Why do people say MAOIs are scary?

[Sras]

I've been reading this thread and I was just wondering why people are saying that MAOIs are scary?

[Guest]

Because they have the potential for death if you eat the wrong thing.

Death is one of the most serious side effects of any medication.

[Sras]

What do you mean by eat the wrong thing? As in food stuff or drug interactions?

[Velvet Elvis]

Food stuff. They have strict dietary limitations.

[Guest]

Yeah, I wasn't very clear at all. Its foods containing tyramine such as some cheeses, some fruit, processed food, soy, red wine and loads of other things.

[Sras]

ok thanks

[nibblerd]

I am a fan of the new type of MAOI called a RIMA (reversible inhibitor of monoamine oxidaise type A). RIMAs have a unique property that allows them to unbind from the MAO enzyme in order for tyramine to be processed. The interesting part is that tyramine does not ever cross the blood-brain barrier, so this new property of reversibility does not mean much with regards to efficacy (the MAOI does not become displaced in the brain, only your gut). In comparison, the older MAOIs would bind to the MAO enzyme irriversibly and non-selectively, requiring up to two weeks to have new MAO floating around. The difference in efficacy is negligible when considering the difference in side-effect profiles.

[bpladybug]

Because they have the potential for death if you eat the wrong thing.

Death is one of the most serious side effects of any medication.

lol, such dead pan humor, ha ha I like it.

[Moil]

Crazymeds lists these as some of the more popular interacting things:

pizza, wine, coffee, chocolate, kim chee, sauerkraut, avocados, fava beans, aged cheeses, especially ripe bananas, practically every OTC medication and a host of other foods and prescription drugs

Personally I would rather not have my morning coffee result in a severe life deficiency...but I only know what little I've read, so the Hensleys of the board would be better sources than I.

Edit: Fixed some grammar issues.

[notfred]

practically every OTC medication

That is a gross generalization. The major ones are decongestants and DXM. There are more on the prescribed meds side of things.

nf

[Aurochs]

The difference in efficacy [between RIMAs and classical MAOIs] is negligible when considering the difference in side-effect profiles.

The only RIMA approved for use in English-speaking countries that I'm aware of is moclobemide, which has a poor clinical impression of efficacy. RIMAs still have dangerous interactions with a variety of other medications, making them much more risky than the SSRIs. Large amounts of tyramine may still cause hypertensive crisis in the presence of a RIMA.

No RIMAs are currently approved by the FDA. I do not expect any to be, unless one proves to be good enough to offset the risks.

Personally I would rather not have my morning coffee result in a severe life deficiency...but I only know what little I've read, so the Hensleys of the board would be better sources than I.

Stimulants are strictly contraindicated when using MAOIs, because the two types of drugs have an additive effect.

[nibblerd]

The difference in efficacy [between RIMAs and classical MAOIs] is negligible when considering the difference in side-effect profiles.

The only RIMA approved for use in English-speaking countries that I'm aware of is moclobemide, which has a poor clinical impression of efficacy. RIMAs still have dangerous interactions with a variety of other medications, making them much more risky than the SSRIs. Large amounts of tyramine may still cause hypertensive crisis in the presence of a RIMA.

No RIMAs are currently approved by the FDA. I do not expect any to be, unless one proves to be good enough to offset the risks.

It's an enormous level of tyramine needed to induce a hypertensive crisis. Honestly, you'd need to eat more smoked sausage or pickles than anyone would ever want to eat. Okay, maybe there are people that like eating that much smoked sausage -- but I digress.. The studies I have read on efficacy demonstrated that it is equivalent to SSRIs (though not on the same people, mind you) and has a 3 to 13% loss compared to the older, irreversible MAOIs. I am aware of the potential for interactions, and I'm sure that the prescribing doctor does too. I'm not trying to say they are a better choice than the SSRI as a first line of defense, because it all depends on the patient's ability to follow medication guidelines.. But if an SSRI, a TCA, and Remeron (yuck) don't work, then instead of using an older MAOI, the patient may have a better chance trying the RIMA first. My pdoc and his colleagues all generally have had excellent results with moclobemide when an SSRI does not work. By the way, I'm Canadian, and we have MOC here

