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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 26. This is the beginning of the thread.
Posted by SLS on June 8, 2008, at 7:50:14
What is the best emergency treatment for managing a MAOI tyramine-reaction hypertensive crisis?
Thanks
- Scott
Posted by okydoky on June 8, 2008, at 9:45:59
In reply to Best treatment for MAOI hypertensive crisis?, posted by SLS on June 8, 2008, at 7:50:14
The only one I have ever gotten at different hospitals was Procardia. I don't know if that is the "best " treatment. It worked every time.
oky
Posted by okydoky on June 8, 2008, at 9:56:33
In reply to Best treatment for MAOI hypertensive crisis?, posted by SLS on June 8, 2008, at 7:50:14
Scott,
That was just my experience and it was many years ago. I should not have posted such a knee jerk reaction. sorry. There are a lot of articles about it that you might understand better than I. Here are a couple I found quickly:
http://www.postgradmed.com/issues/1999/05_01_99/bales.shtml
http://www.chestjournal.org/cgi/reprint/59/2/212.pdf
Not having one at the writing of the post I hope?
Best of luck,
oky
Posted by SLS on June 8, 2008, at 11:36:29
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by okydoky on June 8, 2008, at 9:56:33
> Scott,
>
> That was just my experience and it was many years ago. I should not have posted such a knee jerk reaction. sorry. There are a lot of articles about it that you might understand better than I. Here are a couple I found quickly:
>
> http://www.postgradmed.com/issues/1999/05_01_99/bales.shtml
>
> http://www.chestjournal.org/cgi/reprint/59/2/212.pdf
>
> Not having one at the writing of the post I hope?No. I just want to get an idea as to what drugs are ideal for treating hypertensive crisis.
> Best of luck,Thanks :-)
Regitine (Phentolamine) was the treatment of choice in the 1970s. Unfortunately, it is no longer available as an oral preparation. It remains an I.V. preparation that, at this point, I would ask for were I in the emergency room. Some people like using Thorazine as an antidote. Both drugs accomplish their antihypertensive effect through the antagonism of NE alpha-1 receptors.
- Scott
Posted by Phillipa on June 8, 2008, at 11:55:33
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by SLS on June 8, 2008, at 11:36:29
Something tells me that you are about to embark on a new trial of a med Scott. Wish you the best. If I'm wrong That's okay. Love Phillipa
Posted by bulldog2 on June 8, 2008, at 13:59:52
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by SLS on June 8, 2008, at 11:36:29
> > Scott,
> >
> > That was just my experience and it was many years ago. I should not have posted such a knee jerk reaction. sorry. There are a lot of articles about it that you might understand better than I. Here are a couple I found quickly:
> >
> > http://www.postgradmed.com/issues/1999/05_01_99/bales.shtml
> >
> > http://www.chestjournal.org/cgi/reprint/59/2/212.pdf
> >
> > Not having one at the writing of the post I hope?
>
> No. I just want to get an idea as to what drugs are ideal for treating hypertensive crisis.
>
> > Best of luck,
>
> Thanks :-)
>
>
>
> Regitine (Phentolamine) was the treatment of choice in the 1970s. Unfortunately, it is no longer available as an oral preparation. It remains an I.V. preparation that, at this point, I would ask for were I in the emergency room. Some people like using Thorazine as an antidote. Both drugs accomplish their antihypertensive effect through the antagonism of NE alpha-1 receptors.
>
>
> - ScottScott doesn't nortriptyline antagonize NE alpha-1 receptors?
Posted by bulldog2 on June 8, 2008, at 15:43:30
In reply to Best treatment for MAOI hypertensive crisis?, posted by SLS on June 8, 2008, at 7:50:14
> What is the best emergency treatment for managing a MAOI tyramine-reaction hypertensive crisis?
>
> Thanks
>
>
> - ScottThere was a nurse who use to come to babble. She had a hypertensive crisis from Chinese food (soy sauce) while on emsam 12 mg. She popped 1 milligram clonidine under her tongue and kept doing that until her bp was normal.She never went to the hospital.
Posted by Horned One on June 8, 2008, at 16:51:32
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by bulldog2 on June 8, 2008, at 15:43:30
Someone once used a niroglycerine spray (prescribed for angina) after a sudden hypertensive crisis on EMSAM.
