What Is The Drug Remeron Used For?

Mirtazapine: A Newer Antidepressant

Am Fam Physician. 1999 Jan 1;59(one):159-161.

Abstract
Pharmacology
Efficacy
Side Effects
Drug-Drug Interactions
Dosage
References

Commodity Sections

Abstract
Pharmacology
Efficacy
Side Effects
Drug-Drug Interactions
Dosage
References

Mirtazapine is a newer antidepressant that exhibits both noradrenergic and serotonergic activity. It is at to the lowest degree as constructive as the older antidepressants for treating mild to severe depression. Sedation is the well-nigh common side consequence. Although agranulocytosis is the most serious side issue, it is rare (approximately one in i,000) and usually reversible when the medication is stopped. Mirtazapine is relatively condom in overdose. Many clinicians consider mirtazapine a second-line or even third-line antidepressant, to be used when older antidepressants are non tolerated or are ineffective. Physicians who are concerned about the risks of elevated lipid levels and agranulocytosis may choose to reserve mirtazapine as a tertiary-line selection. It is peculiarly useful in patients who experience sexual side effects from other antidepressants. Mirtazapine is also a good choice in depressed patients with significant anxiety or insomnia. Although mirtazapine has been used successfully in Europe for a number of years, its identify in the care of patients with depression in the Usa has not yet been established.

Antidepressants remain the cornerstone of handling of depression past primary intendance physicians.ane,2 Every bit new antidepressants are introduced to the market, physicians need to determine their identify. Table i compares selected antidepressants in terms of dosages and costs. A recent antidepressant introduced to the U.South. market is mirtazapine (Remeron).

Table one

Comparing of Selected Antidepressants

Antidepressant	Daily dosage range	Cost*
Bupropion (Wellbutrin)	300 to 400 mg	$75 to 100
Fluoxetine (Prozac)	20 to lxxx mg	75 to 290
Mirtazapine (Remeron)	15 to 30 mg	59 to 61
Nefazadone (Serzone)	200 to 600 mg	29 to 87
Paroxetine (Paxil)	10 to 40 mg	60 to 67
Sertraline (Zoloft)	50 to 200 mg	65 to 132

As with any new drug, mirtazapine's identify in the treatment of depression is not yet clear. Selective serotonin reuptake inhibitors (SSRIs) have go the drugs of choice in the treatment of depression.iii Generally, either the older tricyclic antidepressants or the newer antidepressants are used for 2d-line therapy.four During the first few years of introduction to the U.South. market, it is reasonable for an antidepressant such as mirtazapine to be reserved for use in patients who exercise not tolerate or do not respond to initial therapy with SSRIs.

Pharmacology

Abstract
Pharmacology
Efficacy
Side Effects
Drug-Drug Interactions
Dosage
References

Mirtazapine is a tetracyclic piperazinoazepine, which has a dissimilar structure from any other currently used antidepressant. It enhances cardinal noradrenergic and serotonergic activity by blocking alpha₂ receptors and selectively antagonizing 5HT_two and 5HT₃ receptors.5–seven Thus, information technology is being classified equally a noradrenergic and specific serotonergic antidepressant and referred to every bit an NaSSA.eight–x

Mirtazapine is well captivated without regard to food intake. It demonstrates linear kinetics over its usual dosage range and reaches peak plasma level approximately two hours after an oral dose.11 The elimination half-life is twenty to 40 hours, so a steady land is reached in approximately five days. Mirtazapine is metabolized in the liver via the P450 cytochrome oxidase pathway, inhibiting cytochromes 2D6, 1A2 and 3A4. It is excreted in the urine. Clearance of the drug is diminished in the presence of liver or renal impairment. Therefore, a lower dosage is recommended in elderly patients and those with liver or renal dysfunction.

