![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by Elizashae on May 30, 2001, at 15:00:58
Ok, I've done all the new and improved AD's with no luck. I'm thinking of resorting to the older standby's. Can someone name a few tricylics that aren't so harsh? That maybe I can tolerate a bit better? I have anxiety and depression and I can say I don't want anymore weight gain, but I've gained on all SSRI's. Wellbutrin, Serzone, etc...have not helped either.
Any input?
Posted by Elizabeth on May 30, 2001, at 17:08:19
In reply to Tricylics(If I spelled that right), posted by Elizashae on May 30, 2001, at 15:00:58
Desipramine and nortriptyline are the most benign tricyclics available in the USA. Desipramine is the least likely to cause weight gain.
Before you try tricyclics ("TCAs"), you might want to try to determine whether you are a good candidate. They work very well but only in a limited population. What sort of symptoms do you have?
-elizabeth
Posted by Elizashae on May 30, 2001, at 20:03:47
In reply to Re: Tricyclics » Elizashae, posted by Elizabeth on May 30, 2001, at 17:08:19
I'm about as atypical as you can get. I have anxiety as well. I've had depression since I was 13 and I'm 27 now so you can imagine all the meds I've taken. It used to not take over like it does now. It seems to have gotten worse with age. I don't work anymore, I sleep to much, I've lost interest in everything, I've been eating to much. I used to have depression but still kept going and enjoyed life. I've been stuck in a rut for the past couple of years. Thought about a MAOI too, but am scared. Just don't know what road to take.
> Before you try tricyclics ("TCAs"), you might want to try to determine whether you are a good candidate. They work very well but only in a limited population. What sort of symptoms do you have?
>
> -elizabeth
Posted by sl on May 30, 2001, at 20:39:40
In reply to Re: Tricyclics » Elizabeth, posted by Elizashae on May 30, 2001, at 20:03:47
> I'm about as atypical as you can get. I have anxiety as well. I've had depression since I was 13 and I'm 27 now so you can imagine all the meds I've taken. It used to not take over like it
*heh* You aren't me...I'm not 27 for two more days. Otherwise, you sOUND like me. 'Cept I'm better than when I was younger.
I really oughta just change my handle to SuggestsWellbutrin. Cuz that's what I always seem to do. If nothing else, you couldn't sleep all the time cuz Wellbutrin is stimulating. :)
sl
Posted by Phil on May 30, 2001, at 20:39:41
In reply to Re: Tricyclics » Elizabeth, posted by Elizashae on May 30, 2001, at 20:03:47
With anxiety, you may want to start w/ Nortriptyline. It's a little more sedating.
Desipramine may be better as far as weight gain..Elizabeth would be more qualified to answer.
I'm back on Amitriptyline. Save this one for last!!
TCA's can really kick TRD but if you've been struggling for a few years, you may have to exercise a little extra patience in terms of how quickly they kick in. That's been my recent experience. YMMV.Phil
Posted by Elizashae on May 30, 2001, at 20:52:38
In reply to Re: Tricyclics, posted by sl on May 30, 2001, at 20:39:40
> I really oughta just change my handle to SuggestsWellbutrin. Cuz that's what I always seem to do. If nothing else, you couldn't sleep all the time cuz Wellbutrin is stimulating. :)
>
> slI might be able to handle wellbutrin if I didn't get such severe headaches from it. Also, it does nothing for anxiety, but make it worse:(
Posted by mair on May 30, 2001, at 22:06:54
In reply to Re: Tricyclics » Elizashae, posted by Elizabeth on May 30, 2001, at 17:08:19
I, too, have recently considered taking a tricyclic. Over the last 5 or 6 years, I've taken alot of things which have all been either totally non-helpful, impossible to tolerate, or only very moderately successful. I took a tricyclic for a brief time over 20 years ago, and I seem to remember that it did make a difference. I think, but am not certain, that it was amiltryptaline. If I had a positive reaction then, am I likely to respond positively now? If weight gain wasn't a problem then, is it likely that it won't be now? Or should I just disregard my previous experience? Mair
Desipramine and nortriptyline are the most benign tricyclics available in the USA. Desipramine is the least likely to cause weight gain.
>
> Before you try tricyclics ("TCAs"), you might want to try to determine whether you are a good candidate. They work very well but only in a limited population. What sort of symptoms do you have?
