What is the evidence for mirtazapine in treating cancer-related symptomatology? A systematic review

Abstract

Purpose Cancer patients often experience multiple distressing symptoms which are challenging to manage. It would therefore be helpful to find a treatment that alleviates more than one symptom, to avoid polypharmacy: mirtazapine has been used in several studies for this purpose. The objective of this study was to assess the effectiveness and safety of mirtazapine in alleviating one or more frequently encountered cancer-related symptoms. Methods Systematic review of clinical trials in English or French. Eight databases were searched. Included studies assessed the effectiveness of mirtazapine in alleviating one or more frequently encountered cancer-related symptoms. Comparator and validated assessment tools were required. Studies were independently appraised by two investigators before data synthesis. Results The search yielded 1898 references, from which we identified 12 relevant articles evaluating highly heterogeneous outcomes. These were two randomised-controlled (RCTs), three non-randomised controlled, and seven non-randomised noncontrolled trials. In total, 392 participants were included and 185 were in RCTs. No study assessed the effectiveness of mirtazapine in alleviating symptoms at the same time, but some considered more than one symptom. Overall, the data was of poor quality, limited by small sample size and bias. However, mirtazapine showed effectiveness in treating depression, anxiety, sleep disorders, emesis and neuropathic pain. Across all studies, mirtazapine is safe to use, with drowsiness and dizziness the most common side-effects. Conclusion Study design and small sample sizes limit the ability to interpret results. Trials to assess the impact of mirtazapine or other medicines in alleviating multiple symptoms would be valuable.

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Study protocol for SKIPMDD: subcutaneous ketamine infusion in palliative care patients with advanced life limiting illnesses for major depressive disorder (phase II pilot feasibility study)

“…Furthermore, the participation does not negatively impact on their physical symptom control (eg, restricting typical antidepressants dose-titration for managing neuropathic pain or anorexia). 70 71 Given the slow onset of action of the typical antidepressant (i.e. ≥ 4 weeks), 13 and the contrasting rapid onset and offset effects of ketamine (within days), the antidepressive effect of ketamine may still be differentiated from that of the typical antidepressant.…”

Practical aspects of palliative care & palliative radiotherapy in incurable cervical cancer

“…for breakthrough pain (strong opioid) • Tablet paracetamol 1 g at night and s.o.s. (non-opioid) (b) For neuropathic pain, insomnia and low mood 3 • Tablet mirtazapine 3.75 mg at night (c) To prevent opioid-induced constipation and nausea • Tablet bisacodyl 10 mg at night • Tablet domperidone 10 mg t.i.d for three days and then s.o.s (d) To reduce smell, he prescribes metronidazole according to the SNIFFF ladder 4 6 • Tablet metronidazole 400 mg t.i.d. for seven days followed by • Tablet metronidazole 200 mg once daily to continue The doctor assures the patient the pain will be better and that the medicines will not be expensive.…”