-Horny
Posted by Zeba on June 9, 2008, at 20:55:27
In reply to Best treatment for MAOI hypertensive crisis?, posted by SLS on June 8, 2008, at 7:50:14
I had a horrible hypertensive crisis in the 80's, and I ended up in the cardiac intensive care unit of a hospital. I still have the records and will look up what they did for me.
I was on Parnate at the time, and in case anyone thinks that they could have a bad reaction like I had, it is not likely as I deliberately od'd on contac cold meds, and this is why I had a very severe hypertensive reaction. I would not recommend doing something like that to anyone.
Posted by okydoky on June 9, 2008, at 22:09:18
In reply to Re: Best treatment for MAOI hypertensive crisis? » SLS, posted by Zeba on June 9, 2008, at 20:55:27
I had a pdoc who did all sorts of mixes that no one else would do. My hypotention ws so bad I was passing out all the time. He was not treating me but he would suggest treatments on the phone and my treating pdoc usuaoly said okay. He told me if the doc would not prescribe a little ritalin sr for it to take half a sudafed. But you are right it is dangerous. I was in intensive care several times without that mix. But the Parnate worked as an AD so well it was worth the pain I went through.
oky
Posted by Zeba on June 9, 2008, at 23:34:24
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by okydoky on June 9, 2008, at 22:09:18
gees; that was not right. There are safer ways to deal with hypotension. What in the world was he thinking saying to take sudafed. Taking a small dose of Ritalin is one way that even my pdoc suggested.
Posted by okydoky on June 10, 2008, at 0:16:42
In reply to Re: Best treatment for MAOI hypertensive crisis? » okydoky, posted by Zeba on June 9, 2008, at 23:34:24
Well I never had to try it. That pdoc saved my life. But in the end he was not always very lucid himself. I found out a few days ago from a guy I met at the drug store that the reason he stopped practicing was because they found four dead guys from overdoses in a house and they all had scripts for oxycontin in their pockets written by this pdoc.
He really ws brilliant at one time. I think people just started taking advantage of his good will and because he was getting some kind of dementia he did not realise it.
I feel bad for him now.
oky.
Posted by undopaminergic on June 14, 2008, at 8:52:09
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by SLS on June 8, 2008, at 11:36:29
>
> Some people like using Thorazine as an antidote.
>I haven't heard of Thorazine being exploited for its hypotensive effects, but rather as an antidote to serotonin syndrome (although cyproheptadine would be preferred unless intravenous administration is needed).
Nifedipine (Procardia) seems to be the most popular choice by far for MAOI-associated hypertensive attacks. I would expect nitroglycerin to act more quickly, however, as it's very rapidly absorbed through mucous membranes (usually sublingual).
Posted by okydoky on June 14, 2008, at 11:47:38
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by undopaminergic on June 14, 2008, at 8:52:09
It was a long time ago (several times) but to my best recollection it was given Procardia gel caps sublingually with a hole poked in the cap and held the draining cap under my tongue. I remember it worked very quickly, seemed like in minutes the blow your head off pain was completely gone.
Here are several web sites explaining why it is no longer considered a good choice and alternatives. You probably know all this stuff but it is new to me and I am interested because of my prior good experience with Procardia, I intend to try Parnate again and will most likely have spontaneous episodes and want to be prepared, want you to get the information you are asking about. I would love to be helpful to you in some matter:)
I could not post this site as it would not take you back to it: http://www.medscape.com/viewarticle/444263 below is the article
Use of Sublingual Nifedipine in Hypertensive Urgency/Emergency
Question
I would like to inquire about the use of the sublingual nifedipine for patients with hypertensive urgency or emergency. It has been suggested that the drug type should be avoided during a hypertensive crisis, because of the risk of a CVA due to disturbance of the brain blood autoregulation. However, I continue to see this treatment used. Your comments about this will be appreciated.
A. Karim, MBBS
Response from Erica Brownfield, MD
Assistant Professor of Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; Staff Physician, Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia
Hypertensive emergencies require immediate lowering of blood pressure in a controllable and predictable manner. The goal is to lower the mean arterial blood pressure by approximately 20% to 25% in the first hour, while maintaining adequate perfusion to vital organs. Dropping the blood pressure too quickly, or by too much, can worsen target end-organ damage. With cerebral ischemia, a condition in which autoregulation of the ischemic area is lost, cerebral blood flow is directly proportional to the systemic blood pressure. Therefore, if blood pressure is lowered, cerebral perfusion pressure in ischemic areas is also lowered, risking further damage. In this circumstance, it is recommended that blood pressure not be lowered.
