Hyponatremia may occur as a result of treatment with SNRIs and SSRIs, including sertraline hydrochloride. Cases with serum sodium lower than 110 mmol/L have been reported. Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms associated with more severe or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
In patients with symptomatic hyponatremia, discontinue sertraline hydrochloride tablets and institute appropriate medical intervention. Elderly patients, patients taking diuretics, and those who are volume-depleted may be at greater risk of developing hyponatremia with SSRIs and SNRIs [See Use in Specific Populations ( 8.5)] .
False-positive urine immunoassay screening tests for benzodiazepines have been reported in patients taking sertraline hydrochloride tablets. This finding is due to lack of specificity of the screening tests. False-positive test results may be expected for several days following discontinuation of sertraline hydrochloride tablets. Confirmatory tests, such as gas chromatography/mass spectrometry, will help distinguish sertraline hydrochloride from benzodiazepines [See Drug Interactions ( 7.3)].
During post-marketing use of sertraline, cases of QTc prolongation and Torsade de Pointes (TdP) have been reported. Most reports were confounded by other risk factors. In a randomized, doubleblind, placebo- and positive-controlled three-period crossover thorough QTc study in 54 healthy adult subjects, there was a positive relationship between the length of the rate-adjusted QTc interval and serum sertraline concentration. Therefore, sertraline hydrochloride tablets should be used with caution in patients with risk factors for QTc prolongation [See Drug Interactions ( 7.1), Clinical Pharmacology ( 12.2)] .
Use of SSRIs, including sertraline hydrochloride tablets, may cause symptoms of sexual dysfunction [see Adverse Reactions ( 6.1)]. In male patients, SSRI use may result in ejaculatory delay or failure, decreased libido, and erectile dysfunction. In female patients, SSRI use may result in decreased libido and delayed or absent orgasm.
It is important for prescribers to inquire about sexual function prior to initiation of sertraline hydrochloride tablets and to inquire specifically about changes in sexual function during treatment, because sexual function may not be spontaneously reported. When evaluating changes in sexual function, obtaining a detailed history (including timing of symptom onset) is important because sexual symptoms may have other causes, including the underlying psychiatric disorder. Discuss potential management strategies to support patients in making informed decisions about treatment
- Hypersensitivity reactions to sertraline [See Contraindications ( 4)]
- QTc prolongation and ventricular arrhythmias when taken with pimozide [See Contraindications ( 4) , Clinical Pharmacology ( 12.2)] ]
- Suicidal thoughts and behaviors [See Warnings and Precautions ( 5.1)]
- Serotonin syndrome [See Contraindications ( 4), Warnings and Precautions ( 5.2), Drug Interactions ( 7.1)]
- Increased risk of bleeding [See Warnings and Precautions ( 5.3)]
- Activation of mania/hypomania [See Warnings and Precautions ( 5.4)]
- Discontinuation syndrome [See Warnings and Precautions ( 5.5)]
- Seizures [See Warnings and Precautions ( 5.6)]
- Angle-closure glaucoma [See Warnings and Precautions ( 5.7)]
- Hyponatremia [See Warnings and Precautions ( 5.8)]
- Sexual Dysfunction [See Warnings and Precautions ( 5.11)]
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The data described below are from randomized, double-blind, placebo-controlled trials of sertraline hydrochloride (mostly 50 mg to 200 mg per day) in 3066 adults diagnosed with MDD, OCD, PD, PTSD, SAD, and PMDD. These 3066 patients exposed to sertraline hydrochloride
for 8 to12 weeks represent 568 patient-years of exposure. The mean age was 40 years; 57% were females and 43% were males.
The most common adverse reactions (≥5% and twice placebo) in all pooled placebo-controlled clinical trials of all sertraline hydrochloride-treated patients with MDD, OCD, PD, PTSD, SAD and PMDD were nausea, diarrhea/loose stool, tremor, dyspepsia, decreased appetite, hyperhidrosis, ejaculation failure, and decreased libido (see Table 3). The following are the most common adverse reactions in trials of sertraline hydrochloride (≥5% and twice placebo) by indication that were not mentioned previously.
