PATIENT MEDICATION INFORMATION SECTION.

17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Medication Guide).Suicidal Thoughts and Behaviors Advise patients and caregivers to look for the emergence of suicidality, especially early during treatment and when the dosage is adjusted up or down, and instruct them to report such symptoms to the healthcare provider [see Boxed Warning and Warnings and Precautions (5.1)].AgranulocytosisAdvise patients to contact their physician if they experience fever, chills, sore throat, mucous membrane ulceration, flu-like complaints, or other symptoms that might suggest infection [see Warnings and Precautions (5.2)].Serotonin SyndromeCaution patients about the risk of serotonin syndrome, particularly with the concomitant use of mirtazapine tablets with other serotonergic drugs including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, St. Johns Wort, and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid). Advise patients to contact their healthcare provider or report to the emergency room if they experience signs or symptoms of serotonin syndrome [see Dosage and Administration (2.4), Contraindications (4), Warnings and Precautions (5.3), Drug Interactions (7)].QT Prolongation and Torsades de PointesInform patients to consult their physician immediately if they feel faint, lose consciousness, or have heart palpitations [see Warnings and Precautions (5.5), Drug Interactions (7), Overdosage (10)]. Advise patients to inform physicians that they are taking mirtazapine tablets before any new drug is taken.SomnolenceAdvise patients that mirtazapine tablets may impair judgment, thinking, and particularly, motor skills, because of its prominent sedative effect. Caution patients about performing activities requiring mental alertness, such as operating hazardous machinery or operating motor vehicle, until they are reasonably certain that mirtazapine tablets therapy does not adversely affect their ability to engage in such activities. [see Warnings and Precautions (5.7)].AlcoholAdvise patients to avoid alcohol while taking mirtazapine tablets [see Warnings and Precautions (5.7), Drug Interactions (7)].Activation of Mania/HypomaniaAdvise patients and their caregivers to observe for signs of activation of mania/hypomania and instruct them to report such symptoms to the healthcare provider [see Warnings and Precautions (5.8)].Discontinuation SyndromeAdvise patients not to abruptly discontinue mirtazapine tablets and to discuss any tapering regimen with their healthcare provider. Adverse reactions can occur when mirtazapine tablets are discontinued [see Dosage and Administration (2.6), Warnings and Precautions (5.13)].Allergic ReactionsAdvise patients to notify their healthcare provider if they develop an allergic reaction such as rash, hives,swelling, or difficulty breathing [see Contraindications (4), Adverse Reactions (6.2)].Pregnancy1.Advise patients to notify their physician if they become pregnant or intend to become pregnant during mirtazapine tablets therapy.2.Advise patients that there is pregnancy exposure registry that monitors pregnancy outcomes in women exposed to mirtazapine tablets during pregnancy [see Use in Specific Populations (8.2)]. LactationAdvise patients to notify their physician if they are breastfeeding an infant [see Use in Specific Populations (8.2)].Angle-Closure GlaucomaPatients should be advised that taking mirtazapine can cause mild pupillary dilation, which in susceptible individuals, can lead to an episode of angle-closure glaucoma. Pre-existing glaucoma is almost always open-angle glaucoma because angle-closure glaucoma, when diagnosed, can be treated definitively with iridectomy. Open-angle glaucoma is not risk factor for angle-closure glaucoma. Patients may wish to be examined to determine whether they are susceptible to angle-closure, and have prophylactic procedure (e.g., iridectomy), if they are susceptible [see Warnings and Precautions (5.4).]APOTEX INC.MIRTAZAPINE TABLETS, USP15 mg, 30 mg and 45 mgManufactured by:Manufactured for:Apotex IncApotex Corp.Toronto, OntarioWeston, FloridaCanada M9l 1T933326Distributed By:MAJOR(R) PHARMACEUTICALSLivonia, MI 48152Refer to package label for Distributors NDC Number Revised November 2020Rev 15. 1.Advise patients to notify their physician if they become pregnant or intend to become pregnant during mirtazapine tablets therapy.. 2.Advise patients that there is pregnancy exposure registry that monitors pregnancy outcomes in women exposed to mirtazapine tablets during pregnancy [see Use in Specific Populations (8.2)].

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following adverse reactions are described in more detail in other sections of the prescribing information:o Hypersensitivity [see Contraindications (4)]o Suicidal Thoughts and Behaviors [see Warnings and Precautions (5.1)]o Agranulocytosis [see Warnings and Precautions (5.2)]o Serotonin Syndrome [see Contraindications (4), Warnings and Precautions (5.3), Drug Interactions (7)]o Angle-Closure Glaucoma [see Warnings and Precautions (5.4)]o QT Prolongation and Torsades de Pointes [see Warnings and Precautions (5.5)]o Increased Appetite and Weight Gain [see Warnings and Precautions (5.6)]o Somnolence [see Warnings and Precautions (5.7)]o Activation of Mania or Hypomania [see Warnings and Precautions (5.8)]o Seizures [see Warnings and Precautions (5.9)]o Elevated Cholesterol and Triglycerides [see Warnings and Precautions (5.10)]o Hyponatremia [see Warnings and Precautions (5.11)]o Transaminase Elevations [see Warnings and Precautions (5.12)]o Discontinuation Syndrome [see Warnings and Precautions (5.13)]o Use in Patients with Concomitant Illness [see Warnings and Precautions (5.14)]. Most common adverse reactions (>=5% or greater and twice placebo) were somnolence, increased appetite, weight gain, and dizziness. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Apotex Corp. at, at 1-800-706-5575 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch..fda.gov/medwatch. 6.1 Clinical Trial Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.The data described below are from clinical trials in which mirtazapine tablets were administered to 2796 patients in phase and clinical studies. The trials consisted of double-blind controlled and open-label studies, inpatient and outpatient studies, fixed dose, and titration studies.Adverse Reactions Leading to Discontinuation of TreatmentApproximately 16% of the 453 patients who received mirtazapine tablets in US 6-week controlled clinical trials discontinued treatment due to an adverse experience, compared to 7% of the 361 placebo-treated patients in those studies. The most common events (>=1%) associated with discontinuation and considered to be drug related (i.e., those events associated with dropout at rate at least twice that of placebo) are included in Table 2.Table : Common Adverse Events Associated with Discontinuation of Treatment in 6-week US Mirtazapine Tablets TrialsMirtazapine Tablets (n=453)Placebo (n=361)Somnolence10.4%2.2%Nausea1.5%0%Common Adverse ReactionsThe most common adverse reactions (>=5% and twice placebo) associated with the use of mirtazapine tablets are listed in Table 3.Table 3: Common Treatment-emergent Adverse Events Associated with the Use of Mirtazapine Tablets in 