>
> -elizabeth
Posted by sl on May 30, 2001, at 22:30:30
In reply to Re: Tricyclics » sl, posted by Elizashae on May 30, 2001, at 20:52:38
> I might be able to handle wellbutrin if I didn't get such severe headaches from it. Also, it does nothing for anxiety, but make it worse:(Awww...I'm sorry. :(
I'd heard that it might aggravate anxiety but it never did that for me. (made me JUMPY but not anxious exactly)
sl
Posted by Shirley 2 on May 31, 2001, at 5:44:52
In reply to Re: Tricyclics, posted by sl on May 30, 2001, at 22:30:30
I also have depression and anxiety and wondered whether the tricyclics would be appropriate because of my previous problems with SSRI's, including monthly agiation after my period starts.
Cam and anyone else, I wondered if you have seen the same research that intrigued me when I was researching meds.I have a learning disability that affects the right hemisphere. Anyway, I saw various articles that inferred that stroke victims who became depressed and had right hemisphere damage responded better to tricyclics than prozac.
Also, I have severe executive function impairments as the result of learning disability. I ran across an article that said people who had executive dysfunction as the result of their depression did not respond greatly to prozac.
Anyway, Cam, I am curious if you have seen similar research? Personally, I don't think enough attention has been paid to regarding the problems of people with LD and what antidressants might be better for them. Granted, this research wasn't about LD but it was sure close.
John L, I tried to ask my psychiatrist about the possibility of tricyclics but he is in the SSRI mode. He wanted me to try Luvox and he may have perfectly good reasons for wanting me to do this.
But it was obvious he was so biased against the tricyclics and had no interest in my research which my neighbor, a former health care professional, thought was very relevant.Elizabeth, based on what I have said, do I sound like one of the select few who might benefit from tricyclics? I know your mileage may vary and I need to check with my psychiatrist and I will when I find someone to replace the guy I have now.
(another post). But when I saw this thread on tricyclics, I had to jump in because of my research and most recent experience.Shirley
PS - I have never been on any tricylics
Posted by Elizabeth on May 31, 2001, at 21:01:26
In reply to Re: Tricyclics » Elizabeth, posted by Elizashae on May 30, 2001, at 20:03:47
> I'm about as atypical as you can get. I have anxiety as well. I've had depression since I was 13 and I'm 27 now so you can imagine all the meds I've taken. It used to not take over like it does now. It seems to have gotten worse with age. I don't work anymore, I sleep to much, I've lost interest in everything, I've been eating to much. I used to have depression but still kept going and enjoyed life. I've been stuck in a rut for the past couple of years. Thought about a MAOI too, but am scared. Just don't know what road to take.
What you are describing sounds like "atypical" depression, which is known to respond preferentially to MAOIs (and possibly stimulants) and poorly to tricyclics.
Don't be afraid of MAOIs. Their dangers have been greatly exaggerated, and many here will attest to their benefits.
-elizabeth
Posted by Elizashae on May 31, 2001, at 21:29:05
In reply to Re: Tricyclics » Elizashae, posted by Elizabeth on May 31, 2001, at 21:01:26
Any ideas of which MAOIs are tolerated better? What are some of the more popular ones? I don't know really much about them except a certain diet has to be followed. I feel better when I go to talk with my therapist if I have a bit of an idea what to ask about...and know a little myself..
>
> Don't be afraid of MAOIs. Their dangers have been greatly exaggerated, and many here will attest to their benefits.
>
> -elizabeth
Posted by Elizabeth on May 31, 2001, at 23:10:33
In reply to Re: Tricyclics-Elizabeth, Cam, John L. and others, posted by Shirley 2 on May 31, 2001, at 5:44:52
Shirley --
Although you didn't provide enough information to describe a known depressive subtype, I think there is a good chance you would respond either to TCAs or SSRIs.
It is possible to combine TCAs and SSRIs safely. For example, you could try Luvox, as your doctor recommends, and then add desipramine or nortriptyline if you have a partial response. If I were in your shoes, I'd want to know the doctor's rationale for wanting to try Luvox.
A caveat about the combination approach: because Luvox is an inhibitor of several hepatic enzymes involved in TCA metabolism (cytochromes P450 1A2, 3A4, and 2D6 in particular), it can alter serum levels of tricyclics and their metabolites. (Most of the SSRIs do this.) Therefore, if you're going to use such a combination, you should be monitored for elevated TCA levels. This is particularly important if you're going to be on nortriptyline, which has an inverted U-shaped dose-response curve: it becomes less effective when serum levels exceed 150 ng/mL or so (disclaimer: I may be misremembering the numbers here).
You're entering relatively uncharted territory, and I can't help but admire your courage. Godspeed.