- MDD: somnolence;
- OCD: insomnia, agitation;
- PD: constipation, agitation;
- PTSD: fatigue;
- PMDD: somnolence, dry mouth, dizziness, fatigue, and abdominal pain;
- SAD: insomnia, dizziness, fatigue, dry mouth, malaise.
|Sertraline Hydrochloride ( N = 3066 )||Placebo ( N = 2293 )|
|General disorders and administration site conditions|
|Metabolism and nutrition disorders|
|Nervous system disorders|
|Reproductive system and breast disorders|
|Ejaculation failure ( 1 )||8%||1%|
|Erectile dysfunction ( 1 )||4%||1%|
|Ejaculation disorder ( 1 )||3%||0%|
|Male sexual dysfunction ( 1 )||2%||0%|
|Skin and subcutaneous tissue disorders|
In all placebo-controlled studies in patients with MDD, OCD, PD, PTSD, SAD and PMDD, 368 (12%) of the 3066 patients who received sertraline hydrochloride discontinued treatment due to an adverse reaction, compared with 93 (4%) of the 2293 placebo-treated patients. In placebo-controlled studies, the following were the common adverse reactions leading to discontinuation in sertraline hydrochloride-treated patients:
- MDD, OCD, PD, PTSD, SAD and PMDD: nausea (3%), diarrhea (2%), agitation (2%), and insomnia (2%).
- MDD (>2% and twice placebo): decreased appetite, dizziness, fatigue, headache, somnolence, tremor, and vomiting.
- OCD: somnolence.
- PD: nervousness and somnolence.
Although changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of a psychiatric disorder, they may also be a consequence of SSRI treatment. However, reliable estimates of the incidence and severity of untoward experiences involving sexual desire, performance and satisfaction are difficult to obtain, in part because patients and healthcare providers may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in labeling may underestimate their actual incidence.
Table 4 below displays the incidence of sexual adverse reactions reported by at least 2% of sertraline hydrochloride-treated patients and twice placebo from pooled placebo-controlled trials. For men and all indications, the most common adverse reactions (>2% and twice placebo) included: ejaculation failure, decreased libido, erectile dysfunction, ejaculation disorder, and male sexual dysfunction. For women, the most common adverse reaction (≥2% and twice placebo) was decreased libido.
|Men only||( N = 1316 )||( N = 973 )|
|Male sexual dysfunction||2%||0%|
|Women only||( N = 1750 )||( N = 1320 )|
In 281 pediatric patients treated with sertraline hydrochloride in placebo-controlled studies, the overall profile of adverse reactions was generally similar to that seen in adult studies. Adverse reactions that do not appear in Table 3 (most common adverse reactions in adults) yet were reported in at least 2% of pediatric patients and at a rate of at least twice the placebo rate include fever, hyperkinesia, urinary incontinence, aggression, epistaxis, purpura, arthralgia, decreased weight, muscle twitching, and anxiety.
Other Adverse Reactions Observed During the Premarketing Evaluation of Sertraline Hydrochloride
Other infrequent adverse reactions, not described elsewhere in the prescribing information, occurring at an incidence of < 2% in patients treated with sertraline hydrochloride were:
Ear and Labyrinth Disorders:
Mydriasis, blurred vision
Hematochezia, melena, rectal hemorrhage
General Disorders and Administration Site Conditions:
Edema, gait disturbance, irritability, pyrexia
Elevated liver enzymes
Immune System Disorders:
Metabolism and Nutrition Disorders:
Diabetes mellitus, hypercholesterolemia, hypoglycemia, increased appetite
Musculoskeletal and Connective Tissue Disorders:
Arthralgia, muscle spasms, tightness, or twitching
Nervous System Disorders:
Ataxia, coma, convulsion, decreased alertness, hypoesthesia, lethargy, psychomotor hyperactivity, syncope
Aggression, bruxism, confusional state, euphoric mood, hallucination
Renal and Urinary Disorders:
Reproductive System and Breast Disorders:
Galactorrhea, priapism, vaginal hemorrhage
Respiratory, Thoracic and Mediastinal Disorders:
Bronchospasm, epistaxis, yawning
Skin and Subcutaneous Tissue Disorders:
Alopecia; cold sweat; dermatitis; dermatitis bullous; pruritus; purpura; erythematous, follicular, or maculopapular rash; urticaria
Hemorrhage, hypertension, vasodilation
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