Mirtazapine and diazepam?

[janebug]

Hey guys. I take 30mg of mirtazapine daily for my anxiety and depression, prior to this I was on sertraline but it didn't help my insomnia... the joys. Anyways, when I was anxious about certain big events on sertraline my doctor would kindly prescribe me some Valium, but now he won't as he said it's not safe with mirtazapine. I don't want to change my doctor and I respect his decision and his opinion, so, does anyone know any medication that will work in the same way but doesn't have an "adverse" effect on mirtazapine?

Thank you in advance x

[Shazamataz]

I was on diazepam at the same time as Mirtazipine. Maybe the doc just wants you off the diazepam?

[panic_down_under]

prior to this I was on sertraline but it didn't help my insomnia... the joys

Was sertraline effective? If so, it might have been better to stay with it and add something for the insomnia. Small doses of immediate-release trazodone (Desyrel) has become the defacto treatment for SSRI induced insomnia (the slow release Oleptro version is a pretty good antidepressant, btw, with few of the typical antidepressant side-effects which really bug people such as their impact on the libido).



I respect his decision and his opinion, so, does anyone know any medication that will work in the same way but doesn't have an "adverse" effect on mirtazapine?

You could try increasing the mirtazapine. It is mostly just a powerful antihistamine so sedation is what it does best.

You could try also try the afore mentioned trazodone (Desyrel), but I suspect your doctor would freak at the mere thought because his drug interaction check will probably, incorrectly, highlight a potential for serotonin syndrome.

Unfortunately, much of the medical literature on the syndrome is wrong. Not my words, but that of arguably the leading authority on the subject, Dr Ken Gillman (he calls it serotonin toxicity). To quote (http://www.psychotropical.com/1-introduction-to-st):


Even now, in 2016, more than a decade after key research and reviews that demonstrated the essentials of the interactions relevant to serotonin toxicity, there remains a great deal of misinformation and misunderstanding both in medical and non-medical texts.

...Such lack of knowledge and misunderstanding are reflected in advice and warnings concerning ST issued by ‘official’ agencies such as the World Health Organisation (WHO), the American FDA, the UK MHRA, Health Canada and the Australian TGA: their comments and advice have frequently been incorrect and misinformed.

Neither drug is a serotonin reuptake inhibitor, or a serotonin releaser so serotonin syndrome is simply not possible.

[MyNameIsTerry]

I was on diazepam at the same time as Mirtazipine. Maybe the doc just wants you off the diazepam?

That's my thinking.

Sertraline has a Minor interaction with Diazepam whereas Mirtazipine has a Moderate. It's not much of an interaction since it's worded similar to the ones alcohol carries when on these antidepressants. .

---------- Post added at 07:06 ---------- Previous post was at 06:56 ----------


Was sertraline effective? If so, it might have been better to stay with it and add something for the insomnia. Small doses of immediate-release trazodone (Desyrel) has become the defacto treatment for SSRI induced insomnia (the slow release Oleptro version is a pretty good antidepressant, btw, with few of the typical antidepressant side-effects which really bug people such as their impact on the libido).




You could try increasing the mirtazapine. It is mostly just a powerful antihistamine so sedation is what it does best.

You could try also try the afore mentioned trazodone (Desyrel), but I suspect your doctor would freak at the mere thought because his drug interaction check will probably, incorrectly, highlight a potential for serotonin syndrome.

Unfortunately, much of the medical literature on the syndrome is wrong. Not my words, but that of arguably the leading authority on the subject, Dr Ken Gillman (he calls it serotonin toxicity). To quote (http://www.psychotropical.com/serotonin-toxicity):



Neither drug is a serotonin reuptake inhibitor, or a serotonin releaser so serotonin syndrome is simply not possible.

A GP in the UK won't be allowed to apply an adjunct like that so they would need to refer to a psychiatrist. That is where it can be tricky, they can be hard to access.

Trazodone is licenses for anxiety or depression (depression where sedation is required). It's not a mainstream one here but GP's do prescribe it for insomnia, it's mixing it that will be the issue for them.

According to Mirt uses on here, it's sedating at lower doses but activating at higher ones. That could be relevant to how it is dosed in the OP's case?

[Shazamataz]

That's my thinking.

Sertraline has a Minor interaction with Diazepam whereas Mirtazipine has a Moderate. It's not much of an interaction since it's worded similar to the ones alcohol carries when on these antidepressants.

I expect the interaction would simply be due to the sedative effects of both medications.