-elizabeth
Posted by Elizabeth on June 1, 2001, at 0:33:46
In reply to Re: Tricyclics » Elizabeth, posted by Elizashae on May 31, 2001, at 21:29:05
> Any ideas of which MAOIs are tolerated better? What are some of the more popular ones? I don't know really much about them except a certain diet has to be followed. I feel better when I go to talk with my therapist if I have a bit of an idea what to ask about...and know a little myself..
The number of foods that need to be avoided is much smaller than was once thought. A group of researchers at the University of Toronto has made some headway in determining what foods may interact dangerously with MAOIs. The main foods that pose a risk are the most aged cheeses (e.g., cheddar, Stilton, bleu); tap/draft beer and a couple of obscure foreign (Irish and Czech) bottled beers; fava (broad) bean pods; banana peels; and certain yeast or protein extracts such as Bovril and Marmite.
As a rule, protein-containing foods (e.g., meat, fish, milk, yogurt) should be avoided if they are aged or possibly spoiled, or if they may have been stored improperly.
There is still controversy regarding the safety of soy products (soy sauce, tofu, soy milk, etc.) and sauerkraut; until the issue is resolved, these foods are probably best avoided as well. Because liver seems to have been associated with a number of reactions, I believe it should be avoided as well. Certain foods from the Far East, notably miso soup, have also been implicated in interactions; this, too, is up in the air.
There are also some drugs that need to be avoided, including serotonergic antidepressants (SSRIs, clomipramine, Effexor, etc.), the opioid analgesics Demerol (meperidine or pethidine) and Ultram (tramadol), and certain over-the-counter cough and cold or diet drugs (those containing psuedoephedrine, ephedrine (or "ma huang"), phenylpropanolamine, or dextromethorphan). It is risky to combine MAOIs with amphetamine-like stimulants, but some people have done it successfully with careful monitoring.
This list isn't exhaustive but it covers the basics. If you have a question about a particular food, I may be able to answer it. Here are some references:
Shulman KI, Walker SE. Refining the MAOI diet: tyramine content of pizzas and soy products. J Clin Psychiatry. 1999 Mar;60(3):191-3.
Shulman KI, Tailor SA, Walker SE, Gardner DM. Tap (draft) beer and monoamine oxidase inhibitor dietary restrictions. Can J Psychiatry. 1997 Apr;42(3):310-2.
Walker SE, Shulman KI, Tailor SA, Gardner D. Tyramine content of previously restricted foods in monoamine oxidase inhibitor diets. J Clin Psychopharmacol. 1996 Oct;16(5):383-8.
Gardner DM, Shulman KI, Walker SE, Tailor SA. The making of a user friendly MAOI diet. J Clin Psychiatry. 1996 Mar;57(3):99-104.
Sullivan EA, Shulman KI. Diet and monoamine oxidase inhibitors: a re-examination. Can J Psychiatry. 1984 Dec;29(8):707-11.
You should also know that, even if you do accidentally ingest something you shouldn't have, the resulting hypertension is easily detected and completely treatable.
There are three irreversible, nonselective MAOIs that are in common use: Nardil (phenelzine), Marplan (isocarboxazid), and Parnate (tranylcypromine).
The most common side effects of all three of these MAOIs are orthostatic hypotension (lowered blood pressure upon standing up, especially when you get up too quickly or when you first get up in the morning) and insomnia (I experienced this as a reduced *need* for sleep -- I slept little but did not feel tired).
They can also cause anticholinergic side effects such as constipation, tachycardia (rapid heartbeat), and dry mouth. Anticholinergic side effects of MAOIs (if any) tend to be milder than those associated with the tricyclics, and are mainly annoying rather than dangerous.
MAOIs suppress REM sleep (this is also believed to be an aminergic/anticholinergic effect), resulting in decreased dream recollection. For this reason they have been used in the treatment of narcolepsy, posttraumatic stress disorder, and REM sleep parasomnias as well as depression.
They can cause sexual dysfunction (similar to that seen with SSRIs); Nardil seems to be more likely to cause these side effects than does Parnate.
As with all antidepressants, MAOIs can trigger mania; it is believed that they are less likely to induce mania than are tricyclics, and that MAOI-induced mania is less likely to be dysphoric than TCA-induced mania.
Abrupt discontinuation of MAOIs can result in severe depression, REM sleep rebound, and even psychosis, and should be avoided if at all possible.
Nardil and Marplan (the hydrazine-type MAOIs) have similar side effect and safety profiles; Nardil is the better studied of the two. In addition to the side effects listed above, they are known for causing weight gain and/or carbohydrate cravings. They are considered to be contraindicated for diabetics. They carry a minute risk of liver toxicity, so patients with compromised liver function should use them with caution if at all.
