What is the recommended dose of sertraline (selective serotonin reuptake inhibitor - SSRI)?

Sertraline Dosing Recommendations

Start sertraline at 50 mg once daily for major depressive disorder and obsessive-compulsive disorder, or 25 mg once daily for panic disorder, PTSD, and social anxiety disorder (increasing to 50 mg after one week), with a maximum dose of 200 mg daily. 1

Initial Dosing by Indication

Major Depressive Disorder and OCD

• Begin with 50 mg once daily 1
• This starting dose is the usually effective therapeutic dose and represents the optimal balance of efficacy and tolerability for most patients 2
• Can be administered at any time of day (morning or evening) 3, 1

Panic Disorder, PTSD, and Social Anxiety Disorder

• Start at 25 mg once daily 1
• Increase to 50 mg once daily after one week 1
• This lower starting dose helps minimize initial side effects in these anxiety-related conditions 1

Premenstrual Dysphoric Disorder

• Begin with 50 mg daily, either throughout the menstrual cycle or limited to the luteal phase 1
• If dosing during luteal phase only and 100 mg/day dose is established, use a 50 mg/day titration step for 3 days at the beginning of each luteal phase period 1

Dose Titration Strategy

For patients not responding to 50 mg daily, increase the dose in 50 mg increments at intervals of no less than 1 week, up to a maximum of 200 mg daily. 1

• The 24-hour elimination half-life of sertraline necessitates waiting at least one week between dose changes to reach steady state 1, 2
• Dose increases should be based on inadequate therapeutic response after 2-4 weeks at the current dose 2
• The therapeutic range is 50-200 mg/day across all approved indications 3, 1

Pediatric Dosing (Ages 6-17, OCD Only)

• Children ages 6-12: Start at 25 mg once daily 1
• Adolescents ages 13-17: Start at 50 mg once daily 1
• Maximum dose: 200 mg/day for both age groups 1
• Consider lower body weights when advancing doses to avoid excess dosing 1

Special Population Considerations

Elderly Patients

• No dosage adjustment needed based on age alone 1, 4, 5
• Use the same starting dose of 50 mg daily (or 25 mg for anxiety disorders) 4, 5
• Sertraline has a favorable safety profile in elderly patients compared to tricyclic antidepressants, lacking significant anticholinergic effects 4, 5
• The pharmacokinetics in elderly patients are similar to younger adults, eliminating the need for dose reduction 4, 5

Patients with Alzheimer's Disease and Depression

• Initial dose: 25-50 mg per day 3
• Maximum dose: 200 mg per day (morning or evening) 3
• Sertraline is well tolerated and has less effect on metabolism of other medications compared to other SSRIs—an important consideration given polypharmacy in this population 3, 6

Renal Impairment

• No dosage adjustment required 7

Maintenance Treatment Duration

Major Depressive Disorder

• Continue treatment for several months or longer beyond initial response 1
• Efficacy demonstrated for up to 44 weeks following 8 weeks of initial treatment at 50-200 mg/day (mean dose 70 mg/day) 1

PTSD

• Maintain treatment for several months beyond initial response 1
• Efficacy demonstrated for up to 28 weeks following 24 weeks of treatment at 50-200 mg/day 1

Social Anxiety Disorder

• Continue for several months beyond initial response 1
• Efficacy maintained for up to 24 weeks following 20 weeks of treatment at 50-200 mg/day 1

OCD and Panic Disorder

• Require several months or longer of sustained therapy beyond initial response 1

Common Side Effects and Tolerability

Typical side effects include sweating, tremors, nervousness, insomnia or somnolence, dizziness, gastrointestinal disturbances, and sexual dysfunction. 3, 6

• Most frequently reported adverse events in elderly patients: dry mouth, headache, diarrhea, nausea, insomnia, somnolence, constipation, dizziness, sweating, and taste abnormalities 4, 5
• The tolerability profile is generally similar between younger and elderly patients 4, 5
• Sertraline has minimal effects on cytochrome P450 enzymes, resulting in fewer drug-drug interactions compared to other SSRIs 6, 4, 5

Critical Safety Monitoring

Monitor patients closely for clinical worsening, suicidality, and unusual behavioral changes, especially during the initial months of therapy or at times of dose changes. 6

Alternative Dosing for Specific Conditions

Premature Ejaculation (Off-Label)

• Daily dosing: 25,50,100, or 200 mg daily 3
• Situational dosing: 50 mg at 5 p.m. (4-8 hours before intercourse) 3
• Higher doses may increase efficacy but potentially increase risk of erectile dysfunction and decreased libido 3

Cholestatic Pruritus (Fourth-Line)

• Up to 100 mg daily 3
• Only consider after failure of cholestyramine, rifampicin, and naltrexone 3

Irritable Bowel Syndrome (Second-Line)

• SSRIs as a class may be effective for global symptoms in IBS 3
• Careful explanation of rationale required, as patients may be confused about using an antidepressant for GI symptoms 3