ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Mirtazapine: Drug information

Mirtazapine: Drug information
(For additional information see "Mirtazapine: Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Suicidality and antidepressant drugs:

Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. Mirtazapine is not approved for use in pediatric patients.

Brand Names: US
  • Remeron;
  • Remeron SolTab
Brand Names: Canada
  • APO-Mirtazapine;
  • Auro-Mirtazapine;
  • Auro-Mirtazapine OD;
  • MYLAN-Mirtazapine;
  • NRA-Mirtazapine;
  • PMS-Mirtazapine;
  • PRO-Mirtazapine;
  • Remeron;
  • Remeron RD;
  • SANDOZ Mirtazapine;
  • TEVA-Mirtazapine
Pharmacologic Category
  • Antidepressant, Alpha-2 Antagonist
Dosing: Adult
Headache, chronic tension-type, prophylaxis

Headache, chronic tension-type, prophylaxis (alternative agent) (off-label use): Oral: Initial: 15 mg once daily at bedtime; may increase after 1 week to 30 mg/day based on response and tolerability (Ref).

Major depressive disorder

Major depressive disorder (unipolar): Oral: Initial: 15 mg once daily at bedtime; may increase dose in 15 mg increments at intervals of ≥1 week based on response and tolerability. Maximum dose: 45 mg/day (Ref); however, doses up to 60 mg/day have been used in clinical trials (Ref).

Panic disorder

Panic disorder (alternative agent) (off-label use):

Note: For patients nonresponsive to selective serotonin reuptake inhibitors (SSRIs) (Ref).

Oral: Initial: 15 mg once daily at bedtime; may increase in increments of 15 mg at intervals of no less than 1 week based on response and tolerability, up to a usual maximum of 45 mg once daily (Ref). Average doses in clinical trials were ~30 mg/day; doses up to 60 mg/day have been evaluated (Ref).

Discontinuation of therapy: When discontinuing antidepressant treatment that has lasted for >3 weeks, gradually taper the dose (eg, over 2 to 4 weeks) to minimize withdrawal symptoms and detect reemerging symptoms (Ref). Reasons for a slower taper (eg, over 4 weeks) include prior history of antidepressant withdrawal symptoms or high doses of antidepressants (Ref). If intolerable withdrawal symptoms occur, resume the previously prescribed dose and/or decrease dose at a more gradual rate (Ref). Select patients (eg, those with a history of discontinuation syndrome) on long-term treatment (>6 months) may benefit from tapering over >3 months (Ref). Evidence supporting ideal taper rates is limited (Ref).

Switching antidepressants: Evidence for ideal antidepressant switching strategies is limited; strategies include cross-titration (gradually discontinuing the first antidepressant while at the same time gradually increasing the new antidepressant) and direct switch (abruptly discontinuing the first antidepressant and then starting the new antidepressant at an equivalent dose or lower dose and increasing it gradually). Cross-titration (eg, over 1 to 4 weeks depending upon sensitivity to discontinuation symptoms and adverse effects) is standard for most switches, but is contraindicated when switching to or from an MAOI. A direct switch may be an appropriate approach when switching to another agent in the same or similar class (eg, when switching between two SSRIs), when the antidepressant to be discontinued has been used for <1 week, or when the discontinuation is for adverse effects. When choosing the switch strategy, consider the risk of discontinuation symptoms, potential for drug interactions, other antidepressant properties (eg, half-life, adverse effects, and pharmacodynamics), and the degree of symptom control desired (Ref).

Switching to or from an MAOI:

Allow 14 days to elapse between discontinuing an MAOI and initiation of mirtazapine.

Allow 14 days to elapse between discontinuing mirtazapine and initiation of an MAOI.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Altered kidney function:

There are no dosage adjustments provided in the manufacturer's labeling; however, clearance is decreased in kidney impairment (Ref). Use with caution.

eGFR ≥30 mL/minute/1.73 m2: No dosage adjustment necessary (Ref).

eGFR <30 mL/minute/1.73 m2: Initial: 7.5 to 15 mg once daily; titrate slowly with close monitoring for adverse effects (Ref).

Hemodialysis, intermittent (thrice weekly): Unlikely to be significantly dialyzed due to high protein binding and large Vd (Ref):

Initial: 7.5 to 15 mg once daily; titrate slowly with close monitoring for adverse effects (Ref).

Peritoneal dialysis : Unlikely to be significantly dialyzed due to high protein binding and large Vd (Ref):

Initiate at 7.5 to 15 mg once daily and titrate slowly with close monitoring for adverse effects (Ref).

CRRT: Initial: 7.5 to 15 mg once daily; titrate slowly with close monitoring for adverse effects (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration): Initial: 7.5 to 15 mg once daily; titrate slowly with close monitoring for adverse effects (Ref).

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling; however, dosage reductions may be necessary in patients with moderate to severe hepatic impairment (clearance may be decreased). Some experts recommend reducing initial dose by 50% and a maximum dose of 30 mg/day in patients with hepatic impairment (Ref). Use with caution.

Dosing: Older Adult

Major depressive disorder (unipolar): Oral: Initial starting doses of 7.5 mg once daily at bedtime have been suggested (Ref). Use with caution; clearance may be reduced; refer to adult dosing.

Discontinuation of therapy: Refer to adult dosing.

Switching antidepressants: Refer to adult dosing.

Adverse Reactions (Significant): Considerations
Activation of mania or hypomania

Antidepressants (when used without a mood stabilizer) may precipitate a mixed/manic episode in patients with bipolar disorder. Treatment-emergent mania or hypomania in patients with unipolar major depressive disorder (MDD) treated with mirtazapine have been reported rarely. Although some of these cases occurred in patients receiving monotherapy at a therapeutic antidepressant dose, a number of the reports occurred in patients also receiving selective serotonin reuptake inhibitors (SSRIs) (or without a period of washout from a previous SSRI) or had potential risk factors for switching (Ref). It has also been suggested that mirtazapine-induced mania may present with atypical features, consisting of dysphoria, irritability, insomnia, psychomotor agitation, and abnormal gait (Ref).

Mechanism: Unclear to what extent mood switches represent an uncovering of unrecognized bipolar disorder or a more direct pharmacologic effect independent of diagnosis (Ref). Mirtazapine induced-mania has been attributed to central norepinephrine hyperactivity through its unique mechanism of action of blocking central alpha-2 adrenergic autoreceptors and heteroreceptors, resulting in increased serotonin and norepinephrine neurotransmitter release while blocking postsynaptic 5-HT2 and 5-HT3 receptors (Ref).

Onset: Varied; among the limited case reports involving mirtazapine, the average time until onset of mania/hypomania following mirtazapine initiation or a dose increase was 15.7 days (median, 7 days) (Ref).

Risk factors:

• Higher doses (Ref)

• Underlying brain dysfunction (Ref)

• Coadministration with certain SSRIs (Ref)

• Family history of bipolar disorder (Ref)

• Depressive episode with psychotic symptoms (Ref)

• Younger age at onset of depression (Ref)

• Antidepressant resistance (Ref)

• Female sex (Ref)

Drug-induced movement disorders

Mirtazapine has been associated with several hyperkinetic movement disorders. Most case reports describe akathisia, acute dystonia, and restless leg syndrome (RLS). Mirtazapine-induced dyskinesia (including gradual onset, transient, and acute reversible) has also been reported rarely. Mirtazapine-induced akathisia is usually reported in the presence of higher mirtazapine doses (30 mg/day), whereas dystonia and dyskinesia are usually reported at lower doses (15 mg/day). Akathisia may also occur rarely at lower doses (15 mg/day) in select patients (Ref).

Mechanism:

Akathisia: Dose-related (likely). Mechanism has not been clearly defined, although limited data attributes akathisia to blockade of alpha-2 adrenoreceptors from higher therapeutic dosages (ie, 30 mg/day) of mirtazapine, while lower dosage may be beneficial in the treatment of akathisia due to serotonin (5-HT2A) receptor blockade (Ref).

Dystonia: Unknown, but has been attributed to antidopaminergic action due to 5-HT2 receptor inhibition associated with a central noradrenergic effect producing a noradrenergic-dopaminergic imbalance (Ref).

RLS: Unknown, but mirtazapine’s 5-HT1 stimulating properties and 5-HT2/5-HT3 receptor blocking properties have been suggested (Ref).

Dyskinesia: Unknown, but mediation by 5-HT2 receptor antagonism has been suggested, which has been shown to have some activity promoting motor function in states of reduced dopamine release (Ref).

Onset: Varied; among the case reports of mirtazapine hyperkinetic movement disorders, symptom onset occurred within 9 days, with some cases following a single dose (Ref); however, there is also a case report of mirtazapine-induced akathisia following 20 years of continuous treatment (Ref).

Risk factors:

Hyperkinetic movement disorders:

• History of drug-induced movement disorders/extrapyramidal symptoms (Ref)

Dyslipidemia

Mirtazapine commonly causes increased serum cholesterol and, less commonly, increased serum triglycerides. Cases of severe hypertriglyceridemia and acute pancreatitis have also been reported rarely (some of the acute pancreatitis cases occurred in a setting of new-onset diabetes and/or diabetic ketoacidosis, making it difficult to determine whether hypertriglyceridemia was the cause) (Ref).

Mechanism: Unknown; in one study, increases in weight were linearly associated with changes in total cholesterol; however, the clinical significance is unclear, since increased cholesterol might be due to an improvement in depressive symptoms resulting in increased appetite, caloric intake, and weight (Ref).

Onset: Intermediate; increases in total cholesterol have been observed during the first 4 weeks of treatment (Ref).

Hematologic abnormalities

Neutropenia, leukopenia, and agranulocytosis have been reported rarely with mirtazapine (Ref). Mirtazapine is also associated with drug-induced immune thrombocytopenia (DITP) (Ref).

Mechanism:

Leukopenia: Unclear and poorly understood; hypersensitivity/immune mediated mechanisms have been suggested (Ref).

DITP: Non-dose-related; immunologic; mechanism is attributed to drug-dependent antibodies that react with the glycoprotein IIb/IIIa complex on the platelet surface resulting in accelerated platelet destruction (Ref).

Onset: Varied; in general, drug-induced neutropenia usually manifests after 1 or 2 weeks of exposure and agranulocytosis usually appears 3 to 4 weeks following initiation of therapy; however, the onset may be delayed (Ref). Drug-induced thrombocytopenia generally occurs 5 to 10 days after initial drug exposure (Ref).

Orthostatic hypotension

Mirtazapine may cause orthostatic hypotension (eg, dizziness). The actual prevalence is unknown but is likely not common (Ref).

Mechanism: Orthostatic hypotension is likely caused by antagonism of alpha-1 adrenergic receptors; mirtazapine has weak peripheral alpha-1-blocking activity (Ref), although some authors have classified it as having moderate activity (Ref).

Risk factors:

• Cardiovascular disease (history of myocardial infarction, ischemic heart disease, heart failure, or conduction abnormalities) or cerebrovascular disease

• Known predisposing conditions (hypovolemia/dehydration)

• Concurrent medications predisposing patient to orthostatic hypotension (eg, antihypertensives)

• Older adults (≥65 years of age) (Ref)

Sedation

Sedation (drowsiness) is very common with initial use and may cause nonadherence, dizziness, and confusion, particularly in older adults (Ref). However, the dose relationship with mirtazapine is unique, in that lower doses (≤15 mg) are associated with significant sedation compared to less sedation with higher doses (>15 mg) (Ref). Tolerance appears to develop to the sedative effect (Ref).

Mechanism: Dose-related (inverse relationship). Somnolence is primarily attributed to potent histamine H1 antagonism at lower doses; higher doses are less sedating due to increased noradrenergic transmission which partially offsets the antihistamine activity (Ref).

Onset: Rapid; however, tolerance appears to develop quickly (within a few days) to the sedative effect (Ref).

Risk factors:

• Concomitant use of benzodiazepines or alcohol

Serotonin syndrome

Serotonin syndrome has been reported rarely with mirtazapine and typically occurs with coadministration of multiple serotonergic drugs, but can occur following a single serotonergic agent at high therapeutic doses or supratherapeutic doses (Ref). Only a few cases of serotonin syndrome have been reported with mirtazapine monotherapy at therapeutic doses (Ref). Of note, some clinicians have questioned whether serotonin syndrome attributed to mirtazapine is an accurate characterization or if symptoms described are due to other causes, such as extrapyramidal symptoms (Ref). The diagnosis of serotonin syndrome is made based on the Hunter Serotonin Toxicity Criteria (Ref) and may result in a spectrum of symptoms, such as anxiety, agitation, confusion, delirium, hyperreflexia, muscle rigidity, myoclonus, tachycardia, tachypnea, and tremor. Severe cases may cause hyperthermia, significant autonomic instability (ie, rapid and severe changes in blood pressure and pulse), coma, and seizures (Ref).

Mechanism: Dose-related; mirtazapine, which does not inhibit the reuptake of serotonin, is sometimes classified as a noradrenergic and specific serotonergic antidepressant (NaSSA), and acts as an antagonist of presynaptic alpha-2 adrenergic receptors and postsynaptic 5-HT2 and 5-HT3 serotonin receptors, therefore leading to an increase in norepinephrine and 5-HT1A-mediated serotonin activity. Serotonin syndrome has been attributed to the serotonergic activity from stimulation of 5-HT1A receptors (Ref); however, some clinicians have argued that the receptor pharmacology of mirtazapine is not consistent with it being able to cause serotonin toxicity, as it does not cause serotonin (5-HT) excess in the brain (Ref).

