Psycho-Babble Medication Thread 1041200

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Gillman rocks! MAOIs Misconceptions and Questions

Posted by vanvog on March 27, 2013, at 15:14:34

Created on Sunday, 24 March 2013 10:10
Last Updated on Monday, 25 March 2013 07:14
Written by Dr Ken Gillman

MAOIs (Parnate, Nardil): Misconceptions and Questions No. 1

This section will be added to as and when additional relevant questions and issues arise.

Any readers who are not familiar with my website may like to look for themselves at my scientific publications and credibility in this field. There are few practising psychiatrists who have the publications, experience and knowledge that is summarised in this website.

It is, unfortunately, necessary to state clearly from the beginning that much of what is published by doctors in books and journals about MAOIs is either poorly informed, or just plain wrong. As an example, much of the information that comes with MAOIs (the PI, or product information sheet) contains inaccurate material concerning, among other things: serotonin toxicity, drug interactions generally, and dietary tyramine.

As always with the Internet there is a little information that is good, but sadly it is usually drowned by the mass of misinformation. My scientific publications concerning MAOIs and other material on my website should be consulted for detailed information. This series of notes will simply deal with errors and misconceptions briefly, without always going into detailed explanations of why they are incorrect, especially since these can be usually be found elsewhere in my writings.

I will deal with points and misconceptions that seem common amongst my colleagues and with patients, and from what I see on the Internet: e.g.

One Q was (not at askapatient):
Is it true that treatment with parnate is contraindicated for patients with hypertension? ... I have treatment resistant depression but also suffer from hypertension

Their Answer: Hello, I am a psychiatrist. Yes, that is a very real concern. Using Parnate could result in a life-threatening elevation of your blood pressure, if it is already high. (followed by more incorrect info).

My comment: this answer, by someone who states they are a psychiatrist, exemplifies one of the commonest errors and misconceptions that even specialists seem to have about MAOI drugs. The psychiatrists answer is quite wrong: MAOIs actually lower blood pressure, and were indeed used for treatment of hypertension back in the 1960s before better drugs became available (1-3). Many hypertensive patients who take MAOIs for depression are able to reduce their other anti-hypertensive medication, and sometimes even stop it completely, whilst they are on MAOIs. They will of course have to restart anti-hypertensive medication if and when they cease MAOIs.

It is also important to recognise that hypertension can (re-)emerge after cessation of MAOIs even in people who did not have apparent essential hypertension prior to taking MAOIs. One presumes the explanation for this is that whilst on treatment with MAOIs the person has developed underlying essential hypertension which has been effectively treated by the MAOI and therefore is only revealed when the drug is ceased. I have certainly seen this happen several times.


Comment: [BP] freaked me out so I bought a BP monitor and sure enough every morning my BP was around 115/75 which is normal but after taking my first dose of Parnate (2x10mg) it would shoot up to at least 160/90. This wasn't diet related as I checked it for 4 days and made sure I wasn't taking anything even remotely risky for MAOI takers.

My Answer: It is important to get this issue about blood pressure into perspective. Healthy vigorous exercise will increase systolic blood pressure to 200 mmHg (or more) within about five minutes, where it will remain throughout the duration of the exercise: think about the craze for marathon running! All such participants must be supposed to be at higher risk of stroke etc. than the few people who get a little occasional hypertension with MAOIs. This recent Finnish study (4) involved >1,000 normal participants on whom blood pressure data was gathered during exercise and the average BP was 200 mmHg, obviously many people were higher than that. Weight lifting, for instance, raises the blood pressure levels as high as 450 mmHg (5). Has weightlifting been banned? I will not even mention BP driving (6) or sexual intercourse (7).

There are millions of Americans walking round with blood pressures in excess of 160 much of the time, often unrecognised & untreated.

With MAOIs some people do get a short-lived rise in BP for approx. 30-90 minutes post-dose (my estimate is 2-5% of people on doses of up to 50 mg per day), perhaps more so with larger doses. There is no suggestion or evidence that this is severe or dangerous. In my experience that response tends to lessen as you get used to the drug. If it causes subjective symptoms which require action then spreading the dose out will help. In order to understand the how and why of dosing it is useful to understand that the half life of Parnate is very short. It varies in different people but it is generally less than 2 hours (8-10). This is relevant for its possible (non-therapeutic) effects not related to MAO inhibition (e.g. via TAA receptors, see other notes). However because it is an irreversible inhibitor its half life is not relevant to what we think is the main therapeutic effect, which is MAO inhibition.

