mirtazapine

(mer tah' zah peen)

Remeron, Remeron SolTab

Pregnancy Category C

Drug class
Antidepressant (tetracyclic)

Therapeutic actions
Mechanism of action unknown; appears to act similarly to TCAs, which inhibit the
presynaptic reuptake of the neurotransmitters norepinephrine and serotonin;
anticholinergic at CNS and peripheral receptors; sedating; relation of these effects to
clinical efficacy is unknown.

Indication
• Relief of symptoms of depression (endogenous depression most responsive)

Contraindications and cautions

• Contraindicated with hypersensitivity to any tricyclic or tetracyclic drug;
comcomitant therapy with an MAOI; recent MI; myelography within previous 24
hr or scheduled within 48 hr; pregnancy (limb reduction abnormalities reported);
lactation
• Use cautiously with ECT; preexisting CV disorders (eg, severe coronary heart
disease, progressive heart failure, angina pectoris, paroxysmal tachycardia
[possible increased risk of serious CVS toxicity with TCAs]); angle-closure
glaucoma, increased IOP, urinary retention, ureteral or urethral spasm; seizure
disorders (TCAs lower the seizure threshold); hyperthyroidism (predisposes to
CVS toxicity, including cardiac arrhythmias); impaired hepatic, renal function;
psychiatric patients (schizophrenic or paranoid patients may exhibit a worsening
of psychosis with TCAs); manic-depressive disorder (may shift to hypomanic or
manic phase); elective surgery (TCAs should be discontinued as long as possible
before surgery)

Available forms
Tablets—15, 30, 45 mg; orally disintegrating tablet—15, 30, 45 mg

Dosages
ADULTS
Initial dose: 15 mg PO daily, as a single dose in evening. May be increased up to
45 mg/day as needed. Change dose only at intervals greater than 1–2 wk. Continue
treatment for up to 6 mo for acute episodes.
• Switching from MAOI: Allow at least 14 days between discontinuation of MAOI
and beginning of mirtazapine therapy. Allow 14 days after stopping mirtazapine
before starting MAOI.
PEDIATRIC PATIENTS
Not recommended in patients < 18 yr.
GERIATRIC PATIENTS AND PATIENTS WITH RENAL OR HEPATIC DYSFUNCTION
Give lower doses to patients > 60 yr.

Pharmacokinetics
Route Onset Peak Duration
Oral Slow 2–4 hr 2–4 wk

Metabolism: Hepatic; T1/2: 20–40 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine and feces

Adverse effects
• CNS: Sedation and anticholinergic (atropine-like) effects; confusion (especially
in elderly), disturbed concentration, hallucinations, disorientation, decreased
memory, feelings of unreality, delusions, anxiety, nervousness, restlessness,
agitation, panic, insomnia, nightmares, hypomania, mania, exacerbation of
psychosis, drowsiness, weakness, fatigue, headache, numbness, agitation (less
likely with this drug than with other antidepressants)
• CV: Orthostatic hypotension, hypertension, syncope, tachycardia, palpitations,
MI, arrhythmias, heart block, precipitation of CHF, stroke
• Endocrine: Elevated or depressed blood sugar; elevated prolactin levels;
inappropriate ADH secretion
• GI: Dry mouth, constipation, paralytic ileus, nausea (less likely with this drug
than with other antidepressants), vomiting, anorexia, epigastric distress, diarrhea,
flatulence, dysphagia, peculiar taste, increased salivation, stomatitis, glossitis,
parotid swelling, abdominal cramps, black tongue, liver enzyme elevations
• GU: Urinary retention, delayed micturition, dilation of urinary tract,
gynecomastia, testicular swelling in men; breast enlargement, menstrual
irregularity, galactorrhea in women; increased or decreased libido; impotence
• Hematologic: Agranulocytosis, neutropenia
• Hypersensitivity: Rash, pruritus, vasculitis, petechiae, photosensitization, edema

Interactions
Drug-drug
• Risk of serious, sometimes fatal reactions if combined with MAOIs; do not use
this combination or within 14 days of MAOI therapy

Nursing considerations
Assessment
• History: Hypersensitivity to any antidepresssant; concomitant therapy with
MAOI; recent MI; myelography within previous 24 hr or scheduled within 48 hr;
lactation; ECT; preexisting CV disorders; angle-closure glaucoma; increased IOP,
urinary retention, ureteral or urethral spasm; seizure disorders; hyperthyroidism;
impaired hepatic, renal function; psychiatric problems; manic-depressive patients;
elective surgery; pregnancy, lactation
 • Physical: Body weight; T; skin color, lesions; orientation, affect, reflexes, vision
and hearing; P, BP, orthostatic BP, perfusion; bowel sounds, normal output, liver
evaluation; urine flow, normal output; usual sexual function, frequency of menses,
breast and scrotal examination; liver function tests, urinalysis, CBC, ECG

Interventions
• Ensure that depressed and potentially suicidal patients have access only to limited
quantities of the drug.
• Administer orally disintegrating tablets to patients who have difficulty
swallowing: Open blister pack and have patient place tablet on tongue. Do not
split tablet.
• Expect clinical response in 3–7 days up to 2–3 wk (latter is more usual).
• Arrange for CBC if patient develops fever, sore throat, or other sign of infection
during therapy.
• Establish safety precautions if CNS changes occur (use side rails, accompany
patient when ambulating).

Teaching points
• Take this drug exactly as prescribed; do not stop taking the drug abruptly or
without consulting your health care provider.
• Place orally disintegrating tablet on tongue, can be swallowed without water.
Open blister pack with dry hands and use tablet immediately; do not cut or break
tablet.
• Avoid using alcohol, other sleep-inducing drugs, or over-the-counter drugs while
using this drug.
• Avoid prolonged exposure to sunlight or sunlamps; use a sunscreen or protective
garments if long exposure to sunlight is unavoidable.
• These side effects may occur: Headache, dizziness, drowsiness, weakness, blurred
vision (reversible; avoid driving or performing tasks that require alertness);
nausea, vomiting, loss of appetite, dry mouth (eat frequent small meals; use
frequent mouth care, suck on sugarless candies); nightmares, inability to
concentrate, confusion; changes in sexual function.
• Report fever, flulike illness, any infection, dry mouth, difficulty urinating,
excessive sedation.

Adverse effects in Italic are most common; those in Bold are life-threatening.