Ultra high doses of mirtazapine

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Hello. Is there anybody who finds that ultra high doses of mirtazapine wokred better for them? In the past I have taken mirtazapine in doses 30 mg and it had wokred for a while but then I have changed my meds (bad for me). The second time I have taken mirt 45 mg without success sad It's the best drug I have ever taken, but it's not working anymore. I have taken many of the drugs, like SSRI's, buropion and others, but none of them worked like mirtazapine in the past. How do you think, is there any possibility that ultra high doses like 60-90 mg would be work better for me? Thanks.

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  • Posted

    I had a look at the monthly script data from the prescription authority as I am in the process of switching to Mirtazapine and I typically need large doses. The BNF limit before you need a consultant to review it is 45mg but it looks like at least 2% of UK GP scripts are of 60mg or above which suggests that there is a substantial minority of service users who benefit from larger doses. Given GP reticence it is likely that an even larger number of service users would benefit from the larger doses. The price to pay is likely to be more weight gain so be prepared to add in some more daily physical activity to counter this. The LD50 looks to be at least 300mg per Kg so it is much safer than the more effective than the gold standard alternative of Lithium which is very good but requires really careful management as it can become very toxic within days during very hot weather during to excess perspiration. Bottom line is that 60mg should be safe and it looks to be the minimum effective dose for at least 2% of people. 
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    • Posted

      Since when was 2 per cent a substantial minority of service users. A very small minority, yes. I say this as a statistician.
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    • Posted

      Thank you. I have read article about mirtazapine overdose, and it's quite safe in overdose (more than 120 mg). I'm very resistant to treatment and I was on every drug on the market (with brintellix - this was nightmare). My best reaction was to mirtazapine, but I had 2 approaches to it on 45 mg, but without past success... I know some people are on 60 and even 90 mg but don't know if it's becouse better efficacy or lower sedation.
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    • Posted

      Cant say I have ever heard of the increase in the UK to this height. I suspect NICE and the CQC would be interested in knowing GP that are giving patients overdoses. Its usually MIrt with another drug and your monitored, and they chose one that works on different receptors.

       

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    • Posted

      I know, but I was on mirtazapine+sertraline in the past, and now I'm on mirtazapine+paroxetine, but I can't tolerate serotonin drugs. I have bad side effects. I'm feeling better on mirtazapine solo, but now there isn't mood elevation, and anti-anhedonic effects, only sedation and antianxiety effect.
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    • Posted

      I  suggest you look up the meanings of the word substantial. I deliberately avoided using the word significant as it is associated with a very specific meaning in Statistics. 
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    • Posted

      I would do your homework Mirtazapine is Serotonin based. I think you will not find anyone in a great number who has overdosed on Mirtazapine for the good. I find it alarming your GP is going to prescribe against all recommendations.
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    • Posted

      Serotonin based? Via antagonism of alpha-2 heteroreceptors and agonism of apha-1? That don't mean it's mainly and strong serotonin drug. In research there are inconsistent results of extracellular serotonin increase with this drug (mainly in hippocampus). I think it's mainly noradrenergic and dopaminergic drug with main mechanism of action via dopamine release in prefrontal cortex.
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    • Posted

      Well I have looked up the word "substantial" in the OED and it either means a great amount or it means important. Well clearly it was not a great amount, and therefore you are suggesting important. Thereofre you are using it to mean important. I think that "substantial" is what politicians use when they want to say that it is meaningless - what is sometimes called a boo word. I would say that 2 per cent of a large number is significant (ie it is measurable) It does not matter if it is significant in the statistical sense - unless it is a sample - it is the actual size in the population.
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    • Posted

      That is why I used the word substantial. When I looked at the number of Mirtazapine prescription, it was larger than I anticipated and the number of prescriptions of 60mg was more than the a handful and therefore this  is a dosage that appears that is substantive rather than what might be described as just an outlier. 
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    • Posted

      Why don't we just call it 2 per cent. Then we will know precisely what we are talking about. I wrote statistical publications for 15 years trying to think up different ways of saying things, eg where writing separate descriptions of the 33 London boroughs.

      Although Partridge in "Usage and Abusage" says don't use "substantial" where you would use large or big, I get the impression that this is more stylistic. Substantive=tangible - in that sense an atom is substantive. In the OED (1980ish edition) all but one of the definitions of substantial refer to considerable in number or of size, only one refers to the more chemical definition.

