Mirtazapine

hello I'm dr. ken Linda thanks for watching let's talk about mirtazapine or Remeron this is a drug first approved by the Food and Drug Administration in 1996 when generic in 2004 it's an antidepressant more than 6 million prescriptions every year for this drug used especially when depressions complicated by anxiety or difficulty sleeping good news is it's not a controlled substance structurally it's different than all of the other kind of antidepressants it's what we call a tetracyclic antidepressant not a tricyclic antidepressant a tetracycline the effect of it well if antidepressant it also treats anxiety it's a sedative it's an appetite stimulant and it's an antiemetic not only as it uses an anti depressant it's used for off-label uses so for generalized anxiety disorder it seems to be better tolerated and benzodiazepines and the SSRIs drugs like prozac Jews for functional dyspepsia that affects about one in ten individuals there are two different manifestations the uses principally for people who eat and then they feel full very soon after they start eating it's what we call early satiety or postprandial fullness seems that the tricyclics and Remeron are at a subpoena seemed to work much better for this condition SSRIs don't seem to work at all insomnia very good often used instead of the benzodiazepines it seems that it helps in sleep and people who have certain kinds of skin conditions that pediatric eczema and it's good for chronic refractory it's when your skin just seems to itch maybe because you have psoriasis or that atopic dermatitis or maybe have a lymphoma a tumor of blood cells maybe it's because you have some liver or kidney disease or itch of unknown origin also used for migraine prophylaxis although some newer drugs much more expensive have been highly popularized lately also seems to be good for chronic tension type headaches and it's used for schizophrenia for people who have the akathisia or the feeling of not being able to sit still doesn't seem to work so well on the negative symptoms of schizophrenia for instance a lack of social interaction or the apathy it also can treat some pre-existing nausea or vomiting or diarrhea or even the irritable bowel syndrome also works as an inexpensive anti-america drug that's helps prevent vomiting off-label again it can be used for sleep apnea possibly it decreases the visual hallucinations of Parkinson's disease when you have this psychotic manifestations sometimes it's good for hives good for people who are withdrawing from the atypical antipsychotics and have some symptoms also good for the social anxiety disorder panic attacks for some people post-traumatic stress disorder of people with a low appetite doesn't seem that food bothers the medicine very much so you can take it with or without food doesn't change the rate or the extent of absorption when you have symptoms of depression it seems that route as apena Remeron probably works a heck of a lot faster than the SSRIs Prozac and similar drugs it works in a similar fashion similar time fashion to the tricyclics antidepressants drugs like amitriptyline seems to cause improvement often within one to two weeks full effects while they might be delayed still till around four weeks you begin therapy the dose of 15 milligrams and they take the entire dose at bedtime if there isn't any benefit at 15 milligrams then after a week or two not sooner than a week or two but after a week or two you can gradually increase it first to 30 and then to 45 milligrams should only do that every 1 to 2 weeks because the elimination half-life is about 20 to 40 hours so it sticks around for a long time and you have to realize that in elderly individuals there might be a gradual accumulation because of a decrease in the kidney function well it's with any other kind of antidepressant it seems that you need both the acute treatment to control the depression that usually occurs within somewhere around eight to twelve weeks but then you need follow-up therapy it should continue the drug not necessarily at the same dose so the acute treatment dose and the maintenance dose might not be the same so you need to continue to evaluation also have to screen for bipolar disorder so it's not really helpful because there's the concern that it might precipitate manic attacks so with any of the antidepressants that's always a possibility that the depression that you see the doctor with is actually the first manifestation of the bipolar disorder and the mania is going to come later so you need a detailed family history whether there's suicide or bipolar disease or mania in the family or depression careful personal history to of psychiatric conditions mirtazapine or Remer lines not approved for treating bipolar disorder and as with all of the antidepressants there's a label special warning that it might increase suicidality the thoughts of suicide are actually even committing suicide that's with all antidepressant seems that there is indeed a small increase in risk in children and adolescents and young adults but after you get past age 24 the risk of suicide actually starts to decrease and then senior citizens