![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by IanSFO on August 29, 2001, at 0:22:34
In a post I lost track of, someone said the dangers of MAOI interactions are significantly overblown. Where could I find sources to back that up? Parnate was the best antidepressant/anti social-phobia med I have ever taken, but the frequent need for decongestants to combat chronic sinusitis has meant giving up MAOIs. I've been taking Wellbutrin instead, and while it's acceptably effective for depression, it is of no help at all with social phobia. (The side effects of other alternatives were not tolerable.) If I could switch back to Parnate I would be so relieved.
Posted by SalArmy4me on August 29, 2001, at 1:24:25
In reply to MAOIs and safety, posted by IanSFO on August 29, 2001, at 0:22:34
1. American Journal of Nursing
Volume 100 January 2000 p 71
MAOI PRESCRIPTIONS: Way down, but still not out:
2. Shader, Richard I. MD. The Reappearance of a Monamine Oxidase Inhibitor (Isocarboxazid). Journal of Clinical Psychopharmacology. 19(2):105-106, April 1999.
3. Walker, SE. Tyramine Content of Previously Restricted Foods in Monoamine Oxidase Inhibitor Diets. Year Book of Psychiatry & Applied Mental Health. 1998(10):450-453, Annual 1998.
-----------------------------------------------
#1 Amer. Journal of Nursing: "Only 2% of psychiatrists recently surveyed reported prescribing monoamine oxidase inhibitors (MAOIs) frequently. This is down from 25% 10 years ago, before the widespread use of selective serotonin reuptake inhibitors (SSRIs).The most common explanation for never or rarely prescribing MAOIs was potential interactions. Other reasons were side effects, a preference for other drugs, potential legal complications, the dietary restrictions required for patients receiving MAOIs, lack of training regarding their use, and lack of belief in their efficacy.
Meanwhile, the majority of respondents, 92%, acknowledged the usefulness of MAOIs for treating atypical depression, and a substantial percentage found them useful for major depression (melancholic type), panic disorder, social phobia, and other disorders. They are particularly useful for patients who don't respond to SSRIs and can't tolerate the side effects associated with tricyclic antidepressants.
MAOIs are prescribed infrequently, but it's important to be aware of their potential side effects (such as postural hypotension, insomnia, and headache) and the risk of hypertensive crisis with concomitant sympathomimetics, levodopa, and high-tyramine foods such as cheese, chocolate, wine, beer, and coffee."
-----------------------------------------------
#2 Isocarboxazid: The Reappearance of a Monamine Oxidase Inhibitor (Isocarboxazid)
In 1988, we produced a monograph, MAOI Therapy. [1] We did so because of a noticeable trend toward a reemergence of the use of monoamine oxidase inhibitors (MAOIs) at a time when fewer physicians were exposed to them during training. Our goal in that monograph was to put their use in perspective so that prescribing could be done more safely and appropriately. Curiously, this trend toward more prescribing was short-lived. The successful introduction of fluoxetine and other serotonin transporter inhibitors shortly thereafter and the fact that moclobemide and brofaromine, highly touted reversible MAOIs, were not showing consistent utility in their phase 3 trials soon diminished the growing enthusiasm for MAOIs. It was not surprising then that Hoffmann-LaRoche withdrew their MAOI isocarboxazid (Marplan) from the market in 1994. Consistent with this, we have recently learned that another MAOI, nialamide (Niamid), was finally withdrawn by Pfizer from the French market where it was still available.We have had mixed feelings about this trend. When prescribed by appropriately trained physicians who understand their indications and safety concerns, the remaining U.S.-marketed MAOIs, phenelzine and tranylcypromine, have continued to provide relief to many patients who seem almost as if they are unique responders to MAOIs and who are willing to comply with curtailment of their diet.
We recently learned of the reintroduction of isocarboxazid to the U.S. market early in January 1999. Oxford Pharmaceutical Services acquired isocarboxazid and the use of the name, Marplan, from Hoffmann-LaRoche (Roche). Oxford is now marketing isocarboxazid, although Roche will continue to be the manufacturer of the drug, at least for the immediate future. We welcome the reappearance of isocarboxazid because there continue to be patients who fail to have an adequate response to whatever antidepressants we have available. From past experience, we can expect that there will be some patients for whom isocarboxazid provides unique benefit. In fact, a meta-analysis of intent-to-treat cohorts from three double-blind, placebo-controlled, published studies of isocarboxazid in outpatients showed a remarkably robust drug-placebo difference of 41.3% (+/- 18%). [2]
The reintroduction of isocarboxazid prompted us to look into some newer findings about MAOIs. For example, preclinical studies have shown that isocarboxazid and certain other MAOIs inhibit the binding of the dopamine agonist quinpirole to D2 receptors in brain. [3] This effect seems to be unrelated to any MAO inhibiting properties. Quinpirole, when given alone, causes a marked, dose-dependent attenuation of striatal c-fos (an immediate early gene) expression by serotonin agonists. [4] Finally, isocarboxazid and certain other irreversible MAOIs were found after long-term administration to decrease the density of I2 imidazoline-preferring receptors in rat brain as studied by the binding of labeled idazoxan. [5] Readers may recall that idazoxan is a potent [small alpha, Greek]2-adrenergic receptor antagonist. Unfortunately, the behavioral consequences of these effects of isocarboxazid and other MAOIs are not established. We were unable to find, for example, studies of these drugs in MAO knockout mice. Nevertheless, findings such as these suggest that any currently held mechanism of action concepts for MAOIs may be too limited or simplistic.