6-week US Trials Mirtazapine Tablets (n=45 3) Placebo (n=3 61) Somnolence54%18%Increased Appetite17%2%Weight Gain12%2%Dizziness7%3%Table enumerates adverse reactions that occurred in >=1% of mirtazapine tablets-treated patients and were more frequent than the placebo-treated patients, who participated in 6-week, U.S. placebo-controlled trials in which patients were dosed in range of to 60 mg/day. This table shows the percentage of patients in each group who had at least episode of an adverse reaction at some time during their treatment.Table 4: Adverse Reactions (>=1% and greater than placebo) in 6-Week U.S. Clinical Studies ofMirtazapine Tablets in Patients with MDDMirtazapine Tablets in Patients with MDD-Week U.S. Clinical Studies ofMirtazapine Tablets in Patients with MDD Mirtazapine Tablets (n=453) Placebo (n=361) Body as Whole Asthenia8%5%Flu Syndrome5%3%Back Pain2%1%Digestive System Dry Mouth25%15%Increased Appetite17%2%Constipation13%7%Metabolic and Nutritional Disorders Weight Gain12%2%Peripheral Edema2%1%Edema1%0%Musculoskeletal System Myalgia2%1%Nervous System Somnolence54%18%Dizziness7%3%Abnormal Dreams4%1%Thinking Abnormal3%1%Tremor2%1%Confusion2%0%Respiratory System Dyspnea1%0%Urogenital System Urinary Frequency2%1%ECG ChangesThe electrocardiograms for 338 patients who received mirtazapine tablets and 261 patients who received placebo in 6-week, placebo-controlled trials were analyzed. Mirtazapine tablets was associated with mean increase in heart rate of 3.4 bpm, compared to 0.8 bpm for placebo. The clinical significance of these changes is unknown.Other Adverse Reactions Observed During the Premarketing Evaluation of Mirtazapine TabletsThe following list does not include reactions: 1) already listed in previous tables or elsewhere in labeling,2) for which drug cause was remote, 3) which were so general or excessively specific so as to be uninformative, 4) which were not considered to have significant clinical implications, or 5) which occurred at rate equal to or less than placebo.Adverse reactions are categorized by body system according to the following definitions: frequent adverse reactions are those occurring in at least 1/100 patients; infrequent adverse reactions are those occurring in 1/100 to 1/1000 patients; rare adverse reactions are those occurring in fewer than 1/1000 patient.Body as Whole:frequent: malaise, abdominal pain, abdominal syndrome acute; infrequent: chills, fever, face edema, ulcer, photosensitivity reaction, neck rigidity, neck pain, abdomen enlarged; rare: cellulitis, chest pain substernal.Cardiovascular System:frequent: hypertension, vasodilatation; infrequent: angina pectoris, myocardial infarction, bradycardia, ventricular extrasystoles, syncope, migraine, hypotension; rare: atrial arrhythmia, bigeminy, vascular headache, pulmonary embolus, cerebral ischemia, cardiomegaly, phlebitis, left heart failure.Digestive System:frequent: vomiting, anorexia; infrequent: eructation, glossitis, cholecystitis, nausea and vomiting, gum hemorrhage, stomatitis, colitis, liver function tests abnormal; rare: tongue discoloration, ulcerative stomatitis, salivary gland enlargement, increased salivation, intestinal obstruction, pancreatitis, aphthous stomatitis, cirrhosis of liver, gastritis, gastroenteritis, oral moniliasis, tongue edema.Endocrine System: rare: goiter, hypothyroidism.Hemic and Lymphatic System: rare: lymphadenopathy, leukopenia, petechia, anemia, thrombocytopenia, lymphocytosis, pancytopenia.Metabolic and Nutritional Disorders: frequent: thirst; infrequent: dehydration, weight loss; rare: gout, SGOT increased, healing abnormal, acid phosphatase increased, SGPT increased, diabetes mellitus, hyponatremia.Musculoskeletal System:frequent: myasthenia, arthralgia; infrequent: arthritis, tenosynovitis; rare:pathologic fracture, osteoporosis fracture, bone pain, myositis, tendon rupture, arthrosis, bursitis.Nervous System:frequent: hypesthesia, apathy, depression, hypokinesia, vertigo, twitching, agitation, anxiety, amnesia, hyperkinesia, paresthesia; infrequent: ataxia, delirium, delusions, depersonalization, dyskinesia, extrapyramidal syndrome, libido increased, coordination abnormal, dysarthria, hallucinations, manic reaction, neurosis, dystonia, hostility, reflexes increased, emotional lability, euphoria, paranoid reaction; rare: aphasia, nystagmus, akathisia (psychomotor restlessness), stupor, dementia, diplopia, drug dependence, paralysis, grand mal convulsion, hypotonia, myoclonus, psychotic depression, withdrawal syndrome, serotonin syndrome.Respiratory System:frequent: cough increased, sinusitis; infrequent: epistaxis, bronchitis, asthma, pneumonia; rare: asphyxia, laryngitis, pneumothorax, hiccup.Skin and Appendages: frequent: pruritus, rash; infrequent: acne, exfoliative dermatitis, dry skin, herpes simplex, alopecia; rare: urticaria, herpes zoster, skin hypertrophy, seborrhea, skin ulcer.Special Senses: infrequent: eye pain, abnormality of accommodation, conjunctivitis, deafness, keratoconjunctivitis, lacrimation disorder, angle-closure glaucoma, hyperacusis, ear pain; rare: blepharitis, partial transitory deafness, otitis media, taste loss, parosmia.Urogenital System: frequent: urinary tract infection; infrequent: kidney calculus, cystitis, dysuria, urinary incontinence, urinary retention, vaginitis, hematuria, breast pain, amenorrhea, dysmenorrhea, leukorrhea, impotence; rare: polyuria, urethritis, metrorrhagia, menorrhagia, abnormal ejaculation, breast engorgement, breast enlargement, urinary urgency.. 6.2 Postmarketing Experience The following adverse reactions have been identified during post-approval use of mirtazapine tablets. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure.Cardiac disorders: ventricular arrhythmia (Torsades de Pointes): ventricular arrhythmia (Torsades de Pointes)Endocrine disorders: hyperprolactinemia (and related symptoms, e.g., galactorrhea and gynecomastia)Musculoskeletal and connective tissue disorders: increased creatine kinase blood levels and rhabdomyolysisPsychiatric disorders: somnambulism (ambulation and other complex behaviors out of bed)Reproductive system and breast disorder: priapism Skin and subcutaneous tissue disorders: severe skin reactions, including Stevens-Johnson syndrome, bullous dermatitis, erythema multiforme and toxic epidermal necrolysis.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. The mechanism of action of mirtazapine for the treatment of major depressive disorder, is unclear. However, its efficacy could be mediated through its activity as an antagonist at central presynaptic 2- adrenergic inhibitory auto-receptors and heteroreceptors and enhancing central noradrenergic and serotonergic activity.. 12.2 Pharmacodynamics In preclinical studies, mirtazapine acts as an antagonist at 2-adrenergic inhibitory auto-receptors and heteroreceptors and as an antagonist at serotonin 5-HT2 and 5-HT3 receptors. Mirtazapine has no significant affinity for the 5-HT1A and 5-HT1B receptors.Mirtazapine also acts as an antagonist of histamine (H1) receptors, peripheral 1-adrenergic receptors, and muscarinic receptors. Actions at these receptors may explain some of the other clinical effects of mirtazapine (e.g., its prominent somnolent effects and orthostatic hypotension may be explained by its inhibition of histamine (H1) receptors and peripheral 1-adrenergic receptors, respectively).Cardiac ElectrophysiologyThe effect of mirtazapine tablets on QTc interval was assessed in healthy subjects. At dose of 75 mg (1.67 times the maximum recommended dosage), mirtazapine tablets do not prolong the QTc interval to clinically meaningful extent.. 