What medication tracking plan should I use for a patient starting phenelzine, including baseline assessment (blood pressure, heart rate, weight, complete blood count, liver function tests, medication and dietary review), dosing schedule, dietary restrictions (high‑tyramine foods), monitoring for hypertensive crisis and serotonin syndrome, and follow‑up visits?

Phenelzine Medication Tracking Protocol

Patients starting phenelzine require baseline cardiovascular and laboratory assessment, strict dietary tyramine restriction counseling, systematic monitoring for hypertensive crisis and serotonin syndrome, and regular follow-up with blood pressure surveillance at every visit.

Baseline Assessment Before Initiation

Cardiovascular Parameters

• Measure baseline blood pressure and heart rate in all patients, as phenelzine can precipitate hypertensive crisis when combined with tyramine-containing foods or sympathomimetic agents 1, 2
• Obtain baseline electrocardiogram to document cardiac rhythm and identify pre-existing conduction abnormalities 1

Laboratory Studies

• Complete blood count to establish baseline hematologic parameters 1
• Liver function tests (AST, ALT, bilirubin) to screen for hepatic dysfunction before starting therapy 1
• Renal function (blood urea nitrogen, creatinine) to assess baseline kidney status 1
• Fasting glucose and lipid panel if metabolic monitoring is clinically indicated 1

Medication and Dietary Review

• Screen for absolute contraindications: Current use of or use within 14 days of other monoamine oxidase inhibitors, sympathomimetic agents (including decongestants, amphetamines, phentermine), or serotonergic medications (SSRIs, SNRIs, tricyclics) due to risk of hypertensive crisis or serotonin syndrome 1, 3
• Document all prescription medications, over-the-counter drugs, and supplements to identify potential drug interactions 3
• Assess current dietary patterns and identify consumption of high-tyramine foods that will require absolute restriction 4

Dosing Schedule

Initial Titration Phase

• Start phenelzine at 15 mg orally once daily 5
• Increase to 30 mg daily (divided into two doses) between day 3 and day 7 5
• Further titrate to therapeutic dose of 45–90 mg daily in divided doses based on clinical response and tolerability 5, 6
• Target dose: 1 mg/kg body weight per day, which represents a safe and effective dosing strategy 6
• Higher doses (up to 90 mg daily) produce significantly greater and more rapid improvement than standard 45 mg daily dosing 5

Maintenance Phase

• Continue effective dose for duration of treatment, typically measured in months 1
• Clinical response correlates with degree of platelet monoamine oxidase inhibition; high percent MAO inhibition at two weeks predicts greater improvement after six weeks of treatment 6

Dietary Restrictions: High-Tyramine Foods

Foods Requiring Absolute Restriction

• All aged cheeses (cheddar, Swiss, blue cheese, parmesan) due to high tyramine content that can precipitate hypertensive crisis 2, 4
• Concentrated yeast extracts such as Marmite 4
• Sauerkraut 4
• Broad bean pods (fava beans) 4
• Some aged meats that contain relatively high tyramine levels 4

Foods and Beverages Generally Safe in Moderation

• Alcoholic beverages, including Chianti wine, appear safe when consumed in moderation 4
• Fresh (unaged) cheeses such as cottage cheese, cream cheese, and ricotta are typically low in tyramine 4

Mechanism of Hypertensive Crisis

• Tyramine is normally metabolized by monoamine oxidase in the gut and liver; when MAO is inhibited by phenelzine, dietary tyramine is absorbed systemically and displaces norepinephrine from sympathetic nerve terminals, causing acute hypertension 2, 3

Monitoring for Hypertensive Crisis

Clinical Presentation

• Severe occipital or temporal headache (most common warning symptom) 2, 3
• Chest pain or pressure, which may indicate myocardial ischemia or infarction 2
• Severe elevation in blood pressure (systolic >180 mm Hg or diastolic >120 mm Hg) 2
• Palpitations, diaphoresis, neck stiffness, nausea, or vomiting 3

Emergency Management

• Administer intravenous antihypertensive agents such as nitroprusside or phentolamine for acute blood pressure control 2
• Provide intravenous morphine for chest pain and to reduce sympathetic outflow 2
• Obtain serial electrocardiograms and cardiac biomarkers (troponin I) to assess for myocardial injury 2
• Provide intravenous fluid resuscitation if hypotension develops after the hypertensive phase resolves 2

Monitoring for Serotonin Syndrome

High-Risk Drug Combinations

• Concurrent use of phenelzine with selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, tramadol, meperidine, dextromethorphan, or St. John's wort can precipitate serotonin syndrome 1, 3
• Mandatory washout period: Allow at least 14 days between discontinuation of phenelzine and initiation of serotonergic agents, or vice versa 3

Clinical Features of Serotonin Syndrome

• Neuromuscular hyperactivity (tremor, hyperreflexia, clonus, rigidity) 1
• Autonomic instability (hyperthermia, tachycardia, labile blood pressure, diaphoresis) 1
• Altered mental status (agitation, confusion, delirium) 1

Management Approach

• Discontinue all serotonergic agents immediately 1
• Provide supportive care with intravenous fluids, cooling measures, and benzodiazepines for agitation 1

Follow-Up Visit Schedule

Initial Titration Period (Weeks 1–4)

• Weekly contact by telephone or in-person visit during dose adjustment phase to assess efficacy, tolerability, and adherence 1
• Measure blood pressure and heart rate at each in-person visit 1
• Assess target symptoms using standardized rating scales or structured clinical interview 1
• Screen systematically for side effects: insomnia, orthostatic hypotension, weight gain, sexual dysfunction, dry mouth, constipation 1

Maintenance Phase (After Week 4)

• Monthly visits until symptoms are stabilized and dose is optimized 1
• Measure blood pressure and heart rate at every visit to detect delayed cardiovascular effects 1
• Repeat liver function tests and complete blood count every 3–6 months during long-term therapy 1
• Reinforce dietary tyramine restriction and review medication list for new drug interactions at each visit 3, 4

Long-Term Monitoring (After 3–6 Months)

• Continue follow-up visits at 3- to 6-month intervals once clinical response is stable 1
• Maintain blood pressure and heart rate surveillance at every encounter 1
• Reassess indication for continued therapy and consider gradual taper if remission is sustained 1

Common Pitfalls and How to Avoid Them

Inadequate Patient Education

• Patients must receive explicit written and verbal instructions about tyramine-containing foods before the first dose of phenelzine; failure to provide this education is the most common cause of preventable hypertensive crisis 2, 4

Overlooking Drug Interactions

• Clinicians frequently fail to screen over-the-counter medications (decongestants, cough suppressants) and herbal supplements that contain sympathomimetic or serotonergic compounds 3

Insufficient Dosing

• Prescribing phenelzine at 45 mg daily or lower may result in suboptimal response; doses of 60–90 mg daily (approximately 1 mg/kg) produce significantly better outcomes 5, 6

Premature Discontinuation

• Clinical response to phenelzine requires 4–6 weeks of treatment at therapeutic doses; discontinuing therapy before this time frame prevents adequate assessment of efficacy 6