Download Prescribing Framework for Phenelzine (MAOI) in the treatment of

Hull & East Riding Prescribing Committee
Prescribing Framework for Phenelzine (MAOI) in the treatment of
depressive illness
Patients Name:…………………………………………………..… NHS Number: ………………
Patients Address:……………………………………………...……(Use addressograph sticker)
GP’s Name:……………………………………………………….……..
Communication
We agree to treat this patient within this Prescribing Framework.
Specialist Prescriber’s Name ……………………………………………………………...
Specialist Prescriber’s Signature……………………………………………………….Date:……………
Consultant’s Signature (if appropriate)…………………………………………………Date:……………
GP’s Signature:………………………………………………………….
Date:……………
The front page of this form should be completed by the specialist and the form sent to the patient’s general
practitioner.
The patient’s GP should sign and send back to specialist, to confirm agreement to enter into shared care
arrangement. If the General Practitioner is unwilling to accept prescribing responsibility for the above
patient the specialist should be informed within two weeks of receipt of this framework and specialist’s
letter.
Full copy of framework can also be found at : http://www.hey.nhs.uk/amber.htm
Prescribing framework for Phenelzine
Date approved by HERPC : Sep 13
Review date: Sep 2016
Page 1 of 7
1. Background
Monoamine-oxidase inhibitors are used much less frequently than tricyclic and related antidepressants,
or SSRIs and related antidepressants because of the dangers of dietary and drug interactions and the
fact that it is easier to prescribe MAOIs when tricyclic antidepressants have been unsuccessful than
vice versa.
Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features are said to
respond best to MAOIs. However, MAOIs may be tried in any patients who are refractory to treatment
with other antidepressants as there is occasionally a dramatic response. Response to treatment may be
delayed for 3 weeks or more and may take an additional 1 or 2 weeks to become maximal.
MAOIs are associated with withdrawal symptoms on cessation of therapy. Symptoms include agitation,
irritability, ataxia, movement disorders, insomnia, drowsiness, vivid dreams, cognitive impairment, and
slowed speech. Withdrawal symptoms occasionally experienced when discontinuing MAOIs include
hallucinations and paranoid delusions. If possible MAOIs should be withdrawn slowly.
MAOIs inhibit monoamine oxidase, thereby causing an accumulation of amine neurotransmitters. The
metabolism of some amine drugs such as indirect-acting sympathomimetics (present in many cough
and decongestant preparations, section 3.10) is also inhibited and their pressor action may be
potentiated; the pressor effect of tyramine (in some foods, such as mature cheese, pickled herring,
broad bean pods, and Bovril®, Oxo®, Marmite® or any similar meat or yeast extract or fermented soya
bean extract) may also be dangerously potentiated. These interactions may cause a dangerous rise in
blood pressure. An early warning symptom may be a throbbing headache. Patients should be advised
to eat only fresh foods and avoid food that is suspected of being stale or ‘going off’. This is especially
important with meat, fish, poultry or offal; game should be avoided. The danger of interaction persists
for up to 2 weeks after treatment with MAOIs is discontinued. Patients should also avoid alcoholic
drinks or de-alcoholised (low alcohol) drinks.
The guidelines should be read in conjunction with the general guidance on prescribing matters given in
EL (91) 127 “Responsibility for prescribing between hospitals and GPs”.
2. Indication
Depressive Illness. Phenelzine should be initiated in secondary care under specialist supervision.
Once a patient’s mental state and medication have been stabilised they may be considered suitable for
shared care between the specialist and GP.
3. Dose
15 mg 3 times daily, increased if necessary to 4 times daily after 2 weeks (hospital patients, max. 30 mg
3 times daily), then reduced gradually to lowest possible maintenance dose (15 mg on alternate days
may be adequate). The last dose of the day should be taken before 3pm. The effectiveness of the drug
may not become apparent in less than 4 weeks therapy.
Child; not recommended.
