Sertraline dosing

Potential drug interaction between sertraline and St. John s wort cannot be ruled out in one case that experienced manic depressive disorder symptoms one to two weeks after St. John s wort was started into sertraline therapy. The patient was treated with an antipsychotic and has had no problems after discontinuing St. John s wort and decreasing the sertraline dose. 

A 23-year-old woman taking sertraline (dose and length of time not stated) developed a mild pyrexia, right-sided abdominal pain, nausea, vomiting, and chills. She had a raised serum alanine transaminase... 

When blood and milk were sampled in 22 nursing women taking sertraline (25-200 mg/day), sertraline and its metabolite, desmethylsertraline, were found in all the milk samples (89). The maximum concentration of sertraline and desmethylsertraline in the milk occurred 8-9 hours after maternal ingestion of the daily dose of sertraline. Eleven infants had detectable desmethylsertraline of these, four also had detectable sertraline. No adverse effects were noted in any of the children. The authors calculated that the infants had received on average about 0.5% of the maternal sertraline dose. 

Differences exist in primary care between the patterns of prescribing fluoxetine, paroxetine or sertraline, which may influence cost outcomes. Sertraline-treated patients are more likely to have their dose increased (Sclar et al, 1995 Donoghue, 1998), and to drop out of treatment prematurely (Donoghue, 1998). The apparent need to titrate doses upwards with sertraline may require more involvement by the clinician and may delay response to treatment, with resultant increases in direct health costs (Sclar et al, 1995). However, these economic findings are retrospective, may suffer from selection bias, and being derived from HMO patients may not be generalizable to other populations confirmation in further studies is required. 

Hypotension may be related to alterations in levocarnitine levels during dialysis. Patients who have low levels of levocarnitine may benefit from supplementation. Levocarnitine is administered as doses of 20 mg/kg intravenously at the end of each dialysis session. However, levocarnitine should not be used as a first-line agent for the treatment of hypotension because of the significant cost associated with the treatment. Patients receiving levocarnitine should be evaluated every 3 months for response to therapy.47 Other preventive measures that have not been well studied include caffeine, sertraline, or fludrocortisone. 

SSRIs Citalopram 10-30 mg fluoxetine 10-20 mg fluvoxamine 50 mg paroxetine 10-30 sertraline 25-150 mg all agents are given by mouth daily and can be dosed continuously or during the luteal phase only26 Sexual dysfunction (reduced libido, anorgasmia), insomnia sedation, hypersomnia, nausea, diarrhea... 

SSRIs are theorized to reduce the frequency of hot flashes by increasing serotonin in the central nervous system and by decreasing LH. Of the SSRIs, citalopram, paroxetine, and sertraline all have been studied and have demonstrated a reduction in hot flashes while treating other symptomatic complaints such as depression and anxiety.33 Venlafaxine, which blocks the reuptake of serotonin and norepinephrine, has demonstrated a reduction in hot flashes primarily in the oncology population.34 Overall, these antidepressant medications offer a reasonable option for women who are unwilling or cannot take hormonal therapies, particularly those who suffer from depression or anxiety. These agents should be prescribed at the lowest effective dose to treat symptoms and may be titrated based on individual response. 

Risperidone Aripiprazole 2D6 > 3A4 2D6, 3A4 Carbamazepine and phenytoin topiramate hypericum (St. John s Wort). Paroxetine, fluoxetine, sertraline (high dose) grapefruit juice 2D6 or 3A4 substrates acting as competitive inhibitors. 

Quetiapine 3A4 2D6, 2C9 Carbamazepine and phenytoin topiramate prednisolone. Fluvoxamine fluoxetine sertraline (high dose) CYP3A4 substrates grapefruit juice. 

Chinese depressed patients appeared to require lower dosages, with consequently lower plasma concentrations of sertraline compared to Caucasian patients to achieve clinical efficacy (Ng et al, 2006). Again, this finding has supported the fact that Asian patients, especially Chinese, need lower doses of antidepressant drugs than their Western counterparts. 

The SSRIs, with the possible exception of citalopram and sertraline, may have a nonlinear pattern of drug accumulation with chronic dosing. 

Sertraline (Zoloft). Sertraline was the second SSRI released in the United States and is approved for the treatment of major depression and many anxiety disorders. It should be started at 25-50 mg/day and increased to lOOmg/day over the first 10-14 days. Many patients require doses nearing 150 mg/day for full benefit. The side effects of sertraline are comparable to other SSRIs. 

SSRls. SSRI antidepressants have also received considerable scrutiny in the treatment of OCD. Fluoxetine, fluvoxamine, paroxetine, and sertraline are all approved by the FDA for the treatment of OCD. Current studies suggest that each of these medications is more effective for OCD when administered at the higher end of the therapeutic dose range, that is, fluoxetine 60-80 mg/day, fluvoxamine 200-300 mg/ day, paroxetine 40-60 mg/day, and sertraline 150-200 mg/day. No controlled studies are yet available regarding the use of citalopram or escitalopram for OCD. Refer to Chapter 3 for more information regarding SSRl antidepressants. 

An initial controlled study of venlafaxine, a SNRI, indicated that it is as effective as sertraline for overall PTSD symptoms at a mean dose of approximately 225mg/day. 

Serotonin-Boosting Antidepressants. The SSRIs have also been studied in the treatment of generalized social anxiety disorder, and paroxetine, sertraline, and venlafaxine are effective. Preliminary data suggests that the serotonin-boosting atypical antidepressants (mirtazapine and nefazodone) may also be helpful. Like the MAOIs, they appear to be effective at doses comparable to those used to treat depression. They may help avoidant patients to gradually increase their social interaction and become more assertive. 

Another practical example of a pharmacokinetic drug interaction concerns the incidence of seizures in patients given a standard (300 mg/ day) dose of clozapine. Should the patient be given an SSRI antidepressant (such as fluoxetine, fluvoxamine, sertraline or paroxetine) concurrently then the clearance of clozapine could be reduced by up to 50%, an effect which would be comparable with a doubling of the dose. This could lead to a threefold increase in the risk of the patient suffering a seizure. 

Elderly Clearance of fluvoxamine is decreased by about 50% in elderly patients. A lower starting dose of paroxetine is recommended. Sertraline plasma clearance may be lower. In 2 pharmacokinetic studies, citalopram AUC was increased by 23% and 30%, respectively, in elderly subjects as compared with younger subjects, and its half-life was increased by 30% and 50%, respectively. In 2 pharmacokinetic studies, escitalopram half-life was increased by approximately 50% in elderly subjects as compared with young subjects and C ax was unchanged. 

Drug/Food interactions In one study following a single dose of sertraline with and without food, sertraline AUC was slightly increased and 25% greater. 

These drugs increase synaptic serotonin by selectively blocking the serotonin reuptake transporter. In preclinical and human studies acute doses tend to be anxiogenic (Bell and Nutt 1998) but chronic administration has anxiolytic effects, possibly due to downregulation of presynaptic autoreceptors (Blier et al. 1990). There are five SSRIs widely available citalopram, fluoxetine, fluvoxam-ine, paroxetine and sertraline. Escitalopram, the S-enantiomer of citalopram. 

Preskorn SH, Lane RM (1995) Sertraline 50 mg daily the optimal dose in the treatment of depression. IntClin Psychopharmacol 10 129-141 Preskorn SH, Dorey RC, Jerkovich GS (1988) Therapeutic drug monitoring of tricyclic antidepressants. Clin Chem 34 822-828... 

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