![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 16 to 40 of 40. Go back in thread:
Posted by bassman on October 8, 2006, at 16:37:45
In reply to good » bassman, posted by pseudoname on October 8, 2006, at 15:32:19
That's funny! Actually, it's "bassman" like a person who plays the electric bass guitar. Maybe I should say, "tries to play the bass guitar" (I think I have the folks in my band fooled, and that's all that counts! :>}) What's funny is that my wife and I went over a bridge in NH and the name of the river was "Bass River"...and so I mumbled "Bass (bay-suh) River" and my wife said, "uh, I think that is Bass (bah-suh) River". All of Life is perspective...
Posted by pseudoname on October 8, 2006, at 16:47:32
In reply to Good plan for me?, posted by jealibeanz on October 8, 2006, at 15:13:16
> So what do you all think about my plan to approach my doctor in this manner? Any suggestions?
You mean, suggestions for getting him to up your Xanax dose? Or, suggestions about dealing with increasing anxiety? If the former, it (almost) never hurts to ask. However…
He MAY be more easily persuaded if he knows that you are also doing other things to deal with anxiety and not trying to completely rely on his narcotics. Like, using exercise before and mindful attention during anxious periods. Show him the CBT- or meditation-type book you're using (and if you're not, you could get one) and tell him how hard you're working in these other ways. That may reassure him a little, and loosen his prescription pen. (And if not, it might help on its own; no guarantees.)
Good luck. Post how it goes.
Posted by Phillipa on October 8, 2006, at 17:50:38
In reply to Re: more recent data (same times), posted by jealibeanz on October 8, 2006, at 15:11:28
Jelly where did that come from. But thanks I know what you say is true . And unfortunately my mind is too powerful. But I'm working on that. That's one of the reasons I'm so obsessive about the data. The more times I hear good things the more courage I get. I wish there were some stats on how many people are doing well? Love Phillipa
Posted by jealibeanz on October 8, 2006, at 17:57:47
In reply to Re: Good plan for me? » jealibeanz, posted by pseudoname on October 8, 2006, at 16:47:32
I was asking about how to talk to my doctor about my concern of taking Xanax, but conveying that it is improving the quality of my life at the moment. And yes, I would like to increase a little, or switch to XR, or something that would help with anxiety!
If he ever brings up the idea of tryyying an SSRI, since they're all slightly different, I'll tell him flat out that I'd rather take absolutely nothing than go that route. We both know that I would not last very long at school without medication and eventually dropout. Neither of us would like that to happen.
I've been unmedicated for anxiety for the majority of the time that I've had it. I know what it's like. I can live with it. But it would be a low quality, underachieving life, no doubt.
I do exercise, whenever I can. I love it. Actually if he asks, I will tell him that I try to exercise a few days a week, however, sometimes, once I start, I need to stop because my anxiety is so bad that my muscles are all tight and I can't comfortably continue!
I do have CBT tapes and a workbook that I'm completing. I've done biofeedback therapy in the past, which is not an option right now, since that machine was borrowed from a friend and costs about $3000!
The dean of my program referred me to a counselor on campus when she was aware of the fact that I was have anxiety and insomnia problems. I'm just not comfortable with talk therapy right now and have never found it beneficial in the past. I know some swear by it, but if I'm not 100% sold on the idea, then me forcing myself to go is simply a waste. We need to believe in our treatments.
Despite the fact that I've indicated how difficult and demanding my academics are, I'm at a verrry supportive school. They make it as relaxed and low-key as possible, without hindering our education. The faculty act like parents rather than professors. They are always on the lookout for someone who needs help.
So, I am doing the best I can with my situation, I just need some augmentation with meds!
