MAOls

The answer is b. (Katzung, p 1130J Fatalities have been reported when fluoxetine and MAO inhibitors (MAOIs) such as tranylcypromine have been given simultaneously The MAOLs should be stopped at least two weeks before the administration of fluoxetine or paroxetine. The mechanism of this interaction is under investigation... 

The answer is b. (Hardmanr p 444.) This patient ate tyramine-rich foods while taking an MAOI and went into hypertensive crisis. Tyramine causes release of stored catecholamines from presynaptic terminals, which can cause hypertension, headache, tachycardia, cardiac arrhythmias, nausea, and stroke. In patients who do not take MAOls, tyramine is inactivated in the gut by MAO, and patients taking MAOls must be warned about the dangers of eating tyramine-rich foods. 

The answer is g. (Hardman, pp 439 140.) Most MAOls are nonse-lective for MAOA and -B. MAOls mainly act on tissues regulated by sympathomimetic amines and serotonin. 

Heederik, D., and Newman Taylor, A. J. (1999). Occupational asthma in the baking industry. In "Asthma in the Workplace" (1. L. Bernstein, M. Chan-Yeung, J.-L. Maol, and D. I. Bernstein, eds). Marcel Dekker, Inc, New York. 

MAOls Brofaromine Isocarboxizide Moclobemide Phenelzine Tranylcypromine... 

Listing of antidepressants in traditional groupings. Abbreviations TCAs = tricyclic antidepressants MAOls = monoamine oxidase inhibitors SSRls = selective serotonin reuptake inhibitors. 

The second factor includes symptomatic predictors of treatment response. It has long been recognized that MAOls, and now SSRls, are more effective than TCAs... 

When switching between a MAOl and other antidepressants that affects serotonin activity, the first medication must be allowed to wash out of the patient s system before the new antidepressant is started. The duration of this washout period is determined by the half-life of the antidepressant that is being discontinued. If a washout is neglected, then a potentially dangerous serotonin syndrome may result. 

Monoamine Oxidase Inhibitors (MAOIs). Early studies also evaluated the effectiveness of the MAOl phenelzine. Phenelzine, relative to TCAs, provided greater benefit for PTSD however, its usefulness is limited by its potential for drug and food interactions. A recent open label study suggests that the reversible MAOI moclobemide might be helpful for PTSD. It is not available in the United States. 

Antidepressants. In the early 1980s, the recognition that depression is a frequent comorbid feature of BN coupled with the observation that appetite changes are a common feature of depression led researchers to evaluate antidepressant treatment for BN. Since that time, a series of controlled studies have demonstrated efficacy for a wide assortment of antidepressants including the TCAs imipramine (Tofranil) and desipramine (Norpramin), the MAOl phenelzine (Nardil), the SSRl fluoxetine (Prozac), and the atypical antidepressants trazodone (Desyrel) and bupropion (Wellbutrin). Overall, approximately two-thirds of antidepressant-treated patients with bulimia experience symptomatic improvement while nearly one-third achieves complete remission of binging and purging. In addition, the improvement in the symptoms of BN is not dependent on the presence of comorbid depression. 

Yet another MAOI is selegiline (Eldepryl). Unlike the other MAOls, selegiline is seldom used to treat depression. At low doses, selegiline only inhibits the M AO-B enzyme. Therefore, it increases dopamine activity but does not have any pronounced effect on norepinephrine or serotonin. For this reason, it has been less useful as an antidepressant however, its primary use has been to treat Parkinson s disease. Of course, this selectivity for dopamine suggests that it may be helpful for ADHD as well. 

For more information regarding the use of MAOls please refer to Chapter 3 (Mood Disorders) and Chapter 5 (Anxiety Disorders). 

Despite these alternatives, there are a few patients who cannot tolerate stimulants or who may be susceptible to abusing them. In such cases, the alternatives are limited. The best treatments for poor attention (in lieu of the stimulants) are antidepressants that boost norepinephrine and/or dopamine activity in the brain. Currently, this includes the TCAs, MAOls, and possibly venlafaxine or duloxetine. 

Monoamine Oxidase Inhibitors (MAOIs). The MAOls work in a unique fashion by blocking the activity of an enzyme that degrades each of three key brain transmitters norepinephrine, dopamine, and serotonin. These widespread effects on several brain transmitter systems make the MAOls a potentially very effective class of medications for a variety of disorders. A few small studies have evaluated the usefulness of the MAOls in the treatment of BPD and found them moderately helpful for the impulsivity associated with this illness. Unfortunately, the requirements for strict dietary restrictions due to a risk of hypertensive crisis severely limit the usefulness of MAOls in the treatment of BPD. These restrictions are a particular concern when treating patients who have problems with impulsivity and are therefore likely to have difficulty maintaining the dietary regimen. For this reason, although they may theoretically be helpful, MAOls should only be used to treat BPD after other more easily tolerated medications have been tried and have failed. In the near future, so-called reversible MAOls that appear to avoid the need for diet restrictions may become available. If so, this will allow us to reconsider their use in the treatment of BPD. For more information regarding the use of MAOls, please refer to Chapter 3. 