Elderly; same as adult dose but side effects may be more common
4. Duration of treatment
NICE guidance states that people with depression who benefit from treatment with antidepressants are
advised to continue with treatment for at least 6 months after remission, extending to at least 2 years for
people at risk of relapse.
5. Contraindications
Cerebrovascular disease, phaeochromocytoma, liver impairment, not indicated in manic phase
6. Cautions
Diabetes mellitus, cardiovascular disease, epilepsy, blood disorders, concurrent electroconvulsive
therapy; elderly (great caution); monitor blood pressure (risk of postural hypotension and hypertensive
responses—discontinue if palpitations or frequent headaches); if possible avoid abrupt withdrawal;
severe hypertensive reactions to certain drugs and foods (see interactions); avoid in agitated patients;
acute porphyria
Prescribing framework for Phenelzine
Date approved by HERPC : Sep 13
Review date: Sep 2016
Page 2 of 7
Drowsiness:- may affect performance of skilled tasks (e.g. driving)
7. Adverse effects
Commonly postural hypotension (especially in elderly) and dizziness; less common side-effects include
drowsiness, insomnia, headache, weakness and fatigue, dry mouth, constipation and other gastrointestinal disturbances, oedema, myoclonic movement, hyperreflexia, elevated liver enzymes; agitation
and tremors, nervousness, euphoria, arrhythmias, blurred vision, nystagmus, difficulty in micturition,
sweating, convulsions, rashes, purpura, leucopenia, sexual disturbances, and weight gain with
inappropriate appetite may also occur; psychotic episodes with hypomanic behaviour, confusion, and
hallucinations may be induced in susceptible persons; suicidal behaviour; jaundice has been reported
and, on rare occasions, fatal progressive hepatocellular necrosis; paraesthesia, peripheral neuritis,
peripheral neuropathy may be due to pyridoxine deficiency; hyponatraemia
8. Interactions
Information current to July 2013.
Details of contraindications, cautions, drug interactions and adverse effects listed above are not
exhaustive. For further information always check with BNF www.bnf.org.uk or SPC
(www.medicines.org.uk).
ACE Inhibitors
Adrenergic
Neurone Blockers
Alcohol
Alpha-blockers
Angiotensin-II
Receptor
Antagonists
Antidepressants,
SSRI
Antidepressants,
Tricyclic
Antidepressants,
Tricyclic (related)
Antidiabetics
Antiepileptics
Antihistamines
Antimuscarinics
Apraclonidine
Atomoxetine
MAOIs possibly enhance hypotensive effect of ACE inhibitors
enhanced hypotensive effect when MAOIs given with adrenergic neurone blockers
MAOIs interact with tyramine found in some beverages containing alcohol and
some dealcoholised beverages (hypertensive crisis)—if no tyramine, enhanced
hypotensive effect
enhanced hypotensive effect when MAOIs given with alpha-blockers
MAOIs possibly enhance hypotensive effect of angiotensin-II receptor antagonists
MAOIs increase CNS effects of SSRIs (risk of serious toxicity)
increased risk of hypertension and CNS excitation when MAOIs given with
tricyclics, tricyclics should not be started until 2 weeks after stopping MAOIs (3
weeks if starting clomipramine or imipramine), also MAOIs should not be
started for at least 1–2 weeks after stopping tricyclics (3 weeks in the case of
clomipramine or imipramine)
after stopping MAOIs do not start tricyclic-related antidepressants for 2 weeks,
also MAOIs should not be started until at least 1–2 weeks after stopping
tricyclic-related antidepressants
MAOIs possibly enhance hypoglycaemic effect of antidiabetics
MAOIs possibly antagonise anticonvulsant effect of antiepileptics (convulsive
threshold lowered)
increased antimuscarinic and sedative effects when MAOIs given with antihistamines
Note: Sedative interactions apply to a lesser extent to the non-sedating
antihistamines. Interactions do not generally apply to antihistamines used for topical
action (including inhalation)
increased risk of antimuscarinic side-effects when MAOIs given with antimuscarinics
Note: Many drugs have antimuscarinic effects; concomitant use of two or more such