So, what this almost certainly means is that for MAOI therapeutic effect it does not matter at all whether you take one single dose or split it up. Indeed it is probably possible to take it on alternate days. Is all that matters is whether the total dose taken is sufficient to inhibit any new enzyme which has been synthesised by the body since the last dose. However, to the extent that other effects may be mediated in other ways, those are likely to be dependent on the concentration of the drug in the blood and tissues, then the half life is relevant. Therefore, if the objective is to minimise side effects by spreading the effect as evenly as possible in the first part of the day it is logical to take a dose every couple of hours.

For many people Parnate has less side effects than most other drugs, but insomnia is one of the commoner undesirable effects. It seems clear that, in the majority of people, the earlier in the day that the dose is taken the less insomnia is experienced. If it is possible to take the whole daily dose first thing in the morning (on waking) that is the ultimate way of minimising insomnia. If that does not work then splitting the dose up into smaller bits taken at intervals of about two hours or so is the next best solution. It is usually best not to take any of the doses after the middle of the day. However, there are no absolute rules and experimenting to find out what is best for each individual usually gives a satisfactory resolution for any problems.


1. Datey, KK, Namda, NC, and Dalvi, CP, Management of hypertension with pargyline hydrochloride (Eutonyl). J. Postgrad. Med., 1965. 11(3): p. 126-32.
2. Kavanaugh, GJ, Sheps, SG, Fairbairn, JF, 2nd, Osmundson, PJ, et al., Experience with Pargyline Hydrochloride (Nonhydrazine Monoamine Oxidase Inhibitor) as an Antihypertensive Agent: Preliminary Observations in 32 Patients. Minn. Med., 1965. 48: p. 731-5.
3. Oates, JA, Seligmann, AW, Clark, MA, Rousseau, P, et al., The relative efficacy of guanethidine, methyldopa and pargyline as antihypertensive agents. N. Engl. J. Med., 1965. 273(14): p. 729-34.
4. Kurl, S, Laukkanen, JA, Rauramaa, R, Lakka, TA, et al., Systolic blood pressure response to exercise stress test and risk of stroke. Stroke, 2001. 32(9): p. 2036-41.
5. Haykowsky, MJ, Findlay, JM, and Ignaszewski, AP, Aneurysmal subarachnoid hemorrhage associated with weight training: three case reports. Clin J Sport Med, 1996. 6(1): p. 52-5.
6. Simonson, E, Baker, C, Burns, N, Keiper, C, et al., Cardiovascular stress (electrocaridographic changes) produced by driving an automobile. Am. Heart J., 1968. 75(1): p. 125-35.
7. Xue-Rui, T, Ying, L, Da-Zhong, Y, and Xiao-Jun, C, Changes of blood pressure and heart rate during sexual activity in healthy adults. Blood Press. Monit., 2008. 13(4): p. 211-7.
8. Baker, GB, Urichuk, LJ, McKenna, KF, and Kennedy, SH, Metabolism of monoamine oxidase inhibitors. Cell Mol Neurobiol, 1999. 19(3): p. 411-26.
9. Lang, A, Geissler, HE, and Mutschler, E, [Determination and comparison of the plasma and urine concentrations in men given tranylcypromine stereoisomers]. Arzneimittelforschung., 1979. 29(1): p. 154-7.
10. Baselt, RC and Stewart, CB, Determination of serum and urine concentrations of tranylcypromine by electron-capture gas-liquid chromatography. J Anal Toxicol (September-October 1977) 1(5): 215-217 1977. 1(2): p. 215-217.


Re: Gillman rocks! MAOIs Misconceptions and Questions vanvog

Posted by Phillipa on March 27, 2013, at 15:33:00

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

Sorry marathon runners don't unless hypentensive to begin have a BP of 450. Usually vigorious excercise lowers blood pressure. Phillipa


Re: Gillman rocks! MAOIs Misconceptions and Questions Phillipa

Posted by europerep on March 27, 2013, at 17:10:39

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions vanvog, posted by Phillipa on March 27, 2013, at 15:33:00

> Sorry marathon runners don't unless hypentensive to begin have a BP of 450. Usually vigorious excercise lowers blood pressure. Phillipa

You should contact and educate Mr. Gillman so that next time he gets his facts right.


Re: Gillman rocks! MAOIs Misconceptions and Questions

Posted by jono_in_adelaide on March 27, 2013, at 18:55:42

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions Phillipa, posted by europerep on March 27, 2013, at 17:10:39

Ken Gillman is a very smart guy, I think I'd trust his advice.

