![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 25 of 27. This is the beginning of the thread.
Posted by Teknohead on May 19, 2004, at 9:29:54
I feel the need to share a frightening food reaction with Nardil, which I had only last night.
8:30pm and I just finnished my dinner of potatoes, cabbage and LIVER. Yes LIVER! I had no idea this would cause a reaction. Maybe it was slightly off - it tasted fine and the date was ok. But at 9:00 a sudden throbbing, pounding pain in my head hit me like no pain I've ever felt. Not only that but a burning sensation in my stomach like it was filled with sulphuric acid, along with nausia and a electrifying tingling feeling all over. I'm not exagerating, this is axactly what it was like.
I immediately knew what it was and rang an ambulance (unfortunitely my doctor has refused to give me any anti-angina drug for emergencies). When they arrived I told them what was going on and they drove me to hospital. In the ambulance I had no treatment, they didn't use a siren and they drove like it was a family day out! I was in total agony. I thought I would die.
When we arrived, they took me straight to the emergency ward in a wheelchair, left me waiting in a corridoor for 5 minutes, then told me to get on a bed and left me there. All the while the pain was getting worse and I was actually yelling in pain.
25 minutes past and the only person I seen was an on duty nurse who poped his head in from time to time - and smiled.
Thankfully, I felt the pain wearing off almost as suddenly as it came on. I decided to check myself out and went home. When I got home, all I was left with was a simple headache and stomach ache. This I could handle.
I'm now left baffled as to why I was given no urgent medical treatment, especially as MAOI/food reactions can cause permanent damage and even prove fatal in some cases. Did they have no knowledge of MAOIs? They've been around since the 1950s! I don't know what the normal proceduer would be, but I cann't help but feel angry and neglected from my experience.
One last note, since I woke up this morning, I've felt constantly dizzy, and have urine retention, both of which I had at the start of treatment but have since had no more problems with, till now. I hope they die away soon! (2 months into treatment with Nardil, the urine retention got so bad I had to wear a cathetar for a month!)
Anyway, sorry to go on.
Bye for now.
Posted by King Vultan on May 19, 2004, at 11:57:57
In reply to My Nardil food reaction, posted by Teknohead on May 19, 2004, at 9:29:54
Liver is not necessarily on the lists of prohibited foods but can develop shockingly high levels of tyramine (the bad stuff for people on MAOIs) if it is not fresh. In
http://www.vh.org/adult/provider/psychiatry/CPS/17.html
in Table 5, they show how the level of tyramine skyrockets in chicken liver that is five days old. I really think liver products are best avoided for people on MAOIs, but that is from someone who really does not like liver to begin with (I do like braunschweiger, but this is a bad food for people on MAOIs to be taking, so I have dropped it).
You might want to refer your doctor to the subsection on Hypertensive Crisis Management near the end of the Cardiovacular/Blood Pressure section. I think he is doing you a serious disservice not prescribing an emergency hypertensive such as nifedipine that you can carry with you for instances such as what you described. There was another anecdote this year from an MAOI patient who also had a frightening hypertensive experience (from unthinkingly taking some ephedra) and went to an emergency room where the people did not realize what was going on, and he received care that was similarly shoddy to what you experienced. You never know when you might eat some bad or spoiled food--I carry a couple of 10 mg nifedipine pills everywhere I go.
Todd
Posted by King Vultan on May 19, 2004, at 12:24:09
In reply to My Nardil food reaction, posted by Teknohead on May 19, 2004, at 9:29:54
I have some of the same urinary difficulties when taking drugs that can generate anticholinergic type side effects and take an alpha-1 blocker to relieve my difficulties. If you are male, I would certainly consider trying one (females have somewhat different issues, and I must profess ignorance in this area). I personally do not have BPH but have the opposite problem where my prostate is small and constricted because of hypersensitive receptors. I have had relatively good results with both Flomax and doxazosin.
If you are indeed male, I can't believe that you were catheterized rather than trying one of these drugs first, but I am not a urologist. Actually, though, the urologist I saw last year was female, and I seemed to know more about some of this stuff than she did.
Todd
Posted by Sad Panda on May 19, 2004, at 13:08:05
In reply to My Nardil food reaction, posted by Teknohead on May 19, 2004, at 9:29:54
Ask your doc for a script for some Thorazine/Largactil, it will cover a hypertensive crisis as well as serotonin syndrome. I'd agree with King Vultan, liver does taste yucky, :) it possibly is a good idea to avoid organs as they do go off faster.
Cheers,
Panda.
Posted by King Vultan on May 19, 2004, at 14:51:35
In reply to Re: My Nardil food reaction, posted by King Vultan on May 19, 2004, at 11:57:57
http://www.vh.org/adult/provider/psychiatry/CPS/19.htmlSorry for my carelessness and any confusion I might have caused.
Todd
Posted by Teknohead on May 20, 2004, at 6:49:42
In reply to Re: My Nardil food reaction, posted by King Vultan on May 19, 2004, at 11:57:57
Thanks for the feed back. And especialy to King Vultan. Very interesting info. I will see my Dr today about prescribing some emergency nifedipine.
By the way, it was Lambs Liver that I ate and it was indeed at least 5 days old. It had been refridgerated. I ate about 150g of the stuff.
