Sertraline Side Effects: Sertraline is an antidepressant in the selective serotonin reuptake inhibitor (SSRI) class of medications that can have many side effects in common. The most annoying and common of the sertraline side effects is probably sexual dysfunction. This usually manifests as delayed ejaculation in men and difficulty achieving orgasm in women. Sertraline also shares the SSRI discontinuation syndrome, sweating, yawning, grinding of teeth and weight gain as side effects with the most of the other SSRIs. Among the sertraline side effects that are also shared with most of the other SSRIs a black box warning about suicidality in adolescents. Typical sertraline dosage is 50 to 200 mg daily usually as a once daily dosage. Indications for sertraline include major depression, obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder, the type of PMS called premenstrual dysphoric disorder and social anxiety disorder.

Black Box Warning:  Sertraline has an FDA mandated black box warning of the increased risk of suicidality in persons under age 25 taking sertraline. The risk of suicide in patients aged 25 to 65 is not felt to be changed by the use of sertraline and the suicide risk in adults over age 65 may actually be decreased by sertraline use. The reader should refer to the FDA black box warning about things to watch for in young persons using sertraline.

Common Sertraline Side Effects: As mentioned in the introductory paragraph sexual dysfunction problems are among the most common sertraline side effects. These are typically ejaculatory dysfunction, especially delayed ejaculation or inability to ejaculate, in men and anorgasmia or markedly delayed orgasm in women. Gastrointestinal symptoms are quite common sertraline side effects and include nausea, diarrhea, dyspepsia, anorexia, and constipation. Frequently the nausea that is noted at the onset of therapy with sertraline is self-limited and resolves with continued medication use. Central nervous system sertraline side effects include insomnia, somnolence, tremor, anxiety and abnormal vision. Headache, dry mouth, rash, and sweating are other common sertraline side effects.

Serious Sertraline Side Effects:  Fortunately except for the suicidality mentioned above under black box warnings serious sertraline side effects are uncommon. The serotonin syndrome where patients develop symptoms including sweating, tachycardia, agitation and sometimes severe hypertension can be very serious and even at times fatal. The serotonin syndrome is most common when sertraline is used in combination with other serotonergic medications and use of multiple medications that can increase serotonin effect or concentrations is best avoided. Neuroleptic malignant syndrome, mania, seizures, and worsening depression have been noted with sertraline use. Other serious sertraline side effects can be hyponatremia often caused by SIADH, acute closed angle glaucoma, altered platelet function with associated abnormal bleeding, priapism which is a prolonged painful erection in men, and anaphylactoid reactions. With sertraline use in the third trimester of pregnancy persistent pulmonary hypertension, neonatal withdrawal syndrome, and neonatal serotonin syndrome have been noted. A withdrawal syndrome typically manifest by disequilibrium, vertigo, and electric like shocking pains is noted as a sertraline side effect on abrupt withdrawal, especially from high dosage.

Cautions and Drug Interactions: Sertraline is contraindicated for for use with the non-selective MAO inhibitors, with thioridazine, and with primozide. Sertraline use should be avoided or alternatives considered with multiple medications and this list is designed to be intentionally brief. The reader should refer to the manufacturer’s guidelines for the extensive list of medications to avoid and where potential drug interactions exist for a comprehensive list. That said some of the more commonly used medications where alternatives should be considered include haloperidol, all the other SSRIs, the SSRI like herbal product St. John’s Wort, sumatriptan, the serotonin-norepinephrine reuptake inhibitors including venlafaxine and Cymbalta, and methylene blue. The list of drugs where modification of treatment close monitoring is indicated is extensive and again this list will intentionally brief. These drugs include angiotensin converting enzyme inhibitor class of medications like lisinopril, carbamazepine, carvedilol, cyclophosphamide, osmotic and loop diuretics as well as potassium sparing diuretics, all of the nonsteroidal anti-inflammatory drugs, phenytoin, the sulfonylureas, trazodone, and warfarin. Caution is advised with another extensive list of medications including aspirin, acetaminophen, the beta blockers, chloramphenicol, diazepam, several herbal supplements including evening Primrose oil, feverfew, flaxseed, and garlic. Grapefruit is another dietary product where use with sertraline can lead to increased sertraline serum levels and therefore grapefruit should be avoided while taking sertraline. Lithium, meperidine, risperidone, and tramadol, and also require monitoring.

Pregnancy and Lactation: Sertraline is category C for use during pregnancy but trimester specific concerns exist and sertraline is generally best avoided in late pregnancy. Sertraline is generally considered safe for use during lactation. Of note there are class-action lawsuits regarding adverse outcomes of pregnancies where sertraline has been used and the benefits versus potential concerns need to be weighed carefully before use of sertraline during pregnancy.

Pharmacology:  Sertraline is metabolized in the liver primarily through the CYP 450 2C19 pathway as well as being a CYP 3A4 substrate and a week 2D6 substrate. 40 to 45% of sertraline is excreted through the urine after metabolism and about half is excreted in the feces with a small percent unchanged. The serum half-life of sertraline is approximately 26 hours making it one of the medium to longer half-life SSRIs.

Unusual Sertraline Side Effects: Although common to the SSRI class of medications the sexual dysfunction and SSRI withdrawal syndrome would have to be considered unusual side effects for any other medication.

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