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    • Posted

      It was 2% but it wasn't a small number. There are (for the lack of a better adjective, we can agree on) a significant number of patients acroos the country on this dosage. I guess its time to email  Suzy in dictionary corner about the usage of the word substantial, she seems to love it when she is talking about a word whose meaning is in a state of flux from it's original meaning to a different, more modern meaning.
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    • Posted

      mirtazapine is the best anti depressant out there side effects vs results, dreams were bad at first but now they are great, fluoxetine made me a zombie.
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    • Posted

      Yes, I agree, for me it's the best antidepressant. SSRI are making me apathetic, unmotivated and flat (this drugs don't elevate my mood, or cure my anhedonia). I like dreams on mirtazapine - very vivid and fantasy (not nightmares).
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  • Posted

    45 mg is the maximum dose. And for me it made me worse not better, in fact very dark place. IT is a good drug and when 30 mg was working for me it was great, other than the weight gain. I have taken Mirt. twice with a short period on citalopram. I am now on Venlafaxine as Mirtazapine just was horrific at 45mg.

    Please Please Please do not self medicate and take more than your prescribed dose as you will be seriously ill.

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    • Posted

      I know, everything under doc control, she is considering higher doses of mirtazapine becouse my past good reaction to it, but I'm curious if there is someone on higher doses.
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    • Posted

      It is a myth that doctors in the UK cannot prescribe above the BNF published limits. It is normally the remit of Consultants, however, the guidelines clearly permit even GPs to prescribe above the limits without recourse to a consultant. Nowhere did I advocate self-medication and I think it is unhelpful to suggest that I implied this. Wherever possible service users should be actively involved in determining their care plan including the choice of and dose of any medication. From what I can see Jetchan is doing the right thing by 
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    • Posted

      MM3 not sure where you reading the BNF published limits can be contravened and I don't believe I suggested you did advocate an overdose. 

      I don't believe you find many people take more than 45 mg, but if you  do and the GP is cool then who am I to say anything.

      But don't ask for an opinion if you dont like it, this is an open forum. The community are here to help each other and at the end of the day it up to the individual to decide what they do and that will never change despite what you or I put

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    • Posted

      Apologies for the interruption in the posting. I was saying thatI tthink that Jetchan is doing the right thing by informing themselves about a particular treatment option before discussing in detail with their health care professional. I can see you wish to help but it is simply incorrect to describe taking above the BNF limits as overdosing if this is the agreed dosage prescribed. It is also the incorrect to state that this will have a negative impact on someone's health. Consultants particularly in areas such  as pediatrics and mental health regularly have to prescribe "off-licence" to improve the health of their patients. This is often the case where research is limited and the licence has therefore not been extended. It apparently very frequent in pediatrics as there often ethical issues with drug trials involving children. 
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    • Posted

      Jimmy,

                  in answer to where I read that prescribers may go above BNF limits, the answer is that I read this from the Deneral Medical council website at the following location:

      http://www.gmc-uk.org/guidance/ethical_guidance/14327.asp

      In response to the discussion in the use of term overdose. The conversation has gone:

      I stated that I had seen that GPs are prescribing Mirtazapine at a 60mg dose,

      To which you replied "I suspect NICE and the CQC would be interested in knowing GP that are giving patients overdoses."

      Following your logic,your include in your use of the term "overdose" any prescription above the BNF limit (in this case being anything above 45Mg).

      In a later post you state that 45 Mg is the maximum dose and finish of the same posting with "please please please don't self medicate" with the "don't self medicate" in bold. Neither Jetchan nor myself had even hinted at self-medication. The implication is therefore that Jetchan and myself are by suggesting that a 60mg might be a reasonable dose for some patients are also advocating "self-medication" for those same patients. My concern is very much with the use of the word "overdose". By using this emmotive and technically incorrect term (technically incorrect as this is the prescribed dose for some people) you are saying that patients that taking this dose are doing something both unsafe and illegal. This may not have been your intention but it is what you have done. I can see that your principal motivation is to help other people not experience the same negative experience that you experienced which is a laudable motive. I had no agenda replying to Jetchan other than reassuring them that what they proposed was a reasonable proposition and that it was significantly safer than the gold standard treatment Lithium (which also I do not wish to put people of because it is still probably the most effective anti-depressant medication available). I want Jetchan to be comfortable when discussing with their prescriber that the data supports that is a reasonable and relatively safe option and that other health care professionals are already prescribing to the 60mg level. 

          If there is anything that is incorrect or inaccurate in my posting, one of the benfits of an open forum is that can be pointed out and corrected. My posting is intended to reassure those on this drugs that it is OK to look at higher than BNF licensed doses as option (always assuming that they can tolerate it at lower doses). I believe there should be no stigma associated with using "off-licence" doses. If you believe there should be negative pressure put on patients not use prescribed "off-licence" doses, I think that is definitely worth an open debate because I suspect that there are probably quite a few people who like yourself feel extremely uncomfortable with the concept of "off-licence" prescribing and I believe if we can discuss the concept in an open forum that many more people (hopefully including yourself) will when they go thru the data will feel much more comfortable with the practice of "off-licence" prescribing. This in turn I believe will help people who when they find a drug that they can tolerate well to choose jointly with their precriber, the most effective dosage for them, whether this be on or off licence.