it seems like it's lower than taking the placebo some of the symptoms that some people manifest that we think might either be a conversion to the mania or a risk for suicide would be if you're taking the drug and then all of a sudden you develop anxiety or agitation or hostility or impulsivity or aggressiveness or panic disorders or all of a sudden you can't sleep or you start moving around then you gotta go see the doctor right away the drug when it was approved it was so long ago that the diagnosis of depression was defined by the American Psychiatric Association third edition of what's known as the Diagnostic and Statistical Manual well in order to meet the definition a person had to have a prominent and relatively persistent that means lasted every day for nearly two weeks at least either depression sport mood that interfere with the daily function and it could affect the emotions or the cognitive abilities or the somatic or the behavioral abilities some people are more affected emotionally some people more affected with somatic if they think their joints hurt or they think they have headaches or something like that well in addition to that in order to make the diagnosis of depression you have to have at least five of nine pre specified symptoms they are depressed mood of course loss of interest in the usual activities significant change in weight or appetite insomnia or hypersomnia sleep a lot psychomotor agitation or retardation you don't move around or can't stop moving around increased fatigue feelings of worthlessness or guilt slowed thinking or impaired concentration and then the thoughts of suicide will mark as a pain no question about it seems to be better than placebo for depression for anxiety for somatization for sleep disturbances the studies however when they were done to get the drug up for the FDA approval studies only lasted about six weeks in an adult outpatients the mean dose was anywhere between about 20 and 32 milligrams longer study was about 40 milligrams that did indeed show that maintaining therapy seemed to reduce the risk of recurrent depression it seems like Remeron work as opinion is at least as effective as other antidepressants for anything between mild and severe depression it's at least equal to a me trip to leaner elavil or trazadone or the SSRIs like to oxy teen can be used an augmentation strategy so you can take them or tazza pain in addition to the SSRIs of the SN R eyes or the tricyclics antidepressants combination is relatively safe oftentimes purse I'm together if the one drug doesn't relieve the depression to sufficient degree actually combining effexor with mirtazapine Remeron that's often referred to as California rocket fuel combination not only helps with the depression but it also minimizes some of the side effects of the other antidepressant so when you take the Remeron it might reduce some of the symptoms that you have from there other antidepressants like interacts your loss of appetite or sometimes they can cause sleeplessness well that's counteracted by the rammer on or tazza pean sexual dysfunction in nausea and diarrhea can be counteracted by the Remeron so that's relatively good well it's often prescribed as I mentioned when not only do you have the depression but you also have anxiety and insomnia so when you take it fewer awakenings get to sleep sooner after you put head on the pillow and you have a deeper sleep and also if you have erectile dysfunction or some of the other sexual disorders associated with SSRIs or other antidepressants seems that Remeron or Matassa pain might correct them now in a Cochrane evaluation there was no evidence that it was helpful in treatment resistant depression and in an article in JAMA psychiatry generally American Medical Association psychiatry look at 87 randomized controlled studies of antidepressants in general not specifically with mirtazapine but the antidepressants only seem to have about a 14% better response with depression than simply taking a placebo and at least 50% of people improve either very little or could become worse when they take antidepressants so at least at the present time we don't have a perfect solution for depression one 2010 the National Institute of Clinical Health Care excellence over in Britain they said the SSRI is probably the first choice mirtazapine probably a second choice however mirtazapine didn't show any differences as far as the Ithaca the effectiveness compared to the other antidepressants in terms of achieving the remission no long-term difference seem that it acts quicker than the other antidepressants but in the long run that probably isn't all that important because after about four weeks they all seem to have basically the same kind of effect but if you take the Mort as opinion probably less likely to stop it because of side effects again we have that faster onset that I mentioned helps you to fall asleep more quickly actually when they combined the studies and looked at 21 antidepressants what they found in a comparison study in 2018 was that mirtazapine was among the more effective antidepressants it was in the middle group for the tolerance to the