antidepressants - MAOI

Question 1

why are they less frequently used than TCAs or SSRIs and related antidepressants.

Answer 1

due to danger of dietary and drug interactions

Question 2

This MAOI has a greater stimulant action than the other two and are more likely to cause a hypertensive crisis

Answer 2

Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid

How to remember: stimulant is TRANYLCYPROMINE - ST in alphabet

Question 3

These two drugs are more likely to cause hepatoxicity than the this other one

Answer 3

Isocarboxazid and phenelzine are more likely to cause hepatotoxicity than tranylcypromine.

Question 4

This drug should be reserved as a 2nd line treatment

Answer 4

Moclobemide

Question 5

Phobic pt and depressed pt with atypical, hypochondriac or hysteria features are said to respond best to which AD?

Answer 5

MAOIs

Question 6

MAOIs should be tried in any patients who are refractory to treatment with other AD as there is

Answer 6

occasionally a dramatic response

Question 7

response to treatment with MAOI can take ..

Answer 7

can be delayed for 3 weeks or more
may take an additional 1-2 weeks to become maximal

Question 8

How long to start other AD after treatment with MAOIs has been stopped.

Answer 8

do not start for 2 weeks after treatment has been stopped
3 weeks if starting clomipramine or imipramine

Question 9

A patient is to be commenced on imipramine. They were previously on isocarboxazid. How long to wait until they can start taking imipramine?
1 day
1 week
2 weeks
3 weeks
4 weeks
No need to wait

Answer 9

Need to wait 3 weeks (if going onto imipramine or clomipramine from MAOI, otherwise normally wait 2 weeks)

Question 10

A patient is taking tranylcypromine but have not had response. They are going to be switched onto phenelzine. When can they start taking phenelzine?

Answer 10

An MAOI should not be started until at least 2 weeks after a previous MAOI has been stopped (then start at reduced dose)

Question 11

An MAOI should not be started until at least ….. days after a TCA has been stopped

Answer 11

7-14 days
3 weeks for clompiramine, imipramine

Question 12

An MAOI should not be started until at least ……. after an SSRI has been stopped

Answer 12

A week
5 weeks in the case of fluoxetine

Question 13

A patient has just stopped taking fluoxetine and is going to be switched to phenelzine, an MAOI. How long do they have to wait to be switched onto this after stopping?

Answer 13

5 weeks

Question 14

Not MAOI - this drug has antidepressant properties when given by mouth in low doses. It is also used for the treatment of psychoses. It is a thioxanthene.

Answer 14

Fluanxol (flupentixol)

Question 15

What food must be avoided in patients taking MAOIs and why

Answer 15

tyramine rich foods (mature cheese, salami, pickles herring, Borvi, Oxo, Marmite, any similar meat or yeast extract or fermented soya bean extract, some beers, lagers or wines)
food containing dopa (e.g. broad bean pods)
need to avoid these with, or for 2-3 week after stopping MAOI
potentially life threatening hypertensive crisis can develop

Question 16

One reversible and 3 irreversible MAOIs

Answer 16

reversible: mocolobemide
irreversible: tranycylpromine, phenelzine, isocarboxazid

Question 17

A patient is on an MAOI so you counsel them not to eat certain types of food as it increases the risk of potentially life threatening hypertensive crisis. which of the following is NOT a food that they need to avoid?
- Mature cheese
- Salami
- Marmite
- Green vegetables
- Red wine
- Broad bean pods

Answer 17

Green vegetables

Question 18

4 contraindications

Answer 18

• cerebrovascular disease
• not indicated in manic phase
• phaeochromocytoma
• severe CVD

Question 19

is postural hypotension a SE

Answer 19

yes more common in elderly

Question 20

is akathisia (inability to remain still) a SE?

Answer 20

yes

Question 21

what to do if pt develops palpitations or frequent headaches

Answer 21

discontinue

Question 22

use in pregnancy

Answer 22

avoid unless compelling reasons
risk of neonatal malformations

Question 23

use in HI

Answer 23

generally avoid

Question 24

monitoring requirements

Answer 24

BP
risk of postural hypotension and hypertensive responses

Question 25

patient and carer advice regarding fresh food & alcohol & non alcoholic drinks

Answer 25

- only eat fresh food - avoid food suspected of being stale or going off - esp important with meat, fish, poultry or offal - avoid game - danger of interaction persists for up to 2 weeks after treatment discontinued - avoid alcoholic drinks or de-alcoholised drinks

Question 26

true or false - pt should avoid dealcoholised aka low alcohol drinks

Answer 26

true

Question 27

for tranylcypromine, it is given BD, but second dose should be taken at a time no later than...

