MIANSERIN

brands

Class

• Neuroscience-based Nomenclature: norepinephrine multimodal (N-MM)
• Tetracyclic antidepressant
• Noradrenergic agent

MIANSERIN commonly prescribed for

(Bold for FDA approved)

How MIANSERIN works

• Blocks alpha 2 adrenergic presynaptic receptor, thereby increasing norepinephrine neurotransmission

• This is a novel mechanism independent of norepinephrine reuptake blockade

• Blocks alpha 2 adrenergic presynaptic receptors but also alpha 1 adrenergic receptors on serotonin neurons, thereby causing little increase in serotonin neurotransmission

• Blocks serotonin 2A, 2C, and 3 receptors

• Blocks H1 histamine receptors

How long until MIANSERIN works

• Actions on insomnia and anxiety can start shortly after initiation of dosing

• Onset of therapeutic actions in depression, however, is usually not immediate, but often delayed 2–4 weeks

• If it is not working within 6–8 weeks for depression, it may require a dosage increase or it may not work at all

• May continue to work for many years to prevent relapse of symptoms

Notable Side Effects

• Sedation

• Increased appetite, weight gain

Life Threatening Side Effects

• Rare seizures

• Rare blood dyscrasias

• Rare induction of mania

• Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24)

weight gain

common

sedation

common

What to do about MIANSERIN side effects

• Wait

• Wait

• Wait

• Switch to another drug

usual dosage range

• 30–60 mg/day

Dosage Forms

• Tablet 10 mg, 30 mg, 60 mg

long term use

• Safe

habit forming

• Not expected

Renal Impairment

• Dose adjustment not necessary

Hepatic Impairment

• Dose adjustment not necessary

Cardiac Impairment

• Baseline ECG is recommended

• Drug should be used with caution

Elderly

• Baseline ECG is recommended for patients over age 50

• Some patients may tolerate lower doses better

• Blood dyscrasias, though still rare, may be more common in the elderly

Children and Adolescents

• Carefully weigh the risks and benefits of pharmacological treatment against the risks and benefits of nontreatment with antidepressants and make sure to document this in the patient’s chart

• Monitor patients face-to-face regularly, particularly during the first several weeks of treatment

• Use with caution, observing for activation of known or unknown bipolar disorder and/ or suicidal ideation, and inform parents or guardians of this risk so they can help observe child or adolescent patients

• Safety and efficacy have not been established

Pregnancy

• Controlled studies have not been conducted in pregnant women

• Not generally recommended for use during pregnancy, especially during first trimester

• Must weigh the risk of treatment (first trimester fetal development, third trimester newborn delivery) to the child against the risk of no treatment (recurrence of depression, maternal health, infant bonding) to the mother and child

• For many patients this may mean continuing treatment during pregnancy

Breast Feeding

• Some drug is found in mother’s breast milk

• If child becomes irritable or sedated, breast feeding or drug may need to be discontinued

• Immediate postpartum period is a highrisk time for depression, especially in women who have had prior depressive episodes, so drug may need to be reinstituted late in the third trimester or shortly after childbirth to prevent a recurrence during the postpartum period

• Must weigh benefits of breast feeding with risks and benefits of antidepressant treatment versus nontreatment to both the infant and the mother

• For many patients, this may mean continuing treatment during breast feeding