antidepressants - MAOI Flashcards
why are they less frequently used than TCAs or SSRIs and related antidepressants.
due to danger of dietary and drug interactions
This MAOI has a greater stimulant action than the other two and are more likely to cause a hypertensive crisis
Tranylcypromine has a greater stimulant action than phenelzine or isocarboxazid
How to remember: stimulant is TRANYLCYPROMINE - ST in alphabet
These two drugs are more likely to cause hepatoxicity than the this other one
Isocarboxazid and phenelzine are more likely to cause hepatotoxicity than tranylcypromine.
This drug should be reserved as a 2nd line treatment
Moclobemide
Phobic pt and depressed pt with atypical, hypochondriac or hysteria features are said to respond best to which AD?
MAOIs
MAOIs should be tried in any patients who are refractory to treatment with other AD as there is
occasionally a dramatic response
response to treatment with MAOI can take ..
can be delayed for 3 weeks or more
may take an additional 1-2 weeks to become maximal
How long to start other AD after treatment with MAOIs has been stopped.
do not start for 2 weeks after treatment has been stopped
3 weeks if starting clomipramine or imipramine
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
Need to wait 3 weeks (if going onto imipramine or clomipramine from MAOI, otherwise normally wait 2 weeks)
A patient is taking tranylcypromine but have not had response. They are going to be switched onto phenelzine. When can they start taking phenelzine?
An MAOI should not be started until at least 2 weeks after a previous MAOI has been stopped (then start at reduced dose)
An MAOI should not be started until at least ….. days after a TCA has been stopped
7-14 days
3 weeks for clompiramine, imipramine
An MAOI should not be started until at least ……. after an SSRI has been stopped
A week
5 weeks in the case of fluoxetine
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?
5 weeks
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.
Fluanxol (flupentixol)
What food must be avoided in patients taking MAOIs and why
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
One reversible and 3 irreversible MAOIs
reversible: mocolobemide
irreversible: tranycylpromine, phenelzine, isocarboxazid
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
Green vegetables
4 contraindications
- cerebrovascular disease
- not indicated in manic phase
- phaeochromocytoma
- severe CVD
is postural hypotension a SE
yes more common in elderly
is akathisia (inability to remain still) a SE?
yes
what to do if pt develops palpitations or frequent headaches
discontinue
use in pregnancy
avoid unless compelling reasons
risk of neonatal malformations
use in HI
generally avoid
monitoring requirements
BP
risk of postural hypotension and hypertensive responses
patient and carer advice regarding fresh food & alcohol & non alcoholic drinks
- 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
true or false - pt should avoid dealcoholised aka low alcohol drinks
true
for tranylcypromine, it is given BD, but second dose should be taken at a time no later than…
3pm
tranylcypromine CI
history of hepatic disease
hyperthyroidism
use in BF
avoid
MOA moclobemide
reversible inhibition of MAO type A
all MAOIs are licensed for depressive illness. Moclobemide is also licensed for this indication
social anxiety disorder
moclobemide 2 CI
acute confusional states
pheochromocytoma
treatment cessation
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
risk of withdrawal is increased if …
stopped suddenly after regular administration for 8 weeks or more
gradually reduce dose over period of …
about 4 weeks, or longer if withdrawals occur
6 months in pt who have been on long term maintenance
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)
moclobemide
moclomebmide dose reduction with concurrent use of cimetidine
reduce dose to 1/2 or 1/3 usual dose
Moclobemide interactions - these drugs are predicted to increase risk of severe toxic reaction with given with moclobemide. avoid.
(hint: drug class!)
TCAs
Moclobemide slightly increases the exposure to this drug class. avoid.
Triptans (+increased risk serotonin syndrome)
Moclobemide may increase exposure to this BZDPN, adjust dose
clobazam
moclobemide and cimetidine interaction
C increases exposure to M
Adjust M dose to 1/2 or 1/3 normal dose with concurrent use
Bupropion 2 interactions with moclobemide
B might increase risk of serotonin syndrome with given with M, monitor
B may increase risk of severe hypertension with given with M, avoid
Avoid these drugs with moclombemide as they are predicted to increase risk of hypertensive crisis.
dexamfetamine, lisdex, methylphenidate
ephedrine, phenylephrine, pseudoephedrine, reboxetine
opicapone (Increased risk of elevated BP)
Moclobemide interaction with this SSRI
escitalopram
M predicted to increase exposure to E
use with caution and adjust dose
+ increased risk serotonin syndrome
Moclobemide interaction with this anti platelet
clopidogrel
predicted to reduce efficacy of C
moclobemide interaction with tramadol
avoid
serotonin syndrome
moclobemide interaction with MAO-B inhibtiors rasagiline and selegiline
M predicted to increase the effect of this drugs
avoid
also increased risk serotonin syndrome
all MAOI interaction with this high risk abx
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
irreversible MAOIs (phenelzine, tranylcypromine, isocarboxazid). They have antimuscarinic properties, there fore avoid antimuscarinic drugs e.g.
acrivastive
azelastine
buclizine
cetirizine
chlorphenamine
cinnarizine
cyclizine
doxylamine
desloratidine
fexofenadine
hydroxyzine
loratidine
pizotifen
promethazine
True or false - pt taking irreversible MAOIs should avoid antihistamines (even non drowsy)
Yes, avoid as increased antimuscarinic adverse effects
increases risk hypertensive crisis when given with these drugs. avoid and for 14 days after stopping irreversible MAOI
adrenaline, dexamfetamine, ephedrine, dopamine, levodopa, lisdexamfetamine, methylphenidate, midrodrine, phenyl ephedrine, psuedoephedrine, reboxetine
avoid these drugs as they are predicted to increase the risk of CNS excitation or depression when given with irreversible MAOIs
alfentanil, buprenorphine, codeine, diamorphine, dihydrocodeine, dipipanone, fentanyl, hydromorphone, methadone, morphine, oxycodone, pethidine, pentazocine, tramadol, tapentadol
avoid these 3 drugs with irreversible MAOIs because they are predicted to increase risk of elevated BP when given when them.
buspirone, entacapone, opicapone
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.
Carbamazepine + TCAs
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?
MAOIs