Posted by jealibeanz on October 8, 2006, at 18:00:41
In reply to Re: more recent data (same times) » jealibeanz, posted by Phillipa on October 8, 2006, at 17:50:38
This was already posted, but here it is again:
Posted by Phillipa on October 8, 2006, at 18:46:18
In reply to Re: more recent data (same times) » Phillipa, posted by jealibeanz on October 8, 2006, at 18:00:41
Thanks Jelly is effexor really good for anxiety? Thought it had all those liver problems? Love Phillipa
Posted by Phillipa on October 8, 2006, at 18:47:51
In reply to Re: more recent data (same times) » Phillipa, posted by jealibeanz on October 8, 2006, at 18:00:41
I mean that sounds like effexor is better for anxiety than EMSAM? Love Phillipa
Posted by jealibeanz on October 8, 2006, at 19:14:40
In reply to Re: more recent data (same times), posted by Phillipa on October 8, 2006, at 18:47:51
Liver problems? I'm not sure about this. If you have liver disease then maybe that would be an issue.
I took Effexor XR for 7 weeks. Well... as for anxiety, I suppose it helped, in the fact that I was completely apathetic and felt no emotions whatsoever. Oh, and I was completely nauseous, couldn't eat a thing, and gained 20 lbs.
So, my opinion of Effexor is poor, but you may do well since you've done well on SSRI's. I have not. You are not me. I'm sure you'd have a very different reaction. Some people do very well. It's known as a great antidepressant. It definitely pulled me out of a major depression, I just didn't care to continue with it.
You need to trust you doctor's plan. If it's not helping, let that be known. The two of you can come up with another option. If your doctor isn't helping, find a new one.
Posted by Phillipa on October 8, 2006, at 19:28:59
In reply to Re: more recent data (same times), posted by jealibeanz on October 8, 2006, at 19:14:40
No ad that I've taken has ever worked for me except l0mg of paxil with lopressor and xanax and beer. So I'm at a loss. As only 30 to 50% of people respond to antidepressants. Guess I'm one. I can tolerate low doses of luvox that's it. Love phillipa
Posted by psychobot5000 on October 8, 2006, at 20:44:11
In reply to Re: more recent data (same times), posted by Phillipa on October 8, 2006, at 18:47:51
I know a female in her twenties, who took selegiline/EMSAM (quarter patch's worth), and had reduced anxiety and mildly elevated mood--at a quarter dose. Her reaction was pretty quick--a few days. Just imagine if she'd taken a normal dose.
Now she finds she doesn't need it any more. Yay!
Posted by Phillipa on October 8, 2006, at 21:24:10
In reply to Re: more recent data (same times) » jealibeanz, posted by Phillipa on October 8, 2006, at 19:28:59
Thank-you so much that is highly encouraging. Now the decision cut out luvox for EMSAM or up to luvox. Help Love Phillipa
Posted by psychobot5000 on October 8, 2006, at 21:41:58
In reply to Re: more recent data (same times) » Phillipa, posted by Phillipa on October 8, 2006, at 21:24:10
I know nothing about Luvox, other than its drug class. MAOi experts, as far as I know, think you can combine MAO-b inhibitors with SSRIs, at least cautiously.
Doctor might be wary of it, but it makes sense--EMSAM, at least at 6mg and below, effects dopamine almost exclusively. Luvox should effect mostly serotonin, right? They would -seem- to be safe together, and I know expert docs use all of the old tricyclics except clomipramine with the unselective MAOis.
Could try EMSAM alone first, so you know what its effects are alone, and then add the SSRI back in if you need it.
Good luck!
Posted by Phillipa on October 8, 2006, at 21:51:03
In reply to Re: EMSAM Luvox » Phillipa, posted by psychobot5000 on October 8, 2006, at 21:41:58
Ahh you're a sweetie but she said I had to be ad free for two weeks first. So was thinking stay at 25mg and maybe go down to l2.5mg see how I feel and then if okay discontinue and wait the two weeks. Love Phillipa
Posted by jealibeanz on October 9, 2006, at 3:48:27
In reply to Re: more recent data (same times), posted by psychobot5000 on October 8, 2006, at 20:44:11
Really? I cant imagine stopping something that works!
