Managing Sexual Side Effects from Sertraline 100mg
The first step is to switch from sertraline to bupropion, as bupropion has significantly lower rates of sexual dysfunction (8-10%) compared to sertraline and is recommended as first-line therapy by the American College of Physicians when sexual dysfunction occurs with SSRIs. 1
Why Switching to Bupropion is the Preferred First Step
- The American College of Physicians explicitly recommends switching to bupropion as the standard first-line management strategy when sexual dysfunction occurs with sertraline, given bupropion's dramatically lower sexual dysfunction rates (8-10%) versus sertraline's rates (14% ejaculatory failure, 6% decreased libido) 1
- This recommendation is reinforced by direct comparison studies showing bupropion was associated with significantly less sexual dysfunction than both fluoxetine and sertraline 1
- Most improvement with bupropion occurs within the first 2 weeks at low doses (100-200 mg/day), with global response rates of 75% for men and 46% for women 2
Alternative Strategies (If Bupropion is Contraindicated)
Bupropion contraindications to screen for:
- Active seizure disorder or history of seizures 1, 3
- Agitated patients (bupropion can worsen agitation) 1
- Eating disorders (increased seizure risk) 3
If bupropion cannot be used, consider:
- Mirtazapine 15-30 mg/day has lower sexual dysfunction rates than SSRIs, though it causes sedation and weight gain 1
- Dose reduction of sertraline to the minimum effective level, as sexual side effects are strongly dose-related 4
Why Other Strategies Are NOT First-Line
- Waiting for spontaneous resolution: Sexual dysfunction occurs in 50% or more of SSRI patients and rarely resolves without intervention 5
- Adjunctive medications (buspirone, sildenafil): The American College of Physicians recommends against buspirone for SSRI-induced sexual dysfunction due to lack of evidence 1. PDE5 inhibitors only address erectile function, not libido 1
- Drug holidays: Not mentioned in current guidelines as a preferred strategy and may destabilize mood 5
Critical Safety Considerations During the Switch
- Taper sertraline gradually to prevent SSRI withdrawal syndrome (dizziness, nausea, headache, flu-like symptoms) 4
- Monitor blood pressure when starting bupropion, as it can increase blood pressure 3
- Continue monitoring for suicidal ideation during treatment changes, particularly in patients under age 24 4
- Assess seizure risk factors before initiating bupropion, especially if planning doses above 450 mg/day 3
Timeline for Response Assessment
- Begin monitoring for improvement in sexual function within 1-2 weeks of switching to bupropion 2
- Modify treatment if no adequate response within 6-8 weeks 1, 3
- Most improvement with bupropion occurs within the first 2 weeks at doses of 100-200 mg/day 2
Common Pitfall to Avoid
Do not simply add bupropion to sertraline as augmentation initially—the guideline-recommended approach is to switch entirely to bupropion as monotherapy for depression with lower sexual dysfunction risk 1. Augmentation with bupropion is only considered if switching fails or is contraindicated 1.