An increase of BP to 160/100 for a couple of hours isnt dangerous, its when that pressure is maintained unrelentingly for years that its a problem.

Also, by the time you start taking Parnate, its pretty certain that you're suffering severe, treatment resistant depression, which is life threatening - its worth putting up with transient increases in BP to treat a life threatening condition.


Re: Gillman rocks! MAOIs Misconceptions and Questions

Posted by baseball55 on March 27, 2013, at 19:28:42

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions vanvog, posted by Phillipa on March 27, 2013, at 15:33:00

Exercise does increase systolic blood pressure while and immediately after exercising, though it may lower average blood pressure when not exercising. I asked my doctor about this a long time ago when I was taking thyroid (can't recall the name of what I was taking). They told me to take my blood pressure regularly, so I would take it at the pharmacy on my way home from the gym and the systolic would always be alarmingly high. But when I went to see my doctor, my BP would be normal.


Re: Gillman rocks! MAOIs Misconceptions and Questions

Posted by vanvog on March 28, 2013, at 0:20:54

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions, posted by baseball55 on March 27, 2013, at 19:28:42


What happens to my blood pressure during exercise?


Different kinds of activity affect blood pressure differently.
Although blood pressure goes up during any kind of exercise, the changes brought on by exercise vary according to whether the exercise is static or dynamic.

* Dynamic (aerobic) exercise involves large muscle groups engaged in rhythmic, repeated movements. Examples of aerobic activities include jogging, brisk walking, swimming, bicycling and jumping rope.
* Static (isometric) exercise is defined as a sustained contraction of a muscle group and is typified by weight lifting.

Dynamic activities depend mainly on energy derived from consuming oxygen (aerobic). Thus they increase the bodys need for oxygen. Because blood delivers oxygen to the body, aerobic activity challenges the heart and circulatory system to meet this increased need. In dynamic exercise, oxygen consumption and heart rate increase in relation to the intensity of the activity. Systolic blood pressure rises progressively, while diastolic blood pressure stays the same or decreases slightly. Pulse rate rises, and blood flow to the muscles increases. Thus, aerobic exercise exerts primarily a volume load on the heart.

One way to detect changes in cardiovascular activity and oxygen consumption is to measure your pulse rate before, during and after an activity. Aerobic exercise will increase your pulse, and the more intense the activity that is, the more energy demanding the more your pulse will increase. When you stop exercising, your pulse does not immediately return to normal. Instead it gradually returns to its resting level. The greater your fitness level, the sooner your pulse rate will fall.

Isometric exertion involves sustained muscle contraction against an immovable load or resistance with no change in length of the involved muscle group or joint motion. The result is a moderate increase in cardiac output, with little or no increase in oxygen consumption. Despite the increased cardiac output, blood flow to the noncontracting muscles does not significantly increase. This combination of vasoconstriction (the narrowing of blood vessels that restricts, or slows, the blood flow) and increased cardiac output causes a disproportionate rise in systolic, diastolic and mean blood pressures.

Isometric or combined isometric and dynamic (resistance) exercise has traditionally been discouraged in patients with coronary disease. However, it appears that resistance exercise (for example, weight lifting at 8 to 12 repetitions/set) is less hazardous than was once presumed, particularly in patients with good aerobic fitness and normal or near-normal left ventricular (LV) systolic function. (The heart's main pumping chambers are the ventricles. The heart has a right side that pumps blood to the lungs, and a left side that pumps blood to the body. The left side of the heart must work harder than the right, so the heart's main pumping chamber is the left ventricle.)

Recent studies show that moderate-intensity exercise (walking, biking, etc.) effectively lowers blood pressure, perhaps more than vigorous-intensity exercise does. Moderate-intensity exercise optimizes the blood-pressure-lowering benefits of exercise and minimizes the risks sometimes associated with high-intensity exercise.

Difference between arm exertion and leg exertion
Many activities of daily living require more arm work than legwork. That's why people with coronary artery disease are advised to use their arms as well as their legs in exercise training. Although peak heart rates are similar with arm and leg exercise, heart rate and blood pressure response during arm exercise is higher than leg exercise. Therefore, target heart rates are designated 10 beats per minute lower for arm training than for leg training. Dynamic arm exercise is usually well tolerated by people with coronary artery disease; however, blood pressure may rise and be a concern in some people.