MOC treatment is seldom associated with hypertensive crises, even when tyramine ingestion exceeds the concentrations that are present in cheese, red wine, or beer (Laux et al. 1995). MOC is less likely to cause a hypertensive crisis than clorgyline because it is readily displaced by tyramine from its binding site on MAO-A (Youdim, 1995). Thus, it takes about 8 times more tyramine (i.e., 63 mg) to elicit a 30-mm/Hg rise in supine diastolic blood pressure during MOC treatment as compared to tranylcypromine treatment (i.e., 8 mg tyramine) (Laux et al. 1995). Further, because tyramine does not normally cross the blood-brain barrier, central MAO-A will remain inhibited irrespective of dietary intake. Reversibility thus should not alter the RIMAs effects on norepinephrine and serotonin in the central nervous system (Korn et al. 1988).

MOC has linear pharmacokinetics and a wide therapeutic index. Amounts as high as 20,000 mg have been ingested without fatality (Laux et al. 1995). After oral MOC administration, 95% of the dose is recovered in the urine within 4 days, with a mean of 92% excreted during the first 12 h. Although highly protein bound, the elimination half-life of MOC ranges from 1 to 3 h, and metabolism is not greatly affected by age or diet (Laux et al. 1995).

Tyramine is also able to be metabolized by MAO-B if there is a great enough demand. MOC doesn't inhibit MAO-B.. I imagine it could be made more effective for depression by combining it with a small dose of L-selegiline for some MAO-B inhibition as well

[SashaSue]

Nibblerd, could you share links to these studies of which you speak? Everything I can remember seeing suggests that moclobemide's efficacy is none too impressive.

[nibblerd]

Nibblerd, could you share links to these studies of which you speak? Everything I can remember seeing suggests that moclobemide's efficacy is none too impressive.

http://www.nature.co...l/1395258a.html

Note: ITT => Intent To Treat

AT => Adequate Treatment

Moclobemide Contrasted with Older MAOIs: Four studies were available (one with isocarboxazid and three with tranylcypromine) for the ITT comparison, although just two were suitable for the AT comparison (see Table 6).

The overall ITT efficacy of MOC was 68.0% (7.3%) and the AT efficacy was 71.6% (6.8%). The ITT difference was -5.8% (8.4%), and the AT differences was -13.3% (6.8%) in favor of the nonselective MAOIs. Furthermore, in the one trial in which MOC was superior to tranylcypromine (Gabelic and Kuhn 1990), the dosage of the older MAOI drug was clearly subtherapeutic (i.e., 10-30 mg/day).

Five studies compared MOC with imipramine (Lecrubier and Guelfi 1990; Pancheri et al. 1994; Rimon et al. 1993; Ucha Udabe et al. 1990; Versiani et al. 1989).

Three studies used clomipramine (Anafranil) as the comparator (Kragh-Sorensen et al. 1995; Larsen et al. 1991; Lecrubier and Guelfi 1990), two studies each used amitriptyline (Elavil) (Bakish et al. 1992c; Kusalic et al. 1993) or maprotiline (Gachoud et al. 1994; Steinmeyer et al. 1993), and one each compared MOC with isocarboxazid (Marplan) (Larsen et al. 1991), fluvoxamine (Luvox) (Bougerol et al. 1992), amineptine (Macher and Mirabaud 1992), doxepin (Sinequan) (Philipp et al. 1993), or dothiepin (Beaumont et al. 1993). Meta-analysis of the ITT samples showed a 2.6% (2.5%) difference (MOC > comparators), and, for the 13 AT samples, the difference in response rates was 1.7% (3.7%). These findings confirm MOC's comparability to other active antidepressants for treatment of ambulatory patient groups.

Moclobemide versus SSRIs Across inpatient and outpatient settings, eight studies compared MOC with SSRIs. There were two contrasts with fluvoxamine and six against fluoxetine (see Table 5). In these eight trials, MOC had an ITT response rate of 58.0% (3.4%). In the AT samples, the MOC response rate was 67.9% (3.8%). The difference between MOC and the SSRIs was 6.4% (3.9%) in the ITT analysis, and, for AT sample, the difference was of 4.8% (4.1%). In both cases, there was a small but reliable advantage favoring MOC over the SSRIs. However, the clinical significance of these such small differences in response rates is certainly debatable.

