Today's med: Phenelzine (FEN el zeen) (brand name: Nardil)
Drug Class: Antidepressant, Monoamine Oxidase Inhibitor
Other Drugs in this class:
Indications:
Action:Thought to act by increasing endogenous concentrations of norepinephrine, dopamine, and serotonin through inhibition of the enzyme (monoamine oxidase) responsible for the breakdown of these neurotransmitters
Contraindications: Hypersensitivity to phenelzine or any component of the formulation; congestive heart failure; pheochromocytoma; abnormal liver function tests or history of hepatic disease; renal disease or severe renal disease/impairment
Concurrent use of sympathomimetics (including amphetamines, cocaine, dopamine, epinephrine, methylphenidate, norepinephrine, or phenylephrine) and related compounds (methyldopa, levodopa, phenylalanine, tryptophan, or tyrosine), ophthalmic alpha2-agonists (apraclonidine, brimonidine), CNS depressants, cyclobenzaprine, dextromethorphan, ethanol, meperidine, bupropion, or buspirone
At least 2 weeks should elapse between the discontinuation of serotoninergic agents (including SNRIs, SSRIs, and tricyclics) and other MAO inhibitors and the initiation of phenelzine. At least 5 weeks should elapse between the discontinuation of fluoxetine and the initiation of phenelzine. In all cases, a sufficient amount of time must be allowed for the clearance of the serotoninergic agent and any active metabolites prior to the initiation of phenelzine.
At least 2 weeks should elapse between the discontinuation of phenelzine and the initiation of the following agents: Serotoninergic agents (including SNRIs, SSRIs, fluoxetine, and tricyclics), bupropion, buspirone, and other antidepressants.
General anesthesia, spinal anesthesia (hypotension may be exaggerated). Use caution with local anesthetics containing sympathomimetic agents. Phenelzine should be discontinued ≥10 days prior to elective surgery.
Foods high in tyramine or dopamine content; foods and/or supplements containing tyrosine, phenylalanine, tryptophan, or caffeine
Adverse Effects:
Cardiovascular: Edema, orthostatic hypotension
Central nervous system: Anxiety (acute), ataxia, coma, delirium, dizziness, drowsiness, euphoria, fatigue, fever, headache, hyper-reflexia, hypersomnia, insomnia, mania, schizophrenia, seizure, twitching
Dermatologic: Pruritus, rash
Endocrine & metabolic: Decreased sexual ability (anorgasmia, ejaculatory disturbances, impotence), hypermetabolic syndrome, hypernatremia
Gastrointestinal: Constipation, weight gain, xerostomia
Genitourinary: Urinary retention
Hematologic: Leukopenia
Hepatic: Jaundice, necrotizing hepatocellular necrosis (rare), transaminases increased
Neuromuscular & skeletal: Myoclonia, paresthesia, tremor, weakness
Ocular: Blurred vision, glaucoma, nystagmus
Respiratory: Edema (glottis)
Miscellaneous: Diaphoresis, Lupus-like syndrome, transient cardiac or respiratory depression (following ECT), withdrawal syndrome (nausea, vomiting, malaise)
Major psychiatric warnings:
• Suicidal thinking/behavior: [U.S. Boxed Warning]: Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (18-24 years of age) with major depressive disorder (MDD) and other psychiatric disorders; consider risk prior to prescribing. Short-term studies did not show an increased risk in patients >24 years of age and showed a decreased risk in patients ≥65 years. Closely monitor patients for clinical worsening, suicidality, or unusual changes in behavior, particularly during the initial 1-2 months of therapy or during periods of dosage adjustments (increases or decreases); the patient’s family or caregiver should be instructed to closely observe the patient and communicate condition with healthcare provider. A medication guide concerning the use of antidepressants should be dispensed with each prescription.Phenelzine is not FDA approved for the treatment of depression in children ≤18 years of age.