drugs can increase side-effects such as dry mouth, urine retention, and constipation;
concomitant use can also lead to confusion in the elderly. Interactions do not
generally apply to antimuscarinics used by inhalation
avoidance of MAOIs advised by manufacturer of apraclonidine
after stopping MAOIs do not start atomoxetine for 2 weeks, also MAOIs should
not be started until at least 2 weeks after stopping atomoxetine
Prescribing framework for Phenelzine
Date approved by HERPC : Sep 13
Review date: Sep 2016
Page 3 of 7
Beta-blockers
Brimonidine
Bupropion
Buspirone
Calcium-channel
Blockers
Carbamazepine
Citalopram
Clonidine
Clozapine
Diazoxide
Diuretics
Doxapram
Duloxetine
Entacapone
Escitalopram
Fluoxetine
Fluvoxamine
Histamine
Hydralazine
Indoramin
Insulin
Levodopa
MAOIs
Metformin
Methyldopa
Methylphenidate
Minoxidil
Mirtazapine
Moclobemide
Moxonidine
Nefopam
Nicorandil
Nitrates
Opioid Analgesics
enhanced hypotensive effect when MAOIs given with beta-blockers
Note: Since systemic absorption may follow topical application of beta-blockers to the
eye the possibility of interactions, in particular, with drugs such as verapamil should
be borne in mind
avoidance of MAOIs advised by manufacturer of brimonidine
avoidance of bupropion for 2 weeks after stopping MAOIs advised by
manufacturer of bupropion
avoidance of MAOIs advised by manufacturer of buspirone
enhanced hypotensive effect when MAOIs given with calcium-channel blockers
avoidance for 2 weeks after stopping MAOIs advised by manufacturer of
carbamazepine, also antagonism of anticonvulsant effect
after stopping MAOIs do not start citalopram for 2 weeks, also MAOIs should
not be started until at least 1 week after stopping citalopram
enhanced hypotensive effect when MAOIs given with clonidine
CNS effects of MAOIs possibly increased by clozapine
Note: Avoid concomitant use of clozapine with drugs that have a substantial potential
for causing agranulocytosis
enhanced hypotensive effect when MAOIs given with diazoxide
enhanced hypotensive effect when MAOIs given with diuretics
MAOIs enhance effects of doxapram
after stopping MAOIs do not start duloxetine for 2 weeks, also MAOIs should
not be started until at least 5 days after stopping duloxetine
avoid concomitant use of non-selective MAOIs with entacapone
after stopping MAOIs do not start escitalopram for 2 weeks, also MAOIs should
not be started until at least 1 week after stopping escitalopram
after stopping MAOIs do not start fluoxetine for 2 weeks, also MAOIs should not
be started until at least 5 weeks after stopping fluoxetine
after stopping MAOIs do not start fluvoxamine for 2 weeks, also MAOIs should
not be started until at least 1 week after stopping fluvoxamine
avoidance of MAOIs advised by manufacturer of histamine
enhanced hypotensive effect when MAOIs given with hydralazine
avoidance of MAOIs advised by manufacturer of indoramin
MAOIs enhance hypoglycaemic effect of insulin
risk of hypertensive crisis when MAOIs given with levodopa, avoid levodopa for
at least 2 weeks after stopping MAOIs
MAOIs can cause increased risk of hypertension and CNS excitation when
given with other MAOIs (avoid for at least 2 weeks after stopping previous
MAOIs and then start at a reduced dose)
Note: For interactions of reversible MAO-A inhibitors (RIMAs) see Moclobemide, and
for interactions of MAO-B inhibitors see Rasagiline and Selegiline; the antibacterial
Linezolid is a reversible, non-selective MAO inhibitor
MAOIs enhance hypoglycaemic effect of metformin
avoidance of MAOIs advised by manufacturer of methyldopa
risk of hypertensive crisis when MAOIs given with methylphenidate, some
manufacturers advise avoid methylphenidate for at least 2 weeks after stopping
MAOIs
enhanced hypotensive effect when MAOIs given with minoxidil
after stopping MAOIs do not start mirtazapine for 2 weeks, also MAOIs should
not be started until at least 2 weeks after stopping mirtazapine
after stopping MAOIs do not start moclobemide for at least 1 week
enhanced hypotensive effect when MAOIs given with moxonidine
avoidance of MAOIs advised by manufacturer of nefopam
