AboutJoe Haynes, R.Ph., MBA Expertise I can answer pharmacy/pharmacology questions as they relate to both pediatric and adult therapies. Please note that since I practice in Florida that I may not be able to answer specific questions regarding pharmacy practice in your state.
As a disclaimer, I have no financial interest in recommending or failing to recommend any drug product. My goal is to give you the best answer to your questions regardless of product.
Experience I have 24 years experience in pharmacy practice including pediatric and adult hospital, home-infusion, and long-term care (nursing home/ALF). I enjoy assisting with pediatric dosing and medication questions since children respond differently and are dosed differently than adults. I can help you determine if the dose you want to administer to your child is appropriate. I am currently director of pharmacy for a small community hospital in St. Petersburg, FL.
Organizations Florida Society of Health-Systems Pharmacists
American Society of Health-Systems Pharmacists
Florida Pharmacy Association
Education/Credentials BS in Microbiology from Auburn University (1989)
BS in Pharmacy from Northeastern University (1994)
MBA (generalist) from St. Leo University (2005)
Question Dr. Haynes -
My mother is 76, she has suffered chronic depression for many years, and has been on Lorazepam for anxiety since 1976. She was put on Mirtazapine (Remeron) 15mg in 2001. It appeared to help her very quickly. The dose was increased over time, and she has now been on 45mg. for about two years. She has done well on the drug, but has put on 42 lbs., despite not eating more (I live with her, I can vouch for this). She also now has a high cholesterol count for the first time in her life, and after always having a low blood pressure, this has also increased. She also suffers from severe scoliosis of the spine, and the Mirtazapine seems to have exacerbated her general pain levels. She has always been a lively, active person - she was an actress, dancer and producer in musical theatre, and is not the typical geriatric patient!
When and if she tries to cut down the Mirtazapine, however small the increment, after about 48 hours bad anxiety starts and she has to return to the usual dose. She then stabilizes within a few days. We have tried this several times.
I am a qualified clinical hypnotherapist and psychotherapist used to dealing with anxious clients, and I do feel her anxiety when she cuts down the dose is related to the drug, rather than any psychological dependence.
We would like to try switching to Fluoxetine (Prozac) to see if we can control the weight gain and pain level, but in view of her extreme difficulty in cutting down the Mirtazapine, it would have to be done by cross-tapering. I would very much welcome your opinion about trying this, and any advice that you might give us.
Thanks you,
Russell
Answer Russell-
Sorry for the delayed response. I have been on vacation.
You are correct, cross tapering would be the preferred method, however, antidepressants, regardless of chemical category (SSRI, tricyclics, atypicals,) generally will cause weight gain. Not so much from the drug itself, but from the generalized lack of anxiety. Somewhat similar to Ativan- inhibitions are decreased and patients may act in ways they did not when the were drug naive.
Problem with SSRI's like Prozac is serotonin syndrome which results when serotonin is ramped up in the brain. Nystagmus, generalized energy bursts, prickly sensations are not unusual but can be tolerated if the drugs are ramped up slowly.
If Prozac is the drug of choice, it is available in a liquid formulation to make tapering more precise. Zoloft has tablet sizes that go as low as 25mg which can be halved. It is also available as a liquid for more precise tapering.
You're thought process is right on. I would suggest a calendar or spreadsheet to visually track the dose increments or decrements so you have something tangible to point to- on this day I will be at this dose, etc.
