![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by mtom on January 4, 2019, at 18:03:48
After 10 weeks of low dose Citalopram, I was switched to Escitalopram due to continuation of intense side effects (including agitation and anxiety). The same occurred to a lesser degree with Escitalopram, but have not completely resolved after 3 months (I started very low dose and titrated up gradually to 7.5 mg as of about 8 weeks ago). Also poor sleep with vivid dreams and muscle aches. And there has been at best very minor improvement in depressive symptoms. I have not titrated up further because of the side effects, and I am a very small person anyway.
My Doctor is thinking of augmenting with low dose mirtazapine. Weight gain is not a concern as I had already lost weight before starting escitalopram, and it has decreased my appetite further. However other side effects are a concern, including sedation and possible increased anxiety which I read is common at least initially. I am hypersensitive to AD side effects.
Can anyone share experiences with low dose mirtazapine augmentation to escitalopram or other ssri?
By the way, for those who are familiar with Pharmacogenetic testing, my P450 CYP2D6 alleles make me an "intermediate metabolizer" of medications metabolized by this enzyme. Escitalopram is thought to be mostly metabolized by other enzymes, although some research does say CYP2D6 is involved. CYP2D6 is definitely involved in Mirtazapine metabolism (along with other enzymes my Genetic report did not include analysis of).
Posted by linkadge on January 4, 2019, at 18:27:30
In reply to Mirtazapine (remeron) as SSRI add-on therapy?, posted by mtom on January 4, 2019, at 18:03:48
Hey,
Given what you describe, I would say that mirtazapine is a reasonable choice to augment.
I currently take 7.5mg of mirtazapine and 37.5mg of venlafaxine. It is very good for sleep (seemingly for long term) and helps with anxiety as well.
You may get away with less escitalopram if mirtazapine helps. Usually lower doses under 7.5mg are more sedating than higher doses.
Linkadge
Posted by mtom on January 5, 2019, at 12:00:15
In reply to Re: Mirtazapine (remeron) as SSRI add-on therapy?, posted by linkadge on January 4, 2019, at 18:27:30
Why would lower dosages of Mirtazapine be more sedating than higher dosages? Could it be that at lower dosages the anti-histamine effects counteract the norepinehprine/noradrenaline effects?
> Hey,
>
> Given what you describe, I would say that mirtazapine is a reasonable choice to augment.
>
> I currently take 7.5mg of mirtazapine and 37.5mg of venlafaxine. It is very good for sleep (seemingly for long term) and helps with anxiety as well.
>
> You may get away with less escitalopram if mirtazapine helps. Usually lower doses under 7.5mg are more sedating than higher doses.
>
> Linkadge
Posted by Christ_empowered on January 5, 2019, at 13:08:16
In reply to Re: Mirtazapine (remeron) as SSRI add-on therapy?, posted by mtom on January 5, 2019, at 12:00:15
I think its kind of the same deal as seroquel...until the dose hits a couple 100mgs, seroquel is a densely sedating antihistamine. hit the "therapeutic dose" (not a doctor, I cannot tell you what that is...), seroquel becomes a mix of a D2 agonist and NE reuptake inhibitor, etc.
with remeron...the low doses are very sedating and excellent for hay fever. :-) as the dose goes higher, the sedation level goes down and I think the weight gain effect goes down somewhat, too....European shrinks routinely use 60mgs, even 90mgs/daily, sometimes as monotherapy. meanwhile...
I don't know if its marketing or other factors, but it seems that US doctors keep the doses lower and use it w/ other psych drugs, and the weight gain and sedation are viewed as + for some groups of people/patients.
Posted by linkadge on January 5, 2019, at 18:58:12
In reply to Re: Mirtazapine (remeron) as SSRI add-on therapy?, posted by mtom on January 5, 2019, at 12:00:15
>Why would lower dosages of Mirtazapine be more
>sedating than higher dosages?Yeah, just to mirror what ChristEmpowered said...
Basically, any drug has varying 'affinity' for a variety of receptors. Affinity is how strongly the drug likes to bind to one receptor relative to a different type.Mirtazapine has very strong affinity for H1 (blocks histamine receptors which causes sedation), next to that, it binds to serotonin receptors (5-ht2a,2c and 5-ht3 which can relieve some of the side effects of SSRIs like anxiety, sexual dysfunction, insomnia etc). After that, it binds to NE receptors, where it causes norepinephrine release.
Think of it like filling a champaigne glass. You pour the wine into the first glass. Once that glass gets filled it pours over into the next glass and so on and so forth.
Mirtazapine will preferentially bind to histamine receptors. However, as more and more histamine receptors get blocked with higher doses (i.e. receptor saturation), more drug will float around more and bind to its secondary target.
