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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by UgottaHaveHope on February 23, 2007, at 13:05:20
I've seen countless lists of MAOI diet restrictions, but never one on MAOI drug interactions, which I needed this past week with a viral infection. Is there anything out there small and condensed? Thanks, Michael
Posted by ttee on February 23, 2007, at 14:04:32
In reply to Master list of drugs to avoid while on MAOIs?, posted by UgottaHaveHope on February 23, 2007, at 13:05:20
> I've seen countless lists of MAOI diet restrictions, but never one on MAOI drug interactions, which I needed this past week with a viral infection. Is there anything out there small and condensed? Thanks, Michael
I think there is a nice summary of the drugs you can not take with a MAOI on the EMSAM web site. Since EMSAM is new, this is a current list with drug names that are in use today, not 50 years ago when the older MAOI's came out.
Posted by laima on February 23, 2007, at 14:42:09
In reply to Master list of drugs to avoid while on MAOIs?, posted by UgottaHaveHope on February 23, 2007, at 13:05:20
My doctor gave me a couple xeroxed pages right out of one of his own books. (Unfortunately, I don't know the name of the book or publication date- but I reckon it's up to date, as he tends to always be very up to date.) Here's a quick summary:
ANTIASTHMATICS: Oxtriphylline, Alluterol- "Combined with phenelzine, may lead to apprehension, tachycardia, and palpitations."
Isoetharine- "Combined with phenelzine, may lead to hypomania (one case report)."
ANTIBIOTICS: Sulfisoxazole- "Combined with phenelzine, may lead to ataxia, vertigo, tinnitus, muscle pain, and paresthesias."
ANTICHOLINERGICS: Atropine, Scopolamine (potentiated with maois)
ANTIDEPRESSENTS: "Danger of this combo. may be exaggerated, but several reports indicate combined therapy may lead to potentially fatal interaction. Commonly described symptoms: diaphoresis, tremor, fever, confusion, agitation, dyspnea, hallucinations, hypotension, convulsions, coma, and death. Combination may be safe when certain guidelines are followed: start both drugs simultaneously in lower than usual doses, only viua the oral route."
"Amitriptyline, trimipramine, nortriptyline: Appear safest."
"Imipramine, desipramine, clomipramine: Should not be used."
Serotonergic Antidepressents: "Fluoxitine should be avoided, but there is a case report of uncomplicated use of trazadone and phenelzine."
ANTIHYPERTENSIVES: Reserpine ("autonomic excitation, delirious agitation, hypertension"), clonidine ("possibly hypertensive reaction, but clinical experience is lacking"), propranolol ("low doses have been safely used", higher doses= possible hypertensive reactions), thiazides: ("Hypotensive action potentiated."), Guanethidine: ("Antihypertensive effects blocked.")
ATRACURIUM: (a (ie, one) case report of hypertension over just minutes)
BARBITUATES: "Tranylcypromine may prolong barbituate-induced hypnosis"
BENZODIAZEPINES: "One group reports a disinhibited state"..."This combo widely used without serious interactions."
BUSPIRONE: "Manufacturer reports four known cases of elevated blood pressure with this combination. However, many patients taking this combination do not experience blood pressure alterations".
ETHANOL: "Alchoholic beverages with high typramine content..."
GINSENG: "May cause headache, temulousness, or hypomanic symptoms in patients taking phenelzine."
HYPOGLYCEMIC AGENTS (ie, insulin, sulfonylurea hypoglycemics): "Enhanced hypoglycemic responses have been reported."
LITHIUM: says, "The combination may be useful in treatment of refractory depression."
NARCOTIC ANALGESICS: meperidine, dextromethorphan--basically says "hypotension and hypertension"; m. can also cause "excitement, diaphoresis, rigidity, hyper-reflexia, hyperthermia, tachycardia, coma, and death". d. "may also cause a hypertensive, hypermetabolic reaction with maois".
Morphine, Codeine, Fentanyl: "Less likely to interact when used in reduced dosages."
NEUROLEPTICS: "The combination may lead to enhanced anticholinergic side effects and extrapyramidal symptoms. Clinical use includes protection against MAOI-tyramine hypertensive crisis and treatment of anhedonic schizophrenics."