12.3 Pharmacokinetics. Plasma levels of mirtazapine are linearly related to dose over dose range of 15 to 80 mg (1.78 times the maximum recommended dose). Steady state plasma levels of mirtazapine are attained within days, with about 50% accumulation (accumulation ratio=1.5). The (-) enantiomer has an elimination half-life that is approximately twice as long as the (+) enantiomer and therefore achieves plasma levels that are about times as high as that of the (+) enantiomer.AbsorbtionMirtazapine has an absolute bioavailability of about 50% following oral administration. Peak plasma concentrations of mirtazapine are reached within about hours post dose.0% following oral administration. Peak plasma concentrations of mirtazapine are reached within about hours post dose.Food EffectThe presence of food in the stomach has minimal effect on both the rate and extent of absorption.DistributionMirtazapine is approximately 85% bound to plasma proteins over concentration range of 0.01 to10 mcg/mL.EliminationMirtazapine has half-life of about 20 to 40 hours following oral administration of mirtazapine tablets -life of about 20 to 40 hours following oral administration of mirtazapine tablets Metabolism Mirtazapine is extensively metabolized after oral administration. Major pathways of bio-transformation are demethylation and hydroxylation followed by glucuronide conjugation. In vitro data from human liver microsomes indicate that CYP2D6 and CYP1A2 are involved in the formation of the 8-hydroxy metabolite of mirtazapine, whereas CYP3A is considered to be responsible for the formation of the N-desmethyl and N-oxide metabolite. Several unconjugated metabolites possess pharmacological activity but are presentin the plasma at very low levels.Excretion Mirtazapine and its metabolites are eliminated predominantly (75%) via urine with 15% in feces..Specific PopulationsGeriatric PatientsFollowing oral administration of mirtazapine tablets 20 mg/day for days to subjects of varying ages (range 25 to 74 years old), oral clearance of mirtazapine was reduced in the elderly compared to the younger subjects. The clearance in elderly males was 40% lower compared to younger males, while the clearance was 10% lower in elderly females compared to younger females [see Warnings and Precautions (5.14), Use in Specific Populations (8.5)]Male and Female Patients The mean elimination half-life of mirtazapine after oral administration ranges from approximately 20 to 40 hours across age and gender subgroups, with females of all ages exhibiting significantly longer elimination half-lives than males (mean half-life of 37 hours for females vs. 26 hours for males).RaceThere have been no clinical studies to evaluate the effect of race on the pharmacokinetics of mirtazapine tablets.Patients with Renal Impairment When compared to subjects with normal renal function, total body clearance of mirtazapine was reduced approximately 30% in renal impaired patients with GFR=11-39 mL/min/1.73 m2 and approximately 50%in renal impaired patients with GFR=<10 mL/min/1.73 m2) [see Warnings and Precautions (5.14), Use in Specific Populations (8.6)].Patients with Hepatic Impairment Following single 15-mg oral dose of mirtazapine tablets, the oral clearance of mirtazapine in patients with hepatic impairment was decreased by approximately 30%, compared to subjects with normal hepatic function [see Warnings and Precautions (5.12, 5.14), Use in Specific Populations (8.6)].Drug Interactions StudiesWarfarin Mirtazapine (30 mg daily) at steady state caused statistically significant increase (0.2) in theInternational Normalized Ratio (INR) in subjects treated with warfarin [see Drug Interactions (7)].QTc-Prolonging DrugsThe risk of QT prolongation and/or ventricular arrhythmias (e.g., Torsades de Pointes) may be increased with concomitant use of medicines which prolong the QTc interval (e.g., some antipsychotics and antibiotics) and in mirtazapine overdose [see Warnings and Precautions (5.5), Adverse Reactions (6.1,6.2), Drug Interactions (7), and Overdosage (10)].PhenytoinIn healthy male subjects (n=18), phenytoin (200 mg daily, at steady state) increased mirtazapine (30 mg daily, at steady state) clearance about 2-fold, resulting in decrease in average plasma mirtazapine concentrations of 45% [see Drug Interactions (7)]. Mirtazapine did not significantly affect the pharmacokinetics of phenytoin.CarbamazepineIn healthy male subjects (n=24), carbamazepine (400 mg twice day, at steady state) increased mirtazapine (15 mg twice day, at steady state) clearance about 2-fold, resulting in decrease in average plasma mirtazapine concentrations of 60% [see Drug Interactions (7)].CimetidineIn healthy male subjects (n=12), when cimetidine, weak inhibitor of CYP1A2, CYP2D6, and CYP3A4, given at 800 mg b.i.d. at steady state was coadministered with mirtazapine (30 mg daily) at steady state, the Area Under the Curve (AUC) of mirtazapine increased more than 50% [see Drug Interactions (7)]. Mirtazapine did not cause relevant changes in the pharmacokinetics of cimetidine.KetoconazoleIn healthy male Caucasian subjects (n=24), coadministration of the strong CYP3A4 inhibitor ketoconazole (200 mg b.i.d. for 6.5 days) increased the peak plasma levels and the AUC of single 30 mg dose of mirtazapine by approximately 40% and 50%, respectively [see Drug Interactions (7)].AmitriptylineIn healthy, CYP2D6 extensive metabolizer patients (n=32), amitriptyline (75 mg daily), at steady state, did not cause relevant changes to the pharmacokinetics of steady state mirtazapine (30 mg daily); mirtazapine also did not cause relevant changes to the pharmacokinetics of amitriptyline.ParoxetineIn healthy CYP2D6 extensive metabolizer subjects (n=24), mirtazapine (30 mg/day), at steady state, did not cause relevant changes in the pharmacokinetics of steady state paroxetine (40 mg/day), CYP2D6 inhibitor.LithiumNo relevant clinical effects or significant changes in pharmacokinetics have been observed in healthy male subjects on concurrent treatment with lithium 600 mg/day for 10 days at steady state and single30 mg dose of mirtazapine. The effects of higher doses of lithium on the pharmacokinetics of mirtazapine are unknown.RisperidoneMirtazapine (30 mg daily) at steady state did not influence the pharmacokinetics of risperidone (up to3 mg twice day) in subjects (n=6) in need of treatment with an antipsychotic and antidepressant drug.AlcoholConcomitant administration of alcohol (equivalent to 60 g) had minimal effect on plasma levels of mirtazapine (15 mg) in healthy male subjects. However, the impairment of cognitive and motor skills produced by mirtazapine tablets were shown to be additive with those produced by alcohol.DiazepamConcomitant administration of diazepam (15 mg) had minimal effect on plasma levels of mirtazapine (15 mg) in 12 healthy subjects. However, the impairment of motor skills produced by mirtazapine tablets has been shown to be additive with those caused by diazepam.

