_______________________________________________________________________ Depression and Suicide
changes in appetite and weight, sweating, sexual dysfunction, muscle twitches, weakness, nausea and vomiting, hypotension, tachycardia, and arrhythmia. Tolerance to side effects often occurs if treatment is continued. Side effects may also be less troublesome if treatment is initiated with low doses and gradu- ally increased [164; 165]. Monoamine Oxidase Inhibitors MAOIs inhibit monoamine oxidase (MAO), an enzyme that degrades and inactivates 5-HT, norepinephrine, and dopa- mine. This increases monoamine levels and activity. Earlier MAOIs were irreversible MAO inhibitors, deactivating the enzyme until slowly replenished over a two-week period [166; 167]. MAOIs includes phenelzine (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), linezolid (Zyvox, Zyvoxam, Zyvoxid), moclobemide (Aurorix, Manerix), pirlindole (Pira- zidol) (approved for use in parts of Europe), and selegiline (Deprenyl, Eldepryl, Emsam). Most MAOIs appear broadly effective in a range of depressive and anxiety disorders and may be more effective than other antidepressant classes in MDD with pronounced anxiety or panic symptoms [21; 22; 122]. MDD with atypical features may preferentially respond to MAOIs over other antidepres- sant classes. Although effective, MAOIs are rarely the first- or second-line treatment choice due to serious side effect poten- tial from medication interactions and dietary restriction. The selegiline transdermal patch (Emsam) used at the lowest strength (6 mg delivered over 24 hours) may lack the dietary restrictions required of oral MAOIs [168]. Moclobemide is a reversible inhibitor of monoamine oxidase type A, greatly improving its safety, including overdose safety (i.e., 20,000 mg ingestion was non-fatal). This drug lacks TCA side effects or SSRI/SNRI sexual side effects; improved libido, erection, or orgasm is more commonly reported [169; 170]. Moclobemide may be superior to other antidepressants in treatment-resistant depression [171]. This drug is approved for use in Canada and throughout Europe and Asia but is not available in the United States [169].
In general, the American Psychiatric Association recommends that the use of nonselective monoamine oxidase inhibitors (MAOIs) (e.g., phenelzine, tranylcypromine, isocarboxazid) should be restricted to patients who do not respond to other
treatments. (https://psychiatryonline.org/pb/assets/raw/sitewide/ practice_guidelines/guidelines/mdd.pdf. Last accessed July 6, 2023.) Strength of Recommendation : I (Recommended with substantial clinical confidence) Common Side Effects With oral ingestion, MAOIs inhibit the catabolism of dietary amines. When foods containing tyramine are consumed, the individual may suffer from hypertensive crisis ( Table 2 ) [166]. If foods containing tryptophan are consumed, hyperseroto- nemia may result. The amount required to cause a reaction varies greatly from individual to individual and depends on the degree of inhibition, which in turn depends on dosage and selectivity. MAOIs should not be combined with psychotropic drugs or with any other psychoactive substance except under expert care. This includes a wide range of prescribed, over-the-counter, and illicit drugs and nutritional supplements, such as St. John’s wort. Common side effects include orthostatic hypotension, weight gain, sexual dysfunction, sedation, headache, and insomnia [166].
MAOI INTERACTION TO TYRAMINE CONTENT IN FOOD
None to Little Avocados Bananas Bouillon Chocolate Fresh cheeses Fresh meats Peanuts Soy milk Yeast extracts Source: [166]
Moderate
Severe
Red wine White wine Canned beer
Aged cheeses Aged and fermented meats Broad (fava) bean pods Spoiled meats and fish Soy sauce Tap beer Smoked or pickled fish Sauerkraut
Table 2
189
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