Mirtazapine prescribed for stomach issues

[Belleblue]

Hi all,
I have had stomach issues of silent reflux, waking in the early hours with nausea and acid mouth, being unable to get back to sleep and just feeling ill and out of sorts - this has been going on for the last 7 years. I was prescribed the usual PPIs (Lansoprazole, Omeprazole etc.) at varying strengths and for varying lengths of time. They did not work and I had bad side effects from them all. As well as making me feel extremely fatiqued, they made me feel depressed and anxious, so affecting my mental health.

So I was referred to a gastroenterologist two weeks ago and after discussing things he said that they would have to think outside the box as I was intolerant to the Omeprazole class of drugs. He said I had some classic reflux symptoms but that there might be some what they call visceral hypersensitivity going on too. So he recommended that I try a course of mirtazapine (which I had taken years back, but not for reflux). He explained about the gut brain axis and how he has used mirt among other ADs for patients with reflux and IBS issues.

He said he would write to my GP who had to prescribe it. So a GP from the practice I attend rang today to discuss the prescription and in a very haughty tone said "This is highly unorthodox and I doubt it will work, but as you have low mood too it may work for that". He said I should start on 15mg for the first week then increase to two tablets (30mg). I said that when I took these before I did well on 15mg, but found 30mg hard to tolerate. To which he said "You need to take them as recommended or not at all". He was so arrogant that I came off the phone feeling like a chastised child. I felt stigmatized for having a hard to treat stomach issue, that I had failed the conventional drugs, instead of the drugs failing to help me. There are some nice doctors at that practice, but especially at the moment you just have to take what you can get. The Partners and he is one all seem to have God complexes!

I wanted to discuss a couple of things regarding the mirtazapine with him, but all went out the window with his attitude. I will take the mirt, but at the 15mg dose and see how I get on.

By the way Amitriptyline was discussed by the consultant, but mirt was considered better due to fewer side effects. I'm wondering if anyone else here has been prescribed ADs for reflux/stomach issues, and if so, did they help?

Sorry for the ramble and moan, but I just needed to express this outside my own head tonight.

Belle

[panic_down_under]

He explained about the gut brain axis and how he has used mirt among other ADs for patients with reflux and IBS issues.

It is becoming increasingly clear that the enteric nervous system (ENS), the mini brain which controls the gut is also a significant force in anxiety and depression. The ENS is directly linked to the brain via the vagus nerves and seems to be the more dominant partner with most of the data flow originating from it (it is also connected to the heart and lungs). It is arguably the tail wagging the dog. Electronic vagus nerve stimulators which affect the ability of the gut to communicate with the brain have proven to be effective for treatment resistant depression, though much less so for anxiety disorders.

In turn the ENS is influenced by the gut microbiome. How you feel emotionally can literally be affected by your poop! Indeed, it is possible to make a strong argument for us being merely the life support system for the bugs in our guts who can lead us on a merry chase at times. They outnumber the cells of our bodies by about 10:1 so we don't stand a chance if they turn on us!

The gut is by far the most serotonergic organ of the body, making about 50 times as much serotonin as the brain and is replete with serotonin receptors so antidepressants can have significantly more influence on it than they do the brain. Gut microbes also have binding sites targetted by ADs and may also be affected by them. In addition to their direct impact on the ENS, there is also evidence that they can alter the mix of gut flora. Together these may be responsible for the improvement in IBS symptoms often seen with SSRIs and other serotonergic ADs.

See also:

Gut bacteria, the vagus nerve and the brain (PDF)

Gut bacteria and the brain: Are we controlled by microbes?

Gut communicates with the entire brain through cross-talking neurons

Gut microbes may talk to the brain through cortisol

I wanted to discuss a couple of things regarding the mirtazapine with him, but all went out the window with his attitude. I will take the mirt, but at the 15mg dose and see how I get on.

Ultimately, it comes down to what dose works best for you, not what is printed in your GPs guidelines. The optimum dose varies from person the person. The only thing to be aware of with mirtazapine is that it is more a sedating antihistamine than antidepressant and one of the oddities of it and similar meds is that sedation tends to be strongest at lower doses so if this becomes an issue raising the dose may help. It should have less effect on other side-effects.

