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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by HSP Woman on February 15, 2008, at 19:46:45
Hi everyone,
After reading hundreds of posts about Emsam, I am making my first query.
Today is Day 6 on the 6mg Emsam patch.
My first question is: Has anyone started or investigated allergy immunotherapy shots while on a MAOi?
I met with my allergist MD this afternoon, and he was completely clueless.
He had no idea why MAOi's and immunotherapy are contraindicated. I can't seem to find any data in primary literature either.
I would be so grateful to hear from anyone about this. I believe the warning must come from the potential need for epi-pen in case of anaphylactic shock? Not sure if I should start immunotherapy after all. Especially since the Emsam is going so well.
Second question: Is anyone taking Albuterol or Xopenex and Emsam (or another MAOi)?
My pharmacist is having a hard time saying Albuterol and Emsam okay to take together. Allergist MD said okay, but I don't think he has a single patient other than me taking both. He's switched me to Xopenex which he says is a milder form of Albuterol -- all the good stuff minus the isomer that raises heart rate. Anyone familiar with Emsam and Xopenex?
Any insight would be greatly appreciated.
Posted by dbc on February 15, 2008, at 22:05:17
In reply to Emsam, Allergy Shots, Albuterol, Xopenex, posted by HSP Woman on February 15, 2008, at 19:46:45
Im not sure if those are questions you should ask the internet. Those are possibly life threatening things that i wouldnt want to answer incase i hurt someone or did worse.
Posted by HSP Woman on February 16, 2008, at 2:18:46
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex, posted by dbc on February 15, 2008, at 22:05:17
So I can assume you are not taking asthma meds and Emsam?
But, in fact, I think this is the perfect place to ask such questions.
Just look around at the other posts... This wonderful site is full of eager to learn individuals looking for advice from peers, not from doctors.
Thank you, however, for your concern.
Posted by Phillipa on February 16, 2008, at 11:37:51
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex, posted by HSP Woman on February 16, 2008, at 2:18:46
I feel the problem may be that of what the earlier poster said doesn't want to give bad advise. I feel either call a few pharmacists or your pdoc or ask him if he could call another pdoc that has more experience. I wonder if med checker might help. Type that in on google search and the rest on the site is kind of self explanatory. Let us know what you find. Phillipa
Posted by Merge on February 16, 2008, at 12:13:32
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex » HSP Woman, posted by Phillipa on February 16, 2008, at 11:37:51
I would guess that you are right about the epi-pen. I got diagnosed with high blood pressure at the same time that my doctor wanted me tested for allergies - the allergist wanted me to get my high blood pressure under control before they tested me. His explanation was that if I had a bad reaction to an allergen, they would have to use an epi-pen, which would significantly raise my blood pressure (which was already high). It seems like from what I know about MAOIs, that explanation would fit as a reason to be suspicious about getting allergy shots (or even tested for allergies) if you're taking an MAOI.
I took an MAOI for about 5 years so I do have a pretty good understanding about how careful you need to be. I had several surgeries while taking Parnate (some scheduled, one was an emergency surgery) and I have to say, I was shocked at how little my doctors and nurses understood about the potential reactions that I could have as an MAOI patient. When I was in severe pain that wasn't responding to morphine, a nurse asked me if I wanted to try DEMEROL. I told her that if she wanted a major lawsuit, then to go ahead and give me Demerol...and in the meantime she might want to read my chart. LOL. They ended up bringing my psychiatrist in to help them with my medication management.
I guess my point in bringing that up is just to say that I think your pdoc would be the best person to ask - they seem to be the only ones who really understand MAOIs.
Posted by HSP Woman on February 16, 2008, at 12:35:54
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex » HSP Woman, posted by Phillipa on February 16, 2008, at 11:37:51
Phillipa,
Thanks so much. Actually I was asking for data only. I thought someone out here must have done some extensive research already about allergies, asthma, and MAOis,
I always want to know the Why behind things.
I was surprised my MD -- a certified specialist in Allergy and Immunology -- wasn't aware of a medication class that is supposedly contraindicated in a procedure he conducts regularly.
MAOi's and beta-blockers are just written to be avoided while doing immunotherapy. He was more sure of the Why behind beta-blockers but -- what really threw me -- is when he said most MDs WILL do allergy shots if a beta blocker is on board.
