Monoamine Oxidase Inhibitors (MAOI)


Article Author:
Tahrier Sub Laban


Article Editor:
Abdolreza Saadabadi


Editors In Chief:
Steven Anderson


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James Hughes
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Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/7/2019 8:22:46 PM

Indications

Monoamine oxidase inhibitors (MAOIs) were first introduced in the 1950s.[1][2] They are a separate class from other antidepressants, treating different forms of depression as well as other nervous system disorders such as panic disorder, social phobia, and depression with atypical features.[3] Examples of atypical features are oversleeping and overeating. Even though MAOIs were the first antidepressants introduced, they are not the first choice in treating mental health disorders due to several dietary restrictions, side effects, and safety concerns. MAOIs are only a treatment option when all other medications are unsuccessful.

Furthermore, examples of neurological disorders that can benefit from MAOIs are patients with Parkinson disease as well as those diagnosed with multiple system atrophy.[4][5]  Multiple system atrophy is a neurodegenerative disease that includes symptoms affecting movement as well as blood pressure. 

Mechanism of Action

Monoamine oxidase inhibitors are responsible for blocking the monoamine oxidase enzyme. The monoamine oxidase enzyme breaks down different types of neurotransmitters from the brain: norepinephrine, serotonin, dopamine, as well as tyramine. MAOIs inhibit the breakdown of these neurotransmitters thus, increasing their levels and allowing them to continue to influence the cells that have been affected by depression.[6]

Administration

MOAIs administration is almost always orally but sometimes comes in the form of a skin patch.[1] The skin patches were recently FDA approved and can be more beneficial to patients than oral dose forms. An example of this is selegiline, which can be given in a skin patch and causes fewer side effects than when administered orally.[1] Patients with lower doses of MAOIs may not have to be as strict with their diet as those with higher doses.

The different types of MAOIs approved by the FDA include the following: isocarboxazid, phenelzine, selegiline, and tranylcypromine.[7] When patients are prescribed antidepressants like MAOIs, they must be aware of the time it takes to start experiencing the therapeutic effects of the drug. Usually, the medication starts to become effective within two to three weeks. However, patients should take the antidepressant for at least six months for the maximal therapeutic benefit. Patients that take an antidepressant for less than six months are shown to have a high rate of symptomatic relapse.

Adverse Effects

The most frequently encountered side effects are dry mouth, nausea, diarrhea, constipation, drowsiness, insomnia, dizziness and/or lightheadedness; furthermore, if applied via patch, a skin reaction may occur at the patch site.[7] Recommendations are that any patient scheduled for an elective surgery that requires general anesthesia, should not take MAOIs for at least ten days before the surgery as to avoid any drug interaction.[8][9]

Contraindications

MAOIs have the potential to cause drug-to-drug interactions, drug-food interaction, and overdoses, of which the patient should be aware.[7] For example,  patients should not be mixing MAOIs with other antidepressants like selective serotonin reuptake inhibitors (SSRIs).[10] These two drugs combined can cause serotonin syndrome, which is potentially fatal. The first cases of serotonin syndrome were reported during the 1960s when patients were on MAOIs and tryptophan. Patients showed signs and symptoms of fever, confusion, increased perspiration, muscle rigidity, seizures, problems with liver or kidney, fluctuation of heart rhythms, and blood pressure. Furthermore, when changing MAOIs to another antidepressant, patients should give themselves 14 days to pass before initiating the new treatment, to prevent any drug interaction.

MAOIs prevent the break down of tyramine found in the body as well as certain foods, drinks, and other medications. Patients that take MAOIs and consume tyramine-containing foods or drinks will exhibit high serum tyramine level.[11][12] A high level of tyramine can cause a sudden increase in blood pressure, called the tyramine pressor response.[12] Even though it is rare, a high tyramine level can trigger a cerebral hemorrhage which can even result in death.

Eating foods with high tyramine can trigger a reaction that can have serious consequences.[12] Patients should know that tyramine can increase with the aging of food; they should be encouraged to have foods that are fresh instead of leftovers or food prepared hours earlier.  Examples of high levels of tyramine in food are types of fish, as well as types of meat including sausage, turkey, liver, and salami.[13][14] Also, certain fruits can contain tyramine like overripe fruits, avocados, bananas, raisins or figs. Further examples are cheeses, alcohol, and fava beans; all of these should be avoided even after two weeks of stopping MAOIs.[14] Anyone taking MAOIs is at risk for an adverse hypertensive reaction, with accompanying morbidity.

Monitoring

Even though MAOIs are no longer a first-line treatment option, they are still in use, and it is important to note the precautions when treatment is initiated[10]. Patients should be encouraged by health providers to carry identification cards or wear a wrist band[7]. Patients always need to notify every doctor they encounter; whether dental or medical, to avoid any health consequences especially due to the medications' influence on the vasculature.

