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Home » , , , , , » Drug interactions with antidepressants: irreversible nonselective MAOIs
Drug interactions with antidepressants: irreversible nonselective MAOIs
Thursday, September 29, 2011 Posted by Piscean

Drug interactions with antidepressants: irreversible nonselective MAOIs 
Irreversible nonselective MAOIs include phenelzine and tranylcypromine.
Drug
Rating [NB1]
Interaction
Recommended action
Alcohol
2 or 3
Tyramine reaction (see under tyramine) possible with some alcoholic beverages.
See irreversible nonselective MAOI dietary guidelines, Table 8.3.
Analgesics, opioid (including tramadol)
1
Excitation, sweating, rigidity and hypertension; or hypotension and coma with pethidine.
Pentazocine may also be risky.
Case reports of serotonin syndrome occurring with tramadol and MAOI.
Avoid combination of pethidine and MAOIs (absolute contraindication). Morphine may be used judiciously; titrate small IV doses, and have naloxone and noradrenaline (as a vasopressor) available.
Avoid tramadol in patients who are taking MAOIs or who have taken them in the last 14 days.
NSAIDs or paracetamol/codeine combinations may be suitable alternatives.
Buspirone
3
Hypertension reported rarely.
Monitor for increased blood pressure or use an alternative drug.
Clomipramine - 
Dexamphetamine - 
Dextromethorphan
2
A case of nausea, hypotension, fever and coma after low doses of dextromethorphan; dizziness, muscle tremor and urinary retention in another case.
Avoid dextromethorphan with MAOI. Use an alternative antitussive, eg pholcodine.
ECT
3
No interaction, but see also, entry for suxamethonium in this table.
Two-week gap not needed; stop MAOI and start ECT when pre-ECT work-up is done.
Hypoglycaemics, including insulin
3
Enhanced hypoglycaemic response to insulin and oral hypoglycaemics.
Use alternative antidepressant if possible.
Levodopa
1
Severe hypertensive reactions reported.
Avoid combination of MAOI and levodopa.
Linezolid
2
Manufacturer warns to be alert for increased risk of hypertensive crisis with linezolid and MAOI.
Avoid combination of MAOI and linezolid. Use an alternative antidepressant.
MAOIs, irreversible nonselective
1
Rare fatalities reported when changing from 1 irreversible nonselective MAOI to another.
Cease first MAOI, wait 14 days, and start with small doses of new MAOI, see Table 8.11.
Methylphenidate - 
Mianserin and mirtazapine
1
Manufacturer of mirtazapine recommends avoiding concurrent use.
Avoid combination of MAOI and mianserin or mirtazapine. Care needed in changing between MAOI and mianserin or mirtazapine, 
Moclobemide
1
Serotonin syndrome possible.
Avoid combination of MAOI and moclobemide. Care needed in changing between MAOI and moclobemide,
Modafinil
2
Manufacturer recommends caution when administering MAOI with modafinil.
Avoid combination of MAOI and modafinil.
Naratriptan -
Nefazodone - 
Pentazocine - 
Pethidine - 
Psychostimulants: dexamphetamine, methylphenidate -
Reboxetine
1
Manufacturer recommends avoiding concurrent use.
Avoid combination of MAOI and reboxetine. Care needed in changing between MAOI and reboxetine, 
Serotonergic agonists: SSRIs, clomipramine, nefazodone, sibutramine, tryptophan, venlafaxine
1
Serotonin syndrome possible. Fatalities reported with fluoxetine and MAOI combination.
Avoid combination of MAOI and serotonergic agonist.
Care needed in changing between serotonergic antidepressant and MAOI,
Sibutramine - 
SSRIs and nefazodone - 
Sumatriptan - 
Suxamethonium
3
Phenelzine prolongs muscle relaxation by inhibiting metabolism.
Decrease suxamethonium dose and monitor carefully or use pancuronium.
Sympathomimetic amines—directly acting: adrenaline, dopamine, isoprenaline, noradrenaline
3
Directly acting amines like the endogenous transmitters are inactivated principally by catechol-O-methyltransferase, not MAO.
No interaction or only a slight increase in blood pressure. Use cautiously and monitor.
Sympathomimetic amines—indirectly acting (often found in cough and cold remedies): amphetamines, diethylpropion, ephedrine, methylphenidate, phentermine, phenylephrine, pseudoephedrine, tyramine
1
Indirectly acting sympathomimetics and MAOIs may cause severe hypertension, chest pain, severe occipital headache and tachycardia. Also reported are neck stiffness, limb hypertonicity, seizures, sweating, flushing, fever, vomiting, stroke and cardiac failure.
Avoid combination of MAOI and indirectly acting sympathomimetic (absolute contraindication).
TCAs
1
Serotonin syndrome and fatalities reported.
Avoid combination of MAOI and TCA. Care needed in changing between MAOI and TCA, especially clomipramine, 
Tramadol - 
Triptans: naratriptan, sumatriptan, zolmitriptan
2
Rare occurrence of serotonin syndrome is possible.
Monitor for serotonin syndrome.
Tryptophan - 
Tyramine and foodstuffs containing tyramine
1
Hypertensive crisis with tyramine or dopa in foods.
See treatment options for hypertensive emergencies.
Warn and give patient dietary guidelines,
Venlafaxine - 
Zolmitriptan -
NB1:
Rating 1 – Avoid combination; risk always outweighs benefit.
Rating 2 – Usually avoid combination; use combination only under special circumstances.
Rating 3 – Minimise risk; take action as necessary to reduce risk.

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