Can mirtazapine and propranolol be used together?

In this blog post, we are going to answer the question, “Can mirtazapine and propranolol be used together?”. Mirtazapine is an antidepressant which is used to treat a variety of mental health conditions. 

However, it may not do so well in combination with other prescription medications. This blog will cover the safety and efficacy of the concomitant use of mirtazapine and propranolol. 

Can mirtazapine and propranolol be used together? 

Yes, mirtazapine and propranolol can be used together to help control hypertension comorbid with depression. This combination is prescribed by a lot of healthcare providers and it is usually considered safe. 

However, the doses at which you take these meds matter a lot and they can make a huge difference in the expected therapeutic outcome. Several studies have indicated that mirtazapine and other antidepressants can enhance the hypotensive effect of propranolol and other Beta-blockers. 

This is one of the most important concerns and can be avoided by proper dose adjustment. Both of them are also associated with some additive side effects like dizziness or lightheadedness, headaches, abdominal pain, and blackouts. 

However, some case studies showed that propranolol can be used to help control mirtazapine induced akathisia. The most important thing to mention here is that this combination is not suitable for everyone. 

There are some people living with such health conditions which are not compatible either with mirtazapine or with propranolol. Make sure you use this combination only when prescribed by your healthcare provider. No medicine combination works for everyone. 

If you have gained therapeutic benefits from this one, it is not necessary that someone else you know will go through the same. This is exactly why it is strictly prohibited to give medication recommendations to other people, which is becoming a common practice, especially in Asian countries. 

What is the difference between mirtazapine and propranolol? 

Mirtazapine is an atypical antidepressant. It does not belong to any typical class of antidepressants and its mechanism of action is different from SSRIs and SNRIs. It does not block the reuptake of serotonin by any pathway. 

Mirtazapine belongs to the tetracyclic antidepressants. It has a dual mode of action. Mirtazapine is believed to be responsible for the activation of 5-HT1 receptors, which are one of the serotonin receptors. This antidepressant also acts on the noradrenergic system. 

Experts believe that mirtazapine enhances the stimulatory action of the noradrenergic system which increases the secretion of serotonin. It also prevents the inhibitory action of the noradrenergic system which hinders the release of serotonin. 

This way, it actively increases the amount of this excitatory neurotransmitter in your system. Mirtazapine can be used to treat the following health conditions:

• Depression 
• Anxiety 
• Treatment resistant depression 
• Depression in elderly patients
• Post-operative nausea
• Alcohol dependence
• Insomnia or inability to fall asleep 
• Neuropathic pain
• Inability to feel hungry/hunger suppression

Propranolol, on the other hand, is a beta blocker or beta-adrenergic blocker. It is a drug which blocks beta receptors present in the heart and lungs and inhibits the effects of adrenaline, also known as epinephrine. 

It can also dilate blood vessels and decrease the workload of the heart. Propranolol can be used for the treatment of following health conditions:

• Cardiovascular diseases, including high blood pressure, angina pectoris, management of congestive heart failure, arrhythmia or irregular heart beat, myocardial infarction, tachycardia, and coronary artery diseases. 
• Glaucoma 
• Migraine 
• Anxiety 
• Tremors or essential tremors

What are the side effects associated with the use of mirtazapine and propranolol? 

Both mirtazapine and propranolol are associated with some side effects. It is impossible to take an antidepressant, a drug that affects your brain, without having any unwanted effects. 

The intensity of these side effects depends on how much med you’re taking. If you’re at higher doses, you are more likely to suffer from them. Side effects associated with the use of mirtazapine include:

• Sleepiness or drowsiness 
• Excessive tiredness or fatigue 
• Dizziness or lightheadedness 
• Xerostomia or dry mouth 
• Anxiety 
• Agitation 
• Confusion 
• Gain of appetite
• Weight gain 
• Gastrointestinal side effects including nausea, vomiting and diarrhoea/Constipation 

Mirtazapine is also associated with some serious side effects, which may include:

• Allergic reaction associated with symptoms like redness of skin, itching, burning sensation, blisters, blue-purple patches, tightness of chest, wheezing, difficulty in breathing, hoarseness etc. 
• Convulsions 
• QT prolongation 
• Pain and tightness in chest
• Arrhythmia 
• Flu like symptoms 

Make sure you immediately inform your healthcare provider if you exhibit any sign of an allergic reaction or any unusual side effect while being on mirtazapine. 

Antidepressants are not easy to deal with and people usually switch their antidepressants multiple times to find the one that’s compatible with their body. Propranolol is also associated with some side effects. These include:

• Xerostomia or dry mouth 
• Nausea 
• Vomiting 
• Constipation 
• Flatulence 
• Acid reflux 
• Depression 
• Fatigue 
• Lightheadedness 
• Abnormal pain
• Acid reflux 
• Flu like symptoms 
• Skin rash

Some serious side effects include:

• Difficulty in breathing and chest tightness 
• Swollen hands and feet as a result of an allergic reaction. 
• Wheezing
• Blackouts 
• Unexplained weight gain or loss
• Arrhythmia 

The serious side effects of propranolol can become quite disturbing, especially when you’re on higher doses. Every single chemical out there has a potential to kill you. It’s the dose which makes it a medicine. Make sure you stick to the recommended doses and refrain to deviate from it. 

How to ensure the proper use of mirtazapine? 

Make sure mirtazapine is the right choice of antidepressant for you. Do not combine this med with any other medication, unless you don’t know how it makes you feel. This is crucial for new mirtazapine users who are not usually sure how much this antidepressant can affect them. 