[Librella]

I take nortriptyline for IBS. It’s a tricyclic and it’s relatively common in the US to prescribe those for chronic pain type issues. I think you’re right that GPs are often not aware of this only only the GIs who are up on current research think of it. Yes, it does help me, not a cure all but I have fewer flare up days and it relieved my chronic diarrhea simply because one of the side affects is constipation. It did take a long time to see the full benefit, about 3 months. I have actually thought of asking about mirtazapine for myself because its supposed to help with appetite weight gain, and low appetite is one of my big anxiety symptoms. I hope it works out for you.

[Belleblue]

Thank you Ian for that reply and for the additional information re the gut and brain. I have read a fair amount about this in my search for a solution and am amazed that the GP seemed so ignorant. But to be fair to him perhaps he is more used to the TCAs being used for IBS issues and is not aware that SSRIs etc. are being used to help if there may be some visceral hypersensitivity caused by or alongside reflux.

I finally received a copy of the letter sent from the gastroenterologist to the GP in which he stated: increase to 30mg if tolerated. So that's the recommendation from the GI - and not that I specifically increase the dose.

The GP is correct in one thing and that is that it may not work, but that would be the case with any medication.

[Belleblue]

I take nortriptyline for IBS. It’s a tricyclic and it’s relatively common in the US to prescribe those for chronic pain type issues. I think you’re right that GPs are often not aware of this only only the GIs who are up on current research think of it. Yes, it does help me, not a cure all but I have fewer flare up days and it relieved my chronic diarrhea simply because one of the side affects is constipation. It did take a long time to see the full benefit, about 3 months. I have actually thought of asking about mirtazapine for myself because its supposed to help with appetite weight gain, and low appetite is one of my big anxiety symptoms. I hope it works out for you.

Hi Librella, thanks for the reply. Yes, mirtazapine will almost certainly help with appetite and it has a constipating side effect also! So you could be on the right track there.

I have the opposite issue, I am rather inclined to constipation I am a bit concerned about that SE because when I get constipated my reflux gets worse. Perhaps if this doesn't work I may ask to try an SSRI as they move things along so to speak. However when I tried SSRIs many years ago I found I couldn't sleep and felt very jittery and anxious. Though I must confess that I feel I may have given up too quickly.

Wishing you well.

Belle

[panic_down_under]

But to be fair to him perhaps he is more used to the TCAs being used for IBS issues and is not aware that SSRIs etc. are being used to help if there may be some visceral hypersensitivity caused by or alongside reflux.

I can understand the reluctance as SSRIs can be tricky when it comes to the gut. They may work well, or they can make things much worse very quickly. The is also much less data compared to TCAs like amitriptyline and its metabolite nortriptyline which have been in use for decades. It can also take a long time for information to get from the lab to GPs and some may get missed under the avalanche of new info GPs have to cope with. As one of my former GPs used to say, GPs know less and less about more and more (as information grows across all fields and new fields emerge such as on the gut) and specialists more and more about less and less (as specialities increasingly split into sub specialities - it may get to the point that if you want a bunion removed who does the slicing and dicing will depend on which toe and whether it's the right, or left foot!)

However when I tried SSRIs many years ago I found I couldn't sleep and felt very jittery and anxious. Though I must confess that I feel I may have given up too quickly.

Do you remember which ones? Fluoxetine (Prozac) and sertraline (Zolof, Lustral) tend to be be the SSRIs most likely to trigger jitters and insomnia, citalopram and escitalopram less so, though as with everything about ADs, YMMV.

[Belleblue]

I tried most of the SSRIs, Prozac, Citalopram, Escitalopram, Sertraline. My GP at the time wanted me to try Venlafaxine, but I was reluctant due to the stories around it having the most brutal withdrawal if you try to come off them. Also not too pleasant if you miss a dose.

