From the Guidelines
Mirtazapine is not recommended as a first-line treatment for alcohol withdrawal syndrome, and its use should be limited to adjunctive therapy in specific cases, such as insomnia, depression, or anxiety accompanying withdrawal, as stated in the most recent guidelines 1. The standard approach for managing alcohol withdrawal involves benzodiazepines like diazepam, lorazepam, or chlordiazepoxide, which directly target GABA receptors to prevent seizures and other serious withdrawal symptoms.
- Benzodiazepines are considered the ‘gold standard’ treatment for AWS, given their efficacy for reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
- Long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 2, 1. However, mirtazapine may be used as an adjunctive therapy in certain cases, particularly when insomnia, depression, or anxiety accompany withdrawal.
- When used, mirtazapine is typically prescribed at 15-30 mg taken at bedtime, with treatment continuing for several weeks to months depending on the patient's symptoms and response. The medication works by increasing norepinephrine and serotonin neurotransmission, which can help improve mood, appetite, and sleep quality during recovery.
- Patients should be aware that mirtazapine can cause sedation, increased appetite, weight gain, and dry mouth. It should always be used under medical supervision and as part of a comprehensive treatment plan that includes proper monitoring for withdrawal complications, nutritional support, and psychosocial interventions.
- Importantly, mirtazapine should not replace benzodiazepines for managing the acute phase of alcohol withdrawal, as it does not prevent potentially life-threatening complications like seizures or delirium tremens 2, 1.
From the FDA Drug Label
Alcohol Concomitant administration of alcohol (equivalent to 60 g) had a minimal effect on plasma levels of mirtazapine (15 mg) in 6 healthy male subjects However, the impairment of cognitive and motor skills produced by mirtazapine tablets were shown to be additive with those produced by alcohol.
The role of mirtazapine (Remeron) in managing alcohol withdrawal syndrome is not explicitly stated in the provided drug labels. However, it is mentioned that concomitant administration of alcohol had a minimal effect on plasma levels of mirtazapine, but the impairment of cognitive and motor skills produced by mirtazapine were additive with those produced by alcohol 3, 4.
- Key points:
- No direct information on the use of mirtazapine for alcohol withdrawal syndrome
- Mirtazapine and alcohol have additive effects on cognitive and motor skills impairment Therefore, no conclusion can be drawn about the role of mirtazapine in managing alcohol withdrawal syndrome.
From the Research
Role of Mirtazapine in Managing Alcohol Withdrawal Syndrome
- Mirtazapine has been studied as an adjunctive treatment to standard detoxification protocols for alcohol withdrawal syndrome 5.
- The study found that patients treated with mirtazapine in addition to standard treatment showed a marked reduction in anxiety and depressive symptoms, improving at a faster rate compared to controls 5.
- Mirtazapine may help minimize physical and subjective discomfort during the detoxification process, potentially improving patient compliance in alcohol detoxification programs 5.
- However, the primary treatment for alcohol withdrawal syndrome remains benzodiazepines, with anticonvulsants also being used in some cases 6, 7, 8, 9.
- The use of mirtazapine in managing alcohol withdrawal syndrome is not widely established as a primary treatment, but rather as an adjunctive therapy to address collateral anxiety and depressive symptomatology 5.