Onset: Varied; in most serotonin-syndrome cases (74%) (predominantly involving selective serotonin reuptake inhibitors, tricyclic antidepressants, and/or monoamine oxidase inhibitors [MAOIs]), onset occurred within 24 hours of treatment initiation, overdose, or change in dose (Ref). In the few cases involving mirtazapine, most occurred within 24 hours or several days following initiation or a dose increase (Ref).

Risk factors:

• Concomitant use of drugs that increase serotonin synthesis, block serotonin reuptake and/or impair serotonin metabolism (eg, MAOIs). Of note, concomitant use of some serotonergic agents, such as MAOIs, are contraindicated.

Sexual dysfunction

Antidepressants, primarily the selective serotonin reuptake inhibitors, are commonly associated with sexual disorders in patients of any sex. Mirtazapine, however, is generally associated with having less risk for sexual adverse reactions and may also have some beneficial effects on sexual functioning in depressed patients (Ref). One meta-analysis also found no significant difference in treatment-emergent sexual dysfunction with mirtazapine compared to placebo (Ref).

Mechanism: The mechanism attributed to mirtazapine’s role (if any) in sexual dysfunction is unknown, and because a large portion of sexual dysfunction is thought to be mediated via stimulation of the postsynaptic 5-HT2A receptor, the blockade of this receptor by mirtazapine should lead to a reduced incidence of these side effects (Ref).

Risk factors:

• Depression (sexual dysfunction is commonly associated with depression; antidepressant-induced sexual dysfunction may be difficult to differentiate in treated patients) (Ref)

Suicidal thinking and behavior

Antidepressants are associated with an increased risk of suicidal ideation and suicidal tendencies in pediatric and young adult patients (18 to 24 years of age) in short-term studies. In adults >24 years of age, short-term studies did not show an increased risk of suicidal thinking and behavior and in older adults ≥65 years of age, a decreased risk was observed. Although data have yielded inconsistent results regarding the association of antidepressants and risk of suicide, particularly among adults, collective evidence shows a trend of an elevated risk of suicidality in younger age groups (Ref). Of note, the risk of a suicide attempt is inherent in major depression and may persist until remission occurs.

Mechanism: Not established; one of several postulated mechanisms is antidepressants may energize suicidal patients to act on impulses; another suggests that antidepressants may produce a worsening of depressive symptoms leading to the emergence of suicidal thoughts and actions (Ref).

Onset: Varied; increased risk observed in short-term studies (ie, <4 months) in pediatric and young adults; it is unknown whether this risk extends to long-term use (ie, >4 months).

Risk factors:

• Children and adolescents (Ref)

• Depression (risk of suicide is associated with major depression and may persist until remission occurs)

Weight gain

Mirtazapine commonly causes significant weight gain (increase of ≥7% of body weight) following short and long-term use (Ref). Mirtazapine also commonly causes increased appetite (Ref).

Mechanism: Antidepressants may induce weight gain by interacting with central mechanisms regulating food intake and appetite, with differences in weight gain between agents attributed to actions on serotonergic, dopaminergic, noradrenergic, histaminergic, and cholinergic systems. Mirtazapine's weight gain has been attributed to its alpha-2 adrenoreceptor antagonism, its high affinity for antagonizing histamine (H1) receptors, and its effects on 5-HT2c receptors, as well as its low affinity for dopaminergic D1 and D2 receptors. In addition, some of the weight gain may also reflect improvement in mood (Ref).

Onset: Varied; significant increases in weight have been observed after the first week of treatment (Ref). In one meta-analysis, mirtazapine was associated with significant weight gain during acute treatment (4 to 12 weeks), and maintained significant associations with weight gain over longer periods of use (≥8 months) (Ref).

Risk factors:

• Psychiatric disorders (regardless of medication) are associated with a higher risk for obesity compared to the general population (Ref)

Withdrawal syndrome

Withdrawal syndrome following mirtazapine discontinuation has been reported, primarily following abrupt discontinuation, although it has also occurred following gradual tapering. Reported symptoms include dizziness, nausea, vomiting, paresthesia, hypotension, insomnia, reduced need of sleep, anxiety, panic attacks, restlessness, irritability, elated mood, pressure of speech, increased energy, and nightmares (Ref). There is also a single case report of mirtazapine-withdrawal associated pruritus following abrupt discontinuation (Ref). In addition, there are several case reports describing withdrawal-induced mania or hypomania following both abrupt and gradual mirtazapine discontinuation. Some of the reports occurred in patients with bipolar disorder and some reports did not mention a preexisting diagnosis of bipolar disorder (Ref).

Mechanism: Withdrawal; mechanism of withdrawal symptoms is unknown, but has been attributed, in part, to the sudden removal of the blockade of 5-HT receptors, as stimulation of 5-HT2 and 5-HT3 receptors has been associated with nausea, anxiety, and insomnia. In addition, the sudden removal of histamine (H1) blockade may contribute to dizziness (Ref).

Onset: Varied; case reports describe an onset of withdrawal symptoms between 1 to 7 days (following either abrupt or tapered discontinuation) (Ref).

Risk factors:

• Abrupt discontinuation (rather than gradual dosage reduction) of an antidepressant treatment that has lasted >3 weeks, particularly a drug with a half-life <24 hours (eg, paroxetine, venlafaxine) (Ref)

• Prior history of antidepressant withdrawal symptoms (Ref)

• High dose (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Endocrine & metabolic: Increased serum cholesterol (15% (table 1)), weight gain (12%; ≥7% of body weight: 8%; literature suggests that incidence of significant weight gain may be as high as 77% after 13.5 months of use) (table 2) (Uguz 2015)

Mirtazapine: Adverse Reaction: Increased Serum Cholesterol

Drug (Mirtazapine)

Placebo

Number of Patients (Mirtazapine)

Number of Patients (Placebo)

Comments

15%

7%

N/A

N/A

Nonfasting cholesterol increases to ≥20% above the upper limits

Mirtazapine: Adverse Reaction: Weight Gain

Drug (Mirtazapine)

Placebo

Number of Patients (Mirtazapine)

Number of Patients (Placebo)

Comments

12%

2%

453

361

N/A

≥7% of body weight: 8%

0%

N/A

N/A

Gastrointestinal: Constipation (13%), increased appetite (17%) (table 3), xerostomia (25%)

Mirtazapine: Adverse Reaction: Increased Appetite

Drug (Mirtazapine)

Placebo

Number of Patients (Mirtazapine)

Number of Patients (Placebo)

17%

2%

453

361

Nervous system: Drowsiness (54%) (table 4)

Mirtazapine: Adverse Reaction: Drowsiness

Drug (Mirtazapine)

Placebo

Number of Patients (Mirtazapine)

Number of Patients (Placebo)

54%

18%

453

361

1% to 10%:

Cardiovascular: Edema (1%), hypertension, peripheral edema (2%), vasodilation

Dermatologic: Pruritus, skin rash

Endocrine & metabolic: Increased serum triglycerides (6%) (table 5), increased thirst

Mirtazapine: Adverse Reaction: Increased Serum Triglycerides

Drug (Mirtazapine)

Placebo

Number of Patients (Mirtazapine)

Number of Patients (Placebo)

Comments

6%

3%

N/A

N/A

Nonfasting triglyceride increases to ≥500 mg/dL

Gastrointestinal: Abdominal pain, anorexia, vomiting

Genitourinary: Urinary frequency (2%), urinary tract infection

Hepatic: Increased serum alanine aminotransferase (≥3 times ULN: 2%)

Nervous system: Abnormal dreams (4%), abnormality in thinking (3%), amnesia, anxiety, apathy, asthenia (8%), confusion (2%) (table 6), dizziness (7%) (table 7), hypoesthesia, malaise, myasthenia, paresthesia, psychomotor agitation, tremor (2%), twitching, vertigo

Mirtazapine: Adverse Reaction: Confusion

Drug (Mirtazapine)

Placebo

Number of Patients (Mirtazapine)

Number of Patients (Placebo)

2%

0%

453

361

Mirtazapine: Adverse Reaction: Dizziness

Drug (Mirtazapine)

Placebo

Number of Patients (Mirtazapine)

Number of Patients (Placebo)

7%

3%

453

361

Neuromuscular & skeletal: Arthralgia, back pain (2%), hyperkinetic muscle activity, hypokinesia, myalgia (2%)

Respiratory: Dyspnea (1%), flu-like symptoms (5%)

<1%:

Cardiovascular: Acute myocardial infarction, angina pectoris, atrial arrhythmia, bigeminy, bradycardia, cardiomegaly, chest pain, hypotension, left ventricular failure, phlebitis, pulmonary embolism, syncope, ventricular premature contractions

Dermatologic: Alopecia, cellulitis, exfoliative dermatitis, skin photosensitivity, Stevens-Johnson syndrome, urticaria, xeroderma

Endocrine & metabolic: Amenorrhea, dehydration, diabetes mellitus, goiter, heavy menstrual bleeding, hyponatremia, hypothyroidism, increased acid phosphatase, increased libido, weight loss

Gastrointestinal: Ageusia, cholecystitis, colitis, enlargement of abdomen, enlargement of salivary glands, eructation, gastritis, gastroenteritis, gingival hemorrhage, glossitis, intestinal obstruction, nausea, oral candidiasis, pancreatitis, sialorrhea, stomatitis, tongue discoloration

Genitourinary: Breast engorgement, breast hypertrophy, cystitis, dysmenorrhea, dysuria, ejaculatory disorder, hematuria, impotence, leukorrhea, mastalgia, urethritis, urinary incontinence, urinary retention, urinary urgency, uterine hemorrhage, vaginitis

Hematologic & oncologic: Agranulocytosis, anemia, leukopenia, pancytopenia, petechia, severe neutropenia, thrombocytopenia

Hepatic: Hepatic cirrhosis, increased serum aspartate aminotransferase

Hypersensitivity: Facial edema, tongue edema

Nervous system: Akathisia, altered sense of smell, aphasia, ataxia, cerebral ischemia, chills, delirium, delusion, dementia, depersonalization, drug dependence, dysarthria, emotional lability, euphoria, extrapyramidal reaction, hallucination, hostility, hyperacusis, hyperreflexia, hypomania, hypotonia, mania, migraine, myoclonus, neurosis, paranoid ideation, seizure, serotonin syndrome, stupor, tonic-clonic seizure, vascular headache, withdrawal syndrome

Neuromuscular & skeletal: Arthritis, bone fracture (osteoporotic), dyskinesia, dystonia (including Pisa syndrome) (Yamada 2018), gout, myositis, neck pain, neck stiffness, ostealgia, rupture of tendon, tenosynovitis

Ophthalmic: Abnormal lacrimation, accommodation disturbance, angle-closure glaucoma, blepharitis, conjunctivitis, diplopia, eye pain, nystagmus disorder

Otic: Deafness, otalgia

Renal: Nephrolithiasis, polyuria

Respiratory: Epistaxis

Miscellaneous: Abnormal healing, fever, ulcer

Frequency not defined: Cardiovascular: Orthostatic hypotension

Postmarketing:

Cardiovascular: Increased serum creatine kinase, prolonged QT interval on ECG (Matsuda 2020), torsades de pointes, ventricular tachycardia

Dermatologic: Bullous dermatitis, erythema multiforme, excoriation of skin (Keshtkarjahromi 2021), hyperpigmentation (Sukhdeo 2018), toxic epidermal necrolysis

Endocrine & metabolic: Hyperglycemia (Duncan 2015), hyperprolactinemia, hypertriglyceridemia (Chen 2003, Duncan 2015)

Genitourinary: Priapism, sexual disorder (Lee 2010)

Hematologic & oncologic: Immune thrombocytopenia (Stuhec 2014)

Hepatic: Hepatotoxicity (Hui 2002), liver steatosis (Thomas 2017)

Hypersensitivity: Drug reaction with eosinophilia and systemic symptoms

Infection: Neutropenic sepsis (Maidwell-Smith 2023)

Nervous system: Complex sleep-related disorder (Shinith 2018), nightmares (Menon 2017), restless leg syndrome (precipitation or exacerbation) (Kolla 2018, Kim 2008), somnambulism (Yeh 2009), suicidal ideation, suicidal tendencies

Neuromuscular & skeletal: Rhabdomyolysis (Khandat 2004)

Contraindications

Hypersensitivity (eg, severe skin reactions, including drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, bullous dermatitis, erythema multiforme, and toxic epidermal necrolysis) to mirtazapine or any component of the formulation; use of monoamine oxidase inhibitors (MAOIs), including linezolid or methylene blue IV (concurrently or within 14 days of stopping an MAOI).

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Warnings/Precautions

Concerns related to adverse effects:

• Anticholinergic effects: May cause anticholinergic effects (constipation, xerostomia, blurred vision, urinary retention); use with caution in patients with decreased gastrointestinal motility, paralytic ileus, urinary retention, BPH, xerostomia, or visual problems. The degree of anticholinergic blockade produced by this agent is low relative to other antidepressants.

