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Pharmacological properties

sertraline is a potent and specific inhibitor of serotonin uptake in vitro, which in animals leads to potentiation of 5-nt effects. sertraline has only a very weak effect on the reuptake of norepinephrine and dopamine. in therapeutic doses, sertraline blocks the uptake of serotonin in human platelets. the drug does not have a stimulating, sedative, anticholinergic or cardiotoxic effect in animal experiments. during the use of the drug, sertraline did not have a sedative effect and did not affect psychomotor functions. due to selective inhibition of serotonin reuptake, sertraline does not stimulate catecholaminergic activity. the drug does not have affinity for muscarinic (cholinergic), serotonergic, dopaminergic, adrenergic, histaminergic, gamma or benzodiazepine receptors.

Sertraline does not cause the development of drug dependence. In studies of the comparative abuse potential of sertraline, alprazolam, and D-amphetamine in humans, sertraline did not produce any positive subjective effects indicating abuse potential. In contrast, study participants using both alprazolam and D-amphetamine compared with placebo patients showed statistically significantly higher rates of abuse tendency, euphoria, and potential drug dependence. Sertraline does not cause a stimulatory effect or anxiety sensation characteristic of D-amphetamine, or sedative effect and psychomotor disturbances characteristic of alprazolam.

Pharmacokinetics Absorption. The pharmacokinetics of sertraline in a dose range of 50-200 mg is dose-dependent. During a 14-day oral administration of sertraline at a dose of 50-200 mg (orally 1 time per day), the peak concentration of sertraline in blood plasma is reached 4.5-8.4 hours after daily administration of the drug. Food does not significantly alter the bioavailability of sertraline in capsules / tablets.

Distribution. About 98% of circulating sertraline binds to plasma proteins.

Biotransformation. Sertraline undergoes an intensive presystemic metabolism (first-pass effect) in the liver.

Elimination. Average T½ sertraline is about 26 hours (in the range of 22–36 hours). According to terminal T½ accumulation of the drug was noted (with an increase in its level by about 2 times) upon reaching equilibrium concentrations, which are detected after using the drug at a dose of 1 time per day for 1 week. T½ N-desmethylsertraline is 62–104 hours. Sertraline and N-desmethylsertraline are intensively metabolized in the human body, their final metabolites are excreted in feces and urine in equal amounts. Only a very small part (0.2%) of sertraline is excreted unchanged in the urine.

Pharmacokinetics in individual patient groups

Children with obsessive-compulsive disorder (OCD). Sertraline pharmacokinetics was studied in 29 children aged 6–12 years and in 32 adolescents aged 13–17 years. Patients were gradually increased the dose by titration of a daily dose of 200 mg for 32 days, starting with a dose of 25 or 50 mg. When using the drug in doses of 25 and 50 mg, tolerance was the same. In equilibrium, when using the drug at a dose of 200 mg, sertraline plasma concentrations in the group of children aged 6-12 years were approximately 35% higher compared to those in the group of patients aged 13-17 years and 21% higher compared with a reference group of adults. There were no significant differences between the clearance rates in boys and girls. Thus, for the use of the drug in children, especially those with insufficient body weight, a low initial dose and its increase with titration in increments of 25 mg are recommended.Adolescents can be given the same doses as adults.

Adolescents and elderly patients. The pharmacokinetic profile of sertraline in adolescents and in the elderly is not significantly different from that in adults aged 18–65 years.

Impaired liver function. In patients with liver damage T½ sertraline lengthens and AUC increases by 3 times (see APPLICATION and SPECIAL INSTRUCTIONS).

Impaired renal function. In patients with moderate or severe renal impairment, no significant cumulation of sertraline was noted.

Indications

Large depressive episodes (bde). prevention of recurrence of BDE;

  • panic disorders with the presence or absence of agoraphobia;

OCD in adults and children aged 6-17 years;

  • social anxiety disorder;
  • post-traumatic stress disorder (PTSD).

Application

Emoton is used once a day orally in the morning or in the evening. capsules / tablets are taken regardless of the meal.

Start treatment

Depression and OCD. Sertraline treatment should be started with a dose of 50 mg / day.

Panic Disorders, PTSD, and Social Anxiety Disorder. Treatment should begin with a dose of 25 mg / day. After 1 week, the dose must be increased to 50 mg once a day. It was established that such a dosage regimen reduces the incidence of side effects characteristic of panic disorders at the initial stage of treatment.