Obsessive compulsive disorder in an 8-year-old can be treated using fluvoxamine (selective serotonin reuptake inhibitor, SSRI). It is usually administered initially os 25 mg daily, and increased if necessary in steps of 25 mg every 4-7 days to a maximum of 200 mg daily. If there is no improvement within 10 weeks, treatment should be reconsidered. A selective serotonin reuptake inhibitor should not be started until 2 weeks after stopping a monoamine oxidase inhibitor (MAOl), and conversely a MAOl should not be started until at least a week after an SSRI has been stopped. 

Monoamine oxidase inhibitor (MAOl) therapy hypersensitivity. 

Mania/Hypomania Hypomanic or manic episodes may occur, particularly in patients with cyclic disorders. Such reactions may necessitate discontinuation of the drug. MAOIs Do not give MAOIs with or immediately following TCAs. Allow at least 14 days to elapse between MAOl discontinuation and TCA institution. Some TCAs have been used safely and successfully with MAOIs. Initiate TCA cautiously with gradual dosage increase until achieving optimum response. 

Switching to or from a monoamine oxidase inhibitor (MAOl) - At least 14 days should elapse between discontinuation of an MAOl and initiation of therapy with mirtazapine. In addition, allow at least 14 days after stopping mirtazapine before starting an MAOl. 

MAOIs Because venlafaxine is an inhibitor of norepinephrine and serotonin reuptake, it is recommended that venlafaxine not be used in combination with an MAOl or within 14 days of discontinuing treatment with an MAOI. Allow at least 7 days after stopping venlafaxine before starting an MAOI. 

Hypersensitivity to SSRIs in combination with a monoamine oxidase inhibitor (MAOl), or within 14 days of discontinuing an MAOl administration of thioridazine with fluoxetine or within a minimum of 5 weeks after fluoxetine has been discontinued coadministration of fluvoxamine with cisapride, thioridazine or pimozide concomitant use of thioridazine with paroxetine concomitant use of pimozide with sertraline coadministration of sertraline oral concentrate and disulfiram. 

Eideriy Older patients may suffer more morbidity than younger patients during and following an episode of hypertension or malignant hyperthermia with MAOl use. Use with caution in the elderly. 

Hypomania Hypomania has been the most common severe psychiatric side effect reported. This has been largely limited to patients in whom disorders characterized by hyperkinetic symptoms coexist with, but are obscured by, depressive affect. Diabetes There is conflicting evidence as to whether MAOIs affect glucose metabolism or potentiate hypoglycemic agents. Consider this if used in diabetics. Epilepsy The effect of MAOIs on the convulsive threshold may vary. Do not use with metrizamide discontinue MAOl 48 hours or more prior to myelography and resume 24 hours postprocedure. 

Switching MAOIs In several case reports, hypertensive crisis, cerebral hemorrhage and death have possibly resulted from switching from one MAOl to another without a waiting period. However, in other patients no adverse reactions occurred. Nevertheless, a waiting period of 10 to 14 days is recommended when switching from one MAOl to another. 

Patients with marked anxiety, tension, and agitation, because the drug may aggravate these symptoms hypersensitivity to methylphenidate or other components of the product patients with glaucoma, motor tics, or a family history or diagnosis of Tourette s syndrome during treatment with monoamine oxidase inhibitors (MAOIs), and also within a minimum of 14 days following discontinuation of an MAOl (hypertensive crises may result). 

Concurrent treatment with monoamine oxidase inhibitors (MAOIs) and within a minimum of 14 days following discontinuation of an MAOl (hypertensive crisis may result). 

Patients known to be hypersensitive to atomoxetine or other constituents of the product with a monoamine oxidase inhibitor (MAOl) or within 2 weeks after discontinuing an MAOl narrow angle glaucoma (see Warnings). 

MAOIs Do not take atomoxetine with an MAOl or within 2 weeks after discontinuing an MAOl. Do not initiate treatment with an MAOl within 2 weeks after discontinuing atomoxetine. With other drugs that affect brain monoamine concentrations, there... 

Hypersensitivity to brimonidine tartrate or any component of this medication patients receiving monoamine oxidase inhibitor (MAOl) therapy. 

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