PROTEIN DIETARY SUPPLEMENT: "One case report describes a patient on ..phenelzine who experienced a hypertensive crisis...product...contained yeast, yeast spirulina, or yeast extract."
SUCCINYLCHOLINE: "Phenelzine may reduce cholinesterase levels and lead to prolonged apnea during ECT or surgical procedures. Other MAOIs do not appear to have this effect."
SYMPATHOMIMETICS: Indirect, direct- "...amines may interact with maois", "indirect" are "more dangerous". "Concomitant use may lead to hypertension, agitation, fever, convulsion, coma. However, recent case reports suggest that dextroamphetamine, methylphenidate, and phentermine may have a role when coprescribed with an MAOI in treatment-resistant depressions."
TRYPTOPHAN: "Occcasionally used as a hypnotic in patients taking MAOIs or to potentiate the MAOI antidepressent effect. It may cause delirium, myoclonus, or hypomania."
VERAPAMIL: "...blocks phenelzine-induced hypomania."
In addition, in conversation, he told me novocane, ie at the dentist, can be a problem. Weird, huh?Phenelzyn- is that parnate? That one sure seems to have to most potential for interactions!
Posted by laima on February 23, 2007, at 14:50:23
In reply to Re: Master list of drugs to avoid while on MAOIs? » UgottaHaveHope, posted by laima on February 23, 2007, at 14:42:09
Some items from their list:"other medicines used to treat depression, including other MAOIS"
St. John's Wort
Demerol (meperidine), tramadol, methadone, propoxyphene
Tegretol (carbamazepine)
Trileptal (oxcarbazepine)
dextromethorphan (in many cold and flu meds)
Flexeril (cyclobenzaprine)
decongestants
Buspar (note what the report from doctor said of the risk, though)
over the counter diet/weight loss products
Posted by Phillipa on February 23, 2007, at 15:09:35
In reply to Re: few more from Emsam insert, posted by laima on February 23, 2007, at 14:50:23
Laima it's good to know people like you can help so quickly. Love Phillipa
Posted by djmmm on February 24, 2007, at 7:24:32
In reply to Re: few more from Emsam insert, posted by laima on February 23, 2007, at 14:50:23
>
> Some items from their list:
>
> "other medicines used to treat depression, including other MAOIS"
>
> St. John's Wort
>
> Demerol (meperidine), tramadol, methadone, propoxyphene
>
> Tegretol (carbamazepine)
>
> Trileptal (oxcarbazepine)
>
> dextromethorphan (in many cold and flu meds)
>
> Flexeril (cyclobenzaprine)
>
> decongestants
>
> Buspar (note what the report from doctor said of the risk, though)
>
> over the counter diet/weight loss products
>
>
>FWIW...I took Tegretol with Nardil, and didn't experience any problems.
Posted by laima on February 24, 2007, at 8:22:06
In reply to Re: few more from Emsam insert, posted by djmmm on February 24, 2007, at 7:24:32
Well, I noticed that Emsam's insert lists all kinds of meds to avoid, sans explanaitions or assessment of risk. Ie, I notice always, "no amphetamines". The pages that my doctor gave me seem to be far more nuanced, and give explanaitions, such as, "ONE adverse reaction reported", or, "risks exaggerated with this combo", or even, "might be a risk-evidence lacking". And - they note that amphetamines CAN be combined with MAOIs in some cases, and can be great augmentors. I've seens warnings on tryptophan bottles to never use with MAOI- but the pages my doctor gave me say something pretty different. Shoot, I wish I knew what book they are from. Some text for medical professionals. I asked him once, but was admonished to never take anything without asking him first!
Seems the risks roughly, loosly fall into a few categories: risk of hypo or hypertensive crisis, risk of seratonin syndrome, and risks reported by one patient here or there-so they end up on warning lists. No doubt amounts play a role often.
I don't have any doubt that you were safe in your combination!
Posted by laima on February 24, 2007, at 8:31:02
In reply to Re: few more from Emsam insert » djmmm, posted by laima on February 24, 2007, at 8:22:06
One more possibly dicey one: kava.
I've used it in the past, no problem. Just relaxing.