Both MOC and BRO appear to be safer and better tolerated than the older, nonselective, and irreversible MAOIs. Tolerability also appears to favor the RIMAs when compared to TCAs, although these differences were less pronounced. In all, the safety and tolerability advantage of the RIMAs appears to be similar to that of the SSRIs. Preliminary evidence also suggests that MOC has good longer-term tolerability and sustained prophylactic efficacy.

Although the experience prescribing is limited in RIMAs in the United States, many clinicians in Mexico, Canada, Brazil, the United Kingdom, and Europe believe that MOC is not as effective as nonselective MAOIs such as tranylcypromine or phenelzine. Consistent with these clinical impressions, the results of our meta-analysis indicate a clinically significant advantage for the older MAOIs [13.3% (6.8%)] in the "adequate trial" comparison. It should be noted, however, that this conclusion is based on only four direct comparisons and is hardly definitive.

If true, what could account for the difference between MOC and tranylcypromine or phenelzine? On one hand, the inhibition of both the A and B MAO isoenzymes may convey a stronger antidepressant effect by enhancing dopaminergic neurotransmission or by increasing levels of trace biogenic amines such as phenylethylamine. Reversibility of MAO inhibition, in and of itself, also may be associated with less robust or pronounced effects on central monoaminergic systems through some as yet unexplained mechanism. It is also possible that the optimal dose of MOC for treatment of more severe or refractory mood disorders is higher than currently appreciated. For example, Angst et al. (1995) have marshalled data to suggest that MOC at doses of 400 mg/day is a less effective treatment of severely depressed inpatients than either clomipramine (150 mg/day) or MOC at higher dosages (450 mg/day). It would appear, then, that prescription of larger doses (i.e., 450 to 900 mg/day) would be a rational first step for management of an ineffective but well-tolerated trial of MOC.

Soooooo.... looks to me like it is comparable to everything except for the older, irreversible MAOIs. That does not sound like it is inefficacious! The main thing about its current usage is that the dosage hasn't quite been figured out yet. Some do okay on 150mg, some need 600mg, and some may do well on even more. The good thing is that it is well tolerated even into astronomical doses.

[Guest]

Soooooo.... looks to me like it is comparable to everything except for the older, irreversible MAOIs. That does not sound like it is inefficacious! The main thing about its current usage is that the dosage hasn't quite been figured out yet. Some do okay on 150mg, some need 600mg, and some may do well on even more. The good thing is that it is well tolerated even into astronomical doses.

You sound like a drug rep.

[nibblerd]

Soooooo.... looks to me like it is comparable to everything except for the older, irreversible MAOIs. That does not sound like it is inefficacious! The main thing about its current usage is that the dosage hasn't quite been figured out yet. Some do okay on 150mg, some need 600mg, and some may do well on even more. The good thing is that it is well tolerated even into astronomical doses.

You sound like a drug rep.

I'll keep that in mind as a future job possibility!

[Aurochs]

http://www.nature.co...l/1395258a.html

Not only is this a meta-analysis, subject to all the problems that meta-analyses have, but it includes journal supplements. Journal supplements are not consistently peer-reviewed, and are financed entirely by drug companies. They cannot be considered as anything other than advertisements. Since the study does not specify which data came from journal supplements, or even the number of journal supplements they used, it's hard to interpret their findings. The mere fact that they felt the need to include journal supplements speaks to the amount of solid peer-reviewed data available.

[Moil]

practically every OTC medication

That is a gross generalization. The major ones are decongestants and DXM. There are more on the prescribed meds side of things.

nf

You know, I probably shouldn't have quoted that and just used the link...It makes more sense in the original context.  On the original page I believe it was more of a comment on the length of the list of potentially interacting drugs

[null0trooper]

Maybe I shouldn't, but every morning I drink a huge mug of coffee. I have checked my BP after many times and no problem at all. Thank God because I love my morning coffee. I drink it very strong too. I also love chocolate and eat a Bar a few times a week with no problem. I had an entire small cheese and black olive pizza last night. No problem with that either.

Coffee and chocolate make the online lists because too many people assume that anything that can promote wakefulness is exactly the same type of stimulant as amphetamine.

It *might* become a blood pressure problem if you did slip up and consume a high-tyramine meal, but otherwise there should be room for modest consumption.