• Fractures: Bone fractures have been associated with antidepressant treatment. Consider the possibility of a fragility fracture if an antidepressant-treated patient presents with unexplained bone pain, point tenderness, swelling, or bruising (Leach 2017; Rabenda 2013; Rizzoli 2012).

• Ocular effects: May cause mild pupillary dilation which in susceptible individuals can lead to an episode of narrow-angle glaucoma. Consider evaluating patients who have not had an iridectomy for narrow-angle glaucoma risk factors.

Disease-related concerns:

• Hepatic impairment: Use with caution in patients with hepatic impairment; clearance is decreased and half-life and plasma concentrations are increased in mild to moderate impairment. Clinically significant transaminase elevations have been observed.

• Renal impairment: Use with caution in patients with renal impairment; clearance is decreased with moderate and severe renal impairment.

• Seizure disorder: Use with caution in patients at risk of seizures, including those with a history of seizures, head trauma, brain damage, alcohol use disorder, or concurrent therapy with medications that may lower seizure threshold.

Dosage form specific issues:

• Lactose: Tablets may contain lactose.

• Phenylalanine: SolTab formulation may contain phenylalanine.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Tablet, Oral:

Remeron: 15 mg [DSC]

Remeron: 15 mg [scored; contains corn starch]

Remeron: 30 mg [DSC]

Remeron: 30 mg [scored; contains corn starch]

Generic: 7.5 mg, 15 mg, 30 mg, 45 mg

Tablet Disintegrating, Oral:

Remeron SolTab: 15 mg, 30 mg, 45 mg [contains aspartame]

Generic: 15 mg, 30 mg, 45 mg

Generic Equivalent Available: US

Yes

Pricing: US

Tablet, orally-disintegrating (Mirtazapine Oral)

15 mg (per each): $2.35 - $2.36

30 mg (per each): $2.42 - $2.43

45 mg (per each): $2.58 - $2.59

Tablet, orally-disintegrating (Remeron SolTab Oral)

15 mg (per each): $5.87

30 mg (per each): $6.05

45 mg (per each): $6.43

Tablets (Mirtazapine Oral)

7.5 mg (per each): $2.63

15 mg (per each): $2.70 - $2.72

30 mg (per each): $2.77 - $2.80

45 mg (per each): $2.83 - $2.85

Tablets (Remeron Oral)

15 mg (per each): $7.37

30 mg (per each): $7.59

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral:

Remeron: 30 mg [contains corn starch]

Generic: 15 mg, 30 mg, 45 mg

Tablet Disintegrating, Oral:

Remeron RD: 15 mg, 30 mg, 45 mg [contains aspartame]

Generic: 15 mg, 30 mg, 45 mg

Administration: Adult

Oral: Administer without regard to meals.

Orally disintegrating tablet: Do not remove tablet from blister pack until ready to administer; peel back foil to expose tablet; use dry hands to remove tablet and place immediately on tongue. Tablet dissolves rapidly in saliva; water is not needed. Do not chew, crush, or split tablet.

Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and as follows, must be dispensed with this medication:

Remeron, Remeron SolTab: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/020415s038,021208s028lbl.pdf#page=23

Use: Labeled Indications

Major depressive disorder (unipolar): Treatment of unipolar major depressive disorder (MDD) in adults.

Use: Off-Label: Adult

Headache, chronic tension-type, prophylaxis; Panic disorder

Medication Safety Issues
Sound-alike/look-alike issues:

Remeron may be confused with Premarin, ramelteon, Rozerem, Zemuron

Older Adult: High-Risk Medication:

Beers Criteria: Mirtazapine is identified in the Beers Criteria as a potentially inappropriate medication to be used with caution in patients 65 years and older due to the potential to cause or exacerbate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia; monitor sodium concentration closely when initiating or adjusting the dose in older adults (Beers Criteria [AGS 2023]).

International issues:

Avanza [Australia] may be confused with Albenza brand name for albendazole [US]; Avandia brand name for rosiglitazone [US, Canada, and multiple international markets]

Remeron [US, Canada, and multiple international markets] may be confused with Reneuron which is a brand name for fluoxetine [Spain]

Metabolism/Transport Effects

Substrate of CYP1A2 (minor), CYP2C9 (minor), CYP2D6 (minor), CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Alcohol (Ethyl): May enhance the CNS depressant effect of Mirtazapine. Risk X: Avoid combination

Alizapride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Almotriptan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Alosetron: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Alpha2-Agonists: Mirtazapine may diminish the antihypertensive effect of Alpha2-Agonists. Management: Consider avoiding concurrent use. If the combination cannot be avoided, monitor for decreased effects of alpha2-agonists if mirtazapine is initiated/dose increased, or increased effects if mirtazapine is discontinued/dose decreased. Risk D: Consider therapy modification

Amphetamines: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability). Initiate amphetamines at lower doses, monitor frequently, and adjust doses as needed. Risk C: Monitor therapy

Antiemetics (5HT3 Antagonists): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Antipsychotic Agents: Serotonergic Agents (High Risk) may enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonergic agents may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor therapy

Azelastine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Blonanserin: CNS Depressants may enhance the CNS depressant effect of Blonanserin. Management: Use caution if coadministering blonanserin and CNS depressants; dose reduction of the other CNS depressant may be required. Strong CNS depressants should not be coadministered with blonanserin. Risk D: Consider therapy modification

Brexanolone: CNS Depressants may enhance the CNS depressant effect of Brexanolone. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Bromopride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Bromperidol: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Buprenorphine: CNS Depressants may enhance the CNS depressant effect of Buprenorphine. Management: Consider reduced doses of other CNS depressants, and avoiding such drugs in patients at high risk of buprenorphine overuse/self-injection. Initiate buprenorphine at lower doses in patients already receiving CNS depressants. Risk D: Consider therapy modification

BusPIRone: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Cannabinoid-Containing Products: CNS Depressants may enhance the CNS depressant effect of Cannabinoid-Containing Products. Risk C: Monitor therapy

Chlormethiazole: May enhance the CNS depressant effect of CNS Depressants. Management: Monitor closely for evidence of excessive CNS depression. The chlormethiazole labeling states that an appropriately reduced dose should be used if such a combination must be used. Risk D: Consider therapy modification

Chlorphenesin Carbamate: May enhance the adverse/toxic effect of CNS Depressants. Risk C: Monitor therapy

Cimetidine: May increase the serum concentration of Mirtazapine. Risk C: Monitor therapy

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

CNS Depressants: May enhance the adverse/toxic effect of other CNS Depressants. Risk C: Monitor therapy

Cyclobenzaprine: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

CYP3A4 Inducers (Strong): May decrease the serum concentration of Mirtazapine. Risk C: Monitor therapy

CYP3A4 Inhibitors (Strong): May increase the serum concentration of Mirtazapine. Risk C: Monitor therapy

Dapoxetine: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Do not use serotonergic agents (high risk) with dapoxetine or within 7 days of serotonergic agent discontinuation. Do not use dapoxetine within 14 days of monoamine oxidase inhibitor use. Dapoxetine labeling lists this combination as contraindicated. Risk X: Avoid combination

Daridorexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dose reduction of daridorexant and/or any other CNS depressant may be necessary. Use of daridorexant with alcohol is not recommended, and the use of daridorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

DexmedeTOMIDine: CNS Depressants may enhance the CNS depressant effect of DexmedeTOMIDine. Management: Monitor for increased CNS depression during coadministration of dexmedetomidine and CNS depressants, and consider dose reductions of either agent to avoid excessive CNS depression. Risk D: Consider therapy modification

Dexmethylphenidate-Methylphenidate: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Dextromethorphan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Difelikefalin: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Dimethindene (Topical): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Doxylamine: CNS Depressants may enhance the CNS depressant effect of Doxylamine. Risk C: Monitor therapy

DroPERidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (eg, opioids, barbiturates) with concomitant use. Risk D: Consider therapy modification

Eletriptan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Ergot Derivatives: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Esketamine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Fenfluramine: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor therapy

Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Flunarizine: CNS Depressants may enhance the CNS depressant effect of Flunarizine. Risk X: Avoid combination

Flunitrazepam: CNS Depressants may enhance the CNS depressant effect of Flunitrazepam. Management: Reduce the dose of CNS depressants when combined with flunitrazepam and monitor patients for evidence of CNS depression (eg, sedation, respiratory depression). Use non-CNS depressant alternatives when available. Risk D: Consider therapy modification

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Gepirone: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Risk C: Monitor therapy

Haloperidol: QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of Haloperidol. Risk C: Monitor therapy

HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Management: Consider a decrease in the CNS depressant dose, as appropriate, when used together with hydroxyzine. Increase monitoring of signs/symptoms of CNS depression in any patient receiving hydroxyzine together with another CNS depressant. Risk D: Consider therapy modification

Ixabepilone: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Kava Kava: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Kratom: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Lasmiditan: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Lemborexant: May enhance the CNS depressant effect of CNS Depressants. Management: Dosage adjustments of lemborexant and of concomitant CNS depressants may be necessary when administered together because of potentially additive CNS depressant effects. Close monitoring for CNS depressant effects is necessary. Risk D: Consider therapy modification

Linezolid: May enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Risk X: Avoid combination

Lisuride: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Lorcaserin (Withdrawn From US Market): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Metaxalone: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Methotrimeprazine: CNS Depressants may enhance the CNS depressant effect of Methotrimeprazine. Methotrimeprazine may enhance the CNS depressant effect of CNS Depressants. Management: Reduce the usual dose of CNS depressants by 50% if starting methotrimeprazine until the dose of methotrimeprazine is stable. Monitor patient closely for evidence of CNS depression. Risk D: Consider therapy modification

Methylene Blue: Serotonergic Non-Opioid CNS Depressants may enhance the serotonergic effect of Methylene Blue. This could result in serotonin syndrome. Risk X: Avoid combination

Metoclopramide: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Metoclopramide: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Consider monitoring for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

MetyroSINE: CNS Depressants may enhance the sedative effect of MetyroSINE. Risk C: Monitor therapy

Minocycline (Systemic): May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Monoamine Oxidase Inhibitors (Antidepressant): Serotonergic Non-Opioid CNS Depressants may enhance the serotonergic effect of Monoamine Oxidase Inhibitors (Antidepressant). This could result in serotonin syndrome. Risk X: Avoid combination

Nabilone: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Nefazodone: Mirtazapine may enhance the serotonergic effect of Nefazodone. This could result in serotonin syndrome. Nefazodone may increase the serum concentration of Mirtazapine. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and for increased mirtazapine toxicities when these agents are combined. Risk C: Monitor therapy

Olopatadine (Nasal): May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Ondansetron: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Opioid Agonists: CNS Depressants may enhance the CNS depressant effect of Opioid Agonists. Management: Avoid concomitant use of opioid agonists and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Orphenadrine: CNS Depressants may enhance the CNS depressant effect of Orphenadrine. Risk X: Avoid combination

Oxitriptan: Serotonergic Agents (High Risk) may enhance the serotonergic effect of Oxitriptan. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Oxomemazine: May enhance the CNS depressant effect of CNS Depressants. Risk X: Avoid combination

Oxybate Salt Products: CNS Depressants may enhance the CNS depressant effect of Oxybate Salt Products. Management: Consider alternatives to this combination when possible. If combined, dose reduction or discontinuation of one or more CNS depressants (including the oxybate salt product) should be considered. Interrupt oxybate salt treatment during short-term opioid use Risk D: Consider therapy modification

OxyCODONE: CNS Depressants may enhance the CNS depressant effect of OxyCODONE. Management: Avoid concomitant use of oxycodone and benzodiazepines or other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk D: Consider therapy modification

Ozanimod: May enhance the adverse/toxic effect of Serotonergic Agents (High Risk). Risk C: Monitor therapy

Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Risk X: Avoid combination

Perampanel: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Piribedil: CNS Depressants may enhance the CNS depressant effect of Piribedil. Risk C: Monitor therapy

Pitolisant: Mirtazapine may diminish the therapeutic effect of Pitolisant. Risk X: Avoid combination

Pramipexole: CNS Depressants may enhance the sedative effect of Pramipexole. Risk C: Monitor therapy

Procarbazine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

QT-prolonging Agents (Highest Risk): QT-prolonging Agents (Indeterminate Risk - Caution) may enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy

Ramosetron: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Rasagiline: May enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Risk X: Avoid combination

Ropeginterferon Alfa-2b: CNS Depressants may enhance the adverse/toxic effect of Ropeginterferon Alfa-2b. Specifically, the risk of neuropsychiatric adverse effects may be increased. Management: Avoid coadministration of ropeginterferon alfa-2b and other CNS depressants. If this combination cannot be avoided, monitor patients for neuropsychiatric adverse effects (eg, depression, suicidal ideation, aggression, mania). Risk D: Consider therapy modification

ROPINIRole: CNS Depressants may enhance the sedative effect of ROPINIRole. Risk C: Monitor therapy

Rotigotine: CNS Depressants may enhance the sedative effect of Rotigotine. Risk C: Monitor therapy

Rufinamide: May enhance the adverse/toxic effect of CNS Depressants. Specifically, sleepiness and dizziness may be enhanced. Risk C: Monitor therapy