In recent years, the metabolism of isocarboxazid has become more clear. Rather than being metabolized by hepatic microsomal cytochromes or by hepatic acetylation, isocarboxazid is a specific substrate for and is hydrolyzed by RL2 hepatic microsomal carboxylesterase in rat liver microsomes. [6] Interestingly, this metabolizing enzyme is markedly induced by glucocorticoids and methylprednisolone. [7] This latter research convincingly demonstrated dose-dependent increased isocarboxazid hydrolase activity produced by dexamethasone. This finding may explain a clinical experience one of us (R.I.S.) had in the mid-1960s with a patient whose prednisone-induced anergic depression required increasing doses of isocarboxazid to maintain a positive clinical response even after discontinuation of the steroid. Finally, two simple and relatively sensitive spectrophotometric methods (using 7,7,8,8-tetracyanoquinodimethane as a [small pi, Greek]-electron acceptor) have been described to quantify isocarboxazid levels. [8]
--------------------------------------------------
#3 MAOI Diet: Objectives.-To determine the tyramine content of various foods and beverages that have been restricted from the diets of individuals taking monamine oxidase inhibitors (MAOIs), but whose tyramine content is unclear or unknown, and to evaluate the effect of freshness on the tyramine content of some foods.Background.-Monoamine oxidase inhibitors are important in the treatment of refractory depressive illnesses, anxiety, and eating disorders. They have been associated with hypertensive crisis resulting from an interaction with foods containing tyramine. The list of restricted foods linked to hypertensive crisis has grown to more than 70 items. The danger of over-inclusive diets is that if a patient ingests a prohibited food and has no negative reaction, he or she may become careless and indulge in other restricted foods that may be more dangerous. The restricted foods and beverages have now been classified as containing high or low amounts of tyramine. The authors have received requests for information on specific foods for which there is little or no reliable information.
Methods.-The tyramine content of various foods and beverages was tested by liquid chromatography; 51 samples were tested, including samples of the inside and skin or peel of sausages and bananas.
Results.-Foods with dangerously high levels of tyramine include chicken liver aged 9 days, air-dried sausage, soy sauce, and sauerkraut (Table 1). No tyramine was found in Italian Chianti wine. Part-skim mozzarella cheese had extremely low amounts of tyramine. Although only one beer was analyzed and found to have small amounts of tyramine, alarmingly high amounts of tyramine were found in 4 tap beers in a previous report. This indicates that storage and hose contamination may encourage the production of tyramine. The pulp of bananas, even overripe bananas, had acceptable levels of tyramine. Raspberries contained low concentrations of tyramine.
Discussion.-The hypertensive response is variable and depends on many factors. Therefore, patients may be able to ingest 6 mg or more of tyramine and not have a response, but the danger of an increase in blood pressure is always present and may occur the next time a restricted food or beverage is ingested. The amount of ingested tyramine should remain below 6 mg. Most of the reported fatal and nonfatal hypertensive reactions associated with MAOIs have involved the ingestion of cheese. Although all aged cheese has traditionally been restricted, not all cheeses need be prohibited. Tap beer should be avoided. Foods that have been improperly stored or are spoiled may contain higher amounts of tyramine. Only foods with dangerously high levels of tyramine should continue to be restricted. All other foods are safe or safe in moderation. Patients should be given a diet that clearly identifies these two groups of foods. These findings should be combined with findings from similar studies to develop accurate and comprehensive lists of foods that must be absolutely restricted for these individuals.
Psychiatric practitioners who use monoamine oxidase inhibitors are all familiar with the "white-knuckle" approach to treating those patients. Since the selective MAO-A inhibitors failed to make it to the marketplace, we still have to rely on these old agents at least occasionally. This article nicely revisits the issue of tyramine content as a risk factor in the MAOI diet restriction. Psychopharmacologists almost uniformly attest to the effectiveness of these agents for patients who have failed standard treatments. This article gives objective information about the danger of many foods that we have advised patients to avoid. (I have never had any patients, by the way, who ate banana peels.) This article should allow many of us to modify our food restriction lists and the advice we give to patients. It is also probably worth noting that the explosion of "microbreweries" creating new beers every week will continue to make our lives interesting. Caution is probably indicated until we have information about these newer brews (which we are not likely to get any time soon). This report is a useful clinical article for practitioners and patients who already have enough problems on their plate (pun intended)."
--------------------------------------------------
The final chord of help
was the finger of the Almighty
as He split the veil of separation
to allow me into His presence.The symphony of love
was played to perfection
by hands that stretched though time
to heal my shattered life.
--Lt. Rachel Messer, Salvation Army Central Territory
Posted by SalArmy4me on August 29, 2001, at 1:25:44
In reply to MAOIs and safety, posted by IanSFO on August 29, 2001, at 0:22:34
--I took Tranylcypromine for three months last year.
Dangerous?
Yes, there is a chance of a hypertensive crisis in which blood pressure increases so rapidly that a huge headache occurs. The chance of a hypertensive crisis from eating foods with tyramine is 6% from the last study done on it; modified to only 3% with the application of a special diet. These are pretty low percentages. But even if such a hypertensive crisis occurs, a simple dose of oral nifedipine will stop it immediately... The truth is that most hypertensive crises are mild, if they even occur.
Actually, there is more of a chance of _low_ blood pressure (orthostatic) with MAOIs than with the opposite. This may sound like a terrible illness, but it is merely annoying and does not cause any damage to the body. It may make you dizzy when you go from lying down to standing upright. It is easily remedied with a high sodium diet.
http://www.dr-bob.org/tips/split/Orthostatic-hypotension-on.html
If a first or second-line antidepressant fails for you, you should consider an MAOI (Phenelzine, Tranylcypromine, or the now available isocarboxazid. MAOIs are the only medications that work on three chemicals in the brain at once: maximizing chances of relief.)A disadvantage of MAOIs is that they can have severe interactions with other medications. Sometimes a Serotonin Syndrome or Neuroleptic Malignant Syndrome occurs. But to avoid such reactions, all you have to do is remember to ask your doctor before taking any medication with an MAOI. Or, you can use Dr. Koop's Drug Checker at www.drkoop.com.