Posted by saturn on October 9, 2006, at 14:10:18
In reply to New FDA approvals: how long does this take?, posted by jealibeanz on October 8, 2006, at 8:03:38
It's good that you have hope.
Posted by psychobot5000 on October 9, 2006, at 16:02:13
In reply to Re: EMSAM Luvox » psychobot5000, posted by Phillipa on October 8, 2006, at 21:51:03
If you want, I could post an article by two Harvard professors and psychiatrists with extensive experience with MAOis--they were actually consultants involved with the development of EMSAM.
It has lots of good info, including which other antidepressants they believe can be safely combined with MAO inhibitors, and how to combat side-effects. The two docs' experience seems to have made them more relaxed about the potential dangers.
I can send it to anyone who wants it, or post the text of it here.
Posted by jealibeanz on October 9, 2006, at 18:06:13
In reply to Re: New FDA approvals: how long does this take? » jealibeanz, posted by saturn on October 9, 2006, at 14:10:18
My hope has now gone out the door... bad day:(
Sometimes I'm too idealistic about these things.
Posted by Phillipa on October 9, 2006, at 19:43:22
In reply to Re: EMSAM Luvox, posted by psychobot5000 on October 9, 2006, at 16:02:13
I definitely want and others probably do too. Could you post it? And you have my e-mail I think. You're so thoughtful Love Phillipa ps my anxiety is getting worse took 5mg extra last night with .5xanax and slept worse. Still do you think the EMSAM would work? Love Phillipa this decision making is driving me crazy don't want to end up in a hospital
Posted by psychobot5000 on October 9, 2006, at 22:56:18
In reply to Re: EMSAM Luvox » psychobot5000, posted by Phillipa on October 9, 2006, at 19:43:22
I think EMSAM would likely work, but it doesn't seem certain that it would work better than the SSRI, which apparently works for you. Everyone is different--but the more you try these things, the more you learn what works for you.
I'll post the text of the article in a moment.
Posted by psychobot5000 on October 9, 2006, at 23:03:58
In reply to Re: EMSAM Luvox » psychobot5000, posted by Phillipa on October 9, 2006, at 19:43:22
Here is the complete text of the article--it is directed toward healthcare providers, but as a patient, I find it useful also.
_______"Current Psychiatry"
Vol. 1, No. 6 / June 2002MAO inhibitors:
An option worth trying in treatment-resistant cases
• When to use an MAOI
• Characteristics of each agent
• Combinations with other antidepressants
• Determining dosage
• Avoiding MAOI-related hypertension
• Avoiding other MAOI-related side effects
• Toward safer MAOIs
Fears of hypertensive complications, drug-food interactions, and other side effects discourage many psychiatrists from prescribing MAOIs. The authors urge readers to rediscover these drugs, especially for treatment-resistant depressions and related disorders.
Jonathan O. Cole, MDSenior consultant in psychopharmacology McLean Hospital, Belmont, MA Professor of psychiatry, Harvard Medical School
J. Alexander Bodkin, MDChief, Clinical Psychopharmacology Research Program McLean Hospital, Belmont, MA Assistant professor of psychiatry, Harvard Medical School
Many fully trained psychiatrists, even psychopharmacologists, have rarely prescribed a monoamine oxidase inhibitor (MAOI), afraid of the possible consequences. One Boston-area psychiatrist who plans to retire soon has 12 patients who have been doing well for years on MAOIs. Before he called us, no psychiatrist in the area was willing to accept these patients who intended to stay on MAOIs.
Despite their potential side effects, the older MAOIs (phenelzine, tranylcypromine, isocarboxazid, and selegiline) have all been proven effective in depression; some studies have found them more effective than tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs).1,2 In our experience, MAOIs succeed in at least one-half the depressed patients who have failed on other antidepressants, and they are highly useful in treatment-resistant depressions and related disorders. Further, hypertensive crises are rare, and dietary restrictions are often exaggerated.