Safinamide: May enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Risk X: Avoid combination

Selective Serotonin Reuptake Inhibitors: May enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Selegiline: May enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Risk X: Avoid combination

Serotonergic Agents (High Risk, Miscellaneous): May enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Serotonergic Opioids (High Risk): Serotonergic Non-Opioid CNS Depressants may enhance the CNS depressant effect of Serotonergic Opioids (High Risk). Serotonergic Non-Opioid CNS Depressants may enhance the serotonergic effect of Serotonergic Opioids (High Risk). This could result in serotonin syndrome. Management: Consider alternatives to this drug combination. If combined, monitor for signs and symptoms of serotonin syndrome/serotonin toxicity and CNS depression. Risk D: Consider therapy modification

Serotonin 5-HT1D Receptor Agonists (Triptans): May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Serotonin/Norepinephrine Reuptake Inhibitors: Mirtazapine may enhance the serotonergic effect of Serotonin/Norepinephrine Reuptake Inhibitors. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

St John's Wort: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. St John's Wort may decrease the serum concentration of Serotonergic Agents (High Risk). Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Suvorexant: CNS Depressants may enhance the CNS depressant effect of Suvorexant. Management: Dose reduction of suvorexant and/or any other CNS depressant may be necessary. Use of suvorexant with alcohol is not recommended, and the use of suvorexant with any other drug to treat insomnia is not recommended. Risk D: Consider therapy modification

Syrian Rue: May enhance the serotonergic effect of Serotonergic Agents (High Risk). This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) when these agents are combined. Risk C: Monitor therapy

Thalidomide: CNS Depressants may enhance the CNS depressant effect of Thalidomide. Risk X: Avoid combination

Tobacco (Smoked): May decrease the serum concentration of Mirtazapine. Risk C: Monitor therapy

TraZODone: May enhance the CNS depressant effect of Mirtazapine. TraZODone may enhance the serotonergic effect of Mirtazapine. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and CNS depression when these agents are combined. Risk C: Monitor therapy

Tricyclic Antidepressants: May enhance the CNS depressant effect of Serotonergic Non-Opioid CNS Depressants. Tricyclic Antidepressants may enhance the serotonergic effect of Serotonergic Non-Opioid CNS Depressants. This could result in serotonin syndrome. Management: Monitor for signs and symptoms of serotonin syndrome/serotonin toxicity (eg, hyperreflexia, clonus, hyperthermia, diaphoresis, tremor, autonomic instability, mental status changes) and CNS depression when these agents are combined. Risk C: Monitor therapy

Trimeprazine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Valerian: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy

Warfarin: Mirtazapine may enhance the anticoagulant effect of Warfarin. Risk C: Monitor therapy

Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem adult dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider therapy modification

Zuranolone: May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to the use of zuranolone with other CNS depressants or alcohol. If combined, consider a zuranolone dose reduction and monitor patients closely for increased CNS depressant effects. Risk D: Consider therapy modification

Reproductive Considerations

If treatment for major depressive disorder is initiated for the first time in females planning a pregnancy, agents other than mirtazapine are preferred (use of mirtazapine is not preferred in pregnant women) (Larsen 2015).

The incidence of sexual dysfunction with mirtazapine is generally lower than with selective serotonin reuptake inhibitors (WFSBP [Bauer 2013]).

Pregnancy Considerations

Mirtazapine crosses the placenta (Hatzidaki 2008).

A significant increase in major teratogenic effects has not been observed following exposure to mirtazapine during pregnancy; however, information is limited (CANMAT [MacQueen 2016]; Larsen 2015).

Untreated or inadequately treated psychiatric illness may lead to poor compliance with prenatal care. Therapy with antidepressants during pregnancy should be individualized (ACOG 92 2008; CANMAT [MacQueen 2016]). Psychotherapy or other nonmedication therapies may be considered for some women; however, antidepressant medication should be considered for pregnant women with moderate to severe major depressive disorder (MDD) (APA 2010). If treatment for MDD is initiated for the first time during pregnancy, mirtazapine is not recommended (CANMAT [MacQueen 2016]; Larsen 2015; WFSBP [Bauer 2013]); mirtazapine is considered a third-line agent for the treatment of mild to moderate depression during pregnancy (CANMAT [MacQueen 2016]).

Data collection to monitor pregnancy and infant outcomes following exposure to antidepressants is ongoing. Pregnant women exposed to antidepressants during pregnancy are encouraged to enroll in the National Pregnancy Registry for Antidepressants (NPRAD). Women 18 to 45 years of age or their health care providers may contact the registry by calling 844-405-6185. Enrollment should be done as early in pregnancy as possible.

Breastfeeding Considerations

Mirtazapine and its active metabolite are present in breast milk.

The highest relative infant dose (RID) of mirtazapine located in the literature is 4.4%. Authors of the study calculated the RID following maternal administration of mirtazapine 22.5 mg/day to a woman at 6 weeks' postpartum; metabolite concentrations were not evaluated. Breast milk was sampled 4 hours after the maternal dose (Klier 2007). Desmethylmirtazpine can also be detected in breast milk (Kristensen 2007).

In general, breastfeeding is considered acceptable when the RID of a medication is <10% (Anderson 2016; Ito 2000). However, some sources note breastfeeding should only be considered if the RID is <5% for psychotropic agents (Larsen 2015).

Mirtazapine can be detected in the serum of breastfed infants; adverse events have generally not been observed, although possible sedation and weight gain was noted in one case report (Kristensen 2007; Smit 2015; Tonn 2009).

According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother. Infants of mothers using psychotropic medications should be monitored daily for changes in sleep, feeding patterns, and behavior (WFSBP [Bauer 2013]) as well as infant growth and neurodevelopment (ABM [Sriraman 2015]; Sachs 2013). When first initiating an antidepressant in a breastfeeding female, agents other than mirtazapine are preferred (Berle 2011; CANMAT [MacQueen 2016]).

Dietary Considerations

Some products may contain phenylalanine.

Monitoring Parameters

CBC; renal and hepatic function; lipid profile; weight; suicidality (during the initial 1 to 2 months of therapy or during periods of dosage adjustments).

Mechanism of Action

Mirtazapine is a tetracyclic antidepressant that works by its central presynaptic alpha2-adrenergic antagonist effects, which results in increased release of norepinephrine and serotonin. It is also a potent antagonist of 5-HT2 and 5-HT3 serotonin receptors and H1 histamine receptors and a moderate peripheral alpha1-adrenergic and muscarinic antagonist; it does not inhibit the reuptake of norepinephrine or serotonin.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action:

Anxiety disorders (panic disorder): Initial effects may be observed within 2 weeks of treatment, with continued improvements through 4 to 6 weeks (WFSBP [Bandelow 2023]); some experts suggest up to 12 weeks of treatment may be necessary for response (BAP [Baldwin 2014]; Katzman 2014; WFSBP [Bandelow 2023]).

Depression: Initial effects may be observed within 1 to 2 weeks of treatment, with continued improvements through 4 to 6 weeks (Papakostas 2006; Posternak 2005; Szegedi 2009).

Absorption: Rapid and complete.

Protein binding: ~85%.

Metabolism: Extensively hepatic via CYP1A2, 2D6, 3A4 and via demethylation and hydroxylation.

Bioavailability: ~50%.

Half-life elimination: ~20 to 40 hours; increased with renal or hepatic impairment.

Time to peak, serum: ~2 hours.

Excretion: Urine (75%) and feces (15%) as metabolites.

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Clearance is reduced ~30% in patients with moderate (GFR 11 to 39 mL/minute/1.73 m2) and ~50% in patients with severe (GFR <10 mL/minute/1.73 m2) kidney impairment.

Hepatic function impairment: Clearance decreased by 33% and half-life and serum concentration increased by 39% and 55%, respectively, following a single dose of mirtazapine in elderly patients with mild or moderate hepatic impairment (Mauri 2014).

Older adult: Clearance is reduced 40% in elderly men and 10% in elderly women.

Sex: Women have a longer elimination half-life (37 hours) than men (26 hours).

