Remeron Sleep Disruption

[Sushirolls]

Are they still teaching that remeron above 30mg and FDA max of 45mg is activating? Or even testing on PRITE and ABPN?
I've not once seen it activating at higher doses and disrupting sleep.
I think I have greater odds of seeing Big Foot during deer hunting season.

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[Stagg737]

I have seen it a small number of times (<5) and teach my residents that it's possible and something to consider, but that keeping single 45mg QHS dose is the appropriate step is going above 30mg. Did have 1-2 patients in residency where we split the dosing to 30mg QAM and 15mg QHS and patients did well with that, but more often when they didn't tolerate 45mg just had to back down or try something else.

 

[reca]

I was taught in residency that this is a myth. Have never seen any evidence since to convince me otherwise.

 

[Psychferlyfe3000]

Theoretically it comes from alpha-2 antagonism causing increased noradrenergic tone that outcompetes the sedation from H1 antagonism. Unclear how high of a dose would be necessary for this to occur though.

 

[FlowRate]

It was always taught/discussed slightly differently whenever I've talked or read about it--that higher doses can be paradoxically less sedating. Never really hard it described as being potentially "stimulating" though.

 

[clozareal]

I have not been taught this.

The paradoxically less sedating is what people say with mirtazapine too but to know that, wouldn't you need to do a fixed dose study since time can confound the losses in the soporific effects when you ramp the dose up, particularly related to histamine?

 

[splik]

From personal experience I couldn’t sleep at all on 60mg but less than that it was sedating. In geriatric patients the dose at which it will lose its sedative effects is lower. But the idea that the lower those the more sedating it is - that is nonsense for most patients.

 

[calvnandhobbs68]

I have not been taught this.

The paradoxically less sedating is what people say with mirtazapine too but to know that, wouldn't you need to do a fixed dose study since time can confound the losses in the soporific effects when you ramp the dose up, particularly related to histamine?

I'm not sure if this is just awkward wording or if you're implying that mirtazapine is different than remeron....

 

[clozareal]

I'm not sure if this is just awkward wording or if you're implying that mirtazapine is different than remeron....

Ha. It's my skimming the OP too fast. I read ramelteon rather than remeron.

 

[B52slinger]

I was taught in residency that this is a myth. Have never seen any evidence since to convince me otherwise.

agreed, in the real world I've consistently seen higher dosage = more sedating
actually had an outpatient just last week who needed 60 mg to fall asleep and when I cut him back to 30 mg because it would be "more sedating" on paper he got insomnia