What are the potential side effects of sertraline (an antidepressant) in an adult patient with no significant medical history?

Sertraline Side Effects

Sertraline commonly causes gastrointestinal side effects (nausea, diarrhea, indigestion), sexual dysfunction, sleep disturbances, and increased sweating, while potentially serious effects requiring monitoring include behavioral activation/suicidal ideation (especially early in treatment), serotonin syndrome, hyponatremia, and bleeding abnormalities. 1, 2

Common Side Effects

Gastrointestinal Effects

• Nausea and vomiting occur more frequently with sertraline than with other SSRIs, making this the most prominent category of side effects 1
• Diarrhea/loose stools are particularly common with sertraline compared to other antidepressants 1, 3, 4
• Dry mouth, heartburn, indigestion, and loss of appetite are additional gastrointestinal complaints 1, 2
• These gastrointestinal effects are typically mild and transient, decreasing with continued treatment 5

Sexual Dysfunction

• Decreased libido, ejaculation failure, and inability to achieve orgasm are common sexual side effects 2, 5
• Male sexual dysfunction, particularly ejaculatory disturbance, is more frequently reported than female sexual dysfunction 2, 5

Neurological and Sleep Effects

• Headache, dizziness, somnolence, and insomnia can all occur with sertraline 1, 6
• Tremor or shaking may develop during treatment 2
• The drug can cause either increased sleepiness or trouble sleeping, depending on the individual 2

Other Common Effects

• Increased sweating is a characteristic side effect of sertraline 1, 6
• Fatigue and agitation may occur 2
• Taste abnormalities and constipation have been reported 6

Potentially Serious Side Effects Requiring Monitoring

Psychiatric/Behavioral Effects

• Behavioral activation, agitation, and suicidal thinking/behavior require close monitoring, particularly in younger patients and those with anxiety disorders 1
• The FDA warns about increased suicide risk, especially during the first few months of treatment and following dose adjustments 1, 2
• Worsening depression, aggression, hallucinations, delusions, and withdrawal syndrome can occur 2

Serotonin Syndrome

• This rare but potentially life-threatening condition occurs when sertraline is combined with other serotonergic medications (triptans, other SSRIs/SNRIs, tramadol, tryptophan, St. John's Wort) 1, 2
• Symptoms include high fever, uncontrolled muscle spasms, stiff muscles, rapid heart rate changes, confusion, and loss of consciousness 2

Metabolic and Hematologic Effects

• Hyponatremia (low sodium levels) can develop during sertraline treatment 1
• Abnormal bleeding, including easy bruising and prolonged bleeding time, may occur 1
• Rare but serious hematologic effects include agranulocytosis, aplastic anemia, pancytopenia, leukopenia, and thrombocytopenia 2

Cardiovascular Effects

• Torsade de Pointes arrhythmias have been reported 2
• Sertraline is essentially devoid of the cardiovascular effects seen with tricyclic antidepressants, making it safer in patients with cardiac disease 5

Hepatic Effects

• Asymptomatic elevations in liver enzymes (AST/ALT) occur in approximately 0.8% of patients, typically within 1-9 weeks of treatment 2
• Rare cases of hepatitis, jaundice, hepatomegaly, and liver failure (potentially fatal) have been reported 2

Severe Skin Reactions

• Stevens-Johnson syndrome, vasculitis, photosensitivity, and other potentially fatal severe cutaneous disorders can occur 2

Other Serious Effects

• Reversible cerebral vasoconstriction syndrome and seizures have been reported 2
• Rare cases of pancreatitis 2
• Extrapyramidal symptoms and oculogyric crisis 2

Special Population Considerations

Elderly Patients

• Sertraline is generally well tolerated in elderly patients (≥60 years) and lacks the marked anticholinergic effects of tricyclic antidepressants 6
• The side effect profile is similar between younger and elderly patients 6
• No dosage adjustments are needed based solely on age 6
• Elderly patients are particularly prone to anticholinergic effects of tricyclics, making SSRIs like sertraline a better choice 6, 4

Children and Adolescents

• Additional side effects in this population include abnormal increase in muscle movement, agitation, nosebleeds, increased urination, urinary incontinence, aggressive reactions, and heavy menstrual periods 2
• Possible slowed growth rate and weight changes require monitoring of height and weight during treatment 2

Management Strategies

Minimizing Side Effects

• Starting at a lower dose and slowly titrating upward can minimize initial side effects 1
• Most side effects are mild and transient, decreasing in frequency with continued treatment 5

Monitoring Requirements

• Close monitoring is essential during the first few months of treatment and following dosage adjustments, particularly for suicidality or behavioral activation 1
• Regular assessment for signs of serotonin syndrome when combined with other serotonergic agents 1
• Monitor sodium levels, especially in elderly patients or those on diuretics 1
• Watch for signs of abnormal bleeding, particularly in patients on anticoagulants or NSAIDs 1, 2

Important Drug Interactions and Precautions

• Avoid combining with MAO inhibitors, other serotonergic drugs, and use caution with anticoagulants (warfarin), NSAIDs, and aspirin 2
• Sertraline has minimal inhibitory effects on cytochrome P450 enzymes and has a low potential for drug interactions compared to other SSRIs 6, 7
• Patients should avoid alcohol while taking sertraline 2
• The medication can impair ability to drive or operate machinery until individual response is known 2