What are the treatment steps for an accidental overdose of sertraline (Selective Serotonin Reuptake Inhibitor - SSRI) 75 milligrams (mg)?

Management of Accidental Sertraline 75mg Overdose

An accidental overdose of 75mg sertraline requires supportive care with monitoring for serotonin syndrome symptoms, but this dose is unlikely to cause serious toxicity and does not require specific antidotes or aggressive interventions. 1, 2

Immediate Assessment and Risk Stratification

• 75mg represents a low-dose ingestion (typical therapeutic doses range 50-200mg daily), making significant toxicity unlikely 2, 3
• Evaluate the time since ingestion and whether any co-ingestants were involved, as combined ingestions significantly increase risk 2, 4
• Check for symptoms within the first 3-4 hours post-ingestion, as this is the typical presentation window 2

Clinical Monitoring Priorities

Monitor specifically for serotonin syndrome manifestations, which can develop within 24-48 hours: 5, 1

• Mental status changes: confusion, agitation, anxiety
• Neuromuscular hyperactivity: tremors, clonus, hyperreflexia, muscle rigidity, myoclonus
• Autonomic instability: tachycardia, hypertension, diaphoresis, hyperthermia, fever

Additional symptoms to monitor include: 2

• Tremor, lethargy, nausea (most common in isolated sertraline overdose)
• Less commonly: agitation, confusion, vomiting

Treatment Algorithm

For Asymptomatic Patients (Most Likely Scenario at 75mg)

• Observation for 4-6 hours is sufficient if the patient remains completely asymptomatic 2
• No gastrointestinal decontamination (activated charcoal, gastric lavage) is indicated for this dose unless presenting within 1 hour of a larger ingestion 2
• Discharge home with return precautions if asymptomatic after observation period 2

For Symptomatic Patients

• Provide supportive care only - there are no specific antidotes for SSRI overdose 1, 3
• Maintain airway, breathing, and circulation
• Treat symptoms as they arise (antiemetics for nausea, benzodiazepines for agitation if severe) 2
• If serotonin syndrome develops: discontinue sertraline immediately and provide supportive symptomatic treatment with continuous cardiac monitoring 5, 1

Critical Pitfalls to Avoid

• Do NOT administer flumazenil - it has no role in SSRI overdose and is contraindicated unless pure benzodiazepine overdose is confirmed 5
• Do NOT use multiple serotonergic agents for symptom management, as this increases serotonin syndrome risk 5, 6, 1
• Do NOT discharge patients who ingested other medications with sertraline without appropriate observation, as co-ingestions significantly increase morbidity 2, 4
• Be aware that serious reactions can be delayed up to 24 hours, particularly if multiple agents were involved 4

Special Considerations

• Sertraline is relatively safe in overdose compared to older antidepressants like tricyclics, with minimal significant morbidity reported in isolated ingestions 2, 3
• The margin of safety is greater than other antidepressants, though deaths have been reported following very large ingestions (thousands of milligrams) 5, 7
• Steady-state plasma concentrations vary widely (up to 15-fold) even at therapeutic doses, but therapeutic drug monitoring is not clinically useful 3
• The elimination half-life is 22-36 hours, so symptoms that do develop may persist but typically resolve with supportive care alone 3

Disposition

• Discharge home after 4-6 hours if completely asymptomatic with no co-ingestants 2
• Admit for 24-hour observation if any symptoms develop or if co-ingestants are involved 2, 4
• Provide psychiatric evaluation before discharge given the context of overdose 2