Dose titration

Depression, OCD, panic disorder, social anxiety disorder, and PTSD. In patients not responding to a dose of 50 mg, the effect can be achieved with increasing doses. Dose adjustment should begin no earlier than after 1 week of treatment, increasing it gradually by 50 mg at intervals of at least 1 week duration. The maximum dose should not exceed 200 mg / day. Dose adjustment should be carried out no more than 1 time per week, given T½ sertraline, which is 24 hours

The first manifestations of a therapeutic effect can be noted within 7 days of treatment. However, to achieve a therapeutic response, as a rule, a longer period is required, especially in patients with OCD.

Maintenance dose. The dose during long-term therapy should be kept at the minimum effective level, followed by correction depending on the therapeutic response.

Depression. Long-term therapy can also be used to prevent recurrence of BDE. In most cases, the recommended dose for the prevention of recurrence of BDE is the same as the dose used during treatment for this depressive episode. Patients with depression should receive therapy for a sufficient time, at least for 6 months, to make sure that they are completely free of symptoms.

Panic disorders and OCD. With prolonged use in patients with panic disorders and OCD, a regular assessment of therapy should be carried out, since the effectiveness of the drug for preventing relapse of such disorders has not been demonstrated.

Use in children

Children with OCD. The safety and effectiveness of sertraline have been established for children over the age of 6 years. In children aged 6-12 years with OCD, Emoton is used in an initial dose of 25 mg / day, 13-18 years - 50 mg / day, which, if necessary, is increased under the supervision of a doctor, but not more than 1 time in 7 days. The maximum daily dose for adults and children is 200 mg. The course of treatment for primary disorders should last at least 6 weeks, and for relapses - at least 3-6 months.

The effectiveness of the drug for children with major depressive disorder has not been demonstrated.

Data on the use of the drug in children under 6 years of age are not available.

Elderly patients. Elderly patients, the drug should be used with caution, given the increased risk of hyponatremia.

Liver failure.Caution should be exercised when using sertraline in patients with liver disease. With impaired liver function, it is necessary to reduce the dose or frequency of taking the drug. Sertraline should not be used in patients with severe liver failure, since there are no clinical data on the use of the drug in such patients.

Renal failure. In case of impaired renal function, dose adjustment is not required.

Withdrawal symptoms observed when sertraline therapy is discontinued. Sudden discontinuation of the drug should be avoided. Upon termination of sertraline treatment, in order to reduce the risk of withdrawal reactions, the dose should be gradually reduced for at least 1-2 weeks. If pronounced symptoms appear after lowering the dose of the drug or discontinuing its use, the resumption of the drug at the previously prescribed dose can be considered. In the future, the doctor may continue to reduce the dose, but more gradually.

Contraindications

Hypersensitivity to sertraline or other components of the drug. severe liver dysfunction; uncontrolled epilepsy. simultaneous use of MAO inhibitors. simultaneous use of sertraline and pimozide is contraindicated.

Side effects

The most common side effect is nausea. in the treatment of social anxiety disorder with sertraline in men, sexual dysfunction (impaired ejaculation) was noted. these side effects are dose dependent and often disappear on their own with continued therapy.

Infections and infestations: pharyngitis, upper respiratory tract infections, rhinitis, diverticulitis, gastroenteritis, otitis media.

Tumors are benign and malignant (including cysts and polyps): neoplasms (one case was reported in one patient receiving sertraline, compared with the absence of such cases in the group of patients receiving placebo).

From the blood system: lymphadenopathy, leukopenia, thrombocytopenia.

On the part of the immune system: hypersensitivity reactions, anaphylactoid reaction, allergy.

From the endocrine system: hyperprolactinemia, hypothyroidism and syndrome of inadequate secretion of antidiuretic hormone.

From the side of metabolism: decreased appetite, increased appetite, hypercholesterolemia, hypoglycemia, hyponatremia, hyperglycemia.

From the psyche: insomnia, depression, depersonalization, nightmares, anxiety, agitation, nervousness, decreased libido, bruxism, hallucinations, aggression, euphoria, apathy, pathological thinking, conversion disorder, drug dependence, psychotic disorder, paranoia, suicidal thinking / suicidal behavior (only for patients with OCD with short-term use of the drug in studies lasting 1-12 weeks, cases of the presence of suicidal thoughts and suicidal behavior during I sertraline therapy or shortly after discontinuation of therapy), somnambulism, premature ejaculation, paroniriya.

