Is it safe to start a 100-year-old female patient with loss of appetite on Mirtazapine (Remeron)?

From the Guidelines

Starting a 100-year-old female patient with loss of appetite on mirtazapine (Remeron) is not recommended without thorough medical evaluation and consideration of potential risks, particularly in the context of advanced age and potential dementia, as stated in the most recent guideline [ 1 ].

Key Considerations

• The patient's advanced age of 100 years presents significant concerns regarding the use of mirtazapine, including potential sedation, dizziness, increased fall risk, and anticholinergic effects [ 1 ].
• The underlying cause of appetite loss should be investigated, as it could result from medical conditions, other medications, or depression [ 1 ].
• Renal and hepatic function should be assessed, as decreased organ function in advanced age may affect medication metabolism [ 1 ].
• Close monitoring for side effects and effectiveness is essential, with regular follow-up appointments to evaluate the patient's response and adjust treatment as needed [ 1 ].

Potential Benefits and Risks

• Mirtazapine may help stimulate appetite through its antihistaminic properties and can improve sleep, which might indirectly benefit nutritional status [ 1 ].
• However, the use of appetite stimulants, including mirtazapine, is not generally recommended for patients with dementia and reduced appetite, due to limited evidence and potential harmful side effects [ 1 ].
• A recent guideline update recommends that drugs that stimulate appetite should not be offered to promote food intake in persons with dementia [ 1 ].

Recommendations

• A thorough medical evaluation should be conducted before considering mirtazapine or any other medication for appetite loss in a 100-year-old patient [ 1 ].
• Alternative approaches to managing appetite loss, such as addressing underlying medical conditions or providing nutritional support, should be considered [ 1 ].
• If mirtazapine is considered, a lower starting dose of 7.5 mg at bedtime may be recommended, with close monitoring for side effects and effectiveness [ 1 ].

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Safety of Mirtazapine for Loss of Appetite in a 100-year-old Female Patient

• The use of mirtazapine for appetite stimulation in elderly patients has been explored in several studies 2, 3, 4, 5.
• Mirtazapine is considered a feasible option for geriatric patients due to its generally favorable adverse-effect profile and few drug interactions 4.
• However, the evidence underlying its use for appetite stimulation is limited, and results are conflicting 4.
• A study found that mirtazapine was effective for appetite stimulation and weight gain in some settings, but the applicability of the data to elderly individuals is unclear 4.
• Another study found that mirtazapine may show numerical improvements in meal intake, but no serious adverse effects were observed 3.
• It is essential to thoroughly evaluate the use of mirtazapine for weight loss on an individual basis, considering the patient's overall health and potential underlying causes of weight loss 4.

Considerations for Initiating Mirtazapine in a 100-year-old Female Patient

• The patient's age and potential comorbidities should be taken into account when initiating mirtazapine 6.
• The recommended starting dosage of mirtazapine is 15 mg/day, and careful dosage titration as well as regular and close monitoring for adverse events is recommended, especially in patients with hepatic or renal insufficiency 6.
• Concomitant use of mirtazapine and other medications, such as diazepam or alcohol, may impair cognitive and/or motor performance 6.
• The potential benefits and risks of mirtazapine should be weighed carefully, and alternative treatments, such as megestrol acetate or dronabinol, may be considered 2, 3, 5.