Reversal of SSRI-associated urinary retention with mirtazapine augmentation.
Reversal of SSRI-associated urinary retention with mirtazapine augmentation.
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米氮平增强治疗可逆转 SSRI 相关的尿潴留。
DOI：
10.1097/jcp.0b013e3182548c12
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发表时间：
2012
影响因子：
2.9
通讯作者：
Lenze,EricJ
中科院分区：
文献类型：
--
作者：
Lenze,EricJ
病例报告患者是一个白色女性在她30岁出头谁寻求治疗终身焦虑症与恐慌和广泛性焦虑的特点。当时，她刚产后不久。她每天服用20毫克的西酞普兰，由她的初级保健医生处方，这提供了不完全缓解焦虑症状。未进一步滴定剂量，因为其引起尿潴留，使得患者出现令人烦恼和痛苦的排尿犹豫。这种不良反应发生在她服用SSRI的整个过程中，并不是继发于焦虑症。在她怀孕期间，她因为尿潴留而停止了西酞普兰，只是焦虑症状恶化，她在怀孕后期重新开始服用。她的主要焦虑症状是无法控制的焦虑"我觉得我快疯了。“她还出现了类似恐慌的呼吸急促和心悸（但没有其他恐慌症状或广场恐怖行为），沉思的想法，无法控制的哭泣，睡眠和食欲不佳，以及与新生儿的情感依恋适度减弱，尽管没有悲伤或快感缺失。她担心自己会“啪”的一声，伤害女儿，但没有这样做的冲动或愿望。治疗的第一步是将她从西酞普兰改为每天10毫克的艾司西酞普兰，希望其更特异的药效学特征能减少泌尿系统症状。然而，4周后，转换没有改善她的泌尿系统症状，她的焦虑只有很小的改善。因此，下一步是在睡前每天增加15 mg米氮平。6周后，该剂量对焦虑的改善最小，将其滴定至30 mg持续2周，然后每天45 mg。45 mg剂量治疗4周后，患者报告焦虑症状显著改善，达到缓解或接近缓解水平。此外，她报告泌尿系统症状完全缓解，不再有任何排尿犹豫。患者或处方医生都没有预料到这种改善。三个月后，由于米氮平导致食欲增加和体重增加，尝试将米氮平剂量减少至30 mg。1不幸的是，患者的焦虑症状复发，尿潴留复发，都是在减少的一周内。2周后，再次将米氮平滴定至45 mg，患者尿潴留在几天内再次停止，但焦虑症状直到4周后才缓解。她现在每天服用10毫克艾司西酞普兰和45毫克米氮平，没有尿潴留症状。尿潴留是SSRI类药物（如艾司西酞普兰和西酞普兰）的一种不常见的不良反应，缺乏显著的抗胆碱能作用2;然而，胆碱能神经元参与控制下尿路，已有病例报告。3某些患者群体，如老年人或孕妇和产后妇女，发生尿潴留的风险可能更高。米氮平可通过阻断5-羟色胺1A、2A、2C或3受体诱导的效应，或通过外周> 1-肾上腺素能拮抗剂效应直接松弛膀胱肌肉，逆转SSRI相关的尿潴留。4，5由于米氮平对这些受体的亲和力不同，这种效应可能在不同的米氮平剂量下具有临床意义;在这种情况下，仅在每天45 mg时发生尿潴留停止，可能表明> 1-肾上腺素能拮抗剂效应或甚至胆碱能效应可能是原因。由于这些特性，其他人注意到米氮平的...
CASE REPORT The patient is a white female in her early 30s who sought treatment for a lifelong anxiety disorder with panic and generalized anxiety features. At the time, she was recently postpartum. She was taking 20 mg of citalopram daily, prescribed by her primary care physician, which provided incomplete relief from anxiety symptoms. The dose had not been further titrated because it caused urinary retention, such that the patient had bothersome and distressing urinary hesitancy. This adverse effect had occurred for the entire time she was taking the SSRI and was not secondary to the anxiety disorder. During her pregnancy, she had stopped citalopram because of the urinary retention, only to have anxiety symptoms worsen, and she restarted it late in her pregnancy. Her primary anxiety symptom was uncontrollable anxietyV ‘‘I feel like I’m going crazy.’’She also had panic-like attacks of shortness of breath and palpitations (but not other panic symptoms or agoraphobic behavior), ruminative thoughts, uncontrollable crying, poor sleep and appetite, and a modest blunting of emotional attachment with her newborn child, although no sadness or anhedonia. She had worries that she would ‘‘snap’’and hurt her daughter but no urge or desire to do so. The first treatment step was to switch her from citalopram to 10 mg of escitalopram daily in the hope that its more specific pharmacodynamic profile would reduce urinary symptoms. However, after 4 weeks, the switch provided no improvement in her urinary symptoms and only minimal improvement in her anxiety. The next step, therefore, was to augment with 15 mg of mirtazapine daily at bedtime. After 6 weeks, this dose provided minimal improvement in anxiety, and it was titrated to 30 mg for 2 weeks, and then 45 mg daily. After 4 weeks at the 45-mg dose, she reported a significant improvement in her anxiety symptoms, to a remission or near-remission level. Also, she reported a complete remission in urinary symptoms, no longer having any urinary hesitancy. This improvement was unanticipated by either the patient or the prescribing physician.Three months later, a dose reduction of mirtazapine to 30 mg was attempted because of increased appetite and weight gain from mirtazapine. 1 Unfortunately, the patient’s anxiety symptoms relapsed, and the urinary retention returned, both within a week of the reduction. When, 2 weeks later, mirtazapine was titrated again to 45 mg, her urinary retention again ceased within a few days, but anxiety symptoms did not remit until 4 weeks later. She now remains well on the combination of 10 mg of escitalopram daily and 45 mg of mirtazapine, with no urinary retention symptoms. Urinary retention is an uncommon adverse effect of SSRIs such as escitalopram and citalopram, which lack significant anticholinergic effects2; however, serotoner gic neurons are involved in control of the lower urinary tract, and cases have been reported. 3 Some patient groups, such as older adults or pregnant and postpartum women, might be at higher risk for developing urinary retention. Mirtazapine may reverse SSRI-associated urinary retention via blockade of serotonin 1A, 2A, 2C, or 3 receptor-induced effects, or via direct relaxation of urinary bladder muscles via peripheral> 1-adrenergic antagonist effects. 4, 5 Because of the variable affinity of mirtazapine for these many receptors, such effects might become clinically relevant at different mirtazapine doses; in this case, the cessation of urinary retention occurred only at 45 mg daily, possibly suggesting> 1-adrenergic antagonist effects or even cholinergic effects may be responsible. Because of such properties, others have noted mirtazapine’s …
米氮平和度洛西汀联合治疗难治性抑郁症可改善预后和性功能。
影响因子：
2.9
作者：
L. Ravindran;B. Eisfeld;S. Kennedy
通讯作者：
S. Kennedy
临床前数据的临床相关性：米氮平，一种模型化合物。
影响因子：
2.9
作者：
L. Delbressine;R. Vos
通讯作者：
R. Vos