And as for the cathater I had, I did ask, and plead for a medication to try instead but my Dr was simply far too causious about prescribing drugs he's not familiar with. And the urology appointment took over a month to wait for. I guess that's the British NHS for you!
Kev
Posted by gardenergirl on May 21, 2004, at 23:52:14
In reply to Re: My Nardil food reaction, posted by Teknohead on May 20, 2004, at 6:49:42
Kev,
Sorry to hear about your reaction. I dislike liver, so I've never considered eating it. But I had a similar reaction on Thanksgiving from the giblets, which include chicken liver. They were used in the dressing. I never thought of that, as my mother never uses them, and neither do I. Never thougth to ask. I had similar symptoms, which also went away after a couple of hours, so I did not go to the hospital. At the time, I did not know it was an MAOI reaction. I had just had some gum surgery, and I assumed it was triggered from tooth pain.I also have had some mild urinary retention. I'm surprised yours came back like it did. Mine went away until I recently upped from 45 mg to 60 mg. Now UR is back (still mild though, more of an annoyance) and I have the myoclonic jerk blues. :)
Good luck to you, and watch out for those lamb livers!
gg
Posted by Teknohead on May 22, 2004, at 6:38:20
In reply to Re: My Nardil food reaction, posted by gardenergirl on May 21, 2004, at 23:52:14
> Kev,
> Sorry to hear about your reaction. I dislike liver, so I've never considered eating it. But I had a similar reaction on Thanksgiving from the giblets, which include chicken liver. They were used in the dressing. I never thought of that, as my mother never uses them, and neither do I. Never thougth to ask. I had similar symptoms, which also went away after a couple of hours, so I did not go to the hospital. At the time, I did not know it was an MAOI reaction. I had just had some gum surgery, and I assumed it was triggered from tooth pain.
>
> I also have had some mild urinary retention. I'm surprised yours came back like it did. Mine went away until I recently upped from 45 mg to 60 mg. Now UR is back (still mild though, more of an annoyance) and I have the myoclonic jerk blues. :)
>
> Good luck to you, and watch out for those lamb livers!
>
> ggHi all.
Hi gardenergirl!
Thankfull the Urinary retention has gone already. PHEW! But another odd thing is that since the food reaction, I've actually had a kind of "re-kick-in" effect from the Nardil! Although it was helping me anyway, an antidepressant effect similar to what I had when it first kicked in, has reappeared. The only theories I have as to why, is that it either acted a bit like ECT treatment, or I'm simply more glad to be alive!
Unfortunately, there is one more new problem I now have. Whenever I try to masterbate (sorry to sound crude - we all do it dont we?), a similar, but milder headache returns to the point that I cannot actually finish. This is of course worrying. I hope that food reaction didn't leave any real damage.
Bye for now.
Posted by gardenergirl on May 22, 2004, at 7:55:30
In reply to Re: My Nardil food reaction » gardenergirl, posted by Teknohead on May 22, 2004, at 6:38:20
Yikes, I'm soprry about your new reaction. That does sound upsetting. I hope it goes away soon. You might see a doc. for a neuro check to see if there was any damage. You might also get a BP cuff and see if your BP is going up when you get the headache.
Good luck!
gg
Posted by Questionmark on May 22, 2004, at 14:32:56
In reply to My Nardil food reaction, posted by Teknohead on May 19, 2004, at 9:29:54
> I feel the need to share a frightening food reaction with Nardil, which I had only last night.
>
> 8:30pm and I just finnished my dinner of potatoes, cabbage and LIVER. Yes LIVER! I had no idea this would cause a reaction. Maybe it was slightly off - it tasted fine and the date was ok. But at 9:00 a sudden throbbing, pounding pain in my head hit me like no pain I've ever felt. Not only that but a burning sensation in my stomach like it was filled with sulphuric acid, along with nausia and a electrifying tingling feeling all over. I'm not exagerating, this is axactly what it was like.
>
> I immediately knew what it was and rang an ambulance (unfortunitely my doctor has refused to give me any anti-angina drug for emergencies). When they arrived I told them what was going on and they drove me to hospital. In the ambulance I had no treatment, they didn't use a siren and they drove like it was a family day out! I was in total agony. I thought I would die.
>
> When we arrived, they took me straight to the emergency ward in a wheelchair, left me waiting in a corridoor for 5 minutes, then told me to get on a bed and left me there. All the while the pain was getting worse and I was actually yelling in pain.
>
> 25 minutes past and the only person I seen was an on duty nurse who poped his head in from time to time - and smiled.
>
> Thankfully, I felt the pain wearing off almost as suddenly as it came on. I decided to check myself out and went home. When I got home, all I was left with was a simple headache and stomach ache. This I could handle.
>
> I'm now left baffled as to why I was given no urgent medical treatment, especially as MAOI/food reactions can cause permanent damage and even prove fatal in some cases. Did they have no knowledge of MAOIs? They've been around since the 1950s! I don't know what the normal proceduer would be, but I cann't help but feel angry and neglected from my experience.
