Remeron

Action

Potentiates effects of norepinephrine and serotonin by blocking their synaptic reuptake. Also exerts anticholinergic activity by disrupting muscarinic receptors.

Availability

Tablets: 15 mg, 30 mg, 45 mg

Tablets (orally disintegrating): 15 mg, 30 mg, 45 mg

Indications and dosages

➣ Depression

Adults: Initially, 15 mg/day as a single dose at bedtime; may increase dosage q 1 to 2 weeks up to 45 mg/day. For maintenance, 15 to 45 mg/day.

Dosage adjustment

• Renal or hepatic impairment

• Elderly patients

Contraindications

• Hypersensitivity to drug

• MAO inhibitor use within past 14 days

Precautions

Use cautiously in:

• hepatic or renal impairment

• history of seizures, cardiovascular or cerebrovascular disease, or psychiatric illness

• elderly patients

• pregnant or breastfeeding patients

• children (safety not established).

Administration

• Administer orally disintegrating tablet without water. Have patient place it on tongue until it melts. Make sure tablet isn't broken.

• Be aware that drug is usually used in conjunction with psychotherapy.

See Don't give within 14 days of MAO inhibitors.

Adverse reactions

CNS: drowsiness, dizziness, abnormal dreams, abnormal thinking, asthenia, tremor, confusion, suicidal behavior or ideation (especially in child or adolescent)

CV: orthostatic hypotension, chest pain

EENT: sinusitis

GI: constipation, dry mouth

GU: urinary frequency, urinary tract infection

Hematologic: agranulocytosis

Musculoskeletal: back pain, myalgia

Respiratory: increased cough, dyspnea

Skin: photosensitivity

Other: flulike symptoms, edema, increased appetite, weight gain, increased thirst

Interactions

Drug-drug. Benzodiazepines, other CNS depressants: additive CNS depression

Drugs metabolized by CYP450 enzyme: altered metabolism of these drugs

MAO inhibitors: hypertension, seizures, death

Drug-diagnostic tests. Alanine aminotransferase, cholesterol, triglycerides: increased levels

Drug-herbs. Chamomile, hops, kava, skullcap, valerian: increased CNS depression

S-adenosylmethionine (SAM-e), St. John's wort: increased risk of serotonergic adverse effects (including serotonin syndrome)

Drug-behaviors. Alcohol use: additive CNS effects

Patient monitoring

• Monitor vital signs, especially for orthostatic hypotension.

• Assess neurologic status.

• Watch for weight gain caused by edema or increased appetite.

• Stay alert for urinary tract infection, sinusitis, and flulike symptoms.

See Monitor CBC with white cell differential. Stay alert for agranulocytosis.

See Watch for suicidal behavior or ideation (especially in child or adolescent).

Patient teaching

• Advise patient to take with food or milk to reduce GI upset.

• Tell patient he may crush conventional tablets if he can't swallow them whole.

• Instruct patient to take orally disintegrating tablet without water. Tell him to place it on tongue until it melts and to make sure tablet isn't broken.

• Advise patient that therapeutic effects may take 2 to 3 weeks.

See Tell patient to immediately report sore throat, fever, mouth sores, or other signs or symptoms of infection.

See Instruct patient (or parent) to immediately report suicidal thoughts or actions (especially in child or adolescent).

See Caution patient not to discontinue drug abruptly. Dosage must be tapered.

• If drug causes oversedation, tell patient to consult prescriber about taking entire daily dose at bedtime.

• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.

• Tell patient to avoid alcohol and to discuss herbal use with prescriber.

• Instruct patient to avoid exposure to excessive sunlight or sun lamps.

• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.