Why a Mirtazapine For Insomnia is my Second Favorite Med To Prescribe To Patients

[@richardparis8738]

You're right about that he kicks in earlier

[@damoncus8124]

Mirtazapine Is probably the last drug I would take purely for insomnia. The half-life is 20 to 40 hours depending on how you metabolize but even on the lower end that's too long . Low-dose Seroquel (25mg) is hard to beat for insomnia. It has nearly as high in infinity on the KI index for H1. Along with antagonizing many of the same receptors. However it's half-life is only seven hours and it's metabolite 12 hours . I wouldn't recommend either drug on a nightly basis/prolong use unless you need either medication for its intended purpose. As both overtime all of negative effects on Neuroplasticity given all the receptors that are down regulated. Personally, I will go with the benzodiazepine . Half a milligram to 1 mg of either Klonopin or prosom (longer acting a drug). Yes there is always the worry of addiction but the downsides side effects far outweigh either the anti-depressants or antipsychotic I do recommend Seroquel maybe once a month Just to give your brain a rest and let your dopamine, serotonin, and or nephron take a rest whilst the antihistamine put you to sleep. Seroquel will make anyone sleep under just about any condition. That being said insomnia is a PITA. I've had it for over a decade and a half now and it comes and goes, but getting to sleep, there's always a bit of an issue and depending on what's going on sleep maintenance insomnia becomes an issue. This all cropped up after I got a TBI for a car accident and then several other concussions over the next couple years. That all straightened out, but the sleep never did. Anyhow, love the channel keep it up If you need a subject for another video, perhaps you could look into Medicine let's slow the hyperconnectivity of the ACC (interior singular cortex). a lot of studies, but I don't see anything conclusive as to how to improve or repair. 👍

[@OllertonMD]

thanks for the comment! I try to avoid antipsychotics purely for sleep given that even at low dosages, there are still metabolic risks and there is still a small risk of tardive dyskinesia. I never ever prescribe benzos for sleep. They tend to disrupt sleep architecture and can reduce deep sleep, and I don't want to be responsible for someone become addicted or physically dependent on them. I've seen what benzo withdrawal is like. In a perfect world, all insomnia patients would be able and willing to do a full course of CBT-I. In my area, high fidelity CBT-I is essentially non-existent though.

[@j-uk2189]

@@OllertonMDmirtazapine has dislipidemia effects just like seroquel. You can’t debate that.

[@OllertonMD]

@@j-uk2189 yes definitely, but fortunately the risk of dyslipidemia might be somewhat lower for mirtazapine compared to seroquel. Studies show the risk is 10-20% for mirtazapine, and 20-30% for seroquel.

[@willowanderson8106]

Wow! Thanks for this great video! Great info! So much to learn! What would be the difference between this drug and trazodone for sleep and depression? Looking to get away from getting to much serotonin from trazadone, would this be an alternate solution? Does it lower blood pressure (other than at the time you take it which would make sense)? And does it cause daytime fatigue? Thanks!

[@OllertonMD]

its not quite that simple, neither are SSRIs but boost serotonin signaling in different ways. Theres no way to know if one will globally increase serotonin signalling more than the other. Mirtazapine blocks 5-HT2 and 5-HT3 receptors, enhancing serotonin activity. Trazodone increases serotonin via modulating receptors as well, even though neither are serotonin reuptake inhibitors. So overall, mirtazapine won't necessarily be better option than trazodone if you are trying to avoid serotonin signalling increases. Both can lower blood pressure, especially suddenly and temporarily (from seconds to a few minuted via orthostatic hypotension when you stand up) although mirtazapine appears to likely have less of a risk of this. Both can cause daytime fatigue. In my experience, mirtazapine is more powerful when it comes to sedation, and both can definitely cause next day sedation. About a third of the population will metabolize mirtrazapine slowly due to CYP 2D6 mutations that are common, which can make it extremely sedating the next day, and even cause sedation for multiple days after a single dose!

[@willowanderson8106]

@ Now that you mention those characteristics, I think this IS a drug I've tried before and ended up literally sedated for multiple days.... 😑Ugh It sounded like such a good solution and could kill two birds with one stone because of its strong antihistamines properties for my allergies. Well, back to the drawing board. Thanks for the info Dr.O!

[@himanshugupta6589]

Hi .. my brother was on 10.5 mg for 3 months for anxiety and sleep related issues , then 7.5 mg for 3 months and been titrating to now 1/4th to 1/5th of the 7.5 mg tablet for more than a month ... feels normal and sleeps well.... can he stop it cold turkey from these low doses ( 1.5-2 mg) or titration is required ?

