Mirtazapine
REMERON
What it isAlpha-2 antagonist with potent H1 and serotonin-receptor blockade; depression, often with insomnia or poor appetite.
Why this oneIts combination of sleep, appetite and anti-nausea effects is uniquely useful in underweight or medically frail patients.
What limits itWeight gain and daytime sedation commonly end the trial; paradoxically, lower exposure can be more sedating.
FDA-approved for
- depression (1996)
Off-label
- insomnia
- appetite stimulation
- nausea
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Major depressive disorder | Adult | 15 mg QHS | 45 mg QD |
Titration Do not increase at intervals shorter than 1–2 weeks.
Renal Decrease dose in moderate–severe renal impairment.
Hepatic Decrease dose in hepatic impairment.
Instructions
- Administer once daily, preferably in the evening before sleep.
- Taper gradually when discontinuing rather than stopping abruptly.
- Allow ≥14 days between an MAOI and mirtazapine in either direction.
Contraindications
- MAOIs (concurrently or within 14 days) due to risk of serotonin syndrome
Cautions
- Agranulocytosis/severe neutropenia
- Serotonin syndrome (including when used alone)
- Angle-closure glaucoma
- QT prolongation/Torsades
- DRESS and severe skin reactions
- Increased appetite and weight gain
- Somnolence
- Activation of mania/hypomania
- Seizures
- Elevated cholesterol/triglycerides
- Hyponatremia
- Transaminase elevations
Adverse reactions
- Somnolence
- Increased appetite
- Weight gain
- Dizziness
- Dry mouth
- Constipation
Pregnancy Prolonged experience has not reliably identified a drug-associated risk of major birth defects or miscarriage.
Lactation Present in milk at low levels (RID 0.6–2.8%); no adverse effects reported in most breastfed infants.
⚠ BOXED WARNING
- Suicidal thoughts and behaviors in patients under 25
Classes and tags
Clinical profile
Active metabolites
Mechanism of action: Mirtazapine ballicule
Open Mirtazapine in the interactive console ↗
Memory aids: mascots and interaction avatars
NaSSA stands for noradrenergic and specific serotonergic antidepressant
“I only block” → receptor blocker, not reuptake inhibitor
The gun is a reference to α2 agonist guanfacine → opposite effect