Drawing from the evidence and from our nearly 50 years’ experience in the use of MAOIs, we hope to acquaint or re-acquaint you with how to use these agents safely and to maximum effect.
When to use an MAOIReviews, meta-analyses, and more than 250 controlled studies have addressed MAOIs in psychiatric conditions.
The bulk of the literature reports a response rate of about 70% in various types of depression and anxiety.3 Unfortunately, because of the absence of major federal or industry funding, the findings are difficult to integrate, with most investigators testing different MAOIs on different subpopulations. This type of fragmented research, however, is not unique to MAOIs.
We at McLean have found MAOIs useful as second-line agents—and occasionally as first-line agents—in treating depression. We also use them as third-, fourth-, or fifth-line agents because we see many patients who have failed to respond to or tolerate several other antidepressants or whose response to other antidepressants has faded.
MAOIs are effective for a range of clinical presentations in inpatients and outpatients—depressive disorders (endogenous and atypical, unipolar and bipolar, neurasthenic and phobic), anxiety disorders (panic disorder and social phobia), and conditions as far afield as borderline personality disorder and the negative symptoms of schizophrenia.4
In controlled trials, many investigators have shown an MAOI to be more effective in some clinical conditions than a tricyclic and than a placebo.5 For example:
*
A group at Columbia University studied phenelzine in various permutations of atypical depression (rejection sensitivity, overeating, oversleeping, mood reactivity, severe lack of physical energy).6
*Davidson et al studied isocarboxazid in anxious depression.7
*Thase and Himmelhoch studied tranylcypromine in anergic and bipolar depressions.8
*Liebowitz followed up with studies of phenelzine and tranylcypromine in social phobia.9
*At Yale, early studies were done with phenelzine in posttraumatic stress disorder (PTSD).10
*The British have generally argued for use of MAOIs in mixed anxiety and depression.11
*The magisterial text Manic Depressive Illness recommends MAOIs as first-line treatment for bipolar depression.12
All of these studies yielded clinically and statistically substantial results with modest adverse effects.
Box 1HOW MAOIs WORK
The enzymes MAO-A and MAO-B were identified in the 1950s. MAO-A occurs mainly in the intestine and brain, and the enzyme preferentially oxidizes (inactivates) serotonin and norepinephrine. MAO-B occurs in the brain and in platelets as well as in other tissues, and it inactivates phenylethylamine and benzylamine. Both enzymes metabolize tyramine and dopamine. The older MAOIs (phenelzine, tranylcypromine, isocarboxazid and high-dose selegiline) are irreversible MAO A and B inhibitors and block the actions of both enzymes from 14 to 28 days while new MAO enzymes are being resynthesized.
The actions of all MAOIs are presumed to be mediated by the blocking of the metabolism of intra- and extraneuronal biogenic amines, leading to increased brain levels of serotonin, norepinephrine, and dopamine.13 Even in the 1950s, when work with MAOIs was just beginning, these biogenic amines were suspected of being low or underactive in depression.
Research offers no real clues as to which enzyme is more important to inhibit or which of the various brain chemicals increased during MAOI therapy are crucial to clinical improvement. Two small studies suggest that decreasing the synthesis of brain serotonin will produce a temporary return of symptoms in patients clinically improved on MAOIs.14,15
The hypertensive crisis caused by tyramine has been shown to result from the inhibition of MAO-A, not MAO-B. More recent studies show effects of most MAOIs on receptors as well as enzymes. The basis or bases for MAO inhibitor actions may be more complex or different than anticipated.16
Characteristics of each agentIn the United States, a psychiatrist interested in using an MAOI for depressed patients can choose from among four agents. These older MAOIs are irreversible blockers of the enzymes MAO-A and MAO-B (Box 1).13-16
Tranylcypromine has been found effective in patients hospitalized with endogenous depressions.17 Most clinicians experienced with MAOIs prefer this agent because it triggers weight gain to a much lesser degree than other MAOIs. Tranylcypromine can cause insomnia and a greater increase in tyramine sensitivity than other MAOIs, which therefore brings a greater risk of hypertensive crisis.