[@OllertonMD]

I cant give medical advice but being on 1/5th of a 7.5 mg tablet is a tiny tiny dose and if I were in that situation personally I would feel comfortable just stopping it at that point

[@himanshugupta6589]

@@OllertonMD Thank-you for the reply and for being available for your followers :)

[@richardparis8738]

I agree that stuff saved my life but it wasn't easy to get off can you take it occasionally for sleep😊

[@OllertonMD]

it is very common for mirtazapine to be used "PRN" or as needed for sleep

[@GrandmaNick]

3 weeks on 7.5 mg of Mirtazapine. It took me from 4 hours of sleep to a solid 8 hours and STOPPED Anxiety I'd had for 3 years (like a miracle!) BUT Depression, that I rarely had, is now daily. But I'm reading it could take 4 to 6 weeks to work for depression?

[@OllertonMD]

mirtazapine, like any antidepressant, can take 4-8 weeks to fully kick in. however, mirtazapine at 7.5 mg might not have any intrinsic antidepresant properties. it is thought that 30 mg is likely the dose where it can start helping depression fo most people that end up responding to it. 7.5-15 mg is more of an insomnia dose.

[@GrandmaNick]

So increasing to 15 MG would be more effective for the depression but I have read that 15 MG is less sedating than 7.5 and is it the sedating effect that has cut my anxiety? (which was hellish) @@OllertonMD

[@OllertonMD]

@@GrandmaNick whether or not higher dosages are mirtazapine become less sedating is controversial. I tend to think it becomes less sedating in high dosages, ie 45 mg and over, given that the noradrenergic mechanisms start kicking in more around those levels. Generally, it is thought that a solid and intrinsic antidepressant and anxiolytic effects of mirtazapine (ie not just because of its sedating qualities) starts at around 30 mg daily. 7.5-15 mg will likely mostly just improve sleep if there is insomnia in the equation. Keep in mind that a good chunk of the population will find even small dosages of mirtazapine very sedating due to a common CYP2D6 polymorphism in the population. I actually tried 30 mg of mirtazpine when I was in med school (looking back, I have no idea why the doctor I was seeing gave me a full 30 mg just for insomnia haha). For me, a single 30 mg pill make me super sedated, emotional and hungry for 3 days straight! Looking back its actually kind of funny. I was just lazing about in these onsie Christmas pajamas, half asleep, getting teary over and over watching this documentary about kids with cancer, and eating like 7,000 calories a day for 3 days in a row LOL

[@GAB-f1f]

Thanks for the video! I am curently on lexapro since 7 month for anxiety. It works well on me but it also causes me insomnia... Would you recommend to try to add mirtazapine to help find sleep? How about to take directly an antihistaminic like alimemazine? Would it be less effective?

[@OllertonMD]

that would certainly be a common thing to try for insomnia. lexapro and mirtazapine are combined frequently. Mirtazapine affects sleep more than just by blocking histamine receptors. Pure antihistamines don't always lead to the best quality sleep.

[@its_a_bug]

Dr just prescribed me these but having just lost 40lbs for health reasons, there's no way I'm risking putting it back on. My self-esteem issues are bad enough!

[@OllertonMD]

well, what I tell my own patients that share your same concern is this: try it for a while, and if you gain 3 lbs, it can be stopped; starting a medication puts you under no obligation to continue it if its not a good fit for you.

[@jeffwillard7861]

Do you typically have back up plans in place when that happens? Its a good approach, but as a patient with lifelong sleep issues (DSPD), it gets awfully lonely when the med doesnt work/has discussed intolerable side effects and the Dr is MIA until next visit​@OllertonMD

[@jefferybrown6690]

Very educational! Tomorrow I'm supposed to talk to my psych about insomnia that was brought from atomoxetine. Atomoxetine is doing wonders for my ADHD but I have a hard time falling asleep and staying asleep. I've also been on fluoxetine for many months now. I'm a little nervous about adding a 3rd medicine to my regimen, but my QoL is taking a drop. Of course I'm going to listen to whatever he says as we have been working together for a long time, but if you had a patient with a similar situation, what would you recommend? Trazadone as a first trial?

