Before taking Zoloft(Sertralina)

1. Worsening of Clinical Symptoms and Suicide Risk

Adult and pediatric patients with depression, whether or not they are taking antidepressant medications, may experience worsening of depression, suicidal ideation, suicidal behavior, and abnormal behavioral changes. This risk persists until there is significant remission of the condition.

Depression and certain mental disorders are known to be associated with suicide risk, and these disorders themselves are the strongest predictors of suicide. However, there has long been concern that antidepressant medications may play a role in inducing worsening of depressive symptoms, suicidal ideation, and behavior in some patients during the early stages of treatment.

Pooled analyses of short-term placebo-controlled studies of antidepressant drugs (including SSRIs and others) have shown that in children, adolescents, and young adults (18–24 years) with major depressive disorder (MDD) and other mental disorders, antidepressants increase the risk of suicidal thoughts and behavior (suicidal ideation, behavior) compared to placebo. Short-term clinical trials have not shown an increased risk of suicidal ideation or behavior with antidepressant use compared to placebo in adults older than 24 years. In adults aged 65 years and older, the risk of suicidal ideation and behavior is reduced with antidepressant use.

2. Screening for Bipolar Disorder

A depressive episode may be the initial manifestation of bipolar disorder. It is generally believed (though not established by controlled trials) that monotherapy with antidepressant drugs for such episodes may increase the likelihood of mixed/mania episodes in patients at risk for bipolar disorder.

It is unclear whether the symptoms mentioned above indicate such a transition. However, before initiating antidepressant treatment, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder. This screening should include a detailed psychiatric history, including family history of suicide, bipolar disorder, and depression. It should be noted that sertraline is not approved for the treatment of depressive episodes in bipolar disorder.

3. Potential Interactions with Monoamine Oxidase Inhibitors (MAOIs)

There have been case reports of serious, sometimes fatal, adverse reactions when Zoloft (sertraline hydrochloride, a selective serotonin reuptake inhibitor) is used in combination with MAOIs.

MAOIs include selective MAO inhibitors (e.g., selegiline), reversible MAO inhibitors (e.g., moclobemide), and MAOI drugs such as linezolid (an antibiotic, a reversible non-selective MAOI) and methylene blue. These reactions include hyperthermia, rigidity, muscle spasm, unstable vital signs, and changes in mental status (including extreme agitation progressing to delirium and coma).

Similar reactions have been reported in patients who recently discontinued SSRI treatment and initiated MAOI therapy. Some patients exhibited symptoms similar to neuroleptic malignant syndrome.

Additionally, limited animal data on combined SSRI and MAOI use suggest potential synergistic effects of these drugs in elevating blood pressure and inducing excitatory behavior. Therefore, sertraline should not be used in patients receiving MAOI therapy or within 14 days of stopping MAOI treatment. Conversely, at least 14 days should elapse after stopping sertraline before initiating MAOI therapy.

4. Serotonin Syndrome or Neuroleptic Malignant Syndrome (NMS)-Like Reactions

There are reports of potentially life-threatening serotonin syndrome or NMS-like reactions with the use of SNRIs and SSRIs alone, including sertraline, particularly when combined with serotonergic drugs (including triptans and fentanyl), drugs that impair serotonin metabolism (including MAOIs), antipsychotics, or other dopamine antagonists.

Serotonin syndrome may include changes in mental status (e.g., agitation, hallucinations, coma), autonomic nervous system dysfunction (e.g., tachycardia, blood pressure fluctuations, hyperthermia), neuromuscular abnormalities (e.g., hyperreflexia, ataxia), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).

The most severe cases of serotonin syndrome resemble NMS, including hyperthermia, muscle rigidity, autonomic instability with rapid fluctuations in vital signs, and mental status changes. Signs and symptoms of serotonin syndrome or NMS-like reactions should be monitored.

Caution should be taken to avoid combining Zoloft with other drugs that enhance serotonergic neurotransmission, as there may be pharmacodynamic interactions. Examples include tryptophan, fenfluramine, fentanyl, 5-HT agonists, or St. John's wort (Hypericum perforatum).

Combination of sertraline with serotonin precursors (e.g., tryptophan) is not recommended. If any of the above events occur during co-administration of sertraline with any serotonergic or antidopaminergic drug (including antipsychotics), the medication should be discontinued immediately, and supportive symptomatic treatment should be initiated.

5. Diabetes/Impaired Blood Glucose Control

New-onset diabetes has been reported in patients treated with SSRIs (including Zoloft). There are also reports of impaired blood glucose control (including hyperglycemia and hypoglycemia) in patients with or without a history of diabetes. Therefore, patients should be monitored for symptoms and signs of blood glucose fluctuations. Diabetic patients should be closely monitored, as they may require adjustments in insulin and/or oral hypoglycemic medication doses.

6. Angle-Closure Glaucoma

SSRIs, including sertraline, may affect pupil size, causing mydriasis. This mydriatic effect may lead to narrow angle closure, increased intraocular pressure, and angle-closure glaucoma, particularly in patients predisposed to this condition. Therefore, sertraline should be used with caution in patients with angle-closure glaucoma or a history of glaucoma.