What is the recommended starting dose and titration schedule of sertraline for adults, elderly patients, patients with hepatic impairment, and children aged six years and older with obsessive‑compulsive disorder?

Sertraline Dosing Guidelines

Adults (Depression, Anxiety Disorders, OCD)

Start sertraline at 50 mg once daily, which is both the optimal starting dose and the usual therapeutic dose for most adult patients. 1, 2

Titration Schedule

• Initial dose: 50 mg once daily 1, 2
• Timing: Can be administered at any time of day (morning or evening) 1, 2
• Dose increases: If inadequate response after 2-4 weeks, increase by 50 mg increments at intervals of no less than 1 week 1, 2
• Maximum dose: 200 mg/day 1, 2
• Therapeutic range: 50-200 mg/day across all approved indications 1

Important Considerations for Adults

• The 50 mg starting dose represents the optimal balance of efficacy and tolerability for most patients—no need to start lower and titrate up in typical adult cases 2
• Single daily dosing is appropriate due to sertraline's 24-32 hour elimination half-life 1, 3
• Steady-state plasma concentrations are reached after approximately 7 days 3
• Allow 8 weeks at optimal dose for an adequate therapeutic trial before concluding treatment failure 1

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Elderly Patients

Use the standard adult dose of 50 mg daily—no age-based dose reduction is required for elderly patients. 1, 2

Key Points for Elderly

• Starting dose: 50 mg once daily 1, 2
• No routine dose adjustment needed based on age alone 1, 2
• Sertraline pharmacokinetics in elderly patients are similar to younger adults 3
• Exception: Reduce dose only if hepatic impairment is present 1
• Sertraline is preferred in elderly due to lack of anticholinergic effects and minimal cytochrome P450 interactions 1

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Patients with Hepatic Impairment

A reduced dose is recommended in patients with hepatic disease. 1

Dosing Approach

• Starting dose: Consider 25 mg daily 1
• Titration: Increase more slowly than in patients with normal hepatic function 1
• Monitor closely for adverse effects given reduced drug clearance 1

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Children Aged 6 Years and Older with OCD

For pediatric OCD, start with 25 mg daily in children aged 6-12 years, then titrate based on response and tolerability. 4, 5, 6

Dosing Algorithm for Pediatric OCD

Children (6-12 years)

• Starting dose: 25 mg once daily 5, 6
• Titration: Increase by 25 mg increments at approximately 1-2 week intervals 1, 5
• Dose range: 25-200 mg/day 4, 5, 6
• Typical therapeutic dose: 50-200 mg/day 4, 6

Adolescents (13-17 years)

• Starting dose: 50 mg once daily 5, 6
• Titration: Increase by 50 mg increments at approximately 1-2 week intervals 1, 5
• Dose range: 50-200 mg/day 4, 5, 6
• Maximum dose: 200 mg/day 4, 5, 6

Special Considerations for Pediatric Patients

• Weight-based dosing is NOT required—use the age-based algorithm above 5
• Sertraline can be safely administered using the adult titration schedule, as pharmacokinetics are similar when normalized for body weight 5
• At low doses (25 mg), some children may require twice-daily dosing due to sertraline's shorter half-life in younger patients 1
• Parental oversight of medication administration is essential 1
• Response timeline: Expect statistically significant improvement within 2 weeks, clinically significant improvement by week 6, and maximal benefit by week 12 or later 1
• Long-term treatment (up to 52 weeks) is effective and well-tolerated, with continued improvement seen over time 6

Efficacy Data for Pediatric OCD

• In controlled trials, sertraline at 50-200 mg/day was superior to placebo for OCD symptoms 4
• At endpoint in long-term studies, 72% of children and 61% of adolescents met response criteria (>25% decrease in CY-BOCS score) 6
• Further improvement occurs with continued treatment beyond 12 weeks 4, 6

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Critical Safety Monitoring (All Populations)

Suicidality Warning

• All patients, especially those under age 25, require close monitoring for suicidal thinking and behavior, particularly in the first months of treatment and after dose adjustments 1
• Pooled data show 1% absolute risk of suicidal ideation with antidepressants versus 0.2% with placebo (Number Needed to Harm = 143) 1

Common Adverse Effects

• Nausea, diarrhea, headache, insomnia, dizziness, sexual dysfunction, sweating, and tremors 1
• Most adverse effects emerge within the first few weeks and are dose-related 1

Drug Interactions

• Absolutely contraindicated with MAOIs due to serotonin syndrome risk 1
• Exercise caution when combining with other serotonergic agents (triptans, tramadol, fentanyl) 1
• Monitor for bleeding when used with anticoagulants or antiplatelet agents 1
• Sertraline has minimal cytochrome P450 interactions compared to other SSRIs 1

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Common Pitfalls to Avoid

• Never start adults at doses lower than 50 mg unless specific contraindications exist—this delays therapeutic benefit 2
• Never increase doses more frequently than weekly intervals—allow adequate time to assess response 1, 2
• Never discontinue abruptly—taper gradually over minimum 2-4 weeks to avoid discontinuation syndrome 1
• Do not conclude treatment failure before 8 weeks at optimal dose 1
• In children on 25 mg doses, consider twice-daily dosing if once-daily administration is insufficient 1