sertraline mirrors the initial treatment protocol:
- For Major Depressive Disorder and OCD: Start at 50 mg once daily 1
- For Panic Disorder, PTSD, and Social Anxiety Disorder: Start at 25 mg once daily for one week, then increase to 50 mg once daily 1
- For pediatric patients (6-12 years) with OCD: Start at 25 mg once daily 1
- For adolescents (13-17 years) with OCD: Start at 50 mg once daily 1
Titration and Dose Adjustment
Dose increases should occur at intervals of no less than 1 week, given sertraline's 24-hour elimination half-life. 1 The maximum dose is 200 mg/day for most indications 1. For patients who previously responded to a higher dose, you may titrate more rapidly (weekly increments of 50 mg) if the medication is well-tolerated, though starting conservatively minimizes the risk of initial anxiety or agitation 2.
Critical Timing Considerations After MAOI Use
If the patient was previously on an MAOI, wait at least 14 days after MAOI discontinuation before restarting sertraline. 1 This washout period is mandatory to prevent serotonin syndrome, which can manifest within 24-48 hours of combining serotonergic agents with symptoms including mental status changes, neuromuscular hyperactivity (tremors, clonus, hyperreflexia), and autonomic instability (hypertension, tachycardia, diaphoresis) 2.
Managing Previous Discontinuation Syndrome
If the patient experienced discontinuation syndrome when previously stopping sertraline (characterized by dizziness, fatigue, nausea, sensory disturbances, anxiety, or irritability), this does not affect the restart protocol 2. However, it signals that future discontinuation should be gradual rather than abrupt 1.
Sertraline has been associated with discontinuation syndrome, though to a lesser extent than paroxetine. 2 When eventually discontinuing again, taper gradually rather than stopping abruptly 1.
Special Populations
For elderly patients, no dosage adjustment is required based solely on age 2, 3, making sertraline advantageous compared to other SSRIs. The standard starting dose of 50 mg daily applies 2.
For patients with hepatic impairment, use a lower or less frequent dose 1, though specific dosing recommendations are not well-established since moderate-to-severe hepatic impairment has not been adequately studied 1.
Monitoring During Restart
During the first 1-2 weeks after restarting, monitor for:
- Initial anxiety or agitation (a paradoxical early adverse effect of SSRIs that may warrant starting with a subtherapeutic "test dose") 2
- Gastrointestinal symptoms (nausea, diarrhea—the most common reasons for discontinuation) 2
- Sexual dysfunction (primarily ejaculatory disturbance in males) 4
Therapeutic response typically requires 2-4 weeks at an adequate dose 2, with dose adjustments made at 1-2 week intervals for shorter half-life SSRIs like sertraline 2.
Common Pitfalls to Avoid
- Do not restart at the patient's previous maintenance dose—always begin at the standard starting dose to assess current tolerability 1
- Do not increase doses more frequently than weekly—sertraline's 24-hour half-life requires this interval to reach steady-state 1
- Do not combine with MAOIs or start within 14 days of MAOI discontinuation—this is contraindicated due to serotonin syndrome risk 1
- Do not assume the previously effective dose will be needed again—many patients respond adequately to 50 mg daily 5