Answer 27

3pm

Question 28

tranylcypromine CI

Answer 28

history of hepatic disease hyperthyroidism

Question 29

use in BF

Answer 29

avoid

Question 30

MOA moclobemide

Answer 30

reversible inhibition of MAO type A

Question 31

all MAOIs are licensed for depressive illness. Moclobemide is also licensed for this indication

Answer 31

social anxiety disorder

Question 32

moclobemide 2 CI

Answer 32

acute confusional states pheochromocytoma

Question 33

treatment cessation

Answer 33

if possible avoid abrupt withdrawal if possible withdraw slowly withdrawal effects may occur within 5 days of stopping treatment with AD drugs, usually mild and left limiting but sometimes sever

Question 34

risk of withdrawal is increased if ...

Answer 34

stopped suddenly after regular administration for 8 weeks or more

Question 35

gradually reduce dose over period of ...

Answer 35

about 4 weeks, or longer if withdrawals occur 6 months in pt who have been on long term maintenance

Question 36

this drug is claimed to cause less potentiation of the pressor effect of tyramine than the traditional MAOIs but pt should still avoid consuming large amounts of tyramine rich foods e.g. mature cheese, yeast extracts, fermented soya bean products)

Answer 36

moclobemide

Question 37

moclomebmide dose reduction with concurrent use of cimetidine

Answer 37

reduce dose to 1/2 or 1/3 usual dose

Question 38

Moclobemide interactions - these drugs are predicted to increase risk of severe toxic reaction with given with moclobemide. avoid. (hint: drug class!)

Answer 38

TCAs

Question 39

Moclobemide slightly increases the exposure to this drug class. avoid.

Answer 39

Triptans (+increased risk serotonin syndrome)

Question 40

Moclobemide may increase exposure to this BZDPN, adjust dose

Answer 40

clobazam

Question 41

moclobemide and cimetidine interaction

Answer 41

C increases exposure to M Adjust M dose to 1/2 or 1/3 normal dose with concurrent use

Question 42

Bupropion 2 interactions with moclobemide

Answer 42

B might increase risk of serotonin syndrome with given with M, monitor B may increase risk of severe hypertension with given with M, avoid

Question 43

Avoid these drugs with moclombemide as they are predicted to increase risk of hypertensive crisis.

Answer 43

dexamfetamine, lisdex, methylphenidate ephedrine, phenylephrine, pseudoephedrine, reboxetine opicapone (Increased risk of elevated BP)

Question 44

Moclobemide interaction with this SSRI

Answer 44

escitalopram M predicted to increase exposure to E use with caution and adjust dose + increased risk serotonin syndrome

Question 45

Moclobemide interaction with this anti platelet

Answer 45

clopidogrel predicted to reduce efficacy of C

Question 46

moclobemide interaction with tramadol

Answer 46

avoid serotonin syndrome

Question 47

moclobemide interaction with MAO-B inhibtiors rasagiline and selegiline

Answer 47

M predicted to increase the effect of this drugs avoid also increased risk serotonin syndrome

Question 48

all MAOI interaction with this high risk abx

Answer 48

linezolid Moclobemide/others is predicted to increase the risk of adverse effects when given with Linezolid. Manufacturer advises avoid and for 14 days after stopping Moclobemide or the irreversible MAOIs . Also increased risk serotonin syndrome

Question 49

irreversible MAOIs (phenelzine, tranylcypromine, isocarboxazid). They have antimuscarinic properties, there fore avoid antimuscarinic drugs e.g.

Answer 49

acrivastive azelastine buclizine cetirizine chlorphenamine cinnarizine cyclizine doxylamine desloratidine fexofenadine hydroxyzine loratidine pizotifen promethazine

Question 50

True or false - pt taking irreversible MAOIs should avoid antihistamines (even non drowsy)

Answer 50

Yes, avoid as increased antimuscarinic adverse effects

Question 51

increases risk hypertensive crisis when given with these drugs. avoid and for 14 days after stopping irreversible MAOI

Answer 51

adrenaline, dexamfetamine, ephedrine, dopamine, levodopa, lisdexamfetamine, methylphenidate, midrodrine, phenyl ephedrine, psuedoephedrine, reboxetine

Question 52

avoid these drugs as they are predicted to increase the risk of CNS excitation or depression when given with irreversible MAOIs

Answer 52

alfentanil, buprenorphine, codeine, diamorphine, dihydrocodeine, dipipanone, fentanyl, hydromorphone, methadone, morphine, oxycodone, pethidine, pentazocine, tramadol, tapentadol

Question 53

avoid these 3 drugs with irreversible MAOIs because they are predicted to increase risk of elevated BP when given when them.

Answer 53

buspirone, entacapone, opicapone

Question 54

these drugs are predicted to increase the risk of severe toxic reaction when given with Isocarboxazid. Manufacturer advises avoid and for 14 days after stopping the MAOI.

Answer 54

Carbamazepine + TCAs

Question 55

A patient is suffering from pain that paracetamol and NSAIDs have not controlled. You are looking to optimise their pain by adding an opioid, but quickly realise this is contraindicated because they are taking a certain type of AD. Opioids are predicted to increase risk of CNS excitation or depression when given with these type of ADs, so avoid. which AD?

Answer 55

MAOIs