Sertraline Dosing for Anxiety
Start sertraline at 50 mg once daily, which is both the initial and optimal therapeutic dose for most patients with anxiety disorders; if inadequate response after 2–4 weeks, increase by 50 mg increments at weekly intervals to a maximum of 200 mg daily. 1, 2
Initial Dosing Strategy
- Begin with 50 mg once daily, administered at any time of day with or without food 2
- This starting dose is the usually effective therapeutic dose when considering both efficacy and tolerability 2
- No "test dose" or lower starting dose is required, unlike some other SSRIs 2
Titration Schedule
- Maintain 50 mg daily for 2–4 weeks to assess initial response before dose adjustment 1, 2
- If response is inadequate after this period, increase by 50 mg increments at intervals of no less than one week 2
- Continue titration until therapeutic benefit is achieved or dose-limiting side effects occur 2
- Maximum dose: 200 mg daily 2
Duration of Adequate Trial
- Allow 6–8 weeks at therapeutic dose (typically 50–100 mg) before declaring treatment failure 1
- Approximately 50% of patients who ultimately achieve remission do so between weeks 6 and 14 of treatment 1
- Premature switching before completing an adequate trial can delay recovery 1
Special Population Adjustments
Older Adults (≥60 years)
- No dose reduction required based on age alone 2, 3
- Start at standard 50 mg daily; sertraline pharmacokinetics in elderly patients are similar to younger adults 3, 4
- Sertraline lacks the marked anticholinergic effects of tricyclic antidepressants, making it particularly suitable for elderly patients 3
- The drug has minimal cardiovascular effects and may be safely administered to patients with underlying cardiovascular disorders 5
Hepatic Impairment
- Use lower doses or less frequent dosing in patients with hepatic impairment, as sertraline undergoes extensive hepatic metabolism 5
- Monitor closely for adverse effects and titrate cautiously 5
Renal Dysfunction
- No dosage adjustment necessary for renal impairment, as sertraline kinetics are similar in patients with renal dysfunction compared to healthy volunteers 4
Maintenance and Duration
- Continue treatment for 6+ months after remission for first episode of anxiety disorder 1
- For recurrent anxiety, consider maintenance therapy for ≥1 year to minimize relapse risk 1
- Sertraline is the only antidepressant licensed in the UK for prevention of recurrence of depression, demonstrating its efficacy in long-term treatment 5
Common Pitfalls to Avoid
- Do not start below 50 mg daily in adults without specific contraindications; this delays therapeutic response 2
- Do not increase dose more frequently than weekly intervals; this increases risk of adverse effects without improving efficacy 2
- Do not exceed 200 mg daily; higher doses are not more effective and increase side effect burden 2
- Do not switch medications before 6–8 weeks at therapeutic dose; this represents premature treatment failure declaration 1
- Do not combine with MAO inhibitors or multiple serotonergic agents due to serotonin syndrome risk 1
Tolerability Profile
- Most common adverse effects include nausea, diarrhea/loose stools, dry mouth, headache, insomnia, and male sexual dysfunction (primarily ejaculatory disturbance) 5, 3
- These effects are usually mild and transient, decreasing in frequency with continued treatment 5
- Sertraline has minimal anticholinergic activity, is essentially devoid of cardiovascular effects, and has a wide therapeutic index 5
- The drug has low potential for drug interactions at the cytochrome P450 enzyme level, an important advantage in elderly patients receiving multiple medications 3
Monitoring Requirements
- Assess response every 2–4 weeks during dose titration using standardized anxiety rating scales 1
- Monitor for suicidal ideation during the first 1–2 months of treatment and after any dose change 1
- Watch for behavioral activation (agitation, restlessness, insomnia) particularly in the first weeks of treatment 1