From the nervous system: dizziness, drowsiness, headache, paresthesia, tremor, hypertonicity, dysgeusia, impaired attention, cramps, involuntary muscle contractions, impaired coordination of movements, hyperkinesia, amnesia, hypesthesia, impaired speech, postural dizziness, fainting, migraine, coma , choreoathetosis, dyskinesia, hypesthesia, sensory disturbances, motor disorders (including extrapyramidal symptoms, including hyperkinesia, hypertonicity, jaw spasms or gait disturbance). Symptoms of serotonin syndrome or malignant antipsychotic syndrome were also recorded, in some cases associated with concomitant use of serotonergic drugs, namely: agitation, confusion, increased sweating, diarrhea, fever, hypertension,rigidity, tachycardia, akathisia, psychomotor agitation, cerebral vasospasm (including transient cerebral vasoconstriction syndrome or Call-Fleming syndrome).

From the side of the organ of vision: visual impairment, glaucoma, tear secretion disorders, scotoma, diplopia, photophobia, hyphema, mydriasis, visual impairment, pupils of different sizes.

On the part of the organ of hearing: ringing in the ears, pain in the ear.

From the cardiovascular system: palpitations, tachycardia, myocardial infarction, bradycardia, impaired cardiac activity, hot flashes, hypertension, hyperemia, peripheral ischemia, hematuria, pathological hemorrhagic events (such as gastrointestinal bleeding).

From the respiratory system: yawning, bronchospasm, dyspnea, nosebleeds, laryngospasm, hyperventilation, hypoventilation, stridor, dysphonia, hiccups, interstitial lung disease.

From the digestive tract: diarrhea, nausea, dry mouth, abdominal pain, vomiting, constipation, dyspepsia, flatulence, esophagitis, dysphagia, hemorrhoids, hypersalivation, changes in the tongue, belching, melena, hematochesia, stomatitis, tongue ulcers, pathology side of the teeth, glossitis, ulcers on the oral mucosa, pancreatitis.

From the hepatobiliary system: impaired liver function, liver failure, which can rarely be fatal, fulminant hepatitis, necrotic hepatitis, cholestatic jaundice.

On the part of the skin: rash, periorbital edema hyperhidrosis, purpura, alopecia, cold sweat, dry skin, urticaria, dermatitis, bullous dermatitis, vesicular eruptions, pathological changes in the texture of the hair, atypical skin odor; rare cases of severe adverse reactions from the skin, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, angioedema, facial edema, photosensitivity, skin reactions, have been reported.

From the musculoskeletal system: myalgia, osteoarthritis, muscle weakness, back pain, muscle twitching, bone damage, arthralgia, muscle cramps.

From the urinary system: nocturia, urinary retention, polyuria, pollakiuria, impaired urination, oliguria, urinary incontinence, difficulty starting urination.

From the reproductive system: violation of ejaculation, sexual dysfunction, vaginal bleeding, sexual dysfunction in women, menorrhagia, atrophic vulvovaginitis, balanoposthitis, genital discharge, priapism, galactorrhea, gynecomastia.

General disorders: increased fatigue, chest pain, general malaise, peripheral edema, chills, pyrexia, asthenia, thirst, hernia, decreased tolerance to the drug, impaired gait.

Laboratory indicators: increased levels of AlAT and AsAT, decreased / increased body weight, impaired sperm quality, abnormal results of clinical laboratory tests, altered platelet function, increased cholesterol in the blood.

Injury and poisoning: injury.

Surgery and medical procedures: vasodilation.

If an adverse event has been observed in patients with depression, OCD, panic disorder, PTSD, and social anxiety disorder, the terms used to describe adverse events are reclassified according to the terms that were used in relation to patients with depression.

Withdrawal syndrome detected when sertraline is discontinued. Discontinuation of sertraline therapy (especially in the case of a sharp discontinuation of the drug) usually leads to the development of withdrawal symptoms. Side effects such as dizziness, sensory disturbances (including paresthesias), sleep disturbances (including insomnia and vivid dreams), agitation or a sense of anxiety, nausea and / or vomiting, tremor, and headache were more commonly reported.As a rule, these side effects were mild or moderate and resolved on their own, but in some patients they can be severe and / or prolonged. In this regard, in cases where sertraline therapy is no longer necessary, gradual discontinuation of the drug by phasing the dose is recommended.