Phenelzine has the advantage that the effective dosage for depression is probably now known—more than 1 mg/kg body weight—although in three earlier large negative controlled studies, the effective dosage was not known and too little was given for too short a period. Weight gain and hypotension may be more common with this drug than with other MAOIs.
Isocarboxazid is the least studied but has been shown to be effective, with an average 41% drug-placebo difference in two studies.16 One of us (JOC) preferred it for several years, based on good responses in a handful of treatment-resistant patients.
Selegiline is used in low dosages for parkinsonism. At higher dosages (more than 20 mg/d), selegiline is a good antidepressant but is no longer MAO-B selective—inhibiting both the MAO-B and MAO-A enzymes and thus requiring the usual dietary restrictions. One of us (JAB) routinely maintains bipolar patients with mild baseline depression or lethargy on a mood stabilizer plus a low dosage (5 to 10 mg/d) of selegiline. With this combination, patients are more satisfied and compliant with the mood stabilizer regimen and require no dietary restrictions.
Overall, there may be a special clinical benefit to phenelzine in the more anxious, easily distressed patient and to tranylcypromine or selegiline in the more sluggish, lethargic patient. But probably the soundest way to choose MAOIs is if other, more standard treatments have not worked.
Combinations with other antidepressantsWe have found all antidepressants that do not involve significant serotonin reuptake inhibition (e.g., bupropion, trazodone, and tricyclics other than clomipramine) can be safely administered with MAOIs. Combination therapy is worth considering because it may be effective when other approaches have failed.
For a patient switching from an SSRI, a trial of one of these other antidepressants may be appropriate before undertaking MAOI therapy, simply because it avoids the SSRI washout period. Normally, patients should be off fluoxetine for 5 weeks, other SSRIs or clomipramine for 2 weeks, and venlafaxine for 1 week before starting an MAOI.
With the exception of clomipramine, TCAs generally are safe with MAOIs, although the Physician’s Desk Reference warns against adding a TCA to an MAOI. We know of one death and one case of delirium when parenteral imipramine was given to a patient who had been on a MAOI for some time unbeknownst to the MD giving the injection. Both amitriptyline (and by extension, nortriptyline) and trimipramine have been given along with an MAOI in controlled studies with no special adverse effects.18 Both drugs, and probably doxepin, are good hypnotics and seem safe in combination, although one should begin with a low dosage (e.g., 25 mg hs) if the patient is improving on an MAOI but is bothered by insomnia.
Table 1
RECOMMENDED MAOI DOSAGE RANGESDrug
Dosage range
Isocarboxazid
20 to 80 mg/d
Moclobemide*
300 to 900 mg/d
Phenelzine
30 to 90 mg/d
Selegiline
15 to 60 mg/d
Tranylcypromine
20 to 100 mg/d
* Available in Canada but not in the United States
Trazodone is frequently employed as a remedy for MAOI-induced insomnia.19 Mirtazapine can be used safely in combination with MAOIs, and the agent has been reported to acutely treat serotonin syndrome.20
Determining dosageFailure to understand the required effective dosages of MAOIs led to many early treatment failures and fueled clinicians’ perception that drugs in this class were ineffective. The senior author had to hospitalize a depressed man who had failed to improve on 30 mg/d of phenelzine for 10 days. The author later learned that a dose of more than 1 mg/kg per day for 3 to 4 weeks was necessary for response.
A rule of thumb is to start with one MAOI pill the first day and increase the dosage by one pill every 4 to 7 days until these levels are reached:
*
1 mg/kg/d for phenelzine;
*40 mg/d for tranylcypromine and isocarboxazid;
*45 mg/d for selegiline.
