Can I prescribe mirtazapine for 1 week for appetite stimulation?

Mirtazapine for Short-Term Appetite Stimulation

Mirtazapine should NOT be prescribed for a 1-week course solely for appetite stimulation, as this practice is not supported by high-quality evidence and carries risks that outweigh potential benefits. 1

Evidence Against Short-Term Use for Appetite Stimulation

The 2024 ESPEN guidelines on nutrition in dementia explicitly recommend against the systematic use of appetite stimulants, including mirtazapine, when used solely for appetite stimulation 1. While mirtazapine has been associated with weight gain as a side effect, the evidence supporting its use specifically for appetite stimulation is very limited:

• Studies examining appetite stimulants have been conducted with weak methodology
• Short-term benefits are inconsistent and uncertain
• Potential harmful side effects must be weighed against uncertain benefits 1

Appropriate Clinical Contexts for Mirtazapine

Mirtazapine may be appropriate in specific clinical scenarios where appetite stimulation is a secondary benefit:

1. Depression with comorbid appetite loss: When a patient has depression AND appetite/weight loss, mirtazapine can be considered as the antidepressant of choice 1
2. Palliative care settings: In end-stage cardiovascular disease, mirtazapine may be useful for anorexia, particularly when patients also have sleep difficulties or mood disorders 1

Risks of Short-Term Use

Prescribing mirtazapine for just one week raises several concerns:

• Discontinuation syndrome: Even at low doses, abrupt discontinuation after short-term use can cause anxiousness, nausea, tremor, and paradoxically, loss of appetite 2
• Common side effects: Somnolence (54% of patients), increased appetite, weight gain, and dizziness 3, 4
• Serious adverse effects: QT prolongation, angle-closure glaucoma risk, and potential for drug interactions 3

Limited Evidence for Inpatient Short-Term Use

Recent research examining appetite stimulants in hospitalized patients found:

• No significant difference between appetite stimulants (including mirtazapine) in meal intake or weight change 5
• While some numerical improvements in meal intake were observed, the evidence lacks standardization and generalizability 6
• Higher quality evidence is needed before conclusions can be drawn about efficacy in short-term settings 6

Alternative Approaches

Instead of medication for appetite stimulation, consider:

1. Addressing underlying causes of poor appetite
2. Nutritional support strategies such as:
   • More frequent, smaller meals
   • Energy-dense meals
   • Supervision during meals
   • Emotional support during eating 1

Conclusion

The short-term use of mirtazapine solely for appetite stimulation for one week is not recommended based on current guidelines. The potential risks, including discontinuation syndrome and sedative effects, outweigh the uncertain benefits when used for such a short duration. If appetite stimulation is needed, consider addressing underlying causes and implementing non-pharmacological nutritional support strategies first.