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Table includes clinically important drug interactions with Mirtazapine Tablets [see ClinicalPharmacology (12.3)].Table 5: Clinically Important Drug Interactions with Mirtazapine TabletsMonoamine Oxidase Inhibitors (MAOIs)Monoamine Oxidase Inhibitors (MAOIs)Clinical ImpactThe concomitant use of serotonergic drugs, including Mirtazapine Tablets, and MAOIs increases the risk of serotonin syndrome., including Mirtazapine Tablets, and MAOIs increases the risk of serotonin syndrome.InterventionMirtazapine tablets are contraindicated in patients taking MAOIs, including MAOIs such as linezolid or intravenous methylene blue [see Dosage and Administration (2.4), Contraindications (4), Warnings andPrecautions (5.3)]Examplesselegiline, tranylcypromine, isocarboxazid, phenelzine, linezolid, methylene blueOther Serotonergic DrugsOther Serotonergic DrugsClinical ImpactThe concomitant use of serotonergic drugs with mirtazapine tablets increases the risk of serotonin syndrome.InterventionMonitor patients for signs and symptoms of serotonin syndrome, particularly during treatment initiation and dosage increases. If serotonin syndrome occurs, consider discontinuation of mirtazapine tablets and/or concomitant serotonergicdrugs [see Warnings and Precautions (5.3)]ExamplesSSRIs, SNRIs, triptans, tricyclic antidepressants, fentanyl, lithium, amphetamines, St. Johns Wort, tramadol, tryptophan, buspironeStrong CYP3A InducersStrong CYP3A InducersClinical ImpactThe concomitant use of strong CYP3A inducers with mirtazapine tablets decreases the plasma concentration of mirtazapine [see Clinical Pharmacology (12.3)].InterventionIncrease the dose of mirtazapine tablets if needed with concomitant CYP3A inducer use. Conversely, decrease in dosage of Mirtazapine Tablets may be needed if the CYP3A inducer is discontinued [see Dosage and Administration (2.5)].Examplesphenytoin, carbamazepine, rifampin, carbamazepine, rifampinStrong CYP3A InhibitorsStrong CYP3A InhibitorsClinical ImpactThe concomitant use of strong CYP3A inhibitors with mirtazapine tablets may increase the plasma concentration of mirtazapine [see Clinical Pharmacology (12.3)].InterventionDecrease the dose of mirtazapine tablets if needed with concomitant strong CYP3A inhibitor use. Conversely, an increase in dosage of mirtazapine tablets may be needed if the CYP3A inhibitor is discontinued [see Dosage and Administration (2.5)].Examplesitraconazole, ritonavir, nefazodone, ritonavir, nefazodoneCimetidineCimetidineClinical ImpactThe concomitant use of cimetidine, CYP1A2, CYP2D6, and CYP3A inhibitor, with mirtazapine tablets may increase the plasma concentration of mirtazapine [see Clinical Pharmacology (12.3)]InterventionDecrease the dose of mirtazapine tablets if needed with concomitant cimetidine use. Conversely, an increase in dosage of mirtazapine tablets may be needed if cimetidine is discontinued [see Dosage and Administration (2.5)].Benzodiazepines and AlcoholClinical ImpactThe concomitant use of benzodiazepines or alcohol with mirtazapine tablets increases the impairment of cognitive and motor skills produced by mirtazapine tablets alone.InterventionAvoid concomitant use of benzodiazepines and alcohol with mirtazapine tablets [see Warnings and Precautions (5.7), Clinical Pharmacology (12.3)].Examplesdiazepam, alprazolam, alcoholDrugs that Prolong QTc IntervalClinical ImpactThe concomitant use of other drugs which prolong the QTc interval with mirtazapine tablets, increase the risk of QTc prolongation and/or ventricular arrhythmias (e.g., Torsades de Pointes).InterventionUse caution when using mirtazapine tablets concomitantly with drugs that prolong the QTc interval [see Warnings and Precautions (5.5), Clinical Pharmacology (12.3)].WarfarinClinical ImpactThe concomitant use of warfarin with mirtazapine tablets may result in an increase in INR [see Clinical Pharmacology (12.3)].InterventionMonitor INR during concomitant use of warfarin with mirtazapine tablets. 5.Strong CYP3A inducers: Dosage increase may be needed for mirtazapine tablets with concomitant use of strong CYP3A inducers. (2.5, 7) 6. Strong CYP3A inhibitors: Dosage decrease may be needed when mirtazapine tablets are coadministered with strong CYP3A inhibitors. (2.5, 7) 7.Cimetidine: Dosage decrease may be needed when mirtazapine tablets are coadministered with cimetidine. (2.5, 7) 8. Warfarin: Monitor INR during concomitant use. (7). 5.Strong CYP3A inducers: Dosage increase may be needed for mirtazapine tablets with concomitant use of strong CYP3A inducers. (2.5, 7) 6. Strong CYP3A inhibitors: Dosage decrease may be needed when mirtazapine tablets are coadministered with strong CYP3A inhibitors. (2.5, 7) 7.Cimetidine: Dosage decrease may be needed when mirtazapine tablets are coadministered with cimetidine. (2.5, 7) 8. Warfarin: Monitor INR during concomitant use. (7).

PREGNANCY SECTION.

8.1 Pregnancy Pregnancy Exposure RegistryThere is pregnancy exposure registry that monitors pregnancy outcomes in women exposed to antidepressants during pregnancy. Healthcare providers are encouraged to register patients by calling theNational Pregnancy Registry for Antidepressants at 1-844-405-6185 or visiting online at https://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/antidepressants/. Risk Summary Prolonged experience with mirtazapine in pregnant women, based on published observational studiesand postmarketing reports, has not reliably identified drug-associated risk of major birth defects,miscarriage or adverse maternal or fetal outcomes. There are risks associated with untreated depressionin pregnancy (see Clinical Considerations).In animal reproduction studies, oral administration of mirtazapine to pregnant rats and rabbits during theperiod of organogenesis revealed no evidence of teratogenic effects up to 20 and 17 times the maximum recommended human dose (MRHD) of 45 mg, respectively, based on mg/m2 body surface area.However, in rats, there was an increase in post implantation loss at 20 times the MRHD based on mg/m2body surface area. Oral administration of mirtazapine to pregnant rats during pregnancy and lactation resulted in an increase in pup deaths and decrease in pup birth weights at doses 20 times the MRHDbased on mg/m2 body surface area (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is to 4% and 15 to 20% respectively.Clinical ConsiderationsDisease-Associated Maternal and/or Embryo/Fetal RiskWomen who discontinue antidepressants during pregnancy are more likely to experience relapse ofmajor depression than women who continue antidepressants. This finding is from prospective,longitudinal study that followed 201 pregnant women with history of major depressive disorder whowere euthymic and taking antidepressants at the beginning of pregnancy. Consider the risk of untreateddepression when discontinuing or changing treatment with antidepressant medication during pregnancyand postpartum.DataAnimal DataMirtazapine was administered orally to pregnant rats and rabbits during the period of organogenesis atdoses of 2.5, 15, and 100 mg/kg/day and 2.5, 10, and 40 mg/kg/day, respectively, which are up to 20 and17 times the maximum recommended human dose (MRHD) of 45 mg based on mg/m2 body surface area,respectively. No evidence of teratogenic effects was observed. However, in rats, there was an increase inpost implantation loss in dams treated with mirtazapine at 100 mg/kg/day which is 20 times the MRHDbased on mg/m2 body surface area. Oral administration of mirtazapine at doses of 2.5, 15, and 100mg/kg/day to pregnant rats during pregnancy and lactation resulted in an increase in pup deaths duringthe first days of lactation and decrease in pup birth weights at 20 times the MRHD based on mg/m2body surface area. The cause of these deaths is not known. The no effect dose level is times theMRHD based on mg/m2 body surface area.

SPL MEDGUIDE SECTION.