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    • Posted

      Thank you, I think that in treatment resistant people the goal is remission or at least some raction to drug. In my opinion is reasonable to up the drug that have worked in the past, but the last word is to my doc. Now I'm on paroxetine with mirtazapine, some tiritation to 60 mg paroxetine and 60 mg mirtazapine (both above limit), but I must calm you that I'm living in Poland, so there isn't any of  NICE or CQC institutions. I think like MM3, that higher doses of mirtazapine are safer than lithium, but If that higher doses of mirtazapine will not work then my doc will consider lithium augmentation (lower doses than in mania).
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    • Posted

      Best of luck jetchan, if doing this help great, What happens when 60mg doesnt work thou. MM3 I understand off license prescribing, I have taken off license meds for pain management so please don't  label me with the "uncomfortable objector" . These are drugs that are predominantly altering the way the brain works and aren't short term solutions either. Jetchan my concerns are have you consider that if 60mg doesnt work you got to wean off this and you perhaps dont appreciate the problems.

      I really hope it goes well as Lithium treatment is pretty scary stuff get the right balance. Im guess your depression is pretty severe. What every you do I hope it works for you 

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    • Posted

      Jetchan/Jimmy, Lithium isn't as scary as bad aspeople make out and I can say that after suffering from accidental severe lithium poisoning due to excess prespiration on a walking holiday, but you really need regular blood test and it is best if you have a good grip of the technical issues associated with using it (half lives, why it is important to take it at night, why it is important to have blood levels done at the same point of the day, what happens when your body looses to much sodium through perspiration etc as many emergency doctors have no experience of lithium posoining). I took Lithium for 6 years and it really helped but I struggled to tolerate it again after the poisoning episode so I am looking at other alternatives hence the move from velafaxine to mirtazapine which looks to be the more effective drug. 

          Jimmy, I have a fundemental belief that modern day pysc meds are aimed at making your brain work the way it was designed to i.e. they are returning an incorrectly functioning brain back to the way it was designed to function. The deficiencies in modern pysc drugs is a reflection that we have not yet get to the real root cause of the malfunctions but this like cancer is a battle we will win. There should be no shame in taking psyc meds. Decisions on choice and dose of pysc meds should be made on the best quantative evidence available. I understand there is general antipathy to taking medication in the media and in particular there is real antipathy to pysch meds .I firmly believe that this an unhelpful perspective and that it would be better if we got everybody agreeing that "evidenced based medicine" is the best way forward. 

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    • Posted

      Lithium how so scary? You have blood tests every 4 months. After 15 years I have had to come off it because it has been effecting my kidneys. You take it each night, you don't take double the dosage as I once did by mistake.
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    • Posted

      I have taken many of the drugs for my depression - every SSRI's and other, and I think the main problem if serotonin drugs don't work is becouse of prefrontal cortex dopamine shutdown by 5-HT2c agonism in VTA. In that cases drugs like mirtazapine, that don't increase serotonin so much, and increase dopamine release in prefrontal cortex could by more effective (http://www.ncbi.nlm.nih.gov/pubmed/15033381). In my case mirtazapine is most effective drug (but don't work second time) - it had worked for my anhedonia, elevates my mood, changes my perception. 
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    • Posted

      Sorry MM3 if I can answer myself - for once I agree with you, I was responding to Jimmy-UK-Lancs.

      But can I say, my sister is a GP and she doesn't treats her children. They have another GP and if they are sick she takes to their GP or in emergency she takes them to the hospital. She is too involved with their own care and therefore needs to obtain the help of others. She is an extremely competent GP but she hands over the care of her children to others. Likewise it is a good thing to be able to take the responsibility off our own shoulders and where possible to give that to others. On the other hand I recently changed GPs because I didn't think that I could rely on the previous one. I decided in effect that he was not being proactive in reminding me when my next blood test was needed, suggesting that I was getting side-effects from my meds and not going by everything that my pdoc said.

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    • Posted

      hi UK-Ven-medicate

      I too was on mirts'@

      45mg and it became a nightmare it was like it let the bogey man back in my GP has now put me on Venlablue started last week at 35.5mg so I am very concerned what to expect from V/blue I have suffered with depression and major anxiety for several years but did not address it earlier

      what I'm asking is does anybody think things will improve on New meds Vblue

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    • Posted

      Thank you xx

      I'm on here just qurious, it is really late, researching my 45mg prescription. I don't have long at all to see a specialist, but things have just got horrific on these 😐

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