Use in elderly patients. The use of selective serotonin reuptake inhibitors (SSRIs) or norepinephrine and serotonin reuptake inhibitors (SSRIs), including sertraline, has been associated with clinically significant cases of hyponatremia in elderly patients who may be at increased risk for this side effect.

Use in children. In more than 600 children treated with sertraline, the overall profile of adverse reactions is generally similar to that observed in studies involving adult patients. In the course of the studies, the following adverse reactions were recorded: headache, insomnia, diarrhea, nausea, chest pain, mania, pyrexia, vomiting, lack of appetite, affective lability, aggression, agitation, nervousness, impaired attention, dizziness, hyperkinesia, migraine, drowsiness, tremor, visual impairment, dry mouth, dyspepsia, nightmares, fatigue, urinary incontinence, rash, acne, nosebleeds, flatulence, prolonged ECT Q-T interval, suicidal attempts, convulsions, extrapyramidal disorders, paresthesia, depression, hallucinations, purpura, hyperventilation, anemia, impaired liver function, increased ALAT, cystitis, herpes simplex, otitis externa, earache, eye pain, mydriasis, general malaise, hematuria, pustular rashes, rhinitis, trauma, weight loss, muscle twitching, unusual dreams, apathy, albuminuria, pollakiuria, polyuria, breast pain, menstrual irregularities, alopecia, dermatitis, skin lesions, atypical skin odor, urticaria, bruxism, hyperemia, enuresis.

Effects specific to this class of drugs. As a result of epidemiological studies, mainly carried out with the participation of patients aged 50 years and older, an increased risk of bone fractures was revealed in patients receiving SSRIs and tricyclic antidepressants. The mechanism behind this risk increase is unknown.

special instructions

Symptoms such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, psychomotor anxiety, hypomania and mania were noted in adults and children who took antidepressants. these symptoms may precede the onset of suicide. Consideration should be given to changing the therapeutic regimen or withdrawing the drug Emoton if manifestations of depression are steadily worsening, suicidality or symptoms of an increase in the severity of suicidality appear. if a decision is made to discontinue treatment, the drug should be discontinued gradually as quickly as possible, but it should be remembered that a sharp cessation of therapy may be accompanied by a withdrawal syndrome. Before starting treatment, it is necessary to examine the patient in order to determine the risk of developing bipolar disorder. for this, a psychiatric history is carefully collected, including a family history of suicides, bipolar disorders and depression. Emoton is not intended for treatment in bipolar depression.

Serotonin syndrome (SS) or malignant antipsychotic syndrome (CSN). When using SSRIs, including sertraline therapy, the development of syndromes that can be life-threatening, such as SS or ZNS, has been reported.The risk of developing SS or ZNS with SSRIs increases with the simultaneous use of serotonergic drugs (including other serotonergic antidepressants, triptans and fentanyl) with drugs that disrupt serotonin metabolism (including MAO inhibitors, such as methylene blue), antipsychotic drugs, and other dopamine antagonists. SS can include changes in the mental state (e.g., agitation, hallucinations, coma), disorders of the autonomic nervous system (tachycardia, fluctuations in blood pressure, hyperthermia), neuromuscular disorders (hyperreflexia, impaired coordination) and / or digestive disorders (nausea vomiting, diarrhea). Some manifestations of SS, including hyperthermia, muscle stiffness, changes in the autonomic nervous system and changes in mental state are similar to manifestations of ZNS. Patients should be monitored for signs and symptoms of SS or CNS.

Transition from SSRIs, antidepressants, or anti-obsessive drugs. There is limited evidence from studies on the optimal transition time from SSRIs, antidepressants, or anti-obsessive drugs to sertraline. Caution should be exercised with such changes in treatment, especially when switching to sertraline with long-acting drugs such as fluoxetine.

Other serotonergic agents, for example tryptophan, fenfluramine and 5-HT agonists. The simultaneous use of sertraline and other agents that enhance serotonergic neurotransmission, in particular tryptophan, fenfluramine, fentanyl, 5-HT agonists or herbal preparations containing St. Johns wort (Hypericum perforatum), should be carried out with caution, and such combination therapy should be avoided (if possible) to avoid (due to the likely pharmacodynamic interaction).