MEDICATION GUIDE. Mirtazapine Tablets, USP(mir taz peen) What is the most important information should know about mirtazapine tablets Mirtazapine tablets may cause serious side effects, including:o Increased risk of suicidal thoughts or actions in some children and young adults. Mirtazapine tablets, and other antidepressant medicines may increase suicidal thoughts or actions in some people24 years of age and younger, especially within the first few months of treatment or when the dose is changed. mirtazapine tablets are not for use in children.. mirtazapine tablets are not for use in children., especially within the first few months of treatment or when the dose is changed. mirtazapine tablets are not for use in children.. mirtazapine tablets are not for use in children. Depression or other serious mental illnesses are the most important causes of suicidal thoughts or actions.How can watch for and try to prevent suicidal thoughts and actionso Pay close attention to any changes, especially sudden changes in mood, behavior, thoughts, or feelings, or if you develop suicidal thoughts or actions. This is very important when an antidepressant medicine is started or when the dose is changed.o Call your healthcare provider right away to report new or sudden changes in mood, behavior, thoughts, or feelings., thoughts, or feelings.o Keep all follow-up visits with your healthcare provider as scheduled. Call your healthcare provider between visits as needed, especially if you have concerns about symptoms.Call your healthcare provider or get emergency medical help right away if you or your family member have any of the following symptoms, especially if they are new, worse, or worry you:, worse, or worry you:o attempts to commit suicideo acting aggressive, being angry or violento new or worse depressiono panic attackso new or worse irritabilityo an extreme increase in activity or talking (mania)o acting on dangerous impulseso thoughts about suicide or dyingo new or worse anxietyo feeling very agitated or restlesso trouble sleepingo other unusual changes in behavior or moodWhat are mirtazapine tabletsMirtazapine tablets are prescription medicines used to treat certain type of depression called Major Depressive Disorder (MDD) in adults.It is not known if mirtazapine tablets are safe and effective for use to treat MDD in children.Who should not take mirtazapine tablets Do not take mirtazapine tablets if you:o take Monoamine Oxidase Inhibitor (MAOI)o have stopped taking an MAOI in the last 14 dayso are being treated with the antibiotic linezolid or intravenous methylene blueo if you are allergic to mirtazapine or any of the ingredients in mirtazapine tablets. See the end of thisMedication Guide for complete list of ingredients in mirtazapine tablets Ask your healthcare provider or pharmacist if you are not sure if you take an MAOI, including the antibiotic linezolid or intravenous methylene blue.Do not start taking an MAOI for at least 14 days after you stop treatment with mirtazapine tablets. Before taking mirtazapine tablets, tell your healthcare provider about all your medical conditions, including if you:o have history of suicide or depressiono have history or family history of bipolar disorder, mania or hypomania, mania or hypomaniao have low white blood cell counto have glaucoma (high pressure in the eye)o have or had heart problems or strokeo have an abnormal heart beat called QT prolongation or family history of QT prolongationo have seizureso have high cholesterol or triglyceride levelso have low sodium levels in your bloodo have or had kidney or liver problemso have low blood pressureo are pregnant or plan to become pregnant. It is not known if mirtazapine tablets will harm your unborn baby. Talk to your healthcare provider if you become pregnant or think you may be pregnant during treatment with mirtazapine tablets.o If you become pregnant while taking mirtazapine tablets, talk to your healthcare provider about registering with the National Pregnancy Registry for Antidepressants. You can register by calling 1-844-405-6185 or visiting online at http://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/antidepressants/. The purpose of this registry is to monitor the pregnancy outcomes in women who have been treated with mirtazapine tablets at any time during pregnancy. are breastfeeding or plan to breastfeed. Mirtazapine may pass into your breast milk. Talk to your healthcare provider about the best way to feed your baby during treatment with mirtazapine tablets. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.Mirtazapine tablets and other medicines may affect each other causing possible serious side effects. Mirtazapine tablets may affect the way other medicines work and other medicines may affect the way mirtazapine tablets work.Especially tell your healthcare provider if you take:o MAOIso medicines to treat migraine headaches known as triptanso tricyclic antidepressantso fentanylo lithiumo tramadolo tryptophano buspironeo amphetamineso benzodiazepineso St. Johns Worto medicines used to treat mood, anxiety, psychotic or thought disorders, including selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs), psychotic or thought disorders, including selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)o medicines that may affect your heart rhythm (such as certain antibiotics and some antipsychotics)Ask your healthcare provider if you are not sure if you are taking any of these medicines. Your healthcare provider can tell you if it is safe to take mirtazapine tablets with your other medicines.Do not start or stop any other medicines during treatment with mirtazapine tablets without talking to your healthcare provider first. Stopping mirtazapine tablets suddenly may cause you to have serious side effects. What are the possible side effects of mirtazapine tabletsKnow the medicines you take. Keep list of them to show to your healthcare provider and pharmacist when you get new medicine.How should take mirtazapine tabletso Take mirtazapine tablets exactly as your healthcare provider tells you to. Do not change your dose or stop taking mirtazapine tablets without first talking to your healthcare provider..o Your healthcare provider may need to change the dose of mirtazapine tablets until it is the right dose for youo Take mirtazapine tablets time each day, preferably in the evening at bedtimeo If you take too much mirtazapine tablets call your healthcare provider or poison control center at 1-800-222-1222 right away or go to the nearest hospital emergency room.What should avoid while taking mirtazapine tabletso Do not drive, operate heavy machinery, or do other dangerous activities until you know how mirtazapine tablets affects you. or do other dangerous activities until you know how mirtazapine tablets affects you. Mirtazapine tablets can cause sleepiness or may affect your ability to make decisions, think clearly, or react quickly., think clearly, or react quickly.o Avoid drinking alcohol during treatment with mirtazapine tablets.o Avoid taking medicines used to treat anxiety, insomnia, and seizures, called benzodiazepines, during treatment with mirtazapine tablets. Ask your healthcare provider if you are not sure if you take one of these medicines.What are the possible side effects of mirtazapine tabletsMirtazapine tablets may cause serious side effects, including:o See, What is the most important information should know about mirtazapine Low white blood cell count. Tell your healthcare provider right away if you develop any signs or symptoms of low white blood cell count, including: Fever Sore Throat Flu-like symptoms chills mouth and nose sores infectionso Serotonin syndrome. potentially lifeA potentially life-threatening problem called serotonin syndrome can happen when you takemirtazapine tablets with certain other medicines. See, Who should not take mirtazapine tablets Stop taking mirtazapine tablets and call your healthcare provider or go to the nearest hospital emergency room right away if you have any of the following signs and symptoms of serotonin syndrome: Agitation Confusion Fast heart beat Dizziness Flushing tremors, stiff muscles, or muscle twitching Seizures seeing or hearing things that are not real (hallucinations) coma blood pressure changes sweating high body temperature (hyperthermia) loss of coordination nausea, vomiting, diarrheao