Clinically Relevant Drug Interactions with Monoamine Oxidase Inhibitors

Abstract

Monoamine oxidase inhibitors (MAOI) are a class of drugs that were originally developed for the treatment of depression but have since been expanded to be used in management of affective and neurological disorders, as well as stroke and aging-related neurocognitive changes. Ranging from irreversible to reversible and selective to non-selective, these drugs target the monoamine oxidase (MAO) enzyme and prevent the oxidative deamination of various monoamines and catecholamines such as serotonin and dopamine, respectively. Tyramine is a potent releaser of norepinephrine (NE) and is found in high concentrations in foods such as aged cheeses and meats. Under normal conditions, NE is unable to accumulate to toxic levels due to the presence of MAO-A, an enzyme that degrades neurotransmitters, including NE. When MAO-A is inhibited, the capacity to handle tyramine intake from the diet is significantly reduced causing the brain to be vulnerable to overstimulation of postsynaptic adrenergic receptors with as little as 8-10 mg of tyramine ingested and can result in life-threatening blood pressure elevations. In addition to adverse reactions with certain foods, both older and newer MAOIs can negatively interact with both sympathomimetic and serotonergic drugs. In general, patients on a MAOI want to avoid two types of medications: those that can elevate blood pressure via sympathomimetic actions (e.g., phenylephrine and oxymetazoline) and those that can increase serotonin levels via 5-HT reuptake inhibition (e.g., dextromethorphan, chlorpheniramine, and brompheniramine). Illicit drugs that stimulate the central nervous system such as ecstasy (MDMA, 3,4-methylenedioxymethamphetamine) act as serotonin releasers. Patient involvement is also crucial to ensure any interaction within the healthcare setting includes making other providers aware of a MAOI prescription as well as avoiding certain OTC medications that can interact adversely with MAOIs.

Comparison of the Efficacy of Longer versus Shorter Pulsed High Dose Dapsone Combination Therapy in the Treatment of Chronic Lyme Disease/Post Treatment Lyme Disease Syndrome with Bartonellosis and Associated Coinfections

“…Dietary restrictions were also instituted, avoiding foods high in tyramine, which can potentially produce a hypertensive crisis in the presence of MAOIs and/or higher doses of methylene blue [ 126 ]. Patients were given a list of foods to avoid during the protocol, which included: aged cheese, aged chicken or beef liver, air-dried sausage and similar meats, avocados, beer, and wine (in particular, red wine), canned figs, caviar, fava beans, meat tenderizer, overripe fruit, pickled or cured meat or fish, raisins, sauerkraut, shrimp paste, sour cream, soy sauce, and yeast extracts [ 127 ].…”

Targeting monoamine oxidase A: a strategy for inhibiting tumor growth with both immune checkpoint inhibitors and immune modulators

“…When MAOA is inhibited, the capacity to handle tyramine intake from the diet decreases significantly. This causes the brain to become vulnerable to overstimulation by postsynaptic adrenergic receptors after ingesting a small dose of tyramine (8–10 mg), which in turn can result in life-threatening blood pressure elevations [ 75 ]. Therefore, drugs that irreversibly inhibit MAOA (e.g., tranylcypromine) have dietary restrictions, making them less appealing candidates for treating neurological disorders and as ICB therapies than other available options.…”

Combining Double-Dose and High-Dose Pulsed Dapsone Combination Therapy for Chronic Lyme Disease/Post-Treatment Lyme Disease Syndrome and Co-Infections, Including Bartonella: A Report of 3 Cases and a Literature Review

“…In order to minimize potential interactions with methylene blue, including serotonin syndrome/toxicity [108], patients on psychiatric medications, especially a selective serotonin reuptake inhibitor (SSRI), monoamine oxidase inhibitor (MAOI), and/or bupropion (Wellbutrin), were told to taper their psychiatric medication if clinically stable and/or consult with their psychiatrist before increasing the dose of methylene blue to a maximum final dose of 300 mg twice a day. Dietary restrictions also were instituted, avoiding foods high in tyramine, which can potentially produce a hypertensive crisis in the presence of MAOIs and/or higher-dose methylene blue [109]. Patients were given a list of foods to avoid during the protocol, which included aged cheese, aged chicken or beef liver, air-dried sausage and similar meats, avocados, beer, wine (in particular, red wine), canned figs, caviar, fava beans, meat tenderizer, overripe fruit, pickled or cured meat or fish, raisins, sauerkraut, shrimp paste, sour cream, soy sauce, and yeast extracts [110].…”