Reduce the dosage if side effects occur, or increase it if improvement is not noted in 1 to 2 months. We’ve tried starting patients on the 1 mg/kg dose of phenelzine the first day and elicited rapid and severe insomnia. Other intolerable side effects can also emerge from too-rapid dosage escalation. Clinical experience suggests the dosage ranges shown in Table 1.
Avoiding MAOI-related hypertensionWe believe two factors have contributed to disuse of MAOIs by U.S. psychiatrists and slow development of new MAOIs here. These are the fear of severe hypertensive crisis and often vastly inflated MAOI dietary restrictions. In our practice, we provide patients receiving MAOIs with a reasonable list developed at the University of Toronto that explains foods to be avoided and alternatives that are allowed (Table 2).21
Table 2
DIETARY INSTRUCTIONS WITH MAOIsSeveral foods and beverages contain tyramine and may interact with your medication. You MUST follow the dietary instructions below, from the day before you start taking the medication until 2 weeks after you stop taking the medication.
Note: All foods must be fresh or properly frozen. If you are not aware of the storage conditions of a particular food, AVOID that food.
Food to avoid
Food allowed
Cheese
All matured or aged cheese
All casseroles made with cheeses (i.e., pizza, lasagna, etc.)
Fresh cottage cheese, cream cheese, ricotta cheese, and processed cheese slices. All fresh milk products that have been properly stored (i.e., sour cream, yogurt, ice cream)
Meat, fish, and poultry
Fermented/dry sausage (pepperoni, salami, mortadella, summer sausage)
Improperly stored meat, fish, poultry
Improperly stored pickled herring
All fresh packaged or processed meat (e.g., chicken loaf, hot dogs), fish, or poultry. Store in refrigerator immediately, and eat as soon as possible
Fruits and vegetables
Fava or broad bean pods (not beans)
Banana peel
Raspberries up to a maximum of one-quarter pound at one time
Banana pulp
All others
Beverages
All on-tap beer
Alcohol: No more than two bottled or canned beers or 4-fl. oz. glasses of red or white wine per day. This applies to nonalcoholic beer also. Red wine may produce headache unrelated to a rise in blood pressure
Miscellaneous
Marmite-concentrated yeast extract
Sauerkraut
Soy sauce and other soy bean condiments
Other concentrated yeast extract (e.g., brewer’s yeast)
Soy milk
Reprinted with permission of the department of pharmacy, Sunnybrook and Women’s College Health Science Center, North York, Ontario, Canada. Copyright 1994
In experience, tyramine-associated hypertensive crisis in patients receiving the older MAOIs is rare, often very painful, and time-limited. Data on incidence of hypertensive crises with any MAOI is inadequate, except for a negligible incidence with low-dose selegiline and moclobemide (a reversible MAOI available in Canada but not in the United States). Most reported cases have involved tranylcypromine,22 which causes the greatest increase in sensitivity to tyramine, the basis of the dietary interaction with MAOIs.23 Specifically with tranylcypromine, transient hypertension can occur in the absence of dietary indiscretion or drug interaction.24,25
Food-associated hypertensive reactions are more common but unpredictable. A patient at McLean who had eaten cheese without trouble for 4 years while taking tranylcypromine in Europe mysteriously developed a severe headache after one bit of cheddar in the United States; she never tried an MAOI again. Another patient who took tranylcypromine for months at dosages exceeding 100 mg/d (but never took the tyramine restriction seriously) suffered a frightening pulsatile headache after a Chinese restaurant meal with soy sauce.
In our experience, oral adrenergic drugs (e.g., pseudoephedrine) can cause symptomatic hypertensive crises in patients taking MAOIs. Some over-the-counter cold preparations may contain an adrenergic decongestant, but it may not be listed clearly on the bottle. Cough syrup with codeine is preferable to OTC cough syrups that contain dextromethorphan. Patients should be urged to check labels and ask the pharmacist.
