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Monoamine Oxidase Inhibitors (MAOIs)

Information and Side Effect Profile of MAOIs

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Updated July 16, 2014

Information and Side Effect Profile of MAOIs

Monoamine oxidase inhibitors are a class of antidepressants that were developed in the 1950s. They are effective in treating depression, panic disorder and other anxiety disorders. Although they are generally as effective as selective serotonin reuptake inhibitors (SSRI) and tricyclic antidepressants (TCAs), they are used less frequently because of necessary dietary precautions and risks of adverse reactions when mixed with certain drugs.

Examples of MAOIs include:

  • Phenelzine (Nardil)
  • Tranylcypromine (Parnate)
  • Isocarboxazid (Marplan)
  • Selegiline (Emsam)

Emsam a transdermal (skin) patch that is applied once each day. This mode of administration may be less likely to cause the dietary complications associated with an oral route of administration.

How MAOIs Work

It is believed that the brain contains several hundred different types of chemical messengers (neurotransmitters) that act as communication agents between different brain cells. These chemical messengers are molecular substances that can affect mood, appetite, anxiety, sleep, heart rate, temperature, aggression, fear and many other psychological and physical occurrences. Monoamine oxidase (MAO) is an enzyme that degrades or breaks down three neurotransmitters associated with mood and anxiety:

  1. Serotonin, which plays a role in modulating anxiety, mood, sleep, appetite and sexuality.

  2. Norepinephrine, which influences sleep and alertness, is believed to be correlated to the fight-or-flight stress response.

  3. Dopamine, which influences body movement and is also believed to be involved in motivation, reward, reinforcement and addictive behaviors. Many theories of psychosis suggest that dopamine plays a role in psychotic symptoms.

MAOIs reduce the activity of the enzyme MAO. Less MAO results in higher levels of norepinephrine, serotonin and dopamine in the brain. The benefits of these increases are improved mood and an anti-panic effect.

Common Side Effects of MAOIs

  • decreased sleep/insomnia
  • nausea
  • diarrhea
  • dry mouth
  • hypertension (high blood pressure)
  • hypotension (low blood pressure)
  • dizziness
  • weight gain
  • edema (water retention)
  • sexual dysfunction
  • muscle spasms
  • weakness
  • confusion

This list is not all-inclusive, and you may experience other side effects not mentioned here. You should report all medication related side effects to your doctor.

Tyramine-Induced Hypertension Crisis

Tyramine is a compound found in many foods. This compound has an effect on blood pressure and is regulated by the MAO enzyme. When the MAO enzyme is inhibited (i.e., when taking an MAOI), tyramine can reach dangerously high levels, resulting in critically high blood pressure. While taking an MAOI, it will be necessary to avoid foods and beverages high in tyramine to prevent potentially fatal high blood pressure spikes.

Other Precautions and Contraindications

Before beginning MAOI therapy, tell your doctor if you have any of the following conditions:

Tell all of your treating providers that you are taking an MAOI. This includes physicians, physician assistants, dentists and other healthcare providers.

Do not take any medications without your doctor’s approval.

Serotonin Syndrome

Dangerously high levels of serotonin in the brain can cause a potentially life-threatening condition called serotonin syndrome. This rare condition is usually the result of an interaction of two or more drugs that affect brain serotonin levels. Even some over-the-counter supplements, such as St. John’s Wort, can result in serotonin syndrome if mixed with MAOIs. To reduce the risk of serotonin syndrome, MAOIs should never be taken with SSRIs or TCAs. It is recommended that other antidepressant therapy not begin until 10 to 14 days after discontinuation of an MAOI.

MAOIs and Pregnancy

The research on pregnancy and MAOI therapy is limited. It is recommended that MAOI therapy be avoided during pregnancy. If you are nursing or are pregnant, it is best to discuss the risks and benefits of MAOI therapy with your doctor.

MAOI Discontinuation Syndrome

Some people have reported withdrawal-like symptoms when decreasing or stopping MAOI therapy. It is believed that these symptoms are a result of the brain trying to stabilize serotonin and norepinephrine levels after an abrupt change.

Symptoms that may occur during discontinuation of MAOI therapy include:

  • nausea
  • headache
  • muscle aches
  • Dizziness
  • electric shock-like sensations in the neck and head

While all of these symptoms are not believed to be dangerous, they can be quite disconcerting. Do not reduce or discontinue MAOI therapy without consulting your doctor.

MAOIs and Suicide

The association of increased suicidal thoughts, especially among adolescents, with antidepressant treatment has been a center of attention and controversy in recent years. In response to the concerns suggested in case studies and some research, the U.S. Food and Drug Administration (FDA) issued a statement in 2007. The FDA proposed that makers of all antidepressant medications indicate a warning on their products about a possible increased risk of suicidal thinking and behavior in young adults, ages 18 to 24, during initial treatment.

So far, researchers have not found a definitive answer about the antidepressant-suicide connection. For the vast majority of people, antidepressants decrease depression and alleviate the helplessness and hopelessness that consumes their daily existence. But, for a very small percentage of people taking antidepressants, this may not be the case. If you are concerned about this issue, be open with your doctor and don’t be afraid to ask questions.

Sources:

Antidepressant Use in Children, Adolescents, and Adults. Revisions to Product Labeling. U.S. Food and Drug Administration. May 2, 2007.

Kaplan MD, Harold I. and Sadock MD, Benjamin J. Synopsis of Psychiatry, Eighth Edition 1998 Baltimore: Williams & Wilkins.

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