MAOIs are perfectly safe, that is why they are still used after 40 years of existence. They just require that you get used to the idea of taking them and not erroneously think that they will kill you. Point in case: Nobody ever sees an article about someone dying from an MAOI in the paper.
Other stuff: http://www.dr-bob.org/tips/split/Orthostatic-hypotension-on.html
http://www.dr-bob.org/tips/split/MAOI-diet-update.htmlBlood & Fire: The Salvation Army USA West
Posted by Elizabeth on August 29, 2001, at 11:27:09
In reply to MAOIs and safety, posted by IanSFO on August 29, 2001, at 0:22:34
Wellbutrin is not an anxiolytic at all. I don't get why your doctor is trying to use it for social phobia.
Anyway, here are some refs about MAOI-food interactions:
Walker SE, Shulman KI, Tailor SA, Gardner D.
Tyramine content of previously restricted foods in monoamine oxidase inhibitor diets.
J Clin Psychopharmacol. 1996 Oct;16(5):383-8.Gardner DM, Shulman KI, Walker SE, Tailor SA.
The making of a user friendly MAOI diet.
J Clin Psychiatry. 1996 Mar;57(3):99-104.Sweet RA, Brown EJ, Heimberg RG, Ciafre L, Scanga DM, Cornelius JR, Dube S, Forsyth KM, Holt CS.
Monoamine oxidase inhibitor dietary restrictions: what are we asking patients to give up?
J Clin Psychiatry. 1995 May;56(5):196-201.Shulman KI, Walker SE, MacKenzie S, Knowles S.
Dietary restriction, tyramine, and the use of monoamine oxidase inhibitors.
J Clin Psychopharmacol. 1989 Dec;9(6):397-402.Sullivan EA, Shulman KI.
Diet and monoamine oxidase inhibitors: a re-examination.
Can J Psychiatry. 1984 Dec;29(8):707-11.Walker JI, Davidson J, Zung WW.
Patient compliance with MAO inhibitor therapy.
J Clin Psychiatry. 1984 Jul;45(7 Pt 2):78-80.Folks DG.
Monoamine oxidase inhibitors: reappraisal of dietary considerations.
J Clin Psychopharmacol. 1983 Aug;3(4):249-52.McCabe B, Tsuang MT.
Dietary consideration in MAO inhibitor regimens.
J Clin Psychiatry. 1982 May;43(5):178-81.A couple of articles and letters with data on specific foods:
Shulman KI, Walker SE.
Refining the MAOI diet: tyramine content of pizzas and soy products.
J Clin Psychiatry. 1999 Mar;60(3):191-3.Feinberg S, Holzer B.
Clarifying the safety of the MAOI diet and pizza.
J Clin Psychiatry. 2000 Feb;61(2):145-6.Shulman KI, Tailor SA, Walker SE, Gardner DM.
Tap (draft) beer and monoamine oxidase inhibitor dietary restrictions.
Can J Psychiatry. 1997 Apr;42(3):310-2.Tailor SA, Shulman KI, Walker SE, Moss J, Gardner D.
Hypertensive episode associated with phenelzine and tap beer--a reanalysis of the role of pressor amines in beer.
J Clin Psychopharmacol. 1994 Feb;14(1):5-14.Da Prada M, Zurcher G.
Tyramine content of preserved and fermented foods or condiments of Far Eastern cuisine.
Psychopharmacology (Berl). 1992;106 Suppl:S32-4.Da Prada M, Zurcher G, Wuthrich I, Haefely WE.
On tyramine, food, beverages and the reversible MAO inhibitor moclobemide.
J Neural Transm Suppl. 1988;26:31-56.And on differences between different MAOIs:
Bieck PR, Antonin KH.
Tyramine potentiation during treatment with MAO inhibitors: brofaromine and moclobemide vs irreversible inhibitors.
J Neural Transm Suppl. 1989;28:21-31.Bieck PR, Antonin KH.
Oral tyramine pressor test and the safety of monoamine oxidase inhibitor drugs: comparison of brofaromine and tranylcypromine in healthy subjects.
J Clin Psychopharmacol. 1988 Aug;8(4):237-45.Simpson GM, Gratz SS.
Comparison of the pressor effect of tyramine after treatment with phenelzine and moclobemide in healthy male volunteers.
Clin Pharmacol Ther. 1992 Sep;52(3):286-91.I hope this helps.
-elizabeth
Posted by IanSFO on August 29, 2001, at 19:41:29
In reply to Re: MAOIs and safety » IanSFO, posted by SalArmy4me on August 29, 2001, at 1:24:25
Thanks for the replies to my post. It always seemed ironic to me that hypertensive crisis was a concern with a drug that tended to lower your blood pressure. My first night on Parnate my blood pressure dropped to 75 over 35! I was a bit unnerved and called a free medical information line to be sure I wasn't in danger.
But I'm still wondering about the relative danger of decongestants and MAOIs, since tyramine is not an issue.
I'm also curious about the potential for drug interactions when using the deprenyl patch. Bypassing the digestive system may eliminate the danger of tyramine reactions, but does it eliminate dangers from drug reactions? Does anyone know?
> 1. American Journal of Nursing
> Volume 100 January 2000 p 71
> MAOI PRESCRIPTIONS: Way down, but still not out:
> 2. Shader, Richard I. MD. The Reappearance of a Monamine Oxidase Inhibitor (Isocarboxazid). Journal of Clinical Psychopharmacology. 19(2):105-106, April 1999.
> 3. Walker, SE. Tyramine Content of Previously Restricted Foods in Monoamine Oxidase Inhibitor Diets. Year Book of Psychiatry & Applied Mental Health. 1998(10):450-453, Annual 1998.
