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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by Kim on June 4, 2000, at 2:50:27
A while back someone (Elizabeth?) contributed to a thread with a detailed post about the symptoms of MAOI reaction. I thought I'd copied it, but can't find it and can't find the thread. I'd appreciate it if you could repost the information.
Thanks,
Kim
Posted by Jennifer on June 9, 2000, at 3:03:18
In reply to MAOI Reaction Symptoms, posted by Kim on June 4, 2000, at 2:50:27
Kim, I'm new, and I don't know how thorough the post was that you read, however I am familiar with the basic symptoms of an MAOI reaction. If you read about hypertensive crisis, you will learn a bit more. Basically, increased tyrimine levels throw off the blood pressure monitoring part of your brain. Your blood pressure rises over several HOURS. You don't need to worry if you have a headache all of the sudden while you're out to dinner that it may be a reaction. I keep a blood pressure cuff at home. Whenever I have a migraine headache, I find out what it is. Remember that your blood pressure will go up with the pain from the headache. Usually I run 110/60. With a migraine it may be 140/80. The headache is one that starts at the base of your skull and slowly works it's way up. Some people feel nauseated and have vision changes also. If your diastolic (bottom) number of your BP should go above 100, or your top number above 180 or so (assuming you have an average BP now) then it is time to get some help. The worst effect would be a stroke. It occurs on average when your BP is around 300/200. So if you can't decide if it is a reaction, monitor your BP every 15 minutes or so for a couple hours. If you are not seeing a consistent upward trend, it's most likely a different headache. I keep a prescription for Procardia on hand in case of hypertensive crisis. In 8 years I have never used it. My pdoc rx'd Nardil his entire career and never saw a reaction. I hope this helps at least a little bit, although I'm sure it's more vague than what you were looking for. Jennifer
> A while back someone (Elizabeth?) contributed to a thread with a detailed post about the symptoms of MAOI reaction. I thought I'd copied it, but can't find it and can't find the thread. I'd appreciate it if you could repost the information.
> Thanks,
> Kim
Posted by SLS on June 9, 2000, at 9:52:38
In reply to Re: MAOI Reaction Symptoms, posted by Jennifer on June 9, 2000, at 3:03:18
WHEN SYMPTOMS OF A TYRAMINE REACTION APPEAR, ACT IMMEDIATELY.
Hi Jennifer.
I thought it would be a good idea to post my experiences with MAO inhibitors and the tyramine reaction, also known affectionately as the "cheese-reaction".I have been taking MAO-inhibitors (MAOIs) on-and-off since 1982. I agree with some people that many of the special MAO diets are more restrictive than is necessary. I have never felt that my quality of life had been significantly impacted by adhering to such a diet. I deem it a worthwhile trade for the improvement in the quality of life offered by these drugs. Unfortunately, it seems the "relaxation" in the NUMBER of foods restricted in the diet is being confused with a relaxation in the importance of adhering to it. There has been no relaxation in the recognition of the SEVERITY of the consequences of eating a restricted food.
By the way, the reason I have been taking MAOIs off-and-on is because they have not worked. If they had worked, I would never have discontinued them.
> Your blood pressure rises over several HOURS. You don't need to worry if you have a headache all of the sudden while you're out to dinner that it may be a reaction.
This is 180 degrees opposite to my experience.
While I was taking 60mg of Parnate, I accidently ate one and a half (1 1/2) slices of pepperoni on a pizza. Once I recognized my mistake, I immediately employed the use of profanity. It was ineffective. Within TEN MINUTES, I experienced a painful pounding headache located at the base of my skull. It got worse when I sat down, so I remained standing until it dissipated. I think it took about between 45-60 minutes to disappear. I was at work and gambled that it wouldn't end up being fatal. I was lucky.
Let me just emphasize that the total amount of pepperoni I ingested was 1 1/2 slices that were about one inch in diameter and a few millimeters thick.
