(Kiosk 1) Severe Uncontrolled Nausea Resolved with Low Dose Mirtazapine in a Bilateral Lung Transplant Patient - A Case Report

Case Diagnosis: Severe Uncontrolled Nausea Resolved with Low Dose Mirtazapine in a Bilateral Lung Transplant Patient

Case Description or Program Description: A 21-year-old female without significant past medical history presented with parainfluenza/pseudomonas pneumonia and progression to ARDS requiring tracheostomy, venovenous extracorporeal membrane oxygenation, and bilateral lung transplant. Her hospitalization was complicated by persistent nausea limiting her participation in therapy and nutritional intake. She was transferred to acute inpatient rehabilitation for critical illness myopathy, where persistent symptoms significantly affected her rehabilitation course.

Setting: Inpatient Rehabilitation Center

Assessment/Results: The etiology of her nausea was thought to be multifactorial due to gastroparesis, medication side effects, and anxiety. Metoclopramide, promethazine, ondansetron, scopolamine patch, proton pump inhibitors, and conservatively reducing medication burden were ineffective. Low-dose 7.5 mg mirtazapine nightly was initiated to help with nausea (off-label use), anxiety, and appetite. She had improvement in nausea after one dose and resolution of symptoms by day three, allowing her to participate in therapy and improve her nutritional intake to help with sacral wound healing.

Discussion (relevance): Commonly used antiemetic medications include serotonin antagonists, anticholinergics, and prokinetics. Although mirtazapine is rarely used as an antiemetic medication, given its serotonin antagonist activity, mirtazapine has been shown to help treat secondary causes of nausea, such as post-operative or chemotherapy-induced and refractory gastroparesis. In this clinical case, as our patient had failed many common antiemetic medications, mirtazapine was considered to treat her severe nausea associated with anxiety and loss of appetite.

Conclusions: Treatment-resistant nausea can be a barrier to rehabilitation. Mirtazapine has been shown to be an effective option for those with secondary nausea. This case report highlights that mirtazapine can also be effective for treatment-resistant nausea as a side effect of transplantation medications and gastroparesis with concomitant anxiety and decreased appetite.