Mirtazapine is currently canonical for utilise in adults. Considering information technology is unknown if mirtazapine is secreted in chest milk, it should be used with caution in breast-feeding mothers. The U.S. Nutrient and Drug Administration has labeled mirtazapine as a pregnancy category C drug.12

Efficacy

Abstruse
Pharmacology
Efficacy
Side Effects
Drug-Drug Interactions
Dosage
References

In the treatment of depression, equally measured past Hamilton Depression rating scales, mirtazapine is conspicuously superior to placebo.thirteen–15 Several studies have shown mirtazapine to be at least as effective equally amitriptyline (Elavil), trazodone (Desyrel) and fluoxetine (Prozac).eleven,16,17 Mirtazapine has been used successfully in the handling of mild to severe depression.18

Mirtazapine is specially helpful in patients with low who are anxious; this drug has been shown to reduce anxiety and has fifty-fifty been used to relieve preoperative anxiety and insomnia in patients having gynecologic surgery.xiii,19,20 Depressed patients with insomnia by and large experience pregnant improvement while taking mirtazapine, including decreased slumber-onset latency, deeper sleep and fewer awakenings.five,twenty As with other antidepressants, mirtazapine has a delayed onset—although antidepressant effects may be noticeable after just 1 week.11,14,18

Side Effects

Abstruse
Pharmacology
Efficacy
Side Effects
Drug-Drug Interactions
Dosage
References

The almost mutual side furnishings of mirtazapine are dose-dependent drowsiness (54 percent), dry mouth (25 percent), increased appetite (17 percent), weight gain (12 percent) and dizziness (7 percentage). These side furnishings tend to meliorate with fourth dimension.3,7,12,xviii Mild to moderate elevations in cholesterol, triglyceride and alanine aminotransferase (ALT: formerly known as SGPT) levels may as well occur. The nearly serious side effect is agranulocytosis, which occurs in approximately one in i,000 patients. This incidence is no college than the incidence of other antidepressants. To date, all patients with this complexity have recovered completely when the medication was stopped.21 Routine laboratory monitoring is not recommended. A complete blood count and ALT measurement may be obtained if symptoms or signs advise a need.

Mirtazapine has few, if whatsoever, cardiac effects and causes very footling orthostatic hypotension.3,21–23 Unlike the SSRIs, mirtazapine is associated with a very low incidence of sexual dysfunction, so information technology may be a practiced choice for use in patients who accept experienced this side upshot with other antidepressants.9,10,24

Information about overdose of mirtazapine in suicide attempts is limited considering the drug is so new. However, to date no deaths have been recorded, and seizures and cardiotoxicity have not been noted in case reports. Excessive sedation appears to be the principal result of an overdose of mirtazapine.18,21

Drug-Drug Interactions

Abstract
Pharmacology
Efficacy
Side Effects
Drug-Drug Interactions
Dosage
References

Multiple hepatic pathways are used in the metabolism of mirtazapine, then clinically significant drug-drug interactions are unlikely to occur.3,25 Still, little is actually known most drug-drug interactions in the clinical setting.25 Because of its sedative effects, alcohol should non be taken with mirtazapine and excessive sedation may result when it is used with other sedating drugs, such as benzodiazepines.3,26 Mirtazapine should not be used within 14 days of the use of a monoamine oxidase inhibitor because of the possibility that a hypertensive crisis will be triggered.12

Dosage

Abstract
Pharmacology
Efficacy
Side Effects
Drug-Drug Interactions
Dosage
References

The usual starting dosage is 15 mg, with a usual dosage range of 15 to 30 mg per day.18 Considering of its common sedative effect, information technology is normally recommended that mirtazapine be taken at bedtime. Information technology is bachelor in 15-mg and 30-mg scored tablets.

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The Author

PETER M. HARTMANN, Thousand.D., is director of medical education and medical managing director of managed care for the York Health System, York, Pa. He received his medical degree from the University of Maryland Schoolhouse of Medicine, Baltimore, and completed a residency in family practice at the University of Maryland Medical System, Baltimore. Dr. Hartmann also completed a residency in psychiatry at Sheppard and Enoch Pratt Hospital, Baltimore.

Accost correspondence to Peter Thou. Hartmann, M.D., York Health System, 1001 Southward. George St., York, PA 17405. Reprints are non available from the author.

REFERENCES

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three. Preskorn SH. Pick of an antidepressant: mirtazapine. J Clin Psychiatry. 1997;58(Suppl 6):3–8.

4. Egberts AC, Lenderink AW, de Koning FH, Leufkens HG. Channeling of three newly introduced antidepressants to patients not responding satisfactorily to previous treatment. J Clin Psychopharmacol. 1997;17:149–55.

5. Ruigt GS, Kemp B, Groenhout CM, Kamphuisen HA. Event of the antidepressant Org 3770 on human sleep. Eur J Clin Pharmacol. 1990;38:551–4.