> -----------------------------------------------
> #1 Amer. Journal of Nursing: "Only 2% of psychiatrists recently surveyed reported prescribing monoamine oxidase inhibitors (MAOIs) frequently. This is down from 25% 10 years ago, before the widespread use of selective serotonin reuptake inhibitors (SSRIs).
>
> The most common explanation for never or rarely prescribing MAOIs was potential interactions. Other reasons were side effects, a preference for other drugs, potential legal complications, the dietary restrictions required for patients receiving MAOIs, lack of training regarding their use, and lack of belief in their efficacy.
>
> Meanwhile, the majority of respondents, 92%, acknowledged the usefulness of MAOIs for treating atypical depression, and a substantial percentage found them useful for major depression (melancholic type), panic disorder, social phobia, and other disorders. They are particularly useful for patients who don't respond to SSRIs and can't tolerate the side effects associated with tricyclic antidepressants.
>
> MAOIs are prescribed infrequently, but it's important to be aware of their potential side effects (such as postural hypotension, insomnia, and headache) and the risk of hypertensive crisis with concomitant sympathomimetics, levodopa, and high-tyramine foods such as cheese, chocolate, wine, beer, and coffee."
> -----------------------------------------------
> #2 Isocarboxazid: The Reappearance of a Monamine Oxidase Inhibitor (Isocarboxazid)
> In 1988, we produced a monograph, MAOI Therapy. [1] We did so because of a noticeable trend toward a reemergence of the use of monoamine oxidase inhibitors (MAOIs) at a time when fewer physicians were exposed to them during training. Our goal in that monograph was to put their use in perspective so that prescribing could be done more safely and appropriately. Curiously, this trend toward more prescribing was short-lived. The successful introduction of fluoxetine and other serotonin transporter inhibitors shortly thereafter and the fact that moclobemide and brofaromine, highly touted reversible MAOIs, were not showing consistent utility in their phase 3 trials soon diminished the growing enthusiasm for MAOIs. It was not surprising then that Hoffmann-LaRoche withdrew their MAOI isocarboxazid (Marplan) from the market in 1994. Consistent with this, we have recently learned that another MAOI, nialamide (Niamid), was finally withdrawn by Pfizer from the French market where it was still available.
>
> We have had mixed feelings about this trend. When prescribed by appropriately trained physicians who understand their indications and safety concerns, the remaining U.S.-marketed MAOIs, phenelzine and tranylcypromine, have continued to provide relief to many patients who seem almost as if they are unique responders to MAOIs and who are willing to comply with curtailment of their diet.
>
> We recently learned of the reintroduction of isocarboxazid to the U.S. market early in January 1999. Oxford Pharmaceutical Services acquired isocarboxazid and the use of the name, Marplan, from Hoffmann-LaRoche (Roche). Oxford is now marketing isocarboxazid, although Roche will continue to be the manufacturer of the drug, at least for the immediate future. We welcome the reappearance of isocarboxazid because there continue to be patients who fail to have an adequate response to whatever antidepressants we have available. From past experience, we can expect that there will be some patients for whom isocarboxazid provides unique benefit. In fact, a meta-analysis of intent-to-treat cohorts from three double-blind, placebo-controlled, published studies of isocarboxazid in outpatients showed a remarkably robust drug-placebo difference of 41.3% (+/- 18%). [2]
>
> The reintroduction of isocarboxazid prompted us to look into some newer findings about MAOIs. For example, preclinical studies have shown that isocarboxazid and certain other MAOIs inhibit the binding of the dopamine agonist quinpirole to D2 receptors in brain. [3] This effect seems to be unrelated to any MAO inhibiting properties. Quinpirole, when given alone, causes a marked, dose-dependent attenuation of striatal c-fos (an immediate early gene) expression by serotonin agonists. [4] Finally, isocarboxazid and certain other irreversible MAOIs were found after long-term administration to decrease the density of I2 imidazoline-preferring receptors in rat brain as studied by the binding of labeled idazoxan. [5] Readers may recall that idazoxan is a potent [small alpha, Greek]2-adrenergic receptor antagonist. Unfortunately, the behavioral consequences of these effects of isocarboxazid and other MAOIs are not established. We were unable to find, for example, studies of these drugs in MAO knockout mice. Nevertheless, findings such as these suggest that any currently held mechanism of action concepts for MAOIs may be too limited or simplistic.
>
> In recent years, the metabolism of isocarboxazid has become more clear. Rather than being metabolized by hepatic microsomal cytochromes or by hepatic acetylation, isocarboxazid is a specific substrate for and is hydrolyzed by RL2 hepatic microsomal carboxylesterase in rat liver microsomes. [6] Interestingly, this metabolizing enzyme is markedly induced by glucocorticoids and methylprednisolone. [7] This latter research convincingly demonstrated dose-dependent increased isocarboxazid hydrolase activity produced by dexamethasone. This finding may explain a clinical experience one of us (R.I.S.) had in the mid-1960s with a patient whose prednisone-induced anergic depression required increasing doses of isocarboxazid to maintain a positive clinical response even after discontinuation of the steroid. Finally, two simple and relatively sensitive spectrophotometric methods (using 7,7,8,8-tetracyanoquinodimethane as a [small pi, Greek]-electron acceptor) have been described to quantify isocarboxazid levels. [8]
> --------------------------------------------------
> #3 MAOI Diet: Objectives.-To determine the tyramine content of various foods and beverages that have been restricted from the diets of individuals taking monamine oxidase inhibitors (MAOIs), but whose tyramine content is unclear or unknown, and to evaluate the effect of freshness on the tyramine content of some foods.
