Treatment of Sertraline Overdose
Sertraline overdose requires immediate supportive care with cardiac monitoring, airway management, and consideration of gastrointestinal decontamination with activated charcoal if the patient presents within 4 hours of ingestion. 1
Immediate Management Priorities
Airway and Vital Signs
- Ensure adequate airway, oxygenation, and ventilation as the first priority in any sertraline overdose. 1
- Monitor cardiac rhythm and vital signs continuously, as sertraline overdose can cause tachycardia, bradycardia, hypertension, hypotension, QT-interval prolongation, and potentially Torsade de Pointes. 1, 2
- Continuous cardiac monitoring is essential, particularly given reports of QT prolongation (up to 525 ms) even with moderate overdoses. 2
Gastrointestinal Decontamination
- Administer activated charcoal if the patient presents within 1.5 to 4 hours post-ingestion, as it significantly increases sertraline clearance by a factor of 1.9 and decreases maximum plasma concentration. 3
- Gastric lavage with a large-bore orogastric tube (with appropriate airway protection) may be indicated if performed soon after ingestion or in symptomatic patients. 1
- Do not induce emesis, as this is not recommended for sertraline overdose. 1
Clinical Manifestations to Monitor
Common Symptoms
The most frequently observed signs in non-fatal sertraline overdose include: 1
- Somnolence and altered mental status
- Vomiting and nausea
- Tachycardia
- Dizziness and agitation
- Tremor
Serious Complications
Monitor vigilantly for serotonin syndrome, which represents the most life-threatening complication and is characterized by: 4, 5
- Mental status changes (confusion, agitation, anxiety, delirium, hallucinations, coma)
- Neuromuscular hyperactivity (tremors, clonus, hyperreflexia, muscle rigidity, myoclonus)
- Autonomic hyperactivity (hypertension, tachycardia, arrhythmias, tachypnea, diaphoresis, shivering, vomiting, diarrhea, fever)
- Advanced symptoms include seizures, arrhythmias, unconsciousness, and can lead to fatalities. 4, 5, 6
Additional serious complications reported include: 1
- Bundle branch block
- Convulsions
- Pancreatitis
- Stupor and syncope
- Manic reaction
Specific Treatment Interventions
Serotonin Syndrome Management
- Immediately discontinue all serotonergic agents if serotonin syndrome is suspected or confirmed. 4, 5
- Provide hospital-based supportive care with continuous cardiac monitoring. 4, 5
- This is particularly critical if the patient has co-ingested other serotonergic medications (other SSRIs, SNRIs, TCAs, tramadol, meperidine, dextromethorphan, St. John's wort, or illicit drugs like MDMA or cocaine). 4
Supportive Care
- General supportive and symptomatic measures are the mainstay of treatment. 1
- No specific antidotes for sertraline exist. 1
- Forced diuresis, dialysis, hemoperfusion, and exchange transfusion are unlikely to be beneficial due to sertraline's large volume of distribution (5340 L). 1, 3
Pharmacokinetic Considerations
- Sertraline has an elimination half-life of approximately 28 hours in overdose (range 19.4-30.6 hours), meaning prolonged monitoring may be necessary. 3
- The drug demonstrates linear kinetics even in overdose, with parameter values similar to therapeutic use. 3
- Deaths have been reported with very large ingestions (though sertraline is safer than tricyclic antidepressants in overdose), including one fatality with only 2.5 grams ingested, while another patient survived 13.5 grams. 4, 1
Critical Pitfalls to Avoid
- Do not assume safety based on dose alone—fatalities have occurred with relatively modest overdoses (2.5 grams), while others have survived much larger ingestions. 1
- Do not overlook potential co-ingestions—always consider multiple drug involvement and screen for other substances. 1
- Do not delay activated charcoal administration—it remains effective up to 4 hours post-ingestion. 3
- Contact a poison control center for guidance on complex cases. 1