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MAOI Food and Drug Interactions
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Introduction
A value of 120/80, for example, would be considered normal for most people. Most emergency room doctors would not be particularly concerned until these numbers reach in the range of 190 to 200 / 105 to 110. At that level they might observe you carefully and monitor your blood pressure every few minutes. Most of the time, an elevated blood pressure subsides without treatment. If your blood pressure continues to rise, the ER doctor could give you an antidote (such as phentolamine or prazosin) to lower your blood pressure back to a safe range.

The best time to take your blood pressure is about one to one and a half hours after you have taken the medication. About a quarter of my patients have noted modest blood-pressure elevations at this time even if they have not eaten any of the forbidden foods in Table 24.8 or taken the medicines in Table 24.9. These increases are not usually extreme or dangerous-- a 20- or 30- point elevation in the systolic blood pressure is typical. Nevertheless, in those cases I have recommended stopping the medication because these patients seem overly sensitive to the blood-pressure effects of the MAOI. It just did not seem worth the worry and risk, especially since a different antidepressant might be just as effective.

Foods to Avoid

Hypertensive crises may occur if you eat foods (see Table 24.8 on page 537) that contain a substance known as tyramine. If you are taking an MAOI, too much tyramine can interfere with your brain's ability to regulate your blood pressure. Tyramine causes nerves to release more norepinephrine into the synaptic regions that separate them from the postsynaptic nerves. These postsynaptic nerves may become overly stimulated when too much norepinephrine is released. Because these nerves help to regulate blood pressure, all the extra norepinephrine that is released can cause a dangerous and sudden increase in blood pressure.

You will recall that an enzyme called monoamine oxidase (MAO) is located inside the presynaptic nerves. This enzyme usually destroys any excess norepinephrine that builds up inside these nerves and prevents them from releasing too much norepinephrine when they fire. But the MAOI drugs block this enzyme, and so the norepinephrine levels inside these nerves increase substantially. When you eat foods containing tyramine, all that extra norepinephrine suddenly spills into the synaptic region, causing a massive stimulation of the nerves that regulate your blood pressure.


 
TABLE 24.8
FOODS AND BEVERAGES TO AVOID IF YOU ARE TAKING A
MONOAMINE OXIDASE INHIBITOR (MAOI)*
Foods to Avoid Completely
  • Cheese, particularly strong or aged cheeses (cottage cheese and cream cheese are allowed)
  • Beer and ale: particularly tap beers, beers from microbreweries, and strong ales
  • Red wine: especially Chianti
  • Brewer's yeast tablets or yeast extracts (Breads and cooked forms of yeast are safe. The yeast extracts from health food stores are dangerous. Yeast extracts may be found in certain soups. Some powdered protein diet supplements contain yeast extracts.)
  • Pods of fava beans, also called Italian green beans (regular green beans are safe)
  • Meat or fish that is smoked, dried, fermented, unrefrigerated, or spoiled,
  • Including:
  • fermented or air-dried sausages, such as salami and mortadella (some experts state that bologna, pepperoni, summer sausage, corned beef, and liverwurst are safe)
  • pickled or salted herring
  • liver (beef or chicken), especially old chicken liver (fresh chicken liver is safe)
  • Overripe bananas or avocados (most fruits are completely safe)
  • Sauerkraut
  • Some soups, including those made from beef bouillon or Asian soup stocks (e.g., miso soup). Tinned and packet soups are felt to be safe, unless made from bouillon or meat extracts.
Foods or Beverages That May Cause Problems in Large Amounts
  • White wine or clear alcohol, such as vodka or gin
  • Sour cream
  • Yogurt: must be pasteurized and less than 5 days old to be safe
  • Soy sauce
  • NutraSweet (the artificial sweetener)
  • Chocolate
  • Caffeine in beverages (coffee, tea and soda) and chocolate
Foods or Beverages Once Thought to Cause Problems
Which Are Probably Safe in Small Amounts
  • Figs (avoid overripe figs)
  • Meat tenderizers
  • Caviar, snails, tinned fish, pate
  • Raisins
'Modified from B. McCabe and M. T. Twang, "Dietary Considerations in MAO Inhibitor Regimens,"Journal of Clinical Psychiatry, 43, (1982): 178-81.