Recently I used it again, once, same brand. It started out relaxing, for several hours, then kicked into high stimulant gear for another several hours! It woke me up. I mean AGITATION. The only variable that had changed was I was on Emsam this time. Medline says something about how kava can enhance antidepressent effects of MAOIs- but doesn't say, "don't use this combo". It does say there (or somewhere similar) to ask your doctor if using psychotropic medication, and I sure wish I had. I erred.
Yes, I use adderall during day, but last 10mg dose is at 1pm, it peaks at 3hrs per the literature, and then effects fade off after about 5 hours. The half-life is 8-10 hours, I believe- and I took the kava at about 10pm, and got agitated by 2 or later. So I don't think adderall was the culprit factor.
Posted by Ken Blades on February 25, 2007, at 3:06:17
In reply to Re: Master list of drugs to avoid while on MAOIs? » UgottaHaveHope, posted by laima on February 23, 2007, at 14:42:09
>>>>>In addition, in conversation, he told me novocane, ie at the dentist, can be a problem. Weird, huh?<<<<
Novocaine[the common term for local anesthetic but
this one is not used much nowadays], and its
more commonly used younger brother lidocaine[brand name Xylocaine] can be of concern used on MAO inhibitor-dosed people. The dental forms of lidocaine[as well as others used in medicine]
contain epinephrine as a vasoconstrictor, keeping
the lidocaine 'in place' longer. Epinephrine is also a normal substance in the body, one that the
monoamine oxidase enzyme metabolizes. Without
that process, the epinephrine can precipitate
a hypertensive crisis.So you're supposed to tell the dentist that
you're on a MAO inhibitor[and hope to hell he
knows what that is!] before you get any local
anesthetic. You should probably mention the
epinephrine/MAO danger just to be safe.>>>>Phenelzyn- is that parnate? That one sure seems to have to most potential for interactions!<<<<
Phenelzine is NARDIL. Actually, from what I've
read, Parnate is more likely to precipitate
interactions. But I wouldn't be complacent
with either drug.Recently I had an upper GI endoscopy...I
had written my MAOI status on everything,
and even told it to one of the nurses.
When the M.D doing the endoscopy started
injecting something in the I.V., I asked
what it was...he said 'Demerol'..I yelled
'I'm on a MAOI!'...he pulled on the
syringe and removed what he had started
to inject...Next time...I'm writing 'TAKING PARNATE
-NO DEMEROL!' on my forehead
with a marker!Moral of the story...keep telling them you're on a MAOI. Better safe than sorry.
Most non-psychiatrists and non-anesthesiologists
these days don't seem to be too aware of MAOIs.
Posted by laima on February 25, 2007, at 8:58:15
In reply to Re: Master list of drugs to avoid while on MAOIs?, posted by Ken Blades on February 25, 2007, at 3:06:17
Thanks for the clarification about Phenelzyn being nardil, NOT parnate. I apologize for getting mixed up and posting an incorrect speculation- hope no one was confused or upset by it. And again, I don't know what book the pages came from, or if the pages were from a section about any PARTICULAR med, ie, is that why the extra emphasis on nardil? I too had an idea that parnate was the finickiest one. The only MAOI I've ever been prescribed is selegeline/Emsam, and my doctor quickly shuffled up those pages for me at the end of an appointment after I asked for specific info on drug interactions and what happens with them.
But yes- the dangers exist! I use Emsam myself, and am floored by how many medical personell and pharmacy staff, even three separate bona-fide pharmacists (not assistants- but real pharmacists), were unfamiliar with Emsam- ok- this was last summer- but also unfamiliar with selegeline??? I've had to spell it numerous times. I make a fuss about it and explicitly say, "It is an MAOI" whenever a situation arises.
I had an endoscopy- they used morphine- no problems-and made sure to check with psychiatrist in addition to hospital's anaesthetic people. Not sure if this was overkill, but I felt better this way. And no one involved minded or found it to be weird. "Better safe than sorry", they agreed. I mean, gastroenterologist who did my endoscopy was a perfectly competent one, but had to look up in her book about selegeline, had to have me spell it, didn't know it was an MAOI until I explained that- and if I hadn't fussed, I too might have ended up with a dangerous anaesthetic. Are MAOIs that uncommon?
