Download Antidepressant treatment with MAO-inhibitors during general and

International Journal of Clinical Pharmacology and Therapeutics, Vol. ■■ – No. ■■/2013 (1-9)
Original
©2013 Dustri-Verlag Dr. K. Feistle
ISSN 0946-1965
DOI 10.5414/CP201898
e-pub: ■■month, ■■day, ■■year
Antidepressant treatment with MAO-inhibitors
during general and regional anesthesia: A
review and case report of spinal anesthesia
for lower extremity surgery without
discontinuation of tranylcypromine
Ilana Krings-Ernst1, Sven Ulrich2 and Mazda Adli3
GmbH, Cologne, 2Aristo Pharma GmbH and 3Department of Psychiatry
and Psychotherapy, Charité, Berlin, Germany
1Orthoparc
Key words
monoamine oxidase
inhibitor – tranylcypromine – phenelzine –
anesthesia – spinal
anesthesia
Received
January 8, 2013;
accepted
June 2, 2013
Correspondence to
Dr. Ilana Krings-Ernst
Orthoparc GmbH,
Aachenerstrasse 1021B,
50858 Cologne,
Germany
[email protected]
Abstract. Monoamine oxidase-(MAO)inhibitors are a treatment of last resort in
treatment resistant depression, which is regarded as a condition of increased psychiatric risk. General and regional anesthesia
for elective surgery during use of long-term
MAO-inhibitors remains a matter of debate
because of an increased risk of drug interactions and decreased sympathetic stability.
A series of case reports and new comparative studies reveal the safety of anesthesia/
analgesia in non-cardiac surgery without discontinuation of the MAO-inhibitor if best effort is made for maintenance of sympathetic
homeostasis and if known drug interactions
are avoided. Very few reports with severe
adverse incidents have been noted. Severe
cardiovascular morbidity, a contraindication
of MAO-inhibitors, probably contributed
to peri- and postoperative complications.
According to new studies, the risk of pharmacokinetic drug interactions is lower for
tranylcypromine than for phenelzine. In the
present case, a 66-year-old psychiatric patient on permanent treatment with 20 mg/day
tranylcypromine was admitted for forefoot
surgery. Anesthetic premedication consisted
of 7.5 mg oral midazolam. Intravenous midazolam (0.5 mg) was dispensed for intraoperative sedation. After local anesthesia of
the puncture site with 30 mg isobar prilocaine, spinal anesthesia was achieved by a
single shot of 13.5 mg hyperbar bupivacaine
(0.5%) intrathecally. Postoperative regional
and general analgesia were accomplished by
a peripheral nerve block with 50 mg isobar
bupivacaine as well as oral etoricoxib and
oxycodone. No peri- or postoperative complications were encountered. It is concluded
that general or regional anesthesia for noncardiac surgery without discontinuation of
MAO-inhibitor treatment may be a safe intervention after careful evaluation of an individual’s perioperative and psychiatric risk.
•
An increased psychiatric risk in patients
treated with MAO-inhibitors compensates
for an increased, however manageable,
perioperative risk.(■■■bitte Kontrolle:
“compensate” ist evtl. das falsche Wort hier)
Introduction
According to a survey in an American
hospital, ~ 15% of patients admitted for
elective surgery were taking antidepressant
drugs [1]. An increased cardiovascular and
hemodynamic risk of perioperative anesthesia and analgesia has been recognized during
long-term treatment with these frequently
prescribed psychotropic medications [2, 3].
Clinical applications of irreversible monoamine oxidase-(MAO)-A/B-inhibitors (e.g.,
tranylcypromine, phenelzine) have considerably decreased since the 1960s because of the
risk of hypertensive crisis after consumption
of tyramine rich foods (“cheese effect”). A
diet with a low content of tyramine, a strong
indirect sympathomimetic agent, is therefore
mandatory and the use of MAO-inhibitors
is limited today to treatment resistant depression. Elective surgery or emergency
treatment with anesthesia and analgesia is
sometimes needed for these patients. There
is therefore a need for accumulation and
evaluation of medical scientific knowledge
and clinical experience of anesthesia and
analgesia in patients treated with MAOinhibitors. The current data is limited in the
area of regional anesthetic techniques such
as spinal anesthesia, for instance. Therefore,
a review of continuous MAO-inhibitor treat-
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Krings-Ernst, Ulrich and Adli
ment during anesthesia is presented. A new
case of spinal anesthesia for lower extremity
surgery during long-term tranylcypromine is
also included.
