Sertraline-induced oral ulcers: A report of two cases

Selective serotonin reuptake inhibitors (SSRIs) typically offer improved tolerability compared to other antidepressants, but may still cause common side effects like nausea, vomiting, drowsiness, headache, decreased libido, and agitation.[1] This case series highlights two patients who developed oral ulcers as adverse reactions to sertraline, underscoring the necessity of vigilant monitoring for such side effects in clinical practice. These findings contribute to understanding sertraline’s adverse effect profile and the management strategies for such reactions.

Case 1:

Ms X, a 34-year-old married woman presented with a four-year illness characterized by low mood, fatigue, loss of interest, reduced attention, decreased sleep and appetite, self-harm ideas, and three suicide attempts. Mental status examination (MSE) revealed sad affect, hopelessness, and suicidal thoughts. She was diagnosed with single-episode depressive disorder, moderate without psychotic symptoms (as per ICD-11) and admitted for further management. Initially, escitalopram at 10 mg showed minimal benefit, then switched to sertraline 50 mg, gradually increased to 100 mg, resulting in 30% improvement. Her HAM-D score decreased from 23 to 16 at discharge. In follow-ups, her sertraline dose was raised to 150 mg over two months. However, after two weeks, she developed small oval-shaped lesions with a yellow base and an erythematous halo observed on the inner surface of her lips, and the floor of her mouth, accompanied by a burning sensation and pain, which worsened by week five, spreading to her cheeks and gums, causing increased pain during eating. Despite initial improvement, severe ulcers led her to self-discontinue sertraline. Subsequently, her oral ulcers improved, but depressive symptoms returned. Resuming sertraline 100 mg over two months with a 40% symptom improvement but increasing to 150 mg caused recurring oral ulcers. General medicine consultation was sought, revealing vitamin B12 level of 208 pg/ml. She was prescribed methylcobalamin 500 mcg, which increased levels to 268 pg/ml but did not improve her ulcers. Despite mood improvement, she stopped treatment due to ulcer concerns, leading to subsequent improvement in her oral lesions. Naranjo Adverse Drug Reaction Probability Scale indicated score of 8, suggesting “probable” probability of reaction (score range: 5–8) [Figure 1]. Subsequently, she was started on mirtazapine, reaching 15 mg gradually and had improvement. Presently, she has maintained well on mirtazapine for the past three months with a 60–70% improvement in mood symptoms and no medication-related side effects.

Figure 1.

Naranjo ADR Probability Scale scoring

Case 2:

Ms Y, a 30-year-old married woman with illness of one year presented with low mood, sleep and appetite disturbances, interpersonal difficulties with in-laws, episodes of anger outbursts, headaches, anxiety symptoms, and diminished interest in previously enjoyable activities. In MSE, she appeared sad; she expressed concerns about future and interpersonal relationship issues with family members. Her HAM-D score was 14. A diagnosis of adjustment disorder (as per ICD-11) was made and she was started on sertraline 50 mg. The treatment plan included supportive and exploratory sessions, biofeedback techniques, and marital therapy. Four days after initiating sertraline, she reported development of oral ulcers. She had skipped taking medication for one day, and she noticed improvement in ulcers. However, upon resuming medication, ulcers reappeared. An ENT consultation was sought, and upon examination, she had small round-shaped lesions and an erythematous halo observed on the floor of her mouth, accompanied by pain. Oral mucosa appeared pale, with the presence of fibrotic bands. The tongue was highly sensitive to touch, she experienced burning sensation in throat. She was prescribed chlorhexidine mouthwash and vitamin B complex. From Psychiatry side, sertraline was discontinued. Within three days of discontinuing sertraline, patient’s oral ulcers showed improvement. Naranjo Adverse Drug Reaction Probability Scale yielded a score of 11, indicating a “Definitive” probability (score 9 or higher) of reaction [Figure 1]. Primary treatment involved non-pharmacological interventions, such as supportive and exploratory sessions, relaxation exercises, sleep hygiene, and marital therapy, which led to improvement. Patient is maintaining well for the past five months.

The clinical presentation of adverse drug reactions varies depending on factors, like medication dosage, type, and individual patient characteristics. These reactions can occur rapidly or persist for several days following drug administration. Based on existing literature, most drug-induced reactions show improvement in symptoms after reducing dosage or discontinuing medication. Typically, these manifest within the first or second week of initiating the drug and are influenced by the dose and cumulative toxicity of the drug.[2] There are very few case reports on SSRI-induced oral ulcers. Bertini et al.[3] present a case report on sertraline-induced oral ulcers, a 78-year-old woman with depression developed ulcers after four weeks on 100 mg of sertraline. Switching to venlafaxine improved the condition. Antidepressants that hinder serotonin reuptake have been associated with the occurrence of oral ulcers. These medications may induce salivary gland hypofunction, resulting in a dry mouth condition due to reduced stimulated parotid flow. The resultant dry mouth state increases the susceptibility of the oral cavity to trauma, potentially leading to the formation of oral ulcers.[4] It is crucial to have awareness of rare adverse effects associated with medications to ensure early interventions and optimal patient management. Future research should explore the occurrence, mechanisms, and strategies for managing SSRI-induced oral ulcers in psychiatric patients, aiming to enhance understanding and optimize treatment outcomes and patient safety in antidepressant therapy.

Consent

Consent was taken from both the patients

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.