Unfortunately, I do not have a pdoc.
I was prescribed Emsam from a family doctor. I am in the process of trying to find one though. Not so easy. LONG waits. I do have an appointment, but not until May!
Finally, my allergy MD did say he'd ask some of the other (older) doctors as to why MAOi's and immunotherapy are contraindicated.
My allergy MD cannot be more than 25 years old. Maybe 30.
I have done the Google checker and I still cannot find any data (primary or secondary) as to the Why.
Of course, waiting to start the shots is what I will do.
Thank you for your response!
Posted by Merge on February 16, 2008, at 12:45:37
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex, posted by HSP Woman on February 16, 2008, at 12:35:54
Wow, I'm surprised they will do shots if someone is taking a beta blocker...my doctor will not. I went on a non beta-blocker high blood pressure med. just so I could be sure that I could receive allergy shots.
Posted by HSP Woman on February 16, 2008, at 12:49:48
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex, posted by Merge on February 16, 2008, at 12:13:32
Hi Merge,
This is so helpful. I think that the contraindication must be the epi-pen factor. Your allergist seems to be a bit more savvy than mine! That's exactly what I'd expect a specialized MD to have knowledge of.
About the surgeries and Demerol -- I am so shocked. My jaw is hanging open. I guess I am just naive, but I assume people in potentially life-threatening professions would know basic pharmacology of drugs classes that could be dangerous.
But, I guess I have that problem a lot -- Like I expect people with jobs that deal with the public to be polite, too. I am disappointed a lot! ; )
You and Phillipa are right. I really need to get a pdoc soon. I have an appointment with a really competent psychiatrist in May, but that's three months. My Emsam was prescribed by my family physician.
I did go to one appointment with a pdoc last month. He was in his 60s but still hadn't any knowledge about MAOi's. It's a frustrating mission finding a good pdoc.
So the key here, for me, is to find a pdoc that has enough experience and knowledge about MAOi's that he/she can actually help -- like you say -- with medication management in many areas.
Thank you for sharing your story.
Posted by HSP Woman on February 16, 2008, at 13:09:24
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex, posted by HSP Woman on February 16, 2008, at 12:49:48
I guess I should clarify a couple of points I made:
My allergist MD said that, despite the risks of beta blockers and immunotherapy, some people choose to still go ahead with shots.
He implied if a patient was aware of the consequences, some doctors are okay with going ahead with the shots. (Scares me). Not sure if he, himself, would be okay with administering shots.
Second, it was my family physician that finally prescribed Emsam, but after I did a lot of research on it. Also, I had one consultation with an out-of-town pdoc who confirmed Emsam would be a great choice for me to try.
My family doctor has never prescribed it before so I am not sure she'd know the intricacies of immunotherapy's contraindication.
Thanks again, everyone.
Posted by Larry Hoover on February 16, 2008, at 15:53:29
In reply to Emsam, Allergy Shots, Albuterol, Xopenex, posted by HSP Woman on February 15, 2008, at 19:46:45
> I believe the warning must come from the potential need for epi-pen in case of anaphylactic shock?
It is, indeed. I haven't any idea of an alternative treatment, if adrenaline/epinephrine is strictly contraindicated.
> Anyone familiar with Emsam and Xopenex?
Only from the literature. The levalbuterol monograph states: "Xopenex Inhalation Solution should be administered with extreme caution to patients being treated with monoamine oxidase inhibitors or tricyclic antidepressants, or within 2 weeks of discontinuation of such agents, because the action of levalbuterol HCl on the vascular system may be potentiated."
Lar
Posted by HSP Woman on February 16, 2008, at 19:14:02
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex » HSP Woman, posted by Larry Hoover on February 16, 2008, at 15:53:29
Hi Lar,
I am just guessing about the contraindication coming from the potential use of the epi pen. Have you read somewhere this is indeed the reason immunotherapy and MAOi's are contraindicated?
What is it that happens when people on MAOi's are given epinephrine? Is a hypertensive crisis that cannot be mediated?
I did read that exact paragraph about the use of Albuterol-like meds and MAOi's. Thanks for pointing it out though.
But, I did a search for "albuterol and MAOi's" on this site (when I accidently took a dose of albuterol instead of Flovent). I recall reading a few posts from people writing that they took Albuterol (or another beta-2 agonists) and a MAOi.
