Posted by ed_uk on March 13, 2005, at 13:35:29
In reply to Re: I have to go off Nardil! NO!!!!!!!!!!!!!!!!!!!!!, posted by gardenergirl on March 13, 2005, at 13:13:07
Hello Andrew,
>Do you have to have a general anesthesia?
If you can find an anesthetist/dentist who is knowledgeable about MAOIs, drug-interactions, which drugs to avoid, pethidine (meperidine) etc, you almost certainly won't need to come off Nardil. The idea than everyone who takes an MAOI needs to come off it before surgery is outdated.
'There is no clinical evidence of dangerous interactions between adrenaline (epinephrine)-containing local anaesthetics and monoamine-oxidase inhibitors (MAOIs)'
“it seems that the use of adrenaline (epinephrine), whether administered in eye drops or as a component of local anaesthesia in dental and other procedures, should not be contraindicated in patients receiving MAOIs.”
Unfortunately, if you can't find an anesthetist/dentist who is knowledgable about MAOIs, you will need to discontinue Nardil.
Here is some information..........
Anaesthetics, general + MAOIs
It is generally recommended that MAOIs should be withdrawn 2 weeks before anaesthesia, although there is some evidence that this may be unnecessary in most patients. However, individual cases of both hypo- and hypertension have been seen and MAOIs can interact dangerously with other drugs sometimes used during surgery (particularly pethidine (meperidine) and ephedrine).
Clinical evidence and mechanism
The absence of problems during emergency general anaesthesia in 2 patients on MAOIs prompted further study in 6 others on long-term treatment with unnamed MAOIs. All 6 were premedicated with 10 to 15 mg of diazepam 2 hours before surgery, induced with thiopental, given suxamethonium (succinylcholine) before intubation, and maintained with nitrous oxide/oxygen with either halothane or isoflurane. Pancuronium was used for muscle relaxation, and morphine was given postoperatively. One patient experienced hypotension that responded to repeated 100-microgram intravenous doses of phenylephrine without hypertensive reactions. No other untoward events occurred either during or after the anaesthesia. 1No adverse reactions occurred in 27 other patients on MAOIs (tranylcypromine, phenelzine, isocarboxazid, pargyline) when anaesthetised. 2 No problems were seen in dogs on tranylcypromine anaesthetised with enflurane and fentanyl and then give the vasopressors noradrenaline (norepinephrine) and ephedrine. 3 Two single case reports describe the safe and uneventful use of propofol in a patient on phenelzine 4 and another on tranylcypromine. 5 The latter was also given alfentanil. No problems were seen in one patient on tranylcypromine when given ketamine 6 and in another on selegiline when given fentanyl, isoflurane and midazolam. 7 No problems were seen in another patient on phenelzine when anaesthetised firstly with sevoflurane in oxygen, followed by isoflurane, oxygen, air and an infusion of remifentanil. 8 Unexplained hypertension has been described in a patient taking tranylcypromine when etomidate and atracurium were used. 9 Moclobemide was stopped on the morning of surgery in a patient who was anaesthetised with propofol and later isoflurane in nitrous oxide and oxygen. Atracurium, morphine and droperidol were also used. No adverse reactions occurred. 10 Ketorolac, propofol and midazolam were used uneventfully in one patient on phenelzine. 11
There are a few anecdotal reports of MAOIs potentiating the effects of amobarbital, butobarbital and secobarbital–see ‘MAOIs + Barbiturates’.
Importance and management
The BNF 12 states that ‘in view of their hazardous interactions MAOIs should normally be stopped 2 weeks before surgery.’ However, there seems to be little documentary evidence that the withdrawal of MAOI before anaesthesia is normally necessary. Scrutiny of reports 13 alleging an adverse reaction usually shows that what happened could be attributed to an interaction between other drugs used during the surgery (e.g. either ‘directly-acting sympathomimetics’ or ‘indirectly-acting sympathomimetics’, or ‘pethidine’) rather than with the anaesthetics. The authors of the reports cited here offer the opinion that . . ‘general and regional anaesthesia may be provided safely without discontinuation of MAOI therapy, provided proper monitoring, adequate preparation, and prompt treatment of anticipated reactions are utilised’. 1,2 This implies that the possible interactions between the MAOI and other drugs are fully recognised, but be alert for the rare unpredictable response.
Regards,
Ed.
poster:ed_uk
thread:470308
URL: http://www.dr-bob.org/babble/20050312/msgs/470468.html