Eye problems (angle-closure glaucoma). Mirtazapine tablets may cause certain type of eye problem called angle-closure glaucoma. Call your healthcare provider if you have eye pain, changes in your vision, or swelling or redness in or around the eye. Only some people are at risk for these problems.You may want to undergo an eye examination to see if you are at risk and receive preventative treatment if you are.o Heart rhythm problems. Increased appetite and weight gain. Sleepiness. See,What should avoid while taking mirtazapine tablets Mania or hypomania (manic episodes) in people who have history of bipolar disorder. Symptoms may include: greatly increased energy racing thoughts unusually grand ideas talking more or faster than usual severe trouble sleeping reckless behavior excessive happiness or irritabilityo Seizures (convulsions). Increased fat levels (cholesterol and triglycerides) in your blood..o Low sodium levels in your blood (hyponatremia). Low sodium levels in your blood may be serious and may cause death. Elderly people may be at greater risk for this.Signs and Symptoms of low sodium levels in your blood may include: headache memory changes weakness and unsteadiness on your feet which can lead to falls difficulty concentrating confusionIn severe or more sudden cases, signs and symptoms include: hallucinations (seeing or hearing things that are not real) seizures respiratory arrest fainting coma deatho Changes in liver function tests. Discontinuation syndrome. Suddenly stopping mirtazapine tablets may cause you to have serious side effects. Your healthcare provider may want to decrease your dose slowly. Symptoms may include: dizziness irritability and agitation anxiety sweating seizures ringing in your ears (tinnitus) nausea and vomiting problems sleeping tiredness confusion electric shock sensation(paresthesia) shaking (tremor) headache abnormal dreams changes in your mood hypomaniaThe most common side effects of mirtazapine tablets include:o sleepinesso increased appetiteo weight gaino dizzinessThese are not all the possible side effects of mirtazapine tablets. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should store mirtazapine tabletso Store mirtazapine tablets at room temperature between 68F to 77F (20C to 25C).o Keep mirtazapine ablets away from light and moisture.Keep mirtazapine tablets, and all medicines out of the reach of children. General information about the safe and effective use of mirtazapine tablets.Medicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not usemirtazapine tablets for condition for which it was not prescribed. Do not give mirtazapine tablets to other people, even if they have the same symptoms that you have. It may harm them. You can ask your healthcare provider or pharmacist for information about mirtazapine tablets that is written for healthcare professionals.What are the ingredients in mirtazapine tablets Active ingredient: mirtazapineInactive ingredients: Colloidal silicon dioxide anhydrous, corn starch, ferric oxide (yellow), hydroxypropyl cellulose, hypromellose, polyethylene glycol 8000, lactose monohydrate, magnesium stearate, and titanium dioxide. The 30 mg tablets also contain ferric oxide (red). APOTEX INC. MIRTAZAPINE TABLETS, USP 15 mg, 30 mg and 45 mgManufactured by Manufactured for Apotex Inc. Apotex Corp. Toronto, Ontario Weston, Florida Canada M9L 1T9 33326 Distributed By:MAJOR(R) PHARMACEUTICALSLivonia, MI 48152Refer to package label for Distributors NDC Number Revised: November 2020 Rev. 15.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 4.Geriatric Use: Use with caution in elderly patients. (5.11, 5.14, 8.5)5.Renal impairment: Dosage decrease may be needed in patients with moderate to severe renal impairment. (8.6)6.Hepatic impairment: Dosage decrease may be needed in patients with hepatic impairment. (8.6) 4.Geriatric Use: Use with caution in elderly patients. (5.11, 5.14, 8.5). 5.Renal impairment: Dosage decrease may be needed in patients with moderate to severe renal impairment. (8.6). 6.Hepatic impairment: Dosage decrease may be needed in patients with hepatic impairment. (8.6) . 8.1 Pregnancy Pregnancy Exposure RegistryThere is pregnancy exposure registry that monitors pregnancy outcomes in women exposed to antidepressants during pregnancy. Healthcare providers are encouraged to register patients by calling theNational Pregnancy Registry for Antidepressants at 1-844-405-6185 or visiting online at https://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/antidepressants/. Risk Summary Prolonged experience with mirtazapine in pregnant women, based on published observational studiesand postmarketing reports, has not reliably identified drug-associated risk of major birth defects,miscarriage or adverse maternal or fetal outcomes. There are risks associated with untreated depressionin pregnancy (see Clinical Considerations).In animal reproduction studies, oral administration of mirtazapine to pregnant rats and rabbits during theperiod of organogenesis revealed no evidence of teratogenic effects up to 20 and 17 times the maximum recommended human dose (MRHD) of 45 mg, respectively, based on mg/m2 body surface area.However, in rats, there was an increase in post implantation loss at 20 times the MRHD based on mg/m2body surface area. Oral administration of mirtazapine to pregnant rats during pregnancy and lactation resulted in an increase in pup deaths and decrease in pup birth weights at doses 20 times the MRHDbased on mg/m2 body surface area (see Data).The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is to 4% and 15 to 20% respectively.Clinical ConsiderationsDisease-Associated Maternal and/or Embryo/Fetal RiskWomen who discontinue antidepressants during pregnancy are more likely to experience relapse ofmajor depression than women who continue antidepressants. This finding is from prospective,longitudinal study that followed 201 pregnant women with history of major depressive disorder whowere euthymic and taking antidepressants at the beginning of pregnancy. Consider the risk of untreateddepression when discontinuing or changing treatment with antidepressant medication during pregnancyand postpartum.DataAnimal DataMirtazapine was administered orally to pregnant rats and rabbits during the period of organogenesis atdoses of 2.5, 15, and 100 mg/kg/day and 2.5, 10, and 40 mg/kg/day, respectively, which are up to 20 and17 times the maximum recommended human dose (MRHD) of 45 mg based on mg/m2 body surface area,respectively. No evidence of teratogenic effects was observed. However, in rats, there was an increase inpost implantation loss in dams treated with mirtazapine at 100 mg/kg/day which is 20 times the MRHDbased on mg/m2 body surface area. Oral administration of mirtazapine at doses of 2.5, 15, and 100mg/kg/day to pregnant rats during pregnancy and lactation resulted in an increase in pup deaths duringthe first days of lactation and decrease in pup birth weights at 20 times the MRHD based on mg/m2body surface area. The cause of these deaths is not known. The no effect dose level is times theMRHD based on mg/m2 body surface area.. 8.2 Lactation. Risk Summary Data from published literature report the presence of mirtazapine in human milk at low levels with relativeinfant doses for mirtazapine ranging between 0.6 and 2.8% of the maternal weight-adjusted dose (seeData). No adverse effects on the breastfed infant have been reported in most cases of maternal use ofData). No adverse effects on the breastfed infant have been reported in most cases of maternal use ofmirtazapine. There are no data on the effects of mirtazapine on milk production. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for mirtazapine and any potential adverse effects on the breastfed infant from mirtazapine or from the underlying maternal condition.DataIn published pooled analysis of breastfeeding mother-infant pairs, the mean (min, max) total relativeinfant doses for mirtazapine and its desmethyl metabolite were 1.5% (0.6%, 2.8%) and 0.4% (0.1%,0.7%) of the maternal weight-adjusted dose (median (min, max) dose of 38 mg (30 mg, 120 mg),respectively). No adverse drug effects were reported for any of the infants.. 