>
> One last note, since I woke up this morning, I've felt constantly dizzy, and have urine retention, both of which I had at the start of treatment but have since had no more problems with, till now. I hope they die away soon! (2 months into treatment with Nardil, the urine retention got so bad I had to wear a cathetar for a month!)
>
> Anyway, sorry to go on.
>
> Bye for now.That is so sickeningly infuriating. i can't believe they would actually treat you like that-- esp. in the ambulance where they wouldn't have to treat other people/ medical emergencies as well.
Yeah i'm the guy King Vultan (Todd) was referring to who had the reaction to ephedrine on Nardil (in March). My E.R. experience was horribly horribly long and excruciating too. Except my head throbs didn't go away for at least about 3 hours-- when they FINally gave me I.V. clonidine (i believe it was clonidine). That's interesting that yours went away after 2 hours. Of course i'm sure there's a difference between a tyramine-induced h. reaction and a ephedrine-induced one (in terms of duration & stuff, not mechanism)-- (including that a tyramine reaction can be a simple mistake while taking ephedrine on an MAOI is absolutely idiotic form of memory lapse/ not thinking). Anyway...
My pdoc also did not prescribe me any nifedipine or antihypertensive-- which both of our stories prove is an absolutely wrong decision!!!! AHHHHHH!!!!! STUPIDITY !!!!!!
Sorry. But also... Although i'm against a lot of the many many law suits toward medical employees nowadays, i think the E.R. people involved in your experience was wrong and incompetent and ridiculous to warrant a freaking law suit, in my opinion (not that it would legally-- i have no idea-- but ethically, in my opinion). But, i dunno.
My head hurt for awhile afterward, too (and not just when doing a certain particular activity)-- --around a week i think-- but it completely faded eventually.
Anyway, glad you made it through okay. What a horrible, horrible experience, huh? Man.
Posted by Sad Panda on May 23, 2004, at 2:03:05
In reply to Re: Nardil food reaction » Teknohead, posted by Questionmark on May 22, 2004, at 14:32:56
> > I feel the need to share a frightening food reaction with Nardil, which I had only last night.
> >
> > 8:30pm and I just finnished my dinner of potatoes, cabbage and LIVER. Yes LIVER! I had no idea this would cause a reaction. Maybe it was slightly off - it tasted fine and the date was ok. But at 9:00 a sudden throbbing, pounding pain in my head hit me like no pain I've ever felt. Not only that but a burning sensation in my stomach like it was filled with sulphuric acid, along with nausia and a electrifying tingling feeling all over. I'm not exagerating, this is axactly what it was like.
> >
> > I immediately knew what it was and rang an ambulance (unfortunitely my doctor has refused to give me any anti-angina drug for emergencies). When they arrived I told them what was going on and they drove me to hospital. In the ambulance I had no treatment, they didn't use a siren and they drove like it was a family day out! I was in total agony. I thought I would die.
> >
> > When we arrived, they took me straight to the emergency ward in a wheelchair, left me waiting in a corridoor for 5 minutes, then told me to get on a bed and left me there. All the while the pain was getting worse and I was actually yelling in pain.
> >
> > 25 minutes past and the only person I seen was an on duty nurse who poped his head in from time to time - and smiled.
> >
> > Thankfully, I felt the pain wearing off almost as suddenly as it came on. I decided to check myself out and went home. When I got home, all I was left with was a simple headache and stomach ache. This I could handle.
> >
> > I'm now left baffled as to why I was given no urgent medical treatment, especially as MAOI/food reactions can cause permanent damage and even prove fatal in some cases. Did they have no knowledge of MAOIs? They've been around since the 1950s! I don't know what the normal proceduer would be, but I cann't help but feel angry and neglected from my experience.
> >
> > One last note, since I woke up this morning, I've felt constantly dizzy, and have urine retention, both of which I had at the start of treatment but have since had no more problems with, till now. I hope they die away soon! (2 months into treatment with Nardil, the urine retention got so bad I had to wear a cathetar for a month!)
> >
> > Anyway, sorry to go on.
> >
> > Bye for now.
>
>
>
> That is so sickeningly infuriating. i can't believe they would actually treat you like that-- esp. in the ambulance where they wouldn't have to treat other people/ medical emergencies as well.
>
> Yeah i'm the guy King Vultan (Todd) was referring to who had the reaction to ephedrine on Nardil (in March). My E.R. experience was horribly horribly long and excruciating too. Except my head throbs didn't go away for at least about 3 hours-- when they FINally gave me I.V. clonidine (i believe it was clonidine). That's interesting that yours went away after 2 hours. Of course i'm sure there's a difference between a tyramine-induced h. reaction and a ephedrine-induced one (in terms of duration & stuff, not mechanism)-- (including that a tyramine reaction can be a simple mistake while taking ephedrine on an MAOI is absolutely idiotic form of memory lapse/ not thinking). Anyway...
> My pdoc also did not prescribe me any nifedipine or antihypertensive-- which both of our stories prove is an absolutely wrong decision!!!! AHHHHHH!!!!! STUPIDITY !!!!!!
> Sorry. But also... Although i'm against a lot of the many many law suits toward medical employees nowadays, i think the E.R. people involved in your experience was wrong and incompetent and ridiculous to warrant a freaking law suit, in my opinion (not that it would legally-- i have no idea-- but ethically, in my opinion). But, i dunno.