Parnate is chemically similar to amphetamine (as are several antidepressants of various classes). Unsurprisingly, it can be very activating, especially at first. There is also a possibility of spontaneous elevations in blood pressure; these are usually not great enough to pose a risk, but individuals with preexisting hypertension should use Parnate only with extreme caution.
I hope this information reassures you. All drugs have risks, but the risks of MAOIs are often far less than the risks of untreated or undertreated depression.
-elizabeth
Posted by Shirley 2 on June 1, 2001, at 6:18:01
In reply to Re: Tricyclics » Shirley 2, posted by Elizabeth on May 31, 2001, at 23:10:33
Elizabeth,
Thank you so much for responding.
As an FYI, out of desperation yesterday, I tried St. John's Wort. A few years ago, I wouldn't have been caught dead with this stuff. But I figured I had nothing to lose except $6.00.
Well, guess what, my mood improved immensely, and I had more motivation and concentration than I have had in a long time. Had the best sleep I have had in quite a while.
I then read that the chemical action is similar to Wellbutrin and Effexor. I was on Effexor a few years ago and at 350mg, it was perfect. But I couldn't sleep in spite of being on three medications at night.
If St. John's Wort fizzles out for any reason, I am wondering if Effexor might not be worth another try since my depression isn't as severe? Or give Wellbutrin a shot since my psychiatrist wasn't as opposed to it as the tricyclics? I don't think my psychiatrist would be caught dead combining SSRI's and tricyclics.
Yes, I have checked to make sure that St. John's Wort doesn't interact negatively with my other meds and so far, I have not seen Remeron or Adderall on any list. But I know that it might be premature.
My depression has been characterized by problems with sleeping - I fall asleep but the quality is lousy, negative thinking even though there is no reason to feel that way, very short tempered, anxiety. Does that answer your question?
Thanks again.
Shirley
Posted by SLS on June 1, 2001, at 8:34:32
In reply to Re: Tricyclics » Shirley 2, posted by Elizabeth on May 31, 2001, at 23:10:33
Hi folks.
> A caveat about the combination approach: because Luvox is an inhibitor of several hepatic enzymes involved in TCA metabolism (cytochromes P450 1A2, 3A4, and 2D6 in particular), it can alter serum levels of tricyclics and their metabolites. (Most of the SSRIs do this.) Therefore, if you're going to use such a combination, you should be monitored for elevated TCA levels. This is particularly important if you're going to be on nortriptyline, which has an inverted U-shaped dose-response curve: it becomes less effective when serum levels exceed 150 ng/mL or so (disclaimer: I may be misremembering the numbers here).
(you are not)
The accepted therapeutic window for nortriptyline is 50 - 150 ng/ml. For me, 75mg is too little and 125mg is too much. Guess what? 100mg is just right. At 100mg/day, my blood level of nortriptyline is 123ng/ml.
> You're entering relatively uncharted territory, and I can't help but admire your courage. Godspeed.
I once combined Paxil and desipramine. I may be misremembering the numbers here ;-), but I believe I had to cut my dosage of desipramine in half. Both drugs compete for CYP450 D26. I think Luvox is metabolized mainly via 3A4, so I don't know how it would affect nortriptyline blood levels. I can't guess what dosage to make as the first target, but I wouldn't take more than 50mg before getting the first blood test. I found the combination of Paxil and desipramine to be quite safe and without any adverse side effects other than those that are carried by both drugs. I don't remember that anticholinergic side effects were exaggerated, at least after a few weeks of treatment. I doubt this would be a concern with Luvox, anyway. It is much less anticholinergic than Paxil.
I am also curious about the choice of Luvox (fluvoxamine). It seems to be superior to other SSRIs for treating OCD, but I don't know how it compares as an antidepressant. Of course, depression is the condition that this drug was screened and developed for. I wonder if the drug company opted to seek FDA approval for the treatment of OCD because it felt that it had a better chance of getting it approved for an indication that has fewer drugs available.
How do you think Luvox compares to the other SSRIs in terms of efficacy as an antidepressant?
- Scott
Posted by Elizabeth on June 1, 2001, at 13:39:21
In reply to Re: Tricyclics/St, John's Wort » Elizabeth, posted by Shirley 2 on June 1, 2001, at 6:18:01
> Elizabeth,
>
> Thank you so much for responding.You are very welcome.
> As an FYI, out of desperation yesterday, I tried St. John's Wort.