• The possibility of a suicide attempt is inherent in major depression and may persist until remission occurs. Patients treated with antidepressants should be observed for clinical worsening and suicidality, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Worsening depression and severe abrupt suicidality that are not part of the presenting symptoms may require discontinuation or modification of drug therapy. Use caution in high-risk patients during initiation of therapy.
• Prescriptions should be written for the smallest quantity consistent with good patient care. The patient's family or caregiver should be alerted to monitor patients for the emergence of suicidality and associated behaviors such as anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity, akathisia, hypomania, and mania; patients should be instructed to notify their healthcare provider if any of these symptoms or worsening depression or psychosis occur.
Concerns related to adverse effects:
• Hypertensive crisis: Cases of hypertensive crisis (sometimes fatal) have occurred; symptoms include: severe headache, nausea/vomiting, neck stiffness/soreness, photophobia, and sweating. Monitor blood pressure closely in all patients. May occur with foods/supplements high in tyramine, tryptophan, phenylalanine, or tyrosine content; treatment with phentolamine is recommended for hypertensive crisis.
• Orthostatic hypotension: May cause orthostatic hypotension; use with caution in patients at risk of this effect or in those who would not tolerate transient hypotensive episodes (cerebrovascular disease, cardiovascular disease, hypovolemia, or concurrent medication use which may predispose to hypotension/bradycardia).
Special populations:
• Elderly: The MAO inhibitors are effective and generally well tolerated by older patients. It is the potential interactions with tyramine or tryptophan-containing foods and other drugs, and their effects on blood pressure that have limited their use.
Other warnings/precautions:
• Appropriate use: Phenelzine is not generally considered a first-line agent for the treatment of depression; phenelzine is typically used in patients who have failed to respond to other treatments.
• Electroconvulsive therapy: May increase the risks associated with electroconvulsive therapy; consider discontinuing, when possible, prior to ECT treatment.
• Myelography: Discontinue at least 48 hours prior to myelography.
• Pyridoxine deficiency: Has occurred; symptoms include numbness and edema of hands; may respond to supplementation.
Oral: Adults: Depression: Initial: 15 mg 3 times/day
Early phase: Increase rapidly, based on patient tolerance, to 60-90 mg/day (may take 4 weeks of 60 mg/day therapy before clinical response)
Maintenance: After maximum benefit is obtained, slowly reduce dose over several weeks; dose may be as low as 15 mg/day to 15 mg every other day
Elderly: Depression: Select dose with caution; generally initiating at the lower end of the dosing range; some clinicians recommend an initial dose of 7.5 mg, with dose increases of 7.5 mg/day every 4-8 days as tolerated to a usual therapeutic dose of 22.5-60 mg/day in older adults (Alexopoulos, 2004).
Avoid tyramine-containing foods/beverages. Some examples include aged or matured cheese, air-dried or cured meats (including sausages and salamis), fava or broad bean pods, tap/draft beers, Marmite concentrate, sauerkraut, soy sauce and other soybean condiments. Food’s freshness is also an important concern; improperly stored or spoiled food can create an environment where tyramine concentrations may increase.
Drug
interactions: Link:
A total of 941 drugs (5730 brand and generic names) are known to interact with phenelzine.
- 458 major drug interactions (3754 brand and generic names)
- 462 moderate drug interactions (1855 brand and generic names)
- 21 minor drug interactions (121 brand and generic names)
Avoid alcohol and foods high in tyramine.
Reserpine: MAO Inhibitors may enhance the adverse/toxic effect of Reserpine. Existing MAOI therapy can result in paradoxical effects of added reserpine (e.g., excitation, hypertension). Management: Monoamine oxidase inhibitors (MAOIs) should be avoided or used with great caution in patients who are also receiving reserpine. Consider therapy modification
Tryptophan: May enhance the adverse/toxic effect of MAO Inhibitors. Avoid combination
Phenelzine, gimme some MOa.....
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