Toxicity

Patients taking MAOIs can overdose and may show similar side effects as stated above except with more severe presentation.[15] Anyone on MAOIs may experience symptoms slowly within the first 24 to 48 hours. However, symptoms can be nonspecific, which range from mild to severe to even life-threatening. Depending on the MAOI prescribed, some can cause patients to go into a coma, and others  (e.g., overdosing on tranylcypromine) can result in death.[7] The severity not only depends on the amount consumed but also which type of MAOIs were taken. For example, phenelzine and tranylcypromine being nonselective and nonreversible, increase the risk of a patient experiencing a hypertensive crisis when ingested with tyramine.  However, selegiline is a selective MAO-B inhibitor with less hypertensive risk.[4] Any patient experiencing any of the following: agitation, flushing, tachycardia, hypotension or hypertension, palpations, twitching, increased deep tendon reflexes, seizures, or high fevers should immediately report to a health provider.[7]

Enhancing Healthcare Team Outcomes

Safety and optimal treatment are vital to patient health. Patients with a history of seizures or epilepsy should avoid MAOIs; these medications can increase the occurrence of seizures. Also, people with a history of alcoholism, angina, severe headaches, blood vessel disease, diabetes, kidney or liver disease, history of a recent heart attack or stroke, overactive thyroid, and pheochromocytoma should not receive MAOI therapy; since this may cause a hypertensive crisis.[2] This caution is also necessary for patients with a family history of depression, any neurological disorders, or even if any family members have attempted suicide. Due to the high-risks, it is crucial for patients to provide a complete family history. Educating the patient on the importance of possible risks and side effects of the drug are critical for their well being, and it provides them an opportunity for a better outcome.

Ads with other illnesses, depression and other psychiatric treatment plans pose multiple dilemmas for physicians.[15] These patients may need to try multiple medication regimens before achieving effective treatment. Someone experiencing depression or panic attacks may have significant life changes, and usually, the family physician is aware of these changes. While a psychiatric physician is almost always involved with patients dealing with different types of mental health issues; it is important to consult with an interprofessional group specialist that includes a family physician, internal medicine, specialty-trained mental health nurse, neurologist, and pharmacist.[16] Also, all other health providers involved in the care of the patient are vital members of the interprofessional team, for example, other nurses and social workers. Each member provides an essential element to the patient's treatment plan. Evidence has shown promoting interprofessional communication by consulting specialists can improve the outcome of a patient's health as well as their adherence to the plan.[17]


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Monoamine Oxidase Inhibitors (MAOI) - Questions

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Which of the following would not cause shortness of breath, anxiety, chest pain, vomiting, nausea, severe headache when consumed with isocarboxazid?



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Which combination of a food product and drug can result in the idiosyncratic drug reaction leading to hypertensive crises?



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A 16-year-old patient presents to the clinic with severe mood changes. He has been feeling down for the past two months. He generally feels fatigued, lacks concentration, eats more and has started to have suicidal thoughts recently. His family history is significant for schizophrenia in a paternal uncle. His physical examination is unremarkable. The provider prescribes him a medication which inhibits an enzyme required for degradation of serotonin, epinephrine, and dopamine. Which of the following should also be recommended?



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Which of the following antidepressant classes requires a "wash out" period prior to starting another antidepressant agent?



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Which of the following should be avoided when taking a monoamine oxidase inhibitor drug? Select all that apply.



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Monoamine Oxidase Inhibitors (MAOI) - References

References

Culpepper L, Reducing the Burden of Difficult-to-Treat Major Depressive Disorder: Revisiting Monoamine Oxidase Inhibitor Therapy. The primary care companion for CNS disorders. 2013     [PubMed]
Rapaport MH, Dietary restrictions and drug interactions with monoamine oxidase inhibitors: the state of the art. The Journal of clinical psychiatry. 2007     [PubMed]
Thase ME, MAOIs and depression treatment guidelines. The Journal of clinical psychiatry. 2012 Jul     [PubMed]
Volz HP,Gleiter CH, Monoamine oxidase inhibitors. A perspective on their use in the elderly. Drugs & aging. 1998 Nov     [PubMed]
McFarland NR, Diagnostic Approach to Atypical Parkinsonian Syndromes. Continuum (Minneapolis, Minn.). 2016 Aug     [PubMed]
Baker GB,Coutts RT,McKenna KF,Sherry-McKenna RL, Insights into the mechanisms of action of the MAO inhibitors phenelzine and tranylcypromine: a review. Journal of psychiatry & neuroscience : JPN. 1992 Nov     [PubMed]
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Müller T,Riederer P,Grünblatt E, Determination of Monoamine Oxidase A and B Activity in Long-Term Treated Patients With Parkinson Disease. Clinical neuropharmacology. 2017 Sep/Oct;     [PubMed]
Thomas SJ,Shin M,McInnis MG,Bostwick JR, Combination therapy with monoamine oxidase inhibitors and other antidepressants or stimulants: strategies for the management of treatment-resistant depression. Pharmacotherapy. 2015 Apr;     [PubMed]

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