[@OllertonMD]

if I had a patient in this situation I would firs tmake sure they are taking the atomoxetine the moment they woke up in the morning, to ensure if wears off as best as possible by evening. The second thing I would do is see, is possible, if the atomoxetine dose could be reduced to a "minimally effective dose." If it already is, then I would consider a sleep med, but it definitely isn't ideal adding a medication to cover the side effect of another medication. I usually try trazodone first simply because mirtazapine can be super duper sedating for some people, and its much more likely to cause weight gain than trazodone.

[@jefferybrown6690]

@@OllertonMD Thanks for the reply! I take mine as a split dose once in the morning and once at noon because a single dose has too many side effects. I also find it better for managing my ADHD symptoms in the evening after work. Im a programmer so that attention deficit really kills when I am mentally overloaded in the day. What we ended up doing was lowering the afternoon dose and raising the morning dose and will experiment with that to see if it helps. No added medicine yet, but keeping trazodone in mind if things don’t improve. Thank you and everything the medical community does ❤️

[@OllertonMD]

@@jefferybrown6690 hope the new regimen works for you man! Sounds very reasonable to me.

[@criscris5402]

I'm a fifty some women struggling with menopause symptoms wich insomnia is the most difficult one. I'm in France and here we have another drug, related to mirtazapine, called Mianserine. I've been taking that for 7 months now, at very low doses, now 1/4 of 10mg, so 2,5 mg. I've started with one of 10mg, went to 20, then started to decrease two months later (for depression and anxiety, the doses are 30 to 90mg). The HRT sure helped me to decrease it, but i can't stop taking it, i can't sleep when i try. The physician keeps telling me that at this dose i can just stop it, but i can't. Do you think that with this dose a drug like that can really be effective? And is rhis an addictive drug? Thank you!

[@OllertonMD]

I cant give you personal medical advice since I am not your doctor, but I would think that 2.5 mg at night would be effective for some patients since this drug is such a potent antihistamine, even at low dosages. Mirtazapine is NOT addictive, but like with most psych meds, can cause a withdrawal syndrome (or in this case, rebound insomnia) if stopped suddenly. Most doctors would probably say stopping mirtazapine at 2.5 mg is ok since its such a low dose, but it depends on the patients chemistry and body and brain, so its important that dosage changes or discontinuation be done under the guidance of that person's own doctor.

[@giacomograndi5527]

Is the 3.75 mg dosage of mirtazapine potentially effective for insomnia?

[@OllertonMD]

I've had many patients do well on that dose personally, but any dose changes should be discussed with your doctor first. Mirtazapine is a very potent H1 blocker/antagonist, even at very small dosages, so that dose is effective for some people.

[@becky2235]

Hi,thanks for the interesting video. Whst would you recommend for someone eho has gone cold turkey off methadone? I have gone so long without sleep i started hallucinating i knew they wernt real but still very frightening. What medication would tou recommend to sleep? Thank tou so much im desperate

[@frankmarchese283]

Hi I’m on 15mg of mirtazapine for about 9 years now and I’m not getting the same effect for anxiety. When I try to up the dose I get more anxiety. What do you think ?

[@OllertonMD]

@@frankmarchese283 unfortunately it’s not super uncommon for antidepressants to worsen anxiety for the first weeks, or even month, during dose increases; this often goes away as one’s brain gets accustomed to it. On the other hand, some anxious patients simply won’t tolerate noradrenergic antidepressants, as the boost in norepinephrine can trigger anxiety. Going from 15 to 30 mg will lead to a substantial increase in norepinephrine signaling in the brain.

[@ardodaniel32]

Hello, Question, in general what dosage of mirtazapine increase the most vs the least appetite and why? Whats the process?

[@OllertonMD]

the increased appetite from mirtazapine is specifically from antagonizing H1 receptors, and totally saturating your brains H1 receptors even at small dosages. Essentially what this means is that mirtazapine is a very very potent antihistamine. It blocks histamine 1 receptors in the brain, which causes sedation/drowsiness, and increased appetite. This is true of any antihistamine that is able to cross the blood brain barrier and block the activity of H1 receptors. Because mirtazapine has such a high affinity for H1 receptor blocking, it saturates aka completely "covers" H1 receptors at low dosages, probabloy in the 7.5-15 mg range, maybe even much lower than than. This means that any dosages past 15 mg will not increase appetite more than dosages of 15 mg due to the saturation. Theoretically, some patients might find LESS appetite increase at high dosages of mitazapine, ie 45 mg or more, given that at higher dosages, norepinephrine signaling increases, which can lower appetite. But this idea has not been proven.