>
> Background.-Monoamine oxidase inhibitors are important in the treatment of refractory depressive illnesses, anxiety, and eating disorders. They have been associated with hypertensive crisis resulting from an interaction with foods containing tyramine. The list of restricted foods linked to hypertensive crisis has grown to more than 70 items. The danger of over-inclusive diets is that if a patient ingests a prohibited food and has no negative reaction, he or she may become careless and indulge in other restricted foods that may be more dangerous. The restricted foods and beverages have now been classified as containing high or low amounts of tyramine. The authors have received requests for information on specific foods for which there is little or no reliable information.
>
> Methods.-The tyramine content of various foods and beverages was tested by liquid chromatography; 51 samples were tested, including samples of the inside and skin or peel of sausages and bananas.
>
> Results.-Foods with dangerously high levels of tyramine include chicken liver aged 9 days, air-dried sausage, soy sauce, and sauerkraut (Table 1). No tyramine was found in Italian Chianti wine. Part-skim mozzarella cheese had extremely low amounts of tyramine. Although only one beer was analyzed and found to have small amounts of tyramine, alarmingly high amounts of tyramine were found in 4 tap beers in a previous report. This indicates that storage and hose contamination may encourage the production of tyramine. The pulp of bananas, even overripe bananas, had acceptable levels of tyramine. Raspberries contained low concentrations of tyramine.
>
> Discussion.-The hypertensive response is variable and depends on many factors. Therefore, patients may be able to ingest 6 mg or more of tyramine and not have a response, but the danger of an increase in blood pressure is always present and may occur the next time a restricted food or beverage is ingested. The amount of ingested tyramine should remain below 6 mg. Most of the reported fatal and nonfatal hypertensive reactions associated with MAOIs have involved the ingestion of cheese. Although all aged cheese has traditionally been restricted, not all cheeses need be prohibited. Tap beer should be avoided. Foods that have been improperly stored or are spoiled may contain higher amounts of tyramine. Only foods with dangerously high levels of tyramine should continue to be restricted. All other foods are safe or safe in moderation. Patients should be given a diet that clearly identifies these two groups of foods. These findings should be combined with findings from similar studies to develop accurate and comprehensive lists of foods that must be absolutely restricted for these individuals.
>
> Psychiatric practitioners who use monoamine oxidase inhibitors are all familiar with the "white-knuckle" approach to treating those patients. Since the selective MAO-A inhibitors failed to make it to the marketplace, we still have to rely on these old agents at least occasionally. This article nicely revisits the issue of tyramine content as a risk factor in the MAOI diet restriction. Psychopharmacologists almost uniformly attest to the effectiveness of these agents for patients who have failed standard treatments. This article gives objective information about the danger of many foods that we have advised patients to avoid. (I have never had any patients, by the way, who ate banana peels.) This article should allow many of us to modify our food restriction lists and the advice we give to patients. It is also probably worth noting that the explosion of "microbreweries" creating new beers every week will continue to make our lives interesting. Caution is probably indicated until we have information about these newer brews (which we are not likely to get any time soon). This report is a useful clinical article for practitioners and patients who already have enough problems on their plate (pun intended)."
> --------------------------------------------------
> The final chord of help
> was the finger of the Almighty
> as He split the veil of separation
> to allow me into His presence.
>
> The symphony of love
> was played to perfection
> by hands that stretched though time
> to heal my shattered life.
> --Lt. Rachel Messer, Salvation Army Central Territory
Posted by SalArmy4me on August 29, 2001, at 19:55:53
In reply to Re: MAOIs and safety, posted by IanSFO on August 29, 2001, at 19:41:29
Why are you going to want to use deprenyl?
Posted by Jane D on August 30, 2001, at 1:41:53
In reply to Re: MAOIs and safety2 » IanSFO, posted by SalArmy4me on August 29, 2001, at 1:25:44
Hi Sal,
I know this has been mentioned this before but when you just repost the same thing over and over again it makes the search function much less effective. It would be much easier if you would just post a link to your earlier post any time you need to point someone new to one of them. Perhaps with a short explanation of why they should look at it. This will save you a lot of unnecessary typing and will also save space on the server. It should be faster for you as well. For example, with just a minute's searching I found the following four posts which are identical in content and wording to the one you just made.
http://www.dr-bob.org/babble/20010302/msgs/55333.html
http://www.dr-bob.org/babble/20010411/msgs/59512.html
http://www.dr-bob.org/babble/20010411/msgs/59927.html
http://www.dr-bob.org/babble/20010411/msgs/59938.htmlJane
Posted by Elizabeth on August 31, 2001, at 15:11:04
In reply to Re: MAOIs and safety, posted by IanSFO on August 29, 2001, at 19:41:29
> But I'm still wondering about the relative danger of decongestants and MAOIs, since tyramine is not an issue.
I don't think it's fair to say that tyramine isn't an issue; it's just an issue that's been overplayed. Systemic decongestants (like Sudafed) are a problem with MAOIs; nasal sprays (Afrin, etc.) are generally okay since they act locally (even if some got into your bloodstream, the concentration would be insignificant).
> I'm also curious about the potential for drug interactions when using the deprenyl patch. Bypassing the digestive system may eliminate the danger of tyramine reactions, but does it eliminate dangers from drug reactions? Does anyone know?
Yes. There can be drug interactions with transdermally administered selegiline.
-elizabeth
Posted by Adam on August 31, 2001, at 17:29:09
In reply to Re: MAOIs and safety, posted by IanSFO on August 29, 2001, at 19:41:29
I was on "the patch" for six months. I ate and imbibed anything I wanted, sometimes in large quantities, but, unfortunately, drug interactions are still an issue. One needs to observe the same cautions with OTC and prescription drugs that one does on high-dose oral selegiline (and low-dose, for that matter), and the other non-selective MAOIs.
