What can be given as a substitute to mirtazapine (Mirtazapine) for sleep in a patient who is Nothing by Mouth (NPO)?

Alternative Sleep Medications for NPO Patients

For a patient who cannot take mirtazapine orally due to NPO status, zolpidem, eszopiclone, or trazodone administered via alternative routes are the recommended substitutes for sleep management.

First-Line Options for NPO Patients

• Benzodiazepine receptor agonists (BzRAs) are the preferred first-line agents for insomnia when oral mirtazapine is not an option 1:

  • Zolpidem is available in sublingual formulations that can be used in NPO patients 1
  • Eszopiclone may be available in alternative formulations depending on pharmacy availability 1

• These medications are primarily indicated for sleep-onset insomnia (zolpidem) or both sleep-onset and maintenance insomnia (eszopiclone) 1

Second-Line Options

• Sedating antidepressants can be considered as alternatives 1:

  • Trazodone in injectable form may be available and is commonly used for sleep in palliative care settings 1
  • Low-dose doxepin in liquid or injectable form may be considered 1

• These medications have less robust evidence for insomnia alone but are effective options when oral administration is not possible 1

Special Considerations for NPO Patients

• Route of administration is critical in NPO patients:

  • Consider sublingual, injectable, or transdermal formulations based on availability 1
  • Consult with pharmacy about compounding options for alternative delivery methods 1

• Duration of action should be matched to the patient's sleep pattern:

  • Short-acting agents (zaleplon, sublingual zolpidem) for sleep onset issues 1
  • Intermediate-acting agents (eszopiclone) for combined sleep onset and maintenance 1

Cautions and Monitoring

• Benzodiazepines (lorazepam, diazepam) should be avoided in elderly patients or those with cognitive impairment due to increased risk of delirium 1

• Monitor for adverse effects specific to each medication:

  • BzRAs: risk of next-morning impairment, sleep-related behaviors 1
  • Sedating antidepressants: potential for anticholinergic effects, especially with tricyclic antidepressants 1

• Avoid venlafaxine as a substitute, as it can cause sleep disturbances and is not recommended for nighttime administration 2

Dosing Considerations

• Start with lower doses in elderly, debilitated patients, or those with hepatic impairment 1:

  • Zolpidem: 5mg sublingual (if available) 1
  • Eszopiclone: 1mg (if available in appropriate formulation) 1
  • Injectable trazodone: consult pharmacy for appropriate dosing 1

• Timing of administration is important even with parenteral medications:

  • Administer sleep medications approximately 30 minutes before desired sleep time 1

When NPO Status Resolves

• Return to mirtazapine when oral intake is possible if it was previously effective 3, 4
• Consider starting at a lower dose (7.5-15mg) when reinitiating oral mirtazapine 5, 6

Remember that the choice of alternative sleep medication should be based on the specific reason for the patient's sleep disturbance, availability of non-oral formulations, and the patient's overall clinical condition.