> My head hurt for awhile afterward, too (and not just when doing a certain particular activity)-- --around a week i think-- but it completely faded eventually.
> Anyway, glad you made it through okay. What a horrible, horrible experience, huh? Man.I think it's foolish to give a patient MAOI's, but not give them Nifedipine for a hypertensive crisis. Also, Periactin is an OTC antihistamine that can combat serotonin syndrome & Thorazine/Largactil can be used to cover both problems.
Cheers,
Panda.
Posted by Teknohead on May 23, 2004, at 9:21:54
In reply to Re: Nardil food reaction, posted by Sad Panda on May 23, 2004, at 2:03:05
Actually Panda, I've already made an appointment to see a solicitor to find out if I have a chance of compensation. Probably not, but I cann't see the harm in trying, hey. I at least want someone to acknowlege that that things could have been handled better, and a written appology wouldn't go amiss either. That's the least I deserve!
Later.
Posted by harryp on May 27, 2004, at 0:18:50
In reply to Re: Nardil food reaction » Sad Panda, posted by Teknohead on May 23, 2004, at 9:21:54
I'm taking steps to have a bp cuff, phentolamine and IV injection equipment with me when I travel.
Obviously, this isn't a solution for everyone!
I strongly urge everyone on MAOI's to carry a chart signed by their doctor explaining their condition, contraindicated drugs, and appropriate treatment, which is, preferentially:
5 mg phentolamine (an alpha blocker) IV--injected slowly. Phentolamine has a half-life of 15 min IV, repeated injections may be necessary over time.
2nd choice--IV labetalol (an alpha-beta blocker), titrated slowly with monitoring.
an alpha-beta or beta blocker may be used for reflex tachycardia AFTER administering an alpha blocker.
A beta-blocker MUST NOT be administered as a first treatment for a catecholamine-induced hypertensive crisis because of the risk of further vasodialation and bp elevation.
If you go to the ER you must be aggressive about explaining your symptoms, and the fact that you belive they are caused by a MAOI-tyramine interaction. I recommend carrying a bp cuff, so you can tell the triage nurse what your bp is--that will scare them!
I got instant service with the following line:
"Hello! I need to see a doctor IMMEDIATELY. I am taking a MONOAMINE OXIDASE INHIBITOR and am having a HYPTERTENSIVE CRISIS from a tyramine reaction from some food I ate. MY SYSTOLIC BLOOD PRESSURE IS OVER 210!"
That was a great, uncrowded ER in Houston. I was very lucky.
Posted by harryp on May 27, 2004, at 0:19:43
In reply to Re: Nardil food reaction, posted by harryp on May 27, 2004, at 0:18:50
Posted by Sad Panda on May 27, 2004, at 15:37:27
In reply to Re: Nardil food reaction, posted by harryp on May 27, 2004, at 0:18:50
> I'm taking steps to have a bp cuff, phentolamine and IV injection equipment with me when I travel.
>
> Obviously, this isn't a solution for everyone!
>
> I strongly urge everyone on MAOI's to carry a chart signed by their doctor explaining their condition, contraindicated drugs, and appropriate treatment, which is, preferentially:
>
> 5 mg phentolamine (an alpha blocker) IV--injected slowly. Phentolamine has a half-life of 15 min IV, repeated injections may be necessary over time.
>
> 2nd choice--IV labetalol (an alpha-beta blocker), titrated slowly with monitoring.
>
> an alpha-beta or beta blocker may be used for reflex tachycardia AFTER administering an alpha blocker.
>
> A beta-blocker MUST NOT be administered as a first treatment for a catecholamine-induced hypertensive crisis because of the risk of further vasodialation and bp elevation.
>
> If you go to the ER you must be aggressive about explaining your symptoms, and the fact that you belive they are caused by a MAOI-tyramine interaction. I recommend carrying a bp cuff, so you can tell the triage nurse what your bp is--that will scare them!
>
> I got instant service with the following line:
>
> "Hello! I need to see a doctor IMMEDIATELY. I am taking a MONOAMINE OXIDASE INHIBITOR and am having a HYPTERTENSIVE CRISIS from a tyramine reaction from some food I ate. MY SYSTOLIC BLOOD PRESSURE IS OVER 210!"
>
> That was a great, uncrowded ER in Houston. I was very lucky.
>
>Hi Harry,
How about Thorazine? It is a potent Alpha-1 blocker & it can treat Serotonin syndrome too with it's 5-HT2A antagonism. A distant relative, the TCA Doxepin might possibly be the best agent for MAOI users with insomnia. It is a strong Alpha-1 blocker, 5-HT2A blocker & an NE reuptake inhibitor. Tyramine enters the the nerve terminal in the same way that NE does. NE reuptake inhibitors can prevent Tyramine entering & doing it's evil voodoo, this is the reason that some TCA's are able to be taken with MAOI's. Clomipramine & Imipramine are best avoided, but you can find tests of Amitriptyline being used with MAOI's, although I think the MAOI was moclobemide.
Cheers,
Panda.
