From the Guidelines
Yes, a patient with glaucoma can generally take mirtazapine, but caution is advised. Mirtazapine is an antidepressant that is not typically associated with significant effects on intraocular pressure or glaucoma progression, as noted in various studies 1. However, it's essential to monitor the patient closely, especially when starting or adjusting the dose. The standard starting dose for mirtazapine is 15 mg taken orally at bedtime, which can be increased gradually up to 45 mg per day if needed. Patients with glaucoma should inform their ophthalmologist about all medications they are taking, including mirtazapine. Regular eye exams and intraocular pressure checks are crucial for glaucoma patients on any medication, as emphasized in the primary open-angle glaucoma suspect preferred practice pattern guidelines 1. Some key considerations for glaucoma management include:
- Intraocular pressure is the only modifiable parameter in glaucoma and glaucoma suspect patients 1
- Prostaglandin analogs are the most frequently used initial eye drops for lowering IOP 1
- The ophthalmologist should assess the patient for local ocular and systemic side effects, toxicity, and potential life-threatening adverse reactions 1 The reason for caution is that mirtazapine, like many antidepressants, has some anticholinergic effects. While these are generally mild, anticholinergic drugs can potentially cause pupil dilation, which in rare cases might increase the risk of acute angle-closure glaucoma, particularly in predisposed individuals. If a patient experiences any changes in vision, eye pain, or other eye-related symptoms while on mirtazapine, they should seek immediate medical attention. It is also crucial to consider the patient's overall health, including comorbidities and potential interactions with other medications, when managing glaucoma, as highlighted in the primary open-angle glaucoma preferred practice pattern guidelines 1.
From the Research
Treatment of Glaucoma with Mirtazapine
- Mirtazapine, also known as Remeron, is an antidepressant that can have ocular side effects, including increased intraocular pressure and angle closure glaucoma 2.
- According to a review of literature, tricyclic antidepressants, benzodiazepines, and topiramate should be avoided in patients diagnosed with glaucoma or at risk, but mirtazapine is not explicitly mentioned as a medication to avoid 3.
- However, a case study reported a patient who developed bilateral secondary angle closure after using mirtazapine for 6 months, suggesting that mirtazapine may increase the risk of glaucoma in some patients 2.
- The treatment of glaucoma typically involves lowering intraocular pressure, which can be achieved with various classes of glaucoma medications, as well as laser and incisional surgical procedures 4.
- Clinicians should be aware of the possible psychotropic drug-induced glaucoma and monitor at-risk patients closely to prevent this condition 3.
Considerations for Patients with Glaucoma
- Patients with glaucoma should be under the strict supervision of an ophthalmologist, especially if they are taking medications that may increase their risk of glaucoma 3.
- The decision to prescribe a medication to a patient with glaucoma should take into account the patient's medical history and the potential side effects of the medication 5.
- Adherence to medical treatment is crucial to its efficacy and cost-effectiveness, but patients with glaucoma may experience side effects or have difficulty adhering to their treatment regimen 6.
- New molecules and delivery systems are being investigated to improve glaucoma management, but the limits of medical therapy should be considered to identify patients who may need surgical management 6.