The reason for this is fairly simple: MAO-A, which somehow retains function in the intestines (so they say) while one is on transdermal selegiline, can deaminate tyramine sufficiently to protect one from hypertensive reactions to it. But, since MAO-A is not involved in breaking down the vast majority of drugs you take into your system, you are still susceptible to any enhanced CNS and/or sympathetic/parasympathetic effects a drug might cause in the presence of a non-selective MAOI.
I've been waiting quite a while for some explanation as to why transdermal selegiline "protects the gut" from MAO-A inhibition. As far as I can gather, no one knows for sure. Since it can inhibit MAO-A perfectly well in the CNS (to where it traveled via the circulation), but seems to have no effect on enteral epithelial or smooth-muscle enzymes, there must be some exclusion mechanism, I would guess. Maybe stuff enters the circulation from the gut, but the reverse is not always true.
There's a decent article on some relevant stuff here:
http://www.mhsource.com/pt/p010525.html
(Just as an aside, Dr. Bodkin was the principle investigator of the study I was in, and Dr. Detke was the physician who followed me throughout the trial I participated in...both I hold in the highest esteem, and were by far the best psychiatrists I have worked with since I was in a study at the NIH years ago.)
> I'm also curious about the potential for drug interactions when using the deprenyl patch. Bypassing the digestive system may eliminate the danger of tyramine reactions, but does it eliminate dangers from drug reactions? Does anyone know?
>
Posted by SLS on August 31, 2001, at 22:31:09
In reply to Re: MAOIs and safety, posted by Adam on August 31, 2001, at 17:29:09
> (Just as an aside, Dr. Bodkin was the principle investigator of the study I was in, and Dr. Detke was the physician who followed me throughout the trial I participated in...both I hold in the highest esteem, and were by far the best psychiatrists I have worked with since I was in a study at the NIH years ago.)
Hey Adam - I didn't know you were a NIMH alumnus!
Who were your doctors?
I was in the Clinical Pharmacology department on the 4th floor (4-West). Bill Potter headed up the department and Mark Schmidt was my primary doctor.
Were you in Biological Psychiatry with Robert Post? While I was a patient, Ketter, Pazzaglia, George, and Marangall were there. Each of them have since gone on to major universities.
Just curious.
- Scott
Posted by kregpark@yahoo.com on September 1, 2001, at 5:03:18
In reply to Re: MAOIs and safety, posted by IanSFO on August 29, 2001, at 19:41:29
Hi IanSFO:
I'll throw in my 2 cents also.
About the dangers of MAOI interactions:
I have taken Nardil for about 5 years total, 2 years at a high dose, (90 mg) and 3 years at a mild dose (60 mg).
My personal opinion is that serotonin syndrome is the main risk for most MAOI users, but I also think the risk of serotonin syndrome goes for anyone on a serotonergic (almost every antidepressant sold!).
Basically any two antidepressants should be used together with caution (even single drug remigmens like Paxil and Effexor have led to serotononin syndrome deaths).To Nardil, I have cautiously added (incrementally increasing dose) of stimulants or stimulant like meds such as Ritalin, Dexedrine, amantadine, Wellbutrin, amineptine, tianeptine, PROVIGIL, yohimbine, caffeine pills (part of my regimen actually); also Serzone (this one can make Nardil much like Parnate!!!), and others...
None of these led to any notable change in BP (I measured anything potentially risky). Max raise I got was maybe 5 points. BP LOSS is much more common for me with these, enhanced dopaminergic as well as the more complex Norepinephrine effects.Anyway, long story a bit less long:
Many drugs can be dangerous. Being prudent (avoid certain wines, large quantities import beer, huge chunks of cheese, and most of all serotonergic antidepressants or drugs) -
Relative safety is good as you'll see on Medline or by calling manufacturuers.Driving to your docs office is likely factors of 10 times more dangerous than all your years of MAOI!!!
KregPark@yahoo.com
http://www.socialfear.com
> Thanks for the replies to my post. It always seemed ironic to me that hypertensive crisis was a concern with a drug that tended to lower your blood pressure. My first night on Parnate my blood pressure dropped to 75 over 35! I was a bit unnerved and called a free medical information line to be sure I wasn't in danger.
>
> But I'm still wondering about the relative danger of decongestants and MAOIs, since tyramine is not an issue.
>
> I'm also curious about the potential for drug interactions when using the deprenyl patch. Bypassing the digestive system may eliminate the danger of tyramine reactions, but does it eliminate dangers from drug reactions? Does anyone know?
>
Posted by SLS on September 1, 2001, at 7:33:29
In reply to Re: MAOIs and safety » IanSFO, posted by kregpark@yahoo.com on September 1, 2001, at 5:03:18
Hi KregPark.
> I'll throw in my 2 cents also.
>
> About the dangers of MAOI interactions:
>
> My personal opinion is that serotonin syndrome is the main risk for most MAOI usersI would have to agree with you. While taking Parnate (120mg), desperation led me to wanting to see what would happen if I were to add a serotonin reuptake inhibitor. I chose Effexor because it had the shortest half-life. Should anything untoward happen, I figured it was better to use a drug that woul clear as soon as possible. I tried to be smart. I ultimately failed. I decided bite off the smallest piece of a 75mg tablet (original immediate-release preparation) to use as a challenge. It couldn't have been more than 15mg. Somewhere in between 15 and 30 minutes, I was totally incoherent and babbling total nonsense. Lying on the bed, I could not sit up. I don't remember if there was any rigidity involved. I don't think so. My parents were there. Somehow I managed to collect myself enough to have them take my temperature. It might have been a degree or two above my norm. I didn't do a very good job reassuring them that everything would be all right I told them that I just needed to reboot my system. I was pretty much OK within an hour. Of all the aggressive drug combinations my doctor was willing to consider, it was only MAOIs + SSRIs that he firmly rejected.