Advise patients taking MAOIs to purchase a blood pressure cuff or finger sphygmomanometer and learn how to take their own blood pressure. If they experience a “normal” headache and their systolic blood pressure is not elevated by at least 30 mm Hg, they are not having a “cheese reaction” and do not need to worry. MAOI headaches are typically unmistakable (they feel as if one’s head is splitting apart), and blood pressure is markedly elevated.
We give patients starting on MAOIs 10-mg tablets of nifedipine and advise them that if symptoms suggesting a hypertensive crisis appear, they should bite into one tablet to release the fluid inside and then swallow it. We tell patients to repeat this in 15 minutes if the headache is not receding; if the headache persists, they should visit the emergency ward or the internist’s office for observation.
Although there has been concern about the risk of MI or stroke with the hypotensive effect of nifedipine, we believe it is still the best option for acute severe hypertension in patients who do not have chronic hypertension. Chlorpromazine tablets (50 mg) also will stop the headache and lower blood pressure but will leave the patient groggy for about 24 hours, with possible extrapyramidal symptoms.
In the rare instance that a hypertensive crisis occurs, the “official” labeling recommendation is to give IV phentolamine, but we find emergency rooms either no longer stock the drug or do not remember to do this. Send any patient who is hurting and panicky to an ER, and call to suggest what the attending might do (i.e., IV phentolamine or oral nifedipine or chlorpromazine, or the emergency physician’s preference for hypertensive crisis).
Avoiding other MAOI-related side effectsOrthostatic hypotension is the most common early side effect of phenelzine and isocarboxazid. Clinically significant hypotension is best managed via dosage adjustment. If that fails, add Na Cl, 1 to 2 grams bid with increased fluids. If that doesn’t work, administer fludrocortisone, 0.1 to 0.4 mg/d. If that fails, administer d-amphetamine, starting with 2.5 to 5 mg/d, and observe carefully for hypertension.
An altered diurnal sleep cycle is another MAOI-related side effect. Some patients get extremely drowsy in the late afternoon but then may have insomnia at night.26 Attempts to alter this odd cycle by changing the timing of administration have generally not helped. We add a stimulant—pemoline (18.75 to 35.5 mg), d-amphetamine (2.5 to 5 mg), methylphenidate (5 to 10 mg), or modafinil (50 to 100 mg)—either in the morning or during afternoon sleepiness, with good effect and no hypertensive crises. We supervise the effect on blood pressure of the first few doses. Another helpful alternative has been to administer trazodone at night to initiate sleep.
Box 2THE SEARCH FOR SAFER MAOIs
Efforts over the years have been aimed at developing MAOIs that do not cause the tyramine reaction. One approach—devising reversible inhibitors of monoamine oxidase, which can be displaced from the MAO enzyme by tyramine—has resulted in two drugs (moclobemide and toloxatone) that are available in other parts of the world but not in the United States.27
Brofaromine, a reversible MAOI and an SSRI, looked promising in its clinical trials in Europe and the United States but was withdrawn from development by its manufacturer. A more recent approach to averting the MAOI-associated hypertensive interaction with dietary tyramine has been to deliver the drug parenterally, to spare the gut’s MAO-A.
Selegiline awaits Food and Drug Administration approval to be marketed in the United States as a transdermal preparation.28 The agent in this form would have several virtues, including a more stable blood level than the oral preparation and no clinically meaningful inhibition of intestinal MAO and thus no hypertensive crises.
MAOIs are adrenergic agonists, and dry mouth and constipation can occur as side effects; these can be treated with bethanechol. Edema also occurs, mainly with isocarboxazid and phenelzine, and responds in most cases to modest diuretic doses, such as hydrochlorothiazide, 50 mg/d.
The now-recognized trouble reaching orgasm on SSRIs was first reported to us by women on phenelzine, and this side effect is as difficult to treat with MAOIs as it is with other antidepressants. We have found that sexual dysfunction is less likely to occur with tranylcypromine and selegiline than other MAOIs.
