Mirtazapine: A One-Drug Intervention for the Physical and Psychological Symptoms of End-Stage Renal Disease (ESRD).

Patients with end-stage renal disease (ESRD), especially those on dialysis, experience myriad medical and psychological symptoms that impact theirquality of life. These symptoms range from nausea, emesis, and insomnia to pruritus, anxiety, depression, and loss of appetite. These symptoms often require multiple medications (e.g., anticholinergics, antihistamines, tricyclics, benzodiazepines, and Z-drugs), which can lead to polypharmacy, medication non-adherence, and potentially harmful drug-drug interactions, especially in older ESRD patients, a population with an age-related decline in drug metabolism, multimorbidity, and polypharmacy. The current perspective article will discuss evidence from extant literature supporting mirtazapine (a noradrenergic antagonist and selective serotonin antagonist, NASSA) as a potentially useful one-stop pharmacologic agent to alleviate multiple symptoms that ESRD patients face. A one-stop strategy has the potential to decrease polypharmacy, reduce adverse drug-drug and drug-disease interactions, reduce healthcare costs, and improve the quality of life in ESRD patients. Mirtazapine use in an ESRD setting merits a large randomized pragmatic double-blinded controlled trial to evaluate its efficacy as a potential pharmacotherapeutic agent for the management of multiple disabling gastrointestinal and other neuropsychological symptoms in older adults living with ESRD.