From the Guidelines
For an 82-year-old patient already on bupropion XL 300 mg daily and venlafaxine XL 300 mg daily who needs additional antidepressant therapy, mirtazapine 15 mg at bedtime would be a reasonable next option. This recommendation is based on the fact that mirtazapine works through different mechanisms than the current medications by enhancing noradrenergic and specific serotonergic transmission, as noted in studies such as 1. It can be particularly beneficial for elderly patients with depression who also experience sleep disturbances, anxiety, or poor appetite, as it has sedating properties and can stimulate appetite.
Some key points to consider when prescribing mirtazapine in this context include:
- Starting with a low dose of 15 mg at bedtime and monitoring for effectiveness, with potential to increase to 30 mg if needed and tolerated, as suggested by general clinical practice guidelines 1.
- Monitoring for side effects such as increased drowsiness, weight gain, and potential drug interactions with the current regimen.
- Regular assessment of the patient's renal and hepatic function is important, as dose adjustments may be necessary in elderly patients with impaired organ function.
- Blood pressure monitoring is also advised as the combination of these medications may affect cardiovascular parameters.
The choice of mirtazapine is also supported by its inclusion as a preferred agent for older patients with depression, along with other medications like citalopram, escitalopram, sertraline, venlafaxine, and bupropion, as indicated in 1. Given the patient's current regimen, adding mirtazapine offers a complementary mechanism of action without duplicating the effects of the existing medications, thereby potentially enhancing therapeutic efficacy while minimizing the risk of adverse interactions.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Current Medication Regimen
The patient is currently taking bupropion (Wellbutrin) 300 mg extended release (XL) daily and venlafaxine (Effexor) 300 mg extended release (XL) daily.
Potential Next Best Medication
Given the patient's current medication regimen, it is essential to consider alternative options that can be used in conjunction with or instead of the current medications.
- Mirtazapine has been suggested as a treatment option for difficult to treat depressive illness, particularly when combined with venlafaxine 2.
- The combination of venlafaxine and bupropion has been shown to be effective in treating treatment-resistant depression 3.
Considerations for Elderly Patients
When considering alternative medications for an 82-year-old patient, it is crucial to take into account the potential side effects and interactions.
- Bupropion has been shown to be effective and well-tolerated in elderly patients with major depressive disorder, with extended-release formulations having the advantage of reduced frequency of daily administration 4, 5.
- Extended-release bupropion has been demonstrated to be an effective and well-tolerated treatment for major depression in elderly patients, with statistically significant improvements observed on secondary end points, including motivation and energy, and life satisfaction and contentment 5.