The tyramine-induced hypertensitive crisis ("cheese reaction") is a medical emergency for which a treatment decision must be made immediately upon the onset of headache or other symptoms. As you have mentioned, Procardia (nifedipine), a calcium-channel blocker, can be used. However, it is critical that it get into the blood stream as soon as possible. For this reason, it is a good idea to take it via absorption under the tongue (sublingual) or through the cheeks (buccal). I think there may be a sublingual preparation of Procardia, but I'm not sure. The gelatin capsule can be bitten through to release its liquid contents into the mouth. Then it can be spread with the tongue around the inner surface of the cheeks or under the tongue. I guess all of the liquid can be swallowed, but I don't know how effective this would be. I can't comment on the advisability of this method of treating the tyramine reaction, as some doctors insist that one call an ambulance or get to an emergency room as soon as possible.
The most effective treatment for a MAOI-related hypertensive crisis is to have an injection of a drug called Regitine (phentolamine). This is a potent antihypertensive that continues to be used in hospital emergency rooms and in certain surgical situations.
It would seem to be common sense to intervene as soon as possible once the tyramine-reaction is recognized by using an antidote like Procardia, but I don't know if having Procardia in the system would create a situation where Regitine could not be used. An oral preparation of phentolamine called Vasomax is available. Perhaps this would make an ideal substitute for Procardia for one to carry with them in case of an emergency.
* Does anyone know anything about using Vasomax for treating a MAOI tyramine reaction?
WHEN SYMPTOMS OF A TYRAMINE REACTION APPEAR, ACT IMMEDIATELY.
-----------------------------------------------------------
1. Monoamine Oxidase Inhibitors - MAO inhibitors - MAOIs:Parnate (tranylcypromine
Nardil (phenelzine)
Marplan (isocarboxezid)
Eldepryl (selegiline, deprenyl)
Manerix, Aurorix (moclobemide)
Eutonyl (pargyline)* regardless of selectivity or reversibility, all of these drugs have been associated with hypertensive crisis.
2. Symptoms of tyramine reaction:- high blood pressure
- occipital headache which may radiate frontally
- palpitations
- neck stiffness or soreness
- nausea or vomiting
- sweating (sometimes with fever or cold, clammy skin)
- dilated pupils
- photophobia-sensitivity to light
- tachycardia or bradycardia (fast or slow heart-beat)
- constricting chest pain
- intracranial bleeding-stroke (sometimes fatal)
3. MAOI Diet:http://www.dr-bob.org/tips/maoi.html
- Scott
Posted by Tina1 on June 9, 2000, at 10:16:47
In reply to Re: MAOI Reaction Symptoms - EVERYONE, posted by SLS on June 9, 2000, at 9:52:38
Scott---I was on Manerix 7 years ago and stayed on it for 2.5 years. I never had one single problem and I didn't even know that I was supposed to change my diet. I eat cheese by the brick, pepperoni pizzas, processed lunchmeat etc. Is it possible that I'm just not sensitive to this syndrome? Oh, BTW, I'm taking Manerix again now. Been on it 3 days. Take care--Tina
> WHEN SYMPTOMS OF A TYRAMINE REACTION APPEAR, ACT IMMEDIATELY.
>
>
>
> Hi Jennifer.
>
>
> I thought it would be a good idea to post my experiences with MAO inhibitors and the tyramine reaction, also known affectionately as the "cheese-reaction".
>
> I have been taking MAO-inhibitors (MAOIs) on-and-off since 1982. I agree with some people that many of the special MAO diets are more restrictive than is necessary. I have never felt that my quality of life had been significantly impacted by adhering to such a diet. I deem it a worthwhile trade for the improvement in the quality of life offered by these drugs. Unfortunately, it seems the "relaxation" in the NUMBER of foods restricted in the diet is being confused with a relaxation in the importance of adhering to it. There has been no relaxation in the recognition of the SEVERITY of the consequences of eating a restricted food.
>
> By the way, the reason I have been taking MAOIs off-and-on is because they have not worked. If they had worked, I would never have discontinued them.