Sublingual nifedipine has been used commonly in the setting of hypertensive emergency and urgency. In fact, sublingual nifedipine is not approved by the US Food and Drug Administration (FDA) for treatment of hypertensive emergency or urgency. Not only is there no evidence to support such use of sublingual nifedipine, but there are also good data to suggest that sublingual nifedipine should never be used for this purpose.
Sublingual nifedipine causes blood-pressure lowering through peripheral vasodilation. It can cause an uncontrollable decrease in blood pressure, reflex tachycardia, and a steal phenomenon in certain vascular beds. There have been multiple reports in the medical literature of serious adverse effects with sublingual nifedipine, including cerebral ischemia/infarction, myocardial infarction, complete heart block, and death. As a result of this, the FDA reviewed all data regarding the safety and efficacy of sublingual nifedipine for hypertensive emergencies in 1995, and concluded that the practice should be abandoned because it was neither safe nor efficacious.
Posted 12/02/2002
________________________________________
Suggested Readings
Grossman E, Messerli FH, Grodzicki T, Kowey P. Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA. 1996;276:1328-1331.
Messerli FH, Grossman E. The use of sublingual nifedipine: a continuing concern. Arch Int Med. 1999;159:2259-2260.
http://www.vhpharmsci.com/Newsletters/1990s-NEWS/article8.htmThis next one (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1428348 )
is from 1983 and suggests the following:
In conclusion, nifedipine can be a useful drug in the
treatment of hypertensive crisis, which deserves a
more extensive evaluation in this condition. It seems
even suited to be used as a first drug in the treatment
of this condition, since it is so easy to administer, it
has a rapid onset of action and it did not induce
exaggerated falls in blood pressure.
http://www.ima.org.il/imaj/ar05dec-16.pdf Intravenous Chlorpromazine for the Emergency Treatment of
Uncontrolled Symptomatic Hypertension in the Pre-Hospital Setting:After reading this article I was concerned with the amount of time it took for the Throrazine to work:
Intravenous chlorpromazine reduced the systolic BP from
an initial value of 222.82 ± 26.31 mmHg to a final value of
164.93 ± 22.66 mmHg (P < 0.001). Similarly, the diastolic BP
was lowered with chlorpromazine from 113.5 ± 16.63 to 85.83
± 11.61 mmHg (P < 0.001). The resolution of hypertension
was accompanied by a reduction in heart rate as follows: 405
patients (82%) were in sinus rhythm when chlorpromazine was
administered for severe hypertension and their heart rate was
lowered from 97.9 ± 23.5 to 92.2 ± 19.7 beats/min (P < 0.001).
Sixty-three patients (12.7%) were in atrial fibrillation and their
ventricular rate was lowered from 120.9 ± 26.7 to 103.9 ± 22
beats/min (P < 0.001). These results were achieved within the
37 ± 11 minutes that the ambulance team spent with the patients
(estimated from the time of arrival to the patients home
to the time of arrival to the emergency room). The QT interval
was not measured systematically throughout the treatment, but
no episodes of torsade de points were documented.What do you think?
Oky
ps I guess I would know if the Procardia had done any damage to any of my organs? These people that treated me were mostly idiots. One gave me a big shot of Demrol for it one time!
Posted by Crotale on June 17, 2008, at 21:34:10
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by okydoky on June 14, 2008, at 11:47:38
I've had this too, and I also used Procardia (nifedipine) gelcaps. I took them by biting them in half and swallowing them so the calcium channel blocker would work fast. I tried to do this only under a doctor's care (I usually went to the university health centre, although they weren't very competent there!).
I've heard of using beta blockers (like propranolol) but I've read that this can backfire and make the hypertension worse (because beta blockers cause vasoconstriction, although they also decrease cardiac output).
Posted by Crotale on June 18, 2008, at 1:37:09
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by okydoky on June 14, 2008, at 11:47:38
> I intend to try Parnate again and will most likely have spontaneous episodes and want to be prepared, want you to get the information you are asking about. I would love to be helpful to you in some matter:)
I had this kind of problem (spontaneous hypertensive episodes) with Parnate when I was first on it. I ended up solving the problem by taking it in divided doses of no more than 20mg at a time.