Posted by Questionmark on May 28, 2004, at 16:15:15
In reply to Re: Nardil food reaction, posted by harryp on May 27, 2004, at 0:18:50
> I'm taking steps to have a bp cuff, phentolamine and IV injection equipment with me when I travel.
>
> Obviously, this isn't a solution for everyone!
>
> I strongly urge everyone on MAOI's to carry a chart signed by their doctor explaining their condition, contraindicated drugs, and appropriate treatment, which is, preferentially:
>
> 5 mg phentolamine (an alpha blocker) IV--injected slowly. Phentolamine has a half-life of 15 min IV, repeated injections may be necessary over time.
>
> 2nd choice--IV labetalol (an alpha-beta blocker), titrated slowly with monitoring.
>
> an alpha-beta or beta blocker may be used for reflex tachycardia AFTER administering an alpha blocker.
>
> A beta-blocker MUST NOT be administered as a first treatment for a catecholamine-induced hypertensive crisis because of the risk of further vasodialation and bp elevation.
>
> If you go to the ER you must be aggressive about explaining your symptoms, and the fact that you belive they are caused by a MAOI-tyramine interaction. I recommend carrying a bp cuff, so you can tell the triage nurse what your bp is--that will scare them!
>
> I got instant service with the following line:
>
> "Hello! I need to see a doctor IMMEDIATELY. I am taking a MONOAMINE OXIDASE INHIBITOR and am having a HYPTERTENSIVE CRISIS from a tyramine reaction from some food I ate. MY SYSTOLIC BLOOD PRESSURE IS OVER 210!"
>
> That was a great, uncrowded ER in Houston. I was very lucky.
harryp or anyone else: what about yohimbine? Yohimbine is an alpha-2 antagonist. i've taken it about 20 or so times while on Nardil and i have never had any bad reactions yet. i do seem to be somewhat more sensitive to its effects, but not a great deal so. But everything i hear about taking yohimbine with an MAOI is like a "do NOT EVER take yohimbine with an MAOI unless you want your chest and head to explode!" type of statement or something. And certainly it has stimulating properties, but they are different than those of the classical CNS stimulants like amphetamines, cocaine, and caffeine. So what's the conclusion-- is yohimbine dangerous to take with an MAOI, and if so, why? Also, at risk of asking an idiotic question, would yohimbine be helpful at all in alleviating a hypertensive reaction?
Thanks you brilliant peoples you.
Posted by harryp on May 28, 2004, at 22:32:12
In reply to MAOI and Alpha-2 Antagonist (Yohimbine) » harryp, posted by Questionmark on May 28, 2004, at 16:15:15
I'll try to find out more about Yohimbine.
Phentolamine is a non-selective a1+a2 antagonist, and I'm not sure if a a2 alone would do the trick--I'll do some more reading.
I've dug through all the hypertension/MAOI literature I could find on Medline and medical texts to find the best drugs for a MAOI hypertensive crisis. Here's a summary:
The general consensus now is that Nifedipine is too unpredictable in its action to be a good choice for treating a hp crisis. Some people have experienced heart attacks or hypotension from using it. (It may still be better than nothing).
Phentolamine is the "gold-standard" in all the literature. It is very safe and difficult to OD on, because it only blocks the effect of sympathomemetic amines (i.e. tyramine, norepinephrine). It would have little or no effect on the bp of someone who didn't already have sympathomemetic amines in their bloodstream.
The only problem with MAOI hp crises is that they are very rare (just as MAOI's are rare) and many ER personel do not know the proper treatment and what drugs are contraindicated. This is why I feel one should carry a signed chart and instructions. Phentolamine is not a common drug and is often not stocked. (Labetalol is an acceptable substitute, but must be used more cautiously).
Thorazine is listed in some of the literature as an effective treatment. I haven't seen any information on self-administration, though. I would be very reluctant to take a drug that would turn me into a drooling moron (possibly for days) if I were far from home and needed to make decisions, drive, etc.
The best solution, in my opinion, would be to develop something similar to the "epi-pen" that would allow a patient to easily inject 5mg phentolamine intramuscularly (phentolamine can be injected IM, although that slows the onset and lengthens the half-life--[which could be a superior arrangement far from an ER]).
I believe that this would be the safest and most effective way to control a hp crisis if good medical care were not available.
Hopefully, if the backlash against the SSRI's continues (check out David Healy's *Let them Eat Prozac*--published by NYU press.) MAOI's may become more popular. A self-administrated pen injection system could increase the ease of mind for doctors and those patients who need MAOI's and have the good judgement to use them correctly.
Posted by Sad Panda on May 29, 2004, at 0:12:54
In reply to Re: MAOI and Alpha-2 Antagonist (Yohimbine), posted by harryp on May 28, 2004, at 22:32:12
>Thorazine is listed in some of the literature as an effective treatment. I haven't seen any information on self-administration, though. I would be very reluctant to take a drug that would turn me into a drooling moron (possibly for days) if I were far from home and needed to make decisions, drive, etc.
>
>Thorazine isn't going to turn you into a drooling moron. It's a low potency AP.
Alpha-2 Antagonists cause NE release. If A-1 NE antagonism is present, it will lower blood pressure, with no A-1 antagonism an A-2 antagonist will increase blood pressure.
Cheers,
Panda.