Personally Mirt really did not help my anxiety much and even that effect didn't last more than a couple of months.

Hopefully the OP will see some benefits, especially with sleep. Didn't help me sleep at all but a friend swears by it.

[MyNameIsTerry]

I expect the interaction would simply be due to the sedative effects of both medications.

Personally Mirt really did not help my anxiety much and even that effect didn't last more than a couple of months.

Hopefully the OP will see some benefits, especially with sleep. Didn't help me sleep at all but a friend swears by it.

Yep, that's exactly what the interaction says really.

It's a pretty generic warning though seen on many interactions so I always read the pro section too as it reveal something more specific than the consumer one. Nothing really added in this case though.

[janebug]

I expect the interaction would simply be due to the sedative effects of both medications.

Personally Mirt really did not help my anxiety much and even that effect didn't last more than a couple of months.

Hopefully the OP will see some benefits, especially with sleep. Didn't help me sleep at all but a friend swears by it.

Yeah, I am on mirt for my depression mostly - it doesn't help my anxiety but when my depression isn't under control neither am I. I have managed to explain to my doctor what I need the valium for and he has agreed in this instance it is okay.

He basically explain what you both did about the reaction and it basically will make me very tired - but as I want it to go to the dentist I said I was more than happy to have a little nap!

Thank you both for replying in my hours of need. Hope you are both well.

[panic_down_under]

Sertraline has a Minor interaction with Diazepam

But diazepam has a major interaction with sertraline which isn't reflected in the interaction literature, benzodiazepines significantly reduce the effectiveness of antidepressants by blocking hippocampal neurogenesis which is what produces their therapeutic response (see: Stefovska VG (https://www.ncbi.nlm.nih.gov/pubmed/18991352), 2008; Wu X (http://www.biologicalpsychiatryjournal.com/article/S0006-3223(09)00106-1/abstract), 2009; Sun Y (https://www.ncbi.nlm.nih.gov/pubmed/23639432), 2013; Nochi R (https://www.ncbi.nlm.nih.gov/pubmed/23963779), 2013; Boldrini M (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374628/), 2014).

In light of these studies benzodiazepines use should probably be limited to a couple of weeks when first taking antidepressants as they often increase anxiety levels initially, for a while after antidepressant dose increases for the same reason and thereafter for very occasional breakthrough anxiety. If an antidepressant isn't adequately controlling anxiety on its own even at the maximum recommended dose then switching to another which might be more effective should be considered ahead of supplementing it with a benzodiazepine.

Alternatively, adding Buspar (buspirone) may also work as it has a proven track record for boosting the effectiveness of serotonergic antidepressants (and reducing some of their side-effects).

[MyNameIsTerry]

But diazepam has a major interaction with sertraline which isn't reflected in the interaction literature, benzodiazepines significantly reduce the effectiveness of antidepressants by blocking hippocampal neurogenesis which is what produces their therapeutic response (see: Stefovska VG (https://www.ncbi.nlm.nih.gov/pubmed/18991352), 2008; Wu X (http://www.biologicalpsychiatryjournal.com/article/S0006-3223(09)00106-1/abstract), 2009; Sun Y (https://www.ncbi.nlm.nih.gov/pubmed/23639432), 2013; Nochi R (https://www.ncbi.nlm.nih.gov/pubmed/23963779), 2013; Boldrini M (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374628/), 2014).

In light of these studies benzodiazepines use should probably be limited to a couple of weeks when first taking antidepressants as they often increase anxiety levels initially, for a while after antidepressant dose increases for the same reason and thereafter for very occasional breakthrough anxiety. If an antidepressant isn't adequately controlling anxiety on its own even at the maximum recommended dose then switching to another which might be more effective should be considered ahead of supplementing it with a benzodiazepine.

Alternatively, adding Buspar (buspirone) may also work as it has a proven track record for boosting the effectiveness of serotonergic antidepressants (and reducing some of their side-effects).

I'm only going off the drugs database on Drugs.com. Why isn't that interaction in drug interaction literature? Is it approved? Not all studies translate to accepted guidelines.

Buspirone is only licensed in the UK for short term use as it lacks evidence beyond that. Some psychiatrists use it though in longer term care but it's not something a GP is advises to do and they likely will be against taking it on themselves to "off label" it.

[hanshan]

I've taken mirtazapine with diazepam - a long time in the past, but it was okay. Both have some sedating potential, so you really need to first try them out together when you are at home with some free time. It's also useful to have a friend or partner around. Everyone reacts somewhat differently, so you need to know specifically how it affects you.

