Sertraline (Zoloft) has an elimination half-life of 25 hours and can be administered once a day, usually in the morning to avoid insomnia. Sertraline undergoes extensive hepatic metabolism, and doses must be reduced in patients with liver disease. Sertraline may produce more gastrointestinal side effects, such as nausea and diarrhea, than does fluoxetine and is generally thought to be less activating than fluoxetine. It is highly bound to serum proteins (98%) and may alter plasma protein binding of other medications. A 14-day washout period is recommended before starting a MAOI. Sertraline is a weak inhibitor of cytochrome P450 2D6. Intensive therapeutic drug monitoring is indicated when combining sertraline with drugs metabolized by this route that have a narrow therapeutic index, such as the TCAs and the type 1C antiarrhythmics propafenone, encainide, and flecainide.
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