Posted by Questionmark on May 29, 2004, at 0:44:29
In reply to Re: MAOI and Alpha-2 Antagonist (Yohimbine), posted by harryp on May 28, 2004, at 22:32:12
Posted by King Vultan on May 29, 2004, at 0:58:50
In reply to MAOI and Alpha-2 Antagonist (Yohimbine) » harryp, posted by Questionmark on May 28, 2004, at 16:15:15
>
>
> harryp or anyone else: what about yohimbine? Yohimbine is an alpha-2 antagonist. i've taken it about 20 or so times while on Nardil and i have never had any bad reactions yet. i do seem to be somewhat more sensitive to its effects, but not a great deal so. But everything i hear about taking yohimbine with an MAOI is like a "do NOT EVER take yohimbine with an MAOI unless you want your chest and head to explode!" type of statement or something. And certainly it has stimulating properties, but they are different than those of the classical CNS stimulants like amphetamines, cocaine, and caffeine. So what's the conclusion-- is yohimbine dangerous to take with an MAOI, and if so, why? Also, at risk of asking an idiotic question, would yohimbine be helpful at all in alleviating a hypertensive reaction?
> Thanks you brilliant peoples you.
I would be rather concerned taking yohimbine because it is a relatively selective alpha-2 antagonist (selectivity ratio of alpha-2 to alpha-1 blockade of approximately 45:1). As Stahl discusses in "Essential Psychopharmacology", blockading alpha-2 autoreceptors on NE neurons increases the release of NE, while blockading alpha-2 heteroreceptors on serotonin neurons increases the release of 5HT. Considering the considerable amount of stored quantities of each present in someone taking an MAOI, this would appear to potentially be problematic and is likely the reason for the warning about yohimbine.Todd
Posted by don_bristol on May 29, 2004, at 10:54:07
In reply to Re: Nardil food reaction, posted by harryp on May 27, 2004, at 0:18:50
HARRYP wrote :
>
> Phentolamine is a non-selective a1+a2 antagonist, and I'm not sure if a a2 alone
> would do the trick--I'll do some more reading.
>
> I've dug through all the hypertension/MAOI literature I could find on Medline and
> medical texts to find the best drugs for a MAOI hypertensive crisis. Here's a
> summary:
>
> The general consensus now is that Nifedipine is too unpredictable in its action to be
> a good choice for treating a hp crisis. Some people have experienced heart attacks
> or hypotension from using it. (It may still be better than nothing).
>
> Phentolamine is the "gold-standard" in all the literature. It is very safe and
> difficult to OD on, because it only blocks the effect of sympathomemetic amines (i.e.
> tyramine, norepinephrine). It would have little or no effect on the bp of someone
> who didn't already have sympathomemetic amines in their bloodstream.
>
> The only problem with MAOI hp crises is that they are very rare (just as MAOI's are
> rare) and many ER personel do not know the proper treatment and what drugs are
> contraindicated. This is why I feel one should carry a signed chart and
> instructions. Phentolamine is not a common drug and is often not stocked.
> (Labetalol is an acceptable substitute, but must be used more cautiously).
>
> Thorazine is listed in some of the literature as an effective treatment. I haven't
> seen any information on self-administration, though. I would be very reluctant to
> take a drug that would turn me into a drooling moron (possibly for days) if I were
> far from home and needed to make decisions, drive, etc.========
Harry, what you say above is of considerable interest to me as I have started to take Parnate (I couldn't get on with Nardil) and in a few weeks time I will be travelling to Europe where it will be quite hard to know about what is in the meals I am being offered.
I suspect that if I carried any hypodermics with me (even if I did know how to use them properly on myself) then I might struggle to explain it to suspicious policemen!
Last year, when I looked into what medications to take in the event of a hypertensive crisis, I came across these two documents. There may be others now.
"Dangers of Immediate-Release Nifedipine for Hypertensive Crises"
LINK = http://www.ptcommunity.com/ptjournal/fulltext/27/7/PTJ2707362.pdf"Alternatives to Nifedipine in Hypertensive Urgencies"
LINK = http://www.rxfiles.ca/acrobat/nifed-hu.pdfFrom these documents it seems that Captopril might be a better alternative to Nifedipine. What do you think? I already got myself some 250 mg Captopril tablets to take.
I would be very interested in hearing your thoughts about this or those of anyone else here.
Don
Posted by harryp on May 31, 2004, at 0:22:14
In reply to Is Captopril good for MAOI hypertensive crisis? » harryp, posted by don_bristol on May 29, 2004, at 10:54:07
Thank you very much for the article on Captopril. It does look like it could be a good option.
*Kaplan's Clinical Hypertension* has this to say about it:
"Despite the small potential for hypotension, oral captopril may be the safest of nonparenteral agents for urgent hypertension" (8th ed. 353)
Kaplan also noes: "...an ACEI [ACE-inhibitor, i.e. captopril] may be particularly attractive because it shifts the entire curve of cerebral autoregulation to the left, so CBF [cerebral blood flow] should be well maintained as the systemic BP falls." (353)
On Nifedipine:
"[because of the risk of hypotension, some authorities have] recommended that the use of short-acting nifedipine be abandoned. However, IF TAKEN IN THE UNBROKEN CAPSULE, IT SEEMS NO MORE LIKELY TO CAUSE A PRECIPITOUS FALL IN BP THAN OTHER SHORT-ACTING AGENTS (e.g. captopril)." (352, emphasis added)
Clonidine causes significant sedation, and doesn't seem to have any advantages over nifedipine and captopril except slower-onset. Oral labetalol seems to work too slowly and last too long to be a good choice.
