Can Mirtazapine (Mirtazapine) be taken in the presence of elevated liver enzymes and hepatitis?

From the Guidelines

Mirtazapine should be used with caution in patients with elevated liver enzymes or hepatitis, and may need to be discontinued depending on the severity of liver dysfunction. The primary concern is that mirtazapine is metabolized by the liver, and impaired liver function can lead to higher blood levels of the medication, potentially causing increased side effects or toxicity 1. If you have liver issues and are taking mirtazapine, consult your healthcare provider before stopping the medication. Mild liver enzyme elevations may allow continued use with careful monitoring, while moderate to severe liver impairment typically requires dose reduction or discontinuation.

Key Considerations

• Regular liver function tests are recommended for patients with pre-existing liver conditions who take mirtazapine.
• The benefits of continuing mirtazapine against the risks based on your specific liver condition, the degree of enzyme elevation, and your response to the medication should be weighed by your doctor.
• Never stop taking mirtazapine suddenly without medical supervision, as this can cause withdrawal symptoms.
• The likelihood of drug-induced hepatitis is increased with prior advanced liver disease, liver transplant, or hepatitis C infection, as noted in the 2016 guidelines 1.
• Expert consultation is advisable for patients with advanced liver disease or whose serum ALT is >3 times the upper limit of normal at baseline, as adjustments during treatment may be necessary 1.

Monitoring and Adjustments

• Frequent clinical and laboratory monitoring should be performed to detect drug-induced hepatic injury, especially in patients with preexisting liver disease 1.
• Fluctuations of serum aminotransferases and total bilirubin from preexisting liver disease can confound monitoring for DILI, making regular monitoring crucial 1.

From the FDA Drug Label

Mirtazapine tablets should be used with caution in patients with impaired hepatic function [see Use in Specific Populations (8.6), Clinical Pharmacology (12.3)]. The clearance of mirtazapine is reduced in patients with moderate to severe renal or hepatic impairment. Consequently, plasma mirtazapine levels may be increased in these patient groups, compared to levels observed in patients without renal or hepatic impairment Dosage decrease may be necessary when administering mirtazapine tablets to patients with moderate to severe renal or hepatic impairment [see Warnings and Precautions (5.13),Use inSpecific Populations (8.5), and Clinical Pharmacology (12.3)].

Mirtazapine can be taken in patients with elevated liver enzymes and hepatitis, but with caution.

• The dose may need to be decreased in patients with moderate to severe hepatic impairment.
• It is recommended to monitor the patient's liver function and adjust the dose accordingly.
• Stopping the medication may not be necessary, but it should be considered if the liver function worsens or if the patient experiences adverse effects 2, 2, 2.

From the Research

Mirtazapine and Liver Enzymes

• Mirtazapine is an antidepressant that has been studied for its potential effects on liver function and immune-mediated liver injury 3, 4.
• Research suggests that mirtazapine may have a hepatoprotective effect in immune-mediated liver disease, and may even represent a novel therapeutic approach to autoimmune liver disease 3.
• However, the decision to stop taking mirtazapine in the presence of elevated liver enzymes and hepatitis should be made on a case-by-case basis, taking into account the individual's overall health and medical history.

Elevated Liver Enzymes

• Elevated liver enzymes are a common finding in both symptomatic and asymptomatic patients, and can be caused by a variety of factors, including viral hepatitis, genetic liver diseases, and drug-induced liver diseases 5.
• A comprehensive diagnostic evaluation is essential to identify the underlying etiology of abnormal liver function tests and to initiate the appropriate therapeutic strategies 6.
• The management of elevated liver enzymes in the emergency department should involve an algorithmic approach, taking into account the magnitude of enzymatic elevation and the patient's clinical presentation 7.

Mirtazapine and Hepatic Immune Responses

• Mirtazapine has been shown to inhibit hepatic innate immune responses, which can contribute to the development of autoimmune liver injury 3.
• Mirtazapine treatment has also been shown to alter hepatic B cell populations, enhancing the retention of CXCR3-expressing innate-like B cells that generate a more anti-inflammatory cytokine profile 4.
• These findings suggest that mirtazapine may have a beneficial effect on hepatic immune responses, and could potentially be used as a therapeutic agent in the treatment of immune-mediated liver diseases.