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Mezeron | Mirtaza | Remeron;
  • (AR) Argentina: Bilanz | Comenter | Eufotina | Farmapina | Noxibel | Remeron;
  • (AT) Austria: Mirtabene | Mirtapel | Mirtaron | Mirtazapin | Mirtazapin actavis | Mirtazapin Bluefish | Mirtazapin G.L. | Mirtazapin teva | Mirtel | Remeron;
  • (AU) Australia: Apo mirtazapine | Apx mirtazapine | Aurozapine | Avanza | Axit | Blooms the chemist mirtazapine | Chemmart Mirtazapine | GenRx Mirtazapine | Milivin | Mirtanza | Mirtazapine an | Mirtazapine arw | Mirtazapine ga | Mirtazapine pfizer | Mirtazapine sandoz | Mirtazon | Noumed mirtazapine | Remeron | Terry White Chemists Mirtazapine;
  • (BD) Bangladesh: Amiron | Azapin | Mirapin | Mirapro | Mirez | Mirtaz | Mirzalux | Mitaprex | Mitrazin | Rapine | Rejoy;
  • (BE) Belgium: Mirtazapine actavis | Mirtazapine apotex | Mirtazapine eg | Mirtazapine merck-generics | Mirtazapine ratiopharm | Mirtazapine sandoz | Mirtazapine teva | Remergon;
  • (BG) Bulgaria: Esprital | Mirzaten | Mirzaten Q Tab | Remirta;
  • (BR) Brazil: Menelat | Mirtazapina | Razapina | Remeron | Zapsy;
  • (CH) Switzerland: Mirtazap | Mirtazap Mepha | Mirtazapin actavis | Mirtazapin Helvepharm | Mirtazapin Mepha | Mirtazapin Sandoz | Mirtazapin Spirig | Mirtazapin Streuli | Mirtazapin teva | Mirtazapin zentiva | Remeron;
  • (CL) Chile: Amirel | Ciblex | Divaril | Promyrtil | Promyrtil Soltab | Zuleptan;
  • (CN) China: Kang duo ning | Mi er ning | Pai di sheng | Remeron;
  • (CO) Colombia: Depreless | Epilfarmo | Mirtapax | Mirtazapina | Mirzalux | Remeron | Tazepin | Zania | Zimvaken;
  • (CZ) Czech Republic: Esprital | Mirtazapin aurovitas | Mirtazapin Bluefish | Mirtazapin orion | Mirtazapin Sandoz | Mirtazapine teva | Mirzaten | Remeron;
  • (DE) Germany: Mirta | Mirta tad | Mirtagamma | Mirtalich | Mirtazapin | Mirtazapin 1 A Pharma | Mirtazapin actavis | Mirtazapin al | Mirtazapin ametas | Mirtazapin Aurobindo | Mirtazapin AWD | Mirtazapin Axcount | Mirtazapin Basics | Mirtazapin Beta | Mirtazapin biomo | Mirtazapin Bluefish | Mirtazapin ct | Mirtazapin dura | Mirtazapin Heumann | Mirtazapin Hexal | Mirtazapin Isis | Mirtazapin Neurax | Mirtazapin puren | Mirtazapin Ratiopharm | Mirtazapin Sandoz | Mirtazapin Stada | Mirtazapin teva | Mirtazelon | Mirtazop | Mirtazza | Remergil | Remeron | Zispin;
  • (DK) Denmark: Arintapin | Combar | Mirtazapin gea | Mirtazapin Ratiopharm | Remeron;
  • (DO) Dominican Republic: Comenter | Menoxis | Mirtafran | Mirtalon | Mirtapin | Mirtaza | Mirtazapina | Mirtazep | Remeron;
  • (EC) Ecuador: Ciblex | Mirtapax | Mirtaz | Mirtazapina | Mirzalux | Noxibel | Remeron;
  • (EE) Estonia: Esprital | Mirtastad | Mirtazapin | Mirzaten | Remergil | Remeron;
  • (EG) Egypt: Aprimertaz | Mirpresion | Mirtadepine | Mirtimash | Mirtofutal | Ramizipine | Rapizapine | Remeron | Zapimert;
  • (ES) Spain: Afloyan | Mirpik | Mirtamylan | Mirtazapina Actavis | Mirtazapina Almus | Mirtazapina alter | Mirtazapina amneal | Mirtazapina apotex | Mirtazapina Aurobindo | Mirtazapina bayvit | Mirtazapina Bexal | Mirtazapina bluefish pharma | Mirtazapina Cinfa | Mirtazapina combino pharm | Mirtazapina combix | Mirtazapina davur | Mirtazapina flas kern pharma | Mirtazapina merck | Mirtazapina Normon | Mirtazapina Pharmagenus | Mirtazapina Qualigen | Mirtazapina ratiopharm | Mirtazapina rimafar | Mirtazapina sandoz | Mirtazapina Stada | Mirtazapina Tarbis | Mirtazapina Tecnigen | Mirtazapina teva | Mirtazapina ur | Mirtazapina winthrop | Rexer | Rexer Flas | Vastat | Vastat flas;
  • (FI) Finland: Arintapin | Miramerck | Mirtachem | Mirtamerck | Mirtaril | Mirtatsapiini ennapharma | Mirtatsapiini Teva | Mirtazapin alpharm | Mirtazapin Bluefish | Mirtazapin generic | Mirtazapin Hexal | Mirtazapin Krka | Mirtazapin Lannacher | Mirtazapin orion | Mirtazapin Ratiopharm | Mirtazapin Sandoz | Mirtazapin teva | Mirtazapine actavis | Mirtazapine Aurobindo | Mirtazon | Remeron;
  • (FR) France: Mirtazapine actavis | Mirtazapine Almus | Mirtazapine arrow | Mirtazapine Biogaran | Mirtazapine bluefish | Mirtazapine cristers | Mirtazapine eg | Mirtazapine pfizer | Mirtazapine Qualimed | Mirtazapine Ranbaxy | Mirtazapine ratiopharm | Mirtazapine sandoz | Mirtazapine Zydus | Norset;
  • (GB) United Kingdom: Mirtazapine Almus | Mirtazapine arrow | Mirtazapine cox | Mirtazapine focus | Mirtazapine kent | Mirtazapine pfizer | Zispin;
  • (GR) Greece: Azapin | Depreram | Mirrador Flash | Mirtamor | Mirtazafer | Mirtazapine/Generics | Mirtazapine/mylan | Motofen | Remeron | Saxib;
  • (HK) Hong Kong: Mirnite | Mirtazapine teva | Remeron | Remirta;
  • (HR) Croatia: Calixta | Mirzaten | Mirzaten Q Tab | Odonazin;
  • (HU) Hungary: Mirtastad | Mirtawin | Mirtazapin Sandoz | Mirtazapin zentiva | Mirtazapine Aurobindo | Mirtazapine bluefish | Mirtel | Mirzaten | Mirzaten Q Tab | Mizapin | Remeron | Yarocen;
  • (ID) Indonesia: Remeron;
  • (IE) Ireland: Mirap | Mirtall | Mirtaz | Mirtazapine bluefish | Mirtazapine teva | Mirzaten | Tazamel | Zismirt | Zispin | Zispin soltab;
  • (IL) Israel: Miro | Mirtazapine teva | Remeron;
  • (IN) India: M zap | Matiz | Maz | Mira | Miramind | Miraz | Mirazep | Mirdep | Mirfast | Mirnite | Mirsol | Mirt | Mirtadep | Mirtakem | Mirtalite | Mirtasure md | Mirtaz | Mirtee | Mirtex | Mirza | Mirzest | Mitapin | Mitocent | Mitpin | Mitraford | Mitrazac | Mizhra | Mompress | Mtz | Nasdep | Nutaz | Orzap | Tezepin | Zipdep;
  • (IS) Iceland: Miron;
  • (IT) Italy: Mirtazapina | Mirtazapina Actavis | Mirtazapina Almus | Mirtazapina Aurobindo | Mirtazapina blu | Mirtazapina Doc | Mirtazapina eg | Mirtazapina krka | Mirtazapina merck | Mirtazapina ratiopharm | Mirtazapina sandoz | Mirtazapina sandoz gmbh | Mirtazapina winthrop | Remeron | Zatimar;
  • (JO) Jordan: Dinertone | Remeron;
  • (JP) Japan: Mirtazapine ee | Mirtazapine kyorin | Mirtazapine kyosomirai | Mirtazapine nipro | Mirtazapine nissin | Mirtazapine od | Mirtazapine od dsep | Mirtazapine od towa | Mirtazapine pfizer | Mirtazapine takeda teva | Reflex | Remeron;
  • (KE) Kenya: Menelat | Mezeron | Mirtaz;
  • (KR) Korea, Republic of: Milta | Milta od | Mirta | Mirta od | Mirtapin | Mirtax | Mirzentac | Multapine | Pharmascience mirtazapine | Remeron | Remeron soltab | Remixil | Teva mirtazapine odt | Yungjin mirtazapine;
  • (KW) Kuwait: Mirtaza | Remeron;
  • (LB) Lebanon: Mirta | Remeron;
  • (LT) Lithuania: Esprital | Mirtastad | Mirtazapin | Mirtazapin actavis | Mirtazapin orion | Mirtazapine Aurobindo | Mirtazepine Teva | Mirzaten | Remeron | Valdren;
  • (LU) Luxembourg: Docmirtazapine | Mirtazapin Ratiopharm | Mirtazapine eg | Remergon;
  • (LV) Latvia: Esprital | Mirtastad | Mirtazapin Ratiopharm | Mirtazapine Aurobindo | Mirtel | Mirzaten | Mirzaten Q Tab | Remeron | Valdren;
  • (MA) Morocco: Remeron;
  • (MX) Mexico: Alpreak | Comenter | Conalpin | Mirtazapina | Ociples | Ociplos | Remeron | Remeron soltab | Segmir | Zapex;
  • (MY) Malaysia: Menelat | Remeron;
  • (NL) Netherlands: Mirtazapine A | Mirtazapine actavis | Mirtazapine Alpharma | Mirtazapine Aurobindo | Mirzasna | Remeron;
  • (NO) Norway: Mirtazapin | Mirtazapin Arrow | Mirtazapin Bluefish | Mirtazapin Hexal | Mirtazapin orion | Mirtazapin teva | Mirtazapine Aurobindo | Remeron;
  • (NZ) New Zealand: Apo mirtazapine | Avanza | Noumed mirtazapine | Remeron;
  • (PE) Peru: Ciblex | Deprezapina | Exania | Midexar | Mirtalab | Mirtapax | Mirtavitae | Mirtaz | Mirtazapina | Noxibel | Remedrint | Remeron;
  • (PH) Philippines: Menelat | Mirazep | Remeron;
  • (PK) Pakistan: Actizipine | Elaxine | Jeta | M. tazapine | Mazipine | Mipine | Mirtaget | Mirtanel | Mirtasat | Mirtawin | Mirtazameron | Mirtazep | Mzapine | Nassa | Notense | Ramargon | Remeron | Remirta | Rezam | Sypine | Tazip | Tizapine | Valta | Zapmir | Zemer | Zipdep;
  • (PL) Poland: Esprital | Mirtagen | Mirtastad | Mirtazapine bluefish | Mirtazapine teva | Mirzaten | Mirzaten Q Tab | Remeron;
  • (PR) Puerto Rico: Remeron;
  • (PT) Portugal: Mirtaz | Mirtazapina | Mirtazapina Almus | Mirtazapina Aurobindo | Mirtazapina aurovitas | Mirtazapina Ciclum | Mirtazapina Germed | Mirtazapina krka | Mirtazapina ritisca | Mirtazapina sandoz | Mirtazapina wynn | Psidep | Remeron;
  • (PY) Paraguay: Ciblex | Contrelmin | Mirtapax | Noxibel;
  • (QA) Qatar: Mirtaz | Remeron | Remeron Soltab;
  • (RO) Romania: Esprital | Mirtazapine teva | Mirzaten | Mirzaten Q Tab | Remeron | Valdren | Zulin;
  • (RU) Russian Federation: Calixta | Esprital | Mirtalan | Mirtazapine canon | Mirtazonal | Mirzaten | Mirzaten Q Tab | Noxibel | Remeron;
  • (SA) Saudi Arabia: Apo mirtazapine | Mirtaza | Mirzagen | Pms-mirtazapine | Remeron;
  • (SE) Sweden: Mirtazapin 2care4 | Mirtazapin abacus medicine | Mirtazapin actavis | Mirtazapin Alpharma | Mirtazapin Alternova | Mirtazapin Arrow | Mirtazapin Aurobindo | Mirtazapin Bluefish | Mirtazapin ebb | Mirtazapin Ethypharm | Mirtazapin Hexal | Mirtazapin Imi Pharma | Mirtazapin Krka | Mirtazapin Mylan | Mirtazapin orion | Mirtazapin Ratiopharm | Mirtazapin Sandoz | Mirtazapin Stada | Mirtazapin teva | Mirtin | Remeron | Trimazimyl;
  • (SG) Singapore: Apo mirtazapine | Mirtazapine sandoz | Remeron;
  • (SI) Slovenia: Mirtazapin Mylan | Mirzaten | Remeron;
  • (SK) Slovakia: Calixta | Esprital | Mirtazapine bluefish | Mirtazapine teva | Mirzaten | Mirzaten Q Tab | Remeron;
  • (TH) Thailand: Remeron | Zamir 15 | Zamir 30 | Zymron;
  • (TR) Turkey: Minelza | Redepra | Remeron | Velorin OD | Zestat;
  • (TW) Taiwan: Apa mirtazapine | Minivane | Mirtan | Mirtapine | Mirtazapine sandoz | Mirtine | Pms-mirtazapine | Remeron | Sinmaron | Smilon | U Mirtaron | U-Zepine;
  • (UA) Ukraine: Esprital | Mirazep | Mirtastadin | Mirtazapin | Mirtazapine odt | Mirtel | Remeron;
  • (UY) Uruguay: Mizapin | Noxibel | Remeron | Terladep;
  • (VE) Venezuela, Bolivarian Republic of: Comenter | Mirtazapina | Mirtazaval | Mirtazpen | Remeron;
  • (VN) Viet Nam: Itazpam;
  • (ZA) South Africa: ADCO Mirteron | Auro mirtazapine | Miradep | Mytra | Ramure | Remeron
  1. 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372 [PubMed 37139824]
  2. Abou Kassm S, Naja W. Looking for bipolarity in antidepressant discontinuation manic states: update and diagnostic considerations of the phenomenon. J Affect Disord. 2018;235:551-556. doi:10.1016/j.jad.2018.04.080 [PubMed 29694944]
  3. ACOG Committee on Practice Bulletins--Obstetrics, "ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 92, April 2008 (Replaces Practice Bulletin Number 87, November 2007). Use of Psychiatric Medications During Pregnancy and Lactation," Obstet Gynecol, 2008, 111(4):1001-20. [PubMed 18378767]
  4. Ahmed A. Neutropenia associated with mirtazapine use: is a drop in the neutrophil count in a symptomatic older adults a cause for concern?. J Am Geriatr Soc. 2002;50(8):1461-1463. doi:10.1046/j.1532-5415.2002.50375.x [PubMed 12165012]
  5. Ali S, Milev R. Switch to mania upon discontinuation of antidepressants in patients with mood disorders: a review of the literature. Can J Psychiatry. 2003;48(4):258-264. doi:10.1177/070674370304800410 [PubMed 12776393]
  6. American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Published October 2010. Accessed December 3, 2020.
  7. Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-52. [PubMed 27060684]
  8. Ansermot N, Hodel PF, Eap CB. Serotonin toxicity after addition of mirtazapine to escitalopram. J Clin Psychopharmacol. 2014;34(4):540-541. doi:10.1097/JCP.0000000000000170 [PubMed 24977717]
  9. Anttila SA, Leinonen EV. A review of the pharmacological and clinical profile of mirtazapine. CNS Drug Rev. 2001;7(3):249-264. doi:10.1111/j.1527-3458.2001.tb00198.x [PubMed 11607047]
