How many patients do you have on an MAOI right now

[F0nzie]

just curious

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[shan564]

I have three, but I just started my clinic year in residency, so I only have about 60-80 total patients right now. We see a relatively severe population in our clinic.

 

[whopper]

None. The total I've ever had is probably less than 10. This is me being an attending for about 5-6 years and having some very treatment resistance patients. My biggest obstacle with it was the bridge for weeks with no antidepressant on someone that was already doing very bad. I'd rather try Venlafaxine + Mirtazapine before trying an MAO-I.

 

[wolfvgang22]

One. The patient has been doing well on it for years after being started on it in Europe.

 

[st2205]

One. They've been on it since shortly before I was born (and not really been on anything else). There's one individual that I'm looking at perhaps starting on one.

 

[TexasPhysician]

1

 

[SmallBird]

None. The total I've ever had is probably less than 10. This is me being an attending for about 5-6 years and having some very treatment resistance patients. My biggest obstacle with it was the bridge for weeks with no antidepressant on someone that was already doing very bad. I'd rather try Venlafaxine + Mirtazapine before trying an MAO-I.

"weeks" seems like overkill for a bridge before starting? I had thought it's more like 5 days and even then its more theoretical. Post MAOI bridging is more of an issue of course..

 

[st2205]

None. The total I've ever had is probably less than 10. This is me being an attending for about 5-6 years and having some very treatment resistance patients. My biggest obstacle with it was the bridge for weeks with no antidepressant on someone that was already doing very bad. I'd rather try Venlafaxine + Mirtazapine before trying an MAO-I.

I have a few questions on this:

1. If someone were considered for an MAOI, I'd imagine most people would have considered them treatment resistant and non-responders. Would the lack of an antidepressant onboard, that has proven ineffective in the patient, really matter?

2. A big gap between SNRI + mirtazapine and MAOI. Do you not see this utilized that often?

 

[shan564]

1. If someone were considered for an MAOI, I'd imagine most people would have considered them treatment resistant and non-responders. Would the lack of an antidepressant onboard, that has proven ineffective in the patient, really matter?

I agree - that's why I haven't really had qualms about doing it when needed - if the antidepressant isn't working, then I'm not too worried about stopping it for a few days.

2. A big gap between SNRI + mirtazapine and MAOI. Do you not see this utilized that often?

In the STARD study, there was an arm that found venlafaxine+mirtazapine to be superior to tranylcypromine, both at therapeutic doses. I always try that before going to a MAOI. I've started a MAOI twice now, and both of them were already on venlafaxine, so the bridge was shorter because venlafaxine is short-acting. One was also on bupropion, which is also short-acting. The other was also on buspirone, which is also short-acting. One had been on mirtazapine but d/c'd because she didn't like the appetite stimulation. The other didn't want mirtazapine because of the appetite stimulation risk.

 

[psychattending]

In the STARD study, there was an arm that found venlafaxine+mirtazapine to be superior to tranylcypromine, both at therapeutic doses. I always try that before going to a MAOI. I've started a MAOI twice now, and both of them were already on venlafaxine, so the bridge was shorter because venlafaxine is short-acting. One was also on bupropion, which is also short-acting. The other was also on buspirone, which is also short-acting. One had been on mirtazapine but d/c'd because she didn't like the appetite stimulation. The other didn't want mirtazapine because of the appetite stimulation risk.

I believe the STAR-D trial was flawed. If memory serves me correctly, there was a 2 week washout period for the MAOI and then there was an up titration period. Both of these occurred during the 4 week trial period. Thus, subjects were not at the recommended dose of the MAOI for much longer than 1 week.

 

[deleted452516]

Including linezolid?

 

[shan564]

I believe the STAR-D trial was flawed. If memory serves me correctly, there was a 2 week washout period for the MAOI and then there was an up titration period. Both of these occurred during the 4 week trial period. Thus, subjects were not at the recommended dose of the MAOI for much longer than 1 week.

Looking back at the trial, they aimed for a total of 12 weeks on each drug with an additional 2 weeks for patients who achieved response but not remission. They started tranylcypromine at 10mg daily and increased the total daily dose by 10mg every week until the patient either achieved adequate symptom reduction or was no longer able to tolerate the drug, so they reached the mean therapeutic dose (37 mg) in 3.7 weeks on average. The mean therapeutic dose of venlafaxine was 210mg, and it took about 8 weeks to titrate to a similar dose (225mg). The mean for mirtazapine was about 36mg, which took about 3 weeks to reach (30mg). On average, patients were on their final dose of tranylcypromine for about 30 days. They were on venlafaxine/mirtazapine at the final dose for longer, generally due to tolerability.