[SashaSue]

Nibblerd, could you share links to these studies of which you speak? Everything I can remember seeing suggests that moclobemide's efficacy is none too impressive.

http://www.nature.co...l/1395258a.html

Note: ITT => Intent To Treat

AT => Adequate Treatment

Moclobemide Contrasted with Older MAOIs: Four studies were available (one with isocarboxazid and three with tranylcypromine) for the ITT comparison, although just two were suitable for the AT comparison (see Table 6).

The overall ITT efficacy of MOC was 68.0% (7.3%) and the AT efficacy was 71.6% (6.8%). The ITT difference was -5.8% (8.4%), and the AT differences was -13.3% (6.8%) in favor of the nonselective MAOIs. Furthermore, in the one trial in which MOC was superior to tranylcypromine (Gabelic and Kuhn 1990), the dosage of the older MAOI drug was clearly subtherapeutic (i.e., 10-30 mg/day).

Five studies compared MOC with imipramine (Lecrubier and Guelfi 1990; Pancheri et al. 1994; Rimon et al. 1993; Ucha Udabe et al. 1990; Versiani et al. 1989).

Three studies used clomipramine (Anafranil) as the comparator (Kragh-Sorensen et al. 1995; Larsen et al. 1991; Lecrubier and Guelfi 1990), two studies each used amitriptyline (Elavil) (Bakish et al. 1992c; Kusalic et al. 1993) or maprotiline (Gachoud et al. 1994; Steinmeyer et al. 1993), and one each compared MOC with isocarboxazid (Marplan) (Larsen et al. 1991), fluvoxamine (Luvox) (Bougerol et al. 1992), amineptine (Macher and Mirabaud 1992), doxepin (Sinequan) (Philipp et al. 1993), or dothiepin (Beaumont et al. 1993). Meta-analysis of the ITT samples showed a 2.6% (2.5%) difference (MOC > comparators), and, for the 13 AT samples, the difference in response rates was 1.7% (3.7%). These findings confirm MOC's comparability to other active antidepressants for treatment of ambulatory patient groups.

Moclobemide versus SSRIs Across inpatient and outpatient settings, eight studies compared MOC with SSRIs. There were two contrasts with fluvoxamine and six against fluoxetine (see Table 5). In these eight trials, MOC had an ITT response rate of 58.0% (3.4%). In the AT samples, the MOC response rate was 67.9% (3.8%). The difference between MOC and the SSRIs was 6.4% (3.9%) in the ITT analysis, and, for AT sample, the difference was of 4.8% (4.1%). In both cases, there was a small but reliable advantage favoring MOC over the SSRIs. However, the clinical significance of these such small differences in response rates is certainly debatable.

Both MOC and BRO appear to be safer and better tolerated than the older, nonselective, and irreversible MAOIs. Tolerability also appears to favor the RIMAs when compared to TCAs, although these differences were less pronounced. In all, the safety and tolerability advantage of the RIMAs appears to be similar to that of the SSRIs. Preliminary evidence also suggests that MOC has good longer-term tolerability and sustained prophylactic efficacy.

Although the experience prescribing is limited in RIMAs in the United States, many clinicians in Mexico, Canada, Brazil, the United Kingdom, and Europe believe that MOC is not as effective as nonselective MAOIs such as tranylcypromine or phenelzine. Consistent with these clinical impressions, the results of our meta-analysis indicate a clinically significant advantage for the older MAOIs [13.3% (6.8%)] in the "adequate trial" comparison. It should be noted, however, that this conclusion is based on only four direct comparisons and is hardly definitive.

If true, what could account for the difference between MOC and tranylcypromine or phenelzine? On one hand, the inhibition of both the A and B MAO isoenzymes may convey a stronger antidepressant effect by enhancing dopaminergic neurotransmission or by increasing levels of trace biogenic amines such as phenylethylamine. Reversibility of MAO inhibition, in and of itself, also may be associated with less robust or pronounced effects on central monoaminergic systems through some as yet unexplained mechanism. It is also possible that the optimal dose of MOC for treatment of more severe or refractory mood disorders is higher than currently appreciated. For example, Angst et al. (1995) have marshalled data to suggest that MOC at doses of 400 mg/day is a less effective treatment of severely depressed inpatients than either clomipramine (150 mg/day) or MOC at higher dosages (450 mg/day). It would appear, then, that prescription of larger doses (i.e., 450 to 900 mg/day) would be a rational first step for management of an ineffective but well-tolerated trial of MOC.