I do recall getting, I think, nitroprusside once, BTW. I could be misremembering, it was a long time ago.
> ps I guess I would know if the Procardia had done any damage to any of my organs? These people that treated me were mostly idiots. One gave me a big shot of Demrol for it one time!Wow, I can't believe you're still here! That's pretty horrible!
Well, good luck with the Parnate. Hope it works out okay for you.
Posted by undopaminergic on June 18, 2008, at 5:40:10
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by okydoky on June 14, 2008, at 11:47:38
Since MAOI-associated hypertensive crisis results mainly from vasoconstriction due to excessive release of noradrenaline (by tyramine, ephedrine or similar), it makes sense to use a vasodilating antihypertensive agent.
Although prazosin and doxazosin would seem to address the problem most directly, the question is whether they do so fast enough.
I don't think the use of nifedipine for MAOI-type hypertension is particularly dangeous, unless too much of it is taken - which could lead to hypotension and ischaemia.
I suggested nitroglycerin, and now that I've researched it better, it does seem to be a better choice than nifedipine. Not only does it act faster, but it's safer for the heart (coronary arteries, etc.). Furthermore, nitroglycerin seems to maintain - or even improve - cerebral blood flow, whereas calcium antagonists (e.g. nifepidine and nicardipine) may disturb it.
http://www.ncbi.nlm.nih.gov/pubmed/8470417
"[Nitroglycerin in comparison with nifedipine in patients with hypertensive crisis]"http://www.ncbi.nlm.nih.gov/pubmed/2503945
"A comparison of sublingual nifedipine versus nitroglycerin in the treatment of acute angina pectoris."http://www.ncbi.nlm.nih.gov/pubmed/11772822
"The influence of nicardipine-, nitroglycerin-, and prostaglandin E(1)-induced hypotension on cerebral pressure autoregulation in adult patients during propofol-fentanyl anesthesia."
Posted by SLS on June 18, 2008, at 6:00:36
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by undopaminergic on June 18, 2008, at 5:40:10
The nitroglycerin sounds like a good idea. The only thing is, it can produce a significant headache by itself. It might get confusing. However, the pounding at the base of the skull in the back of the neck is a give-away that a headache continues to be due to a tyramine reaction.
- Scott
Posted by Zeba on June 19, 2008, at 21:17:55
In reply to Re: Best treatment for MAOI hypertensive crisis? » undopaminergic, posted by SLS on June 18, 2008, at 6:00:36
This is very interesting re what might work best. I must go back and look at my records to see what they gave me in the hospital in the 80's when I had a hypertensive crisis from an overdose of contac cold time released capsules. I felt like my whole head was going to explode. I know they made me vomit and then a lot I don't remember except that they put me in the cardiac intensive care unit. I think I screwed up a valve in my heart.
So now I am on Parnate again, and it works for me, and I am careful about what I eat, etc. But my pdoc/therapist has never prescribed anything for me to deal with an accidental hypertensive crisis. I think I will ask him about it tomorrow. Worst headache I ever had. I guess nitroglycerin would have made my headache worse, but maybe they gave that to me.
I had to wear a nitro patch once when they thought I was having a heart attack that turned out to be GERD. I sure did get a headache from the patch which was put on my neck.
For someone who already has hypertension and takes Cozaar, I wonder what would be best--an extra Cozaar??? Any comments welcome, please.
Posted by regaudio on June 29, 2008, at 22:08:40
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by okydoky on June 8, 2008, at 9:45:59
immeditate nefedipine under the tongue- carry it with you. i was given it to carry and had an episode and it reduces your blood pressure fairly quickly though still a risky pressure, you will reach the hospital with reasonable or low blood pressure
Posted by okydoky on June 30, 2008, at 12:22:17
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by regaudio on June 29, 2008, at 22:08:40
I think I posted this. I carried the gel caps of nefedipine around also. I had several hypertensive episodes and took one and monitored my bp to decide if I needed another. I was supposed to go to hospital after taking it but I never did. I was tired of the perilous treatment and felt safer doing it myself!
Scott,
Have you come to any conclusions about the best treatment yet?
oky
Posted by SLS on June 30, 2008, at 17:21:35
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by okydoky on June 30, 2008, at 12:22:17
> I think I posted this. I carried the gel caps of nefedipine around also. I had several hypertensive episodes and took one and monitored my bp to decide if I needed another. I was supposed to go to hospital after taking it but I never did. I was tired of the perilous treatment and felt safer doing it myself!