Review of MAO-inhibitors and
anesthesia/analgesia
Antidepressant drugs and
anesthesia/analgesia
The perioperative risk of antidepressant
drugs is caused mainly by a higher peripheral and central tonus of amine neurotransmitters. One or more pathways of amine
neurotransmission (serotonin, norepinephrine, dopamine) are affected by the different
antidepressant classes. In addition, tricyclic
antidepressants (TCA) also display anticholinergic, antihistaminergic and alpha-adrenolytic activities. Selective serotonin reuptake
inhibitors (SSRI) may cause increased bleeding and hyponatremia [2, 4, 5]. However,
SSRI are generally regarded as the safest
antidepressants in anesthesia because of the
lack of norepinephrinergic activity. Pharmacodynamic drug interactions with anesthetic
and analgesic drugs have to be considered, in
particular the risk of serotonin toxicity with
MAO-inhibitors [6] and SSRI [2, 7, 8, 9],
which has also been described as excitatory
syndrome (Type I excitatory reaction: hypertension, hyperpyrexia, seizures) in anesthesia [10, 11, 12]. Hypertensive crisis is a risk
associated with MAO-inhibitors and indirect
sympathomimetics used in anesthesia for the
treatment of perioperative hypotonia [12].
The relevance of pharmacokinetic SSRIinteractions is still unknown for anesthesia
despite the fact that strong inhibition of microsomal cytochrome P450 (CYP) enzymes
is well known for paroxetine, fluoxetine and
fluvoxamine [2, 13, 14]. In the past, pharmacokinetic drug interactions were also suspected for irreversible MAO-A/B-inhibitors
such as phenelzine [6]. More recent studies
have shown that tranylcypromine, in contrast
to phenelzine, may be devoid of significant
inhibition of CYP enzymes at therapeutic
doses [15, 16]. Increased plasma concentrations of opioid analgesics because of pharmacokinetic drug interactions may result in
a depressant syndrome (Type II depressive
•
reaction: sedation, hypotension, respiratory
depression and coma) [10, 11, 13]. Enzymes
determining the metabolism of opioids
are CYP enzymes (e.g. fentanyl, sufentanil, propoxyphene, tramadol) and uridine
5’-diphospho-(UDP)-glucuronyltransferases
(e.g., morphine) [13, 17, 18]. Depressant
syndrome may also arise as an additive pharmacodynamic interaction, e.g. more severe
hypotension by opioids with TCA or MAOinhibitors, or as a potentiation of the narcotic
effect of morphine, for example.
Reports of continuous MAOinhibitors during anesthesia/
analgesia
Several case reports were published
which described in more detail general anesthesia during long-term treatment with
tranylcypromine without peri- or postoperative complications, e.g., non-cardiac surgery
with diazepam, thiopental, succinylcholine,
pancuronium, N2O/halothane, N2O/enflurane or N2O/isoflurane as well as morphine
or fentanyl (n = 11) [19]. Another case was
with lorazepam, propofol, N2O/enflurane,
and fentanyl/morphine for non-cardiac surgery (n = 1) [20]. Conscious sedation with
diazepam, methohexital, and lidocaine/
epinephrine (n = 1) during long-term tranylcypromine and lithium was described for
periodontal surgery [21]. Anesthesia with
lorazepam, thiopental, sufentanil, isoflurane/
N2O, and vecuronium (n = 1) was used for
elective gastric surgery in a patient taking
60 mg/day tranylcypromine and a TCA [22].