  10. Arnold DM, Kukaswadia S, Nazi I, et al. A systematic evaluation of laboratory testing for drug-induced immune thrombocytopenia. J Thromb Haemost. 2013a;11(1):169-176. doi:10.1111/jth.12052 [PubMed 23121994]
  11. Arnold DM, Nazi I, Warkentin TE, et al. Approach to the diagnosis and management of drug-induced immune thrombocytopenia. Transfus Med Rev. 2013b;27(3):137-145. doi:10.1016/j.tmrv.2013.05.005 [PubMed 23845922]
  12. Atmaca M, Korkmaz S, Topuz M, Mermi O. Mirtazapine augmentation for selective serotonin reuptake inhibitor-induced sexual dysfunction: a retrospective investigation. Psychiatry Investig. 2011;8(1):55-57. doi:10.4306/pi.2011.8.1.55 [PubMed 21519537]
  13. Bakchoul T, Marini I. Drug-associated thrombocytopenia. Hematology Am Soc Hematol Educ Program. 2018;2018(1):576-583. doi:10.1182/asheducation-2018.1.576 [PubMed 30504360]
  14. Balaz M, Rektor I. Gradual onset of dyskinesia induced by mirtazapine. Neurol India. 2010;58(4):672-673. doi:10.4103/0028-3886.68693 [PubMed 20739826]
  15. Baldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-439. doi:10.1177/0269881114525674 [PubMed 24713617]
  16. Bandelow B, Allgulander C, Baldwin DS, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - version 3. Part I: anxiety disorders. World J Biol Psychiatry. 2023;24(2):79-117. doi:10.1080/15622975.2022.2086295 [PubMed 35900161]
  17. Bartlett D. Drug-Induced Serotonin Syndrome. Crit Care Nurse. 2017;37(1):49-54. doi:10.4037/ccn2017169 [PubMed 28148614]
  18. Basavraj V, Nanjundappa GB, Chandra PS. Mirtazapine induced mania in a woman with major depression in the absence of features of bipolarity. Aust N Z J Psychiatry. 2011;45(10):901. doi:10.3109/00048674.2011.589369 [PubMed 21692606]
  19. Bauer M, Pfennig A, Severus E, Whybrow PC, Angst J, Möller HJ; World Federation of Societies of Biological Psychiatry Task Force on Unipolar Depressive Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. Part 1: update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry. 2013;14(5):334-385. doi:10.3109/15622975.2013.804195 [PubMed 23879318]
  20. Bauer M, Severus E, Köhler S, Whybrow PC, Angst J, Möller HJ; WFSBP Task Force on Treatment Guidelines for Unipolar Depressive Disorders. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. Part 2: maintenance treatment of major depressive disorder-update 2015. World J Biol Psychiatry. 2015;16(2):76-95. doi:10.3109/15622975.2014.1001786 [PubMed 25677972]
  21. Benazzi F. Mirtazapine withdrawal symptoms. Can J Psychiatry. 1998;43(5):525. [PubMed 9653542]
  22. Benazzi F. Serotonin syndrome with mirtazapine-fluoxetine combination. Int J Geriatr Psychiatry. 1998;13(7):495-496. doi:10.1002/(sici)1099-1166(199807)13:7<495::aid-gps803>3.0.co;2-i [PubMed 9695042]
  23. Bendtsen L, Jensen R. Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology. 2004;62(10):1706-1711. [PubMed 15159466]
  24. Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J; EFNS. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol. 2010;17(11):1318-1325. doi:10.1111/j.1468-1331.2010.03070.x [PubMed 20482606]
  25. Berigan TR. Mirtazapine-associated withdrawal symptoms: a case report. Prim Care Companion J Clin Psychiatry. 2001;3(3):143. doi:10.4088/pcc.v03n0307a [PubMed 15014614]
  26. Berle JO, Spigset O. Antidepressant use during breastfeeding. Curr Womens Health Rev. 2011;7(1):28-34. [PubMed 22299006]
  27. Berling I, Isbister GK. Mirtazapine overdose is unlikely to cause major toxicity. Clin Toxicol (Phila). 2014;52(1):20-24. doi:10.3109/15563650.2013.859264 [PubMed 24228948]
  28. Bhanji NH, Margolese HC, Saint-Laurent M, Chouinard G. Dysphoric mania induced by high-dose mirtazapine: a case for 'norepinephrine syndrome'?. Int Clin Psychopharmacol. 2002;17(6):319-322. doi:10.1097/00004850-200211000-00009 [PubMed 12409687]
  29. Biswas PN, Wilton LV, Shakir SA. The pharmacovigilance of mirtazapine: results of a prescription event monitoring study on 13554 patients in England. J Psychopharmacol. 2003;17(1):121-126. doi:10.1177/0269881103017001716 [PubMed 12680749]
  30. Boshuisen ML, Slaap BR, Vester-Blokland ED, den Boer JA. The effect of mirtazapine in panic disorder: an open label pilot study with a single-blind placebo run-in period. Int Clin Psychopharmacol. 2001;16(6):363-368. [PubMed 11712626]
  31. Bowers RD, Valanejad SM, Holombo AA. Mirtazapine-induced pancreatitis-a case report. J Pharm Pract. 2019;32(5):586-588. doi:10.1177/0897190018760645 [PubMed 29486665]
  32. Boyarsky BK, Haque W, Rouleau MR, Hirschfeld RM. Sexual functioning in depressed outpatients taking mirtazapine. Depress Anxiety. 1999;9(4):175-179. doi:10.1002/(sici)1520-6394(1999)9:4<175::aid-da5>3.0.co;2-0 [PubMed 10431683]
  33. Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007;356(23):2437] [published correction appears in N Engl J Med. 2009;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867 [PubMed 15784664]
  34. Butler S, Holt C, Agius M, Zaman R. An audit to compare the efficacy of treatment (as indicated by discharge rates and reduction in suicidality) among patients with refractory depression in a Bedfordshire Community Mental Health Team receiving augmentation therapy with either mirtazepine or atypical antipsychotics. Psychiatr Danub. 2011;23 Suppl 1:S171-S174. [PubMed 21894129]
  35. Carli V, Sarchiapone M, Camardese G, Roman L, DeRisio S. Mirtazapine in the treatment of panic disorder. Arch Gen Psychiatry. 2002;59(7):661-662. [PubMed 12090820]
  36. Chen JL, Spinowitz N, Karwa M. Hypertriglyceridemia, acute pancreatitis, and diabetic ketoacidosis possibly associated with mirtazapine therapy: a case report. Pharmacotherapy. 2003;23(7):940-944. doi:10.1592/phco.23.7.940.32725 [PubMed 12885107]
  37. Chiu HW, Li TC. Rapid weight gain during mirtazapine treatment. J Neuropsychiatry Clin Neurosci. 2011;23(1):E7. doi:10.1176/jnp.23.1.jnpe7 [PubMed 21304130]
  38. Civalier KA, Krahn LE, Agrwal N. Repeated episodes of neutropenia triggered by mirtazapine. Psychosomatics. 2009;50(3):299-300. doi:10.1176/appi.psy.50.3.299 [PubMed 19567774]
  39. Cosci F. Withdrawal symptoms after discontinuation of a noradrenergic and specific serotonergic antidepressant: a case report and review of the literature. Personalized Medicine in Psychiatry. 2017;1-2:81-84. doi:10.1016/j.pmip.2016.11.001
  40. Coskun M, Karakoc S, Kircelli F, Mukaddes NM. Effectiveness of mirtazapine in the treatment of inappropriate sexual behaviors in individuals with autistic disorder. J Child Adolesc Psychopharmacol. 2009;19(2):203-206. doi:10.1089/cap.2008.020 [PubMed 19364298]
  41. Coupland C, Hill T, Morriss R, Arthur A, Moore M, Hippisley-Cox J. Antidepressant use and risk of suicide and attempted suicide or self harm in people aged 20 to 64: cohort study using a primary care database. BMJ. 2015;350:h517. doi:10.1136/bmj.h517 [PubMed 25693810]
  42. Decoutere L, De Winter S, Vander Weyden L, et al. A venlafaxine and mirtazapine-induced serotonin syndrome confirmed by de- and re-challenge [published correction appears in Int J Clin Pharm. 2012;34(5):689]. Int J Clin Pharm. 2012;34(5):686-688. doi:10.1007/s11096-012-9666-7 [PubMed 22752315]
  43. De Picker L, Van Den Eede F, Dumont G, Moorkens G, Sabbe BG. Antidepressants and the risk of hyponatremia: a class-by-class review of literature. Psychosomatics. 2014;55(6):536-547. doi:10.1016/j.psym.2014.01.010 [PubMed 25262043]
  44. Dholakia R, Schleifer SJ, Ahmad YJ, Narang IS. Delayed-onset mirtazapine-related leukopenia and rechallenge. J Clin Psychopharmacol. 2010;30(6):758. doi:10.1097/JCP.0b013e3181faa564 [PubMed 21057250]
  45. Djulus J, Koren G, Einarson TR, et al. Exposure to mirtazapine during pregnancy: a prospective, comparative study of birth outcomes. J Clin Psychiatry. 2006;67(8):1280-1284. doi:10.4088/jcp.v67n0817 [PubMed 16965209]
  46. Duncan NA, Clifford KM, Shvarts OM. Mirtazapine-associated hypertriglyceridemia and hyperglycemia. Consult Pharm. 2015;30(11):657-663. doi:10.4140/TCP.n.2015.657 [PubMed 26629801]
  47. Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109 [PubMed 12925718]
  48. Einarson A, Choi J, Einarson TR, et al, "Incidence of Major Malformations in Infants Following Antidepressant Exposure in Pregnancy: Results of a large Prospective Cohort Study," Can J Psychiatry, 2009, 54(4):242-6. [PubMed 19321030]
  49. Expert opinion. Senior Renal Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
  50. Fauchère PA. Recurrent, persisting panic attacks after sudden discontinuation of mirtazapine treatment: a case report. Int J Psychiatry Clin Pract. 2004;8(2):127-129. doi:10.1080/13651500410006134 [PubMed 24926846]
  51. Fava M. Prospective studies of adverse events related to antidepressant discontinuation. J Clin Psychiatry. 2006;67(Suppl 4):14-21. [PubMed 16683858]
  52. Fernandez A, Bang SE, Srivathsan K, Vieweg WV. Cardiovascular side effects of newer antidepressants. Anadolu Kardiyol Derg. 2007;7(3):305-309. [PubMed 17785222]
  53. Flanagan RJ, Dunk L. Haematological toxicity of drugs used in psychiatry. Hum Psychopharmacol. 2008;23 Suppl 1:27-41. doi:10.1002/hup.917 [PubMed 18098216]
  54. Friedman RA, Leon AC. Expanding the black box - depression, antidepressants, and the risk of suicide. N Engl J Med. 2007;356(23):2343-2346. doi:10.1056/NEJMp078015 [PubMed 17485726]
  55. Gandotra K, Chen P, Jaskiw GE, Konicki PE, Strohl KP. Effective treatment of insomnia with mirtazapine attenuates concomitant suicidal ideation. J Clin Sleep Med. 2018;14(5):901-902. doi:10.5664/jcsm.7142 [PubMed 29734995]
  56. Gholyaf M, Sheikh V, Yasrebifar F, Mohammadi Y, Mirjalili M, Mehrpooya M. Effect of mirtazapine on pruritus in patients on hemodialysis: a cross-over pilot study. Int Urol Nephrol. 2020;52(6):1155-1165. doi:10.1007/s11255-020-02473-3 [PubMed 32383050]
  57. Gill H, Gill B, El-Halabi S, et al. Antidepressant medications and weight change: a narrative review. Obesity (Silver Spring). 2020;28(11):2064-2072. doi:10.1002/oby.22969 [PubMed 33022115]
  58. Gill N, Bayes A, Parker G. A review of antidepressant-associated hypomania in those diagnosed with unipolar depression-risk factors, conceptual models, and management. Curr Psychiatry Rep. 2020;22(4):20. doi:10.1007/s11920-020-01143-6 [PubMed 32215771]
  59. Gillman PK. A systematic review of the serotonergic effects of mirtazapine in humans: implications for its dual action status. Hum Psychopharmacol. 2006;21(2):117-125. doi:10.1002/hup.750 [PubMed 16342227]
  60. Gillman PK. Mirtazapine: unable to induce serotonin toxicity? Clin Neuropharmacol. 2003;26(6):288-290. doi:10.1097/00002826-200311000-00003 [PubMed 14646604]
  61. Girishchandra BG, Johnson L, Cresp RM, Orr KG. Mirtazapine-induced akathisia. Med J Aust. 2002;176(5):242. [PubMed 11999246]
  62. Gnanadesigan N, Espinoza RT, Smith R, Israel M, Reuben DB. Interaction of serotonergic antidepressants and opioid analgesics: is serotonin syndrome going undetected? J Am Med Dir Assoc. 2005;6(4):265-269. doi:10.1016/j.jamda.2005.04.012 [PubMed 16005413]
  63. Gorman JM. Mirtazapine: clinical overview. J Clin Psychiatry. 1999;60 Suppl 17:9-48. [PubMed 10446735]
  64. Gregorian RS, Golden KA, Bahce A, Goodman C, Kwong WJ, Khan ZM. Antidepressant-induced sexual dysfunction. Ann Pharmacother. 2002;36(10):1577-1589. doi:10.1345/aph.1A195 [PubMed 12243609]
  65. Grunze H, Vieta E, Goodwin GM, et al; Members of the WFSBP Task Force on Bipolar Affective Disorders working on this topic. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: Acute and long-term treatment of mixed states in bipolar disorder. World J Biol Psychiatry. 2018;19(1):2-58. doi:10.1080/15622975.2017.1384850 [PubMed 29098925]