>
> > Your blood pressure rises over several HOURS. You don't need to worry if you have a headache all of the sudden while you're out to dinner that it may be a reaction.
>
> This is 180 degrees opposite to my experience.
>
> While I was taking 60mg of Parnate, I accidently ate one and a half (1 1/2) slices of pepperoni on a pizza. Once I recognized my mistake, I immediately employed the use of profanity. It was ineffective. Within TEN MINUTES, I experienced a painful pounding headache located at the base of my skull. It got worse when I sat down, so I remained standing until it dissipated. I think it took about between 45-60 minutes to disappear. I was at work and gambled that it wouldn't end up being fatal. I was lucky.
>
> Let me just emphasize that the total amount of pepperoni I ingested was 1 1/2 slices that were about one inch in diameter and a few millimeters thick.
>
> The tyramine-induced hypertensitive crisis ("cheese reaction") is a medical emergency for which a treatment decision must be made immediately upon the onset of headache or other symptoms. As you have mentioned, Procardia (nifedipine), a calcium-channel blocker, can be used. However, it is critical that it get into the blood stream as soon as possible. For this reason, it is a good idea to take it via absorption under the tongue (sublingual) or through the cheeks (buccal). I think there may be a sublingual preparation of Procardia, but I'm not sure. The gelatin capsule can be bitten through to release its liquid contents into the mouth. Then it can be spread with the tongue around the inner surface of the cheeks or under the tongue. I guess all of the liquid can be swallowed, but I don't know how effective this would be. I can't comment on the advisability of this method of treating the tyramine reaction, as some doctors insist that one call an ambulance or get to an emergency room as soon as possible.
>
> The most effective treatment for a MAOI-related hypertensive crisis is to have an injection of a drug called Regitine (phentolamine). This is a potent antihypertensive that continues to be used in hospital emergency rooms and in certain surgical situations.
>
> It would seem to be common sense to intervene as soon as possible once the tyramine-reaction is recognized by using an antidote like Procardia, but I don't know if having Procardia in the system would create a situation where Regitine could not be used. An oral preparation of phentolamine called Vasomax is available. Perhaps this would make an ideal substitute for Procardia for one to carry with them in case of an emergency.
>
> * Does anyone know anything about using Vasomax for treating a MAOI tyramine reaction?
>
>
> WHEN SYMPTOMS OF A TYRAMINE REACTION APPEAR, ACT IMMEDIATELY.
>
>
> -----------------------------------------------------------
>
>
> 1. Monoamine Oxidase Inhibitors - MAO inhibitors - MAOIs:
>
> Parnate (tranylcypromine
> Nardil (phenelzine)
> Marplan (isocarboxezid)
> Eldepryl (selegiline, deprenyl)
> Manerix, Aurorix (moclobemide)
> Eutonyl (pargyline)
>
> * regardless of selectivity or reversibility, all of these drugs have been associated with hypertensive crisis.
>
>
> 2. Symptoms of tyramine reaction:
>
> - high blood pressure
> - occipital headache which may radiate frontally
> - palpitations
> - neck stiffness or soreness
> - nausea or vomiting
> - sweating (sometimes with fever or cold, clammy skin)
> - dilated pupils
> - photophobia-sensitivity to light
> - tachycardia or bradycardia (fast or slow heart-beat)
> - constricting chest pain
> - intracranial bleeding-stroke (sometimes fatal)
>
>
> 3. MAOI Diet:
>
> http://www.dr-bob.org/tips/maoi.html
>
>
> - Scott
Posted by SLS on June 9, 2000, at 13:22:28
In reply to Re: MAOI Reaction Symptoms -SCOTT, posted by Tina1 on June 9, 2000, at 10:16:47
> Scott---I was on Manerix 7 years ago and stayed on it for 2.5 years. I never had one single problem and I didn't even know that I was supposed to change my diet. I eat cheese by the brick, pepperoni pizzas, processed lunchmeat etc. Is it possible that I'm just not sensitive to this syndrome? Oh, BTW, I'm taking Manerix again now. Been on it 3 days. Take care--Tina
Hi Tina,
I'm glad you posted a reply.