For example - a post I found -- "I have taken both Nardil and Emsam long-term with asthma. The main concern was the albuterol inhaler, but neither my doctor nor pharmacist had any real concerns. I never had a problem, and I use the albuterol heavily."
I also recall reading that not all beta-2 agonists are created equal in the eyes of MAOi's. Some are potentiating, some are not.
I was just hoping for more clarification from people who use it (or chose not to).
The one time I took it by accident (and I am on the 6 mg patch), I monitored my blood pressure for hours afterwards. No change.
Interesting...
Thanks, Lar, for replying. I appreciate it a lot.
Posted by bleauberry on February 20, 2008, at 19:02:50
In reply to Emsam, Allergy Shots, Albuterol, Xopenex, posted by HSP Woman on February 15, 2008, at 19:46:45
Be sure your allergy shots have ZERO mercury in them. The last thing a psych patient or an immunology patient needs is more mercury. It is actually a major cause of both psych and allergy symptoms. Many allergies shots have small amounts of mercury in them. Vaccines had mercury as a preservative. Some still do. Many flu shots today have mercury.
Ask about every single ingredient in the shot and then study to be sure one of them isn't a disguised version of mercury. They call it something else when it is used in medicine.
I know people snicker at me when I mention mercury, but it IS serious. Tiny amounts can be deceptively devastating to some people, especially if there is a known allergy conditon already in play.
Anyway, sorry to get off topic. I don't know about Ensam and allergy shots. I do know from visiting other forums that it is common for allergy shots to have mercury in them. You want to specifiy NO MERCURY. None. Zero. Zip. Nada.
Posted by Larry Hoover on February 21, 2008, at 9:56:08
In reply to Re: Emsam, Allergy Shots, Albuterol, Xopenex, posted by HSP Woman on February 16, 2008, at 19:14:02
> Hi Lar,
>
> I am just guessing about the contraindication coming from the potential use of the epi pen. Have you read somewhere this is indeed the reason immunotherapy and MAOi's are contraindicated?No. From my knowledge of biochemistry, it is a perfectly sensible answer.
> What is it that happens when people on MAOi's are given epinephrine? Is a hypertensive crisis that cannot be mediated?Yes. That would be expected. I suppose that a much reduced dose might prove appropriate, but in an anaphylactic emergency, getting just a minimal epinephrine dose would be expecting a lot from the caregivers involved.
In a risk/benefit analysis, risking fatal anaphylaxis and/or fatal hypertension seems hardly worth the benefit of reducing allergic response to any allergen I can think of.
> I did read that exact paragraph about the use of Albuterol-like meds and MAOi's. Thanks for pointing it out though.
>
> But, I did a search for "albuterol and MAOi's" on this site (when I accidently took a dose of albuterol instead of Flovent). I recall reading a few posts from people writing that they took Albuterol (or another beta-2 agonists) and a MAOi.
>
> For example - a post I found -- "I have taken both Nardil and Emsam long-term with asthma. The main concern was the albuterol inhaler, but neither my doctor nor pharmacist had any real concerns. I never had a problem, and I use the albuterol heavily."Here's the thing.....collections of individual experiences provide statistical guidance for risk/benefit analyses. They do not allow one to predict individual experience. Just because other people got away with it, doesn't mean you will. Individals live in a binary world. You get the adverse reaction, or you don't. Statistics/probabilities don't predict binary outcomes.
Is the risk of vascular effects worth the benefit from the albuterol? Is there another way to manage your asthma?> I also recall reading that not all beta-2 agonists are created equal in the eyes of MAOi's. Some are potentiating, some are not.
If you have specific alternatives in mind, I can look at those.....I don't have specific knowledge to advise here.
> I was just hoping for more clarification from people who use it (or chose not to).
>
> The one time I took it by accident (and I am on the 6 mg patch), I monitored my blood pressure for hours afterwards. No change.
>
> Interesting...That's comforting, I suppose. The adverse effects can include rhythm disturbances, which wouldn't be found by monitoring only blood pressure. It's up to you, if you want to combine them.
> Thanks, Lar, for replying. I appreciate it a lot.You're welcome.
Lar
This is the end of the thread.
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