Moclobemide Ecstasy

Overdose of moclobemide by itself rarely appears to give rise to serious problems. This is in contrast to overdose with conventional monoamine oxidase inhibitors, which can cause fatal 5HT toxicity. However, if patients take moclobemide together with serotonergic antidepressants, such as SSRIs or clomipramine, 5HT toxicity is common. 5HT toxicity occurred in 11 of 21 patients who took overdoses of moclobemide and serotonergic agents but in only one of 33 patients who took moclobemide alone (13). Consistent with this, four patients died, presumably of 5HT toxicity, after co-ingesting 3,4-methyle-nedioxymethamphetamine (MDMA, ecstasy) and moclobemide (14). 

Vuori E, Henry JA, Ojanpera I, Nieminen R, Savolainen T, Wahlsten P, Jantti M. Death following ingestion of MDMA (ecstasy) and moclobemide. Addiction. Soc Study Addiction Alcohol Other Drugs 2003 98 365-8. 

There have been four deaths after interactions of moclobemide, a monoamine oxidase A inhibitor, with ecstasy (138). 

An 18-year-old woman took an unknown quantity of ecstasy and the next day became confused and had seizures, loss of consciousness, and respiratory arrest. At autopsy, no cause of death was found. There were no specific findings on histology except visceral hyperemia. MDMA, moclobemide, and some alcohol were found in the blood. There was no history of mental illness or evidence of prescription drugs. 

A 23-year-old man was found dead in his apartment, having previously been confused. At autopsy there was no clear cause of death. His urine was positive for amphetamines, opiates, moclobemide, dextromethorphan, cyclizine, oxazepam, diazepam, and temazepam. The coroner concluded that the death was from a combination of ecstasy and moclobemide, with a possible contribution from dextromethorphan. 

A 19-year-old man took 10 ecstasy tablets and became unconscious, had problems breathing, and later died. At autopsy, his lungs were edematous and there was general visceral congestion. His blood contained MDMA, MDA, cannabis, and moclobemide. The cause of death was recorded as having been due to the combination of moclobemide and ecstasy. 

The authors suggested that the serotonin syndrome possibly occurred as a result of the combination of moclobemide and ecstasy, although it was not clear why the combination had been used. 

Moclobemide 300 mg twice daily for 9 days markedly reduced the O-demethylation of dextromethorphan (seven 20-mg doses given every 4 hours over 2 days), in 4 healthy subjects. The manufacturer notes that isolated cases of severe CNS adverse reactions have been seen with the combination. Concurrent use of dextromethorphan may have contributed to a fatality involving the illicit use of moclobemide and ecstasy , (p.1144). 

The concurrent use of non-selective MAOIs and amfetamines and related drugs can result in a potentially fatal hypertensive crisis and/or serotonin syndrome. Interactions have been reported for amfetamine, dexamfetamine, metamfetamine, and methylpheni-date. Interactions have also been reported with the illicit drug ecstasy (MDMA, methylenedioxymethamfetamine) when taken with phenelzine or moclobemide. The manufacturers of fenfluramine and dexfenfluramine contraindicated their use with MAOIs. 

Four patients died after taking moclobemide and ecstasy (MDMA, methylenedioxymethamfetamine). The clinical evidence is limited, but in each case the forensic pathologist concluded that the cause of death was the combined use of these drugs. It was suggested that what happened is consistent with the serotonin syndrome, although the evidence is fairly slim. Two patients had taken maximum therapeutic doses and two moderate overdoses of moclobemide. Note that moclobemide had not been prescribed to any of them. Post-mortem analysis also found the presence of dextromethorphan in one patient, which was thought to have contributed, see also MAOIs or RIMAs -i- Dextromethorphan , p.ll34. 

Pilgrim JL, Gerostamoulous N, Woodford N, Drummer OH. Serotonin toxicity involving MDMA (ecstasy) and moclobemide. Forensic Sci Int 2012 215 184-8. 

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