MAOI and psychostimu;ants
Mike Newman
I am treating a patient with depression and ADHD. I would like to add
cylert ot parnate. Any experience out there?
Jerry Miller
I've used Cylert and Nardil I didn't have any ill effects, and I must say that my own experience with cylert is:
A. It isn't effective
B. It doesn't have much sympatomimetic activity
Later, I took ONE pill of the decongestent psuedoephedrine (25mg). I got BP of 200/130 !!!
My advise - give your MAOI patients nifedipine (sublingual or chewable), it saves lives in hypertensive episodes !
Scott L. Schofield
Jerry Miller <jmi...@nym.alias.net> wrote:
: My advise - give your MAOI patients nifedipine (sublingual or chewable),
: it saves lives in hypertensive episodes !
Thanks and appreciation from an MAOI patient...
Sincerely,
Scott
dr5...@cnsvax.albany.edu
Dr. Newman,
Psychostimulants are all contraindicated with MAOI's. They displace NE,
Epi, DA and 5HT from presynaptic vesicles into the synapse, where they
will continue to associate and disassociate with receptors (since MAO is
inhibited they will not be degraded), with the NE
and Epi resulting in hypertensive crises. Forgive my asking, but,
shouldn't you know this?
Dan Ruisi
University at Albany
State University of New York
dr5...@cnsvax.albany.edu
http://cnsvax.albany.edu/~dr5898
Scott L. Schofield
On Wed, 22 Jan 1997, Mike Newman wrote:
> > I am treating a patient with depression and ADHD. I would like to add
> > cylert ot parnate. Any experience out there?
Dan Ruisi wrote:
> Dr. Newman,
>
> Psychostimulants are all contraindicated with MAOI's. They displace NE,
> Epi, DA and 5HT from presynaptic vesicles into the synapse, where they
> will continue to associate and disassociate with receptors (since MAO is
> inhibited they will not be degraded), with the NE
> and Epi resulting in hypertensive crises. Forgive my asking, but,
> shouldn't you know this?
Dear Dan,
Consider yourself forgiven.
- Scott
----------------------------------------------------------
MAOIs in high doses and with stimulants / indexed under:
柊ntidepressants, monoamine oxidase inhibitors 百timulants
------------------------------------------------------------------------
Date: Sat, 1 Apr 1995 13:33:03 -0800 (PST)
From: Ivan Goldberg <psy...@psycom.net>
Subject: Non-response to tranylcypromine
The commonest reason people do not respond to tranylcypromine
(Parnate) is an inadequate dose. When using an MAOI I follow
platelet MAO levels and keep increasing the dose is sufficient to
reduce those levels almost to zero. This often takes > 60 mg/day of
tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant
improvement, the next thing I usually do is to add a
psychostimulant such as methylphenidate or dextroamphetamine to the
cocktail. Starting with small doses, the dose is gradually
increased until the patient is taking about 30 mg/day of
dextroamphetamine, or twice as much methylphenidate.
------------------------------------------------------------------------
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psy...@psycom.net>
Subject: MAOIs in high doses and with stimulants
There are recently been a number of warnings posted there that
MAOIs should not be prescribed together with psychostimulants.
While that is the conventional wisdom, if universally implemented,
it would deprive many severely and intractably depressed people
from relief.
In the olden days, the early 1960s, we used to treat some patients
with resistant depressions with up to 200 mg/day of tranylcypromine
and if that was not effective potentiate it with dextroamphetamine,
starting with 2.5 mg once a day and gradually increasing to 15 or
20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine
was only able to continue in his professional work by taking 170
mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since
the isocarboxazid became unavailable, he has been doing almost as
well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is
often necessary to use combinations [and doses] of medication that
are conventionally considered to be contraindicated.
------------------------------------------------------------------------
From: "Steven L. Dubovsky" <Steven....@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulants
It is common practice where I come from to combine maois and
stimulants for rx of MAOI-induced hypotension and treatment
resistance. This is also mentioned in Jan Fawcett's book of a
number of years ago. Also, remember Feighner's report of MAOI + TCA
+ stimulant in ECT-resistant depression. I have tried this a number
of times and found it helpful. Since half the caucasian population
are (is?) rapid acetylators, higher doses of parnate are frequently
necessary. Other pts are rapid metabolizers of hydrazide MAOIs and
need high doses of those. The PDR is a legal, not a medical,
document, so I don't think their doses are always reliable.
------------------------------------------------------------------------
From: Donald Franklin Klein <df...@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulants
MAOIs plus methylphenidate (Ritalin) has not been a problem in my
hands altho theoretical risk requires discussion with patient,
consent, and available nifedipine. Very useful for orthostatic
hypotension.
------------------------------------------------------------------------
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112...@compuserve.com>
Subject: MAOIs with stimulants
None other than my teacher, John Rush, some years ago referred just
such a refractory person to me specifically to try adding a
stimulant to her MAOI. This was in the days when doctors could
still hospitalize and had authority to do things. Apparently, we
private practitioners had a bit more autonomy than the university
MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very
slowly Dexedrine or Desoxyn to the patient's regimen. It was
wonderful -- a grand remission occurred -- and complications were
zero. I've tried it since a few times, starting a low doses and
titrating gradually upward, and each time no complications arose.
