Serotonin, one of the neurotransmitters, is a brain chemical that carries nerve impulses from one nerve cell to another. Researchers think that depression and certain other mental disorders may be caused, in part, because there is not enough serotonin being released and transmitted in the brain. Like the other SSRI antidepressants, fluvoxamine (Luvox), fluoxetine (Prozac), and paroxetine(Paxil), sertraline increases the level of brain serotonin (also known as 5-HT). Increased serotonin levels in the brain may be beneficial in patients with obsessive-compulsive disorder, alcoholism, certain types of headaches, post-traumatic stress disorder (PTSD), pre-menstrual tension and mood swings, and panic disorder. Sertraline is not more or less effective than the other SSRI drugs although selected characteristics of each drug in this class may offer greater benefits in some patients. Fewer drug interactions have been reported with sertraline, however, than with other medications in the same class.
The benefits of sertraline develop slowly over a period of up to four weeks. Patients should be aware of this and continue to take the drug as directed, even if they feel no immediate improvement.
Sertraline is available in 25-mg, 50-mg and 100-mg tablets, or as a 20-mg per ml solution.
Recommended dosage
The recommended dosage of sertraline depends on the disorder being treated. The initial recommended dosage for depression and obsessive-compulsive disorder is 50 mg daily. This may be increased at intervals of at least one week to the maximum recommended dosage of 200 mg daily. For the treatment of panic disorder and post-traumatic stress disorder, the initial dose is 25 mg once daily. This dosage is increased to 50 mg daily after one week. If there is no therapeutic response, the dosage may be increased to the maximum of 200 mg daily at intervals of at least one week. These dosages may need to be reduced in elderly patients (over age 65) or in people with liver disease.
For the treatment of obsessive-compulsive disorder in the pediatric population, treatment should be initiated at a dose of 25 mg per day in children six to 12 years of age and 50 mg per day in children 13 to 17 years of age. Doses may be increased at one-week intervals to a total daily dose of 200 mg.
Precautions
A group of serious side effects, called serotonin syndrome, have resulted from the combination of antidepressants such as sertraline and members of another class of antidepressants known as monoamine oxidase (MAO) inhibitors. Serotonin syndrome usually consists of at least three of the following symptoms: diarrhea, fever, sweatiness, mood or behavior changes, overactive reflexes, fast heart rate, restlessness, shivering or shaking. Because of this, sertraline should never be taken in combination with MAO inhibitors. Patient taking any MAO inhibitors, for example Nardil (phenelzinesulfate) or Parmate (tranylcypromine sulfate), should stop the MAO inhibitor then wait at least 14 days before starting sertraline or any other antidepressant. The same holds true when discontinuing sertraline and starting an MAO inhibitor. Also, people should not take sertraline oral concentrate while using disulfiram (Antabuse). Sertraline should never be taken by people who are any other SSRI antidepressants.
Sertraline should be used with cautiously and with close physician supervision by people with a prior history of seizures, people who are at an increased risk of bleeding, and those for whom weight loss is undesirable. Sertraline may precipitate a shift to mania in patients with bipolar (formerly manic-depressive) disease.
Side effects
More than 5% of patients experience insomnia, dizziness, and headache. About 14% of men report delayed ejaculation while 6% report decreased sex drive while taking this drug. In order to reduce these sexual side effects, patients can wait for tolerance to develop (this may take up to 12 weeks), reduce the dose, have drug holidays (where the weekend dose is either decreased or skipped), or discus with their physician using a different antidepressant.
More than 10% of patients report nausea and diarrhea while taking sertraline. Other possible side effects include agitation, anxiety, rash, constipation, vomiting, tremors, or visual difficulty. Although most side effects eventually subside, it may take up to four weeks for people to adjust to the drug.
Interactions
Sertraline interacts with St. John's Wort, an herbal remedy for depression. The risk of seizures is increased in patients using tramadol and sertraline. Taking sertraline with MAO inhibitors may result in the serious side effects discussed above. Erythromycin, an antibiotic, may inhibit the breakdown of sertraline in the liver and cause increased central nervous system effects such as drowsiness and decreasing of mental alertness. Other antidepressants should not be taken by people using sertraline except in rare cases when prescribed by a physician. If a combination of antidepressants is considered beneficial, a low dose of tricyclic antidepressants (10–25 mg daily) should be used.
Sertraline should not be taken with grapefruit juice as the combination may increase sertraline levels in the body.
BOOKS
Kay, Jerald. Psychiatry: Behavioral Science and ClinicalEssentials. Philadelphia: W. B. Saunders Company, 2000.
Pfizer Inc. Staff. Product Information for Zoloft-Sertraline. New York: Pfizer Inc. Revised 9/2000, reviewed 3/2001.
PERIODICALS
Edwards, Guy. "Systemic Review and Guide to Selection of Selective Serotonin Reuptake Inhibitors." Drugs. 57(1999): 507-33.
Hirschfeld, Robert. "Management of Sexual Side Effects of Antidepressant Therapy." Journal of Clinical Psychiatry. 60 (1999): 27-30.