enhanced hypotensive effect when MAOIs given with nicorandil
enhanced hypotensive effect when MAOIs given with nitrates
possible CNS excitation or depression (hypertension or hypotension) when
Prescribing framework for Phenelzine
Date approved by HERPC : Sep 13
Review date: Sep 2016
Page 4 of 7
Paroxetine
Pethidine
Pholcodine
Promethazine
Rasagiline
Reboxetine
Rizatriptan
Selegiline
Sertraline
Sodium
Nitroprusside
Sulfonylureas
Sumatriptan
Suxamethonium
Sympathomimetics
Tetrabenazine
Tolcapone
Tramadol
Tryptophan
Venlafaxine
Zolmitriptan
Artemether with
Lumefantrine
Atomoxetine
Piperaquine with
Artenimol
MAOIs given with opioid analgesics—some manufacturers advise avoid
concomitant use and for 2 weeks after stopping MAOIs
after stopping MAOIs do not start paroxetine for 2 weeks, also MAOIs should
not be started until at least 1 week after stopping paroxetine
CNS excitation or depression (hypertension or hypotension) when MAOIs given
with pethidine—avoid concomitant use and for 2 weeks after stopping MAOIs
avoidance of pholcodine for 2 weeks after stopping MAOIs advised by manufacturer
of pholcodine
avoidance of promethazine for 2 weeks after stopping MAOIs advised by
manufacturer of promethazine
risk of hypertensive crisis when MAOIs given with rasagiline, avoid MAOIs for
at least 2 weeks after stopping rasagiline
Note: Rasagiline is a MAO-B inhibitor
increased risk of hypertension and CNS excitation when MAOIs given with
reboxetine (MAOIs should not be started until 1 week after stopping reboxetine,
avoid reboxetine for 2 weeks after stopping MAOIs)
risk of CNS toxicity when MAOIs given with rizatriptan (avoid rizatriptan for 2
weeks after MAOIs)
enhanced hypotensive effect when MAOIs given with selegiline—manufacturer
of selegiline advises avoid concomitant use
Note: Selegiline is a MAO-B inhibitor
after stopping MAOIs do not start sertraline for 2 weeks, also MAOIs should not
be started until at least 1 week after stopping sertraline
enhanced hypotensive effect when MAOIs given with sodium nitroprusside
MAOIs enhance hypoglycaemic effect of sulfonylureas
risk of CNS toxicity when MAOIs given with sumatriptan (avoid sumatriptan for
2 weeks after MAOIs)
phenelzine enhances effects of suxamethonium
risk of hypertensive crisis when MAOIs given with sympathomimetics
risk of CNS toxicity when MAOIs given with tetrabenazine (avoid tetrabenazine
for 2 weeks after MAOIs)
avoid concomitant use of MAOIs with tolcapone
possible increased serotonergic effects and increased risk of convulsions
when MAOIs given with tramadol—some manufacturers advise avoid
concomitant use and for 2 weeks after stopping MAOIs
CNS excitation and confusion when MAOIs given with tryptophan (reduce dose
of tryptophan)
enhanced CNS effects and toxicity when MAOIs given with venlafaxine
(venlafaxine should not be started until 2 weeks after stopping MAOIs, avoid
MAOIs for 1 week after stopping venlafaxine)
increased risk of CNS toxicity when MAOIs given with zolmitriptan
avoidance of antidepressants advised by manufacturer of artemether with
lumefantrine
possible increased risk of convulsions when antidepressants given with atomoxetine
avoidance of antidepressants advised by manufacturer of piperaquine with
artenimol
Note: Piperaquine has a long half-life; there is a potential for drug interactions to
occur for up to 3 months after treatment has been stopped
Other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped (3
weeks with clomipramine or imipramine). Only experienced psychiatrists should use selected tricyclics in
conjunction with MAOIs as this is potentially fatal. There is no evidence that the combination is more
effective than when either constituent is used alone. The combination of tranylcypromine with clomipramine
Prescribing framework for Phenelzine
Date approved by HERPC : Sep 13
Review date: Sep 2016
Page 5 of 7
is particularly dangerous. Conversely, an MAOI should not be started until at least 7–14 days after a
tricyclic or related antidepressant (3 weeks in the case of clomipramine or imipramine) has been stopped.