>
> Scott,
>
> Have you come to any conclusions about the best treatment yet?
I really haven't seen anything compelling to choose one method over another. However, I am still carrying nifedipine capsules. I once came across some literature claiming that overall, nifedipine might be counterproductive as it confounds the protocol used by hospital emergency rooms to treat the crisis with phentolamine i.v., the treatment of choice.
- Scott
Posted by okydoky on June 30, 2008, at 22:22:43
In reply to Re: Best treatment for MAOI hypertensive crisis?, posted by SLS on June 30, 2008, at 17:21:35
Scott,
I did not realize you were taking the MAOI? I thought I had read recently your treatment regime and that you were doing well on it? I found the thread:
" wouldn't have given a darn about psychiatric medicine if I hadn't contracted a psychiatric illness. So, yes, my failed treatment history inspired and required me to self-educate. One of the reasons I am not as intensely focused on this stuff anymore is that it seems I'm on the right medication regime to bring me to remission. Mission accomplished? Maybe I'll sell cars next"
How are you now? I hope all is still well, and as experienced on this site you are exceedingly honest and hence would make a terrible car salesman!
I guess I'll get sighted to the administrators for berating car salesmen!
oky
Posted by SLS on July 1, 2008, at 5:15:04
In reply to Re: Best treatment for MAOI hypertensive crisis? » SLS, posted by okydoky on June 30, 2008, at 22:22:43
> Scott,
>
> I did not realize you were taking the MAOI? I thought I had read recently your treatment regime and that you were doing well on it? I found the thread:
>
> " wouldn't have given a darn about psychiatric medicine if I hadn't contracted a psychiatric illness. So, yes, my failed treatment history inspired and required me to self-educate. One of the reasons I am not as intensely focused on this stuff anymore is that it seems I'm on the right medication regime to bring me to remission. Mission accomplished? Maybe I'll sell cars next"
>
> How are you now? I hope all is still well, and as experienced on this site you are exceedingly honest and hence would make a terrible car salesman!
>
> I guess I'll get sighted to the administrators for berating car salesmen!:-) You are funny.
I am still making gains. Right now, I am in the process of experimenting with Lamictal. I am trying to reduce the dosage from 200mg to 150mg in an effort to abolish my hand tremors and cognitive side effects. Lamictal is really tough on short-term memory. So is depression, though, so it would be hard to tell the difference without assessing to what degree these impairments resolve. If I begin to relapse, then, of course, I will have to return to the higher dosage.
My best results have been with MAOIs, usually in combination with a tricyclic. It is too bad that we don't see more of this combination here. People think it's too radical and riskier than taking an MAOI alone. Considering how far people are willing to go with polypharmacy, this posture doesn't make sense to me. How can someone claim to be completely treatment-resistant if they are unwilling to try mixing Parnate or Nardil with desipramine or nortriptyline? The latter two drugs are the only TCAs that I regard as safe to use in this type of combination. Trimipramine may be safe also, considering it has not demonstrated any monoamine reuptake inhibition. The main risk involves the development of serotonin syndrome, not a hypertensive reaction. Imipramine is actually too serotoninergic to combine with any of the irreversible MAOIs like Parnate, Nardil, or Marplan.
Many people feel that using a TCA actually buffers a hypertensive reaction to the ingestion of tyramine. Norepinephrine (NE) reuptake inhibition and NE alpha-1 blockade are the two properties cited for this reduced liability. However, I experienced the classic pounding tyramine reaction headache after eating 2 or 3 slices of pepperoni. I am therefore skeptical that the TCA would reduce the liability for hypertensive crisis.
It might be best to start the MAOI and the TCA at the same time. However, it is also indicated that there is adequate safety when adding an MAOI while the TCA is already established. I have done it in reverse order without problems.
- Scott
Posted by undopaminergic on July 2, 2008, at 15:30:01
In reply to Re: Best treatment for MAOI hypertensive crisis? » okydoky, posted by SLS on July 1, 2008, at 5:15:04
Although MAOI + TCA is a potentially useful option that probably should be used more frequently than is currently the case, I presume the same to be even more accurate for MAOI + stimulant.
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