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MAOI expert interview

Posted by undopaminergic on February 18, 2020, at 10:44:27

I found this interview with MAOI expert Jonathan Cole, MD:

Some quotes:
Q: ".. the early studies of MAOIs were not very impressive. Is that true?"
A: ".. we increased the dose of Nardil (phenelzine) to about 45 mg a day for three weeks. It didnt show much efficacy, but the dose was too low."

Q: "What would have been a more adequate dose?"
A: "At least 60 mg, but probably higher. One rule of thumb .. is that 1 mg/kg is a good threshold for Nardil."

Q?: ".. That is a pretty high dose!"
A: "Dr. Cole: I know. But what Robinson found was that people below that threshold had a 30% improvement rate versus a 60% improvement rate above that dose. Jay Amsterdam .. goes up as high as 120 mg of Parnate(tranylcypramine) and claims fewer side effects at higher doses."

Q: "What are some of the differences among the oral MAOIs on the market in this country?"
A: "Parnate is alleged to be more stimulating, although in my own practice, I have found it sedating. Every time I use it to energize a patient, the patient goes to sleep. Nardil tends to cause more weight gain and sedation. .. I have used oral selegiline in five patients and have had good results. It seems to be a clean drug."

Q: "What do you think of the selegiline patch?"
A: "At $15 per patch per day, its extremely expensive. .. I have one patient who has been on oral selegeline for several years, .. She recently tried the patch and it didnt work as well as the oral version."

Q?: "But trazodone is officially contraindicated with MAOIs."
A: "Yes, but my colleague Alex Bodkin and I must have treated 80 patients with trazodone on top of an MAOI and it has been safe and effective. Typically, we discontinue the SSRI and start trazodone or increase the dose in order to get an antidepressant effect while we are waiting to start the MAOI."

Q: "Are there any medications that you use adjunctively with MAOIs?"
A: "I use psychostimulants. Initially, I began using them because I had a couple of patients who had the common MAOI side effect of sleepiness around 5 pm. .. I have used Dexedrine (dextroamphetamine) and Ritalin (methylphenidate) and I have never seen a hypertensive crisis with either one. In addition, in my experience, Remeron (mirtazipine), trimipramine, and amitriptyline all mix fine with MAOIs. Anafranil, however, is clearly dangerous, as it has the potential to trigger the serotonin syndrome."

Q: "Overall, what has been your experience with dangerous interactions in using MAOIs?"
A: "Dangerous events are extremely rare. Over 30 years of clinical practice at McLean Hospital, the only bad reaction I know of involved a patient on Nardil .. She .. took a massive overdose of Sudafed and developed a left-sided stroke."

Q: "What about less severe reactions?"
A: "Ive had a couple of people on Parnate who would get what seemed like a hypertensive headache at four in the afternoon for no apparent reason."

Q: "If we decide to try one of the more risky combinations, .. what are the things that we should watch for and what do you tell your patients?"
A: "I tell them to watch out for a really bad headache that comes on rapidly and feels like their head is going to split. If they are able to take their own blood pressures, I tell them that if their blood pressure goes up by 40 points, they need to do something. I generally prescribe nifedipine, 10 mg, and have them carry it around. If they get a bad headache, I have them take one pill, bite it in half and swallow it, and repeat the dose if there is no relief in 30 minutes. Simply having patients go to an emergency room tends not to be helpful, because in my limited experience, such patients sit in a corner in the waiting room until the headache goes away."

* My commentary: Dr. Cole, above, only addresses the danger of hypertensive crisis. However, the more I learn about MAOIs, the more it seems that serotonin toxicity (serotonin syndrome in more extreme cases) is a more likely complication.

Q: "Have you had any bad experiences with patients taking nifedipine and then passing out because their blood pressure goes too low?"
A: "Not so far. According to my last discussions with the emergency room at Mass General five years ago, nifedipine was considered a reasonably safe treatment for acute hypertension. .."

Q: "Now what about this popular idea that MAOIs are particularly good for people with atypical depressive symptoms; is that true in your experience?"
A: "I think the answer to that is sort of. Don Klein .. tried hard to answer that question and they ended up concluding that tricyclics are less effective than MAOIs for atypical depression, rather than that MAOIs are the gold standard. So it wasnt an overwhelming validation."

Q: "A lot of patients are terrified of taking MAOIs. What can we say to convince patients to try them?"
A: "I think all you can say is that .. bad reactions are pretty rare and that if nothing else has helped their depression, an MAOI is worth trying. I give them nifedipine to carry as an amulet, which is reassuring to many patients. And if they are very reluctant, you might suggest the EMSAM patch, which is quite safe at the lowest dose."





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