Posted by don_bristol on May 31, 2004, at 20:26:53
In reply to MAOI hypetensive crisis treatment, posted by harryp on May 31, 2004, at 0:22:14
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> Thank you very much for the article on Captopril. It does look like it could be a good option.
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> *Kaplan's Clinical Hypertension* has this to say about it:
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> "Despite the small potential for hypotension, oral captopril may be the safest of nonparenteral agents for urgent hypertension" (8th ed. 353)
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> Kaplan also noes: "...an ACEI [ACE-inhibitor, i.e. captopril] may be particularly attractive because it shifts the entire curve of cerebral autoregulation to the left, so CBF [cerebral blood flow] should be well maintained as the systemic BP falls." (353)
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> On Nifedipine:
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> "[because of the risk of hypotension, some authorities have] recommended that the use of short-acting nifedipine be abandoned. However, IF TAKEN IN THE UNBROKEN CAPSULE, IT SEEMS NO MORE LIKELY TO CAUSE A PRECIPITOUS FALL IN BP THAN OTHER SHORT-ACTING AGENTS (e.g. captopril)." (352, emphasis added)
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> Clonidine causes significant sedation, and doesn't seem to have any advantages over nifedipine and captopril except slower-onset. Oral labetalol seems to work too slowly and last too long to be a good choice.
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> Good news:
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> Judging from my British psychiatry text, MAOI's seem to be more widely used in Britian, at least, and hopefully Western Europe in general. This would mean that you would likely get fast, appropriate care at an ER. You could also contact the NHS in Britian for European-food-oriented MAOI advice. I fear you will have to pass on the tap Guiness! Bernstein's *Drug Therapy in Psychiatry* has the most exhaustive info on the tyramine content of common and unusual foods.
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> As far as oral drugs go when the ER isn't an option--we are our own guinea-pigs...
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> I think Captopril sounds like a good option, although I have no idea what the best dosage would be.
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> I get the impression that many of the dangers of Nifedipine can be lessened if one takes only one 10 mg immediate release capsule WITHOUT breaking the capsule. This will be what I will do if I don't have access to phentolamine.
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> Keep in mind that all oral drugs are a bit sketchy (as Kaplan and other authorities note) becauase you can't titrate the dosage precisely. Don't mess with them unless you KNOW for sure you are having a hp urgency, and qualified medical care is not available.
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> Keep in mind the following (for all MAOI users):
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> Make sure you can identify a true hypertensive urgency/crisis. I think all MAOI patients should be skilled in monitoring their own bp and know what is normal for them. The pounding headache is unmistakable, but taking your bp can give you advance warning (it did in my case--the headache doesn't start immediately) if you "feel funny" and also can help get you attention at the ER.
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> "My bp is over 200/100!"
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> gets better results than
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> "uhh. I have a bad headache and I think I'm having a drug reaction..."
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>
> Don't panic! A prescribed anti-anxiety drug can help lower the "anxiety-component" of your bp. Stroke or death from an untreated MAOI crisis is INCREDIBLY rare. Stay calm, (if getting to an ER isn't an option, lie down in a quiet, darkened room) and you will probably be just fine. If you do go to the ER, BE SURE to tell the doctor (in addition to the MAOI stuff) if you took any bp lowering drug recently (like nifedipine or captopril, etc.). I saw one chart in which an overzealous ER doc added phentolamine on top of nifedipine, and caused a(non-fatal) hypotensive reaction.
===============================Harry
Thank you for a well-considered reply. It is much appreciated. I will try and address all the several points you make.
First of all I should dispel any confusion as to where I am. I live in the UK and we here often use the term 'Europe' to refer to the continental countries. So don't let that mislead you!
You quotation of Kaplan seems to endorse the use of Captopril. I also see you point out that short-acting Nifedipine was now discredited (no wonder my doctors wouldn't give it to me last year!) I seem to recall that the short-acting form was a capsule that was broken and the gel contents placed under the tongue.
I rather felt that both papers which I quoted just now http://www.ptcommunity.com/ptjournal/fulltext/27/7/PTJ2707362.pdf and http://www.rxfiles.ca/acrobat/nifed-hu.pdf both felt there were better meds than Nifedipine from a safety point of view.
You say that MAOIs seem to be more widely used in the UK than the US but my experience has been that they are quite rarely used here. Maybe I am not aware of the real numbers of users in the UK. However one strange thing is the recommended range for Parnate in the US is 30 to 60 mg (source PDR http://www.drugs.com/PDR/Parnate_Tablets.html) whereas in the UK it is 10 to 30 mg (source BNF http://www.bnf.org/bnf/bnf/current/noframes/3346.htm). That may mean in the UK the tyramine problems are fewer because the dose is lower. Also UK doctors can prescribe the food-insensitive reversible MAOI Moclobemide which the US does not. And furthermore the UK has not discontinued use of Marplan (isocarboxazid). But all this does not mean that it seems to people like me that MAOIs are common.
By the way, I have settled on a 250 (even 500 mg) dose of Captopril. It all depends on the rate of raise of BP and its absolute value. I hope I never have to use the Captopril. In truth I don't recall if I have to swallow, crush or keep it in the mouth - so I need to check. However I am told that tyramine food reactions are more likely with Parnate than with the Nardil I tried before so it seems more likely that a Parnate user might hit this problem. Please let me know if you or anyoe else has a view on what quanitity to take and when after/during a hypertensive crisis.
I think someone here posted this link recently http://www.vh.org/adult/provider/psychiatry/CPS/19.html and here is something similar regarding debunking diet myths http://www.deoxy.org/maoidiet.htm
I can add to these this following link which I find particularly interesting as it has figures on the actual number of hypertensive incidents http://www.emedicine.com/EMERG/topic318.htm. More modern figures would be even better.
Over in the Yahoo group on MAOIS http://health.groups.yahoo.com/group/maois/ which I am a member of, I think someone recently mentioned taking chlorpromazine because it lowered BP and it also sedated the person without making them go 'gaga'.
I think your advice to have access to a BP machine and to quote its figures is a very good one. I have now added my BP machine to my packing list! And I will quote it's readings if I have problems.
I am mindful too of your postscript in a second posting here which refers to potential problems when Captopril is taken with aspirin. But this seems to be one of those suspected interactions. Pubmed didn't have much on this topic. I found only "Comparative effects of aspirin with ACE inhibitor or angiotensin receptor blocker on myocardial infarction and vascular function” (2003) and one other called "Interaction between aspirin and angiotensin-converting enzyme inhibitors: should they be used together in older adults with heart failure?” (2002).
In actual fact I currently take 75 mg aspirin daily.
Well I guess there is a lot of info here. I have not fully absorded it yet. I probably wont ever absorb all of it so any comments and observations will help me see my way through it.
Best wishes -- Don
poster:don_bristol
thread:348520
URL: http://www.dr-bob.org/babble/20040527/msgs/352527.html