Cool. It's supposed to be effective. What brand did you use?
> Well, guess what, my mood improved immensely, and I had more motivation and concentration than I have had in a long time. Had the best sleep I have had in quite a while.
That's *very* interesting. SJW is *not* supposed to work immediately. Weird -- and terrific. :-)
> If St. John's Wort fizzles out for any reason, I am wondering if Effexor might not be worth another try since my depression isn't as severe? Or give Wellbutrin a shot since my psychiatrist wasn't as opposed to it as the tricyclics?
I'd go with something new rather than something that you tried and got no result from at all. But I hope that the SJW keeps working so you don't have to worry about it.
> I don't think my psychiatrist would be caught dead combining SSRI's and tricyclics.
Nonsense -- it was a very popular combination before the other new drugs (Effexor, Serzone, Remeron, etc.) started popping up.
> My depression has been characterized by problems with sleeping - I fall asleep but the quality is lousy, negative thinking even though there is no reason to feel that way, very short tempered, anxiety. Does that answer your question?
Yes...what about eating? Are you pretty much depressed all the time, or do you sometimes feel better, and if so, is there a pattern to when you feel better?
> Thanks again.
You're welcome again :)
-elizabeth
Posted by Elizabeth on June 1, 2001, at 14:01:18
In reply to Re: Tricyclics, posted by SLS on June 1, 2001, at 8:34:32
> > You're entering relatively uncharted territory, and I can't help but admire your courage. Godspeed.
>
> I once combined Paxil and desipramine.To clarify: the "uncharted territory" remark was in regard to Shirley's right-hemisphere neurological deficit which may be associated with her depression.
> I may be misremembering the numbers here ;-), but I believe I had to cut my dosage of desipramine in half. Both drugs compete for CYP450 D26. I think Luvox is metabolized mainly via 3A4, so I don't know how it would affect nortriptyline blood levels.
Luvox inhibits multiple cytochromes. Also, TCAs have multiple metabolic pathways: they undergo demethylation (e.g., imipramine - > desipramine) aromatic hydroxylation (e.g., imipramine - > 2-hydroxyimipramine; desipramine - > 2-hydroxydesipramine), and desalkylation (e.g., imipramine - > iminodibenzyl), and the hydroxy- metabolites undergo conjugation (e.g., 2-hydroxyimipramine - > 2-OH-imipramine-glucuronide) and desalkylation.
> I can't guess what dosage to make as the first target, but I wouldn't take more than 50mg before getting the first blood test.
Yeah, that's about standard I think. When I was a teenager they tried to test Prozac + desipramine on me (starting at 50 mg desipramine) but
(Typical of the incompetence of the MIT med center, they didn't do any blood testing.) I kept forgetting to take them, though, and eventually gave up on it altogether.> I found the combination of Paxil and desipramine to be quite safe and without any adverse side effects other than those that are carried by both drugs. I don't remember that anticholinergic side effects were exaggerated, at least after a few weeks of treatment. I doubt this would be a concern with Luvox, anyway. It is much less anticholinergic than Paxil.
SSRIs in general aren't supposed to be anticholinergic at clinical doses! They might have indirect anticholinergic effects, though. I don't know anything about the interactions of the 5-HT and ACh systems.
> I am also curious about the choice of Luvox (fluvoxamine). It seems to be superior to other SSRIs for treating OCD, but I don't know how it compares as an antidepressant.
I don't think it's really superior to other SSRIs for OCD; I'd bet that's just a marketing thing. It's a fine AD; it was used in Europe even before Prozac came out.
> Of course, depression is the condition that this drug was screened and developed for. I wonder if the drug company opted to seek FDA approval for the treatment of OCD because it felt that it had a better chance of getting it approved for an indication that has fewer drugs available.
Exactly.
> How do you think Luvox compares to the other SSRIs in terms of efficacy as an antidepressant?
I think they're all about the same (YMMV). But Paxil seems to be the nastiest in terms of side effects. (Luvox has a rep for causing nausea a little bit more than the rest, tho'.)
-elizabeth
Posted by Shirley 2 on June 1, 2001, at 17:33:34
In reply to Re: Tricyclics/St, John's Wort » Shirley 2, posted by Elizabeth on June 1, 2001, at 13:39:21
Elizabeth,
The brand I bought is from Nature's Resource. At first, I thought that maybe I should make sure I use one that has received a good rating but why mess with success? I also like the fact that they are in 150mg capsules because of my extreme sensitivity to meds.