 
TABLE 24.9
PRESCRIPTION DRUGS AND OVER THE COUNTER MEDICATIONS
10 AVOID IF YOU ARE TAKING A MONOAMINE OXIDASE INHIBITOR (MAOI)
Note: This list is not exhaustive; new information about drug interactions comes out frequently. If you are taking an MAOI and any other medication, ask your doctor and pharmacist if there are any drug interactions.
Antidepressants
DrugComment
tricyclic antidepressants,' especially some (e.g., clomipramine) may cause desipramine (Norpramin, Pertofrane) and clomipramine (Anafranil) a hyperpyrexic crisis or seizures; others (e.g. desipramine) may cause a hypertensive crisis
tetracyclic antidepressants, especially Bupropion (Wellbutrin) hypertensive crisis (noradrenergic syndrome)
SSRIs (all are extremely dangerous)hyperpyrexic crisis (serotonin syndrome)
other MAOIshyperpyrexic crisis (serotonin syndrome); Hypertensive crisis (noradrenergic syndrome)
serotonin antagonists, including trazodone (Desyrel) and nefazodone (Serzone)hyperpyrexic crisis (serotonin syndrome)
mirtazapine (Remeron)hypertensive crisis (noradrenergic syndrome)
venlafaxine (Effexor)hypertensive crisis (noradrenergic syndrome)


Asthma Medicines
DrugComment
ephedrine, a bronchodilator contained in Marax, Quadrinal, and other asthma drugshypertensive crisis
inhalants which contain albuterol (Proventil, Ventolin), metaproterenol (Alupent, Metaprel), or other beta-adrenergic bronchodilators blood pressure elevations and a rapid heart; beclomethasone and other nonsystemic steroid inhalers are generally safer
theophylline (Theo-Dur), a common ingredient in asthma drugsrapid heart and anxiety
Information in this table was obtained from several sources including the Manual of Clinical Psychopharmacology and Psychotropic Drug, Fair Facts These excellent references are highly recommended. 'Many patients have been successfully treated with a combination of an MAOI and a tricyclic antidepressant under close observation, but such drug combinations are dangerous and require a high level of expert supervision.


 
Cold, Cough, Allergy, Sinus, Decongestant and Hay Fever Medications
(including tablets, drops, or sprays)
DrugComment
antihistamines: terfenadine (Seldane-D)can cause an increase in MAOI blood levels
dextromethorphan can be found in many cold and cough medications, especially any drug with DM or Tuss in its name. These include Bromarest-DM or -DX, Dimetane-DX cough syrup, Dristan Cold & Flu, Phenergan with Dextromethorphan, Robitussin-DM, several Tylenol cold, cough, and flu preparations, and many others hyperpyrexic crisis (serotonin syndrome); may also cause brief episodes of psychosis or bizarre behavior
ephedrine can be found in Bronkaid, Primatene, Vicks Vatronol nose drops, and several other asthma and cold medications.hypertensive crisis (noradrenergic syndrome)
oxymetazoline (Afrin)nose drops or sprays used to treat nasal decongestionhypertensive crisis (noradrenergic syndrome)
phenylephrine can be found in Dimetane, Dristan decongestant, Neo-Synephrine nasal spray and nose drops, and many other similar preparations, including some eye-drop medicationshypertensive crisis (noradrenergic syndrome)
phenylpropanolamine is contained in Alka-Seltzer Plus Cold and Night-Time Cold medicine, Allerest, Contac decongestants, Coricidin D decongestants, Dexatrim appetite pills, Dimetane-DC Cough syrup, Ornade Spansules, Robitussin-CF Sinarest, St. Joseph Cold Tablets, Tylenol Cold medicine, and many others hypertensive crisis (noradrenergic syndrome)
pseudoephedrine can be found in Actifed, Allerest No Drowsiness formula, Benadryl combinations, CoAdvil, Dimetane DX cough syrup, Dristan Maximum Strength, Robitussin DAC syrup, Robitussin-PE, Seldane D tablets, Sinarest No Drowsiness, Sinutab, Sudafed, Triaminic Nite Light, and numerous Tylenol allergy, sinus, flu, and cold preparations, as well as several Vicks products including NyQuil, to mention just a fewhypertensive crisis (noradrenergic syndrome)


Diabetes Medications
DrugComment
insulinmay cause a greater drop in blood sugar
oral hypoglycemic agentsas above