Soooooo.... looks to me like it is comparable to everything except for the older, irreversible MAOIs. That does not sound like it is inefficacious! The main thing about its current usage is that the dosage hasn't quite been figured out yet. Some do okay on 150mg, some need 600mg, and some may do well on even more. The good thing is that it is well tolerated even into astronomical doses.

Right. So it's less effective than the older MAOI's, and has no apparent advantage over SSRI's.

[Moil]

Maybe I shouldn't, but every morning I drink a huge mug of coffee. I have checked my BP after many times and no problem at all. Thank God because I love my morning coffee. I drink it very strong too. I also love chocolate and eat a Bar a few times a week with no problem. I had an entire small cheese and black olive pizza last night. No problem with that either.

I wouldn't want to give up pizza and my BP maybe goes up 4 points after eating one. For cheese just stick to Mozzerella, provolone, or American which are not aged and no problems.

Fava Beans and Saurkuart.....Uck! Wouldn't want them anyway, but I do miss pickles.

As for OTC drugs, yea you need to be careful, but you would be supprised how many of them are ok to take. Some cold medicines are off limits, but I never took much of them even when I got sick.

I was doing some reading and found that coffee and chocolate both have MAOI like things in them...I wonder if this is the reason they make these lists...I guess I have another question for my PDoc when next I seen him.

I think I'll stop here before I get any more off topic...

[nibblerd]

Phenelzine looks yummy.

[null0trooper]

Phenelzine looks yummy.

That's nothin'. At least one brand of Parnate is red, shiny-coated, and cinnamon-flavored.

[nibblerd]

Phenelzine looks yummy.

That's nothin'. At least one brand of Parnate is red, shiny-coated, and cinnamon-flavored.

I found certain advil, tylenol and semi-synthetic opioids had very pleasant tastes to them but it's only slightly coated in sugar.. once it runs out, blech!

[Guest]

Have a chew on a xanax, They have a pretty unique taste.

[nibblerd]

Have a chew on a xanax, They have a pretty unique taste.

I bit one in half before, not pleasant at all!

[Moil]

 I talked to my PDoc about it and coffee doesn't appear to be a big deal...at least as long as you don't go crazy about it.  I've come to the belief that it only makes those lists because it contains things that could interact with the MAOI, but not necessarily in a way that is a problem...and not because it contains that substance who's name I cannot remember at the moment that can cause headaches...and those other things that can happen with a ridiculous blood pressure. 

[Velvet Elvis]

 I talked to my PDoc about it and coffee doesn't appear to be a big deal...at least as long as you don't go crazy about it.  I've come to the belief that it only makes those lists because it contains things that could interact with the MAOI, but not necessarily in a way that is a problem...and not because it contains that substance who's name I cannot remember at the moment that can cause headaches...and those other things that can happen with a ridiculous blood pressure. 

I think you mean thymine.

[nibblerd]

I talked to my PDoc about it and coffee doesn't appear to be a big deal...at least as long as you don't go crazy about it. I've come to the belief that it only makes those lists because it contains things that could interact with the MAOI, but not necessarily in a way that is a problem...and not because it contains that substance who's name I cannot remember at the moment that can cause headaches...and those other things that can happen with a ridiculous blood pressure.

I think you mean thymine.

I don't know what you're referring to. Do you mean thiamine? tyramine? Thymine is a part of RNA.

[Guest]

I talked to my PDoc about it and coffee doesn't appear to be a big deal...at least as long as you don't go crazy about it. I've come to the belief that it only makes those lists because it contains things that could interact with the MAOI, but not necessarily in a way that is a problem...and not because it contains that substance who's name I cannot remember at the moment that can cause headaches...and those other things that can happen with a ridiculous blood pressure.

I think you mean thymine.

I don't know what you're referring to. Do you mean thiamine? tyramine? Thymine is a part of RNA.

He meant tyramine, Which is the thing MAOI's inhibit the breakdown of. AKA it builds up and then kills you.

[Velvet Elvis]

easy words to confuse

[nibblerd]

What happens if you take something for hypertension (like.. propranolol) while on a MAOI, and eat cheese? Would you still get a headache?

[Velvet Elvis]

What happens if you take something for hypertension (like.. propranolol) while on a MAOI, and eat cheese? Would you still get a headache?

