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  1. #1
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    Ever increasing venlafaxine, plus mirtazapine

    Hello everyone

    I hope all are well on this fine sunny day.

    I'd been on 75mg Ven for 5 years until May, when due to ongoing struggles for months with anxiety/depression/PTSD the GP upped it to 150mg. I take it twice daily immediate release, being one of the few who can't tolerate XR because I start withdrawing between doses.

    I'd tried upping it before but gave up due to side effects (mainly just exhaustion). Anyway got through that but wasn't feeling better. I felt numb, distant, flat. Derealisation maybe, also some pretty difficult thoughts. I went to a psychiatrist and had an assessment. He diagnosed "an episode of depression with prominent anxiety" and after a few negotiations, he has persuaded me to up it again to 225mg, as he says that's where the noradrenaline receptors kick in. Psych was good about listening to my views on meds so we reached a compromise.

    We've decided that I'll take 150mg XR in the morning, and 75mg immediate release at night. I have to take the night dose earlier, like 5pm, because my sleep has been terrible. He's also added 7.5mg mirtazapine at night, "as and when", to help with sleep. I took the first mirtazapine last night and it knocked me out for 10 hours! I still feel exhausted.

    Today I'll increase the Ven and take the first 150mg XR. I was waiting until I didn't need to drive for a few days to try these.

    Sorry this is so long. I'm just interested to know if anyone has had this sort of combo before?! Thank you in advance
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  2. #2
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Quote Originally Posted by Dying_Swan View Post
    he has persuaded me to up it again to 225mg, as he says that's where the noradrenaline receptors kick in
    True, but not by much. Despite what it says on the label, venlafaxine is really a SSRI, not a SNRI. Paroxetine is a more potent noradrenaline/norepinephrine reuptake inhibitor, albeit still only a weak one.

    I took the first mirtazapine last night and it knocked me out for 10 hours! I still feel exhausted.
    That isn't that unusual. The effect tends to diminish after a while. It also lessens for most as the mirtazapine dose increases.

    I'm just interested to know if anyone has had this sort of combo before?!
    Using mirtazapine as a sleep aid is fairly common with serotonin reuptake inhibitors which can be quite activating, though some experience sedation instead.

  3. #3
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Thank you for your reply, panic down under. That's really helpful. He wanted to switch the Ven entirely to mirtazapine but I declined (due to worrying about weight gain), hence the compromise on Ven increase. Maybe paroxetine would have been better :/

    Do you know whether the sedating effect of mirtazapine will diminish if I just use it occasionally? On the one hand I'm encouraged that it worked, but on the other hand I don't want to feel so tired in the morning. He didn't specify how often I should take it. As far as I know, there's no plan to increase it, and it's for sleep only rather than for its AD properties.

    I'm also unsure about why there would be a benefit in having the 150mg as extended release. I have to go back in a few weeks so will ask, but it's always helpful to hear of others experiences.

    Thank you again.
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  4. #4
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Quote Originally Posted by Dying_Swan View Post
    He wanted to switch the Ven entirely to mirtazapine but I declined (due to worrying about weight gain), hence the compromise on Ven increase. Maybe paroxetine would have been better :/
    I'm not a fan of mirtazapine as the only anti anxiety, or depression med. Venlafaxine is likely to be a better bet. As may paroxetine, however, it can be difficult to quit due to its very short half-life and lack of active metabolites so I'd try another SSRI first should that be required. Venlafaxine's active metabolite desvenlafaxine performs better as a SNRI, as does duloxetine.

    Do you know whether the sedating effect of mirtazapine will diminish if I just use it occasionally? On the one hand I'm encouraged that it worked, but on the other hand I don't want to feel so tired in the morning.
    Ask your psychiatrist about trazodone. Like mirtazapine it is very sedating at low doses, but it has a much shorter half-life, about 1-3 hours compared to mirtazapine's 20-40 hours, so is less likely to be sedating into the next day.

    I'm also unsure about why there would be a benefit in having the 150mg as extended release.
    I'm guessing because plasma levels are more consistent so less chance of a yo-yo effect which many find disturbing.

  5. #5
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Quote Originally Posted by Dying_Swan View Post
    I'm also unsure about why there would be a benefit in having the 150mg as extended release. I have to go back in a few weeks so will ask, but it's always helpful to hear of others experiences.
    As Ian says, less harsh side effect profile due to a longer half life. It's the one they switch too from immediate release for those who struggle with the side effects.

    What I do find interesting is the immediate release night dose. That's going to be a short half life and it's not going to mean getting 225mg a day (unless the peak periods overlap) but it is going to give your blood plasma levels a boost in this drug towards the end of the day when the XR is winding down. That's not necessarily a bad thing though because with a shorter half life drug over the course of the day we can eliminate quite a bit of it and a later boost might help.

    On this basis it may be a suck it & see and maybe they will adjust it to better times if needed?
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  6. #6
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Thank you both. Your replies are both really helpful. I will ask about trazodone next time I go. I'm hoping the mirtazapine is a temporary thing just to help me reset my sleep schedule. So far, so good, but I think something shorter acting might be better. He wasn't keen on benzos because he said it might worsen depression.

    I had thought the immediate release night dose was to pacify me and my concerns about interdose withdrawal. A while ago I briefly took XR twice a day and didn't sleep a wink. Interesting and helpful to think there could be some benefit to doing things this way. I'd never have agreed to revert to once daily.

    Thanks again. Lots of food for thought and very reassuring.
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  7. #7
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Quote Originally Posted by Dying_Swan View Post
    He wasn't keen on benzos because he said it might worsen depression.
    They also inhibit neurogenesis which is the mechanism that produces the antidepressant and therapy response. They may be useful for helping get onto antidepressants, but can be counterproductive in long term use.

  8. #8
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Quote Originally Posted by panic_down_under View Post
    They also inhibit neurogenesis which is the mechanism that produces the antidepressant and therapy response. They may be useful for helping get onto antidepressants, but can be counterproductive in long term use.

    Really helpful to know, thank you. I'll be mindful of that when taking diazepam. I've had 3 good nights sleep thanks to Mirtazapine
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  9. #9
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Im coming off Mirt and starting Ven so at the moment its a cross over taper. Been on Mirt over 3 yrs and can say the drowsiness does or did go away after a week or so. I always have a hangover feeling am on mirt @ 30mg and yes I gained 3 stone in weight in the 3 yrs the tabs don't pick the food up and force feed me but my god it don't half give you cravings so you gotta have alot of willpower not to gain weight.

  10. #10
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    Re: Ever increasing venlafaxine, plus mirtazapine

    Hi Maca.

    Thank you for your reply and the information about mirtazapine. How are you getting on with your cross taper? The weight gain aspect worries me and I've definitely had the munchies a few times. I'm being careful though and watching my weight closely.

    So far, this medication regime has worked really quite well for me. I've always been sceptical about whether antidepressants did anything for me, but I noticed an improvement within 2 days this time. The mirtazapine hangover only lasted a day and then disappeared. My prescription for mirtazapine is "as needed" so I don't take it every night now, although I think my mood the next day is better if I do. Getting some sort of sleep pattern back I'm sure has helped, as I was previously up and down all night. For some reason, 150mg Ven didn't agree with me at all, and I'm better on 225mg, even with my strange mix of XR and IR. I've noticed my mood seems to dip around 5pm so maybe the boost of 75mg IR at that time is a good thing. I'm already dreading the thought of reducing it, but I'll cross that bridge if and when I come to it. Back to the psych soon so will see what he has to say.

    Good luck Maca with your med change ��
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