What is Nardil (phenelzine) used for?

Uses of Nardil (Phenelzine)

Phenelzine (Nardil) is primarily indicated for the treatment of depression, particularly in patients with "atypical," "nonendogenous," or "neurotic" depression who have failed to respond to more commonly used antidepressants. 1

Primary Indications

Depression

• FDA-approved for depressed patients with:
  • Atypical features (mood reactivity, hypersomnia, increased appetite)
  • Mixed anxiety and depression
  • Phobic or hypochondriacal features 1
• Generally recommended as a second-line or later option after failure of other antidepressants 1
• Effective in treatment-resistant depression, including melancholic depression 2, 3
• Dosage typically 1 mg/kg body weight per day for optimal therapeutic effect 4

Other Psychiatric Conditions

• PTSD-associated nightmares
  • Studies show phenelzine can eliminate nightmares entirely within 1 month with sustained effects up to 18 months 5
  • Dosage ranges from 30-90 mg daily for this indication 5
• Anxiety disorders with phobic features 1, 4
• Bulimia nervosa
  • Significantly more effective than placebo in reducing binge frequency 6
  • In clinical trials, 5 of 9 phenelzine-treated patients ceased binging entirely 6

Pharmacological Mechanism

Phenelzine works as a potent monoamine oxidase inhibitor (MAOI) that:

• Inhibits the breakdown of neurotransmitters (serotonin, norepinephrine, dopamine)
• Increases availability of these neurotransmitters in the brain
• Has the ability to reduce REM sleep, which may contribute to its effectiveness in treating nightmares 5

Important Safety Considerations

Dietary and Medication Restrictions

• Requires strict avoidance of tyramine-containing foods to prevent hypertensive crisis 5
• Contraindicated with:
  • Other serotonergic drugs (SSRIs, SNRIs, TCAs, other MAOIs)
  • Sympathomimetic medications
  • Opioids (especially meperidine, tramadol)
  • Stimulants 5

Monitoring and Side Effects

• Common side effects include dizziness, drowsiness, and malaise 5
• Risk of serotonin syndrome when combined with other serotonergic medications 5
• Can cause hypertensive crisis if dietary/medication restrictions not followed 5
• Requires careful monitoring, especially during initiation and dose adjustments

Clinical Decision Making

When considering phenelzine:

1. Verify failure of first-line antidepressants (SSRIs, SNRIs)
2. Assess patient's ability to adhere to dietary restrictions and medication precautions
3. Screen for contraindications (concurrent serotonergic medications, history of hypertension)
4. Start at low dose (15 mg daily) and titrate gradually to effective dose (typically 45-90 mg daily)
5. Monitor blood pressure regularly, especially during dose adjustments

Phenelzine should be considered before electroconvulsive therapy in treatment-resistant depression, taking into account patient preference and ability to comply with dietary restrictions 3.