Given that the means by which tyramine causes a hypertensive crisis is not well understood, I wouldn't venture a guess.

[null0trooper]

What happens if you take something for hypertension (like.. propranolol) while on a MAOI, and eat cheese? Would you still get a headache?

It's not whether you eat any cheese or not (not all cheeses are high in tyramine) but how much total tyramine is in the meal you consumed.

Since most doctors try to only get high blood pressure under control and within normal limits, my guess is that you'd have as much risk as a person with normal blood pressure not on antihypertensives. Don't forget that the "cheese syndrome" headache is only a symptom and that a person's blood pressure can be high enough to trigger a stroke without causing a headache.

So, for anyone seriously considering an MAOI:

- find out which foods really are high in tyramine (and which parts - *I* don't eat banana peels, so I saw no reason to skip the fleshy part of the fruit)

- get a decent home BP monitor and use it to help keep track of what your blood pressure is

- sign up with MedicAlert or a similar organization. If you're in an accident, or pass out after a meal with more fermented or aged proteins than you were led to expect, EMT/ER personnel need the warning that there could be interactions with what they use or complications from your med(s)

[nibblerd]

What happens if you take something for hypertension (like.. propranolol) while on a MAOI, and eat cheese? Would you still get a headache?

It's not whether you eat any cheese or not (not all cheeses are high in tyramine) but how much total tyramine is in the meal you consumed.

Since most doctors try to only get high blood pressure under control and within normal limits, my guess is that you'd have as much risk as a person with normal blood pressure not on antihypertensives. Don't forget that the "cheese syndrome" headache is only a symptom and that a person's blood pressure can be high enough to trigger a stroke without causing a headache.

So, for anyone seriously considering an MAOI:

- find out which foods really are high in tyramine (and which parts - *I* don't eat banana peels, so I saw no reason to skip the fleshy part of the fruit)

- get a decent home BP monitor and use it to help keep track of what your blood pressure is

- sign up with MedicAlert or a similar organization. If you're in an accident, or pass out after a meal with more fermented or aged proteins than you were led to expect, EMT/ER personnel need the warning that there could be interactions with what they use or complications from your med(s)

Well I found numbers for mg of tyramine required for 30mmHg (unit maybe incorrect) increase in blood pressure which in a normal person is called a hypertensive crisis. I had normal blood pressure (120/70) before going on the beta blocker, and now I'm down to 90/60. I assume this means that in order for a hypertensive crisis to occur in me, it will require roughly double the amount of tyramine to be consumed and an astronomical amount on a RIMA. Not that I feel like trying it out or anything.

[Katyusha]

First of all, I strongly second null0trooper's advice for anyone considering an MAOI.

Well I found numbers for mg of tyramine required for 30mmHg (unit maybe incorrect) increase in blood pressure which in a normal person is called a hypertensive crisis. I had normal blood pressure (120/70) before going on the beta blocker, and now I'm down to 90/60. I assume this means that in order for a hypertensive crisis to occur in me, it will require roughly double the amount of tyramine to be consumed [...]

No, not necessarily.

First, propanolol is not generally a good idea with an MAOI. MAOIs will lower your baseline blood pressure for a LOT of people. Taking most beta-blockers and other antihypertensives with MAOIs is contraindicated because of this, and it's also why anesthesia for surgery requires super-extra monitoring for people on MAOIs -- it's dangerous if your blood pressure (or heart rate or respiratory rate) goes too low. Plus, chronic baseline hypotension can cause unpleasant symptoms, easy fatigue and such.

But if you overload your system with tyramine, a low baseline may not protect you in any way. The severity of the blood pressure reaction from combining tyramine + MAOI seems -- from what I understand -- to be somewhat variable by individual. It's dangerous in any case, but it may not have any relationship to whether or not your baseline blood pressure is low, normal, or high.

At the least, you can't make accurate calculations of what is safe for you specifically (like if your BP is XXX/XX, you can take Y mg of tyramine...etc).

I think doctors, and people in general, can be very wary of MAOIs because of (1) unfamiliarity, and (2) the enormous risks inherent in noncompliance. Doctors, nurses, pharmacists, etc. see patients every single day who don't comply with their medications, whether that means not taking them regularly, ignoring drug interactions, etc. Plus you have two decades of SSRI marketing and now antipsychotics for treatment-resistant depression. It makes some sense that MAOIs would get left behind, but it's sad that younger doctors have no experience with them. I'm astounded when some people rank them after tricyclics and even ECT for treatment-resistant depression.