The importance of warm-up and cool-down in exercise
Warming up and cooling down in exercise help your body transition from rest to activity and back again. You also decrease your risk of injury or of being sore. Warm-up should last at least 10 minutes longer for older people and those who have been sedentary for a long time. Cool-down is especially important. Target heart rate for cool down is 1015 beats above your resting rate. If you stop exercising too quickly, your blood pressure can drop sharply, which can be dangerous and can also cause muscle cramping.

Make sure that you breathe regularly throughout your warm-up, exercise routine and cool-down. Holding your breath can raise blood pressure and cause muscle cramping.

Always consult your physician before starting an exercise program, particularly if you have high blood pressure or any other pre-existing condition, or if you've been sedentary for a long time. Also try to avoid caffeine, which increases heart rate and blood pressure during physical activity.

In closing, note that there is no good correlation between pulse rate and blood pressure. In people with high blood pressure there's no substitute for measuring blood pressure. Measuring pulse rate does not indicate blood pressure.

Sources: American Heart Association


Re: Gillman rocks! MAOIs Misconceptions and Questions

Posted by Laney on March 28, 2013, at 10:13:55

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions, posted by vanvog on March 28, 2013, at 0:20:54

I'm a fan of Dr. Gillman. I have skyped with him several times and have found him to be an excellent help. I also love his sense of humor!



Re: Gillman rocks! MAOIs Misconceptions and Questions vanvog

Posted by Phillipa on March 28, 2013, at 19:09:03

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions, posted by vanvog on March 28, 2013, at 0:20:54

Physical Activity and Blood Pressure


Updated:Mar 26,2013

Physical activity not only helps control your blood pressure, it also helps you manage your weight, strengthen your heart and manage your stress level. A healthy weight, a strong heart and general emotional health are all good for your blood pressure.

Take charge of your activity level

Exercise in our culture may not "just happen." When your daily routine includes hours of sitting at a desk using computers and browsing the internet, staying current with television shows and using countless labor-saving devices, you can easily fall into inactivity. But taking charge of your fitness may be one of the best decisions you'll ever make. The choice is yours.

What happens if I'm inactive?

All Americans should be regularly physically active to improve overall health and fitness. People who aren't physically active are much more likely to develop health problems. Even moderately intense physical activity, such as brisk walking, is beneficial when done regularly for a total of 30 minutes or longer at least 5 days a week. Lack of physical activity increases your risk for heart attack and stroke and can contribute to obesity. On the other hand, regular physical activity helps to reduce blood pressure, control weight and reduce stress.

AHA Recommendation

For overall health benefits to the heart, lungs and circulation, perform any moderate- to vigorous-intensity aerobic activity using the following guidelines:
Get the equivalent of at least 150 minutes of moderate intensity aerobic physical activity (2 hours and 30 minutes) each week.
You can incorporate your weekly physical activity with 30 minutes a day on at least 5 days a week.
Physical activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the week.
Include flexibility and stretching exercises.
Include muscle strengthening activity at least 2 days each week.

When it comes to physical activity, just get moving. Find ways to enjoy and savor the benefits as you gradually increase your activity level.

Don't be afraid to be active.
If you have not been active for quite some time or if you are beginning a new activity or exercise program, take it gradually. Consult your healthcare professional if you have cardiovascular disease or any other pre-existing condition. It's best to start slowly with something you enjoy, like taking walks or riding a bicycle. Scientific evidence strongly shows that physical activity is safe for almost everyone. Moreover, the health benefits of physical activity far outweigh the risks.

Find something you like!
If you love the outdoors, combine it with exercise and enjoy the scenery while you walk or jog. If you love to listen to audiobooks, enjoy them while you use an elliptical machine.

These activities are especially beneficial when done regularly:
Brisk walking, hiking or stair-climbing
Jogging, running, bicycling, rowing or swimming
Fitness classes at your appropriate level
Activities such team sports, a dance class or fitness games

Mix it up. Variety is good for you.
A variety of activity helps you stay interested and motivated. When you include strength and flexibility goals (using weights, resistance bands, yoga and stretching exercises), you also help reduce your chances of injury so you can maintain a good level of heart-healthy fitness for many years.

Know what moderate means for you.
If you injure yourself right at the start, you are less likely to keep going. Focus on doing something that gets your heart rate up to a moderate level. If you're physically active regularly for longer periods or at greater intensity, you're likely to benefit more. But don't overdo it. Too much exercise can give you sore muscles and increase the risk of injury.

