Monoamine oxidase indications

FIGURE 14-3 Synthesis and metabolism of histamine. Solid lines indicate the pathways for histamine formation and catabolism in brain. Dashed lines show additional pathways that can occur outside the nervous system. HDC, histidine decarboxylase HMT, histamine methyltransferase DAO, diamine oxidase MAO, monoamine oxidase. Aldehyde intermediates, shown in brackets, have been hypothesized but not isolated. 

Urine catecholamines may also serve as biomarkers of disulfoton exposure. No human data are available to support this, but limited animal data provide some evidence of this. Disulfoton exposure caused a 173% and 313% increase in urinary noradrenaline and adrenaline levels in female rats, respectively, within 72 hours of exposure (Brzezinski 1969). The major metabolite of catecholamine metabolism, HMMA, was also detected in the urine from rats given acute doses of disulfoton (Wysocka-Paruszewska 1971). Because organophosphates other than disulfoton can cause an accumulation of acetylcholine at nerve synapses, these chemical compounds may also cause a release of catecholamines from the adrenals and the nervous system. In addition, increased blood and urine catecholamines can be associated with overstimulation of the adrenal medulla and/or the sympathetic neurons by excitement/stress or sympathomimetic drugs, and other chemical compounds such as reserpine, carbon tetrachloride, carbon disulfide, DDT, and monoamine oxidase inhibitors (MAO) inhibitors (Brzezinski 1969). For these reasons, a change in catecholamine levels is not a specific indicator of disulfoton exposure. 

Bromocriptine is a dopamine agonist acting by direct stimulation of the dopamine receptors. In Parkinson s disease, it is reserved for use in patients who are intolerant to levodopa or in whom levodopa alone is not sufficient. Orphenadrine is an antimuscarinic indicated in Parkinson s disease. Antimuscarinics tend to be more effective than levodopa in targeting tremor rather than rigidity and bradykinesia. Moclobemide is an antidepressant referred to as a reversible monoamine oxidase inhibitor (RIAAA) type A. 

Lorazepam is a short-acting benzodiazepine indicated for use in relieving anxiety and insomnia. Lorazepam may also be administered perioperatively to alleviate pain and in status epilepticus. Imipramine is a tricyclic antidepressant, paroxetine is a selective serotonin re-uptake inhibitor, venlafaxine is a serotonin and adrenaline re-uptake inhibitor and moclobemide is a reversible monoamine oxidase inhibitor. Imipramine, paroxetine, venlafaxine and moclobemide are all classified as antidepressants. 

Maintenance/Continuation/Extended treatment There is no evidence to indicate how long the depressed patient should be treated with nefazodone. However, it is generally agreed that pharmacologic treatment for acute episodes of depression should continue for at least 6 months. Whether the dose of antidepressant needed to induce remission is identical to the dose needed to maintain euthymia is unknown. In clinical trials, more than 250 patients were treated for at least 1 year. Switching to or from a monoamine oxidase inhibitor (MAOi) At least 14 days should elapse between discontinuation of an MAOI and initiation of therapy with nefazodone. In addition, wait at least 7 days after stopping nefazodone before starting an MAOI. 

Examples of monoamine oxidase inhibitors are phenelzine, tranylcypromine, isocarboxazid and mo-clobemide. They are indicated for atypical depression. Changes in the neurotransmitter levels are seen in several days but the clinical effect may lag by several weeks. Phenelzine is a non-selective hydrazine-type monoamine oxidase inhibitor while the also non-selective inhibitor tranylcypromine is of the non-hydrazine-type. Phenelzine, tranylcypromine and isocarboxazid are irreversible inhibitors. Phenelzine is partly metabolized by acetylation and slow acetylators are more prone to toxicity. It has anxiolytic properties and superior efficiacy in treating severe anxiety. 

There is no place anymore for the amphetamines in our therapeutic armamentarium. The only indications for the other stimulants, modaflnil and methylphenidate, are respectively narcolepsy and the attention deflcit disorders (ADHD) and hyperactivity syndromes in children. Their mechanisms of action include enhanced release of dopamine and norepinephrine, re-uptake inhibition of dopamine and norepinephrine and to some extend monoamine oxidase inhibition. 

