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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by Janelle on March 28, 2002, at 2:56:19
Now that I've figured out from a thread on here what an MAOI inhibitor is, let me see if I get this straight - well, first, I'm always reading and hearing that people on SSRI's should NOT take MAOI's and vice versa, and if you're gonna switch from one to the other, you should wait at least 2 weeks for whichever one you're on to clear out of your system.
Okay, now it seems to me that the reason you must NOT take an SSRI and MAOI together is that since they both act to keep Serotonin in the synapse longer than usual (SSRI with inhibiting the reuptake pump, MAOI with inhibiting the enzyme that breaks down serotonin), you could wind up with TOO MUCH serotonin and have some kind of terrible reaction, like mega-serotonin syndrome????
Please let me know if I'm getting this right, and if not, please correct me! Thanks.
Posted by Frankie on March 28, 2002, at 3:06:38
In reply to If both SSRI + MAOI were taken what would happen?, posted by Janelle on March 28, 2002, at 2:56:19
> Now that I've figured out from a thread on here what an MAOI inhibitor is, let me see if I get this straight - well, first, I'm always reading and hearing that people on SSRI's should NOT take MAOI's and vice versa, and if you're gonna switch from one to the other, you should wait at least 2 weeks for whichever one you're on to clear out of your system.
>
> Okay, now it seems to me that the reason you must NOT take an SSRI and MAOI together is that since they both act to keep Serotonin in the synapse longer than usual (SSRI with inhibiting the reuptake pump, MAOI with inhibiting the enzyme that breaks down serotonin), you could wind up with TOO MUCH serotonin and have some kind of terrible reaction, like mega-serotonin syndrome????
>
> Please let me know if I'm getting this right, and if not, please correct me! Thanks.
Janelle,You are partially right. The part you did not get is the blood pressure problems that will likely result. This could cause bleeding inside the skull! I don't want to take any chances and have this happen! But, in retrospect, the MAO-I's do inhibit the enzyme that breaks down all three neurotransmitters, in the order of serotonin, norepinephrine, dopamine. They are much more activating than the SSRI's, and most comparable in effectiveness to tricyclics. Most say that the MAO-I's are the best! I know that they are the best antidepressants for anxious depressants. But, they are dangerous with certain foods, as you know, and there are many serious, potentially fatal, drug interactions. This includes any other med that acts on any neurotransmitter system! This may be overblown, to an extent, but like I said, I would rather not take my chances. I am not a very lucky guy!
Frankie.
Posted by fachad on March 28, 2002, at 7:20:26
In reply to If both SSRI + MAOI were taken what would happen?, posted by Janelle on March 28, 2002, at 2:56:19
Serotonin Syndrome is actually the medical name for what happens when you take an MAOI with and SSRI.
You can also get Serotonin Syndrome from taking L-typtophan (which the body makes into serotonin) along with an SSRI.
Someone here could probably give you a more accurate description of Serotonin Syndrome, but from what I've heard it's awful and medically dangerous.
> Now that I've figured out from a thread on here what an MAOI inhibitor is, let me see if I get this straight - well, first, I'm always reading and hearing that people on SSRI's should NOT take MAOI's and vice versa, and if you're gonna switch from one to the other, you should wait at least 2 weeks for whichever one you're on to clear out of your system.
>
> Okay, now it seems to me that the reason you must NOT take an SSRI and MAOI together is that since they both act to keep Serotonin in the synapse longer than usual (SSRI with inhibiting the reuptake pump, MAOI with inhibiting the enzyme that breaks down serotonin), you could wind up with TOO MUCH serotonin and have some kind of terrible reaction, like mega-serotonin syndrome????
>
> Please let me know if I'm getting this right, and if not, please correct me! Thanks.
Posted by djmmm on March 28, 2002, at 9:59:13
In reply to If both SSRI + MAOI were taken what would happen?, posted by Janelle on March 28, 2002, at 2:56:19
You may get serotonin syndrome combining a SSRI and a MAOI. It seems that some people are more susceptible to it than others.
Serotonin syndrome isn't always fatal, in fact most of the time it resolves itself with no medical intervention...Serotonin syndrome is basically a group of symptoms resulting from serotonin overstimulation. The symptoms can range from a mild headache to coma, and death (rarely)
Posted by OldSchool on March 28, 2002, at 21:13:32
In reply to If both SSRI + MAOI were taken what would happen?, posted by Janelle on March 28, 2002, at 2:56:19
If you combined an SSRI with an MAOI, most likely you would die. At the very least, you would end up in the hospital for a while. If you did this stupidly voluntarily on your own without your doctor's permission, nothing would happen to your doctor. If on the other hand this idea was your doctor's, your doctor who prescribed this concoction would most likely lose his medical license and possibly even face criminal charges. It would be an easy medical malpractice lawsuit which your family would win.
Does that answer the question?
Old School
Posted by Elizabeth on April 4, 2002, at 19:01:30
In reply to Re: If both SSRI + MAOI were taken what would happen?, posted by Frankie on March 28, 2002, at 3:06:38
I have some experience with the "serotonin syndrome" (also known as "central serotonin syndrome," perhaps to distinguish it from the bad things which can happen from taking drugs that increase serotonin concentrations in the periphery, such as fenfluramine). After it happened to me I did some reading about it, and I learned some stuff which might be of interest to you if you're curious about this odd and potentially serious interaction (it's almost always associated with two or more drugs that increase serotonin concentrations). I call it the "CSS" for short.