[panic_down_under]

I'm only going off the drugs database on Drugs.com. Why isn't that interaction in drug interaction literature?

Because it isn't strictly a drug-drug interaction. Neither drug directly interferes with the other, the issue is with the 'downstream' effects.

Also treat Drug.com interactions database with caution, especially on antidepressants. Medscape's (http://reference.medscape.com/drug-interactionchecker) is more reliable, ime.


Buspirone is only licensed in the UK for short term use as it lacks evidence beyond that. Some psychiatrists use it though in longer term care but it's not something a GP is advises to do and they likely will be against taking it on themselves to "off label" it.

It isn't about Buspar's efficacy per se, but the effect it has on the potency of serotonergic antidepressants when taken as a supplement.

Sound like British GPs need better training so they can do their job without Big Brother constantly looking over their shoulder.

[MyNameIsTerry]

Because it isn't strictly a drug-drug interaction. Neither drug directly interferes with the other, the issue is with the 'downstream' effects.

Also treat Drug.com interactions database with caution, especially on antidepressants. Medscape's (http://reference.medscape.com/drug-interactionchecker) is more reliable, ime.



It isn't about Buspar's efficacy per se, but the effect it has on the potency of serotonergic antidepressants when taken as a supplement.

Sound like British GPs need better training so they can do their job without Big Brother constantly looking over their shoulder.

No, the views on Buspirone are reviews of clinical evidence. They don't believe there is enough therefore they are unwilling to make the recommendation.

It's not a view of GP's, it's the view of our medical system who review all meds. People like the MHRA, NICE, etc. Those qualified to perform such reviews on every med & medical practice licenced.

Of course, individual psychiatrists will look for emerging evidence or decide to try something if there is a chance it will help.

Why treat Drugs.com with caution? Even the FDA feed into that.

[panic_down_under]

No, the views on Buspirone are reviews of clinical evidence. They don't believe there is enough therefore they are unwilling to make the recommendation.

Again, the issue isn't the efficacy of the med itself as an anxiety treatment. They are correct, as an anxiolytic buspirone doesn't work that well for most on its own.

But using it to boost the effectiveness of serotonergic antidepressants, or to treat SSRI induced sexual dysfunction is well established and excepted practice in most countries. In fact it is so well established that there are now two antidepressants, vilazodone (Viibryd) and vortioxetine (Brintillix/Trintellix), which combine the attributes of a SSRI and buspirone in a single pill.


Why treat Drugs.com with caution?

Because I've found it gets it wrong often enough to be of concern.

[MyNameIsTerry]

Again, the issue isn't the efficacy of the med itself as an anxiety treatment. They are correct, as an anxiolytic buspirone doesn't work that well for most on its own.

But using it to boost the effectiveness of serotonergic antidepressants, or to treat SSRI induced sexual dysfunction is well established and excepted practice in most countries. In fact it is so well established that there are now two antidepressants, vilazodone (Viibryd) and vortioxetine (Brintillix/Trintellix), which combine the attributes of a SSRI and buspirone in a single pill.



Because I've found it gets it wrong often enough to be of concern.

Ok on Drugs.com, I've found it matches on many but I shall have a scan at the other site too. I've found it better than most although there are still useful studies highlighting things not on Drugs.com.

My point on Buspirone is that it doesn't matter, those who regulate our medical sector say it is only to be used short term and have licensed it quoting a lack of evidence beyond this. I can't recall a recommendation for use alongside antidepressants but I've never seen best practice recommend that. Therefore psychiatrists may go off label with it but when your medical system says not to do it, GP's won't as they are stepping outside their experience, their licence and the cover of the NHS.

It's the same with pill cutting. Perfectly acceptable in the right circumstances but the NHS have no agreed policy therefore recommend against. A GP is sticking his legal neck out from there and consequently many will opt to make it harder for the patient by reducing at 50% because the manufacturer makes it that way hence the GP is covered by the licence issued for the med. Psychiatrist bodies advise gradual reduction but they have specialist medical licences and don't need the cover of the NHS trust quite so much.

If you look at Citalopram, it has no licence in the UK for anxiety treatment yet GP's frequently it off label for it. The reason for this is the NHS have issued prescribing guidelines to allow it. Otherwise you would need a psychiatrist over here or a GP willing to step over the line where their licence comfort zone ends.

So, I take your points but I haven't looked into them to enough to be able to agree. But whether a doctor will listen will be hard unless pushing for a psychiatrist .