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In the medical literature, occurrence of edema during treatment with mirtazapine is stated as the least frequently reported side effect. A case of edema occurring during mirtazapine treatment is reported below.
Case: A 34 year-old female patient was admitted to the psychiatric ward with a diagnosis of recurrent depressive disorder. There were no specific findings in the patient's medical history other than high blood pressure and irregularly administered antihypertensive drugs. There was no use of alcohol or illicit drugs. The treatment regimen of the patient included escitalopram 5 mg daily, alprazolam 0.5 mg daily, and hydroxyzine 12.5 mg daily. Mirtazapine 15 mg daily was added to the medical treatment, as the depression and insomnia continued. The day after beginning the treatment with mirtazapine pretibial edema developed. The CBC, ALT, AST, GGT, ALP, bilirubin, albumin, urea, creatinine, Na, K, Cl, Ca, urine analysis, thyroid function tests and chest X-ray were repeated and all were within normal limits, as before. Cardiac insufficiency, cirrhosis, nephrotic syndrome, and venous insufficiency, all of which can cause edema, were ruled out by the internal medicine consult. The patient was not in the premenstrual period and not pregnant. It was also reported that such a side effect was observed during the administration of escitalopram to the patient. The edema was assessed as being due to mirtazapine. The edema decreased three days after the cessation of the mirtazapine treatment and the administration of furosemide 40 mg/day at the recommendation of internal medicine. It disappeared ten days later. Escitalopram 10 mg daily and hydroxyzine 25 mg daily were continued. The patient, whose depressive symptoms decreased and anxiety disappeared, has continued to be followed up as an outpatient after discharge. The patient's depressive symptoms did not recur and her blood pressure remained within normal limits although she did not receive any antihypertensive treatment. She had no edema at her two month follow up visit. Her CBC, electrolytes, biochemical and thyroid function tests, and urine analysis all remained within normal limits.
Discussion: In our case, the occurrence of edema simultaneously with the administration of mirtazapine, the exclusion of systemic diseases that can cause edema, the lack of continuation or recurrence of the edema even as the patient remained on escitalopram between the previous and the current depressive episodes, and finally the disappearance of the edema right after the cessation of mirtazapine treatment made us to think that the edema was caused by mirtazapine. In the medical literature, it is reported that MAOIs, escitalopram, and sertraline can cause edema. Kutscher et al. reported that peripheral edema occurred in a male patient of 60 years of age after the use of mirtazapine and disappeared right after the cessation of mirtazapine treatment (1,2,3,4). More detailed studies should be conducted to explore and understand this issue better.
References:
1. Remick RA,Froeze C,Keller FD(1989)Common side effects associated with monoamine oxidase inhibitors.Prog Neuropsychopharmacol Biol Psychiatry 13:497-504.
2. Masdrakis VG,Oulis P,Kouzoupis AV,Masdrakis GV,Soldatos CR(2009)Bilateral ankle oedema in a patient taking escitalopram.World J Biol Psychiatry 10:939-41.
3. Dadic-Hero E,Ruzic K,Grahovac T,Graovac M,Palijan TZ,Sepic-Grahovac D(2011) Allergic reactions--outcome of sertraline and escitalopram treatments.Psychiatr Danub. Mar;23(1):120-2.
4. Kutscher EC,Lund BC,Hartman BA(2001)Peripheral edema associated with mirtazapine. Ann Pharmacother.35(11):1494-5. Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S196