From the Guidelines
Mirtazapine should be used with caution in patients with sleep apnea, as it may worsen symptoms due to its sedating and muscle-relaxing properties. According to the evidence from 1, mirtazapine acts as an agonist at some serotonin receptors and can increase serotonin secretion, which might increase serotonergic tone to the hypoglossal nerve, but its use in obstructive sleep apnea (OSA) is not recommended due to reports of side effects such as sleepiness and weight gain. The American College of Physicians guideline from 1 and 1 also states that pharmacologic therapy, including mirtazapine, is not currently supported by evidence and should not be prescribed for OSA treatment.
Key Considerations
- Mirtazapine can cause sedation, weight gain, and muscle relaxation, which may potentially worsen sleep apnea symptoms
- Close monitoring is essential if mirtazapine is prescribed to a patient with sleep apnea, particularly during the initial treatment period
- Patients should be advised to use their CPAP or other sleep apnea treatments consistently while taking mirtazapine
- Alternative antidepressants with less sedating properties might be preferable for patients with severe or unstable sleep apnea
Recommendations
- If mirtazapine is prescribed, the starting dose should typically be low (7.5-15mg at bedtime) with gradual titration as needed
- Monitor for excessive daytime sleepiness, morning headaches, or worsening sleep quality, which could indicate exacerbation of sleep apnea
- Consider alternative treatments for OSA, such as CPAP or mandibular advancement devices, as recommended by the American College of Physicians guideline 1
From the Research
Mirtazapine and Sleep Apnea
- Mirtazapine is not recommended for the treatment of obstructive sleep apnea (OSA) due to its potential to worsen the condition, as it can cause weight gain, which may further exacerbate OSA 2, 3.
- Some studies have shown that mirtazapine can reduce the apnea-hypopnea index (AHI) in patients with OSA, but these findings are not consistent across all studies 3, 4.
- Mirtazapine may be effective in reducing AHI in certain patient populations, such as stroke survivors with OSA, but its use should be monitored closely due to the potential for worsening central and mixed sleep apnea 5.
- A recent pilot study found that mirtazapine can decrease the susceptibility to hypocapnic central sleep apnea in males with sleep-disordered breathing, but further research is needed to understand the significance of this finding 6.
Key Findings
- Mirtazapine can cause weight gain, which may worsen OSA 2, 3.
- Mirtazapine may improve sleep efficiency and reduce AHI in certain patient populations, but its effects can vary widely 3, 5, 4.
- The use of mirtazapine in patients with OSA should be approached with caution and monitored closely due to the potential for adverse effects 2, 3, 5.