Mirtazapine is commonly used in elderly patients with depression who are also suffering from insomnia. Mirtazapine is often chosen because it is much safer than benzodiazepines, “z-drugs”, and antipsychotics. The mechanisms of mirtazapine (podcast episode on the pharmacology) include the release of norepinephrine via presynaptic adrenergic auto-receptor blockade, increased serotonin production through stimulation of adrenoreceptors on serotonergic cell bodies, and the direct blockade of 5-HT2 and 5-HT3 receptors. Mirtazapine has a high H1 receptor affinity, leading to antihistamine effects. So what does this mean as far as dosing of mirtazapine for insomnia?
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