What are the precautions and alternative options when using Monoamine Oxidase (MAO) inhibitors?

Precautions and Alternative Options for MAO Inhibitors

MAO inhibitors require strict dietary and medication restrictions to prevent potentially life-threatening hypertensive crises, and selective serotonin reuptake inhibitors (SSRIs) are generally preferred as safer alternatives for most patients requiring antidepressant therapy. 1

Key Precautions with MAO Inhibitors

Dietary Restrictions

• Must avoid tyramine-rich foods:
  • Aged cheeses (especially aged varieties)
  • Pickled herring
  • Beer and wine
  • Liver
  • Yeast extract (including large quantities of brewer's yeast)
  • Dry sausage (including Genoa salami, hard salami, pepperoni, Lebanon bologna)
  • Pods of broad beans (fava beans)
  • Yogurt
  • Excessive amounts of caffeine and chocolate 2

Medication Contraindications

1. Sympathomimetic drugs:

   • Amphetamines, cocaine, methylphenidate
   • Pseudoephedrine, phenylephrine
   • Epinephrine, norepinephrine
   • Risk: Hypertensive crisis 1

2. Serotonergic medications:

   • SSRIs (fluoxetine, paroxetine, sertraline, citalopram, escitalopram)
   • SNRIs (venlafaxine, desvenlafaxine, duloxetine, levomilnacipran)
   • Tricyclic antidepressants
   • Risk: Serotonin syndrome (hyperthermia, rigidity, myoclonic movements, death) 2

3. Opioid medications:

   • Particularly meperidine (absolute contraindication)
   • Also: methadone, tramadol, oxycodone, hydrocodone, morphine, codeine, fentanyl
   • Risk: Excitation, seizures, delirium, hyperpyrexia, circulatory collapse, coma, death 2

4. Other MAO inhibitors:

   • Never combine different MAOIs
   • Risk: Hypertensive crisis, convulsive seizures, fever, marked sweating, excitation, delirium, tremor, coma, circulatory collapse 2

5. Additional contraindicated medications:

   • Dextromethorphan
   • Buspirone
   • Bupropion
   • Tryptophan supplements 2

Timing Considerations

• Washout periods required:
  • At least 14 days between discontinuing an MAOI and starting most other antidepressants
  • At least 14 days between discontinuing most antidepressants and starting an MAOI
  • Exception: Fluoxetine requires 5 weeks washout before starting an MAOI due to its long half-life 2

Surgical Considerations

• Discontinue MAOIs at least 10 days prior to elective surgery
• Avoid general anesthesia while on MAOIs
• Avoid local anesthetics containing sympathomimetic vasoconstrictors 2

Alternative Treatment Options

First-line Alternatives

• SSRIs: Safer side effect profile, no dietary restrictions, preferred for most patients with depression 1
• SNRIs: Effective alternatives with fewer restrictions than MAOIs 1

Second-line Alternatives

• Reversible MAO-A inhibitors (e.g., moclobemide):
  • Better tolerated than traditional MAOIs
  • Fewer dietary restrictions
  • Lower risk of hypertensive crisis 3, 4

For Treatment-Resistant Depression

• Combination therapies:
  • Antidepressant + mood stabilizer
  • Antidepressant + atypical antipsychotic (e.g., aripiprazole) 5
  • Note: Careful monitoring required with any combination therapy

Monitoring Requirements When Using MAOIs

• Regular blood pressure monitoring
• Patient education about warning signs of hypertensive crisis (severe headache, neck stiffness, nausea, vomiting, sweating, dilated pupils)
• Immediate medical attention if hypertensive symptoms occur
• Provide patients with written dietary and medication restrictions 6

Common Pitfalls to Avoid

1. Inadequate patient education about dietary and medication restrictions
2. Insufficient washout periods when switching between MAOIs and other antidepressants
3. Overlooking over-the-counter medications containing sympathomimetics
4. Failing to alert all healthcare providers about MAOI use (including dentists, surgeons)
5. Not recognizing early signs of hypertensive crisis or serotonin syndrome

MAOIs remain valuable for specific patient populations with treatment-resistant depression, atypical depression, and certain bipolar depression presentations, but their use requires strict adherence to safety protocols and careful patient selection 7.