In addition, an MAOI should not be started for at least 2 weeks after a previous MAOI has been stopped
(then started at a reduced dose).
9. Monitoring
Regular blood pressure measurement is recommended during initiation and routine checks should be made
during maintenance.
Depression is associated with an increased risk of suicidal thoughts, self harm and suicide (suicide-related
events). This risk persists until significant remission occurs. As improvement may not occur during the first
few weeks or more of treatment, patients should be closely monitored until such improvement occurs. It is
general clinical experience that the risk of suicide may increase in the early stages of recovery.
10. Information to patient
Verbal information along with the patient information leaflet from the Choice & Medication website will be
provided. It is essential that the patient has a good understanding of the food restrictions and is able to
adhere to these. Information on these food risks will be given to the patient prior to starting treatment.
11. Responsibilities of clinicians involved
Stage of
Treatment
Initiation
Hospital Specialist
General Practitioner


Provide details of any concurrent medication,
coexisting health problems and compliance
issues to the specialist

Continued discussion of risks and benefits of
medication with patients and carers as
required.
Prescribing once maintenance doses
established. Switching or discontinuation
should only be done through the specialist
Continued monitoring blood pressure, as
agreed with secondary care and referral back
to secondary care if patient becomes noncompliant and/or if mental state deteriorates
Respond to adverse reactions and advise on
concomitant medication.
Update specialist on any changes in medical
condition or prescribed concomitant medication
until discharged from specialist services
Seek support from specialist when considering
switching antidepressants


Maintenance





Switching

Prescribing until maintenance
regime established.
Discussion of risks and
benefits with patients and
carers in particular the dietary
restrictions and interactions
with medication, including
those available over the
counter
Provision of written
information on the use, side
effects and dietary restrictions
Provide details of concurrent
medication prescribed via
secondary psychiatric care to
GP.
Provide details of ongoing
monitoring requirements to
GP.
Provide details of patient
follow up including care plan.
Inform GP of any identified
problems e.g. compliance
with treatment.
Provide details of mental
health key worker if
appropriate.
Provide support to GP in
response to queries about
switching antidepressants





Prescribing framework for Phenelzine
Date approved by HERPC : Sep 13
Review date: Sep 2016
Page 6 of 7
Contact Details:
During Office hours: HFT Pharmacy Department (01482) 301724
Out of hours: On Call Psychiatrist via Switchboard (01482) 223191
APPROVAL PROCESS
Written by:
Consultation process:
Approved by:
Ratified by:
Review date:
Jackie Stark, Principal Pharmacist HFT
Wendy Tucker, Pharmacist
Specialist Team, HFT
Include MMIG (July 13), HFT DTC (July 13)
HERPC Sep 2013
Sep 2016
Prescribing framework for Phenelzine
Date approved by HERPC : Sep 13
Review date: Sep 2016
Page 7 of 7