medicine well what are some of the side effects side effects number one in somnolence you get tired when you take the pill that's why you take the pill at bedtime well some people become dizzy some people actually about 1 in 6 increase the appetite increase the weight and about one person in 14 gonna gain at least 7 percent of the initial body weight and in the pediatric population probably somewhere around half of the children are going to gain at least 7 percent of body weight not approved for children sometimes can lead to constipation or complete the dry mouth increase the cholesterol increase the triglycerides in a small percentage of people and if you happen to have narrow angles in your eye it could precipitate an acute attack of narrow angle glaucoma well other side effects include psychomotor restlessness the being subjectively distressing and unpleasant you want to move around you can't sit still can't stand still usually that occurs within the first couple weeks of therapy tends to resolve on its own or resolve when you lower the dose and in some people it might be associated with a low level of sodium in the bloodstream rarely it can activate the main or the hypomania sometimes lead to seizures or orthostatic hypotension that's when you stand up you get a little dizzy and then you feel like you're going to faint rarely it can cause a decrease in the white blood cells and really hasn't been studied in people who have a history of heart attacks or other kind of heart disease when we compare it to some of the other kind of medicines like the tricyclics antidepressants seems to cause less tremor less cardiovascular effect then the tricyclics seems to cause less nausea less sexual dysfunction than the SSRIs and can improve some of the SSRI effects for instance sometimes the SSRIs cause you to suffer from insomnia or urinary retention sometimes it cause excessive sweating well with many of the drugs but much less so with mirtazapine there's the chance of developing what's known as the serotonin syndrome that tends not to be a major issue with mirtazapine but sometimes it may occur especially when it's taken with the mao inhibitors symptoms of the serotonin syndrome well mental status change so people become agitated or start to hallucinate have delirium sometimes they have some neuromuscular symptoms neuromuscular symptoms can be anything from tremor or rigidity or increase in the reflexes in coordination sometimes autonomic instability the heart rate goes up the blood pressure is very labile changes a lot get dizzy start to perspire and skin looks flushed increase the body temperature and sometimes leads to seizures or gastrointestinal symptoms like nausea and vomiting diarrhea doesn't tend to be a major issue and as a matter of fact a drug that works on the serotonin system the same way that mirtazapine works drug known as psycho Hecht Adeem seems to be the treatment for the serotonin syndrome so something to keep sort of in the back of your mind if something unusual happens when you're taking too interactions well with clonidine it can lead to an increase a very severe increase a dangerous increase in the blood pressure there's a risk of the serotonin syndrome with the mao inhibitors if you combine it with you there alcohol or Valium they're all sedatives so you might fall asleep and stay asleep for a longer period of time than you anticipate drugs that either inhibit or induce certain liver drug metabolizing enzymes these are enzymes that are in the liver that metabolize most of the drugs well might be an issue but fortunately with mirtazapine doesn't seem to be an issue even when you take the azores the antifungal drugs and the protease inhibitors for HIV or if from mice inner packs though tends not to be a problem discontinuation again not a problem like we see in some of the other antidepressants so you can stop the medicine if you stop it you should stop it mildly slowly come off of the medicine but even with abrupt discontinuation it's just usually a little mild nausea and vomiting and sweating and headache dizziness ringing in the ears or some tremor sometimes peculiar sensations and your fingers and your toes we call paresthesias sometimes they feel like electric shocks sometimes people have some anxiety or fatigue or confusion over those relatively non-toxic drug especially compared to some of the others so if you take 30 to 50 times more than you're supposed to chances are not going to have all that much trouble completely different than the tricyclics antidepressants where you can't get in a lot of trouble if you overdose on a me trip to lean total they're only been about 12 deaths associated with the drug and even then some of the drugs for some of the effects rather are in people who are taking other kind of drugs so one person was reported to have died from an overdose but they also were taking a me trip to lean and they were taking an antipsychotic that's not available in the United States and the person had only taken 30 to 45 milligrams of mirtazapine or Remeron and they had taken toxic doses of the amitriptyline and psychotic so again it doesn't seem that that's