Reports are also available for anesthesia during phenelzine treatment, e.g., with remifentanil (pharyngolaryngectomy and free jejunal
flap repair) [23], propofol (mandible surgery)
[24], and ketorolac (coloscopy and polypectomy) [25]. A retrospective study of 46 general anesthesias for joint replacement surgery
during continuous isocarboxazid showed no
difference to the comparison group in perioperative hypotension and hypertension. The
percentages of hypo- and hypertension were
10% and 2%, respectively, in the isocarboxazid group. No postoperative complications
were attributed to the MAO-inhibitor [26]. A
letter in the British Medical Journal in 1975
estimated that thousands of general anes-
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Tranylcypromine and anesthesia
thesias were used in patients taking MAOinhibitors and undergoing electroconvulsive
therapy (ECT) [27]. More recent reports of
ECT are also available, e.g., with phenelzine
and propofol-alfentanil anesthesia [28].
El-Ganzouri et al. [19] described three
cases of spinal and epidural anesthesia during long-term treatment with MAO-inhibitors: removal of the tibial plate (12 mg tetracaine 1%, morphine), total gastrectomy
(13 ml bupivacaine 0.5%, thiopental, succinylcholine, N2O/isoflurane, morphine), and
transurethral prostate resection (10 mg tetracaine 1%, morphine). Management of labor
over 14 hours (bupivacaine 0.25%) and subsequent successful Caesarean section with
epidural anesthesia (bupivacaine 0.5%, morphine) was described for a 25-year-old pregnant woman taking phenelzine [29]. Epidural
anesthesia (15 ml bupivacaine 0.5%) with
general anesthesia (fentanyl, thiopentone,
vecuronium, isoflurane) for an abdominal
hysterectomy was conducted in a 70-yearold patient during long-term moclobemide
therapy, a reversible MAO-A-inhibitor [30].
Five regional anesthesia cases for joint replacement were reported using isocarboxazid [26].
In contrast to these complication-free
surgeries, a case of severe postoperative
complications and fatal outcome was reported for a 64-year-old patient with severe
cardiac morbidity, including a recent myocardial infarction, and coronary arterial bypass grafting. The patient received multiple
medications including continuous 60 mg/day
tranylcypromine for depression. Anesthetic/
analgesic medication consisted of fentanyl,
midazolam and pancuronium. The causal
relationship of the incident with the MAOinhibitor was weak, however, the authors
suggested that the MAO-inhibitor may have
hindered successful management of the cardiovascular system. It is important to note
the difference here from the previous reports
because severe cardiac morbidity is a contraindication of tranylcypromine, and cardiac
surgery was still performed. The authors
concluded that surgery without such stress
to the cardiovascular system may be safe
in the presence of MAO-inhibitors [31]. A
similar case was reported for a multi-morbid
patient one week after myocardial infarction
and with continuous treatment with phen•
elzine (30 mg/day) in coronary arterial bypass grafting (premedication scopolamine/
morphine, general anesthesia with fentanyl/
midazolam, vecuronium). Perioperative hypertonia and supraventricular tachycardia
occurred and subsided only after substitution
of fentanyl/midazolam infusion with enflurane/ketorolac. The total dose of fentanyl
was 78 mg/kg and the authors suggested that
fentanyl may not be safe for cardiac surgery
patients at high doses [32]. However, they
did not consider differences in pharmacokinetic interactions of phenelzine and tranylcypromine as known from more recent studies
[15, 16, 17, 18]. Increased plasma levels of
fentanyl may be possible with phenelzine but
not with tranylcypromine.
Irreversible MAO-A/B-inhibitors
and their perioperative risk
Irreversible MAO-A/B-inhibitors, such
as tranylcypromine, decrease the metabolism
of monoamine neurotransmitters, including
norepinephrine, and considerably increase
their availability in presynaptic storage vessels of the peripheral and central nervous
system. Because of this modification of sympathetic homeostasis and the risk of interactions with indirect sympathomimetic drugs,
management of perioperative hemodynamic
instability may be more complicated in anesthesia during long-term MAO-inhibitor
treatment. In addition, drug interactions with
opioids and, for instance, serotonergic opioids
(meperidine, tramadol, dextromethorphan)
have to be considered [33]. Discontinuation
of irreversible MAO-inhibitors usually two
weeks before elective surgery has therefore been recommended to provide the time
needed for regeneration of MAO activity [3].