When I mentioned to my psychiatrist that I'd be making some dental appointments soon, and that I was worried about the painkillers, I off-handedly said, "Well, at least novocaine will be alright" and he said "NO!!!!" And something about how it can act as something akin to a local stimulant (?? Not sure if I heard that right- sounds weird. Numb stimulant??) And since it's so local- how can it be trouble? Maybe the potential reaction isn't local? Thank goodness I mentioned it- I had been certain it would be fine. I'll by all means be careful with the dentist, but figured it couldn't hurt to clear things with the psychiatrist, too, just in case dentist isn't up on everything. But he said for the more major work I need, ie gums, I will probably have to go off Emsam for at least 2 weeks :( I'm quite anxious about that. I guess low dose morphine and relaxation tapes won't quite be enough.
Since when and why did they stop using novocane? I think my dentist is awsome and pretty with-it with her methods- and unless I'm mixed up, she uses novocane, (as well as nitrous for the truely squeemish.) And of course, relaxation tapes and all that business. I don't like novocane-or whatever those shots are- I'd be delighted to use an alternative.
Thanks again for all of your helpful information.
> >>>>>In addition, in conversation, he told me novocane, ie at the dentist, can be a problem. Weird, huh?<<<<
>
> Novocaine[the common term for local anesthetic but
> this one is not used much nowadays], and its
> more commonly used younger brother lidocaine[brand name Xylocaine] can be of concern used on MAO inhibitor-dosed people. The dental forms of lidocaine[as well as others used in medicine]
> contain epinephrine as a vasoconstrictor, keeping
> the lidocaine 'in place' longer. Epinephrine is also a normal substance in the body, one that the
> monoamine oxidase enzyme metabolizes. Without
> that process, the epinephrine can precipitate
> a hypertensive crisis.
>
> So you're supposed to tell the dentist that
> you're on a MAO inhibitor[and hope to hell he
> knows what that is!] before you get any local
> anesthetic. You should probably mention the
> epinephrine/MAO danger just to be safe.
>
> >>>>Phenelzyn- is that parnate? That one sure seems to have to most potential for interactions!<<<<
>
> Phenelzine is NARDIL. Actually, from what I've
> read, Parnate is more likely to precipitate
> interactions. But I wouldn't be complacent
> with either drug.
>
> Recently I had an upper GI endoscopy...I
> had written my MAOI status on everything,
> and even told it to one of the nurses.
> When the M.D doing the endoscopy started
> injecting something in the I.V., I asked
> what it was...he said 'Demerol'..I yelled
> 'I'm on a MAOI!'...he pulled on the
> syringe and removed what he had started
> to inject...
>
> Next time...I'm writing 'TAKING PARNATE
> -NO DEMEROL!' on my forehead
> with a marker!
>
> Moral of the story...keep telling them you're on a MAOI. Better safe than sorry.
>
> Most non-psychiatrists and non-anesthesiologists
> these days don't seem to be too aware of MAOIs.
>
>
Posted by Ken Blades on February 25, 2007, at 12:22:28
In reply to Re: Master list of drugs to avoid while on MAOIs? » Ken Blades, posted by laima on February 25, 2007, at 8:58:15
You're welcome :)
I'm sure nobody was bothered by anything; it's
easy to get mixed-up/confused...happens to me all the time.Even my psychiatrist didn't know about EMSAM
[this was last year[[?]] or so when it first
came out]; I brought a printout of a press
release from the manufacturer upon EMSAM's
availability. Maybe they didn't do a good
marketing campaign, sending sales reps to
the docs? I would have been willing to try
EMSAM if it didn't mean having to go off
Parnate and have to re-adjust to it if EMSAM
didn't work as well for me. Funny that the
pharmacists weren't familiar with it..but
if they didn't have any other customers
coming in to fill Rxs for it, I guess they
would be in the dark.I had Versed only for the endoscopy; why
they tend to use an narcotic with it I
don't know. This particular endoscopy
was done by the gastroenterologist who
is the endoscopy specialist, with two
nurses in the room. Evidently he hadn't
run into a MAOI patient before..and
this is a large teaching hospital!
