What is the recommended treatment and dosage for major depressive disorder using Remeron (mirtazapine)?

From the Guidelines

For major depressive disorder, Remeron (mirtazapine) is typically started at 15 mg once daily, taken in the evening before bedtime, and the dose can be gradually increased every 1-2 weeks based on response and tolerability, with an effective dose range of 15-45 mg per day, as recommended by the American College of Physicians 1.

Key Considerations

• The dose can be increased every 1-2 weeks based on response and tolerability.
• Most patients respond to doses between 15-30 mg daily, while some may require the maximum recommended dose of 45 mg.
• Treatment should continue for at least 6-9 months after symptom resolution to prevent relapse, with some patients requiring longer maintenance therapy.

Mechanism of Action and Side Effects

• Mirtazapine works by enhancing noradrenergic and serotonergic neurotransmission through antagonism of central alpha-2 adrenergic receptors and certain serotonin receptors.
• It has a unique side effect profile that includes sedation (particularly at lower doses), increased appetite, and weight gain, which can be beneficial for patients with insomnia or poor appetite.
• Sedation typically decreases at higher doses.

Monitoring and Response

• Patients should be monitored for improvement in depressive symptoms, with most seeing benefits within 2-4 weeks, though full response may take 6-8 weeks.
• The American College of Physicians recommends that clinicians assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1 to 2 weeks of initiation of therapy 1.

From the FDA Drug Label

2.1 Recommended Dosage The recommended starting dose of mirtazapine tablets is 15 mg once daily, administered orally, preferably in the evening prior to sleep. If patients do not have an adequate response to the initial 15 mg dose, increase the dose up to a maximum of 45 mg per day Dose changes should not be made in intervals of less than 1 to 2 weeks to allow sufficient time for evaluation of response to a given dose

The recommended treatment and dosage for major depressive disorder using Remeron (mirtazapine) is to start with 15 mg once daily, administered orally, preferably in the evening prior to sleep. If patients do not have an adequate response to the initial dose, the dose can be increased up to a maximum of 45 mg per day. Dose changes should not be made in intervals of less than 1 to 2 weeks 2.

• Key points:
  • Starting dose: 15 mg once daily
  • Maximum dose: 45 mg per day
  • Dose change interval: 1 to 2 weeks

From the Research

Recommended Treatment and Dosage for Major Depressive Disorder using Remeron (Mirtazapine)

The recommended treatment and dosage for major depressive disorder using Remeron (mirtazapine) can be summarized as follows:

• Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA) that is approved for use in the treatment of major depression 3.
• The recommended starting dosage of mirtazapine is 15 mg/day for 4 days, then 30 mg/day for 10 days, and if effective, the drug should be continued unchanged at this dosage or increased to 45 mg/day 4.
• Monotherapy with mirtazapine 15-45 mg/day leads to rapid and sustained improvements in depressive symptoms in patients with major depression, including the elderly 3.
• Mirtazapine is as effective as other antidepressants and may have a more rapid onset of action than selective serotonin reuptake inhibitors (SSRIs) 3.

Efficacy and Tolerability of Mirtazapine

The efficacy and tolerability of mirtazapine can be summarized as follows:

• Mirtazapine produces clinical improvements significantly superior to those of placebo, similar to those of tricyclic antidepressants (TCAs), and possibly superior to those of trazodone 4.
• Mirtazapine is generally well tolerated in patients with depression, with fewer anticholinergic-, adrenergic-, and serotonergic-related adverse events than TCAs 4.
• The most common adverse events associated with mirtazapine include drowsiness, excessive sedation, dry mouth, increased appetite, and body weight gain 4.

Comparison with Other Antidepressants

The comparison of mirtazapine with other antidepressants can be summarized as follows:

• Mirtazapine and SSRIs have similar response rates in the treatment of major depressive disorder, with a response rate of 67.1% for mirtazapine and 62.1% for SSRIs 5.
• Mirtazapine and SSRIs differ in their side-effect profile, with mirtazapine associated with fewer complaints of insomnia, nausea, and weight gain, but more complaints of fatigue and excessive sleepiness 5.
• The optimal dose of mirtazapine for the treatment of major depression is around 30 mg, with higher doses associated with decreased efficacy 6.