This recommendation received the lowest
evidence level in a guideline of the European
Society of Anesthesiology [34]. However,
prolonged cardiovascular collapse with blood
pressure 40/20 mmHg (recovered) occurred
during combined general anesthesia and epidural administration of 10 mg bupivacaine in
partial colorectal surgery still three weeks after discontinuation of tranylcypromine [35].
The patient was a multimorbid 79-year-old
woman (including recent congestive heart
failure) treated continuously with a calcium
201898Krin / 10. July 2013, 2:15 PM
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Krings-Ernst, Ulrich and Adli
blocker (verapamil) and an inhalative β2sympathomimetic (metaproterenol). Reports
of severe incidents and death are available
for continuous calcium blockers during anesthesia [10]. Disregarding a possible role of
the calcium blocker and the general physical risk in this patient, the authors discussed
down-regulation of adrenoceptors, which
developed during MAO-inhibitor treatment
as a possible reason. They also suggest, that
recovery of receptor hyposensitivity requires
additional time. Two or 3 weeks of discontinuation of MAO-inhibitors may be too short
for some patients to achieve full sympathetic
homeostasis. In a similar case, tranylcypromine treatment of 10 mg/day was suspended
8 days before non-cardiac surgery. No data
on concomitant morbidity and medications
was provided for this 75-year-old female
patient. Severe complications (hypotension,
bradyarrhythmia, cyanosis, cardiac arrest)
emerged 10 minutes after induction of general anesthesia with thiopental, succinylcholine, N2O and isoflurane. Reanimation
was needed and the patient recovered [36].
Consequently, it is thought that a recent discontinuation may not decrease the risk of
shock or may even increase it. Four weeks of
MAO-inhibitor discontinuation is discussed
as a minimum [35]. This is confirmed by a
prospective and randomized study of three
days of preoperative TCA-discontinuation
in 80 chronically depressed patients undergoing orthopedic surgery. (■■■Autor: bitte
Kontrolle:) The 3 days of TCA-discontinuation are equivalent to 8 to 14 (21) days
of MAO-inhibitor discontinuation because the primary pharmacologic effect in
the norepinephrinergic and serotonergic
systems is vanished (reuptake or MAOinhibition) along with, however, enduring
changes of sympathetic homeostasis due
to reduced receptor density. After a duration of anesthesia of 141.1 ± 42.4 min and
146.0 ± 47.1 min (mean ± standard deviation), respectively, postoperative delirium or
confusion occurred in five patients (13%) of
a group who continued, and in 12 patients
(30%) who discontinued the antidepressant
(p = 0.05). The incidence of hypotension and
arrhythmias during anesthesia was equal in
both groups (5 and 6%, respectively) [37]. A
recent observational cohort study of 51 patients in 8 Dutch hospitals investigated the
•
occurrence of intraoperative hemodynamic
events without stopping MAO-inhibitors
(index group: tranylcypromine (n = 26) and
moclobemide (n = 25), reference group: no
MAO-inhibitors (n = 149)) during anesthesia
and non-cardiac surgery [38] and is in agreement with the TCA data [37]. The tranylcypromine group was comprised of 17 cases of
general anesthesia, 7 cases of regional anesthesia, and 2 cases of combined general and
regional anesthesia. The median duration of
anesthesia in the tranylcypromine group was
79 minutes (interquartile range 85 minutes).
Intraoperative hypotension occurred less frequently in tranylcypromine users than nonusers. Hypertension/bradycardia/tachycardia
did not occur more frequently in users of
both the irreversible MAO-A/B- and reversible MAO-A inhibitor compared to nonusers.