> , but I also think the risk of serotonin syndrome goes for anyone on a serotonergic (almost every antidepressant sold!).
> Basically any two antidepressants should be used together with caution (even single drug regimens like Paxil and Effexor have led to serotononin syndrome deaths).You'll even find reports of serotonin syndrome developing upon the addition of lithium to an SSRI.
> To Nardil, I have cautiously added (incrementally increasing dose) of stimulants or stimulant like meds such as Ritalin, Dexedrine, amantadine, Wellbutrin, amineptine, tianeptine, PROVIGIL, yohimbine, caffeine pills (part of my regimen actually);
Oh my. You've been busy.
I hope you don't mind if I ask but a few questions.
What has worked best for you?
How did you react upon adding each of Provigil, amantadine, and yohimbine?
> also Serzone (this one can make Nardil much like Parnate!!!),
This is one combination that I have been very interested to try. Last year, I was about to add Serzone to Parnate + desipramine + Lamictal, but grew shy when one of our posters here described what might have been some sort of dystonic reaction upon adding it to Nardil. Can you be specific on how adding Serzone changed your experience such that Nardil felt like Parnate?
> Relative safety is good as you'll see on Medline or by calling manufacturuers.
> Driving to your docs office is likely factors of 10 times more dangerous than all your years of MAOI!!!
I agree.
Thanks much in advance for any input you can provide me.
Sincerely,
Scott
Posted by Adam on September 1, 2001, at 10:00:52
In reply to Re: MAOIs and safety » Adam, posted by SLS on August 31, 2001, at 22:31:09
>
> Hey Adam - I didn't know you were a NIMH alumnus!
>
Yes, I am. In brief, I didn't know I had an OCD-spectrum disorder until I just happened to go to a summer lecture on OCD given by Dr. Judith Rapoport (yes, THE Dr. Judith Rapoport). Talk about serendipity. After the lecture, which you might say "rocked my world", I grabbed my NIH directory and rang her up (I was working in the NCI at the time).> Who were your doctors?
Dr. Rapoport directed me to a study being run by Dr. Susan Swedo. It was a non-drug study, so my work with Dr. Swedo was limited largely to various diagnostic tests and the imaging (MRI, PET). She was great to talk to, and also gave me a drug consult after I left the study. Dr. Rapoport and Dr. Swedo are about as big as you can get in the area of child psychiatry. Dr. Rapoport needs no introduction; Dr. Swedo's big focus was psychiatric disorders and PANDAS, for which she is duly famous. I guess the experience of talking and working with them set my bar kind of high.
During the study, most of my nitty-gritty time was spent with a psychologist, Dr. Charles Mansueto of Silver Spring, MD, who specialized in anxiety disorders and used behavioral Tx to treat them. Torture, but the best psychotherapeutic experience of my life, when all was said and done.
>
> I was in the Clinical Pharmacology department on the 4th floor (4-West). Bill Potter headed up the department and Mark Schmidt was my primary doctor.
>
> Were you in Biological Psychiatry with Robert Post? While I was a patient, Ketter, Pazzaglia, George, and Marangall were there. Each of them have since gone on to major universities.
>
> Just curious.
>
>
> - Scott
Posted by kregpark@yahoo.com on September 3, 2001, at 3:57:35
In reply to Re: MAOIs and safety » kregpark@yahoo.com, posted by SLS on September 1, 2001, at 7:33:29
Hi Scott, sure.
(I HAVE A QUESTION FOR YOU AT END TOO!! :) )> I hope you don't mind if I ask but a few questions.
> What has worked best for you?I think the next thing i'll put at http://socialfear.com
is my drug diary, but I can answer that pretty quick.Overall (pre-Provigil) I prerred Klonopin regularly and ...
R1) 3 years: Nardil 45-60 + Klonopin 4.25-4.75
R2) 1/2 year: Zoloft 50 + Serzone 300 + Klonopin 4.25-4.75R1 for me is non-sedating and more energy, vigilance, and sexual assertivness.
R2 for me is more Pro-Social but not as good for work (lower energy, vigilance,
sometimes lazy and less assertive sexually)Actually, I have thought recently that
PROVIGIL could fit or replace drug(s) in R2 nicely,I also like TRAMADOL + DA/NE enhancer (ie; Wellbutrin)
but lack much experience to date (work makes it hard
to experiment: employers like a person whose personality
they recognize each day !!! :)I also very much like Xanax + DA/NE enhancer,
HOWEVER, I could not handle the 8 times a day
dosing of Xanax I require (why wasn't Xanax SR brought to U.S.?)
> How did you react upon adding each of Provigil, amantadine, and yohimbine?
Adding Provigil: GREAT! Fast acting energizing felt happier.
Adding Amantadine: Energizing but started becoming more serious.
Effective for energy and sexual side effects
but moderate anti-sp effect. Overall did not like.
Adding yohimbine: Did not like. Helpful some for sexual side effects,
Nardil actually seems to blunt yohimbines effect to a large degree
(was axiogenic but low or high dose not much different).
Overall unpleasant and I definitely don't recommend
for any reason with MAOI for sexual side effects because
other agents work far better if that is the purpose.
As for pro-social, I can't imagine it's application there.> > also Serzone (this one can make Nardil much like Parnate!!!),
> This is one combination that I have been very interested to try. Last year, I was about to add Serzone to Parnate + desipramine + Lamictal, but grew shy when one of our posters here described what might have been some sort of dystonic reaction upon adding it to Nardil. Can you be specific on how adding Serzone changed your experience such that Nardil felt like Parnate?Years ago I tried Serzone with Zoloft50 + Klonopin4.5. I was pleased to disconver that
it reduced sedation, increased efficacy, and reduced sexual side effects of Zoloft (all good stuff!!)About a year ago I temporary had raised Nardil from 60 to 75mg.
