Is 1400mg Sertraline Fatal for a 90kg Patient?
A 1400mg sertraline ingestion is unlikely to be fatal in an otherwise healthy patient, though it requires immediate emergency evaluation and supportive care due to risk of serotonin syndrome and other serious complications. 1
Evidence from Overdose Data
The FDA drug label documents extensive overdose experience with sertraline, providing critical context for this dose 1:
- Among 634 cases where sertraline was the only drug ingested, 8 resulted in fatal outcomes 1
- The largest known ingestion was 13.5 grams (13,500mg) in a patient who took sertraline alone and subsequently recovered 1
- Another patient who took 2.5 grams (2,500mg) of sertraline alone experienced a fatal outcome, demonstrating that fatality is not strictly dose-dependent 1
The 1400mg dose in question falls well below the largest survived ingestion but above some fatal cases, indicating that individual patient factors and complications (particularly serotonin syndrome) are more predictive of outcome than absolute dose alone 1.
Expected Clinical Manifestations
Most Common Symptoms
The most frequently reported signs and symptoms in sertraline overdose include 1, 2:
- Somnolence
- Vomiting and nausea
- Tachycardia
- Dizziness
- Agitation and tremor
- Lethargy
Serious Complications to Monitor
More concerning adverse events that can occur with sertraline overdose include 1:
- Serotonin syndrome (confusion, agitation, myoclonus, hyperreflexia, fever, elevated creatine kinase) 3
- Seizures/convulsions
- Cardiac conduction abnormalities (bradycardia, bundle branch block, QT-interval prolongation, Torsade de Pointes)
- Hypotension or hypertension
- Coma or stupor
Risk Factors for Severe Toxicity
Serotonin syndrome is the primary life-threatening complication and may present with 3, 4:
- High-grade fever (mean temperature 41.6°C in fatal cases)
- Seizures (present in 36% of fatal serotonin syndrome cases)
- Markedly elevated creatine kinase (>25,000 IU/L in severe cases)
- Rapid symptom evolution within 24 hours
Fatal serotonin syndrome cases show that approximately 50% of patients died within 24 hours of symptom onset 4, emphasizing the need for immediate evaluation.
Critical Management Considerations
Immediate Actions Required
Emergency management should include 1:
- Ensure adequate airway, oxygenation, and ventilation
- Monitor cardiac rhythm and vital signs continuously
- Gastric lavage with large-bore orogastric tube (if performed soon after ingestion or in symptomatic patients)
- Activated charcoal administration
- General supportive and symptomatic measures
Interventions That Are NOT Effective
Forced diuresis, dialysis, hemoperfusion, and exchange transfusion are unlikely to be beneficial due to sertraline's large volume of distribution 1.
Induction of emesis is not recommended 1.
Prognostic Factors
A prospective study of 40 sertraline overdoses (mean dose 1,579mg, range 50-8,000mg) found 2:
- No significant morbidity in isolated sertraline ingestions
- Most common abnormalities were tremor, lethargy, and nausea
- Mean ED length of stay was 3.9 hours for discharged patients
- 12 patients were admitted for 24-hour observation with no adverse outcomes
However, co-ingestion of other substances (particularly benzodiazepines, alcohol, or other serotonergic agents) significantly increases risk 2, 5.
Key Clinical Pitfalls
- Do not assume dose correlates linearly with toxicity: A patient survived 13,500mg while another died from 2,500mg 1
- Serotonin syndrome can occur from sertraline overdose alone, not just from drug combinations 3
- Rapid symptom evolution is characteristic: 59% of fatal serotonin syndrome cases developed symptoms within 24 hours 4
- The presence of fever, seizures, and elevated CK should trigger aggressive management as these are associated with severe outcomes 4
Bottom Line for This Case
For a 90kg patient who has ingested 1400mg of sertraline, immediate emergency department evaluation is mandatory, but the prognosis is generally favorable with appropriate supportive care 1, 2. The patient requires cardiac monitoring, assessment for serotonin syndrome, and observation for at least 24 hours given the potential for delayed complications 1, 4.