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Inhibitors: Myths vs. Truths Regarding Dietary and Drug Interactions

The Tyramine Reaction The Tricyclic Interaction The Psychotropic Medication Interaction (cont.) The Anesthetic Interaction

The Myth The Myth Switching from a Serotonergic Drug to an MAOI The Myth If you’re taking an MAOI, you can’t eat cheese, drink wine or beer, or have many If you’re taking an MAOI, you can’t have a tricyclic or anything that If you’re taking an MAOI, you can’t have a local or a general anesthetic, so patients other foods that contain tyramine, or else you will develop hypertensive crisis. resembles them, including carbamazepine and cyclobenzaprine. who need dental work, stitches, or surgery cannot take an MAOI. Half-Lives*

The Truth The Truth The Truth 5-HT Drug MAOI** There are a few things to avoid (which are easy to remember), but in practice, diet is Other than clomipramine, tricyclic and related agents can be used Be careful using local anesthetics that contain epinephrine and using general not really a problem… with caution in patients taking MAO inhibitors. anesthesia, as it can cause changes.

…unless you plan to eat more than 25 pieces of pizza or drink more than 25 cans of Using Tricyclic Antidepressants With MAO Inhibitors Use of Anesthetics With MAOIs beer or 25 glasses of wine. Contraindicated Use with caution Local anesthetic Elective surgery Urgent or elective surgery where patient is still taking Recommended Dietary Restrictions for MAOIs (not necessary for 6 mg transdermal or clomipramine other tricyclic antidepressants 1 2 3 4 5 low-dose oral ) MAO inhibitor cyclobenzaprine *5–7 days for most drugs; 5 Choose agent that does not Wash out of the MAO Cautiously use a Foods to avoid Foods allowed carbamazepine weeks for fluoxetine oxcarbazepine contain vasoconstrictors inhibitor 10 days prior to benzodiazepine, Dried, aged, smoked, fermented, spoiled, or Fresh or processed meat, poultry, and fish; surgery mivacurium, rapacuronium, **Titration schedule for MAOI may differ depending on the individual agent improperly stored meat, poultry, and fish properly stored pickled or smoked fish morphine, or codeine Broad bean pods All other vegetables Aged cheeses Processed cheese slices, cottage cheese, Switching from an MAOI to a Serotonergic Drug ricotta cheese, yogurt, cream cheese The Psychotropic Medication Interaction Tap and unpasteurized beer Canned or bottled beer and alcohol Weeks The Cold Medication/ Interactions Marmite Brewer’s and baker’s yeast The Myth MAOI The Myth Sauerkraut, kimchee You can’t take any medications that block reuptake, which means you 5-HT drug* can’t take any psychotropic medications. Since all patients who are candidates for Soy products/tofu Peanuts If you’re taking an MAOI, you can’t take cold medications, such as decongestants, an MAOI need concomitant medications, no one can take an MAOI. Banana peel Bananas, avocados, raspberries antihistamines, or cough medicines, so patients who get colds cannot take MAOIs. Besides, you cannot get there from here because in order to start an MAOI, you Tyramine-containing nutritional supplement If you’re taking an MAOI, you can’t take , so patients who need stimulants have to disrupt everything, stopping all other meds for 2 weeks after taper. And if cannot take MAOIs. you have to stop an MAOI to go back to a psychotropic medication, you have to go 1 2 without all meds for another 2 weeks. This is an unacceptable risk and a hassle. *Titration schedule for 5-HT drug may differ depending on the individual agent The Truth

The Painkiller Interaction The Truth Sympathomimetic decongestants and stimulants should be used with caution while monitoring blood pressure in patients for which the benefits are greater than the You must avoid only agents that block serotonin reuptake. There are many options How to Bridge When Starting or Stopping an MAOI risks and should be avoided only in high-risk/low-benefit populations. The Myth for not only bridging between serotonin reuptake inhibitors and MAOIs, but also augmenting MAOIs. If you’re taking an MAOI, you can’t you can’t take painkillers because they will kill Drugs to Use: Drugs That Boost and Thus Should Be Used With Caution With you, so patients who have sprained ankles, sore muscles, dental extractions, or MAO Inhibitors Drugs to Avoid Due to Risk of /Toxicity surgeries cannot take MAOIs, as they must avoid all opiate and non-opiate benzodiazepines Decongestants Stimulants Antidepressants Other painkillers. Antidepressants Drugs of Abuse Opioids Other Z-drug hypnotics With NRIs trazodone most TCAs SSRIs MDMA (ecstasy) meperidine non-subcutaneous The Truth lamotrigine sumatriptan NRIs local anesthetics valproate containing There are a few things to avoid (which are easy to remember), and in practice, this is SNRIs tramadol chlorpheniramine gabapentin, pregabalin, topiramate, carbamazepine, oxcarbazepine vasoconstrictors not really a problem. stimulants clomipramine meth-amphetamine methadone brompheniramine SNRIs tramadol, tapentadol atypical antipsychotics Using Painkillers With MAO Inhibitors NDRIs cocaine, St. John’s wort High-dose or ? Avoid Can Use injected amphetamine dextromethorphan meperidine morphine Bortolato M, Chen K, Shih JC. Monoamine oxidase inactivation: from pathophysiology to therapeutics. Adv Drug methadone codeine Delivery Rev 2008;60:1527-33. tramadol oxycodone Gillman PK. Advances pertaining to the pharmacology and interactions of irreversible nonselective monoamine oxidase tapentadol hydrocodone inhibitors. J Clin Psychopharmacology 2011;31:66-74. Stahl SM. Stahl's essential psychopharmacology. 3rd ed. New York, NY: Cambridge University Press; 2008. suboxone Sun-Edelstein C, Tepper SJ, Shapiro RE. Drug-induced serotonin syndrome: A review. Expert Opin Drug Saf NSAIDs 2008;7(5):587-96. Wimbiscus M, Kostenkjo O, Malone D. Mao inhibitors: risks, benefits, and lore. Cleveland Clinic J Med 2010;77(12):859-82.

Presented at the 2011 NEI Global Psychopharmacology Congress.