The effect wasn't as dramatic today but I thought that might happen so I wasn't disappointed. Because I felt so good, I didn't take it with my morning Adderall Dose but I sure felt the effects of not taking it mid morning. A little scary but heck, I got off Effexor so how much worse can it be if things don't go well?
I am wondering if I responded quickly because the Prozac has only been completely out of my system since May 17? But I swear I remember responding quickly to Paxil when I hadn't been taking AD's so I strongly believe in the John L theory that there are medications that people can respond quickly to.
Anyway, motivation continues to be excellent. While surfing the web, I have been cleaning my apartment without effort which hasn't happened in quite awhile. It's almost like I don't know what to do with this new brain and I fear there will be a poopout just like there was when the Prozac and Adderall were working so well and then quit after my period started.
About my symptoms, that's tough to answer but let me take a shot. When I am depressed, if I haven't slept, I feel lousy all day. Eating is pretty normal with a slight excess. It doesn't get too out of hand because due to having ativan being prescribed on a PRN Basis when I had the monthly agiation, it will stop my mood from sliding momentarily. If I haven't slept, I think I feel better in the morning with my mood worsening during the day. It might be good to keep a journal when this happens.
Elizabeth, thanks again, I have learned so much from you.
Shirley
Posted by SLS on June 2, 2001, at 17:07:13
In reply to MAOIs » Elizashae, posted by Elizabeth on June 1, 2001, at 0:33:46
Hi.
I checked out one of Shulman's more recent abstracts of those you so kindly listed (sincere - no sarcasm, just in case it sounded that way). I found in it a statement that I find dubious, and emphasised it by separating it from the surrounding text using asterisks.
------------------------------------------------
: J Clin Psychiatry 1999 Mar;60(3):191-3Comment in: J Clin Psychiatry. 2000 Feb;61(2):145-6
Refining the MAOI diet: tyramine content of pizzas and soy products.
Shulman KI, Walker SE.
Department of Psychiatry, University of Toronto, Sunnybrook Health Science
Centre, Ontario, Canada.BACKGROUND: Continuous refinement of the monoamine oxidase inhibitor
(MAOI) diet has resulted in much reduced and simplified recommendations
that attempt to balance safety and practicality. In the spirit of
evidence-based practice, dietary restrictions should be based on carefully
documented case reports and valid tyramine analyses. Residual concerns
have focused on combination foods such as pizza and a variety of soy
products. We determined the tyramine content of pizzas and a variety of
soy products in order to refine dietary recommendations for use with
MAOIs. METHOD: High-pressure liquid chromatography analysis of tyramine
content was performed on a variety of pizzas, soy sauces, and other
soybean products. A tyramine level of 6 mg or less was considered safe.
RESULTS: No significant tyramine levels were found in any of the pizzas,
*** including those with double pepperoni ***and double cheese. Marked
variability was found in soy products, including clinically significant
tyramine levels in tofu when stored for a week and high tyramine content
in one of the soy sauces. CONCLUSION: Pizzas from large chain commercial
outlets are safe for consumption with MAOIs. However, caution must be
exercised if ordering pizzas from smaller outlets or gourmet pizzas known
to contain aged cheeses. All soybean products should be avoided,
especially soy sauce and tofu. Individualized counseling and continuous
surveillance of compliance are still essential.PMID: 10192596 [PubMed - indexed for MEDLINE]
--------------------------------------------------
Here is a good example of how elusive this whole MAOI diet thing is. I suffered a robust MAOI-food reaction when I accidentally ate one and one-half (1½) thin slices of pepperoni at the end of a slice of pizza. I was taking Parnate 60mg combined with desipramine 125mg at the time. I had been eating pizza from this same shop for at least six months while on this drug combination. Previously, I had always made sure that any pizza with toppings not include pepperoni or sausage. I consumed this pepperoni with an empty stomach. Within five minutes I suffered a severe headache that manifest as a pounding in the back of my head at the base of my skull (occipital). This pounding was more pronounced while sitting than while standing. I was at work on a busy Saturday and was reluctant to ask someone to drive me to the hospital or call an ambulance. I decided to ride it out. Probably stupid, but I needed the job. I had to remain standing for about 45 minutes before it dissipated. It was the real thing. My doctor explained very explicitly what it would feel like. I had never had such a headache previously nor have I had one since. I continued to eat pizza from this shop.I used the term "MAOI-food reaction" because it might not have been dependent exclusively upon tyramine. I have vague recollections that there are other mechanisms by which foodstuffs can precipitate a reaction other than through the ingestion of tyramine. My advice to anyone considering ordering a pepperoni pizza for personal consumption is to remove the pepperoni before eating it. :-) I also stay away from pastrami and corned-beef.