Make it social.
Consider walking with a neighbor, friend or spouse. Take an exercise challenge. Connecting with others can keep you focused and motivated to walk more join, or create, an American Heart Association Walking Club to find walking buddies near you.

Reward yourself with something that supports your goals.
Pay yourself. Set aside a small amount of money for every workout. After one month, invest your payoff in something that motivates you to keep up the good work, like new music to enjoy while you walk or a new workout shirt.
Celebrate your milestones. Fitness needs to a regular part of your life, so finding ways to savor your success is important. Log your walk time or distance and write yourself a congratulatory note when you achieve a milestone, or indulge in a massage after every 100 miles - whatever incentive works to keep you moving!

Warm up and cool down.
Warming up before exercising and cooling down afterwards helps your heart move gradually from rest to activity and back again. You also decrease your risk of injury or soreness. Warm-up should last at least 10 minutes longer for older people and those who have been inactive for a long time. Cool-down is especially important. If you stop exercising too quickly, your blood pressure can drop sharply, which can be dangerous and can also cause muscle cramping. Try adding some relaxing yoga poses to your routine; they will also increase your flexibility.

Practice breath control.
Make sure that you breathe regularly throughout your warm-up, exercise routine and cool-down. Holding your breath can raise blood pressure and cause muscle cramping. Regular, deep breathing can also help relax you.

No time for exercise? Try our top 10 tips!

Do I need to consult my doctor before increasing my activity level?
Healthy adults generally do not need to consult a healthcare provider before becoming physically active. Adults with chronic conditions should talk with their healthcare provider to determine whether their conditions limit their ability to do regular physical activity.

What is moderately intense physical activity?

Use these simple tests to determine if you are reaching a moderate level of intensity.
If you can easily carry on a full conversation and perform the activity at the same time, you probably aren't working hard enough.
If you can sing and maintain your level of effort, you're probably not working hard enough.
If you can exchange brief sentences easily while performing the activity, but not a comfortable or lengthy conversation, your intensity level is likely on target.
If you get out of breath quickly, or if short sentences feel like a strain, you're probably working too hard, especially if you have to stop and catch your breath.
Learn how to identify and monitor your target heart rate to measure the intensity of your activity.

How do I calculate my heart rate?
To calculate your target training heart rate, you need to know your resting heart rate. Resting heart rate is the number of times your heart beats per minute when it's at rest. The best time to find your resting heart rate is in the morning after a good night's sleep and before you get out of bed. The average resting heart rate is 60-80 beats per minute. However, for people who are physically fit, it's generally lower. Also, resting heart rate usually rises with age.

How much do I need to exert myself?

Once you know your resting heart rate, you can then determine your target training heart rate. Target heart rates let you measure your initial fitness level and monitor your progress in a fitness program. You do this by measuring your pulse periodically as you exercise and staying within 50 to 85 percent of your maximum heart rate. This range is called your target heart rate. Learn more about target heart rate.

Remember, pacing is important
It's important to pace yourself properly when exercising. If you're just starting a program, aim at the lowest part of your target zone (50 percent) during the first few weeks. Gradually build up to the higher part of your target zone (85 percent). After six months or more of regular exercise, you may be able to exercise comfortably at up to 85 percent of your maximum heart rate. However, you don't have to exercise that hard to stay in shape.

A simpler intensity test
If you don't want to take your pulse while exercising, try using a "conversational pace" to monitor your efforts during moderate activities like walking. It works like this:

If you can talk and walk at the same time, you are working at a moderate physical activity level.
If you can sing and maintain your level of effort, you're probably not working hard enough.
If you get out of breath quickly, you're probably working too hard, especially if you have to stop and catch your breath.

"This content was last reviewed on 04/04/2012."


Re: Gillman rocks! MAOIs Misconceptions and Questions vanvog

Posted by Phillipa on March 28, 2013, at 19:13:34

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions, posted by vanvog on March 28, 2013, at 0:20:54

Lots of articles on internet. Phillipa


Re: Gillman rocks! MAOIs Misconceptions and Questions

Posted by Tyrannosaur on March 29, 2013, at 17:29:55

In reply to Re: Gillman rocks! MAOIs Misconceptions and Questions vanvog, posted by Phillipa on March 28, 2013, at 19:13:34

> Lots of articles on internet. Phillipa

Phillipa, vanvog, Ken Gillman, you're all three correct in your own way.

Ken Gillman mentions that blood-pressure rises to high levels during strenuous exercise.

While the articles you posted Phillipa states that blood-pressure is lowered over time for those who do frequent exercise. (Not during exercise)


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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