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HomeAnswersPsychiatrymirtazapineI have been prescribed Mirtazapine for my intestinal issues. How long should I take it?

What are the chances of interactions between Mirtazapine, Escitalopram, Flupenthixol, and Nortryptyline?

The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Medically reviewed by

iCliniq medical review team

Published At December 26, 2022
Reviewed AtNovember 6, 2023

Patient's Query

Hello doctor,

I moved to a new country four years ago. I used to eat at hotels or restaurants. As a result, I had frequent food poisoning episodes. I got food poisoning more than 20 times in two years. Each time, it was treated with a course of antibiotics. For the last three years, I have completely shifted to home-cooked food. Attempts were made to correct this issue by using probiotics and fiber supplements. Also, a non-absorbing antibiotic called Rifaximin was tried to see if there was an improvement, but in vain. The doctor said I have some problems in my intestine. For the functional intestinal issue, treatment using Mirtazapine 7.5 mg has been recommended. I want to try Mirtazapine and see if there is an improvement. Please answer the following: If I am getting relief, what is the course duration for Mirtazapine 7.5 mg? Will mild cases like mine recover from this issue? I am currently on Escitalopram 15 mg, Flupenthixol 5 mg, and Nortryptyline 25 mg for stress. Even though I have anxiety, I did not feel any digestive discomfort proportional to stress in the past. Is it possible to add Mirtazapine 7.5 mg to this regimen? Will there be any unwanted interactions?

Thanks.

Hello,

Welcome to icliniq.com.

I understand your concern.

Frequent gastrointestinal infections have triggered irritable bowel syndrome. Mirtazapine is used for IBS (irritable bowel syndrome) and shows promising results. It is quite safe. Initially, take it for three months. Then, you can stop and check if there is a further need to continue. IBS can go into remission or exacerbation, and the duration of treatment is decided upon the course of an active illness. Yes, you will recover from this completely. I would suggest you continue taking probiotics. Mirtazapine goes well with Escitalopram. They act in conjunction, and it boosts the antidepressant effect of Escitalopram. No significant interactions with Nortriptyline 25 mg or Flupenthixol 0.5 mg are seen. Consult a specialist doctor, discuss with them, and take medications with their consent.

I hope this information will help you.

Thank you.

Patient's Query

Hi doctor,

Thank you for the reply.

I started taking the tablet Mirtazapine 7.5 mg three days ago. I was advised to start with half a tablet of 7.5 mg at night for ten days and then continue with 7.5 mg. The result is positive. The stool has become rigid and well-formed to a reasonable extent. I would like to understand if IBS is an issue with nerves connected to the intestine. Has the brain become sensitive to signals from nerves associated with the intestines?

Thank you.

Hello,

Welcome back to icliniq.com.

I understand your concern.

I am glad to know that you are doing well. The mechanism of IBS is still a medical mystery. The brain and gut are connected bidirectionally through nerves, hormones, and immune pathways. This is known as the brain-gut axis. In IBS, the brain-gut axis is malfunctioning, but it is unknown where or what exactly the issue is.

I hope this information will help you.

Thank you.

Patient's Query

Hi doctor,

Thanks for the reply,

  1. Can I take Escitalopram 15 mg, Flupenthixol 5 mg, Nortryptyline 25 mg, and Mirtazapine 7.5 mg at night together?
  2. Does this combination cause serotonin syndrome?
  3. Which exercise is good for mental health?
  4. Are some food items that are good for mental health when consumed daily?
  5. Is there a diet plan suitable for mental health?

Thanks.

Hello,

Welcome back to icliniq.com.

I understand your concern.

Yes, there is no problem with taking them together at one time at night. Theoretically, combining antidepressants could lead to serotonin syndrome, but in practice, antidepressants are combined very often, and serotonin syndrome is still rare. Taking into consideration the medicines and the doses that you are taking, I would not worry much about serotonin syndrome. It would not be wise to discontinue a working combination of medicines to avoid the theoretical rare risk of serotonin syndrome. All exercise is good for mental health. But if you have time and energy for just one, choose aerobic exercise. You can also do weight training two to three times a week and aerobic exercise on other days to keep it interesting. As I said, any activity for 30 to 45 minutes daily boosts mental health. Fresh fruits, vegetables, and nuts contain antioxidants that promote mental health. Dark chocolate is also good. Simple carbohydrates like sugars are not suitable for mental health. They cause tiredness and lethargy. A diet with sufficient protein (1 mg/kg body weight) is needed for excellent and sustained energy levels. Likewise, your diet should include complex carbohydrates and fats. All nutrients in adequate proportions are needed for good functioning of the brain.

I hope this information will help you.

Thanks.

Patient's Query

Hi Doc 1) Does Mirtazapine has a potential to increase anxiety initially ?. If so how long will it last? After 10 days of taking 1/2 of 7.5 mg tablet , I am taking 7.5mg from last 5 days. I feel a spike in anxious thoughts(Disturbing my concentration) from last 3 days.
Hello George, No, mirtazapine is not known to increase anxiety initially. Infact, it is used to control anxiety at the beginning of treatment. Regarding your increase in disturbing thoughts, are they obsessive in nature ( repeatative, disturbing, unwanted and intrusive, which are difficult to control).? some people report increase in obsessions with mirtazapine. Any new change in symptoms, if it is transient and because of a medicine, it should usually go away in 1 to 2 weeks after increasing the dosage. If it doesn't, then it might not be transient. Regards

