taking, titrating, and tapering Zoloft (sertraline)

> How to Take Zoloft



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Taking & Titration Overview

One of the most important aspects of any medication is how to go about taking it. This includes:

  • how much to take (the dosage or dose)
  • when and how often to take it (dosing schedule or doses)
  • how much to start with and how to increase the dose/dosage until you’re taking the target amount (titration or titration schedule).

Although we often disagree with them, we’ll always give you the manufacturer’s recommendations from Zoloft’s full US Prescribing Information. If, for some reason, that isn’t available, we’ll use information for patients leaflets, SPCs from overseas, or whatever official sources we can find. Most doctors will give you some idea of what it will be like, and this is what every pharmacist is trained and paid to tell you.1 As “often” doesn’t mean “always”, whatever is in the PI sheet works for us a lot of the time.

We usually advocate starting at a lower dosage than recommended. One of our core philosophies is increasing the dosages as slowly as one’s condition allows, and staying at the dosage that works instead of a target dosage2. More and more doctors are agreeing with us3. You and your doctor can always discuss increasing the dosage when you need to in advance.

And since you never really know how a drug might affect you, it’s best to start when you have some time off of work. Like Friday night / Saturday morning, or your equivalent. Better still would be to get someone to stay with you or at least check on you frequently, especially if you’re the primary caretaker of young children and similar critters.4

Zoloft (sertraline) Dosage and Doses

  • Typically it’s one 25, 50, or 100mg tablet once a day, usually in the morning. Larger tablets are often split in half to save money.
  • The Crazymeds’ suggestion: However many whole and half tablets of any size it takes to get the dosage that works for you, anywhere a range of 12.5 to 100mg a day, in increments of 12.5mg. So that’s 12.5, 25, 37.5 and so forth.
  • Zoloft is rated safe up to 200mg a day, and many people take dosages above 100mg a day. The are probably ultra-rapid metabolizers.

Special Instructions/Best Way to Take Zoloft (sertraline)

  • Unless you find it makes you sleepy, take Zoloft in the morning. Zoloft tends to wake people up.
  • Taking it with food would probably help with any gastro-intestinal problems you might have.
    • However, taking Zoloft with food slightly alters its pharmacokinetics. Not enough to affect how much you need to take, but possibly enough to affect how it makes you feel a few hours after you take it, so taking it before or with breakfast might make a difference.
  • Just don’t mess around too much with when you take it. Like almost all SSRIs Zoloft has a half-life in the neighborhood of 24 hours, so taking it at the same time each day, give or take an hour, will make your life a lot easier.
  • If you’re Chinese you can probably get away with taking no more than 25mg a day. At least that’s what they found in this single, small study. And while that is a frequent occurrence with crazy meds, don’t base your insurance plan selection on your ethnicity.
  • The oral concentrate has some interesting instructions:

ZOLOFT Oral Concentrate contains 20 mg/mL of sertraline (as the hydrochloride) as the active ingredient and 12% alcohol. ZOLOFT Oral Concentrate must be diluted before use. Just before taking, use the dropper provided to remove the required amount of ZOLOFT Oral Concentrate and mix with 4 oz (1/2 cup) of water, ginger ale, lemon/lime soda, lemonade or orange juice ONLY. Do not mix ZOLOFT Oral Concentrate with anything other than the liquids listed. The dose should be taken immediately after mixing. Do not mix in advance. At times, a slight haze may appear after mixing; this is normal.--the Zoloft PI sheet

  • Why only ginger ale, lemonade, OJ, and what I guess is 7-Up or Sprite (or generic equivalents)?5 Did the R&D guys grow up drinking Gin Bucks or something? Furthermore…

Note that caution should be exercised for patients with latex sensitivity, as the dropper dispenser contains dry natural rubber.--ibid

  • OK, that’s easy enough to deal with. At least they warn you. Back to making mixed drinks with Zoloft…

ZOLOFT Oral Concentrate is contraindicated with ANTABUSE (disulfiram) due to the alcohol content of the concentrate.--ibid

  • There’s nothing in the literature about it, but I’ve read a few reports and seen it myself, Zoloft makes some people drunker faster. So it seems extra weird to even supply Zoloft in a liquid form if it needs a solution with 12% alcohol to keep the sertraline stable.

Zoloft (sertraline) Titration (Dosage Increase)

Pfizer recommends:

Major Depressive Disorder (MDD) and Obsessive-Compulsive Disorder (OCD)–ZOLOFT treatment should be administered at a dose of 50 mg once daily.

Panic Disorder, Posttraumatic Stress Disorder and Social Anxiety Disorder (PTSD)–ZOLOFT treatment should be initiated with a dose of 25 mg once daily. After one week, the dose should be increased to 50 mg once daily.

While a relationship between dose and effect has not been established for MDD, OCD, panic disorder, PTSD or social anxiety disorder, patients were dosed in a range of 50–200 mg/day in the clinical trials demonstrating the effectiveness of ZOLOFT for the treatment of these indications. Consequently, a dose of 50 mg, administered once daily, is recommended as the initial therapeutic dose. Patients not responding to a 50 mg dose may benefit from dose increases up to a maximum of 200 mg/day. Given the 24 hour elimination half-life of ZOLOFT, dose changes should not occur at intervals of less than 1 week.--the Zoloft PI sheet

We suggest:
Everybody starts at 12.5–25mg and waits at least two weeks, if you can, before increasing by 12.5–25mg a day. And increase the dosage only if you need to.