  66. Gulsun M, Doruk A. Mirtazapine-induced akathisia. J Clin Psychopharmacol. 2008;28(4):467. doi:10.1097/JCP.0b013e31817ed22c [PubMed 18626283]
  67. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry. 2006;63(3):332-339. doi:10.1001/archpsyc.63.3.332 [PubMed 16520440]
  68. Hatzidaki E, Toutoudaki M, Christaki, et al. A non-fatal suicide attempt of a pregnant woman using mirtazapine and venlafaxine. Toxicol Lett. 2008;180(suppl):S141-S142.
  69. Hennings JM, Heel S, Lechner K, et al. Effect of mirtazapine on metabolism and energy substrate partitioning in healthy men. JCI Insight. 2019;4(1):e123786. doi:10.1172/jci.insight.123786 [PubMed 30626746]
  70. Hernández JL, Ramos FJ, Infante J, Rebollo M, González-Macías J. Severe serotonin syndrome induced by mirtazapine monotherapy. Ann Pharmacother. 2002;36(4):641-643. doi:10.1345/aph.1A302 [PubMed 11918514]
  71. Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN. Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database Syst Rev. 2012;11:CD004851. doi:10.1002/14651858.CD004851.pub3 [PubMed 23152227]
  72. Himmerich H, Fulda S, Schaaf L, Beitinger PA, Schuld A, Pollmächer T. Changes in weight and glucose tolerance during treatment with mirtazapine. Diabetes Care. 2006;29(1):170. doi:10.2337/diacare.29.1.170 [PubMed 16373922]
  73. Hirsch M, Birnbaum RJ. Discontinuing antidepressant medications in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed June 28, 2021a.
  74. Hirsch M, Birnbaum RJ. Switching antidepressant medications in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed March 9, 2021b.
  75. Houlihan DJ. Serotonin syndrome resulting from coadministration of tramadol, venlafaxine, and mirtazapine. Ann Pharmacother. 2004;38(3):411-413. doi:10.1345/aph.1D344 [PubMed 14970364]
  76. Hui CK, Yuen MF, Wong WM, Lam SK, Lai CL. Mirtazapine-induced hepatotoxicity. J Clin Gastroenterol. 2002;35(3):270-271. doi:10.1097/00004836-200209000-00014 [PubMed 12192206]
  77. Hutchins D, Hall J, Sharma A. Mirtazapine-induced transient dyskinesia. Prim Care Companion CNS Disord. 2019;21(2):18l02377. doi:10.4088/PCC.18l02377 [PubMed 30985094]
  78. Hutchison LC. Mirtazapine and bone marrow suppression: a case report. J Am Geriatr Soc. 2001;49(8):1129-1130. doi:10.1046/j.1532-5415.2001.49224.x [PubMed 11555082]
  79. Isbister GK, Whyte IM. Adverse reactions to mirtazapine are unlikely to be serotonin toxicity. Clin Neuropharmacol. 2003;26(6):287-290. doi:10.1097/00002826-200311000-00002 [PubMed 14646603]
  80. Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343(2):118-126. [PubMed 10891521]
  81. Iwamoto K, Kawano N, Sasada K, et al. Effects of low-dose mirtazapine on driving performance in healthy volunteers. Hum Psychopharmacol. 2013;28(5):523-528. doi:10.1002/hup.2327 [PubMed 23813948]
  82. Jing E, Straw-Wilson K. Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review. Ment Health Clin. 2016;6(4):191-196. doi:10.9740/mhc.2016.07.191 [PubMed 29955469]
  83. Karsten J, Hagenauw LA, Kamphuis J, Lancel M. Low doses of mirtazapine or quetiapine for transient insomnia: a randomised, double-blind, cross-over, placebo-controlled trial. J Psychopharmacol. 2017;31(3):327-337. doi:10.1177/0269881116681399 [PubMed 28093029]
  84. Kasper S, Montgomery SA, Möller HJ, et al. Longitudinal analysis of the suicidal behaviour risk in short-term placebo-controlled studies of mirtazapine in major depressive disorder. World J Biol Psychiatry. 2010;11(1):36-44. doi:10.3109/15622970701691503 [PubMed 20146649]
  85. Kasper S, Praschak-Rieder N, Tauscher J, Wolf R. A risk-benefit assessment of mirtazapine in the treatment of depression [published correction appears in Drug Saf. 1998;18(2):123]. Drug Saf. 1997;17(4):251-264. doi:10.2165/00002018-199717040-00005 [PubMed 9352961]
  86. Katzman MA, Bleau P, Blier P, et al; Canadian Anxiety Guidelines Initiative Group. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(suppl 1):S1. doi:10.1186/1471-244X-14-S1-S1 [PubMed 25081580]
  87. Keshtkarjahromi M, Mariscal J, Dempsey K, Tonarelli S. Treatment of severe excoriation disorder with mirtazapine: a case report. Clin Neuropharmacol. 2021;44(5):189-190. doi:10.1097/WNF.0000000000000467 [PubMed 34326284]
  88. Khan A, Khan S, Kolts R, Brown WA. Suicide rates in clinical trials of SSRIs, other antidepressants, and placebo: analysis of FDA reports. Am J Psychiatry. 2003;160(4):790-792. doi:10.1176/appi.ajp.160.4.790 [PubMed 12668373]
  89. Khandat AB, Nurnberger JI Jr, Shekhar A. Possible mirtazapine-induced rhabdomyolysis. Ann Pharmacother. 2004;38(7-8):1321. doi:10.1345/aph.1D487 [PubMed 15187213]
  90. Khawaja IS, Feinstein RE. Cardiovascular effects of selective serotonin reuptake inhibitors and other novel antidepressants. Heart Dis. 2003;5(2):153-160. doi:10.1097/01.hdx.0000061695.97215.64 [PubMed 12713682]
  91. Kim SW, Shin IS, Kim JM, Park KH, Youn T, Yoon JS. Factors potentiating the risk of mirtazapine-associated restless legs syndrome. Hum Psychopharmacol. 2008;23(7):615-620. doi:10.1002/hup.965 [PubMed 18756499]
  92. Klier CM, Mossaheb N, Lee A, et al, "Mirtazapine and Breastfeeding: Maternal and Infant Plasma Levels," Am J Psychiatry, 2007, 164(2):348-9. [PubMed 17267804]
  93. Kolla BP, Mansukhani MP, Bostwick JM. The influence of antidepressants on restless legs syndrome and periodic limb movements: a systematic review. Sleep Med Rev. 2018;38:131-140. doi:10.1016/j.smrv.2017.06.002 [PubMed 28822709]
  94. Konitsiotis S, Pappa S, Mantas C, Mavreas V. Acute reversible dyskinesia induced by mirtazapine. Mov Disord. 2005;20(6):771. doi:10.1002/mds.20432 [PubMed 15732128]
  95. Kraus T, Haack M, Schuld A, Hinze-Selch D, Koethe D, Pollmächer T. Body weight, the tumor necrosis factor system, and leptin production during treatment with mirtazapine or venlafaxine. Pharmacopsychiatry. 2002;35(6):220-225. doi:10.1055/s-2002-36390 [PubMed 12518269]
  96. Kristensen JH, Ilett KF, Rampono J, et al, "Transfer of the Antidepressant Mirtazapine Into Breast Milk," Br J Clin Pharmacol, 2007, 63(3):322-7. [PubMed 16970569]
  97. Laimer M, Kramer-Reinstadler K, Rauchenzauner M, et al. Effect of mirtazapine treatment on body composition and metabolism. J Clin Psychiatry. 2006;67(3):421-424. doi:10.4088/jcp.v67n0313 [PubMed 16649829]
  98. Larsen ER, Damkier P, Pedersen LH, et al. Use of psychotropic drugs during pregnancy and breast-feeding. Acta Psychiatr Scand Suppl. 2015;(445):1-28. [PubMed 26344706]
  99. Leach MJ, Pratt NL, Roughead EE. The risk of hip fracture due to mirtazapine exposure when switching antidepressants or using other antidepressants as add-on therapy. Drugs Real World Outcomes. 2017;4(4):247-255. doi:10.1007/s40801-017-0120-y [PubMed 28940138]
  100. Lee KU, Lee YM, Nam JM, et al. Antidepressant-induced sexual dysfunction among newer antidepressants in a naturalistic setting. Psychiatry Investig. 2010;7(1):55-59. doi:10.4306/pi.2010.7.1.55 [PubMed 20396434]
  101. Leon AC. The revised warning for antidepressants and suicidality: unveiling the black box of statistical analyses. Am J Psychiatry. 2007;164(12):1786-1789. doi:10.1176/appi.ajp.2007.07050775 [PubMed 18056231]
  102. Lennestål R and Källén B, "Delivery Outcome in Relation to Maternal Use of Some Recently Introduced Antidepressants," J Clin Psychopharmacol, 2007, 27(6):607-13. [PubMed 18004128]
  103. Liu X, Sahud MA. Glycoprotein IIb/IIIa complex is the target in mirtazapine-induced immune thrombocytopenia. Blood Cells Mol Dis. 2003;30(3):241-245. doi:10.1016/s1079-9796(03)00037-8 [PubMed 12737939]
  104. MacCall C, Callender J. Mirtazapine withdrawal causing hypomania. Br J Psychiatry. 1999;175:390. doi:10.1192/bjp.175.4.390a [PubMed 10789310]
  105. MacQueen GM, Frey BN, Ismail Z, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 6. special populations: youth, women, and the elderly. Can J Psychiatry. 2016;61(9):588-603. [PubMed 27486149]
  106. Maidwell-Smith A, Kirk C. Mirtazapine-induced neutropenic sepsis in an older person: a case report. J Med Case Rep. 2023;17(1):163. doi:10.1186/s13256-023-03881-6 [PubMed 37055872]
  107. Makiguchi A, Nishida M, Shioda K, Suda S, Nisijima K, Kato S. Mirtazapine-induced restless legs syndrome treated with pramipexole. J Neuropsychiatry Clin Neurosci. 2015;27(1):e76. doi:10.1176/appi.neuropsych.13120357 [PubMed 25716506]
  108. Markoula S, Konitsiotis S, Chatzistefanidis D, Lagos G, Kyritsis AP. Akathisia induced by mirtazapine after 20 years of continuous treatment. Clin Neuropharmacol. 2010;33(1):50-51. doi:10.1097/WNF.0b013e3181bf213b [PubMed 20124786]
  109. Martin A, Young C, Leckman JF, Mukonoweshuro C, Rosenheck R, Leslie D. Age effects on antidepressant-induced manic conversion. Arch Pediatr Adolesc Med. 2004;158(8):773-780. doi:10.1001/archpedi.158.8.773 [PubMed 15289250]
  110. Mason PJ, Morris VA, Balcezak TJ. Serotonin syndrome. Presentation of 2 cases and review of the literature. Medicine (Baltimore). 2000;79(4):201-209. doi:10.1097/00005792-200007000-00001 [PubMed 10941349]
  111. Matsuda Y, Furukawa Y, Yamazaki R, et al. Mirtazapine-induced long QT syndrome in an elderly patient: a case report. Psychogeriatrics. 2020;20(4):536-537. doi:10.1111/psyg.12520 [PubMed 31975466]
  112. Mauri MC, Fiorentini A, Paletta S, Altamura AC. Pharmacokinetics of antidepressants in patients with hepatic impairment. Clin Pharmacokinet. 2014;53(12):1069-1081. doi:10.1007/s40262-014-0187-5 [PubMed 25248846]
  113. Mehrpooya M, Gholyaf M, Yasrebifar F, Mohammadi Y, Sheikh V. Evaluation of efficacy of mirtazapine on pruritus and serum histamine and serotonin levels in patients undergoing hemodialysis: a before-after pilot clinical trial. Int J Nephrol Renovasc Dis. 2020;13:129-138. doi:10.2147/IJNRD.S246393 [PubMed 32547158]
  114. Menon V, Madhavapuri P. Low-dose mirtazapine-induced nightmares necessitating its discontinuation in a young adult female. J Pharmacol Pharmacother. 2017;8(4):182-184. doi:10.4103/jpp.JPP_116_17 [PubMed 29472752]
  115. Mirtazapine tablets [prescribing information]. Weston, FL: Apotex Corp; June 2023.
  116. Montañés-Rada F, De Lucas-Taracena MT, Sánchez-Romero S. Mirtazapine versus paroxetine in panic disorder: an open study. Int J Psychiatry Clin Pract. 2005;9(2):87-93. doi:10.1080/13651500510018248 [PubMed 24930788]
  117. Mullish BH, Kabir MS, Thursz MR, Dhar A. Review article: depression and the use of antidepressants in patients with chronic liver disease or liver transplantation. Aliment Pharmacol Ther. 2014;40(8):880-892. doi:10.1111/apt.12925 [PubMed 25175904]
  118. Nagler EV, Webster AC, Vanholder R, Zoccali C. Antidepressants for depression in stage 3-5 chronic kidney disease: a systematic review of pharmacokinetics, efficacy and safety with recommendations by European Renal Best Practice (ERBP). Nephrol Dial Transplant. 2012;27(10):3736-3745. doi:10.1093/ndt/gfs295 [PubMed 22859791]
  119. Nelson JC, Devanand DP. A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia. J Am Geriatr Soc. 2011;59(4):577-585. [PubMed 21453380]
  120. Nicholas LM, Ford AL, Esposito SM, Ekstrom RD, Golden RN. The effects of mirtazapine on plasma lipid profiles in healthy subjects. J Clin Psychiatry. 2003;64(8):883-889. doi:10.4088/jcp.v64n0805 [PubMed 12927002]
  121. Novak KJ, Douglas WI, Kuhn RJ. Hypotension following cardiac surgery associated with paroxetine and mirtazapine withdrawal. J Pediatr Pharmacol Ther. 2008;13(1):25-28. doi:10.5863/1551-6776-13.1.25 [PubMed 23055861]
  122. Nutt D. Mirtazapine: pharmacology in relation to adverse effects. Acta Psychiatr Scand Suppl. 1997;391:31-37. doi:10.1111/j.1600-0447.1997.tb05956.x [PubMed 9265949]