a major problem most of the people who overdose recover sometimes you have some disorientation or some drowsiness or some pure impaired memory or increase in the heart rate but if you take the mirtazapine by itself not going to have any changes in the electrocardiogram probably not going to have comon not going to have any convulsions it's a tetracyclic compound so it's present is two mirror images it's like one molecule looking in the mirror and seeing the other molecule now that molecules do something a little bit different the s or the plus drug that antagonizes the serotonin 2a and 2c receptors the R or the negative and antemer that antagonizes the serotonin 3 receptors and that drug the R form or the negative form is present three times more in the serum than the s and antemer both of them block the histamine receptors of the great anti histamines that's why they make you go to sleep and they also seem to work on the alpha-2 adrenergic receptor so we call them an n a s sa the NA is nor adrenergic and specific serotonergic antidepressant so this is a family in and of itself doesn't seem to block the sodium channels doesn't block the calcium channels so it tends to not cause any anticholinergic activity however some people still were going to get a dry mouth and get some constipation and get some dilated pupil that could cause the problem if you happen to have a narrow angle that we talked about with narrow angle glaucoma well overall the drug seems to be relatively well tolerated there's rapid and complete absorption the bioavailability is about 50% of the medicine half life as I mentioned is anywhere between 20 and 40 hours the peak concentration in the plasma is within two hours a steady-state within five days that 85% floats around and plasma proteins the elimination is about 75% new your and about 15% in the feces hasn't been studied in pregnant women but it's probably best to avoid in rats in studies it shows an increase in the post implantation loss of the embryo from the uterus lactation there's something that's present in the breast milk so it's probably best to avoid pediatric use hasn't been established that it's either safe or effective and in older people especially older men there seems to be a reduced clearance so if we look at older men it seems that the concentration in the serum is about 40% more than it is in younger men that means it can lead to more confusion and sedation as older people become somewhat more fragile now there's a minimal effect in older women if you have renal insufficiency if it kidneys aren't working well you have to take a smaller dose if your liver doesn't work so well again a smaller dose it seems to be carcinogenic and test animals not in humans but in test animals causes liver cell adenoma sliver cell carcinomas and thyroid follicular adenomas x' but the drug is not new the genic no routine laboratories necessary when you take the drug it was first synthesized by a company called or Gannon in 1989 approved in the Netherlands in 1994 and interestingly even though it's called mirtazapine the suffix of peen it has no relation to the benzodiazepines actually the benzodiazepines their suffix is as a pan like lorazepam or as a lamb like triazole and that's a sleeping pill well there's a problem with the veterinary product actually animals have issues too and one of the problems that's ongoing as of at least January of 2020 is that they put too much in the pills so instead of having the seven and a half milligrams that bottle is labeled actually has 15 milligrams so the cost of the drug for humans of course the generic cash anywhere between a low $30 and a high of 56 dollars cash that's for a month worth of therapy the highest price at Walgreens and CVS if you have a coupon it's only about 10 to 20 dollars for a month if you want the Remeron which is the brand-name cost anywhere between a low of about $190 and about $290 $290 if you go to Walgreens but if you have a coupon anywhere between 167 and about a hundred and eighty dollars so Reb we're on alert as apena it's quite useful for treating depression especially if you have the depression coupled with anxiety or insomnia as an antidepressant it seems to be as the found as good as any of the other antidepressant seems to work in combination with some of the antidepressants if one doesn't help then you can add on a second naturally we're Taza feed by itself has a lot going for it it's worthy of consideration as an antidepressant and maybe because of its side effect profile it's a heck of a lot better than some of the other medicines that are on the market anyway thanks for watching if you enjoyed the show please tell a friend consider subscribing so you'll be notified when we post new videos I appreciate your interest I'm dr. ken landau [Music]

Channel: wellnowdoctor

Views: 34,256

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Keywords: Mirtazapine, Remeron, antidepressant, depression, anxiety treatment, insomnia, SSRI, Prozac, Paxil, Zoloft, appetite stimulant, chronic itch, Effexor, treating sexual dysfunction

Id: MoskJDgYz7Q

Length: 23min 52sec (1432 seconds)

Published: Mon Apr 27 2020