I did not do a good job of describing Manerix. I should have stated that the risk of experiencing a hypertensive reaction to tyramine is reduced for Manerix (moclobemide). It is also reduced for Eldepryl (selegiline, deprenyl) when it is taken at dosages of 30mg or less. I tried to emphasize the fact that neither of these two drugs are free of the potential to cause it. The potential is not simply theoretical, it is documented. However, the incidence of this happening is infrequent. The term "wide safety margin" has been used.
One of the putative advantages of using Manerix is that there is no need to adhere to a special diet. I really don't know on what side of the fence to stand on this issue. When I tried it a few years ago, I remained cautious about my choices of foods. I was not willing to tempt fate by eating a chunk of cheddar or blue cheese and washing it down with a bottle of chiante. I have seen recommendations that when Manerix is taken at dosages of 600mg and higher, the tyramine content of a meal should not exceed 50mg.
I think the words you used were well chosen. You are not sensitive to this syndrome.
Thanks for helping to create a more balanced view regarding Manerix and the low-tyramine diet. A good Canadian pharmacist would be able to offer some valuable input based upon his experience with it. Just in case, I'll offer the Good Lord a little prayer for you. *** Now you're immune. :-)
For what ailment are you taking Manerix?Why did you discontinue Manerix?
What dosages do you use?
Did you find that you needed raise the dosage a few times when you began taking it the last time?
Are you taking any other drugs along with it?
Thanks.
GOOD LUCK!
- Scott
Posted by Tina1 on June 9, 2000, at 14:58:36
In reply to Re: MAOI Reaction Symptoms -SCOTT, posted by SLS on June 9, 2000, at 13:22:28
Quite a list of questions. Here goes:
I was taking it for depression/anxiety
I discontinued it because I felt that I was cured and i think I was a little cockey
I titrated up to 450mg/day slowly and stayed there with no increases over the two year period
I take clonazepam 1.5-2mg daily to control anxiety/panic attacks.
Thanks for being interested, I love this place. You are a very knowledgable person and have found your posts insightful and informative. You're a great asset to this board.
Love ya
Tina> > Scott---I was on Manerix 7 years ago and stayed on it for 2.5 years. I never had one single problem and I didn't even know that I was supposed to change my diet. I eat cheese by the brick, pepperoni pizzas, processed lunchmeat etc. Is it possible that I'm just not sensitive to this syndrome? Oh, BTW, I'm taking Manerix again now. Been on it 3 days. Take care--Tina
>
>
>
> Hi Tina,
>
> I'm glad you posted a reply.
>
> I did not do a good job of describing Manerix. I should have stated that the risk of experiencing a hypertensive reaction to tyramine is reduced for Manerix (moclobemide). It is also reduced for Eldepryl (selegiline, deprenyl) when it is taken at dosages of 30mg or less. I tried to emphasize the fact that neither of these two drugs are free of the potential to cause it. The potential is not simply theoretical, it is documented. However, the incidence of this happening is infrequent. The term "wide safety margin" has been used.
>
> One of the putative advantages of using Manerix is that there is no need to adhere to a special diet. I really don't know on what side of the fence to stand on this issue. When I tried it a few years ago, I remained cautious about my choices of foods. I was not willing to tempt fate by eating a chunk of cheddar or blue cheese and washing it down with a bottle of chiante. I have seen recommendations that when Manerix is taken at dosages of 600mg and higher, the tyramine content of a meal should not exceed 50mg.
>
> I think the words you used were well chosen. You are not sensitive to this syndrome.
>
> Thanks for helping to create a more balanced view regarding Manerix and the low-tyramine diet. A good Canadian pharmacist would be able to offer some valuable input based upon his experience with it. Just in case, I'll offer the Good Lord a little prayer for you. *** Now you're immune. :-)
>
>
> For what ailment are you taking Manerix?