Patient's Query

Yes. It is exactly what you describe. Obsessive in nature ( repetitive, disturbing, unwanted and intrusive, which are difficult to control focused on friction with people that happened in the past.)
Hello, OK, some medicines like mirtazapine / olanzapine can cause increase in obsessions. Sometimes, it is transient, sometimes, it stays. My recommendation would be - if you can bear it for few more days, wait and see if it goes away. If it doesn't reduce after 7-15 days of increasing dosage , then you might need to discontinue the medicine. Regards,

Patient's Query

I will wait for couple of days and see if there is a reduction. If so I will continue till the 15th day and then further continue based on the outcome. I had a hope that if it is due to medicine then it goes away but as per your latest comment the issue may stay. I am hoping for the best.
Hello, Yes, it is difficult to predict in advance, if it stays or goes.your plan sounds reasonable. I hope that it goes away and you are able to continue the medicine without any issue. Regards and best wishes,

Patient's Query

I continued 7.5 mg for straight 7 days and it didn't show any signs of reduction in anxiety and I stopped it. Now I feel better. I hope the induced obsessive thoughts will resolve on its own with the current medications. I understand that there are other medicines used by gastroenterologist for the same purpose. One such recommendation is Chlordiazepoxide HCI & Clidinium Bromide. I am yet to receive the dosage from gastro. 1) Is Chlordiazepoxide the only benzodiazepine anxiolytic which calms down the Vagus nerve and relieves the symptoms of IBS. 2) What is your opinion on trying Chlordiazepoxide HCI & Clidinium Bromide. 3) I red about a feature of mind called placebo and nocebo. can you shed some details on it ?.
Hello George, Ya, I think the obsessions should wane out gradually in a matter of time. Coming to your questions 1) no, all benzodiazepines help ibs by reducing anxiety. Chlordiazepoxide is preferred because its mild, not very sedating and least habit forming. Besides, it comes in one tablet in combination with clidinum bromide. 2)it helps a lot of people with ibs. Older practitioners use it a lot with good results. And its quite safe too. 3)placebo effect is when a pill/procedure makes you feel better because of your expectations about it. The effect is not due to any active pharmaceutical ingredient but because of your own mind. Nocebo is getting an adverse effect from such a neutral non active drug. Psychological phenomena like pain are most responsive to placebos. In my experience, these are transient effects and don't show long term benefit for psychiatric / physical disorders. Hopefully, the new medicine will help your ibs. Best wishes.

Patient's Query

The recommended dosage is Librax 3 times daily 30 mins before food for 1 week and then follow up. 1) I hope this combination goes well with my current medications.
Hello, yes, that's the recommended dosing initially. After a while, you'll be able to reduce it. 1)Yes, it will go smoothly along with escitalopram, Nortriptyline and Flupenthixol. I wish it works for you. Regards,

Patient's Query

Hi doctor,

Thanks for the reply.

I have completed Librax three times daily 30 minutes before food for three weeks. I do not see a positive response. The stool does not have a rigid consistency. The only thing which I feel is increased sleep (nine to10 hours). With Mirtazapine it was positive ( stool has rigid consistency ) but unfortunately it gave obsessions as side effect.1. Why does Mirtazapine slows down over active gut motility. is it because of the antagonism at 5HT3 receptor?

2. Is 5HT3 receptor only found in brain and vagus nerve?

3. Can we use a pure 5HT3 antagonist drug instead of Mirtazapine.

4. I came to know that Ramosetron (5HT3 antagonist) 5mcg is effective for stool consistency and rigidity.

5. Can I trial it and note the response. Does it have a potential to spike obsessive thoughts like mirtazapine?

6. Does 5HT3 antagonists antagonize the serotonin receptors both in brain and vagus nerve?

7. Please let me know your thoughts if there is a better alternative.

Thanks.

Hello,

Welcome back to icliniq.com.

I understand your concern.

1. Mirtazapine has anticholinergic and antihistamine action in addition to 5HT3 antagonism. Anticholinergic agents are known to slow down gut motility.

2. 5HT3 receptors are found in the gut and are related to the gastroenteric system.

3. Ramosetron is used for IBS (irritable bowel syndrome) and can certainly be tried. It is unlikely to cause a spike in obsessive symptoms. Those symptoms of mirtazapine are probably due to antihistamine action.

4. 5HT3 antagonists block 5HT3 receptors involved in gut motility. So, they could help you.

I recommend increasing dietary fiber as the first resort. Salads could help a lot. If your diet is insufficient in fiber, you can always take fiber supplements. We need about 30 grams of dietary fiber daily.

I hope this information will help you.

Thank you.

Patient's Query

Hi doctor,

Thanks for the reply.

For the last two years, I have been regularly taking fiber supplements. I take Isaphagula Husk powder 5 grams in the morning and 5 grams at night. In addition to that, I take one probiotic capsule. I am experiencing good effects of fiber. I can pass more stool in a single go. Also, my gastrointestinal immunity has improved. Most of the time, I eat home-cooked meals.

  1. To switch to Ramosetron, I need to taper Librax (three times daily). What is the schedule for tapering?
  2. I hope I am not disturbing you with follow-ups. If possible, I need to get back my tummy back to normal.

Thanks.

Hello,

Welcome back to icliniq.com.

I understand your concern.

Yes, please taper off Librax (Chlordiazepoxide hydrochloride). Whenever you decide to stop, I recommend taking it once daily for seven days and then quitting it.

I hope this information will help you.

Thanks.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Saraswat Kumarshri Shriniwas
Dr. Saraswat Kumarshri Shriniwas

Psychiatry

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