So, in low doses, it mostly fills histamine receptors causing sedation. In higher doses, you get the norepinephrine binding, which counteracts the antihistamine effect.
I found 0-7.5mg very sedating. I found 15mg a little less so sedating and 30mg almost 'neutral' although there is still some wonkiness untill the receptors get more balanced out.
Linkadge
Posted by bleauberry on January 14, 2019, at 10:06:14
In reply to Mirtazapine (remeron) as SSRI add-on therapy?, posted by mtom on January 4, 2019, at 18:03:48
I hate SSRIs. Especially the trendy ones like these. Why do I hate them? Because of stories like yours, which are way to frequent. It's not fair to take depressed patients like you and put them through the hell they put you through.
10 weeks? Ok I understand the dose is low. But 10 weeks is plenty of time. You should be a lot better than you are, even at a low dose. Keep in mind, I had a doctor who had people in remission on 1mg Lexapro or 5mg Lexapro - lower than the lowest starting dose! A lot of doctors really just have no idea what they are doing and just go by whatever the drug companies tell them. Real doctors do exist, and they know better ways to manage these meds.
What will low dose remeron do for you? I will make a prediction. It will make you sleep better, it will add a lot of weight to your body, and it will not do anything for your depression, and the sleepy part will wear off in a few months. I feel pretty confident with all that. Seen it too many times.
What you really want to go with that Lexapro, if you are going to stay with it, is Ritalin or Adderall. I strongly favor Ritalin. Even though it is a stimulant, it is calming after it kicks in in a few weeks, rapid mood lift, rapid energy lift, rapid hobby boost, rapid re-interest in life again, and you may get the best sleep of your life on it. It is a stimulant. It is used for ADHD. I bet if you take an ADHD test - ask your doc for it - I bet you score poorly on it. People with ADHD who take Ritalin experience mood lift and calm, generally speaking. To be fair, it can go wrong also and make things worse. But Lexapro or Remeron are much more likely to do that than Ritalin.
There are clinical studies on senior citizens that show Ritalin is a great antidepressant for them due to fast action and low side effects - the opposite of antidepressants which are slow action, often never-action, and high side effects. But you don't have to be a senior citizen.
I guess you can get the hint at this point that I really do not like what your doctor is doing to you. There are much better and faster ways to restore you to the person you were. I can tell you with almost 100% certainty that the journey you are on now is not likely to restore you to the person you once were.
Long story short - ditch the Remeron idea, and think about ditching the Lexapro idea, and just pause and rethink the whole thing. Or get a second opinion. See if you can find someone in your area called an LLMD - Lyme Literate Medical Doctor. Every state has about a half dozen of these experts. I just know from experience that those guys are way better at diagnosing psychiatric stuff, and especially way, way better at treating it, than psychiatrists or family doctors are. You can save yourself years of suffering, possibly decades of suffering, by finding an LLMD to take over your psychiatric care.
At the very least, get a second or third opinion. Your doctor's approach sounds too inexperienced, too conservative, and likely a misdiagnosis stirred up in it. (like maybe it's ADHD or Lyme instead) Heck, I have even seen major depression cured by simply going gluten free!
There aren't too many meds that are going to have serious drug-drug reactions. The ones that do are usually in the CYP-3A4 department, not the P450 department. Like the antibiotic Rifampin, for example, which will cut the blood level of either Viagra or Doxycycline in half! In half! In your case, I don't see any issues there that would be significant enough to impact therapeutic results.
Rethink. Pause. Rethink.
> After 10 weeks of low dose Citalopram, I was switched to Escitalopram due to continuation of intense side effects (including agitation and anxiety). The same occurred to a lesser degree with Escitalopram, but have not completely resolved after 3 months (I started very low dose and titrated up gradually to 7.5 mg as of about 8 weeks ago). Also poor sleep with vivid dreams and muscle aches. And there has been at best very minor improvement in depressive symptoms. I have not titrated up further because of the side effects, and I am a very small person anyway.
>
> My Doctor is thinking of augmenting with low dose mirtazapine. Weight gain is not a concern as I had already lost weight before starting escitalopram, and it has decreased my appetite further. However other side effects are a concern, including sedation and possible increased anxiety which I read is common at least initially. I am hypersensitive to AD side effects.
>
> Can anyone share experiences with low dose mirtazapine augmentation to escitalopram or other ssri?
>
> By the way, for those who are familiar with Pharmacogenetic testing, my P450 CYP2D6 alleles make me an "intermediate metabolizer" of medications metabolized by this enzyme. Escitalopram is thought to be mostly metabolized by other enzymes, although some research does say CYP2D6 is involved. CYP2D6 is definitely involved in Mirtazapine metabolism (along with other enzymes my Genetic report did not include analysis of).
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.