Evidence-Based Reviews

MAO inhibitors: An option worth trying in treatment-resistant cases

Current Psychiatry. 2002 June;1(6):40-47

References

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Table 2

DIETARY INSTRUCTIONS WITH MAOIs

Several foods and beverages contain tyramine and may interact with your medication. You MUST follow the dietary instructions below, from the day before you start taking the medication until 2 weeks after you stop taking the medication.	Note: All foods must be fresh or properly frozen. If you are not aware of the storage conditions of a particular food, AVOID that food.
Food to avoid	Food allowed
Cheese
All matured or aged cheese All casseroles made with cheeses (i.e., pizza, lasagna, etc.)	Fresh cottage cheese, cream cheese, ricotta cheese, and processed cheese slices. All fresh milk products that have been properly stored (i.e., sour cream, yogurt, ice cream)
Meat, fish, and poultry
Fermented/dry sausage (pepperoni, salami, mortadella, summer sausage) Improperly stored meat, fish, poultry Improperly stored pickled herring	All fresh packaged or processed meat (e.g., chicken loaf, hot dogs), fish, or poultry. Store in refrigerator immediately, and eat as soon as possible
Fruits and vegetables
Fava or broad bean pods (not beans) Banana peel	Raspberries up to a maximum of one-quarter pound at one time Banana pulp All others
Beverages
All on-tap beer	Alcohol: No more than two bottled or canned beers or 4-fl. oz. glasses of red or white wine per day. This applies to nonalcoholic beer also. Red wine may produce headache unrelated to a rise in blood pressure
Miscellaneous
Marmite-concentrated yeast extract Sauerkraut Soy sauce and other soy bean condiments	Other concentrated yeast extract (e.g., brewer’s yeast) Soy milk
Reprinted with permission of the department of pharmacy, Sunnybrook and Women’s College Health Science Center, North York, Ontario, Canada. Copyright 1994

In experience, tyramine-associated hypertensive crisis in patients receiving the older MAOIs is rare, often very painful, and time-limited. Data on incidence of hypertensive crises with any MAOI is inadequate, except for a negligible incidence with low-dose selegiline and moclobemide (a reversible MAOI available in Canada but not in the United States). Most reported cases have involved tranylcypromine,²² which causes the greatest increase in sensitivity to tyramine, the basis of the dietary interaction with MAOIs.²³ Specifically with tranylcypromine, transient hypertension can occur in the absence of dietary indiscretion or drug interaction.^24,25

Food-associated hypertensive reactions are more common but unpredictable. A patient at McLean who had eaten cheese without trouble for 4 years while taking tranylcypromine in Europe mysteriously developed a severe headache after one bit of cheddar in the United States; she never tried an MAOI again. Another patient who took tranylcypromine for months at dosages exceeding 100 mg/d (but never took the tyramine restriction seriously) suffered a frightening pulsatile headache after a Chinese restaurant meal with soy sauce.

In our experience, oral adrenergic drugs (e.g., pseudoephedrine) can cause symptomatic hypertensive crises in patients taking MAOIs. Some over-the-counter cold preparations may contain an adrenergic decongestant, but it may not be listed clearly on the bottle. Cough syrup with codeine is preferable to OTC cough syrups that contain dextromethorphan. Patients should be urged to check labels and ask the pharmacist.

Advise patients taking MAOIs to purchase a blood pressure cuff or finger sphygmomanometer and learn how to take their own blood pressure. If they experience a “normal” headache and their systolic blood pressure is not elevated by at least 30 mm Hg, they are not having a “cheese reaction” and do not need to worry. MAOI headaches are typically unmistakable (they feel as if one’s head is splitting apart), and blood pressure is markedly elevated.

We give patients starting on MAOIs 10-mg tablets of nifedipine and advise them that if symptoms suggesting a hypertensive crisis appear, they should bite into one tablet to release the fluid inside and then swallow it. We tell patients to repeat this in 15 minutes if the headache is not receding; if the headache persists, they should visit the emergency ward or the internist’s office for observation.

Although there has been concern about the risk of MI or stroke with the hypotensive effect of nifedipine, we believe it is still the best option for acute severe hypertension in patients who do not have chronic hypertension. Chlorpromazine tablets (50 mg) also will stop the headache and lower blood pressure but will leave the patient groggy for about 24 hours, with possible extrapyramidal symptoms.

In the rare instance that a hypertensive crisis occurs, the “official” labeling recommendation is to give IV phentolamine, but we find emergency rooms either no longer stock the drug or do not remember to do this. Send any patient who is hurting and panicky to an ER, and call to suggest what the attending might do (i.e., IV phentolamine or oral nifedipine or chlorpromazine, or the emergency physician’s preference for hypertensive crisis).

Avoiding other MAOI-related side effects