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MAOIs may also cause hypotension (see abstracts)

Posted by cassandracomplex on March 30, 2013, at 17:09:44

In reply to Gillman rocks! MAOIs Misconceptions and Questions, posted by vanvog on March 27, 2013, at 15:14:34

Abstracts are in chronological order, starting with the oldest (I did not examine research preceding 1985, so I'm sure there are more articles out there).

Pharmacokinetics of tranylcypromine in patients who are depressed: relationship to cardiovascular effects.
Mallinger AG, Edwards DJ, Himmelhoch JM, Knopf S, Ehler J.
Clin Pharmacol Ther. 1986 Oct;40(4):444-50.
We investigated the pharmacokinetics of tranylcypromine, as well as the relationship between plasma levels of this agent and its effects on blood pressure and pulse rate. Tranylcypromine was absorbed rapidly after oral dosing, with the peak level being attained within 0.67 to 3.50 hours. Absorption was biphasic in seven of nine subjects. Elimination of tranylcypromine also was rapid, with a t 1/2 between 1.54 and 3.15 hours. From 2 to 7 hours after dosing, standing systolic and diastolic blood pressures were lowered and standing pulse was raised, compared with baseline. Onset of the effect on standing systolic blood pressure was correlated with the time of peak plasma tranylcypromine concentration. Maximum orthostatic drop of blood pressure and rise of pulse rate occurred 2 hours after dosing. Mean plasma tranylcypromine concentrations were correlated with mean orthostatic drop of systolic blood pressure and rise of pulse rate. Patients who have clinically significant hypotensive reactions to this agent may benefit from changes in their dose regimen aimed at minimizing peak tranylcypromine levels.

Blood pressure effects of tranylcypromine when prescribed singly and in combination with amitriptyline.
O'Brien S, McKeon P, O'Regan M, O'Flaherty A, Patel R.
J Clin Psychopharmacol. 1992 Apr;12(2):104-9.
Data on blood pressure was extracted from the findings of a 6-week double-blind study that was carried out to evaluate the efficacy and safety of prescribing tranylcypromine (TCP) singly and in combination with amitriptyline (AMI). The effect of TCP on blood pressure was one of the methods used to evaluate its safety. Target daily doses of medication for the final 2 weeks of the study were: TCP 30 mg, AMI 150 mg, or the two in combination. Because of side effects, mean daily doses actually achieved were lower: single TCP 18.5 mg; single AMI 114.3 mg; combined TCP/AMI: TCP 19.7 mg, AMI 108.7 mg. *** When TCP alone was prescribed, a significant fall in diastolic blood pressure in the standing position was noted and orthostatic hypotension was more frequently observed. *** Dizziness was complained of on at least one occasion in over three quarters of patients on TCP/AMI. No correlation between blood pressure effects and dizziness was detected and there were no other troublesome side effects from this antidepressant combination. The study concluded that although TCP's overall effect on mean blood pressure readings when prescribed alone or in combination was small, its orthostatic effect is noteworthy and should be borne in mind by the prescribing clinician.

Monoamine oxidase inhibitors. A perspective on their use in the elderly.
Volz HP, Gleiter CH.
Drugs Aging. 1998 Nov;13(5):341-55.
Monoamine oxidase inhibitors (MAOIs) are mainly used in psychiatry for the treatment of depressive disorders and in neurology for the treatment of Parkinson's disease. While the classical, nonselective and nonreversible MAOIs, such as phenelzine and tranylcypromine, are characterised by the risk of inducing a hypertensive crisis when dietary tyramine is ingested, the selective monoamine oxidase-B (MAO-B) inhibitor selegiline (deprenyl) and, even more so, the selective and reversible monoamine oxidase-A (MAO-A) inhibitor moclobemide, are free from this potential interaction. Drug tolerability data for the elderly show that moclobemide is one of the most well tolerated compounds. Selegiline, especially when used in combination with levodopa, can cause anorexia, dry mouth, dyskinesia and, most problematic, orthostatic hypotension. For the traditional MAOIs, phenelzine and tranylcypromine, published data are insufficient to be able to give a conclusive tolerability statement regarding the use of these compounds in elderly people. *** Although orthostatic hypotension occurs in most patients treated with traditional MAOIs, the incidence in elderly patients with depression does not appear to be greater than that reported with tricyclic antidepressants. ***

Antidepressive treatment with monoamine oxidase inhibitors and the occurrence of intraoperative hemodynamic events: a retrospective observational cohort study.
van Haelst IM, van Klei WA, Doodeman HJ, Kalkman CJ, Egberts TC; MAOI Study Group.
J Clin Psychiatry. 2012 Aug;73(8):1103-9. Epub 2012 Jul 10.
To investigate the occurrence of intraoperative hemodynamic events when antidepressive treatment with monoamine oxidase inhibitors (MAOIs) was continued during anesthesia.
A retrospective observational cohort study was conducted among patients who were admitted for elective surgery requiring anesthesia in 8 Dutch hospitals (2004-2010). The index group included current users of irreversible (tranylcypromine) and reversible (moclobemide) MAOIs. The reference group included a sample of nonusers matched to the index group on hospital, type and period of surgery, and type of anesthesia (ratio 1:3). The outcome of interest was the occurrence of the following intraoperative hemodynamic events: hypotension or hypertension and tachycardia or bradycardia.
Approximately 280,000 surgical procedures were performed in the participating hospitals in the total observational period of 33 years. The index group included 26 and 25 users of tranylcypromine and moclobemide, respectively. The reference groups included 149 nonusers. Intraoperative hypotension occurred less frequently in users of tranylcypromine (46%) than in nonusers (73%) (P = .01). The occurrence of hypertension, bradycardia, and tachycardia during anesthesia was not different between users of tranylcypromine (27%, 50%, and 12%, respectively) and those in the reference group (35%, 61%, and 26%, respectively). The occurrence of hypotension, hypertension, bradycardia, and tachycardia was not different between users of moclobemide and the reference group.
Severe adverse hemodynamic events, such as hypertension and tachycardia, did not occur more frequently in users of both the irreversible MAOI tranylcypromine and the reversible MAO-A inhibitor moclobemide compared to nonusers. These findings suggest that there is no longer much justification to discontinue these MAOIs before surgery, with the considerable risk of compromising patients' psychiatric status.

Recently, I asked both my doctor (a MAOI expert) and PADI about becoming a certified SCUBA diver while taking a MAOI, as my certification has expired. Both informed me that it was safe. My doctor recommended quitting smoking - of course - and starting to exercise again, since I have atypical depression and when I am depressed I experience "leaden paralysis" and do not go outside for days or even weeks at a time.

Also, I was having ECT while starting to take a MAOI again several months ago. Now I am no longer having ECT (thankfully) and I am in full remission. My ECT doctor and my psychiatrist are both very familiar with the literature (my psychiatrist wrote a good portion of it, after all) and know that the pervasive fear of doing anything that might be considered contraindicated by your everyday psychiatrist is not based on hard evidence, but rather fears of liability.

I used to take Dexedrine and Adderall XR along with Parnate. And we're not talking low doses here: 20 mg of Dexedrine, 20 mg of Adderall XR, and 120 mg of Parnate. I have never had a hypertensive crisis or experienced an elevation in blood pressure, and I still make sure to check it twice a day just in case even though I no longer take stimulants.




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