8.4 Pediatric Use The safety and effectiveness of mirtazapine tablets have not been established in pediatric patients with MDD. Two placebo-controlled trials in 258 pediatric patients with MDD have been conducted with mirtazapine tablets, and the data were insufficient to establish the safety and effectiveness of mirtazapine tablets in pediatric patients with MDD.Antidepressants increased the risk of suicidal thoughts and behaviors in pediatric patients [see Boxed Warning and Warnings and Precautions (5.1)].In an 8-week-long clinical trial in pediatric patients receiving doses between 15 to 45 mg per day, 49% of mirtazapine tablets-treated patients had weight gain of at least 7%, compared to 5.7% of placebo-treated patients. The mean increase in weight was kg (2 kg SD) for mirtazapine tablets-treated patients versus kg (2 kg SD) for placebo-treated patients [see Warnings and Precautions (5.6)].. 8.5 Geriatric Use Approximately 190 patients >=65 years of age participated in clinical studies with mirtazapine tablets. Mirtazapine tablets are known to be substantially excreted by the kidney (75%), and the risk of decreased clearance of this drug is greater in patients with impaired renal function. Pharmacokinetic studies revealed decreased clearance of mirtazapine in the elderly [see Clinical Pharmacology (12.3)]Sedating drugs, including mirtazapine tablets, may cause confusion and over-sedation in the elderly. Elderly patients may be at greater risk of developing hyponatremia. Caution is indicated when administering mirtazapine tablets to elderly patients [see Warnings and Precautions (5.11), (5.14) and Clinical Pharmacology (12.3)]. In general, dose selection for an elderly patient should be conservative, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.. 8.6 Renal or Hepatic Impairment. The clearance of mirtazapine is reduced in patients with moderate to severe renal or hepatic impairment. Consequently, plasma mirtazapine levels may be increased in these patient groups, compared to levels observed in patients without renal or hepatic impairment. Dosage decrease may be necessary when administering mirtazapine tablets to patients with moderate to severe renal or hepatic impairment [see Warnings and Precautions (5.12), Use in Specific Populations (8.5), and Clinical Pharmacology (12.3)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. 12.Agranulocytosis: If sore throat, fever, stomatitis or signs of infection occur, along with low white blood cell count, treatment with mirtazapine tablets should be discontinued and the patient should be closely monitored. (5.2) 13.Serotonin Syndrome: Increased risk when co-administered with other serotonergic drugs (e.g., SSRI, SNRI, triptans), but also when taken alone. If it occurs, discontinue mirtazapine tablets and initiate supportive treatment. (2.4, 4, 5.3, 7) 14. Angle-Closure Glaucoma: Angle closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants. (5.4)15.QT Prolongation: Use mirtazapine tablets with caution in patients with risk factors for QT prolongation. (5.5, 7) 16. Increased Appetite/Weight Gain: Mirtazapine tablets have been associated with increased appetite and weight gain. (5.6) 17.Somnolence: May impair judgment, thinking and/or motor skills. Use with caution when engaging in activities requiring alertness, such as driving or operating machinery. (5.7, 7) 18.Activation of Mania/Hypomania: Screen patients for bipolar disorder prior to initiating treatment. (2.3, 5.8) 19.Seizures: Use with caution in patients with seizure disorder. (5.9) 20. Elevated Cholesterol/Triglycerides: Has been reported with mirtazapine tablet use. (5.10) 21. Hyponatremia: May occur as result of treatment with serotonergic antidepressants, including mirtazapine tablets. (5.11) 22.Transaminase Elevations: Clinically significant elevations have occurred. Use with caution in patients with impaired hepatic function. (5.12). 12.Agranulocytosis: If sore throat, fever, stomatitis or signs of infection occur, along with low white blood cell count, treatment with mirtazapine tablets should be discontinued and the patient should be closely monitored. (5.2) 13.Serotonin Syndrome: Increased risk when co-administered with other serotonergic drugs (e.g., SSRI, SNRI, triptans), but also when taken alone. If it occurs, discontinue mirtazapine tablets and initiate supportive treatment. (2.4, 4, 5.3, 7) 14. Angle-Closure Glaucoma: Angle closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants. (5.4). 15.QT Prolongation: Use mirtazapine tablets with caution in patients with risk factors for QT prolongation. (5.5, 7) 16. Increased Appetite/Weight Gain: Mirtazapine tablets have been associated with increased appetite and weight gain. (5.6) 17.Somnolence: May impair judgment, thinking and/or motor skills. Use with caution when engaging in activities requiring alertness, such as driving or operating machinery. (5.7, 7) 18.Activation of Mania/Hypomania: Screen patients for bipolar disorder prior to initiating treatment. (2.3, 5.8) 19.Seizures: Use with caution in patients with seizure disorder. (5.9) 20. Elevated Cholesterol/Triglycerides: Has been reported with mirtazapine tablet use. (5.10) 21. Hyponatremia: May occur as result of treatment with serotonergic antidepressants, including mirtazapine tablets. (5.11) 22.Transaminase Elevations: Clinically significant elevations have occurred. Use with caution in patients with impaired hepatic function. (5.12). 5.1 Suicidal Thoughts and Behaviors in Adolescents and Young Adults In pooled analyses of placebo-controlled trials of antidepressant drugs (SSRIs and other antidepressant classes) that included approximately 77,000 adult patients and 4,500 pediatric patients, the incidence of suicidal thoughts and behaviors in antidepressant-treated patients age 24 years and younger was greater than in placebo-treated patients. There was considerable variation in risk of suicidal thoughts and behaviors among drugs, but there was an increased risk identified in young patients for most drugs studied. There were differences in absolute risk of suicidal thoughts and behaviors across the different indications, with the highest incidence in patients with MDD. The drug-placebo differences in the number of cases of suicidal thoughts and behaviors per 1000 patients treated are provided in Table 1. Table 1Age RangeDrug-placebo Difference in Number of Cases of Suicidality per 1,000 Patients Treated Increases Compared to Placebo <1814 additional cases18 to 245 additional cases Decreases Compared to Placebo 25 to 641 fewer case>=656 fewer cases It is unknown whether the risk of suicidal thoughts and behaviors in children, adolescents, and young adults extends to longer-term use, i.e., beyond four months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with MDD that antidepressants delay the recurrence of depression and that depression itself is risk factor for suicidal thoughts and behaviors.Monitor all antidepressant-treated patients for any indication of clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy, and at times of dosage changes. Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider. Consider changing the therapeutic regimen, including possibly discontinuing mirtazapine tablets, in patients whose depression is persistently worse, or who are experiencing emergent suicidal thoughts or behaviors.. 5.2 Agranulocytosis. In premarketing clinical trials, (1 with Sjogrens Syndrome) out of 2796 patients treated with mirtazapine tablets developed agranulocytosis [absolute neutrophil count (ANC) <500/mm3 with associated signs and symptoms, e.g., fever, infection, etc.] and third patient developed severe neutropenia (ANC <500/mm3 without any associated symptoms). For these patients, onset of severe neutropenia was detected on days 61, 9, and 14 of treatment, respectively. All patients recovered after mirtazapine tablets were stopped. If patient develops sore throat, fever, stomatitis, or other signs of infection, along with low white blood cell (WBC) count, treatment with mirtazapine tablets should be discontinued and the patient should be closely monitored.. 5.3 Serotonin Syndrome Serotonergic antidepressants, including mirtazapine tablets, can precipitate serotonin syndrome, potentially life-threatening condition. The risk is increased with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. Johns Wort) and with drugs that impair metabolism of serotonin, i.e., MAOIs [see Contraindications (4), Drug Interactions (7)]. Serotonin syndrome can also occur when these drugs are used alone.Serotonin syndrome signs and symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).The concomitant use of mirtazapine tablets with MAOIs is contraindicated. In addition, do not initiate mirtazapine tablets in patient being treated with MAOIs such as linezolid or intravenous methylene blue. