MAOIs and Stimulant Use: Contraindicated Combination
Concomitant use of MAOIs and stimulants is absolutely contraindicated due to the risk of severe hypertensive crisis, which can lead to cerebrovascular accidents (stroke) and death. 1, 2
Mechanism of Risk
- MAOIs prevent the breakdown of norepinephrine and other catecholamines by inhibiting monoamine oxidase enzymes 3
- Stimulants (including amphetamines, methylphenidate, and sympathomimetic agents like pseudoephedrine and phenylephrine) trigger the release of norepinephrine or act as sympathomimetics 1, 3
- When combined, this creates a dangerous accumulation of catecholamines that can cause life-threatening blood pressure elevations and hypertensive crisis 1, 3
- The risk extends to all sympathomimetic drugs including over-the-counter decongestants, diet pills, and illicit stimulants 2, 3
Specific Contraindications
Stimulants that must be avoided with MAOIs include: 1, 2
- Prescription stimulants: amphetamines, methylphenidate, dextroamphetamine
- Sympathomimetic decongestants: pseudoephedrine, phenylephrine, oxymetazoline
- Other sympathomimetics: midodrine, clonidine
- Bronchodilators: albuterol, salmeterol, terbutaline
- Illicit stimulants: cocaine, MDMA (ecstasy), methamphetamine
Required Washout Periods
Critical timing requirements to prevent dangerous interactions: 2, 4
- After stopping an MAOI: Wait at least 2 weeks before starting any stimulant medication 1, 4
- Before starting an MAOI: Discontinue all stimulants at least 2 weeks prior 4
- For atomoxetine (a non-stimulant ADHD medication): the same 2-week washout period applies in both directions 4
Clinical Consequences of Violation
Severe hypertensive crisis can manifest as: 1, 3
- Sudden, severe elevation in blood pressure
- Severe headache, often described as "thunderclap"
- Chest pain and palpitations
- Stroke or intracranial hemorrhage
- Seizures
- Hyperthermia
- Death
Additional Serotonergic Risk
- Some stimulants (particularly amphetamines and MDMA) also have serotonergic activity, creating additional risk for serotonin syndrome when combined with MAOIs 3, 5
- Serotonin syndrome presents with mental status changes, autonomic instability (fever, tachycardia), and neuromuscular abnormalities (myoclonus, hyperreflexia, tremor) 1, 5
Special Considerations for ADHD Treatment
For patients requiring both ADHD treatment and an MAOI: 4
- Atomoxetine (Strattera), a non-stimulant ADHD medication, is also contraindicated with MAOIs and requires the same 2-week washout period 4
- There are no safe options for combining ADHD stimulant treatment with MAOIs
- The MAOI must be discontinued with appropriate washout before initiating any stimulant therapy 1, 4
Patient Education Imperatives
Patients on MAOIs must be explicitly warned to avoid: 2, 3
- All over-the-counter cold and allergy medications containing sympathomimetics
- Energy drinks and supplements containing stimulants
- Weight loss products
- Illicit drugs, particularly cocaine, methamphetamine, and MDMA
- Informing all healthcare providers (including emergency departments, dentists, and surgeons) about MAOI use before receiving any medications 2
Common Pitfalls to Avoid
- Never assume a patient has stopped taking stimulants: Verify discontinuation and ensure adequate washout time has elapsed 4
- Screen for over-the-counter sympathomimetic use: Patients may not recognize decongestants as "stimulants" 2, 3
- Emergency situations: If a patient on an MAOI requires urgent treatment, inform emergency personnel immediately as many emergency medications (epinephrine, norepinephrine) are contraindicated or require dose adjustments 3
- Linezolid (antibiotic) has MAOI properties: This creates the same risk when combined with stimulants or serotonergic agents 5