What is the recommended protocol for tapering off sertraline (Selective Serotonin Reuptake Inhibitor) in an adult patient with a history of depression or anxiety?

How to Taper Off Sertraline

Gradually reduce sertraline by 25-50 mg decrements every 1-4 weeks, with slower tapers (10% of current dose per month) for patients on long-term therapy, never stopping abruptly due to risk of withdrawal symptoms.

Understanding Sertraline Discontinuation

Sertraline has a 24-hour elimination half-life, which means dose changes should not occur at intervals of less than 1 week 1. Abrupt discontinuation can cause withdrawal symptoms including dizziness, nausea, fatigue, sensory disturbances, anxiety, agitation, and irritability 2. While the FDA label emphasizes that "abrupt discontinuation can be associated with certain symptoms," it does not provide specific tapering protocols 1.

Recommended Tapering Protocol

Standard Taper (For patients on sertraline <1 year)

• Start by reducing from current dose to 25-50 mg below current dose 2
• Wait at least 1 week between dose reductions (due to sertraline's 24-hour half-life) 1
• Continue reducing by 25-50 mg every 1-2 weeks until reaching 25 mg daily 2
• Maintain 25 mg daily for 1-2 weeks before complete discontinuation 3

For example, if a patient is on 100 mg daily:

• Weeks 1-2: Reduce to 75 mg daily
• Weeks 3-4: Reduce to 50 mg daily
• Weeks 5-6: Reduce to 25 mg daily
• Weeks 7-8: Discontinue completely

Extended Taper (For patients on sertraline >1 year)

For long-term users, slow the taper to 10% of the current dose per month to minimize withdrawal symptoms 4. This hyperbolic tapering approach (exponential dose reduction) appears most promising for preventing withdrawal 4.

For a patient on 100 mg daily for >1 year:

• Month 1: Reduce to 90 mg daily (10% reduction)
• Month 2: Reduce to 81 mg daily (10% of 90 mg)
• Month 3: Reduce to 73 mg daily (10% of 81 mg)
• Continue this pattern until reaching lowest available dose

The entire taper will likely require 6-12 months minimum 5.

Critical Safety Considerations

Never Stop Abruptly

Medication should be tapered, as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms 1. Discontinuation symptoms emerge most frequently after abrupt cessation and include somatic symptoms (dizziness, nausea, fatigue, myalgia, sensory disturbances) and psychological symptoms (anxiety, agitation, crying spells, irritability) 2.

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 5
• Monitor for withdrawal symptoms including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, and confusion 5
• Screen for depression, anxiety, and suicidal ideation that may emerge during tapering 5
• Watch for symptoms that might represent worsening depression or emerging suicidality, especially if severe, abrupt in onset, or not part of the patient's original presentation 1

Managing Withdrawal Symptoms

If withdrawal symptoms emerge:

• Reinstitute the previous dose and slow the rate of taper 2
• Reassure patients that symptoms are usually transient and self-limiting 2
• Do not mistake withdrawal symptoms for physical illness or depression relapse, as this leads to unnecessary testing and treatment 2

Practical Dosing Challenges

Only 8.9% of patients receive evidence of deliberate tapering in clinical practice, though this has increased from 4.9% in 2014 to approximately 10% in recent years 3. The main barrier is that sertraline is available in 25 mg, 50 mg, and 100 mg tablets, making very gradual tapers difficult in the final stages 4.

For the extended taper requiring doses like 90 mg or 73 mg, consider:

• Using liquid formulation if available
• Alternating doses (e.g., alternate 100 mg and 75 mg for an average of 87.5 mg)
• Having compounding pharmacy prepare custom doses

Adjunctive Strategies

Cognitive Behavioral Therapy

Integrating CBT during the taper significantly increases success rates 5. Offer CBT as the primary long-term anxiety management strategy rather than continuing medication 5.

Patient Education

Patient education about withdrawal risks and benefits of tapering improves outcomes and engagement in the tapering process 5. Explain that:

• Withdrawal symptoms are temporary and manageable
• The taper rate will be adjusted based on their tolerance
• Pauses in the taper are acceptable when symptoms emerge

When to Refer to Specialist

Immediate specialist referral is indicated for patients with 5:

• History of withdrawal seizures
• Unstable psychiatric comorbidities
• Co-occurring substance use disorders
• Previous unsuccessful office-based tapering attempts

Key Pitfalls to Avoid

• Never use straight-line percentage reductions from the starting dose, as this subjects patients to disproportionately large final decrements 5
• Never abandon the patient even if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy 5
• The taper rate must be determined by the patient's tolerance, not a rigid schedule 5
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 5

Special Populations

Elderly Patients

There is no need for altered dose recommendations in the elderly for sertraline specifically 6, but use lower doses and more gradual tapers to minimize adverse effects 5.

Pregnant Patients

Pregnant patients should not taper during pregnancy without specialist consultation, as withdrawal can cause spontaneous abortion and premature labor 5.