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection). If it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in patient taking mirtazapine tablets, discontinue mirtazapine tablets before initiating treatment with the MAOI [see Contraindications (4), Drug Interactions (7)].Monitor all patients taking mirtazapine tablets for the emergence of serotonin syndrome. Discontinue treatment with mirtazapine tablets and any concomitant serotonergic agents immediately if the above symptoms occur and initiate supportive symptomatic treatment. If concomitant use of mirtazapine tablets with other serotonergic drugs is clinically warranted, inform patients of the increased risk for serotonin syndrome and monitor for symptoms., inform patients of the increased risk for serotonin syndrome and monitor for symptoms.. 5.4 Angle-closure Glaucoma. The pupillary dilation that occurs following use of many antidepressant drugs, including mirtazapine tablets, may trigger an angle-closure attack in patient with anatomically narrow angles who does not have patent iridectomy.. 5.5 QTc Prolongation and Torsades de Pointes. The effect of mirtazapine tablets on QTc interval was assessed in clinical randomized trial with placebo and positive (moxifloxacin) controls involving 54 healthy volunteers using exposure response analysis. This trial showed positive relationship between mirtazapine concentrations and prolongation of the QTc interval. However, the degree of QT prolongation observed with both 45 mg and 75 mg (1.67 times the maximum recommended daily dose) doses of mirtazapine was not at level generally considered to be clinically meaningful. During postmarketing use of mirtazapine, cases of QT prolongation, Torsades de Pointes, ventricular tachycardia, and sudden death, have been reported [see Adverse Reactions (6.1, 6.2)]. The majority of reports occurred in association with overdose or in patients with other risk factors for QT prolongation, including concomitant use of QTc-prolonging medicines [see Drug Interactions (7) and Overdosage (10)]. Exercise caution when mirtazapine tablets is prescribed in patients with known cardiovascular disease or family history of QT prolongation, and in concomitant use with other drugs thought to prolong the QTc interval.. 5.6 Increased Appetite and Weight Gain. In U.S. controlled clinical studies, appetite increase was reported in 17% of patients treated with mirtazapine tablets, compared to 2% for placebo. In these same trials, weight gain of >=7% of body weight was reported in 7.5% of patients treated with mirtazapine, compared to 0% for placebo. In pool of premarketing U.S. clinical studies, including many patients for long-term, open-label treatment, 8% of patients receiving mirtazapine tablets discontinued for weight gain.In an 8-week-long pediatric clinical trial of doses between 15 to 45 mg/day, 49% of mirtazapine tablets-treated pediatric patients had weight gain of at least 7%, compared to 5.7% of placebo-treated patients. The safety and effectiveness of mirtazapine tablets in pediatric patients with MDD have not been established [see Use in Specific Populations (8.4)].. 5.7 Somnolence In U.S. controlled studies, somnolence was reported in 54% of patients treated with mirtazapine tablets, compared to 18% for placebo. In these studies, somnolence resulted in discontinuation for 10.4% of mirtazapine tablets-treated patients, compared to 2.2% for placebo. It is unclear whether tolerance develops to the somnolent effects of mirtazapine tablets. Because of the potentially significant effects of mirtazapine tablets on impairment of performance, caution patients about engaging in activities that require alertness, including operating hazardous machinery and motor vehicles, until they are reasonably certain that mirtazapine does not affect them adversely. The concomitant use of benzodiazepines and alcohol with mirtazapine tablets should be avoided [see Drug Interactions (7)].. 5.8 Activation of Mania or Hypomania In patients with bipolar disorder, treating depressive episode with mirtazapine tablets or another antidepressant may precipitate mixed/manic episode. In controlled clinical trials, patients with bipolar disorder were generally excluded; however, symptoms of mania or hypomania were reported in 0.2% of patients treated with mirtazapine tablets. Prior to initiating treatment with mirtazapine tablets, screen patients for any personal or family history of bipolar disorder, mania, or hypomania.. 5.9 Seizures Mirtazapine tablets has not been systematically evaluated in patients with seizure disorders. In premarketing clinical trials, seizure was reported among the 2796 U.S. and non-U.S. patients treated with mirtazapine tablets. Mirtazapine tablets should be prescribed with caution in patients with seizure disorder.. 5.10 Elevated Cholesterol and Triglycerides. In U.S. controlled studies, nonfasting cholesterol increases to >=20% above the upper limits of normal were observed in 15% of patients treated with mirtazapine tablets, compared to 7% for placebo. In these same studies, nonfasting triglyceride increases to >=500 mg/dL were observed in 6% of patients treated with mirtazapine tablets, compared to 3% for placebo.. 5.11 Hyponatremia Hyponatremia may occur as result of treatment with serotonergic antidepressants, includingmirtazapine tablets. Cases with serum sodium lower than 110 mmol/L have been reported.mirtazapine tablets. Cases with serum sodium lower than 110 mmol/L have been reported.Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. Signs and symptoms associated with more severe or acute cases have included hallucination, syncope, seizure, coma, respiratory arrest, and death. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH).In patients with symptomatic hyponatremia, discontinue mirtazapine tablets and institute appropriate medical intervention. Elderly patients, patients taking diuretics, and those who are volume- depleted may be at greater risk of developing hyponatremia [see Use in Specific Populations (8.5)].. 5.12 Transaminase Elevations Clinically significant ALT (SGPT) elevations (>=3 times the upper limit of the normal range) were observed in 2.0% (8/424) of patients treated with mirtazapine tablets in pool of short-term, U.S. controlled trials, compared to 0.3% (1/328) of placebo patients. While some patients were discontinued for the ALT increases, in other cases, the enzyme levels returned to normal despite continued mirtazapine treatment.Mirtazapine tablets should be used with caution in patients with impaired hepatic function [see Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].. 5.13 Discontinuation Syndrome There have been reports of adverse reactions upon the discontinuation of mirtazapine tablets (particularly when abrupt), including but not limited to the following: dizziness, abnormal dreams, sensory disturbances (including paresthesia and electric shock sensations), agitation, anxiety, fatigue, confusion, headache, tremor, nausea, vomiting, and sweating, or other symptoms which may be of clinical significance.A gradual reduction in the dosage, rather than an abrupt cessation, is recommended [see Dosage and Administration (2.6)].. 5.14 Use in Patients with Concomitant Illness Mirtazapine tablets have not been systematically evaluated or used to any appreciable extentin patients with recent history of myocardial infarction or other significant heart disease. Mirtazapine tablets were associated with significant orthostatic hypotension in early clinical pharmacology trials with normal volunteers. Orthostatic hypotension was infrequently observed in clinical trials with depressed patients [see Adverse Reactions (6.1)]. Mirtazapine tablets should be used with caution in patients with known cardiovascular or cerebrovascular disease that could be exacerbated by hypotension (history of myocardial infarction, angina, or ischemic stroke) and conditions that would predispose patients to hypotension (dehydration, hypovolemia, and treatment with antihypertensive medication).