Good news:
Judging from my British psychiatry text, MAOI's seem to be more widely used in Britian, at least, and hopefully Western Europe in general. This would mean that you would likely get fast, appropriate care at an ER. You could also contact the NHS in Britian for European-food-oriented MAOI advice. I fear you will have to pass on the tap Guiness! Bernstein's *Drug Therapy in Psychiatry* has the most exhaustive info on the tyramine content of common and unusual foods.
As far as oral drugs go when the ER isn't an option--we are our own guinea-pigs...
I think Captopril sounds like a good option, although I have no idea what the best dosage would be.
I get the impression that many of the dangers of Nifedipine can be lessened if one takes only one 10 mg immediate release capsule WITHOUT breaking the capsule. This will be what I will do if I don't have access to phentolamine.
Keep in mind that all oral drugs are a bit sketchy (as Kaplan and other authorities note) becauase you can't titrate the dosage precisely. Don't mess with them unless you KNOW for sure you are having a hp urgency, and qualified medical care is not available.
Keep in mind the following (for all MAOI users):
Make sure you can identify a true hypertensive urgency/crisis. I think all MAOI patients should be skilled in monitoring their own bp and know what is normal for them. The pounding headache is unmistakable, but taking your bp can give you advance warning (it did in my case--the headache doesn't start immediately) if you "feel funny" and also can help get you attention at the ER.
"My bp is over 200/100!"
gets better results than
"uhh. I have a bad headache and I think I'm having a drug reaction..."
Don't panic! A prescribed anti-anxiety drug can help lower the "anxiety-component" of your bp. Stroke or death from an untreated MAOI crisis is INCREDIBLY rare. Stay calm, (if getting to an ER isn't an option, lie down in a quiet, darkened room) and you will probably be just fine. If you do go to the ER, BE SURE to tell the doctor (in addition to the MAOI stuff) if you took any bp lowering drug recently (like nifedipine or captopril, etc.). I saw one chart in which an overzealous ER doc added phentolamine on top of nifedipine, and caused a(non-fatal) hypotensive reaction.
Posted by harryp on May 31, 2004, at 1:01:47
In reply to MAOI hypetensive crisis treatment, posted by harryp on May 31, 2004, at 0:22:14
I have read that effect of Captopril appears to be nullified by non-steroidal anti-inflammatory agents like Asprin. This is an important thing to remember if you and your doctor elect to use this drug. (i.e. if you take a nonprescription painkiller for a "headache" and then find you are having a hp urgency, the captopril might not work.)
Posted by Sad Panda on May 31, 2004, at 8:50:09
In reply to one other thing about Captopril..., posted by harryp on May 31, 2004, at 1:01:47
>I have read that effect of Captopril appears to be nullified by non-steroidal anti-inflammatory agents like Asprin. This is an important thing to remember if you and your doctor elect to use this drug. (i.e. if you take a nonprescription painkiller for a "headache" and then find you are having a hp urgency, the captopril might not work.)
>
>
>What about if you are already taking an ACE inhibitor? Do you think other ones would work as well as Capotril?
Cheers,
Panda.
Posted by don_bristol on May 31, 2004, at 20:26:53
In reply to MAOI hypetensive crisis treatment, posted by harryp on May 31, 2004, at 0:22:14
>
> Thank you very much for the article on Captopril. It does look like it could be a good option.
>
> *Kaplan's Clinical Hypertension* has this to say about it:
>
> "Despite the small potential for hypotension, oral captopril may be the safest of nonparenteral agents for urgent hypertension" (8th ed. 353)
>
> Kaplan also noes: "...an ACEI [ACE-inhibitor, i.e. captopril] may be particularly attractive because it shifts the entire curve of cerebral autoregulation to the left, so CBF [cerebral blood flow] should be well maintained as the systemic BP falls." (353)
>
> On Nifedipine:
>
> "[because of the risk of hypotension, some authorities have] recommended that the use of short-acting nifedipine be abandoned. However, IF TAKEN IN THE UNBROKEN CAPSULE, IT SEEMS NO MORE LIKELY TO CAUSE A PRECIPITOUS FALL IN BP THAN OTHER SHORT-ACTING AGENTS (e.g. captopril)." (352, emphasis added)
>
> Clonidine causes significant sedation, and doesn't seem to have any advantages over nifedipine and captopril except slower-onset. Oral labetalol seems to work too slowly and last too long to be a good choice.
>
> Good news:
>
> Judging from my British psychiatry text, MAOI's seem to be more widely used in Britian, at least, and hopefully Western Europe in general. This would mean that you would likely get fast, appropriate care at an ER. You could also contact the NHS in Britian for European-food-oriented MAOI advice. I fear you will have to pass on the tap Guiness! Bernstein's *Drug Therapy in Psychiatry* has the most exhaustive info on the tyramine content of common and unusual foods.