No excitatory syndromes were found. The
authors concluded that, “These findings suggest that there is no longer much justification
to discontinue these MAO-inhibitors before
surgery.”
Discontinuation of MAO-inhibitors before surgery has been repeatedly described as
a high risk for severe relapse of depression
[39, 40]. Because a gradual decrease of the
MAO-inhibitor dose is recommended, the
time without MAO-inhibitor and the time
at insufficient dose may add up to a period
of 7 weeks of increased risk of relapse. The
decision either for discontinuation for a sufficient period of time or for continuous treatment depends therefore on the comparative
evaluation of the risk of relapse of severe
depression during a period of several weeks
and the specific MAO-inhibitor related risk
of severe perioperative complications during
one or two hours of anesthesia/surgery. The
substitution of irreversible MAO-inhibitors
by moclobemide is regarded as an unsystematic approach because irreversible MAOinhibitors are defined as an ultima ratio in the
treatment of depression. An increased number of relapses in patients after switch from
tranylcypromine to moclobemide is also
found in practice [41, 42].
An operationalization of the peri- and
postoperative risk according to the American
Society of Anesthesiologists (ASA) resulted
in a general Classification III (severe systemic disease) for MAO-inhibitors, lithium,
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Tranylcypromine and anesthesia
TCA, and clozapine in contrast to a Classification II (mild systemic disease) for SSRI.
Physical risk: MAO-inhibitor ≈ TCA > SSRI
The difficulty of such an approach is
obvious when taking into account a survey
in 150 American anesthesiology programs,
which revealed a ratio of 51% for discontinuation of MAO-inhibitors but only 9%
for TCA, despite an equal ASA-classification [3]. The authors recommended an individualized evaluation of patients which
should also include their psychiatric risk.
The mean psychiatric risk in recent MAOinhibitor patients is estimated considerably
higher than in SSRI-treated patients. There
is an increased risk of relapse because of
chronicity, treatment resistance, and residual symptoms. For instance, the complications of relapse are considerably more
severe because of increased suicidality, a
lower chance of psychiatric improvement
after relapse, and also because of an increased physical risk.
Psychiatric risk: MAO-inhibitor > TCA > SSRI
The decision for either discontinuation
of antidepressant medications or continuous
perioperative treatment depends therefore
on the ratio of physical and psychiatric risk
which, in a consequent conclusion, may be
roughly evaluated as similar for e.g., MAOinhibitors and SSRI.
Ratio
physical
risk: MAO-inhibitor ≈ SSRI
psychiatric
(■■■Autor: bitte Kontrolle:) Thus, an
increased psychiatric risk of 4 weeks discontinuation of MAO-inhibitors compensates for an increased perioperative risk
of continuous treatment. However, some
reluctance to continue MAO-inhibitor treatment may be explained by (i) negligence
of the change of place in therapy of MAOinhibitors, i.e., today’s clinical application
mainly in treatment-resistant depression with
increased psychiatric risk, (■■■Autor: bitte
Kontrolle:) (ii) negligence of the psychiatric risk at all because experience exists only
with SSRI, (iii) negligence of the knowledge
and chances of avoiding and reducing MAOinhibitor related peri- and postoperative risk,
•
and (iv) negligence of the risk of short-term
MAO-inhibitor discontinuation.
