Is Remeron (mirtazapine) safe to take in a patient being worked up for a cerebrovascular accident (CVA)?

Safety of Mirtazapine in Patients Being Worked Up for CVA

Mirtazapine can be safely used in patients being worked up for cerebrovascular accident (CVA), but caution is warranted due to its potential to cause orthostatic hypotension in patients with cardiovascular or cerebrovascular disease. 1

Cardiovascular Considerations with Mirtazapine

Mirtazapine's FDA label specifically addresses its use in patients with cerebrovascular disease:

• Mirtazapine should be used with caution in patients with known cardiovascular or cerebrovascular disease that could be exacerbated by hypotension 1
• The medication was associated with significant orthostatic hypotension in early clinical trials, though this was infrequently observed in clinical trials with depressed patients 1
• Caution is particularly important in conditions that would predispose patients to hypotension (dehydration, hypovolemia, and treatment with antihypertensive medication) 1

Monitoring Recommendations

When using mirtazapine in a patient being worked up for CVA:

• Monitor blood pressure regularly, especially during initial dosing and dose adjustments
• Start with a lower dose (15 mg at bedtime) and titrate slowly based on response and tolerability
• Watch for symptoms of orthostatic hypotension (dizziness, lightheadedness upon standing)
• Be vigilant for signs of hyponatremia, which can occur with mirtazapine and may present with headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness 1

Benefits in Post-Stroke Patients

Interestingly, research suggests mirtazapine may actually have benefits in post-stroke patients:

• Mirtazapine has been shown to be effective in preventing and treating post-stroke depression 2
• In one study, only 5.7% of acute stroke patients who received prophylactic mirtazapine developed post-stroke depression compared to 40% in the untreated group 2
• Mirtazapine has also shown efficacy in treating pathological laughing and crying after stroke, a condition that can be distressing for patients 3

Safety Profile Considerations

Mirtazapine has several safety advantages that may be relevant in CVA patients:

• It appears to be relatively safe in overdose, which may be important in patients with depression following stroke 4
• Unlike some antidepressants, mirtazapine has a low seizure risk (reported in only 1 of 2796 patients in premarketing trials) 1
• Mirtazapine does not significantly affect heart rate or blood pressure in most patients without pre-existing cardiovascular conditions 5

Precautions and Contraindications

Exercise caution in the following situations:

• Patients with a history of myocardial infarction, angina, or ischemic stroke 1
• Patients on antihypertensive medications, as mirtazapine may potentiate hypotensive effects
• Elderly patients, who may be more sensitive to orthostatic effects
• Patients with hyponatremia risk factors (elderly, those taking diuretics, volume-depleted) 1

Dosing Recommendations

• Start with 15 mg once daily at bedtime
• After 4 days, may increase to 30 mg daily if tolerated and clinically indicated
• Maximum dose is 45 mg daily
• Consider lower starting doses and slower titration in elderly patients or those with cardiovascular/cerebrovascular disease

In conclusion, while mirtazapine requires careful monitoring in patients being worked up for CVA due to potential orthostatic hypotension, its overall safety profile and potential benefits in post-stroke depression make it a reasonable option when antidepressant therapy is indicated.