Tramadol MAOIs

MAOIs, metoclopramide, phenytoin, sibutramine, smoking, St. John s wort, tramadol, linezolid, L-tryptophan. 

Serotonin syndrome SSRIs, second generation antidepressants, MAOIs, linezolid, tramadol, meperidine, fentanyl, ondansetron, sumatriptan, MDMA, LSD, St. John s wort, ginseng Hypertension, hyperreflexia, tremor, clonus, hyperthermia, hyperactive bowel sounds, diarrhea, mydriasis, agitation, coma onset within hours Sedation (benzodiazepines), paralysis, intubation and ventilation consider 5-HT2 block with cyproheptadine or chlorpromazine... 

MAOIs PETHIDINE, MORPHINE, PHENOPERIDINE, DEXTROMETHORPHAN Two types of reaction are reported 1. Risk of serotonin syndrome with dextromethorphan, pethidine or tramadol and MAOIs 2. Depressive - respiratory depression, hypotension, coma Type 1 reactions are attributed to inhibition of reuptake of serotonin -more common with pethidine, phenoperidine, dextromethorphan. Type II reactions are attributed to MAOI inhibition of metabolism of opioids - more common with morphine Avoid co-administration do not give dextromethorphan, pethidine or tramadol for at least 2 weeks after cessation of MAOI... 

Not understood, despite the extensive studies undertaken. The reae-tion has proved difficult to study in animals, since mice appear to be more sensitive to the reaetion than humans. There is some evidence that the reactions may be due to an increase in levels of 5-HT within the brain, causing the serotonin syndrome , (p.9). Tramadol, an opioid with additional noradrenergie and serotonergic properties, has clearly caused the serotonin syndrome when used with MAOIs, see tramadol , (p.ll41). 

This demonstrates that there are sound practical and theoretical reasons for patients on MAOIs to avoid tramadol. Note that the serotonin syndrome has also occurred with tramadol and SSRIs , (p.l222). 

A small study in healthy subjects found no problems when moclobemide was given 24 hours after clomipramine. However, the serotonin syndrome occurred in 3 patients when clomipramine was replaced by mo-clobemide without a washout period or with only a 24-hour washout period, " and in another patient when moclobemide was replaced by clomipramine after only 12 hours. A fatal case of the serotonin syndrome occurred in a patient taking clomipramine and amitriptyline, with symptoms manifesting within 30 minutes of a 300-mg dose of moclobemide. Two other patients developed fatal serotonin syndrome after taking moderate overdoses of moclobemide and clomipramine. The serotonin syndrome has been reported in at least 8 other cases of moclobemide and clomipramine overdose, one of which also involved tramadol (see also MAOIs + Opioids Tramadol, p.ll41), another fluoxetine (see also MAOIs or RIMAs + SSRIs, p.l 142), and yet another buspirone (see also MAOIs or RIMAs + Buspirone, p.l 133). Conversely, a case of an overdose of moclobemide and clomipramine resulted in no adverse effects except sinus tachycardia. ... 

Relative history of seizure disorder, bipolar disorder (may induce mania), urinary retention, narrow-angle glaucoma, delirium, hyperthyroidism, bradycardia (or drugs that cause bradycardia), or electrolyte disturbance (esp. K+ or Mg ). Use caution in conjunction with other antidepressants (including MAOIs and SSRIs), other anticholinergic medications, drugs that increase plasma levels (phenothiazines, haloperidol, cimetidine), or drugs that lower seizure threshold (esp. tramadol). Use caution in elderly, children/adolescents. 

Know the mechanism of action of your muscle relaxant. If the patient is already taking tramadol or tapentadol as well as amitriptyline, consider your rationale for adding a third agent with serotonergic activity such as cyclobenzaprine, as well as the increased risk of serotonin syndrome. Do not use cyclobenzaprine within 2 weeks of the last dose of an MAOI. Some MAOIs include isocarboxazid (Marplan), tranylcypromine (Parnate), phenelzine (Nardil), selegiline (Eldepryl, Emsam),... 

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