Recommendations for
anesthesia/analgesia during
continuous MAO-inhibitor
treatment
Detailed recommendations are available for general anesthesia during continuous treatment with antidepressant drugs and
MAO-inhibitors [11, 12]: (i) prevention of
sympathetic activation by sufficient preoperative antianxiety medications and by perioperative avoidance of pain, hypoxia, hypercapnia and hypotension, (ii) careful dosage
of short-term lead-in medications, (iii) use of
non-depolarizing muscle relaxants, (iv) balanced anesthesia with enflurane or isoflurane
as examples of inhalation anesthetics, (v)
careful and extended hemodynamic monitoring, (vi) volume supplementation and direct sympathomimetics (norepinephrine) for
perioperative hypotension, (vii) vasodilatator
drugs for hypertension. Serotonergic opioids
and indirect sympathomimetics are strictly
contraindicated. Morphine and fentanyl are
regarded as relatively safe as well as other
fentanyl derivatives [11, 12, 22, 23, 28]. Bajwa et al. [43] deemed regional anesthesia
as a safer alternative than general anesthesia
for patients on psychotropic medications. No
drug interactions with local anesthetic drugs
have been found, but high concentrations of
catecholamine supplements should be avoided. A slow sympathicus blockade, as found
in epidural and continuous spinal anesthesia,
is preferred.(■■■Bitte Kontrolle:) It is recommended to treat hemodynamic complications in spinal anesthesia as for general
anesthesia [12, 44].
Case report with discussion
In February 2012, an elective surgery of
the anterior of the right foot was planned in
a 66-year-old female patient (170 cm, 75 kg)
who had been being treated with 20 mg/day
tranylcypromine (Jatrosom®) and 10 mg/
day zolpidem for depression lasting 3 years.
Standard laboratory data was normal before
surgery including a fasting blood glucose of
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Krings-Ernst, Ulrich and Adli
4.7 mmol/l. The electrocardiogram was unremarkable. Arterial hypertension was treated with 4 mg/day candesartan. No treatment
was required for a mild case of Hashimoto
thyroiditis. The patient used simeticone for
meteorism and acetaminophen as needed.
The patient had had local anesthesia during an ambilateral cataract surgery without
discontinuation of tranylcypromine 2 years
before foot surgery. She refused discontinuation of tranylcypromine for the planned foot
surgery. Psychiatric consultation including
psychiatric interview of the patient revealed
sufficient psychic and intellectual capability
and the need for continuous antidepressant
treatment. Thus, it was decided to perform
surgery and spinal anesthesia during longterm MAO-inhibitor treatment without discontinuation of tranylcypromine and after
written informed consent.
After admission to hospital, medication
consisted of 10 mg oral zolpidem, 120 mg
oral etoricoxib, and 3,000 IU s.c. certoparin sodium the evening before surgery. At
7 a.m. the day of surgery, the patient received
her daily doses of 20 mg tranylcypromine
and 4 mg candesartan together with a small
breakfast (coffee, zwieback, water). Anesthetic premedication was 7.5 mg oral midazolam at 1.30 p.m. Stable vital parameters of
160/90 mmHg blood pressure, 82 min–1 heart
rate, 99% oxygen saturation, and 36.8 °C
body temperature as well as general physical well-being were monitored ~ 2 hours later
after arrival in the operating room. The start
of anesthesia and surgery was ~ 7.5 hours
after taking the daily tranylcypromine dose.
Volulyte® 350 ml as volume supplement and
a dose of 1.5 g cefuroxime for perioperative
antibiotic prophylaxis were infused. Local anesthesia at the site of lumbar puncture (L3/4)
consisted of 30 mg isobar prilocaine. Spinal
anesthesia was achieved by a single shot of
13.5 mg hyperbar bupivacaine at a volume of
2.7 ml (0.5%) intrathecally. After 2 minutes in
a right lateral position, the patient was transferred to a supine position. Stable vital parameters were consistently found also during a
subsequent 500 ml volume supplement-blood
pressure of ~ 150/80 mmHg and heart rate of
75 – 82 min–1. Sedation was achieved with
0.5 mg intravenous midazolam. A considerable extension of spinal anesthesia was found
after an additional time of 2 minutes (right
•
Th7, left Th9). Tilting the patient to raised upper part of the body stabilized the extension
of spinal anesthesia (right Th7, however left
Th5). After 35 minutes of surgery, postoperative regional analgesia was applied by peripheral nerve block (foot block) with 50 mg isobar bupivacaine in a volume of 10 ml (0.5%).
Postoperative arterial hypertension with
180/105 mmHg (heart rate of 72 min–1) was
treated with 5 mg sublingual nifedipine. The
patient was admitted to the general ward in
good health, analgesia, stable blood pressure,
and without an increase in body temperature.
