ABSTRACT
Introduction: Chronic breathlessness is a common and distressing symptom of advanced disease with few effective treatments. Central nervous system mechanisms are important in respiratory sensation and control. Consequently, drugs which may modify processing and perception of afferent information in the brain may have a role. Antidepressants have been proposed; however, current evidence is limited. Of potentially suitable antidepressants, mirtazapine is an attractive option given its tolerability profile, low cost, and wide availability, along with additional potential benefits.
Areas covered: The paper provides an overview of the physiology of breathlessness, with an emphasis on central mechanisms, particularly the role of fear circuits and the associated neurotransmitters. It provides a potential rationale for how mirtazapine may improve chronic breathlessness and quality of life in patients with advanced disease. The evidence was identified by a literature search performed in PubMed through to October 2018.
Expert opinion: Currently, there is insufficient evidence to support the routine use of antidepressants for chronic breathlessness in advanced disease. Mirtazapine is a promising candidate to pursue, with definitive randomized controlled trials required to determine its efficacy and safety in this setting.
Article highlights
Chronic breathlessness remains a common and distressing symptom of advanced disease with few effective treatment options
While there is evidence to support the use of parental and oral opioids, not all patients report benefit, and long-term safety data is currently lacking
Therefore, new effective treatments are urgently needed
In recent years thinking has moved towards drugs which may modify the processing and perception of afferent information in the brain, such as antidepressants
Mirtazapine is a promising candidate, but there is currently insufficient evidence to support routine use to treat breathlessness in clinical practice
Definitive randomized controlled trials are needed to provide evidence to guide clinical practice
Declaration of interest
The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.