The thing is that when I was going through a very anxious blip with some depression thrown in about 18 months ago I asked the GP if I could try Escitalopram again, but could she give me two weeks diazepam to help cope with the kick in period. She told me that they no longer prescribe Escitalopram at that surgery and that Citalopram is exactly the same anyway (I'm aware it's not). So I said well I'll try Citalopram again, but with diazepam just short term. She said no they can't do that. I have no history of abusing medications whatsoever, so I really don't understand their logic. It's not as if diazepam is even an expensive drug.

[panic_down_under]

I tried most of the SSRIs, Prozac, Citalopram, Escitalopram, Sertraline. My GP at the time wanted me to try Venlafaxine, but I was reluctant due to the stories around it having the most brutal withdrawal if you try to come off them. Also not too pleasant if you miss a dose.

If the SSRIs didn't work the venlafaxine probably wouldn't have either. Despite what it claims on the box venlafaxine is really only a SSRI, not SNRI. Fluoxetine, paroxetine and sertraline are more potent noradrenaline/norepinephrine reuptake inhibitors.

The thing is that when I was going through a very anxious blip with some depression thrown in about 18 months ago I asked the GP if I could try Escitalopram again, but could she give me two weeks diazepam to help cope with the kick in period. She told me that they no longer prescribe Escitalopram at that surgery and that Citalopram is exactly the same anyway (I'm aware it's not).

She is more right than wrong. Citalopram is made up of two isomers, the 'S' form of citalopram, which is the active component, and a 'R' mirror image form which is a poorer fit biologically and so is mostly inactive. Escitalopram is more refined and contains only the 'S' isomer. If one doesn't work the other likely won't either, however, their side-effects can differ so if one is causing a worrisome problem then switching to the other may resolve the issue.

So I said well I'll try Citalopram again, but with diazepam just short term. She said no they can't do that. I have no history of abusing medications whatsoever, so I really don't understand their logic. It's not as if diazepam is even an expensive drug.

The addiction issue is much overblown, especially in the UK, thanks to some very expensive damages claims a couple of decades ago. A couple of the ADs, venlafaxine and paroxetine, can be every bit as hard to quit as the benzodiazepines (BZDs), arguably even more so, yet venlafaxine seems to be especially favoured by the NHS and UK GPs for some reason. Baffling!

There is, however, another issue with BZDs that you need to be aware of. They may significantly reduce the effectiveness of antidepressants by blocking hippocampal neurogenesis which is how ADs create the therapeutic response (see: Boldrini M, 2014; Nochi R, 2013; Sun Y, 2013; Song J, 2012; Wu X, 2009; Stefovska VG, 2008).

In light of this BZDs use should probably be limited to a couple of weeks when first taking antidepressants just to ease the initial increase in anxiety levels, for a while after AD dose increases for the same reason, and thereafter for occasional breakthrough anxiety. If an AD isn't adequately controlling anxiety on its own even at the maximum recommended or tolerated dose then switching to another which might be more effective should be considered ahead of supplementing it with a benzodiazepine.

[Belleblue]

Yes you are right Ian, the addiction issue is very overblown in the UK. And yes, GPs are very quick here to push people onto ADs which may be even more difficult to withdraw from than BZDs. When I say that I am not in any way diminishing the fact that the BZDs can cause serious problems for some people. But I'm afraid they have thrown the baby out with the bathwater with this one size fits all policy. They have a reluctance to even countenance two weeks of BZDs for almost anything, not just as an adjunct to ease someone onto a stimulating AD, thus allowing people to suffer unnecessarily.

I think in the future if I need to go onto a medication specifically for anxiety/depression I will go to see a psychiatrist privately.

Thanks once again for your observations and insight.

Belle

[panic_down_under]

I think in the future if I need to go onto a medication specifically for anxiety/depression I will go to see a psychiatrist privately.

Probably a good idea, Belle. UK GPs seem to be hamstrung in what they can prescribe by the NHS. That seems particularly so in terms of what they can offer patients to ease the common initial AD side-effects. They apparently can't even prescribe a good alternative to BZDs, the antihistamine hydroxyzine to ease heightened anxiety. While not quite as potent, it is often potent enough to make a significant difference.