Toward safer MAOIsNewer reversible MAOIs are in development, and two agents are available (although not in the United States). Delivery systems that reduce the risk of hypertensive crisis also may soon be available (Box 2).27,28
Related resources
*
Amsterdam JD, Chopra M. Monoamine oxidase inhibitors revisited. Psychiatric Ann2001;31(6):361-70.
*Treatment with antidepressants. In: Janicak PG, Davis JM, Preskorn SH, Ayd FJ, eds. Principles and practice of psychopharmacotherapy. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001:215-326.
*Kennedy SH, ed. Clinical Advances in Monoamine Oxidase Inhibitor Therapies. Progress in Psychiatry Series. Washington, DC: American Psychiatric Press, 1994.
Drug brand names
Isocarboxazide • Marplan
Moclobemide • Aurorix, Manerix
Phenelzine • Nardil
Selegiline • Eldepryl
Tranylcypromine • ParnateDisclosure
Dr. Cole reports that he has served as a consultant to SmithKline Beecham Pharmaceuticals, manufacturer of tranylcypromine, and to Somerset Pharmaceuticals, manufacturer of selegiline in the United States. He also has participated in clinical studies of selegiline.
Dr. Bodkin reports that he has served as a consultant to Somerset Pharmaceuticals and has been principal investigator in several multicenter trials of selegiline.
Posted by willyee on October 9, 2006, at 23:46:08
In reply to MAO inhibitors--text of a good article, posted by psychobot5000 on October 9, 2006, at 23:03:58
Incredable find,very useful.
I have read the part on combos from similiar articles,and search for more trying to find a safer more effective combination,but i have used parnate in conjunction with TONS of substances,i personaly dont trust the tca`s as the dose i believe can be a part of possable danger.However still great reading.
Posted by psychobot5000 on October 10, 2006, at 10:34:06
In reply to MAO inhibitors--text of a good article, posted by psychobot5000 on October 9, 2006, at 23:03:58
The original form of the article is available by searching the archives of Current Psychiatry Online, though the site now appears to require that one give them certain information in order to create an account. (I saved the text some time ago)
Thus, if one wished to have a formal version to bring to a psychiatrist, (I have done so), it is available on www.currentpsychiatry.com, (archives, June 2002)
Posted by Phillipa on October 10, 2006, at 19:17:32
In reply to Re: original of MAOi article available online, posted by psychobot5000 on October 10, 2006, at 10:34:06
Thanks appreciate it so much. Love Phillipa
Posted by river1924 on October 13, 2006, at 23:59:27
In reply to Re: original of MAOi article available online » psychobot5000, posted by Phillipa on October 10, 2006, at 19:17:32
Hi,
Just a few points I've noticed over the last ten years.
1. Drugs are more likely to be approved if funded and pressed by gigantic US/multinationals.
2. Up and coming drugs often do as well as established drugs in drug studies which place them head to head... the problem is that neither do better than placebo.
3. Drugs must fit a DSM category. I'm sure some abandoned drugs have some worth with people. But there is no oversleeping disorder, no apathy disorder, no irritable disorder, ...just a big freaking label called "depression."
4. Drugs studies exclude people on meds or who have taken meds or who have symptoms of more than one "problem." Personally, I think that leaves the more seriously ill or those who need drug "cocktails" in the cold.
Thanks for letting me get that off my chest. River.
Posted by jealibeanz on October 14, 2006, at 2:47:56
In reply to Re: drug process, posted by river1924 on October 13, 2006, at 23:59:27
I just noticed that there is a drug on the "fast track" for psychosis/depression. Pretty interesting, huh? At least the FDA is acknowledging that one aspect of mental health needs immediate help. I would if you have to be diagnosed with psychosis to have this prescrived on-label. Here's the info:
Name: Corlux ®
(AKA mifepristone or RU-486)Mechanism: Glucocorticoid receptor type II (GRII) antagonist, progesterone receptor antagonist
Manufacturer:Corcept
Use: Psychosis, depression
Status: Phase III, granted fast track status by FDA
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