Increased hypomania or mania. Increased symptoms of mania / hypomania have been reported in a small number of patients receiving registered antidepressants and anti-depressant drugs, including sertraline. Therefore, sertraline should be used with caution in patients with a history of mania / hypomania. Careful supervision by a doctor is necessary. If signs of the manic phase are identified, the use of sertraline should be discontinued.

Schizophrenia. Against the background of taking the drug in patients with schizophrenia, psychotic symptoms may intensify.

Cramps. During therapy with sertraline, convulsions may occur: sertraline should not be prescribed to patients with unstable epilepsy; the use of sertraline in patients with controlled epilepsy requires careful monitoring. For patients who have seizures, the drug must be discontinued.

Suicides / suicidal thoughts / suicidal attempts or clinical signs of deterioration. Patients with depression have an increased tendency to develop suicidal thoughts, inflict damage on themselves and attempt suicide (suicidal actions and manifestations). This risk exists right up to the time of achieving significant remission. Since improvement in patients may occur during the first few weeks or a longer period of therapy, patients should be closely monitored until this improvement occurs. Clinical experience suggests that suicide risk may increase in the early stages of recovery.

Other mental disorders for which sertraline is prescribed can also be associated with a risk of suicidal actions and manifestations. In addition, these diseases can accompany a major depressive disorder. Thus, similar measures regarding the treatment of patients with major depressive disorder are necessary in the treatment of patients with other mental disorders.

It is known that in patients with a history of suicidal behavior and manifestations, or in patients who already have significant suicidal ideation before therapy, there is a greater risk of suicidal thoughts or suicidal attempts during treatment, and therefore they should be monitored against the background of taking the drug. A meta-analysis of the data obtained from studies on the use of antidepressants in adult patients with mental disorders indicates an increased risk of suicidal behavior when using antidepressants compared with those using placebo.

Against the background of the use of the drug Emoton, careful monitoring of patients with a high risk of developing suicide is shown, especially at the beginning of therapy and after any changes in the dose of the drug. Patients (and those who care for them) should be warned about the need to monitor any manifestations of clinical impairment, the occurrence of suicidal behavior or suicidal thoughts, as well as any unusual changes in behavior, and seek medical attention immediately if these symptoms occur.

Use in children. Sertraline should not be used to treat children, with the exception of patients with OCD between the ages of 6-17 years. In clinical trials, children who received antidepressants, compared with patients who received placebo, were more likely to show suicidal behavior (suicidal attempts and suicidal thoughts) and hostility (mainly aggression, opposition behavior and anger). If, based on clinical need, a decision is nevertheless made in favor of prescribing this drug, careful monitoring is required to identify signs of suicidal symptoms. In addition, there is not enough data for a long-term assessment of the safety of the drug in children regarding the effect of treatment on their growth, maturation, as well as cognitive and behavioral development. Several cases of stunted growth and puberty have been reported. The clinical relevance and causal relationship have not yet been clarified. With prolonged therapy of pediatric patients, a doctor’s control is necessary to identify abnormalities in the growth process and development of the body.

Abnormal bleeding / hemorrhage. When using SSRIs, cases of pathological skin hemorrhagic phenomena, such as ecchymosis and purpura, and other hemorrhagic phenomena, such as gastrointestinal or gynecological bleeding, have been reported. It is recommended to use SSRIs with caution in patients, especially when combined with drugs that are known to affect platelet function (for example, with anticoagulants, atypical antipsychotics and phenothiazines, most tricyclic antidepressants, acetylsalicylic acid and NSAIDs), as in patients with a history of hemorrhagic disorders.

Hyponatremia. As a result of treatment with SSRIs or SSRIs, including sertraline, hyponatremia may develop. In many cases, hyponatremia is the result of an inadequate secretion of antidiuretic hormone. Plasma sodium levels of 110 mmol / L have been reported. In elderly patients, there may be a higher risk of developing hyponatremia when using SSRIs and SSRIs. Also, the risk of this complication may be increased in patients taking diuretics, or in people with hypovolemia of any other origin. For patients with symptomatic hyponatremia, discontinuation of sertraline therapy should be considered and appropriate treatment should be prescribed. Symptoms of hyponatremia include headache, difficulty concentrating, memory loss, confusion, weakness and loss of physical balance, which can lead to falls.Symptoms associated with more severe and / or acute episodes of hyponatremia include hallucinations, fainting, cramping, coma, respiratory arrest, and death.