I eat cheese pizza or pizza topped with vegetables all of the time while taking MAOIs. I have also eaten sausage on occasion without having a reaction. Cheap processed American, mozzarella and ricotta cheeses are fine, but I would be careful with Parmesan, a cheese sometimes added to the pizza sauce. I pretty much roll the dice with that one. I stay away from "gourmet" and expensive imported cheeses. I am suspicious of those that I find hanging from the window curing.
I don't think measuring the tyramine content of food with the methods currently in use is sufficient to predict the potential for a food to elicit the "cheese reaction".
- Scott
Posted by Elizabeth on June 3, 2001, at 21:18:38
In reply to Re: MAOIs, posted by SLS on June 2, 2001, at 17:07:13
> *** including those with double pepperoni ***
Yup. It's bizarre. I think it's because the pepperoni on pizzas from chain restaurants is so, you know, lame. < g > There were also other factors that might have contributed in your case.
> Here is a good example of how elusive this whole MAOI diet thing is.
It is elusive. That's why you have to consider *both* measured tyramine content in foods and well-documented case reports. (And be careful not to get all worked up over badly-documented case reports!)
> I suffered a robust MAOI-food reaction when I accidentally ate one and one-half (1½) thin slices of pepperoni at the end of a slice of pizza. I was taking Parnate 60mg combined with desipramine 125mg at the time.
Some thoughts:
* Where did the pizza slice come from?
* Parnate potentiates tyramine at clinically used doses to a much greater degree than other MAOIs, and 60 mg is a fairly high dose.
* Although MAOI-TCA combinations are generally safe (exception: clomipramine), desipramine is a pretty selective NE reuptake inhibitor, and 125 mg is within the therapeutic dose range (for normal metabolisers) even by itself
* Although by your description you clearly had an elevation in blood pressure, it's not known how high your blood pressure got. Different people have different levels of sensitivity to BP elevation.So there were multiple contributing factors, and we don't know how bad the reaction was (although I'm assuming you didn't suffer any major hemorrhaging).
> I used the term "MAOI-food reaction" because it might not have been dependent exclusively upon tyramine.
You're right. There are other biogenic amines that have pressor effects. Fava bean pods, for example, contain DOPA, a direct precursor to dopamine. It's possible that other amines, such as putrescine and cadaverine (I swear I didn't make those names up!), occur in certain meats in the presence of certain bacteria.
BTW, does anyone know of *any* MAOI-associated reaction to a mozzerella cheese pizza (no meats or other cheeses)? I don't.
-elizabeth
Posted by SLS on June 4, 2001, at 9:58:36
In reply to Re: MAOIs » SLS, posted by Elizabeth on June 3, 2001, at 21:18:38
> > *** including those with double pepperoni ***
> Yup. It's bizarre. I think it's because the pepperoni on pizzas from chain restaurants is so, you know, lame. < g > There were also other factors that might have contributed in your case.
> > Here is a good example of how elusive this whole MAOI diet thing is.
> It is elusive. That's why you have to consider *both* measured tyramine content in foods and well-documented case reports. (And be careful not to get all worked up over badly-documented case reports!)
> > I suffered a robust MAOI-food reaction when I accidentally ate one and one-half (1½) thin slices of pepperoni at the end of a slice of pizza. I was taking Parnate 60mg combined with desipramine 125mg at the time.
> Some thoughts:
>
> * Where did the pizza slice come from?It was a local pizzaria, not part of any chain or franchise.
> * Parnate potentiates tyramine at clinically used doses to a much greater degree than other MAOIs, and 60 mg is a fairly high dose.
Why do you suppose that is? Are Parnate or its metabolites amphetamine-like? Are they catecholamine releasers?
> * Although MAOI-TCA combinations are generally safe (exception: clomipramine), desipramine is a pretty selective NE reuptake inhibitor, and 125 mg is within the therapeutic dose range (for normal metabolisers) even by itself
I am not sure if I am a rapid-metabolizer of desipramine or not. When I was being treated by W. Harrison and F. Quitkin at Columbia in 1982, they had me take 450mg of imipramine, claiming that my blood work indicated that this was necessary to achieve a therapeutic level. However, my blood level of nortriptyline is towards the upper end of its therapeutic level when taking a modest dosage of 100mg. I guess the two tricyclics follow different routes of elimination, or perhaps the assays used in 1982 were unreliable. I have taken a combination of Parnate 150mg and desipramine 300mg (along with Lamictal). I ate plenty of pizza during this period of time. In fact, I had no problem with pizza when I was taking Parnate 120mg + desipramine 200mg + Dexedrine 15mg + Synthroid.