Further postoperative analgesic treatment
consisted of short infusions of acetaminophen, oral acetaminophen, 90 mg/day oral
etoricoxib for 5 days, and oral oxycodone
as needed. The patient had continued her
antidepressant and antihypertensive medications since the first day postoperatively. No
peri- or postoperative complications were
observed.
Taking into account the review, it was
the right decision for this patient to perform
spinal anesthesia for forefoot surgery during long-term antidepressant treatment with
tranylcypromine. The patient was informed
in detail about the course and the risks of
the intervention. Cooperation during preparation for regional and nerve blocks was
regarded as a minor problem in this depressed patient. It was also important that
the patient had refused discontinuation of
tranylcypromine and that treatment with
tranylcypromine was the ultima ratio in the
clinical-psychiatric context. The individual
risk of exacerbation of severe depression after discontinuation of tranylcypromine (psychiatric risk) was rated higher compared to
the additional tranylcypromine-related risks
of anesthesia (physical risk). Accordingly,
single shot spinal anesthesia with subsequent foot block for postoperative analgesia
was conducted without peri- or postoperative complications. Single shot bupivacaine
was found to be safe with regard to speed of
sympathicus blockade despite the fact that
continuous spinal anesthesia was more recommended [44]. The single shot technique
was chosen for practical reasons. Midazolam and other benzodiazepine drugs are discussed as being safe with MAO-inhibitors
and this was confirmed in the present patient [12]. In agreement with the literature,
201898Krin / 10. July 2013, 2:15 PM
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Tranylcypromine and anesthesia
careful establishment of the block and careful intravenous fluid loading for prophylaxis of hypotension were applied [19, 29].
No direct sympathomimetics were required.
Phenylephrine was used by other therapists
for perioperative hypotension in epidural
anesthesia [19, 30], however, it was suggested that phenylephrine exhibits partly
indirect sympathomimetic activity and
may be better substituted by norepinephrine [29]. An interaction of phenelzine and
selegilin with indirect sympathomimetic
ephedrine was reported for spinal anesthesia with blood pressure of 245/125 mmHg
and 240/120 mmHg, respectively [45]. In
contrast, moclobemide and ephedrine did
not yield an interaction in one patient [30].
Oxycodone for postoperative analgesia is
an opioid without serotonergic activity and
therefore devoid of the risk of severe interactions of the excitatory type [12, 33]. Also,
no interactions of the depressive type, which
may occur in very rare cases [11, 12], were
observed with oxycodone. The MAO-inhibitor was also safe with regard to the cyclooxygenase-(COX)-2 inhibitor etoricoxib. So
far, no data is available for this combination
in the literature, however, the COX-inhibitor
ketorolac was used during anesthesia of a
phenelzine-patient and no drug interaction is
expected according to a mechanistic examination [25, 43]. Dihydropyridine antihypertensive drugs were recommended for MAOinhibitor related moderate hypertension [46].
A low dose of short-acting nifedipine met
this aim for the present patient with a blood
pressure of 180/105 mmHg however, this approach is no longer advised in hypertensive
crisis [47].
Conclusion
For the most part, general and regional
anesthesia is a safe intervention in psychiatric patients with long-term MAO-inhibitor
treatment after careful evaluation of the individual risk in an integrated anesthetic/intensivistic/psychiatric strategy [3]. A global
recommendation for discontinuation of the
MAO-inhibitor in regional anesthesia is
not adequate as also discussed for general
anesthesia [10, 12, 38]. (■■■Autor: bitte
Kontrolle) The physical risk should be
evaluated higher in patients who are being
•
treated with the MAO-inhibitor despite
contraindications or in cardiac surgery
than in “normal” MAO-inhibitor patients.
Tranylcypromine is expected to bear a lower
risk than phenelzine because of a lower potential for pharmacokinetic interactions.
Conflict of interest
Dr. Adli has received grant/research support from Aristo Pharma.
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