>
> Why did you discontinue Manerix?
>
> What dosages do you use?
>
> Did you find that you needed raise the dosage a few times when you began taking it the last time?
>
> Are you taking any other drugs along with it?
>
> Thanks.
>
> GOOD LUCK!
>
>
> - Scott
Posted by Jennifer on June 10, 2000, at 23:49:44
In reply to Re: MAOI Reaction Symptoms -SCOTT, posted by Tina1 on June 9, 2000, at 14:58:36
Just had time to read up on these posts. I agree with Scott about seeking emergency help ASAP with signs of a tyramine rxn. I had 3 reasons for pointing out that the tyramine rxn is often a delayed one. First, if you eat something with high tyramine content and begin to have symptoms 6-12 hours later...don't ignore them. Also, many people rush to the hospital or call their MD with the onset of any HA. Close monitoring of bp should reveal a slow increase. A diastolic bp over 120 &/or systolic of 220 is indicative of the beginning of a HTN crisis...seek medical help. This can be helpful to those that are close to medical care, and can wait to see if any rxn's occur. The third reason is that if you may have the onset of a severe headache, but no bp changes, the ER doc may conclude that you have a migraine. By noting the often delayed rxn to tyramines, you can be informed since many medical professional aren't.
The severe HA in the base of the skull is the classical onset of a rxn, however, if it does not proceed past that point, it only requires monitoring of bp (by a professional, unless you are skilled at this). If you have the increased BP, heart palpitations, chest pains, severe HA that starts at the base of the skull and moves up and over the top of your head, emergency care is essential.
MAOI rxn's can not only occur with food rxn's, but also with med rxn's and overdosage. The symptoms for all 3 are nearly identical.
The most common high tyramine foods are: aged cheese (check the label, many are not aged), aged or pickled meats (ie: salami), yeast extracts, beer (dark is worst, on tap is bad, glass bottles are best as tyramine is absorbed into the glass...domestic beers in glass are lowest - avoid imported beers), red wine is higher than white wine, avocado, sauerkraut.
Drugs can cause bad rxn's too: Meperidine (Demerol), Dextromethorphan (cough med), and epinephrine are 3 of the worst. Whenever in the hospital, I say I'm allergic to Demerol in addition to being on MAO. I also always check when the dentist is going to use novacaine...if it has black lettering it's without epinephrine, red lettering has epinephrine. I actually caught my dentist as the needle was approaching my mouth. This would cause an immediate rxn, and I doubt most dental offices are perfectly compliant with their CPR and emergency management skills.
Hope this made more sense. Jen> Quite a list of questions. Here goes:
> I was taking it for depression/anxiety
> I discontinued it because I felt that I was cured and i think I was a little cockey
> I titrated up to 450mg/day slowly and stayed there with no increases over the two year period
> I take clonazepam 1.5-2mg daily to control anxiety/panic attacks.
> Thanks for being interested, I love this place. You are a very knowledgable person and have found your posts insightful and informative. You're a great asset to this board.
> Love ya
> Tina
>
>
>
>
>
> > > Scott---I was on Manerix 7 years ago and stayed on it for 2.5 years. I never had one single problem and I didn't even know that I was supposed to change my diet. I eat cheese by the brick, pepperoni pizzas, processed lunchmeat etc. Is it possible that I'm just not sensitive to this syndrome? Oh, BTW, I'm taking Manerix again now. Been on it 3 days. Take care--Tina
> >
> >
> >
> > Hi Tina,
> >
> > I'm glad you posted a reply.
> >
> > I did not do a good job of describing Manerix. I should have stated that the risk of experiencing a hypertensive reaction to tyramine is reduced for Manerix (moclobemide). It is also reduced for Eldepryl (selegiline, deprenyl) when it is taken at dosages of 30mg or less. I tried to emphasize the fact that neither of these two drugs are free of the potential to cause it. The potential is not simply theoretical, it is documented. However, the incidence of this happening is infrequent. The term "wide safety margin" has been used.
