Names and pronunciation
(mer-ta′za-peen) Remeron, Remeron SolTab
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Drug reference
(mer-ta′za-peen) Remeron, Remeron SolTab
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Func. class.: Antidepressant
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Chem. class.: Tetracyclic
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ACTION: Blocks reuptake of norepi- nephrine and serotonin into nerve end- ings, thereby increasing action of norepi- nephrine and serotonin in nerve cells; antagonist of central α2-receptors; blocks histamine receptors
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USES: Depression; dysthymic disor- der; bipolar disorder: depressed, agi- tated depression
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Unlabeled uses: Panic disorder, PTSD, generalized anxiety disorder (GAD)
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CONTRAINDICATIONS: Hyper- sensitivity to tricyclics, recovery phase of MI, agranulocytosis, jaundice, MAOIs Precautions: Pregnancy, geriatric patients, suicidal patients, severe depres- sion, increased intraocular pressure, closed-angle glaucoma, urinary reten- tion, cardiac/renal/hepatic disease, hypo/hyperthyroidism, electroshock therapy, elective surgery, seizure disor- der, bone marrow suppression, thrombocytopenia
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Black Box Warning: Suicidal ideation, children Black Box Warning: Mental status: mood, sensorium, affect, suicidal ten- dencies (especially among adolescents, young adults), increase in psychiatric symptoms: depression, panic; product should be discontinued in those who exhibit worsening depression, emergent suicidality; EPS primarily in geriatric pa- tients: rigidity, dystonia, akathisia • Serotonin syndrome: hyperthermia, hypertension, myoclonus, rigidity, de- lirium, coma (if using other serotonergic products) • Alcohol consumption; if alcohol consumed, hold dose until morning • Assistance with ambulation during be- ginning therapy because drowsiness, diz- ziness occurs • Pregnancy/breastfeeding: use only if clearly needed; excreted in breast milk, discontinue product or breastfeeding Black Box Warning: To notify prescriber immediately of suicidal thoughts, be- havior
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SIDE EFFECTS CNS: Dizziness, drowsiness, confusion, nightmares, abnormal dreams, neurolep- tic malignant syndrome, suicidal thoughts CV: Orthostatic hypotension, ECG changes, tachycardia, twitching EENT: Blurred vision, tinnitus, mydriasis GI: Dry mouth, nausea, vomiting, increased appetite, cramps, epigastric distress, constipation, weight gain GU: Urinary frequency HEMA: Agranulocytosis, thrombocytope- nia, eosinophilia, leukopenia META: Hyponatremia, hypercholesterol- emia INTEG: Rash, urticaria, sweating, pruri- tus, photosensitivity MS: Back pain, myalgia RESP: Cough, dyspnea SYST: Flulike symptoms, serotonin syn- drome
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INTERACTIONS Increase: hyperpyretic crisis, seizures, hypertensive episode—MAOIs; avoid within 14 days Increase: CNS depression—alcohol, bar- biturates, benzodiazepines, other CNS depressants Increase: serotonin syndrome, risk— SSRIs, buspropion, SNRIs, serotonin- receptor agonists, fentanyl, triptans, tricy- clics, linezolid, methylene blue; monitor for symptoms Decrease: effects of cloNIDine, indirect- acting sympathomimetics (ePHEDrine) Drug/Herb • Serotonin syndrome: St. John’s wort; monitor for symptoms Increase: CNS depression—kava Drug/Lab Test Increase: cholesterol, triglycerides
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TREATMENT OF OVERDOSE: ECG monitoring, lavage; administer anti- convulsant, IV fluids
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DOSAGE AND ROUTES Major depressive disorder • Adult: PO 15 mg/day at bedtime, main- tenance to continue for 6 mo, titrate up to 45 mg/day at intervals of ≥1 wk; ORALLY DISINTEGRATING tabs: open blister pack, place tab on tongue, allow to disin- tegrate, swallow • Geriatric: PO 7.5 mg at bedtime, in- crease by 7.5 mg q1-2wk to desired dose, max 45 mg/day
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Available forms: Tabs 7.5, 15, 30, 45 mg; orally disintegrating tab (SolTab) 15, 30, 45 mg
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Administer: • Increased fluids, bulk in diet for con- stipation, especially for geriatric patients • Without regard to meals • Dosage at bedtime if oversedation oc- curs during day; may take entire dose at bedtime; geriatric patients may not toler- ate once-daily dosing • Gum, hard candy, or frequent sips of water for dry mouth • Store in tight container at room tem- perature; do not freeze • Orally disintegrating tab: no water needed; allow to dissolve on tongue, do not split; contains phenylalanine
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Assess: • B/P (lying, standing), pulse often; if systolic B/P drops 20 mm Hg, hold product, notify prescriber; vital signs more frequently in patients with CV disease • Seizures: in those with seizure disor- der, may be increased, provide seizure precautions • Neuroleptic malignant syndrome: fever, dyspnea, sweating, change in B/P, discontinue immediately • Blood studies: ECG, lipid profile, blood glucose, LFTs, serum creatinine/ BUN if patient is receiving long-term therapy • Weight weekly; appetite may increase with product
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Evaluate: • Therapeutic response: decreased de- pression
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • That therapeutic effects may take 2-3 wk; to take at bedtime; that there is de- creased sedation with increased doses; not to discontinue abruptly • To use caution when driving, perform- ing other activities requiring alertness because of drowsiness, dizziness, blurred M vision • To avoid alcohol, other CNS depres- sants without prescriber approval • Infection: to report flulike symptoms, other signs of infection • Serotonin syndrome: to report im- mediately symptoms that include fever, delirium, rigidity; may occur in combina- tion with other products • About how to take orally disinte- grating tabs; dissolve on tongue, swal- low • Not to crush, break, chew ODT product • To notify prescriber immediately if pregnancy is suspected, or if breast feeding • Not to use within 14 days of MAOIs • That follow-up exams will be needed
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PHARMACOKINETICS PO: Peak 2 hr, metabolized by CYP1A2, 2D6, 3A4 in liver; excreted in urine, feces; crosses placenta; half-life 20-40 hr, protein binding 85%
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• Adult: PO 15 mg/day at bedtime, main- tenance to continue for 6 mo, titrate up to 45 mg/day at intervals of ≥1 wk; ORALLY DISINTEGRATING tabs: open blister pack, place tab on tongue, allow to disin- tegrate, swallow
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• Geriatric: PO 7.5 mg at bedtime, in- crease by 7.5 mg q1-2wk to desired dose, max 45 mg/day
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