Fetal Circulation Physiology and Features

 Sertraline

Uses of Sertraline

Treatment of major depressive disorders, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), premenstrual dysphoric disorder (PMDD), and social anxiety disorder.

OFF-LABEL: Eating disorders, bulimia nervosa, generalized anxiety disorder (GAD).

CLASSIFICATION OF SERTRALINE

PHARMACOTHERAPEUTIC: Selective serotonin reuptake inhibitor. 

CLINICAL: Antidepressant, anxiolytic, obsessive-compulsive disorder adjunct. 

BLACK BOX ALERT ■ Increased risk of suicidal ideation and behavior in children, adolescents, young adults 18–24 yrs with major depressive disorder, other psychiatric disorders. 

Action of Sertraline

Blocks reuptake of the neurotransmitter serotonin at CNS neuronal presynaptic membranes, increasing availability at postsynaptic receptor sites. Therapeutic Effect: Relieves depression, reduces obsessive-compulsive behavior, decreases anxiety.

Fetal Circulation Physiology and Features

Precautions for Sertraline

Contraindications: Hypersensitivity to sertraline. MAOI use within 14 days (concurrently or within 14 days of stopping an MAOI or sertraline). Concurrent use of oral concentrate (contains alcohol) with disulfiram. Concurrent use with pimozide; initiation in pts treated with linezolid or methylene blue. Cautions: Seizure disorder, hepatic impairment, pts at risk for uric acid nephropathy, elderly pts, pts in third trimester of pregnancy, pts at high risk for suicide, family history of bipolar disorder or mania, pts with risk factors for QT prolongation (e.g., hypokalemia, hypomagnesemia), alcoholism. Pts in whom weight loss is undesirable. 

Pharmacokinetics

 Incompletely, slowly absorbed from GI tract; food increases absorption. Protein binding: 98%. Widely distributed. Metabolized in liver. Excreted in urine (45%), feces (45%). Not removed by hemodialysis. Half-life: 26 hrs. 

Lifespan considerations of Sertraline

Pregnancy/Lactation: Unknown if drug crosses placenta or is distributed in breast milk. Children: Children and adolescents are at increased risk for suicidal ideation and behavior or worsening of depression, esp. during the first few mos of therapy. Elderly: No age-related precautions noted, but lower initial dosages recommended.

Interactions of Sertraline

DRUG: Anticoagulants (e.g., heparin, rivaroxaban, warfarin), antiplatelets (e.g., aspirin, clopidogrel), NSAIDs (e.g., ibuprofen, ketorolac, naproxen), thrombolytics (e.g., alteplase) may increase risk of bleeding. May increase concentration, risk of toxicity of highly protein-bound medications (e.g., digoxin, warfarin). MAOIs (e.g., phenelzine, selegiline) may cause neuroleptic malignant syndrome, serotonin syndrome. Concomitant use of other serotonergic drugs (e.g., buspirone, carBAMazepine, fentanyl, linezolid, SNRIs [e.g., duloxetine, venlafaxine], triptans [e.g., sumatriptan]) may cause serotonin syndrome. May increase concentration, toxicity of tricyclic antidepressants (e.g., amitriptyline, doxepin). 

Face Presentation: Causes, Diagnosis, Management, Complications

HERBAL: Gotu kola, kava kava, St. John’s wort, valerian may increase CNS depression. St. John’s wort may increase risk of serotonin syndrome. 

FOOD: None known. 

LAB VALUES: May increase total serum cholesterol, triglycerides, ALT, AST. May decrease serum uric acid. 

Availability (Rx) of Sertraline

Oral Concentrate: 20 mg/mL. Tablets: 25 mg, 50 mg, 100 mg.

Administration/handling of Sertraline

PO 

• Give with food, milk if GI distress occurs. 

• Oral concentrate must be diluted before administration. Mix with 4 oz water, ginger ale, lemon/lime soda, or orange juice only. Give immediately after mixing. 

Indications/routes/dosage of Sertraline

Depression 

PO: ADULTS: Initially, 50 mg/day. May increase by 50 mg/day at 7-day intervals up to 200 mg/day. ELDERLY: Initially, 25 mg/day. May increase by 25–50 mg/day at 7-day intervals up to 200 mg/day.

Obsessive-Compulsive Disorder (OCD) 

PO: ADULTS, CHILDREN 13–17 YRS: Initially, 50 mg/day with morning or evening meal. May increase by 50 mg/day at 7-day intervals up to 200 mg/day. ELDERLY, CHILDREN 6–12 YRS: Initially, 25 mg/day. May increase by 25– 50 mg/day at 7-day intervals. Maximum: 200 mg/day. 

Panic Disorder, Post-Traumatic Stress Disorder (PTSD), Social Anxiety Disorder (SAD) 

PO: ADULTS, ELDERLY: Initially, 25 mg/day. May increase by 50 mg/day at 7-day intervals. Range: 50–200 mg/day. Maximum: 200 mg/day. 

Premenstrual Dysphoric Disorder (PMDD) 

PO: ADULTS: Initially, 50 mg/day either daily throughout menstrual cycle or limited to luteal phase of menstrual cycle. May increase up to 150 mg/day per menstrual cycle in 50-mg increments when dosing throughout menstrual cycle or 100 mg/day when dosing during luteal phase only. 

Dosage in Renal Impairment: No dose adjustment. 

Dosage in Hepatic Impairment: Use caution.

Side effects of Sertraline

Frequent (26%–12%): Headache, nausea, diarrhea, insomnia, drowsiness, dizziness, fatigue, rash, dry mouth. Occasional (6%–4%): Anxiety, nervousness, agitation, tremor, dyspepsia, diaphoresis, vomiting, constipation, sexual dysfunction, visual disturbances, altered taste. Rare (Less Than 3%): Flatulence, urinary frequency, paresthesia, hot flashes, chills.

Adverse effects/toxic reactions of Sertraline

 Serotonin syndrome (seizures, arrhythmias, high fever), neuroleptic malignant syndrome (muscle rigidity, cognitive changes), suicidal ideation have occurred.

Nursing considerations of Sertraline

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Baseline assessment

 Assess appearance, behavior, speech patterns, level of interest, mood. For pts on long-term therapy, CBC, renal function, LFT should be performed periodically. 

Intervention/evaluation of Sertraline

Assess mental status for depression, suicidal ideation (esp. at beginning of therapy or change in dosage), anxiety, social function, panic attack. Monitor daily pattern of bowel activity, stool consistency. Assist with ambulation if dizziness occurs. 

Patient/family teaching 

• Dry mouth may be relieved by sugarless gum, sips of water. 

• Report headache, fatigue, tremor, sexual dysfunction. 

• Avoid tasks that require alertness, motor skills until response to drug is established (may cause dizziness, drowsiness).

• Take with food if nausea occurs. 

• Inform physician if pregnancy occurs. 

• Avoid alcohol. 

• Do not take OTC medications without consulting physician. 

• Report worsening of depression, suicidal ideation.