Duloxetine to Mirtazapine

[Puggy1910]

I been on Gabapentin from 23.02.24 and was previously on Pramipexole but had compulsive eating so asked to change. I stopped Pramipexole straight away and moved to Gabapentin and went from 300mg three times a day to 900mg three times a day and not really helped me. Spoke to Dr today who’s decided I should stop all rls meds and change my antidepressants from Duloxetine to Mirtazapine. He said I probably won’t sleep for a while but thinks Duloxetine causing my RLS. I don’t agree as was on it some time before getting RLS. Can’t go through a month of hell to change to something as in mirtazapine which I read can activate RLS . Any ideas

[SueJohnson]

Welcome to the forum. You will find lots of help, support and understanding here.

If you take more than 600 mg of gabapentin at one time, it is not fully absorbed so it as though you are taking only 540 mg. So you are in effect only taking 1620 mg total. Unless you have RLS during the day there is no point taking it during the day. It is prescribed that way by doctors who are not knowledgeable about RLS because it is generally prescribed for neuropathic pain so that is what the leaflet says to do. It is prescribed off label for RLS. Since RLS is generally only at night that is when it should be taken.

Take it 1 to 2 hours before bedtime as the peak plasma level is 2 hours. Since you need more than 600 mg take the extra 4 hours before bedtime as it is not as well absorbed above 600 mg. If you need more than 1200 mg, take 400 mg (which makes 1600 mg total) 6 hours before bedtime. According to the Mayo Clinic Updated Algorithm on RLS: "Most RLS patients require 1200 to 1800 mg of gabapentin ." If you take magnesium even in a multivitamin, don't take it within 3 hours of taking gabapentin (it is OK with pregabalin) as it will interfere with the absorption of gabapentin and don't take calcium within 2 hours for the same reason (not sure about pregabalin). Check out the Mayo Clinic Updated Algorithm on RLS which will tell you everything you want to know including about its treatment and refer your doctor to it if needed as many doctors do not know much about RLS or are not uptodate on it at Https://mayoclinicproceedings.org/a...

I suspect changing it to this way it will control Your RLS.

Both Duloxetine and Mirtazapine can make RLS worse. Just because you were on Duloxetine before you had RLS doesn't necessarily mean anything since RLS can start as you get older. It is possible though that it doesn't make your RLS worse. The only antidepressants that are safe for RLS are Wellbutrin and Trazodone.

Have you had your ferritin checked? If so what was it? If not this is the first thing that should be done for RLS. When you see your doctor ask for a full iron panel. Stop taking any iron supplements including in a multivitamin 48 hours before the test, don't eat a heavy meat meal the night before and fast after midnight. Have your test in the morning before 9 am if possible. When you get the results, ask for your ferritin and transferrin saturation (TSAT) numbers. You want your ferritin to be over 100 as improving it to that helps 60% of people with RLS and in some cases completely eliminates their RLS and you want your transferrin saturation to be between 20 and 45. If your ferritin is less than 100 or your transferrin saturation is not between 20 and 45 post back here and we can give you some advice.

Meanwhile some things that can make RLS symptoms worse for some people are alcohol, nicotine, caffeine, sugar, artificial sweeteners, carbs, foods high in sodium(salt), foods that cause inflammation, ice cream, eating late at night, oestrogen (estrogen) including HRT, dehydration, MSG, collagen supplements, electrolyte imbalance, melatonin, stress and vigorous exercise. Some things that help some people include caffeine, moderate exercise, weighted blankets, compression socks, elastic bandages, masturbation, magnesium glycinate, fennel, low oxalate diet, selenium, 5 minute shower alternating 20 seconds cold water with 10 seconds hot water finishing with hot water for another couple of minutes, hot baths, distractions, CBD, applying a topical magnesium lotion or spray, doing a magnesium salts soak, vitamins B1, B3, B6, B12, D3, K2, if deficient, and potassium and copper if deficient, massage including using a massage gun, vibration devices like therapulse, using a standing desk, listening to music, meditation and yoga. Keep a food diary to see if any food make your RLS worse.

Many medicines and OTC supplements can make RLS worse. If you are taking any and you list them here, I can tell you if any make RLS symptoms worse and if so may be able to give you a safe substitute.

By the way it would really help us to give you advice if you would indicate on your profile what country you live in and your gender.

[Puggy1910 in reply to SueJohnson]

Hi Sue

Thanks for the reply. Spoke to different gp today and keeping me on my duloxetine and anitriptylene for now and to continue the gabapentin just now as not been on it a month and this dr says takes a while to work .

Dosage wise the dr said 900mg three times a day to try for month and see how I go .

How should I go about taking these ? Times etc . You seem very knowledgeable which is amazing as the GP does not seem to know that much. It’s so debilitating . I work 12 hour shifts and am on feet all day as work in hospital

Thanks

[SueJohnson in reply to Puggy1910]

Do you have RLS symptoms during the day?

[Puggy1910 in reply to SueJohnson]

No usually starts about 7-8pm

[SueJohnson in reply to Puggy1910]

When do you go to bed?

[Puggy1910 in reply to SueJohnson]

Usually about 11pm or 10pm when I working next day

[SueJohnson in reply to Puggy1910]

Since you don't have RLS during the day, take 600 mg at 5 pm, 600 mg at 7 pm and 600 mg at 9 pm. I strongly suspect that will control your RLS.

[Puggy1910 in reply to SueJohnson]

Thanks will give it a go. I take it 900mg three times a day like dr said is too much as read in your previous post that body can only absorb so much

[SueJohnson in reply to Puggy1910]

Right. By the way Amitriptyline also makes RLS worse. Why would your doctor put you on 2 antidepressants?

[Puggy1910 in reply to SueJohnson]

I had reduced it but the dr said amitriptylene could help rls. I think I will reduce it again if it can make it worse

[Joolsg]

RLS can start up several months or years after starting Duloxetine, so it could well have caused your RLS BUT, all anti depressants can trigger RLS, including Mirtazapine, so switching to that won't help. Your doctor should read the Mayo Clinic Algorithm which lists the anti depressants that worsen RLS.As SueJohnson says, trazodone and wellbutrin are regarded as safe anti depressants, but they may not cover your depression.You will need your doctor to monitor any switch, as your depression needs to be controlled.

It seems a little harsh to make you come off gabapentin at the same time.

I think you should get a second opinion and find someone who will work with you to find something that won't trigger your RLS, but WILL cover your depression.

You may have to stay on an effective anti depressants AND stay on a medication that will cover the RLS caused by the anti depressant.

Gabapentin takes around a month to be fully effective and is best taken in 600mg doses 2 hour's apart, at night.