Symptoms of withdrawal noted upon discontinuation of sertraline therapy. Withdrawal symptoms are common when the drug is discontinued, especially if the drug is suddenly discontinued. According to studies, in patients who stopped using sertraline, the withdrawal reaction rate was 23% compared with 12% in those who continued to receive sertraline therapy.

The risk of developing withdrawal syndrome may depend on several factors, in particular on the duration of therapy, dose and rate of dose reduction. More commonly reported reactions include dizziness, sensory disturbances (including paresthesias), sleep disturbances (including insomnia and vivid dreams), agitation or a sense of anxiety, nausea and / or vomiting, tremor and headache. In general, these symptoms were mild or moderate, but in some patients they can be severe. Usually they occur within the first few days after discontinuation of therapy, very rarely such symptoms were observed in individuals who accidentally missed a dose of the drug. In most cases, these symptoms disappear on their own within 2 weeks, although in some patients they may last longer (2-3 months or more). Thus, it is recommended that the dose of sertraline be gradually reduced upon discontinuation of drug therapy for a period of several weeks or months, in accordance with the needs of the patient.

Akathisia / psychomotor anxiety. The use of sertraline is associated with the development of akathisia, characterized by subjectively unpleasant or irrepressible anxiety and the need to move, often accompanied by an inability to sit or stand still. The risk of such complications is maximum during the first 2 weeks of therapy. In patients who develop these symptoms, increasing the dose can be harmful.

Liver failure. Sertraline is extensively metabolized in the liver. According to the results of a pharmacokinetic study with multiple doses of the drug, elongation of T was observed in patients with stable mild cirrhosis½ and increase in AUC and Cmax approximately three times compared with these indicators in individuals with normal liver function. Significant differences in the degree of binding of the drug to plasma proteins between the two groups of study participants were not identified. Caution should be exercised when using sertraline in patients with liver disease. In the case of the appointment of sertraline in patients with impaired liver function, it is necessary to weigh the feasibility of reducing the dose or frequency of taking the drug. Sertraline should not be used in patients with severe hepatic impairment.

Renal failure. Sertraline is extensively metabolized; excretion of unchanged compounds in the urine is a secondary route of elimination. In studies involving patients with impaired renal function of mild to moderate degree (creatinine clearance - 30-60 ml / min) or moderate to severe (creatinine clearance - 10-29 ml / min) pharmacokinetic parameters (AUC0–24 and Cmax) with multiple doses of the drug, there were no statistically significant differences from these indicators in the control group. There is no need for dose adjustment depending on the degree of impaired renal function.

Elderly patients. More than 700 elderly patients (aged 65 years) participated in clinical trials. The nature and frequency of adverse reactions in the elderly were similar to those observed in younger patients.

However, the use of SSRIs and SSRIs, including sertraline, is associated with cases of clinically significant hyponatremia in elderly patients who may be at a higher risk of developing this side effect (seeHyponatremia in the section SPECIAL INSTRUCTIONS).

Diabetes. New cases of diabetes have been reported in patients treated with SSRIs, including sertraline. A loss of glycemic control was detected, including both hyperglycemia and hypoglycemia, in individuals with and without diabetes. Therefore, patients were monitored for signs and symptoms of changes in blood glucose levels. Patients with diabetes require careful monitoring of changes in glucose levels, as their dose of insulin and / or other oral hypoglycemic drug may need to be corrected.

Electroshock therapy (ECT). Clinical studies aimed at studying the risks or benefits of the combined use of ECT and sertraline have not been conducted.

Grapefruit juice. The simultaneous use of sertraline with grapefruit juice is not recommended.

Interaction with screening analysis of urine. Received reports of false-positive immunological tests of urine to determine the content of benzodiazepine metabolites in patients taking sertraline. False positive results are due to the low specificity of the indicated laboratory test and are possible within a few days after stopping treatment with sertraline. Differentiate sertraline from benzodiazepines in the urine by conducting refinement tests - gas chromatography / mass spectrometry.

Glaucoma. SSRIs, including sertraline, can affect pupil size with the development of mydriasis. Such an effect can lead to a narrowing of the angle of the eye with a subsequent increase in intraocular pressure and the development of angle-closure glaucoma, especially in individuals with a corresponding predisposition. Sertraline should be used with caution in patients with a history of angle-closure glaucoma and glaucoma.

Application in