Cymbalta and Mirtazapine (Is there any interaction?)

In this blog post, we are going to talk about the possible interactions between cymbalta and mirtazapine. Both of these meds are antidepressants in nature and can be used for a number of mental health related problems. 

However, the concomitant use can lead to disturbing side effects and this is what we are going to cover in this blog. We will also discuss how cymbalta is different from mirtazapine. 

Is there any interaction between cymbalta and mirtazapine? 

Cymbalta and mirtazapine may interact with one another and increase the risk of serotonin syndrome, which results from excessive serotonergic activity in your body. 

These drugs treat depression by increasing the amounts of excitatory neurotransmitters in your body, usually serotonin and norepinephrine. The excessive amount of serotonin can result in serotonin syndrome, which is associated with symptoms like:

• Fever with chills
• Excessive sweating 
• Restlessness and fatigue
• Headache, which often feels like your head is pounding
• Changes in blood pressure and/or temperature
• Nausea
• Vomiting
• Diarrhoea
• Bradycardia
• Tremors
• Muscle twitching and muscle pain
• Shivering and goosebumps

However, these two can still be used together for exceptional conditions. Several researchers have indicated some beneficial effects of the combination therapy of cymbalta and mirtazapine, but they also reported some disturbing side effects. 

Later it was indicated that these two can only be used together after weighing the risk vs benefit ratio in specific conditions. However, more research is needed for the safety, efficacy, and appropriate dosage of the combination therapy of cymbalta and mirtazapine. 

Make sure you use these two together only when prescribed by your healthcare provider. Do not deviate from the recommended dose. 

What is the difference between cymbalta and mirtazapine? 

Cymbalta, a generic name for duloxetine, belongs to the class of serotonin norepinephrine reuptake inhibitors (SNRIs). It inhibits the reuptake of both serotonin and norepinephrine by blocking SERT and NET respectively.

Norepinephrine is another excitatory neurotransmitter which is responsible for a number of physiological functions including breathing rate and blood pressure. 

SNRIs can also be used as a first line of treatment in some patients and are considered quite effective in the treatment of depression and several other mental health conditions, including:

• Major depression
• Generalised anxiety disorder (GAD) 
• Fibromyalgia induced pain
• Skeletal muscle pain
• Urinary incontinence 
• Peripheral Neuropathy associated with Chemotherapy 

Mirtazapine, on the other hand, 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

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

Both cymbalta and mirtazapine 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 cymbalta include:

• Drowsiness
• Fatigue
• Sleepiness or hypersomnia
• Decreased salivation leading to dry mouth 
• Vertigo 
• Loss of appetite 
• Excessive sweating
• Constipation or diarrhoea 
• Weight gain or loss
• Abdominal pain
• Bloating 
• Flatulence 
• Headache 
• Muscular pain 

Serious side effects include:

• Urinary problems 
• Vision problems 
• Low sodium levels 
• Orthostatic Hypotension. 
• High doses can cause serotonin syndrome, associated with chills, fever, confusion, delirium, cloudiness, convulsions etc. 
• It can cause liver damage associated with abdominal pain, excessive itching, yellowing of eyes and skin etc. 
• Allergic reaction to the drug, which includes breathing issues, skin rashes associated with itching, redness, blisters, blue-purple patches, burning sensation etc. 
• It can cause manic behaviour in some patients, associated with aggressiveness, anger, improper behaviour, chills, sweating, hyperventilation etc. 

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 

How to ensure the proper use of cymbalta and mirtazapine? 

Immediately talk to your healthcare provider if you experience unusual side effects while taking cymbalta and mirtazapine together. Do not recommend this combination to someone else and use it as long as your doctor has advised. 

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

Inform your doctor if you’re a breastfeeding mother. Both cymbalta and mirtazapine are capable of passing into the breastmilk and may cause side effects in newborns. 

Both cymbalta and mirtazapine can induce suicidal behavior 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 cymbalta and 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. 

Make sure these drugs are not interacting negatively with one another or any other prescription medication that you might be taking. Drug interactions should be an important consideration before taking two or more medicines together. 

Yes, drugs in combination are often used to achieve better therapeutic response but this is not the case with every interaction. Some drugs are highly incompatible with one another. 

They often cancel out each other’s effects or antagonise them. Some drugs are so incompatible that they end up changing the entire chemical composition of one another. 

Some interfere with metabolism or bioavailability (the rate and extent at which the active drug moiety enters systemic circulation/blood). This can lead to drug accumulation in different parts of the body. 

It is always advised to inform your healthcare provider of any medicine you take before getting a new prescription. Your doctor will make sure not to prescribe any such drug which might interfere with those you are already taking. 

Conclusion 

In this blog post, we have discussed the possible interactions between cymbalta and mirtazapine. These two antidepressants may interact with each other and increase the risk of serotonin syndrome, which is the condition associated with too much serotonergic activity. 

Experts suggest that these two medicines should be used at low doses if they are used together. However, monotherapy with either cymbalta and mirtazapine is considered safe and effective for the treatment of depression and anxiety. 

Make sure you ask your healthcare provider before you start using any medication. It is not recommended to self medicate. This combination can not only cause serotonin syndrome, but several other disturbing side effects. 

Make sure you use these meds or any other medication only when your doctor has advised it. Using medications which can affect your brain is not something ideal and should not be encouraged unless it is absolutely necessary to do so. 

FAQs: Cymbalta and mirtazapine  

What antidepressant works well with Cymbalta?

Cymbalta works well with a number of antidepressants, but it depends on the doses at which both of the meds are used. It can be paired with sertraline, paroxetine, escitalopram, citalopram, fluoxetine, mirtazapine and several other antidepressants. 

What is the difference between Cymbalta and mirtazapine?

Cymbalta, a generic name for duloxetine, belongs to the class of serotonin norepinephrine reuptake inhibitors (SNRIs). It inhibits the reuptake of both serotonin and norepinephrine by blocking SERT and NET respectively.

Mirtazapine, on the other hand, 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. 

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. 

What should you not mix with Cymbalta?

• 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 

What is the #1 antidepressant?

Fluoxetine, sertraline, and escitalopram are the most commonly prescribed antidepressants. They work quite well for a large sum of people and are well tolerated, but this is not the case with everyone. Some people are allergic to these meds and show signs of allergic reactions soon after taking them. 

So, it completely depends on how your body treats the med and it is hard to tell if these antidepressants would act like #1 antidepressant for you. Always stick to the drug and dose suggested by your healthcare provider.

References 

• Drug Interactions between Cymbalta and mirtazapine https://www.drugs.com/drug-interactions/cymbalta-with-mirtazapine-949-2273-1640-0.html#:~:text=Using%20mirtazapine%20together%20with%20DULoxetine,shivering%20or%20shaking%2C%20blurred%20vision%2C 
• David Meagher et al. Ir J Psychol Med. (2006) – Duloxetine-mirtazapine combination in depressive illness https://pubmed.ncbi.nlm.nih.gov/30290515/ 
• National Library of Medicine – Mirtazapine https://medlineplus.gov/druginfo/meds/a697009.html 
• Mirtazapine Tablet – Uses, Side Effects, and More https://www.webmd.com/drugs/2/drug-13706-4047/mirtazapine-oral/mirtazapine-oral/details 
• Duloxetine – Uses, Side Effects, and More https://www.webmd.com/drugs/2/drug-91490-2114/duloxetine-oral/duloxetine-sprinkle-capsule-oral/details