> * Although by your description you clearly had an elevation in blood pressure, it's not known how high your blood pressure got. Different people have different levels of sensitivity to BP elevation.
I guess you are a good example of that.
You'll have to forgive my fuzzy memory, but I think I encountered something that indicated that the pounding headache produced during the MAOI-food reaction is not exclusive or dependant upon a significant rise in blood pressure. I don't know. I would think that for me it was, given that the magnitude of the throbbing pain changed with posture.
> So there were multiple contributing factors, and we don't know how bad the reaction was (although I'm assuming you didn't suffer any major hemorrhaging).
Well, I don't know. I did see red when I became angry at myself for being so careless.
> > I used the term "MAOI-food reaction" because it might not have been dependent exclusively upon tyramine.
> You're right. There are other biogenic amines that have pressor effects. Fava bean pods, for example, contain DOPA, a direct precursor to dopamine. It's possible that other amines, such as putrescine and cadaverine (I swear I didn't make those names up!), occur in certain meats in the presence of certain bacteria.
LOL
That explains it. I am surely brain-dead.
:-)
- Scott
Posted by Elizabeth on June 4, 2001, at 16:55:38
In reply to Re: MAOIs » Elizabeth, posted by SLS on June 4, 2001, at 9:58:36
> > * Parnate potentiates tyramine at clinically used doses to a much greater degree than other MAOIs, and 60 mg is a fairly high dose.
>
> Why do you suppose that is? Are Parnate or its metabolites amphetamine-like? Are they catecholamine releasers?Parnate itself is *most* amphetamine-like. (If it hadn't been grandfathered out, Parnate would definitely be a Schedule II Controlled Substance under the Analogue Act.)
As for metabolites -- nobody knows. It was hypothesised at one point that Parnate was metabolised into amphetamine or methamphetamine, but this has pretty much been disproven. We are left with the possibility that Parnate has catecholamine-releasing activity (or has a metabolite with such activity). Unfortunately nobody is interested in doing new research on old drugs.
> I am not sure if I am a rapid-metabolizer of desipramine or not. When I was being treated by W. Harrison and F. Quitkin at Columbia in 1982, they had me take 450mg of imipramine, claiming that my blood work indicated that this was necessary to achieve a therapeutic level. However, my blood level of nortriptyline is towards the upper end of its therapeutic level when taking a modest dosage of 100mg. I guess the two tricyclics follow different routes of elimination, or perhaps the assays used in 1982 were unreliable.
I'm guessing it's the second one. Both are secondary amine TCAs, and they have similar metabolic pathways.
> I have taken a combination of Parnate 150mg and desipramine 300mg (along with Lamictal). I ate plenty of pizza during this period of time. In fact, I had no problem with pizza when I was taking Parnate 120mg + desipramine 200mg + Dexedrine 15mg + Synthroid.
Pepperoni, or just plain? Plain cheese pizza is pretty certain to be harmless, as long as it's mozzarella and not some weird cheese like feta. (Sprinkles of parmesan, BTW, are probably ok simply because the amount is so small.)
> > Different people have different levels of sensitivity to BP elevation.
>
> I guess you are a good example of that.I dunno. I am pretty good at guessing what my blood pressure is at any given moment, but that's most likely a result of practise. I don't think that I feel worse when my BP is too high than others do. The one time I had a serious reaction (pulmonary hemorrhage, max BP measured 240/140), I definitely had a bad headache, but it wasn't so bad that I felt a need for treatment for the pain itself. (Treatment for the hypertension would have been nice, but there's the MIT medical centre for you.)
> You'll have to forgive my fuzzy memory, but I think I encountered something that indicated that the pounding headache produced during the MAOI-food reaction is not exclusive or dependant upon a significant rise in blood pressure.
I'm not in any position to be criticising people for fuzzy memory. But anyway, I don't recall reading anything like that. It is true that people who are already mildly hypertensive or hypotensive may respond differentaly to elevated BPs than normotensive people. (Clumsy sentence -- hope it made sense anyway.)
> I don't know. I would think that for me it was, given that the magnitude of the throbbing pain changed with posture.
Postural changes in BP are normal for people on MAOIs, especially high-dose MAOIs.
> Well, I don't know. I did see red when I became angry at myself for being so careless.
< g >
> That explains it. I am surely brain-dead.
That's nothing. I'm drain-bead!
-elizabeth
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.