  123. Nutt DJ. Tolerability and safety aspects of mirtazapine. Hum Psychopharmacol. 2002;17 Suppl 1:S37-S41. doi:10.1002/hup.388 [PubMed 12404669]
  124. Ogle NR, Akkerman SR. Guidance for the discontinuation or switching of antidepressant therapies in adults. J Pharm Pract. 2013;26(4):389-396. doi:10.1177/0897190012467210 [PubMed 23459282]
  125. Papakostas GI, Perlis RH, Scalia MJ, Petersen TJ, Fava M. A meta-analysis of early sustained response rates between antidepressants and placebo for the treatment of major depressive disorder. J Clin Psychopharmacol. 2006;26(1):56-60. doi:10.1097/01.jcp.0000195042.62724.76 [PubMed 16415707]
  126. Papazisis G, Siafis S, Tzachanis D. Tachyphylaxis to the sedative action of mirtazapine. Am J Case Rep. 2018;19:410-412. doi:10.12659/ajcr.908412 [PubMed 29626184]
  127. Patel R, Reiss P, Shetty H, et al. Do antidepressants increase the risk of mania and bipolar disorder in people with depression? A retrospective electronic case register cohort study. BMJ Open. 2015;5(12):e008341. doi:10.1136/bmjopen-2015-008341 [PubMed 26667012]
  128. Pombo R, Johnson E, Gamboa A, Omalu B. Autopsy-proven mirtazapine withdrawal-induced mania/hypomania associated with sudden death. J Pharmacol Pharmacother. 2017;8(4):185-187. doi:10.4103/jpp.JPP_162_16 [PubMed 29472753]
  129. Posternak MA, Zimmerman M. Is there a delay in the antidepressant effect? A meta-analysis. J Clin Psychiatry. 2005;66(2):148-158. doi:10.4088/jcp.v66n0201 [PubMed 15704999]
  130. Poyurovsky M, Pashinian A, Weizman R, Fuchs C, Weizman A. Low-dose mirtazapine: a new option in the treatment of antipsychotic-induced akathisia. A randomized, double-blind, placebo- and propranolol-controlled trial. Biol Psychiatry. 2006;59(11):1071-1077. doi:10.1016/j.biopsych.2005.12.007 [PubMed 16497273]
  131. Praharaj SK, Kongasseri S, Behere RV, Sharma PS. Mirtazapine for antipsychotic-induced acute akathisia: a systematic review and meta-analysis of randomized placebo-controlled trials. Ther Adv Psychopharmacol. 2015;5(5):307-313. doi:10.1177/2045125315601343 [PubMed 26557987]
  132. Rabenda V, Nicolet D, Beaudart C, et al. Relationship between use of antidepressants and risk of fractures: a meta-analysis. Osteoporos Int. 2013;24(1):121-137. [PubMed 22638709]
  133. Radhakishun FS, van den Bos J, van der Heijden BC, Roes KC, O'Hanlon JF. Mirtazapine effects on alertness and sleep in patients as recorded by interactive telecommunication during treatment with different dosing regimens. J Clin Psychopharmacol. 2000;20(5):531-537. doi:10.1097/00004714-200010000-00006 [PubMed 11001237]
  134. Raymond CB, Wazny LD, Honcharik PL. Pharmacotherapeutic options for the treatment of depression in patients with chronic kidney disease. Nephrol Nurs J. 2008;35(3):257-263. [PubMed 18649586]
  135. Raveendranathan D, Swaminath GR. Mirtazapine induced akathisia: understanding a complex mechanism. Indian J Psychol Med. 2015;37(4):474-475. doi:10.4103/0253-7176.168615 [PubMed 26702190]
  136. Reeves RR, Ladner ME. Antidepressant-induced suicidality: an update. CNS Neurosci Ther. 2010;16(4):227-234. doi:10.1111/j.1755-5949.2010.00160.x [PubMed 20553304]
  137. Refer to the manufacturer's labeling.
  138. Remeron (mirtazapine) [prescribing information]. Jersey City, NJ: Organon USA LLC; June 2021.
  139. Remeron (mirtazapine) [prescribing information]. Whitehouse Station, NJ: Merck & Co Inc; November 2021.
  140. Remeron SolTab (mirtazapine) [prescribing information]. Whitehouse Station, NJ: Merck & Co Inc; November 2021.
  141. Revet A, Montastruc F, Roussin A, Raynaud JP, Lapeyre-Mestre M, Nguyen TTH. Antidepressants and movement disorders: a postmarketing study in the world pharmacovigilance database. BMC Psychiatry. 2020;20(1):308. doi:10.1186/s12888-020-02711-z [PubMed 32546134]
  142. Ribeiro L, Busnello JV, Kauer-Sant'Anna M, et al. Mirtazapine versus fluoxetine in the treatment of panic disorder. Braz J Med Biol Res. 2001;34(10):1303-1307. [PubMed 11593305]
  143. Rizzoli R, Cooper C, Reginster JY, et al. Antidepressant medications and osteoporosis. Bone. 2012;51(3):606-613. [PubMed 22659406]
  144. Sachs HC, Committee on Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3):e796-809. [PubMed 23979084]
  145. Salvi V, Mencacci C, Barone-Adesi F. H1-histamine receptor affinity predicts weight gain with antidepressants. Eur Neuropsychopharmacol. 2016;26(10):1673-1677. doi:10.1016/j.euroneuro.2016.08.012 [PubMed 27593622]
  146. Sarchiapone M, Amore M, De Risio S, et al. Mirtazapine in the treatment of panic disorder: an open-label trial. Int Clin Psychopharmacol. 2003;18(1):35-38. [PubMed 12490773]
  147. Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol. 2009;29(3):259-266. doi:10.1097/JCP.0b013e3181a5233f [PubMed 19440080]
  148. Serretti A, Mandelli L. Antidepressants and body weight: a comprehensive review and meta-analysis. J Clin Psychiatry. 2010;71(10):1259-1272. doi:10.4088/JCP.09r05346blu [PubMed 21062615]
  149. Shelton RC. Steps following attainment of remission: discontinuation of antidepressant therapy. Prim Care Companion J Clin Psychiatry. 2001;3(4):168-174. [PubMed 15014601]
  150. Shinith D, Mathilakath A, Kim DI, Patel B. Sleep-related eating disorder with mirtazapine. BMJ Case Rep. 2018;2018:bcr2018224676. doi:10.1136/bcr-2018-224676 [PubMed 30344142]
  151. Smit M, Wennink H, Heres M, Dolman KM, Honig A. Mirtazapine in pregnancy and lactation: data from a case series. Clin Psychopharmacol. 2015;35(2):163-167. [PubMed 25689290]
  152. Soutullo CA, McElroy SL, Keck PE Jr. Hypomania associated with mirtazapine augmentation of sertraline. J Clin Psychiatry. 1998;59(6):320. doi:10.4088/jcp.v59n0608e [PubMed 9671349]
  153. Spitznogle B, Gerfin F. Pruritus associated with abrupt mirtazapine discontinuation: single case report. Ment Health Clin. 2019;9(6):401-403. doi:10.9740/mhc.2019.11.401 [PubMed 31824812]
  154. Sriraman NK, Melvin K, Meltzer-Brody S. ABM clinical protocol #18: use of antidepressants in breastfeeding mothers. Breastfeed Med. 2015;10(6):290-299. [PubMed 26204124]
  155. Stuhec M, Alisky J, Malesic I. Mirtazapine associated with drug-related thrombocytopenia: a case report. J Clin Psychopharmacol. 2014;34(5):662-664. doi:10.1097/JCP.0000000000000201 [PubMed 25118079]
  156. Sukhdeo K, Yoon GH, Rothman L, Meehan SA, Levin MK, Kim RH. Mirtazapine-induced hyperpigmentation with type II histopathologic findings. JAAD Case Rep. 2018;4(10):1077-1079. doi:10.1016/j.jdcr.2018.09.022 [PubMed 30511003]
  157. Sun-Edelstein C, Tepper SJ, Shapiro RE. Drug-induced serotonin syndrome: a review. Expert Opin Drug Saf. 2008;7(5):587-596. doi:10.1517/14740338.7.5.587 [PubMed 18759711]
  158. Szegedi A, Jansen WT, van Willigenburg AP, van der Meulen E, Stassen HH, Thase ME. Early improvement in the first 2 weeks as a predictor of treatment outcome in patients with major depressive disorder: a meta-analysis including 6562 patients. J Clin Psychiatry. 2009;70(3):344-353. doi:10.4088/jcp.07m03780 [PubMed 19254516]
  159. Terevnikov V, Stenberg JH, Tiihonen J, et al. Relationships between pharmacotherapy-induced metabolic changes and improved psychopathology in schizophrenia: data from a mirtazapine and first-generation antipsychotics combination trial. Int J Neuropsychopharmacol. 2013;16(7):1661-1666. doi:10.1017/S146114571200137X [PubMed 23217660]
  160. Thomas E, Haboubi H, Williams N, Lloyd A, Ch'ng CL. Mirtazapine-induced steatosis. Int J Clin Pharmacol Ther. 2017;55(7):630-632. doi:10.5414/CP202983 [PubMed 28427497]
  161. Tondo L, Vázquez G, Baldessarini RJ. Mania associated with antidepressant treatment: comprehensive meta-analytic review. Acta Psychiatr Scand. 2010;121(6):404-414. doi:10.1111/j.1600-0447.2009.01514.x [PubMed 19958306]
  162. Tonn P, Reuter SC, Hiemke C, et al, "High Mirtazapine Plasma Levels in Infant After Breast Feeding: Case Report and Review of the Literature," J Clin Psychopharmacol, 2009, 29(2):191-2. [PubMed 19512989]
  163. Turkel SB, Nadala JG, Wincor MZ. Possible serotonin syndrome in association with 5-HT(3) antagonist agents. Psychosomatics. 2001;42(3):258-260. doi:10.1176/appi.psy.42.3.258 [PubMed 11351116]
  164. Ubogu EE, Katirji B. Mirtazapine-induced serotonin syndrome. Clin Neuropharmacol. 2003;26(2):54-57. doi:10.1097/00002826-200303000-00002 [PubMed 12671522]
  165. Uguz F, Sahingoz M, Gungor B, Aksoy F, Askin R. Weight gain and associated factors in patients using newer antidepressant drugs. Gen Hosp Psychiatry. 2015;37(1):46-48. doi:10.1016/j.genhosppsych.2014.10.011 [PubMed 25467076]
  166. US Department of Veterans Affairs/Department of Defense (VA/DoD). VA/DoD clinical practice guideline for the management of major depressive disorder. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf. Updated February 2022. Accessed June 15, 2022.
  167. van Geffen EC, Hugtenburg JG, Heerdink ER, van Hulten RP, Egberts AC. Discontinuation symptoms in users of selective serotonin reuptake inhibitors in clinical practice: tapering versus abrupt discontinuation. Eur J Clin Pharmacol. 2005;61(4):303-307. doi:10.1007/s00228-005-0921-x [PubMed 15906018]
  168. Vayne C, Guéry EA, Rollin J, Baglo T, Petermann R, Gruel Y. Pathophysiology and diagnosis of drug-induced immune thrombocytopenia. J Clin Med. 2020;9(7):2212. doi:10.3390/jcm9072212 [PubMed 32668640]
  169. Verma JK, Mohapatra S. Mirtazapine withdrawal-induced mania. J Pharmacol Pharmacother. 2015;6(4):214-215. doi:10.4103/0976-500X.171878 [PubMed 26816474]
  170. Waldinger MD. Psychiatric disorders and sexual dysfunction. Handb Clin Neurol. 2015;130:469-489. doi:10.1016/B978-0-444-63247-0.00027-4 [PubMed 26003261]
  171. Watanabe N, Omori IM, Nakagawa A, et al. Mirtazapine versus other antidepressive agents for depression. Cochrane Database Syst Rev. 2011;(12):CD006528. doi: 10.1002/14651858.CD006528.pub2. [PubMed 22161405]
  172. Wichniak A, Jarkiewicz M, Okruszek Ł, Wierzbicka A, Holka-Pokorska J, Rybakowski JK. Low risk for switch to mania during treatment with sleep promoting antidepressants. Pharmacopsychiatry. 2015;48(3):83-88. doi:10.1055/s-0034-1396802 [PubMed 25599460]
  173. Williams AJ, Lai Z, Knight S, Kamali M, Assari S, McInnis MG. Risk factors associated with antidepressant exposure and history of antidepressant-induced mania in bipolar disorder. J Clin Psychiatry. 2018;79(3):17m11765. doi:10.4088/JCP.17m11765 [PubMed 29873955]
  174. Wu CS, Tong SH, Ong CT, Sung SF. Serotonin syndrome induced by combined use of mirtazapine and olanzapine complicated with rhabdomyolysis, acute renal failure, and acute pulmonary edema-a case report. Acta Neurol Taiwan. 2015;24(4):117-121. [PubMed 27333965]
  175. Yamada Y, Takano H, Yamada M, et al. Pisa syndrome associated with mirtazapine: a case report. BMC Pharmacol Toxicol. 2018;19(1):82. doi:10.1186/s40360-018-0272-8 [PubMed 30522528]
  176. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018;20(2):97-170. doi:10.1111/bdi.12609 [PubMed 29536616]
  177. Yeh YW, Chen CH, Feng HM, Wang SC, Kuo SC, Chen CK. New onset somnambulism associated with different dosage of mirtazapine: a case report. Clin Neuropharmacol. 2009;32(4):232-233. doi:10.1097/WNF.0b013e318187bafc [PubMed 19644232]
  178. Yonkers KA, Wisner KL, Stewart DE, et al, “The Management of Depression During Pregnancy: A Report From the American Psychiatric Association and the American College of Obstetricians and Gynecologists,” Obstet Gynecol, 2009, 114(3):703-13. [PubMed 19701065]
  179. Yoon WT. Hyperkinetic movement disorders induced by mirtazapine: unusual care report and clinical analysis of reported cases. J Psychiatry. 2018;21(2):437. doi:10.4172/2378-5756.1000437
Topic 9656 Version 563.0

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