Psych · Psychopharmacology — monoamine oxidase inhibitors
Monoamine oxidase inhibitors
Also known as MAOIs · Phenelzine · Tranylcypromine · Isocarboxazid · Moclobemide · Selegiline patch · EMSAM · RIMA · Tyramine diet · Cheese reaction
Exam-exhaustive fellowship pharmacology of monoamine oxidase inhibitors — irreversible nonselective agents, RIMA moclobemide, selegiline transdermal system, tyramine and washouts, serotonin toxicity combinations, hypertensive crisis, atypical depression and STAR*D late-pathway TRD use. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Irreversible MAOI plus SSRI, SNRI, clomipramine, imipramine, pethidine, tramadol, dextromethorphan, linezolid or St John's wort — stop and treat as high-risk serotonin toxicity combination
- Severe throbbing headache, neck stiffness or marked blood-pressure surge after aged cheese, cured meat or draft beer on a classic MAOI — treat as tyramine hypertensive crisis
- Fever, clonus, hyperreflexia, agitation and diaphoresis on an MAOI with any serotonergic co-drug — Hunter-criteria serotonin toxicity pathway
- Starting an irreversible MAOI less than about 5 weeks after stopping fluoxetine — incomplete washout is a classic exam fail
- Assuming selegiline 9–12 mg/24 h patch needs no tyramine diet — diet liberalisation teaching applies primarily at 6 mg/24 h
- Orthostatic syncope after phenelzine dose increase without lying/standing BP check
Meet the patient
A 41-year-old librarian has "failed" sertraline, escitalopram and venlafaxine over two years. Her depression is atypical — she sleeps twelve hours, eats for comfort, and feels rejected for days after a minor slight — but her mood still reacts to good news. After a careful review of trial adequacy, your consultant suggests phenelzine.[4][5]
Two exam questions are now live, and the referring team has already fumbled one: "How long since her last antidepressant?" and "What do you teach her before the first tablet?" This topic is the answer to both — the washout arithmetic, the diet, the never-combine list, and why a drug that fell from fashion still belongs in the late-pathway toolkit when the illness is atypical or treatment-resistant.[1][2][4]
References18ShowHide
- [1]Van den Eynde V, Abdelmoemin WR, Abraham MM, et al. The prescriber's guide to classic MAO inhibitors (phenelzine, tranylcypromine, isocarboxazid) for treatment-resistant depression CNS Spectr, 2023.PMID 35837681
- [2]Shulman KI, Herrmann N, Walker SE Current place of monoamine oxidase inhibitors in the treatment of depression CNS Drugs, 2013.PMID 23934742
- [3]Fiedorowicz JG, Swartz KL The role of monoamine oxidase inhibitors in current psychiatric practice J Psychiatr Pract, 2004.PMID 15552546
- [4]Liebowitz MR, Quitkin FM, Stewart JW, et al. Antidepressant specificity in atypical depression Arch Gen Psychiatry, 1988.PMID 3276282
- [5]McGrath PJ, Stewart JW, Fava M, et al. Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medication trials for depression: a STAR*D report Am J Psychiatry, 2006.PMID 16946177
- [6]Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report Am J Psychiatry, 2006.PMID 17074942
- [7]Bodkin JA, Amsterdam JD Transdermal selegiline in major depression: a double-blind, placebo-controlled, parallel-group study in outpatients Am J Psychiatry, 2002.PMID 12411221
- [8]Amsterdam JD A double-blind, placebo-controlled trial of the safety and efficacy of selegiline transdermal system without dietary restrictions in patients with major depressive disorder J Clin Psychiatry, 2003.PMID 12633131
- [9]Lotufo-Neto F, Trivedi M, Thase ME Meta-analysis of the reversible inhibitors of monoamine oxidase type A moclobemide and brofaromine for the treatment of depression Neuropsychopharmacology, 1999.PMID 10063483
- [10]Walker SE, Shulman KI, Tailor SA, et al. Tyramine content of previously restricted foods in monoamine oxidase inhibitor diets J Clin Psychopharmacol, 1996.PMID 8889911
- [11]Van den Eynde V, Gillman PK, Blackwell BB The Prescriber's Guide to the MAOI Diet-Thinking Through Tyramine Troubles Psychopharmacol Bull, 2022.PMID 35721816
- [12]Gillman PK Advances pertaining to the pharmacology and interactions of irreversible nonselective monoamine oxidase inhibitors J Clin Psychopharmacol, 2011.PMID 21192146
- [13]Gillman PK Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity Br J Anaesth, 2005.PMID 16051647
- [14]Boyer EW, Shannon M The serotonin syndrome N Engl J Med, 2005.PMID 15784664
- [15]Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity QJM, 2003.PMID 12925718
- [16]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391
- [17]Kennedy SH, Lam RW, McIntyre RS, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments Can J Psychiatry, 2016.PMID 27486148
- [18]Lam RW, Kennedy SH, Adams C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder Can J Psychiatry, 2024.PMID 38711351