Initial Dose and Safety Recommendations for Emsam (Selegiline Transdermal System)
Start Emsam at 6 mg per 24 hours applied once daily to dry, intact skin on the upper torso, upper thigh, or outer surface of the upper arm 1.
Dosing Algorithm
Starting Dose
- Initial and target dose: 6 mg/24 hours applied once every 24 hours 1
- This is both the recommended starting dose AND the effective target dose for most patients
- Apply to dry, intact skin on upper torso (below neck, above waist), upper thigh, or outer arm 1
Dose Escalation (if clinically indicated)
- If inadequate response after at least 2 weeks, may increase by 3 mg/24 hours increments 1
- Maximum dose: 12 mg/24 hours
- Minimum interval between dose increases: 2 weeks 1
- Full antidepressant effect may be delayed 1
Special Population: Elderly Patients
- Recommended dose for patients ≥65 years: 6 mg/24 hours only 1
- Do not escalate doses in elderly patients
Critical Safety Recommendations
Dietary Restrictions Based on Dose
At 6 mg/24 hours:
- NO dietary tyramine restrictions required 1, 2, 3
- This is a key advantage of the transdermal formulation at this dose
At 9 mg/24 hours or 12 mg/24 hours:
- MUST avoid tyramine-rich foods and beverages beginning on the first day of treatment at these higher doses 1
- Continue dietary restrictions for 2 weeks after dose reduction to 6 mg/24 hours or discontinuation 1
- Failure to follow dietary restrictions at higher doses risks hypertensive crisis 1
Contraindicated Medications (Must Screen and Discontinue)
Absolutely contraindicated - risk of serotonin syndrome 1:
- SSRIs (fluoxetine, sertraline, paroxetine, etc.)
- SNRIs (venlafaxine, duloxetine, etc.)
- Tricyclics: clomipramine, imipramine
- Analgesics: meperidine, tramadol, methadone, pentazocine, propoxyphene
- Dextromethorphan (cough suppressant)
- Carbamazepine 1
Washout periods before starting Emsam 1:
- Most contraindicated medications: minimum 1 week (4-5 half-lives) 1, 4
- Fluoxetine specifically: minimum 5 weeks due to long half-life of active metabolite 1
After stopping Emsam:
Medications Requiring Blood Pressure Monitoring
If used with Emsam, monitor blood pressure closely 1:
- Buspirone
- Amphetamines
- Sympathomimetic amines (pseudoephedrine, phenylephrine, phenylpropanolamine, ephedrine)
- Cold products or weight-reducing preparations containing these agents
Age Restrictions
- Contraindicated in patients <12 years of age due to increased risk of hypertensive crisis 1
Pre-Treatment Screening
- Screen for bipolar disorder, mania, or hypomania (personal or family history) before initiating treatment 1
- This applies to all antidepressants but is particularly important with MAOIs
Monitoring for Suicidality
- Close monitoring required for clinical worsening and emergence of suicidal thoughts/behaviors, especially in young adults 1
- This is a black box warning for all antidepressants
Common Pitfalls to Avoid
- Starting at higher doses: Always start at 6 mg/24 hours, even if planning eventual escalation
- Premature dose escalation: Wait minimum 2 weeks between increases 1
- Forgetting dietary counseling: Even though 6 mg doesn't require restrictions, counsel patients that restrictions WILL be needed if dose is increased 1
- Inadequate washout periods: Particularly dangerous with fluoxetine (needs 5 weeks) 1
- Missing contraindicated medications: Thoroughly review all medications including over-the-counter products
- Applying to wrong body areas: Avoid face, scalp, or areas with broken skin
Application Site Reactions
- Most common adverse event with Emsam 2, 5
- Usually mild to moderate severity 2
- Rotate application sites to minimize reactions
The transdermal delivery system's key advantage is bypassing first-pass hepatic metabolism, which allows effective antidepressant dosing (6 mg/24 hours) without dietary tyramine restrictions—a significant improvement over oral MAOIs 2, 3.