Expert: Ivan Goldberg, M.D. - 2/26/2010

Question
QUESTION: after taking all benzos and sleeping pills that were worthless i finally settled on remeron.i take 15mg for sleep for the past 2 weeks and sleep the best ever,only problem in 3 weeks gained 5 lbs.foes  the weight gain eventually level off.aside bfrom the weight gain is it stioo na good med for sleep problems,are there any bad side effects besidw weight gain?

ANSWER: Hi Wesley . . .

Although most people can take Remeron without experiencing too many side-effects, the list of possible side-effects is quite long. Most of my patints who take it as a sleep aid expereince little more than weight gain and a little daytime sedation.

Here is a list of possible side-effects:

Side Effects by Body System

Nervous system
Although the exact incidence has not been reported, paresthesia appears to be a relatively common side effect of mirtazapine. Patients typically experience paresthesia in the extremities or generalized in the body. However, several cases of oral paresthesia associated with the orally disintegrating tablet have been reported. Patients have described a sensation of swelling in the mouth, numbness, and anesthesia. The symptoms occur shortly after ingestion and resolve after a few hours.

Nearly all selective serotonin reuptake inhibitors, mixed serotonin/norepinephrine reuptake inhibitors, and tricyclic antidepressants cause sleep abnormalities to some extent. These antidepressants have marked dose-dependent effects on rapid eye movement (REM) sleep, causing reductions in the overall amount of REM sleep over the night and delays the first entry into REM sleep (increased REM sleep onset latency (ROL)), both in healthy subjects and depressed patients. The antidepressants that increase serotonin function appear to have the greatest effect on REM sleep. The reduction in REM sleep is greatest early in treatment, but gradually returns towards baseline during long-term therapy; however, ROL remains long. Following discontinuation of therapy the amount of REM sleep tends to rebound. Some of these drugs (i.e., bupropion, mirtazapine, nefazodone, trazodone, trimipramine) appear to have a modest or minimal effect on REM sleep.

Nervous system side effects including somnolence (56%), headache (12%), dizziness (7% to 12%), insomnia (8%), abnormal dreams (4%), abnormal thinking (3%), confusion (2%), tremor (2%), sleep abnormalities, and paresthesia have been reported. Activation of mania and seizures have occurred rarely. One case of seizures, one case of akathisia, and one patient with a transient ischemic attack have also been reported.

Gastrointestinal
Gastrointestinal side effects including dry mouth (25%), increased appetite (17%), and constipation (13%) have been reported. Other reported gastrointestinal adverse effects have included diarrhea (9%), nausea (4%), vomiting, anorexia, cholecystitis, glossitis, and colitis. One case of subclinical pancreatitis has also been reported.

Metabolic
Metabolic side effects have been reported. Nonfasting triglyceride increases to greater than 20% above the normal upper limits have been reported in 15% of patients receiving mirtazapine in clinical trials. Weight gain has been reported in 12% of patients. Less frequently reported were peripheral edema (2%), thirst, and weight loss. In one small study, mirtazapine appeared to improve glucose tolerance by reducing cortisol secretion.

Musculoskeletal
Musculoskeletal side effects including myalgia, arthralgia (2.4%), and myasthenia have been reported in less than 2% of patients receiving mirtazapine.

Numerous cases of mirtazapine- induced arthralgia have been reported. Symptoms tend to appear within 2 to 22 days of starting mirtazapine and resolve shortly after discontinuation of treatment.

Hepatic
Hepatic side effects including liver function test abnormalities (primarily ALT (SGPT) elevations greater than three times normal concentrations) have been reported in 2% of patients receiving mirtazapine. Patients typically did not develop signs or symptoms of hepatic dysfunction

A case of mirtazapine- associated, dose-dependent asymptomatic elevation of liver enzymes has been reported. In this patient, elevated liver enzymes were discovered 3 months after starting mirtazapine (30 mg/day) and following a dose reduction (15 mg/day) liver enzymes decreased, but remained above normal. Liver enzymes returned to normal 2 months after discontinuation of mirtazapine.

Respiratory
Respiratory side effects including dyspnea (1%) have been reported.

Cardiovascular
Cardiovascular side effects including hypertension, vasodilation, angina pectoris, bradycardia, and ventricular extrasystoles have been reported infrequently.

Tachycardia, palpitation, chest pain, and postural hypotension were reported by at least 1% of patients in clinical trials, however, the incidence was less than that of placebo. ECG changes were also noted in 3% of patients. The incidence was similar to that of placebo and the changes were not considered clinically significant.

Hematologic
Coagulopathy (i.e., ecchymosis) developed in a patient three days after initiating mirtazapine therapy (30 mg/day). Following discontinuation of mirtazapine, prothrombin time, activated partial thromboplastin time, and international normalized ratio returned to normal and symptoms of ecchymosis disappeared.

Hematologic and lymphatic side effects such as lymphadenopathy, leukopenia, anemia, petechiae, thrombocytopenia, lymphocytosis, and pancytopenia have been reported but are uncommon. Agranulocytosis occurred in two patients and neutropenia in one patient during premarketing clinical trials. One case of coagulopathy has been reported.

Dermatologic
Dermatologic side effects including pruritus, rash, acne, dry skin, and alopecia have been reported infrequently.

General
General side effects have included asthenia (8%), flu syndrome (5%), and back pain (2%).

Ocular
Ocular side effects including eye pain, abnormality of accommodation, conjunctivitis, lacrimation, and glaucoma have been reported infrequently. A case of palinopsia has also been recorded.

Genitourinary
Genitourinary side effects including urinary frequency (2%), urinary tract infection, kidney calculus, cystitis, urinary incontinence, vaginitis, hematuria, impotence, and polyuria have been reported.

Source: http://www.drugs.com/sfx/remeron-side-effects.html

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: thankyou for your lengthy answer about remeron side effects.i feel it is better then sleeping pills and most of the bad side effects occur very little?do you agrtee the weight gain is overblown.the average weighjt gain is ib therange of 5-15 lb not 30 -50 ehat is from fatties  who cant control themselves,overall do you feel remeron is worth a try instead of benzos and the overpriced sleeping pills that quit on you in a few weeke,thank you nfor your time im done####

Answer
Wesley,, Hi again . . .

The weight gain is usually something that people can handle, but as I'm sure you know, it is easier not to gain weight than to lose weight.

I cannot give you personal advice but I can tell you that I often prescribe generic mirtazapine (Remeron) for sleep rather than one of the higher priced medications.

Best regards . . .

Ivan
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