> >
> > One of the putative advantages of using Manerix is that there is no need to adhere to a special diet. I really don't know on what side of the fence to stand on this issue. When I tried it a few years ago, I remained cautious about my choices of foods. I was not willing to tempt fate by eating a chunk of cheddar or blue cheese and washing it down with a bottle of chiante. I have seen recommendations that when Manerix is taken at dosages of 600mg and higher, the tyramine content of a meal should not exceed 50mg.
> >
> > I think the words you used were well chosen. You are not sensitive to this syndrome.
> >
> > Thanks for helping to create a more balanced view regarding Manerix and the low-tyramine diet. A good Canadian pharmacist would be able to offer some valuable input based upon his experience with it. Just in case, I'll offer the Good Lord a little prayer for you. *** Now you're immune. :-)
> >
> >
> > For what ailment are you taking Manerix?
> >
> > Why did you discontinue Manerix?
> >
> > What dosages do you use?
> >
> > Did you find that you needed raise the dosage a few times when you began taking it the last time?
> >
> > Are you taking any other drugs along with it?
> >
> > Thanks.
> >
> > GOOD LUCK!
> >
> >
> > - Scott
Posted by SLS on June 12, 2000, at 8:17:12
In reply to Re: MAOI Reaction Symptoms , posted by Jennifer on June 10, 2000, at 23:49:44
Dear Jennifer,
Thank you for contributing such a great post. I hadn't known that the MAOI-tyramine reaction could take such a delayed and gradual course. You know more about this reaction than anyone I have encountered, and this is very important information.
That tyramine can be absorbed by glass is fascinating. Do you know if this occurs regularly with other compounds? Is it because glass is a liquid?
I'm going to remember the black vs red label on the dentist's novacaine bottle or syringe.
Thanks again.
- Scott
> Just had time to read up on these posts. I agree with Scott about seeking emergency help ASAP with signs of a tyramine rxn. I had 3 reasons for pointing out that the tyramine rxn is often a delayed one. First, if you eat something with high tyramine content and begin to have symptoms 6-12 hours later...don't ignore them. Also, many people rush to the hospital or call their MD with the onset of any HA. Close monitoring of bp should reveal a slow increase. A diastolic bp over 120 &/or systolic of 220 is indicative of the beginning of a HTN crisis...seek medical help. This can be helpful to those that are close to medical care, and can wait to see if any rxn's occur. The third reason is that if you may have the onset of a severe headache, but no bp changes, the ER doc may conclude that you have a migraine. By noting the often delayed rxn to tyramines, you can be informed since many medical professional aren't.> The severe HA in the base of the skull is the classical onset of a rxn, however, if it does not proceed past that point, it only requires monitoring of bp (by a professional, unless you are skilled at this). If you have the increased BP, heart palpitations, chest pains, severe HA that starts at the base of the skull and moves up and over the top of your head, emergency care is essential.
> MAOI rxn's can not only occur with food rxn's, but also with med rxn's and overdosage. The symptoms for all 3 are nearly identical.
> The most common high tyramine foods are: aged cheese (check the label, many are not aged), aged or pickled meats (ie: salami), yeast extracts, beer (dark is worst, on tap is bad, glass bottles are best as tyramine is absorbed into the glass...domestic beers in glass are lowest - avoid imported beers), red wine is higher than white wine, avocado, sauerkraut.
> Drugs can cause bad rxn's too: Meperidine (Demerol), Dextromethorphan (cough med), and epinephrine are 3 of the worst. Whenever in the hospital, I say I'm allergic to Demerol in addition to being on MAO. I also always check when the dentist is going to use novacaine...if it has black lettering it's without epinephrine, red lettering has epinephrine. I actually caught my dentist as the needle was approaching my mouth. This would cause an immediate rxn, and I doubt most dental offices are perfectly compliant with their CPR and emergency management skills.
> Hope this made more sense. Jen
This is the end of the thread.
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