The term "serotonin syndrome" was coined when it was noted that a cluster of symptoms appeared in patients who took fluoxetine in combination with MAOIs (a cocktail which is now considered to be absolutely contraindicated under any circumstances). This is *not* the same as the hypertensive reactions that occur more frequently when patients taking MAOIs eat certain foods (aged cheese, etc.) or take certain drugs (such as amphetamine and pseudoephedrine).
Most serious cases of the CSS involve MAOIs (including reversible MAOIs such as moclobemide) in combination with some other drug. IMO, the CSS is the most dangerous of all the potential food or drug interactions involving MAOIs (hypertensive reactions are pretty easy to identify and treat, while the CSS is difficult to diagnose and there isn't any specific treatment, only supportive measures).
Some of the drugs which can be associated with the CSS are serotonergic antidepressants (MAOIs, SSRIs, Effexor, Serzone, Remeron, clomipramine and perhaps occasionally other TCAs, and yes, St. John's wort), certain synthetic opioids (mainly Demerol and Ultram), MDMA ("ecstasy") and similar drugs, fenfluramine, antimigraine drugs of the "triptan" family (such as Imitrex), and serotonin precursors such as L-tryptophan and 5-hydroxytryptophan (this does *not* mean that it's dangerous to eat tryptophan-containing foods such as milk and turkey, but supplements should be avoided).
There have been isolated cases of the CSS reported involving lithium, antipsychotic drugs, and trazodone (probably others that I don't recall off the top of my head, too). These are extremely rare, though (like, one-report-in-fifty-years rare). It's considered safe to take any of these drugs with SSRIs or even with MAOIs (although the dose of trazodone used in combination with MAOIs is generally low).
Usually it is a combination of two or more of these drugs that triggers the CSS, and while MAOIs are most often involved in serious reactions, there are other combinations that are risky as well. SSRIs and Effexor should not be used in combination with Ultram or Demerol, in particular -- there are plenty of other pain medications to choose from. The cough medicine dextromethorphan should probably also be avoided by people taking SSRIs (it doesn't work very well anyway). In some cases that involve the newer ADs there may be pharmacokinetic factors contributing to the reaction, as some of the new-generation ADs -- notably fluoxetine, paroxetine, fluvoxamine, and nefazodone -- are inhibitors of one or more enzymes in the cytochrome P450 family. When these drugs are used in combination with other drugs, the potential for pharmacokinetic interactions should be taken into account; for example, a migraine sufferer who takes sumatriptan may wish to choose sertraline rather than fluoxetine.
Certain foods (exotic ones, like banana peels (!)) even contain serotonin (not tryptophan, but actual serotonin). Normally, the serotonin would be metabolized in the GI tract by MAO, but in the absence of MAO, the serotonin will be left to its own devices and may travel all over the body wreaking mayhem.
Although the CSS wasn't identified and given a name until fluoxetine came into use, in retrospect it was recognized that there had been some cases of the same syndrome decades earlier when psychiatrists experimented with cocktails that included MAOIs. Today it's become more common as a result of widespread use of the non-MAOI serotonergic ADs.
Like other CNS disorders, the CSS is a fairly amorphous syndrome, but some researchers feel that the symptoms can be divided into four major categories: autonomic, motor, gastrointestinal, and mental status changes. Autonomic symptoms include dilated (sometimes nonreactive) pupils, labile pulse, hypertension or hypotension (sometimes rapid shifting between the two: e.g., blood pressure increases initially, then "crashes;" hypotension may progress to shock), and fever which may progress to malignant hyperthermia. (I believe that in fatal cases, malignant hyperthermia is most often found to be the immediate cause of death.) Motor symptoms include hyperreflexia, rigidity, myoclonus (i.e., twitching), tremor, shivering (chattering teeth seems to be a particularly common manifestation), and nystagmus. Gastrointestinal symptoms can include nausea, vomiting, diarrhea, abdominal cramping, and hypersalivation. Mental status changes can include anxiety, mania, agitation, confusion, delirium, and coma. Some other common symptoms are excessive sweating, rapid and shallow breathing, and seizures. This list probably isn't exhaustive -- like I said, the syndrome is pretty amorphous and subject to much interindividual variation -- but it should give you an idea.
There are certainly plenty of centrally acting drugs that can be used safely in combination with MAO inhibitors. The risk of the CSS is limited to drugs affecting serotonin. Nonserotonergic drugs such as Wellbutrin can be used safely. Some drugs, such as stimulants, may have the potential for causing increased blood pressure (*not* the CSS), but many people can use them safely (monitoring is important here). Some drugs, such as the atypical neuroleptics and the antidepressant trazodone, interact with the serotonin system but do not appear to interact with MAOIs (or if they do, it is very rare and exceptional), and such combinations are commonly used. And of course, plenty of chemicals act as neurotransmitters and aren't affected by MAOIs at all: acetylcholine, endogenous opioids and other neuropeptides, GABA, glutamate, etc.; drugs whose effects are limited to these systems present no special danger when used with MAOIs.
"Serotonin syndrome" isn't a diagnostic category, and there isn't any universally agreed-upon definition (although several attempts have been made to define the syndrome, and in particular to draw the line between ordinary side effects of serotonergic drugs and the CSS).
I'm not sure what the mortality rate is from the CSS, but it's not like it's 100% fatal, or even close. (It's not a very effective way to attempt suicide, if that's what you have in mind.) Still, best not to tempt fate, eh?
-elizabeth
This is the end of the thread.
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