The first endoscopy I had was by a
gastroenterologist and an anesthesiologist
was doing the I.V. drugs. I mentioned
the MAOI again while I was getting
'stuck', and this prompted a call from
the room to somewhere[the pharmacy?]
regarding what agents could be used
safely...they wanted to be sure even
Versed was safe[up until this time I
had never had an endoscopy or Versed].
So I got Versed alone and was fine.
It sure seems that MAOIs are not too
common, doesn't it? I mean, looking at
this board and the number of people on
MAOIs, you'd think they were pretty
common. I guess we're actually a
small percentage of the whole
psychopharmacology crowd.As I said, there is the common use of
the word 'novocaine' to represent ALL
local anesthetics because that is the
name that the public understands...if
they used the words Xylocaine or lidocaine,
they'd probably get 'what's that?'
from everyone. It's like using 'Crisco'
to represent all hydrogenated vegetable
shortenings....no explanation necessary.Not to say no one uses Novocain[e] anymore,
but its use has been overwhelmingly supplanted
by Xylocaine/lidocaine. Novocaine is over
100 years old....lidocaine is about 50 years old lol. Novocaine by itself has vasoconstrictor
properties, so you wouldn't necessarily need
epinephrine added, but one of its breakdown
products caused a problem in some people.
Lidocaine is faster and longer acting, and
doesn't cause the problem mentioned above.
When you see your dentist the next time,
ask her to show you the bottle that the
local anesthetic comes from...you'll see if
it's novocaine[procaine] or lidocaine...and if it
contains epinephrine. Why not ask her
if she can use lidocaine without epinephrine
when you have your gum surgery, since lidocaine
itself is not a problem. She would probably have
to reinject you since it would wear off faster, but it would be easier on you rather than to have
to go off your EMSAM.I hate dental local anesthetic injections too..
especially the DEEP ones I've had when having impacted wisdom teeth removed. I had nitrous before I had the injections the last time...weird feeling that nitrous!
Posted by platinumbride on February 26, 2007, at 20:06:20
In reply to Master list of drugs to avoid while on MAOIs?, posted by UgottaHaveHope on February 23, 2007, at 13:05:20
> I've seen countless lists of MAOI diet restrictions, but never one on MAOI drug interactions, which I needed this past week with a viral infection. Is there anything out there small and condensed? Thanks, Michael
Michael,
This is weird and awkward, but I think I had a bit of a hypertensive crisis from Preparation-H!!!! I missed the warning that said do not take with some antidepressants.
It wasn't a bad one. I took cardura which is what my doc gave me) and went to sleep. The headache was the worst part.
Caveat: Always read labels!!!
Diane
Posted by Ken Blades on February 27, 2007, at 1:36:02
In reply to Re: Master list of drugs to avoid while on MAOIs?, posted by platinumbride on February 26, 2007, at 20:06:20
Diane~
Who'da thunk....Preparation H contains
Phenylephrine HCl,an alpha-adrenergic sympathomimetic amine, used as a vasoconstrictor...SHRINK, SHRINK, SHRINK [it's Neo-Synephrine,the nose drops]...."Monoamine oxidase (MAO) inhibitors should not be used with phenylephrine because of a pronounced pressor effect."
Posted by platinumbride on February 27, 2007, at 12:40:02
In reply to Re: Master list of drugs to avoid while on MAOIs? » platinumbride, posted by Ken Blades on February 27, 2007, at 1:36:02
> Diane~
>
> Who'da thunk....Preparation H contains
> Phenylephrine HCl,an alpha-adrenergic sympathomimetic amine, used as a vasoconstrictor...SHRINK, SHRINK, SHRINK [it's Neo-Synephrine,the nose drops]....
>
> "Monoamine oxidase (MAO) inhibitors should not be used with phenylephrine because of a pronounced pressor effect."
>
> I have no clue, but I think the shrinking part of it would be it.Weird.....
Diane
Posted by Ken Blades on February 27, 2007, at 12:49:03
In reply to Re: Master list of drugs to avoid while on MAOIs?, posted by platinumbride on February 27, 2007, at 12:40:02
Diane~
They really should have mentioned MAOI on the
package specifically along with 'antidepressants'...
it would have clarified things a lot,
and spared you an episode.
This is the end of the thread.
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