A 38-year-old woman is treated with sertraline (Zoloft) due to depression. After a few days she dev

Fråga: A 38-year-old woman is treated with sertraline (Zoloft) due to depression. After a few days she developed a tingling sensation in her finger tips. A neurological examination confirmed a reduced sensibility for pin-prick and sense of touch. When the dose was altered from 75 mg to 66 mg daily the symptoms diminished. A further treatment is planned for a couple of months. Is there any risk for irreversible side-effect when treatment with sertraline is discontinued?

Sammanfattning: Neurological side-effects like paresthesias and other sensational disorders have been reported during treatment with different SSRI:s. Withdrawal symptoms may develop and last for several weeks. It is suggested that clinicians should consider tapering of SSRI:s and temporary reinstitution if discontinuation symptoms develop (1). In the present case sertraline associated paresthesia has been judged as possible by the regional centre of Adverse Drug Effects. However, no information concerning paresthesia as an irreversible side-effect was found. No conclusion can be made upon the incidence of paresthesia for the different SSRI´s. An alternative antidepressant could be tried in this patient.

Svar: A thorough search in Medline on all SSRI:s revealed a few cases with symptoms due to discontinuation of SSRI:s (1,2). A 37-year-old woman with recurrent major depression was started on sertraline and treated with 100 mg daily. After 8 months she requested that sertraline treatment should be discontinued due to sexual dysfunction. The dose was decreased to 75 mg the first week, to 50 mg the following week and then discontinued. One week later she had a constant tingling under the skin that she described like a sunburn. The symptom changed to an itch after ten days and lasted for two more weeks before it disappeared (1).

A depressed 33-year-old man who had been treated with sertraline 100 mg daily for nine months stopped treatment after five days with a dose of 50 mg per day. The following days after discontinuation he had vertigo, loss of balance, flu-like symptoms, burning and tingling that ascended from his feet to his face. After two weeks the symptoms had disappeared (1).

Electric shock-like sensations after discontinuation of paroxetine (two cases) and sertraline (one case) have also been described (2). The patients experienced attacks that lasted a few seconds and ran through the upper body down to the fingers and/or toes.

Paresthesia has been associated with treatment of SSRI:s (3). A case concerns a woman who developed resistent paresthesia associated with fluoxetine treatment. Tingling in her feet began after two days on 10 mg of fluoxetine and aggravated during several weeks when the dose was increased to 20 mg. While the abnormal sensation progressed to her thighs and hands the treatment was discontinued. Two weeks later the paresthesia had disappeared. Later she was treated with sertraline without recurrence of paresthesia.

The files of the Swedish Adverse Drug Reactions Advisory Committee contain 38 cases of paresthesia during treatment with SSRI:s. Among these there are one case of fluoxetine, two cases of sertraline, including this case, 15 cases of citalopram and 20 cases of fluvoxamine.

The database WHO has received 688 reports of paresthesia in connection with SSRI treatment. The reports are as follows: 439 cases of fluoxetine, 142 cases of sertraline, 81 cases of fluvoxamine, and 26 cases of citalopram.