TCA, tricyclic antidepressant SSRI, selective serotonin reuptake inhibitor MAOI, monoamine oxidase inhibitor. 0, no effect +, + +, + + + indicate increasing effect. 

Fig. 1. Influence of substituents in the aromatic ring on the selectivity of 3-(2-aminoethoxy)-1,2-benzisoxazole derivatives as monoamine oxidases (MAO) A or B inhibitors. Ratio of selectivity was calculated from IC50 values of MAO A and B determined by an in vitro assay of mouse brain mitochondria using 5-hydroxy tryptamine (5-HT) and 2-phenylethylamine (PEA) as specific substrates, respectively (see Ref. [9]). Smaller values indicate that inhibitors are MAO A selective [71].

Fig. 2. isozyme seiectivity of fluoroaiiyi amine monoamine oxidases (MAO) inhibitors. The seiectivity ratio was defined as the ratio of the concentrations of inhibitors required to decrease the activity of both forms of the enzyme at the same rate [77]. A high ratio thus indicates a B-seiective inhibitor. 

Some evidence indicates that social phobia responds to SSRls, and case reports and studies with fluoxetine [B. Black et al. 1992 Van Ameringen et al. 1993), fluvoxamine [Mendels et al. 1995), paroxetine [Pitts et al. 1996 Ringold 1994), and sertraline [Katzelnick et al. 1995) have reported positive results. Although the full details of these studies have not been published, it seems that SSRls might well prove, in due course, to be effective treatments for social phobia. At the moment, the only treatment licensed for social phobia is moclobemide, which is a reversible inhibitor of monoamine oxidase-A [Nutt and Montgomery 1996 Versiani et al. 1992), and it is possible that it... 

Although behavioral treatments for social phobia have been well studied, there are very limited data on its pharmacological management, b- Blockers (propranolol, atenolol) have been recommended, but available evidence indicates their effect may be no different than that of placebo ( 78). In a controlled study, the monoamine oxidase inhibitor (MAOl) phenelzine has been shown to be more effective than placebo (78, 79). Anecdotal reports have also described efficacy with alprazolam, clonidine, and fluoxetine, but systematic data are lacking (80, 81, 82 and 83). 

Monoamine oxidase (MAO) serves as a marker enzyme for outer membrane. There is some MAO activity in the inner membrane and therefore also in SMPs however, a high level of monoamine oxidase in the SMP preparation indicates a large contamination by outer membrane. Mitochondrial monoamine oxidase is an FAD-dependent enzyme that catalyzes the oxidation of amines to aldehydes (Equation E10.2). A convenient assay for this enzyme uses benzylamine as substrate and monitors the rate of ben-zaldehyde production at 250 nm. 

FIGURE 6—3. The neurotransmitter receptor hypothesis of antidepressant action—part 2. Here, a monoamine oxidase (MAO) inhibitor is blocking the enzyme and thereby stopping the destruction of neurotransmitter. This causes more neurotransmitter to be available in the synapse (indicated in the red circle). 

FIGURE 6—22. Tyramine is an amine present in food such as cheese. Indicated in this figure is how tyramine (depicted as cheese) acts to increase the release of norepinephrine (NE) (red circle 1). However, in normal circumstances, the enzyme monoamine oxidase (MAO) readily destroys the excess NE released by tyramine, and no harm is done (see red circle 2). 

FIGURE 6-24. Shown in this figure also is the combination of a monoamine oxidase (MAO) inhibitor and tyramine. However, in this case the MAO inhibitor is of the reversible type (reversible inhibitor of MAO A, or RIMA). In contrast to the situation shown in the previous figure (Fig. 6— 23), the accumulation of norepinephrine (NE) caused by tyramine (indicated in red circle 1) can actually strip the RIMA off MAO (arrow 2). MAO, now devoid of its inhibitor, can merrily do its job, which is to destroy the NE (red circle 3) and thus prevent the dangerous accumulation of NE. Such a reversal of MAO by NE is only possible with a RIMA and not with the classical MAO inhibitors, which are completely irreversible. 

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