Premenstrual Dysphoric Disorder (PMDD)–ZOLOFT treatment should be initiated with a dose of 50 mg/day, either daily throughout the menstrual cycle or limited to the luteal phase of the menstrual cycle, depending on physician assessment.
While a relationship between dose and effect has not been established for PMDD, patients were dosed in the range of 50–150 mg/day with dose increases at the onset of each new menstrual cycle. Patients not responding to a 50 mg/day dose may benefit from dose increases (at 50 mg increments/menstrual cycle) up to 150 mg/day when dosing daily throughout the menstrual cycle, or 100 mg/day when dosing during the luteal phase of the menstrual cycle. If a 100 mg/day dose has been established with luteal phase dosing, a 50 mg/day titration step for three days should be utilized at the beginning of each luteal phase dosing period.--ibid

Sure, why not. I have no freaking idea. Girls’ plumbing is complicated. Maybe starting at 25mg like everyone else will work. Try to find an OB/GYN who knows about psych meds or a head doctor who treats PMDD on a regular basis.



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One thing PI sheets and doctors infrequently discuss, and don’t go into enough detail about, is how to discontinue a medication. With some meds it’s not too bad, but with others (most notably SNRIs like Effexor and Cymbalta) it can be a nightmare if not done carefully.

How to Stop Taking Zoloft (sertraline)

The usual way with SSRIs. Reduce your dosage by 12.5–25mg each week. If the discontinuation syndrome is too harsh you have two options, getting a prescription for the oral concentrate and reducing your dosage by whatever you can tolerate, or getting a prescription for 10mg fluoxetine capsules and take 20–30mg a day (if you’re at 25mg of Zoloft) for two weeks and lowering your dosage by 10mg a day each week.

Discontinuation Symptoms

The same as with any other SSRI.

Notes, Tips, Helpful Hints, etc. for Withdrawing Zoloft (sertraline)

As with every other SSRI/SNRI, if a really slow taper isn’t working for you, beg your doctor for liquid Prozac. It tastes like mint-flavored mouthwash / cheap schnapps and lets you control the dosage to the milliliter.



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References

  1. Zoloft full US Prescribing Information
  2. Faught, Edward. “Topiramate in the treatment of partial and generalized epilepsy.” Neuropsychiatric disease and treatment 3.6 (2007): 811-821.

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How Long & How Likely To Work, Comparisons with Other Meds | Zoloft Index | Pros & Cons, Interesting Stuff Your Doctor Didn’t Tell You


1 And everyone has the time to do their jobs properly, when said time isn't being wasted by idiots asking for grocery store phone numbers** or they aren't playing Angry Farmers on the Faecesbooks.

2 Although not everyone has the luxury of stopping at a dosage when the symptoms abate and not increasing it unless the return. Sometimes you just have to keep going up until you reach that target dosage. E.g. you have a history of seizures that haven't yet responded to several medications.

3 Most notably Dr. Edward Faught, founder and Director of the Epilepsy Center, and vice chairman of the Department of Neurology, at the University of Alabama School of Medicine in Birmingham. His article on new antiepileptic drugs in Volume 7 issue 1 of Peer Review in Review stressed starting at low dosages, doing a slow titration, and stopping at the dosage where symptoms were under control. In Topiramate in the treatment of partial and generalized epilepsy, the one free, full-text article I could find (that's not about geriatric patients), he again stresses the low and slow approach to avoid or lessen most side effects, while still achieving seizure control in the same amount of time.

4 Assuming you have the luxury of a job, being able to cope with your symptoms not being dealt with for however many days you need to wait in order to do this, and/or someone who can and is willing to stay with you for a few days. Read enough of this site and you can tell what sort of fantasy world I live in.

5 Because there aren't many exclusively lemon sodas or exclusively lime sodas on the US market.

**DrugMonkey, Master of Pharmacy, answers the question “Why your prescription takes so damn long to fill”


If you have any questions not answered here, please see the Crazymeds Zoloft discussion board. We welcome criticisms of the articles, notifications of bad links, site problems, consumer experiences with medications, etc. I’m not always able to write back. Hence I never answer questions about meds via e-mail that are answered by this or other articles. Especially if they have been repeatedly asked on the forum. That’s why we write these damn things. Questions about which meds are best for your condition should also be asked on the forum; because this is a free site, so the price of admission is making things easier for somebody else searching for the same answer. We don’t deal with children on the forum or in private because after doing this for ten years I don’t have the emotional stamina to deal with kids who have brain cooties. How to contact Crazymeds. — Jerod Poore, CME, Publisher Crazymeds (crazymeds.us)


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will probably have the name of the manufacturer and trademark owner (they’re not always the same company) at or near the very bottom. Or ask Google who the owner is. The way pharmaceutical companies buy each other and swap products like Monopoly™ real estate, the ownership of the trademark may have changed without my noticing. It may of changed hands by the time you finished reading this article.




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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.

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