How do I taper off sertraline (selective serotonin reuptake inhibitor)?

How to Taper Sertraline

Sertraline should be tapered gradually using a hyperbolic (percentage-based) reduction schedule, decreasing by approximately 10-25% of the current dose every 1-4 weeks, continuing down to very small doses before complete discontinuation to minimize withdrawal symptoms. 1, 2

Recommended Tapering Strategy

Standard Tapering Approach

• Reduce the dose by 10-25% of the current dose (not the original dose) every 1-4 weeks, with slower tapers (10% per month) preferred for patients who have been on sertraline for extended periods (>1 year). 3, 2
• The FDA label explicitly states that "a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible" to avoid discontinuation symptoms. 1
• Hyperbolic tapering is superior to linear tapering because it reduces the biological effect on serotonin transporter inhibition in a more consistent manner, minimizing withdrawal symptoms that occur with traditional short tapers. 2

Tapering Timeline

• Traditional guideline recommendations of 2-4 week tapers show minimal benefit over abrupt discontinuation and are often poorly tolerated. 2
• Tapers extending over months, reaching doses much lower than minimum therapeutic doses (well below 25 mg), have shown greater success in reducing withdrawal symptoms. 2
• Once the smallest available dose is reached (typically 25 mg tablets can be split), extend the interval between doses before complete cessation. 3

Monitoring Requirements

Follow-Up Schedule

• Monitor patients at least monthly during the taper, with more frequent contact needed during difficult phases or when withdrawal symptoms emerge. 4
• The FDA recommends monitoring for discontinuation symptoms for at least 2 weeks after the last dose. 1

Symptoms to Monitor

• Withdrawal symptoms may include anxiety, insomnia, irritability, dizziness, sensory disturbances, tremor, confusion, headache, and flu-like symptoms. 1
• Return of original psychiatric symptoms (depression, panic, OCD) may take weeks to months to emerge after dose reduction and must be distinguished from withdrawal. 4
• Monitor for mood changes and suicidal ideation throughout the taper. 4

Managing Intolerable Symptoms

If Withdrawal Symptoms Occur

• Pause the taper when withdrawal symptoms emerge—this is acceptable and often necessary. 4
• If intolerable symptoms occur, resume the previously prescribed dose, then continue decreasing at a more gradual rate. 1
• The taper rate must be determined by patient tolerance, not a rigid schedule. 4

Distinguishing Withdrawal from Relapse

• Withdrawal symptoms typically emerge within days of dose reduction and improve over 1-2 weeks. 1
• Relapse of the underlying condition develops more gradually over weeks to months. 4

Special Considerations

Concurrent Benzodiazepine Use

• If a patient is taking both sertraline and a benzodiazepine, taper the benzodiazepine first due to higher risks of benzodiazepine withdrawal, including seizures and delirium tremens. 3, 4
• Tapering opioids can be associated with anxiety, making it safer to address benzodiazepine dependence before SSRI discontinuation when both are present. 3

Pregnancy

• Pregnant patients should not taper sertraline without specialist consultation, as withdrawal can cause complications and neonates exposed to SSRIs late in the third trimester may develop complications requiring prolonged hospitalization. 4, 1
• The physician must carefully weigh potential risks and benefits when treating pregnant women during the third trimester. 1

Hepatic Impairment

• Patients with liver disease require lower or less frequent dosing during tapering, as sertraline effects are prolonged in hepatic impairment. 1

Common Pitfalls to Avoid

• Do not use traditional short tapers (2-4 weeks) down to only minimum therapeutic doses—these are inadequate and poorly tolerated. 2
• Do not abruptly discontinue—this significantly increases withdrawal symptom severity. 1
• Do not assume all symptoms are withdrawal—monitor carefully for relapse of the underlying psychiatric condition. 4
• Do not restart at full dose if symptoms occur—resume the previous dose and slow the taper further. 1