PsychRounds: The Psychiatry Podcast [NaSSA] - Mirtazapine (Remeron)
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Dec 29, 2023 Discover the fascinating world of mirtazapine, a unique antidepressant with a dual action on noradrenaline and serotonin. Explore its sedative effects, rapid relief for sleep issues, and its controversial 'California rocket fuel' combination. Learn about its pharmacokinetics, minimal interactions, and FDA-approved uses for major depression. The discussion also delves into the benefits for the elderly, such as appetite stimulation, against concerns like weight gain. It highlights ideal candidates for treatment and dispels common misconceptions surrounding this intriguing medication.
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Mirtazapine’s Unique Mechanism
- Mirtazapine works by antagonizing several receptors to increase norepinephrine and serotonin release without monoamine reuptake inhibition.
- It hits alpha-2 adrenergic, H1, 5-HT2A, 5-HT2C, and 5-HT3 receptors, explaining its unique effects such as sedation and appetite stimulation.
Combination Use Guidance
- Mirtazapine can be combined with SSRIs or SNRIs safely because it does not inhibit monoamine reuptake.
- The combination called "California rocket fuel" is common, though some evidence questions its superior efficacy over monotherapy.
Pharmacokinetics and Dosing
- Mirtazapine has a long half-life (20-40 hours) allowing once-daily dosing, usually at bedtime due to sedation.
- Its sedative effect can lessen at higher doses as activating noradrenergic effects increase.