Medications to Treat Low Blood Pressure (for patients in shock)
DrugComment
sympathomimetic amines including:
  • dopamine (Intropin)
  • epinephrine (Adrenalin)
  • isoproterenol (Isuprel)
  • metaraminol (Aramine)
  • methyldopa (Aldomet)
  • norepinephrine(Levophed)
hypertensive crisis (noradrenergic syndrome) because these drugs cause blood vessels to constrict


Medications for High Blood Pressure
DrugComment
guanadrel (Hylorel)
guanethidine (Ismelin)
hydralazine (Apresoline)
methyldopa (Aldomet)
reserpine (Serpasil)
These blood-pressure medications may cause a paradoxical increase in blood pressure when combined with MAOIs
beta-blockersmay be more potent when combined with MAOIs, leading to a greater than expected drop in blood pressure and dizziness when standing
calcium channel blockersappear to be reasonably safe when combined with MAOIs. Check with your doctor and monitor blood pressure closely. Watch for a greater than expected drop in blood pressure
diureticswatch for a greater than expected drop in blood pressure. May increase blood level of the MAOI


Mood Stabilizers
DrugComment
carbamazepine (Tegretol)hyperpyrexic crisis (serotonin syndrome); MAOI may cause carbamazepine levels to fall, so epileptics may experience seizures
lithium (Eskalith)can cause hyperpyrexic crisis (serotonin syndrome) in animal studies


Painkillers and Anesthetics
DrugComment
anesthetics: generalTell your anesthesiologist you are on an MAOI. If possible, discontinue the MAOI two weeks before elective surgery. Muscle relaxants such as succinylcholine and tubocurarine may have a more pronounced or prolonged effect. General anesthetics such as halothane may lead to excitement, excessive depression of the brain, or hyperpyrexic reactions
anesthetics: localSome contain epinephrine or other sympathomimetics--make sure you tell your dentist you are taking an MAOI
cyclobenzaprine (Flexeril) (a muscle relaxant used to treat muscle spasm) hyperpyrexic crisis (serotonin syndrome) or severe seizures
meperidine (Demerol)A single injection can cause seizures, coma, and death (serotonin syndrome). Most other narcotics, including morphine and codeine, have been used safely with MAOIs.


Sedatives and Tranquilizers
DrugComment
alcoholMay have enhanced sedative effects, especially when combined with phenelzine (Nardil.) This could be hazardous when driving or operating dangerous machinery
barbiturates (such as phenobarbital)enhanced sedative effects as described above
buspirone (BuSpar)enhanced sedative effects as described above
major tranquilizers (neuroleptics)enhanced sedative effects as described above; some neuroleptics may cause a drop in blood pressure when combined with MAOIs
minor tranquilizers (benzodiazepines) enhanced sedative effects as such as alprazolam (Xanax), diazepam described above (Valium), and others sleeping pills enhanced sedative effects as described above
L-tryptophanhyperpyrexic crisis (serotonin syndrome); blood-pressure elevations; disorientation, memory impairment, and other neurologic changes


Stimulants (Pep Pills) and Street Drugs
DrugComment
amphetamines ("speed" or "crank")
cocaine syndrome)
benzedrine
benzphetamine (Didrex)
dextroamphetamine (Dexedrine)
methamphetamine (Desoxyn)
methylphenidate (Ritalin)
hypertensive crisis (noradrenergic is possible; methylphenidate considered somewhat less risky than the amphetamines)


Weight Loss and Appetite-Suppression Medications
DrugComment
cylert (Pemoline)drug interactions have not been studied in humans; great caution should be used; some experts report that Pemoline has been combined with MAOIs in some cases
fenfluramine (Pondimin)hyperpyrexic crisis (serotonin syndrome)
phendimetrazine (Plegiline)hypertensive crisis (noradrenergic syndrome)
phentermine and some over-the-counter medicationshypertensive crisis (noradrenergicsyndrome)
phenylpropanolamine (Acutrim)hypertensive crisis (noradrenergic syndrome)
stimulants (listed above)hypertensive crisis (noradrenergic syndrome)


Other MAOI Drug Interactions
DrugComment
caffeine (in coffee, tea, soda, chocolate) Probably safe in moderate amounts; avoid large amounts; may cause blood-pressure elevations, a racing heart, and anxiety
disulfiram (Antabuse) (used to treat alcoholism)Severe reactions when mixed with an MAOI
L-dopa (Sinemet) (used to treat Parkinson's disease)hypertensive crisis (noradrenergicsyndrome)