On a personal level:

I'm glad I went with an MAOI. It helped save my life. That's it in a nutshell.

The diet becomes a habit. The drug interactions can be studied. The side effects have not been so bad for me on Emsam, as most of them have lessened over the months (except for the intractable insomnia).

I take caffeine without a problem. My baseline BP is 102/64 last I checked on my current cocktail, and it would be a good bit lower without the Adderall and caffeine.

(Stimulant + MAOI is a rare and generally not-approved combo because of blood pressure issues as well as serotonin syndrome risk, but because my BP has been so low -- and I monitored it very carefully when my pdoc was titrating me up on tiny step-doses of Adderall -- it turns out mostly OK. I gave Provigil and Nuvigil a damn good try first, as they are somewhat safer options. I'd rather not need a stimulant to feel focused and alive...and I hope I won't need it for terribly long...but I guess we'll see.)

[nibblerd]

First of all, I strongly second null0trooper's advice for anyone considering an MAOI.

Well I found numbers for mg of tyramine required for 30mmHg (unit maybe incorrect) increase in blood pressure which in a normal person is called a hypertensive crisis. I had normal blood pressure (120/70) before going on the beta blocker, and now I'm down to 90/60. I assume this means that in order for a hypertensive crisis to occur in me, it will require roughly double the amount of tyramine to be consumed [...]

No, not necessarily.

First, propanolol is not generally a good idea with an MAOI. MAOIs will lower your baseline blood pressure for a LOT of people. Taking most beta-blockers and other antihypertensives with MAOIs is contraindicated because of this, and it's also why anesthesia for surgery requires super-extra monitoring for people on MAOIs -- it's dangerous if your blood pressure (or heart rate or respiratory rate) goes too low. Plus, chronic baseline hypotension can cause unpleasant symptoms, easy fatigue and such.

But if you overload your system with tyramine, a low baseline may not protect you in any way. The severity of the blood pressure reaction from combining tyramine + MAOI seems -- from what I understand -- to be somewhat variable by individual. It's dangerous in any case, but it may not have any relationship to whether or not your baseline blood pressure is low, normal, or high.

At the least, you can't make accurate calculations of what is safe for you specifically (like if your BP is XXX/XX, you can take Y mg of tyramine...etc).

I think doctors, and people in general, can be very wary of MAOIs because of (1) unfamiliarity, and (2) the enormous risks inherent in noncompliance. Doctors, nurses, pharmacists, etc. see patients every single day who don't comply with their medications, whether that means not taking them regularly, ignoring drug interactions, etc. Plus you have two decades of SSRI marketing and now antipsychotics for treatment-resistant depression. It makes some sense that MAOIs would get left behind, but it's sad that younger doctors have no experience with them. I'm astounded when some people rank them after tricyclics and even ECT for treatment-resistant depression.

On a personal level:

I'm glad I went with an MAOI. It helped save my life. That's it in a nutshell.

The diet becomes a habit. The drug interactions can be studied. The side effects have not been so bad for me on Emsam, as most of them have lessened over the months (except for the intractable insomnia).

I take caffeine without a problem. My baseline BP is 102/64 last I checked on my current cocktail, and it would be a good bit lower without the Adderall and caffeine.

(Stimulant + MAOI is a rare and generally not-approved combo because of blood pressure issues as well as serotonin syndrome risk, but because my BP has been so low -- and I monitored it very carefully when my pdoc was titrating me up on tiny step-doses of Adderall -- it turns out mostly OK. I gave Provigil and Nuvigil a damn good try first, as they are somewhat safer options. I'd rather not need a stimulant to feel focused and alive...and I hope I won't need it for terribly long...but I guess we'll see.)

The doctors I have come into contact with since being in Canada have differing opinions on the use of MAOIs based on their background. My GP, who treats many patients of all shapes and sizes has expressed concern about my ability to follow the diet. The pdoc that diagnosed me with Bipolar I was a fan of the MAOI because of the low risk for antidepressant-induced mania.

Thanks for the info on blood pressure increase, I was mostly being silly.