Mirtazapine comes with a suicidal warning in users younger than 24 years of age. If you have someone who shows suicidal behavior or you see hopelessness in them, make sure you keep an eye on them and get medical attention as soon as you can. 

Do not stop mirtazapine abruptly. If it’s time for you to stop one or both of these meds, your doctor will simply recommend a taper schedule for you, which should be followed vigilantly if you wish to keep withdrawal symptoms at bay. 

Inform your doctor if you’re pregnant or trying to conceive. It is extremely important to ensure safety of mirtazapine during your pregnancy. Some antidepressants can cross the placenta and are capable of causing unwanted side effects in the growing fetus.

How to ensure the proper use of propranolol? 

Propranolol is contraindicated to be used in patients who suffer from chronic breathing illnesses, including asthma and chronic obstructive pulmonary disease (COPD). 

Propranolol is a non selective beta blocker which blocks beta-receptors present in heart, lung and airways. This drug causes vasodilation to reduce blood pressure and heart rate, and at the same time, it also causes bronchoconstriction and makes the airways narrow. 

People with asthma and COPD already live with breathing difficulty and this propranolol bronchoconstriction can make their symptoms much more severe. It can also lead to hospitalisation. This is why the drug would never be prescribed to such patients. 

Propranolol should be used cautiously in people with diabetes. People who are diabetic are often on prescription medications to manage their blood glucose levels. 

Oftentimes, such people suffer from hypoglycemia (low blood sugar), which is indicated by low heart rate and blood pressure. With propranolol, the rate rate and blood pressure remain low, which is why a diabetic patient fails to detect the low blood sugar levels. 

For such people, it is advised to monitor their blood sugar levels regularly to avoid getting any complications associated with hypoglycemia. 

Propranolol should be used cautiously in pregnancy. You should also ask your healthcare provider if you are trying to get pregnant as this drug may produce unwanted side effects. However, the intensity of these effects can vary from woman to woman. 

Propranolol actually comes with a black box warning, issued by the Food and Drug Administration (FDA), stating that this med should never be stopped abruptly because of the life threatening risks. This risk is much greater in patients who are at risk of a heart attack.

Conclusion 

In this blog post, we have discussed the safety and efficacy of the concomitant use of mirtazapine and propranolol. This combination is prescribed by a lot of healthcare providers and it is usually considered safe. 

However, the doses at which you take these meds matter a lot and they can make a huge difference in the expected therapeutic outcome. Both of these meds require precautions and should not be used in certain conditions. It is important to make sure you’re taking your meds properly.

FAQs: mirtazapine and propranolol

Can you take propranolol with antidepressants?

Yes, antidepressants and propranolol can be used together to help control hypertension comorbid with depression. This combination is prescribed by a lot of healthcare providers and it is usually considered safe. However, the doses at which you take these meds matter a lot and they can make a huge difference in the expected therapeutic outcome. Several studies have indicated that antidepressants can enhance the hypotensive effect of propranolol and other Beta-blockers.

What drugs should not be taken with mirtazapine?

• Monoaminoxidase inhibitors (MAOIs). The combination use can increase the risk of serotonin syndrome. 
• Non-steroidal anti-inflammatory drugs (NSAIDS). The combination use can increase the risk of bleeding. 
• Pimozide. The concomitant use can increase the plasma concentration(availability of a drug in the blood) of pimozide to much higher levels. It can result in life-threatening arrhythmia.
• Controlled substances, including all narcotic analgesics. The concomitant use can cause severe psychological side effects. 
• Mood stabilisers 
• Alcohol 

Is propranolol better than mirtazapine?

Propranolol and mirtazapine are two separate medications and you can not compare meds that produce different kinds of effects. Mirtazapine belongs to the tetracyclic antidepressants. Mirtazapine is believed to be responsible for the activation of 5-HT1 receptors, which are one of the serotonin receptors. This way, it actively increases the amount of this excitatory neurotransmitter in your system. 

Propranolol, on the other hand, is a beta blocker or beta-adrenergic blocker. It is a drug which blocks beta receptors present in the heart and lungs and inhibits the effects of adrenaline, also known as epinephrine. It can also dilate blood vessels and decrease the workload of the heart. 

What drugs should not be taken with propranolol?

Propranolol should not be taken with other beta blockers or any other drug that can reduce blood pressure or workload of your heart rate. The additive effects can dangerously slow down your circulatory system and give rise to a number of complications. 

What antidepressant works well with mirtazapine?

Several studies have suggested that mirtazapine works well when it is used in combination with an SSRI or an SNRI. However, a combination of antidepressants can only be taken when prescribed by your healthcare provider. 

This is because when two meds for the same illness are used, the doses are adjusted. Individual therapy comes with higher doses, while combination therapy has to be adjusted on the comfortable doses to help avoid the side effects. 

References

• Drug Interactions between mirtazapine and propranolol https://www.drugs.com/drug-interactions/mirtazapine-with-propranolol-1640-0-1956-0.html#:~:text=Interactions%20between%20your%20drugs&text=Propranolol%20and%20mirtazapine%20may%20have,in%20pulse%20or%20heart%20rate.
• Katherine Koller, PharmD, BCPP (2019) – Propranolol for mirtazapine-induced akathisia: Single case report https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322814/
• Dariusz Andrzejczak,Katarzyna Kocon,Remigiusz Zięba (2008) – Influence of Mirtazapine on the Hypotensive Activity of Enalapril and Propranolol in Spontaneously Hypertensive Rats https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-7843.2008.00310.x
• National Library of Medicine – Mirtazapine https://medlineplus.gov/druginfo/meds/a697009.html 
• National Library of Medicine – propranolol  https://medlineplus.gov/druginfo/meds/a682607.html