I had more anxiety and tried Serzone, about 200.
This actually made me *more* anxious, and quite horny!!!
300 Serzone was max of this effect, more led to sedative effects.
I have previously and since often added low dose
Serzone to Nardil + Klonopin. It allows me to reduce
Klonopin and I used it at 200mg while lowering Klonopin
from 4.5mg to 1mg. I then raised K to 2.5 where it's at now.QUESTION:
What is lamictal like? Isn't that lamotrigine?I've often wondered about it, as lamotrigine is
in the same class as gabapentine, but while
gabapentin has SSRI like side effects, lamotrigine
appears to have dopaminergic like side effects
in many people, such as rash, and some others I can't
recall exactly but I think possible insomnia or hypotension
or something...Any comments on lamictal (lamotrigine?) and
your current regimen also - greatly appreciated,KregPark
Posted by SLS on September 3, 2001, at 9:25:18
In reply to Re: MAOIs and safety » SLS, posted by kregpark@yahoo.com on September 3, 2001, at 3:57:35
Hi KregPark.
Thanks for taking the time.
I'm glad that you found Serzone and Nardil combatable. I may end up on that combination yet.
I'm currently taking:
300mg lamotrigine (Lamictal)
75mg nortriptyline (Pamelor, Aventyl)
300mg venlafaxine (Effexor)I just added ziprasidone (Geodon) last night. I'll probably start at 40mg.
> I've often wondered about it, as lamotrigine is
in the same class as gabapentine, but while
gabapentin has SSRI like side effects, lamotrigine
appears to have dopaminergic like side effects
in many people, such as rash, and some others I can't
recall exactly but I think possible insomnia or hypotension
or something...> Any comments on lamictal (lamotrigine?) and
your current regimen also - greatly appreciated,I think you are right about Lamictal. My guess is that Lamictal does have some pro-dopamineric effects, most probably indirect. I have little to base this on, except for how it seems to affect me. It definitely possesses distinct antidepressant properties. I have even seen people describe manic reactions to it.
Although Lamictal and Neurontin both exert anticonvulsant effects and are thus labelled as such, they do very different things to neurons. Lamictal has two distinct pharmacological effects. It helps stabilize a neuron by blocking sodium channels, a property shared by some other anticonvulsants like Depakote and Tegretol. However, it also reduces the levels of extracellular glutamate, an excitory neurotransmitter. This might be the property that produces antidepressant effects. Neurontin does not seem to do any of these things. Although it was once thought to promote the synthesis of GABA, I think this hypothesis has since been rejected. Cam W. would be a better source of information regarding all of this.
Regarding Neurontin, I think one source of its antianxiety and anti-phobic effects might involve a stabilization or reduction in the excitability of certain pathways located in the amygdala and temporal lobes. I'm not familiar with the effects Neurontin has on serotonergic neurotransmission.
Just as an aside - I think one must be careful when categorizing or assigning labels to specific drugs. For instance, is amantadine (Symmetrel) an antiviral drug or is it a drug with antiviral properties? It is really a drug with antiviral (herpes) *and* antiparkinsonian properties. Likewise, Depakote is a drug with anticonvulsant, antimanic and mood stabilizing properties.
I couldn't guess as to how well Lamictal would work for you. However, Neurontin has definitely displayed efficacy in the treatment of social-anxiety and social-phobia. (Are these two terms interchangeable?) I'm not sure how well it works as monotherapy for severe cases.
- Scott
> > also Serzone (this one can make Nardil much like Parnate!!!),
> This is one combination that I have been very interested to try. Last year, I was about to add Serzone to Parnate + desipramine + Lamictal, but grew shy when one of our posters here described what might have been some sort of dystonic reaction upon adding it to Nardil. Can you be specific on how adding Serzone changed your experience such that Nardil felt like Parnate?> Years ago I tried Serzone with Zoloft50 + Klonopin4.5. I was pleased to disconver that
it reduced sedation, increased efficacy, and reduced sexual side effects of Zoloft (all good stuff!!)> About a year ago I temporary had raised Nardil from 60 to 75mg.
I had more anxiety and tried Serzone, about 200.
This actually made me *more* anxious, and quite horny!!!
300 Serzone was max of this effect, more led to sedative effects.
I have previously and since often added low dose
Serzone to < B >Nardil + Klonopin< /B >. It allows me to reduce
Klonopin and I used it at 200mg while lowering Klonopin
from 4.5mg to 1mg. I then raised K to 2.5 where it's at now.
Posted by Elizabeth on September 8, 2001, at 21:40:11
In reply to Re: MAOIs and safety » kregpark@yahoo.com, posted by SLS on September 1, 2001, at 7:33:29
> I would have to agree with you. While taking Parnate (120mg), desperation led me to wanting to see what would happen if I were to add a serotonin reuptake inhibitor. I chose Effexor because it had the shortest half-life.
Oh boy. < g > You've got cojones!
> Somewhere in between 15 and 30 minutes, I was totally incoherent and babbling total nonsense.
That sounds familiar!
> Of all the aggressive drug combinations my doctor was willing to consider, it was only MAOIs + SSRIs that he firmly rejected.
With good reason, as you've seen!
> You'll even find reports of serotonin syndrome developing upon the addition of lithium to an SSRI.
Yeah, all kinds of things can cause it. I had a bad episode while taking Effexor XR (by itself).
> This is one combination that I have been very interested to try. Last year, I was about to add Serzone to Parnate + desipramine + Lamictal, but grew shy when one of our posters here described what might have been some sort of dystonic reaction upon adding it to Nardil.
Dystonias can be part of the serotonin syndrome.
-e
This is the end of the thread.
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