What should be done if a patient develops a cough after taking sertraline (selective serotonin reuptake inhibitor (SSRI)) for two weeks?

Sertraline-Associated Cough: Evaluation and Management

Stop the sertraline immediately and monitor for cough resolution within 1-4 weeks, as this temporal pattern strongly suggests drug-induced cough rather than a common respiratory cause. 1

Initial Assessment

The two-week timeline is critical here. While ACE inhibitors are the most notorious culprits for drug-induced cough (occurring in 5-50% of patients depending on ethnicity), sertraline can rarely cause respiratory complications including cough. 2, 3

Key diagnostic features to evaluate:

• Cough characteristics: Dry, nonproductive cough with a persistent "tickle" sensation suggests drug-induced etiology 2
• Respiratory symptoms: Assess for pleuritic chest pain, dyspnea, or hypoxia that could indicate sertraline-induced interstitial lung disease (a rare but serious complication) 3
• Timing: Cough appearing within weeks to months of drug initiation supports drug causation 2, 1
• Exclude common causes: Rule out upper respiratory infection, postnasal drip, asthma, or GERD before attributing to medication 2

Management Algorithm

Step 1: Discontinue Sertraline

Immediately stop sertraline regardless of the temporal relationship. Even if the cough preceded the medication, the original cause may have resolved and sertraline could now be perpetuating it. 2

Step 2: Monitor Resolution Timeline

• Expected resolution: 1-4 weeks after discontinuation confirms drug-induced cough 1
• Median time to resolution: 26 days for drug-induced cough 2
• If cough resolves: Diagnosis confirmed; consider alternative antidepressant (see below)
• If cough persists beyond 4 weeks: Pursue full chronic cough workup for UACS, asthma, GERD 2

Step 3: Red Flag Assessment

Obtain chest X-ray and consider urgent evaluation if:

• Pleuritic chest pain, hypoxia, or dyspnea develop (possible interstitial lung disease) 3
• Hemoptysis, constitutional symptoms, or respiratory distress occur 4
• Ground-glass opacities or lymphadenopathy on imaging suggest pneumonitis 3

If interstitial lung disease is suspected, initiate oral corticosteroids (dexamethasone or prednisone) immediately after sertraline discontinuation. 3

Alternative Antidepressant Selection

Switch to an antidepressant without respiratory side effects:

• Preferred alternatives: Other SSRIs (escitalopram, fluoxetine) have minimal respiratory effects, though cross-reactivity is theoretically possible 2
• Avoid: Do not rechallenge with sertraline, as cough will recur within days 2
• Discontinuation considerations: Sertraline has moderate risk for discontinuation syndrome (less than paroxetine, more than fluoxetine), so taper if clinically stable 2

Symptomatic Cough Management During Transition

While awaiting cough resolution after sertraline discontinuation:

• First-line: Honey and lemon for symptomatic relief 5
• If additional relief needed: Dextromethorphan 30-60 mg (not standard OTC doses which are subtherapeutic) 5
• For nocturnal cough: First-generation antihistamines (diphenhydramine) 5
• Avoid: Codeine offers no advantage over dextromethorphan with worse side effects 5

Critical Pitfalls to Avoid

• Do not continue sertraline "to see if it improves": Drug-induced cough will not spontaneously resolve with continued exposure 2, 1
• Do not assume viral cause at 2 weeks: While acute cough is common, the medication history takes precedence 2, 4
• Do not miss interstitial lung disease: This rare complication requires immediate recognition and corticosteroid treatment 3
• Do not use antibiotics: Unless clear bacterial infection is present, antibiotics have no role 6

Expected Outcome

With sertraline discontinuation, expect complete cough resolution within 1-4 weeks in true drug-induced cases. 1 If cough persists beyond this timeframe, systematically evaluate for the common chronic cough triad: UACS, asthma, and GERD. 2