>
> As far as oral drugs go when the ER isn't an option--we are our own guinea-pigs...
>
> I think Captopril sounds like a good option, although I have no idea what the best dosage would be.
>
> I get the impression that many of the dangers of Nifedipine can be lessened if one takes only one 10 mg immediate release capsule WITHOUT breaking the capsule. This will be what I will do if I don't have access to phentolamine.
>
> Keep in mind that all oral drugs are a bit sketchy (as Kaplan and other authorities note) becauase you can't titrate the dosage precisely. Don't mess with them unless you KNOW for sure you are having a hp urgency, and qualified medical care is not available.
>
> Keep in mind the following (for all MAOI users):
>
> Make sure you can identify a true hypertensive urgency/crisis. I think all MAOI patients should be skilled in monitoring their own bp and know what is normal for them. The pounding headache is unmistakable, but taking your bp can give you advance warning (it did in my case--the headache doesn't start immediately) if you "feel funny" and also can help get you attention at the ER.
>
> "My bp is over 200/100!"
>
> gets better results than
>
> "uhh. I have a bad headache and I think I'm having a drug reaction..."
>
>
> Don't panic! A prescribed anti-anxiety drug can help lower the "anxiety-component" of your bp. Stroke or death from an untreated MAOI crisis is INCREDIBLY rare. Stay calm, (if getting to an ER isn't an option, lie down in a quiet, darkened room) and you will probably be just fine. If you do go to the ER, BE SURE to tell the doctor (in addition to the MAOI stuff) if you took any bp lowering drug recently (like nifedipine or captopril, etc.). I saw one chart in which an overzealous ER doc added phentolamine on top of nifedipine, and caused a(non-fatal) hypotensive reaction.
===============================Harry
Thank you for a well-considered reply. It is much appreciated. I will try and address all the several points you make.
First of all I should dispel any confusion as to where I am. I live in the UK and we here often use the term 'Europe' to refer to the continental countries. So don't let that mislead you!
You quotation of Kaplan seems to endorse the use of Captopril. I also see you point out that short-acting Nifedipine was now discredited (no wonder my doctors wouldn't give it to me last year!) I seem to recall that the short-acting form was a capsule that was broken and the gel contents placed under the tongue.
I rather felt that both papers which I quoted just now http://www.ptcommunity.com/ptjournal/fulltext/27/7/PTJ2707362.pdf and http://www.rxfiles.ca/acrobat/nifed-hu.pdf both felt there were better meds than Nifedipine from a safety point of view.
You say that MAOIs seem to be more widely used in the UK than the US but my experience has been that they are quite rarely used here. Maybe I am not aware of the real numbers of users in the UK. However one strange thing is the recommended range for Parnate in the US is 30 to 60 mg (source PDR http://www.drugs.com/PDR/Parnate_Tablets.html) whereas in the UK it is 10 to 30 mg (source BNF http://www.bnf.org/bnf/bnf/current/noframes/3346.htm). That may mean in the UK the tyramine problems are fewer because the dose is lower. Also UK doctors can prescribe the food-insensitive reversible MAOI Moclobemide which the US does not. And furthermore the UK has not discontinued use of Marplan (isocarboxazid). But all this does not mean that it seems to people like me that MAOIs are common.
By the way, I have settled on a 250 (even 500 mg) dose of Captopril. It all depends on the rate of raise of BP and its absolute value. I hope I never have to use the Captopril. In truth I don't recall if I have to swallow, crush or keep it in the mouth - so I need to check. However I am told that tyramine food reactions are more likely with Parnate than with the Nardil I tried before so it seems more likely that a Parnate user might hit this problem. Please let me know if you or anyoe else has a view on what quanitity to take and when after/during a hypertensive crisis.
I think someone here posted this link recently http://www.vh.org/adult/provider/psychiatry/CPS/19.html and here is something similar regarding debunking diet myths http://www.deoxy.org/maoidiet.htm
I can add to these this following link which I find particularly interesting as it has figures on the actual number of hypertensive incidents http://www.emedicine.com/EMERG/topic318.htm. More modern figures would be even better.
Over in the Yahoo group on MAOIS http://health.groups.yahoo.com/group/maois/ which I am a member of, I think someone recently mentioned taking chlorpromazine because it lowered BP and it also sedated the person without making them go 'gaga'.
I think your advice to have access to a BP machine and to quote its figures is a very good one. I have now added my BP machine to my packing list! And I will quote it's readings if I have problems.
I am mindful too of your postscript in a second posting here which refers to potential problems when Captopril is taken with aspirin. But this seems to be one of those suspected interactions. Pubmed didn't have much on this topic. I found only "Comparative effects of aspirin with ACE inhibitor or angiotensin receptor blocker on myocardial infarction and vascular function” (2003) and one other called "Interaction between aspirin and angiotensin-converting enzyme inhibitors: should they be used together in older adults with heart failure?” (2002).
In actual fact I currently take 75 mg aspirin daily.
Well I guess there is a lot of info here. I have not fully absorded it yet. I probably wont ever absorb all of it so any comments and observations will help me see my way through it.
Best wishes -- Don
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