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Its use in inhibiting the development of opioid tolerance has not been tested in children.

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It is at least as effective as the older antidepressants for treating mild to severe depression. Although agranulocytosis is the most serious side effect, it is rare (approximately one in 1,000) and usually reversible when the medication is stopped. Many clinicians consider mirtazapine a second-line or even third-line antidepressant, to be used when older antidepressants are not tolerated or are ineffective.

Mirtazapine is metabolized in the liver via the P450 cytochrome oxidase pathway, inhibiting cytochromes 2D6, 1A2 and 3A4. Clearance of the drug is diminished in the presence of liver or renal impairment.

Therefore, a lower dosage is recommended in elderly patients and those with liver or renal dysfunction.

Mirtazapine is currently approved for use in adults. Food and Drug Administration has labeled mirtazapine as a pregnancy category C drug.1217 Mirtazapine has been used successfully in the treatment of mild to severe depression.18Mirtazapine is especially helpful in patients with depression who are anxious; this drug has been shown to reduce anxiety and has even been used to relieve preoperative anxiety and insomnia in patients having gynecologic surgery.13The most common side effects of mirtazapine are dose-dependent drowsiness (54 percent), dry mouth (25 percent), increased appetite (17 percent), weight gain (12 percent) and dizziness (7 percent).

Because it is unknown if mirtazapine is secreted in breast milk, it should be used with caution in breast-feeding mothers. These side effects tend to improve with time.318 Mild to moderate elevations in cholesterol, triglyceride and alanine aminotransferase (ALT: formerly known as SGPT) levels may also occur.

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