Like all treatment efforts, it has been variably effective, but
definitely worth trying. Of course, give them nifedipine as an
antidote to carry.
------------------------------------------------------------------------
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <Mill...@wpogate.slu.edu>
Subject: MAOIs with stimulants
Hypotension is a frequent side-effect of MAOIs. If hypotension
limits appropriate dosage increases, either based on clinical
response, or on not reaching the target dose of about 1mg/kg in the
case of phenelzine (Robinson and Nies), the slow and careful
addition of stimulants while monitoring BP makes wonderful sense.
The hypotension is treated, the antidepressant effect is augmented,
and, if methylphenidate is used, there may be pharmacokinetic
effects as well. This is riskier with tranylcypromine given that
spontaneous elevations of BP have been noted with this MAOI despite
strict dietary adherence. It's also easier to do safely on an
inpatient basis.
------------------------------------------------------------------------
From: JoelS...@aol.com (Joel S Hoffman, M.D.)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulants
There is fortunately a small literature on combining MAOI and
stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132;
Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych
1990, 226-231, reported in a survey of prescribing habits of
Pennsylvania psychiatrists that among those who prescribed MAOIs,
use of high doses and combined use of MAOIs with stimulant meds
were not unusual.
I have used this combination for the treatment of refractory
depression and have at times have found it a great help and at
other times useless. I do not remember it being helpful when a
patient was not at least partially responsive to either the
stimulant or the MAOI alone. However if there is a partial response
to one of those meds, then when the two are combined, there can be
either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often
add the MAOI to the stimulant rather than the reverse... If I do
add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or
equivalent, the idea being that it probably takes at least 5 mg
tyramine to precipitate a hypertensive crisis, and since the
molecular weights are about the same 1.25 mg amphetamine would be
sub-threshold. Starting at that level has not caused any reactions
but I still prefer to start with the stimulant and add the MAOI
later.
I find that with time, as more treatment options are available, I
use this combination less but there are still some patients for
whom nothing else seems to work. The side effects that do cause
problems include activation sometimes resembling or identical to
dysphoric mania. Stereotypy and choreiform movements including
bucco-facial dyskinesia can also occur. These side effects have to
watched for closely. If it is essential to continue the regimen,
pimozide can usually alleviate the movement disorder.
------------------------------------------------------------------------
From: "David A. Kahn" <kah...@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulants
I'm always in the position of trying to augment an existing MAOI
regimen, so it's never seemed feasible to stop the MAOI, start the
stimulant, and then restart the MAOI. I just add the stimulant. The
only adverse reaction I've encountered is an odd lability of blood
pressure on two occasions, where supine blood pressure was somewhat
elevated on a tonic basis, together with a worsening of orthostatic
hypotension. The supine elevation made it impossible to think of
Florinef, etc., so we had to stop the combo. Interestingly, both of
these individuals had prior histories of intermittent bordereline
essential hypertension which had resolved on the MAOI alone.
------------------------------------------------------------------------
From: JoelS...@aol.com (Joel S Hoffman, M.D.)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulants
By the way, I do not get signed consent. I do not think that that
holds up very well anyway. Well documented clear chart notes
indicating the clinical rationale and including what is told to the
patient should always be standard practice and especially with
atypical treatment modalities such as this.
------------------------------------------------------------------------
psy...@netcom.com
The message below is "correct" in that it reflects orthodoxs medical-student
level psychopharmacology. In the real world, experienced psycho-
pharmacologists have been using MAOIs in conjunction with psychostimulants
for the past 30+ years.
See:
http://www,psycom.net/depression.central.expert.html
Best regards . . .
Ivan
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
dr5...@cnsvax.albany.edu wrote:
: Dr. Newman,
: Psychostimulants are all contraindicated with MAOI's. They displace NE,
: Epi, DA and 5HT from presynaptic vesicles into the synapse, where they
: will continue to associate and disassociate with receptors (since MAO is
: inhibited they will not be degraded), with the NE
: and Epi resulting in hypertensive crises. Forgive my asking, but,
: shouldn't you know this?
: Dan Ruisi
: University at Albany
: State University of New York
: dr5...@cnsvax.albany.edu
: http://cnsvax.albany.edu/~dr5898
: On Wed, 22 Jan 1997, Mike Newman wrote:
: > I am treating a patient with depression and ADHD. I would like to add
: > cylert ot parnate. Any experience out there?
: >
: >
--
-- \\\\
(@ @)
||-----------------------------------------------------ooOo-( )-oOoo----||
|| Ivan Goldberg, MD ~ ||
|| IK...@Columbia.Edu Psy...@PsyCom.Net ||
|| V: 212 876 7800 / 1346 Lexington Ave NYC 10128 / F: 212 737 0473 ||
|| http://www.psycom.net/depression.central.html ||
|| http://www.psycom.net/ijppp.html ||
||----------------------------------------------------------------------||
Andrew Davis
On Wed, 22 Jan 1997 20:03:21 -0800, Mike Newman <mmne...@digisys.net>
wrote:
>I am treating a patient with depression and ADHD. I would like to add
>cylert ot parnate. Any experience out there?
Add Cylert or Parnate to what???????