Sertraline Removal During Hemodialysis
Sertraline is NOT removed by hemodialysis and does not require post-dialysis supplementation. 1, 2
Pharmacokinetic Evidence in Dialysis Patients
The FDA drug label explicitly states that in patients with severe renal impairment receiving hemodialysis, sertraline pharmacokinetics and protein binding were not altered when 200 mg/day was maintained for 21 days compared to patients with normal renal function 1. This indicates that:
- Sertraline multiple-dose pharmacokinetics are unaffected by renal impairment 1
- The drug is extensively metabolized hepatically, with urinary excretion of unchanged drug being only a minor route of elimination 1
Direct Dialyzability Studies
A dedicated hemodialysis study in two anuric patients demonstrated that:
- Sertraline was not detected in any dialysate sample collected during hemodialysis 2
- The elimination half-life was prolonged (42-92 hours versus the normal 24-36 hours), suggesting impaired clearance but not dialytic removal 2
- Initial serum concentrations were similar to those in patients with normal renal function, implying normal absorption and distribution 2
Clinical Implications for Dialysis Patients
Dosing Considerations
- Smaller maintenance doses may be required in ESRD patients due to prolonged elimination half-life, but this is unrelated to dialytic removal 2
- Post-hemodialysis supplementation is unnecessary since the drug is not removed during dialysis 2
- Starting with low doses (25-50 mg/day) and using lower maintenance doses is recommended to avoid accumulation 3
Therapeutic Benefits in Dialysis Population
Sertraline has demonstrated specific benefits beyond antidepressant effects in hemodialysis patients:
- Reduces intradialytic hypotension (IDH) by attenuating paradoxical sympathetic withdrawal 4, 5
- Improves hemodynamic parameters during dialysis sessions 5
- May improve quality of life, treatment compliance, nutritional status, and inflammatory markers 3
Key Clinical Pitfalls to Avoid
- Do not hold or supplement sertraline after dialysis sessions - the drug is not dialyzable and maintaining steady-state levels is important 1, 2
- Do not assume standard SSRI dosing is appropriate - despite lack of dialytic removal, the prolonged half-life in ESRD necessitates dose reduction 2
- Monitor for hypotension carefully - while sertraline can help IDH, it may also contribute to blood pressure changes in some patients 6
- Be aware that evidence for SSRI efficacy in ESRD depression remains limited, with some guidelines advising against routine use due to lack of consistent benefit 7