[@ardodaniel32]

@@OllertonMD hey, thanks you very much for the detailed answer, would you say that dosage lower than 15mg might increase appetite more since usually mirtazapine prescribed between 15-45mg for depression while anything lower is probably off label so if 15 mg still help with depression because it effects norepinephrine but to a very mild degree, while 7.5mg for example doesn't effect norepinephrine at all or to a degree that doesn't have any noticable change? So than there is zero counteract and purely anti histamine? Im not sure how accurate the data in Wikipedia but they say that 15mg gives over 80% occupancy of the H1 receptor, not sure if there is higher than that and if that even make a change. "A single 15 mg dose of mirtazapine to healthy volunteers has been found to result in over 80% occupancy of the H1 receptor and to induce intense sleepiness."

[@rusty81998]

Hi, I have just been prescribed Mirtazapine for insomnia. My doctor has told me I should take them for 6 months to see if it helps. I am worried that I will not be able to come off the Mirtazapine as I won’t be able to sleep without it. I want to be cured rather than have something that masks the problem. I would appreciate a reply if possible, thanks.

[@OllertonMD]

@@rusty81998 I can’t give you medical advice, but in general, the only way to cure insomnia is either to address the underlying cause, if known, or to do a full course of CBTI-I and then continue with what you learned in CBT-I for the rest of your life .

[@adamscaife6931]

Hey Dr, do you know anything about wellbutrin causing itchiness ( particularly after discontinuation)?

[@damoncus8124]

How long have you been off the drug? If it's only been a couple days, it's likely the metabolites are still active in your system. The main drug has a half-life of about 15 hours - but the half-life of its metabolites are up to 35 hours. so depending on your dosage, it could be close to a week before any of the allergic reaction you're having disappears Anyhow, I don't know that much about the drug other than what it does and what receptors it binds to mostly because I don't think it's that great of a drug to start with So depending on what your dosage was it could be up to seven days before you see normalcy. Now, if it's been a couple of weeks and you're still having a reaction that needs to get looked at. However, I will defer to the doctor

[@OllertonMD]

that is very interesting. I have never heard of wellbutrin causing itchiness as a withdrawal syndrome.

[@damoncus8124]

@@OllertonMD it's not often listed on the side effects if you're just searching the web or general literature. However if you look at some publications on the drug, you'll see it there . The incident rate is very low though, hence why not being listed with the common

[@OllertonMD]

@@damoncus8124 yeah i looked into it after reading his comment and essentially found what you found. Very interesting. Haven't had a patient experience that yet but will keep this in mind from now on.

[@robertmalone4161]

Does it also cause sexual side effects that the ssri's do?

[@OllertonMD]

not in my experience. In my experience, dopamine agonists can actually improve libido. Sometimes the dose is too high and it causes hypersexuality actually. Thats why its so important to make sure you take pramipexole under the guidance of your own doctor.

[@imeono5955]

I take 1 gram is enough to sleep all night

[@carringtonsmith8512]

Thanks for the great video. I have just started taking mirtazapine for sleep. If a low dose is more sedating, is 3.75mg more sedating than 7.5mg? I am cautious with meds and started on 3.75mg. Making me quite tired the next day.

[@OllertonMD]

thanks for the comment and you are welcome! I need to figure out how to carve out more time to make videos. My schedule with my day job makes it really hard though, as does having low testosterone (which I am in the middle of getting treated thankfully) I don't think the noradenergic/activating effects noticably start until you get into the 30-45+ mg dosages in my clinical experience. Although I'm not sure if 7.5 mg is going to be more sedating than 3.75 mg, its impossible to know at which dose any given person is going to have completely or near completely saturated histamine 1 receptors from mirtazapine. But if someone is having next-day sedation from 7.5 mg, trying half of that might allow them to still sleep well without the next day sedation, strictly because serum levels will be lower if you lower the dose.

[@richardparis8738]

How about a tryptophan 5 htp😅

[@OllertonMD]

both of those would be dangerous to be taken when combined with a prescription medication that boosts serotonin signaling due to the risk of serotonin syndrome. And there is always the small but serious risk of Eosinophilic Myalgia with both of those. I will make a video about both of these supplements soon.

[@maggiemagsbond83]

Would you still gain weight if you didn’t overeat on it?

[@JonahTheWhite]

This is kind of a funny question. I'm not a doctor but I can say no. It's like asking "Would I gain weight by getting hungry?" The answer is no, you don't gain weight by getting hungry. You gain weight by overeating. Common sense huh :D