6. de Boer Thursday, Maura K, Raiteri M, de Vos CJ, Wieringa J, Pinder RM. Neurochemical and autonomic pharmacological profiles of the 6-aza-counterpart of mianserin, Org 3770 and its enantiomers. Neuropharmacology. 1988;27:399–408.

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9. Sambunaris A, Hesselink JK, Pinder R, Panagides J, Stahl SM. Development of new antidepressants. J Clin Psychiatry. 1997;58(Suppl 6):40–53.

x. Nutt D. Mirtazapine: pharmacology in relation to adverse furnishings. Acta Psychiatr Scand. 1997;391(Suppl):31–7.

xi. Kasper Due south, Praschak-Rieder Due north, Tauscher J, Wolf R. A hazard-benefit assessment of mirtazapine in the treatment of depression. Drug Saf. 1997;17:251–64.

12. Remeron (mirtazapine) tablets. In: Physician's desk reference: PDR, 1998. 52nd ed. Montvale, N.J.: Medical Economics, 1998:1956–ix.

13. Bremner JD. A double-blind comparison of Org 3770, amitriptyline, and placebo in major depression. J Clin Psychiatry. 1995;56:519–25.

14. Claghorn JL, Lesem MD. A double-blind placebo-controlled report of Org 3770 in depressed outpatients. J Touch on Disord. 1995;34:165–71.

15. Smith WT, Glaudin V, Panagides J, Gilvary E. Mirtazapine vs. amitriptyline vs. placebo in the treatment of major depressive disorder. Psychopharmacol Balderdash. 1990;26:191–six.

16. Catterson M, Preskorn SH. Double blind crossover study of mirtazapine, amitriptyline and placebo in patients with major depression. New Research Program and Abstracts, 149th annual meeting of the American Psychiatric Association, May 6, 1996, New York. Abstract NR157.

17. Van Moffaert Thou, de Wilde J, Vereecken A, Dierick M, Evrard JL, Wilmotte J, et al. Mirtazapine is more effective than trazadone: a double-blind controlled written report in hospitalized patients with major depression. Int Clin Psychopharmacol. 1995;x:3–9.

xviii. Burrows GD, Kremer CM. Mirtazapine: clinical advantages in the treatment of depression. J Clin Psychopharmacol. 1997;17:34S–39S.

19. Sitsen JM, Moors J. Mirtazapine, a novel antidepressant, in the handling of feet symptoms: results from a placebo-controlled trial. Drug Invest. 1994;eight:339–44.

20. Sorensen M, Jorgensen J, Viby-Mogensen J, Bettum V, Dunbar GC, Steffensen K. A double-blind grouping comparative study using the new antidepressant Org 3770, placebo and diazepam in patients with expected indisposition and anxiety before constituent gynaecological surgery. Acta Psychiatr Scand. 1985;71:339–46.

21. Nelson JC. Prophylactic and tolerability of the new antidepressants. J Clin Psychiatry. 1997;58(Suppl 6):26–31.

22. Stimmel GL, Dopheide JA, Stahl SM. Mirtazapine: an antidepressant with noradrenergic and specific serotonergic furnishings. Pharmacotherapy. 1997;17:10–21.

23. Stimmel GL, Sussman N, Wingard P. Mirtazapine safe and tolerability: analysis of the clinical trials database. Chief Psychiatry. 1997;1:82–96.

24. Montgomery SA. Safe of mirtazapine: a review. Int Clin Psychopharmacol. 1995;ten(Suppl 4):37–45[Published erratum in Int Clin Psychopharmacol 1996;11:153]

25. Richelson E. Pharmacokinetic drug interactions of new antidepressants: a review of the effects on the metabolism of other drugs. Mayo Clin Proc. 1997;72:835–47.

26. Mattila Thou, Mattila MJ, Vrijmoed-de Vries K, Kuitunen T. Actions and interactions of psychotropic drugs on homo performance and mood: unmarried doses of ORG 3770, amitriptyline, and diazepam. Pharmacol Toxicol. 1989;65:81–viii.

Richard W. Sloan, M.D., R.PH., coordinator of this series, is chairman and residency plan director of the Department of Family Medicine at York (Pa.) Infirmary and clinical associate professor in family and customs medicine at the Milton Southward. Hershey Medical Center, Pennsylvania Land University, Hershey, Pa.

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