Tetracyclic antidepressants include -

Mirtazapine and Maprotiline, Mianserin

Refer - Mitrazapine

Adverse Reactions-

MIRTAZIPINE -
-------------------
CARDIOVASCULAR - 

  Hypertension > 1% Hypotension  1%

CNS-     

 Somnolence 54%Dizziness 7%  Asthenia 8%  Abnormal dreams 4%
  Abnormal thinking 3%  Tremor 2% Agitation 1%  Anxiety 1%

DERMATOLOGIC -

Alopecia  1%,Rash 1%  

GI-

 Dry mouth 25%  Increased appetite 17%Constipation 13%  Nausea  >1%
 Nausea and vomiting 1%

METABOLIC/NUTRIONAL -

Peripheral edema 2%  Edema 1%  Weight gain 12% Weight loss 1%

MISCELLANEOUS -

 Flu syndrome 5% Myalgia 2%    Back pain 2% Urinary frequency 2%
  Altered liver function 1% Dyspnea 1%

Hypersensitivity to Maprotiline

 Maprotiline - known or seizure disorder

Use during acute phase of myocardial infarction MI ,

Co-adminstration with MAOI inhibitors

Special precautions-

Clinical worsening of suicide risk - Adults and children with MDD may experience of worsening of their depression and/or emergence of suicidal ideation and behaviour or unusual changes in behaviour

Consider changing the therapeuticc regimen including possibly of discontinuing the medication in patients whose depression is persistently worse

Seizures- have been associated with the use of maprotiline.

Risk of seizure may be increased when meprotiline is taken concomittantly with phenothiazines, when the dosage is rapidly tapered in patients receiving maprotiline. The risk can be reduced by initiating therapy at a low dose, maintain the initial dose for 2 weeks and raising it gradually as needed

MAOIs - concomittant use of maprotiline with an MAOI is contraindicated

Renal/hepatic function impairment- caution must be excercised when administering mirtazapine to such patients

Special risk patients- Administer maprotiline with caution in patients with increased intraocular pressure, history of urinary retention, or history of narrow angle glaucoma because of the drugs anticholinergic properties

Pregnancy- Use the drug during pregnancy only if clearly needed Labor and delivery. As with any other CNS depedent drugs excercise caution during labor and delivery

Lactation- Excercise caution when maprotiline is administered to a breast feeding woman.

Children - safety for use in children have not been established

Elderly- excecise caution when administering mitrazapine to elderly patients

Date of Approval    2001

Indication

Major depressive disorder

Dosage-

Maximum dose 45mg/day

Iinitial - 15mg/day as a single dose preferably in the evening prior to sleep. The effective dose range is generally 15 to 45mg/day Patients not responding to initial dose of 15mg/day may benefit from dose increases of up to 45mg/day

Tetracyclic antidepressants includes

- Mirtazapine and Maprotiline, Mianserin

Refer - Mitrazapine

1. Clinical worsening and suicide risk- Advice families to observe for the emergence of suicidal symptoms/ tendency on a daily basic and report such symptoms to your doctor

2. Hazardous tasks- caution patients about engaging inhazardous activites until they are re resonably certain that tetracyclics do not adversely affect their ability to engage in such activites

3. Alcohol- advice patients to avoid alcohol while taking tetracyclic antidepressants becuase of aditive impairment of cognitive and motor skills

4. Pregnancy and breast feeding- advice patients to notify their doctor if thet become pregnant or intend to become pregnant or are breast feeding during tetracyclic therapy

Pharmacology-

The mechanism of action of tetracyclic is not precisely known. Maprotiline and mirtazapine are both considered tetracyclic antidepressants ( because of their chemical structure ), but they each affect different neurotransmitters and thus have different adverse reaction profiles

Maprotiline primarily acts by potentiation of central adrenergic synapses by blocking reuptake of noreppinephrine at nerve endings. This pharmacologic action is thought to be responsible for its antidepressant and anxiolytic effects.

Absoption/distribution-

Maprotiline is slowly and completely absorbed after oral admiin. and steady state is acheived after 1 week. of therapy Mirtazapine tablets are rapidly and completely absorbed following oral admin.

Presence of food in the stomach has a minimal effect in the rate and extent of absorption and does not require dose adjustment Maprotiline is slowly eliminated primarily as metobolites ( most of which are glucoronides )

Mirtazapine is extensively matabolised after oral admin.

Presence of food has a minmal effect on the rate and extent of absorption

Pregnancy-

Use the drug during pregnancy only if clearly needed Labor and delivery- as with any other CNS depedent drugs excercise caution during labor and delivery

Lactation-

Excercise caution when maprotiline is administered to a breast feeding woman.

Children -

Safety for use in children have not been established

Elderly-

excecise caution when administering mitrazapine to elderly patients