Can a Patient Start on Sertraline?
Yes, most patients can safely start sertraline, but you must first screen for absolute contraindications including current MAOI use, pimozide use, disulfiram use (with liquid formulation), known sertraline allergy, and bipolar disorder risk. 1
Absolute Contraindications to Screen For
Before initiating sertraline, you must exclude:
- MAOI use within the past 2 weeks - including linezolid and intravenous methylene blue, as concurrent use can cause life-threatening serotonin syndrome 1
- Current pimozide (Orap®) therapy - causes serious cardiac complications 1
- Disulfiram (Antabuse®) use - only applies to liquid sertraline formulation due to alcohol content 1
- Known allergy to sertraline or its components 1
- Unscreened bipolar disorder risk - treating bipolar depression with an SSRI alone may precipitate manic episodes. Obtain detailed psychiatric history including family history of bipolar disorder, suicide, and depression before starting 1
Critical Drug Interactions to Assess
Exercise caution and consider alternatives if the patient is taking:
- Other serotonergic agents - triptans, tramadol, fentanyl, lithium, tryptophan, St. John's Wort, other antidepressants (SNRIs, TCAs), buspirone - due to serotonin syndrome risk 2, 1
- Anticoagulants or antiplatelet agents - warfarin, aspirin, NSAIDs - as SSRIs increase bleeding risk including ecchymosis, epistaxis, and hemorrhage 2, 1
- Drugs metabolized by CYP2D6 - sertraline has moderate effects on this pathway 2
Recommended Starting Approach
For adults with depression or anxiety disorders:
- Start at 50 mg once daily (morning or evening) 3, 4, 5
- This starting dose is typically the optimal therapeutic dose for most patients 5
For children and adolescents with OCD:
For elderly patients:
- Start at 50 mg once daily - no dose reduction needed based on age alone 4, 6, 7
- Sertraline is preferred in elderly due to lack of anticholinergic effects and minimal drug interactions 4, 6, 7
Special Population Considerations
Hepatic impairment: Use reduced doses 4
Renal impairment: No dose adjustment needed 4
Patients prone to anxiety/agitation: Consider starting with a subtherapeutic test dose (e.g., 25 mg) as SSRIs can initially worsen these symptoms 4
Mandatory Monitoring Requirements
Close monitoring is essential, especially in the first weeks:
- Suicidal ideation and behavior - particularly critical in the first months and after dose changes. The absolute risk is 1% for antidepressants versus 0.2% for placebo (number needed to harm = 143) 4, 1
- Behavioral activation - watch for agitation, anxiety, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania 4, 1
- Serotonin syndrome - especially in first 24-48 hours after starting or dose increases. Symptoms include mental status changes (confusion, agitation), neuromuscular hyperactivity (tremors, clonus, hyperreflexia), and autonomic instability (hypertension, tachycardia, diaphoresis) 2, 1
- Abnormal bleeding - particularly with concurrent NSAIDs or anticoagulants 2, 4
Titration Strategy
- Dose increases: Can be made at 1-2 week intervals for sertraline (shorter half-life SSRI) 4
- Increments: Increase in 50 mg steps if inadequate response after 2-4 weeks 3, 4
- Maximum dose: 200 mg daily 3, 4
- Response timeline: Statistically significant improvement may occur within 2 weeks, clinically significant improvement typically by week 6, maximal improvement by week 12 or later 4
Common Pitfalls to Avoid
Do not abruptly discontinue sertraline - it is associated with discontinuation syndrome (dizziness, fatigue, myalgias, headaches, nausea, insomnia, sensory disturbances). Taper gradually when stopping 2, 4, 1
Ensure parental oversight in children and adolescents for medication adherence 4
Counsel patients about the indication - many are reluctant to start SSRIs due to concerns about taking an "antidepressant." Explain the rationale clearly, especially when using for non-depression indications like IBS or premature ejaculation 2