Can a patient taking Abilify (Aripiprazole) 10mg also take Remeron (Mirtazapine) 7.5mg for sleep?

Can a Patient on Abilify 10mg Also Take Remeron 7.5mg for Sleep?

Yes, a patient taking Abilify (aripiprazole) 10mg can safely take Remeron (mirtazapine) 7.5mg for sleep, as there are no significant contraindications to this combination and mirtazapine is specifically recommended as a sedating antidepressant option for insomnia. 1, 2

Treatment Algorithm for This Combination

Safety Profile of the Combination

• Mirtazapine 7.5mg is well-tolerated and specifically promotes sleep, making it appropriate for bedtime dosing 2
• Aripiprazole 10mg is an effective maintenance dose for psychiatric conditions with a favorable tolerability profile 3, 4
• No direct drug-drug interactions exist between aripiprazole and mirtazapine that would contraindicate their concurrent use 1
• The combination may actually be beneficial, as both medications can be used together in patients with comorbid psychiatric conditions and insomnia 5

Positioning Mirtazapine in the Treatment Algorithm

• Mirtazapine should only be used after first-line treatments have been attempted, including cognitive behavioral therapy for insomnia (CBT-I) and FDA-approved hypnotics like zolpidem, eszopiclone, or ramelteon 1, 6
• Sedating antidepressants like mirtazapine are third-line agents, recommended after benzodiazepine receptor agonists or ramelteon have failed 1, 6
• However, mirtazapine is particularly appropriate when comorbid depression or anxiety is present alongside insomnia 1, 2

Specific Dosing Recommendations

• Start mirtazapine at 7.5mg at bedtime, which is the appropriate starting dose for insomnia 2
• Maximum dose for insomnia is 30mg at bedtime, though 7.5-15mg is typically sufficient 2
• Aripiprazole 10mg once daily is within the recommended therapeutic range (10-30mg/day) 3, 7

Important Clinical Considerations

Patient Education Requirements

• Counsel about potential additive sedation when combining these medications 8
• Advise taking mirtazapine on an empty stomach at bedtime to maximize sleep-promoting effects 6
• Warn about daytime drowsiness, dizziness, and psychomotor impairment, particularly in elderly patients 6
• Discuss treatment goals, expected timeline for improvement (4-8 weeks for full effect), and potential side effects 1, 2

Monitoring Requirements

• Follow-up every few weeks initially to assess effectiveness and side effects 1, 6
• Monitor for mood destabilization if the patient has bipolar disorder, including decreased need for sleep, increased energy, racing thoughts, or irritability 2
• Employ the lowest effective maintenance dose and attempt to taper when conditions allow 1, 6
• Regular assessment should continue long-term if chronic use is necessary 1

Common Pitfalls to Avoid

What NOT to Do

• Do not use mirtazapine as first-line therapy without attempting CBT-I or FDA-approved hypnotics first 1, 6
• Do not combine two sedating antidepressants together 6
• Do not use over-the-counter antihistamines (diphenhydramine) or herbal supplements (valerian, melatonin) as alternatives, as these are not recommended for chronic insomnia 1
• Do not prescribe without concurrent consideration of cognitive behavioral therapy for insomnia 1, 6

Special Populations

• Exercise caution and consider dose reduction in elderly patients taking mirtazapine 6
• Avoid mirtazapine in pregnancy and nursing 6
• Use caution in patients with compromised respiratory function, hepatic dysfunction, or heart failure 6

Preferred Alternatives if This Combination is Not Appropriate

Second-Line Options (Before Mirtazapine)

• Eszopiclone 2-3mg for sleep onset and maintenance insomnia 1, 6
• Zolpidem 10mg for sleep onset and maintenance insomnia 1, 6
• Zaleplon 10mg for sleep onset insomnia only 1, 6
• Ramelteon 8mg for sleep onset insomnia only 1, 6
• Low-dose doxepin 3-6mg for sleep maintenance insomnia, with minimal anticholinergic effects 1, 6, 2

When to Consider This Combination Particularly Appropriate

• Patient has comorbid depression or anxiety requiring antidepressant treatment 1, 2
• Patient has failed first and second-line insomnia treatments 1, 6
• Patient is already stable on aripiprazole for a psychiatric indication and develops insomnia 5
• Patient requires a medication with low risk of dependence compared to benzodiazepines 2