I think that the number to which you're referring might be the dropouts - 29% of the patients taking tranylcypromine dropped out within 4 weeks (including the 2-week washout) due to side effects. That number was much smaller for venlafaxine/mirtazapine.

Overall, it seems like they followed a realistic titration for both drugs. If a patient didn't get an adequate trial of tranylcypromine, it seems like it was due to tolerability rather than due to study design.

They did point out that the mean dose of tranylcypromine was lower than what might otherwise be used. The total side effect burden was similar for the two regimens, so they suspected that earlier discontinuation of tranylcypromine might have been related to the fact that clinicians were less comfortable with continuing a MAOI in the face of side effects due to less experience with it, since it was an open label study.

So now that I review it, I'm somewhat more comfortable with the idea that tranylcypromine would probably be more effective if we push the dose higher without getting nervous about a side effect burden that is otherwise similar to other drugs. But I'd still be reluctant to use it before at least offering California Rocket Fuel, since the common wisdom is that you should only use a MAOI after everything else has failed - I did start tranylcypromine on a patient last week without first adding mirtazapine to her venlafaxine, but that was after a long discussion about risks/benefits and the patient preferred the risks of an MAOI over the risks of mirtazapine (appetite stimulation --> weight gain)... and her daughter/caregiver is an RN, so I was comfortable with their ability to comply.

 

[shan564]

Including linezolid?

Ha... you don't have any patients on linezolid long-term as an antidepressant, do you?

 

[deleted452516]

Ha... you don't have any patients on linezolid long-term as an antidepressant, do you?

MRSA pneumonia can be kind of a downer... but no, not long term as an antidepressant per se...

I did have an interesting consult recently regarding discontinuing a patient's home SSRI during a prolonged course of linezolid. Since they were in-house for the foreseeable future we recc-ed continuing the home med, but monitoring closely for signs of seritonergic excess.

 

[shan564]

MRSA pneumonia can be kind of a downer... but no, not long term as an antidepressant per se...

I did have an interesting consult recently regarding discontinuing a patient's home SSRI during a prolonged course of linezolid. Since they were in-house for the foreseeable future we recc-ed continuing the home med, but monitoring closely for signs of seritonergic excess.

That's pretty ballsy, but I'm sure it's probably the right call...

 

[Fermata]

Currently none. In my prior job I inherited several patients from another provider who had been stabilized (for many years) on Parnate (which I guess he was big into prescribing) that I trusted to maintain the necessary diet (and were well informed enough to discuss the med with other providers). I believe that I've started new prescriptions of MAOI's a grand total of twice (one due to patient preference having failed multiple SSRI's/wellbutrin as their parent had done well on it - the result being successful; the other being treatment resistant MDD having failed nearly every other med and ECT - the result with them remaining treatment resistant).

 

[cookymonster]

None, but I work in inpatient, so taking patients off meds for two weeks isn't really an option.

I did see a consult about a month ago on a patient who came in the hospital after developing the worst serotonin syndrome I've ever seen after switching MAO-I's (I think isocarboxazid and tranylcypromine). I admit I don't understand why this occurred.

I used to think I'd be comfortable with short bridges and even combining MAO-Is and TCA, but after seeing that, I don't think I'm comfortable going outside of the book. I might even try nefazodone first.

 

[shan564]

None, but I work in inpatient, so taking patients off meds for two weeks isn't really an option.

Does it really have to be two weeks on an inpatient basis if the patient isn't on Prozac? You could monitor them for side effects more closely...

 

[keifernny2]

Not much love for Emsam in this thread apparently. ...


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[FrasierMD]

Quick question for the group:

We know that clozapine is a reasonable/best option for TR Schizophrenia after 2 full adequate trials of an AP. STARD gave us multiple combo/switch strategies with diminishing returns. Knowing that, it seems ECT should be a discussion long before we get to an MAOI, no?

 

[shan564]

Not much love for Emsam in this thread apparently. ...


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Because selegiline perferentially inhibits MAO-B, while Parnate and Nardil inhibit MAO-A. MAO-A has combined serotonin/norepinephrine/dopamine activity, while MAO-B is mostly dopaminergic. That's why selegiline is better for Parkinson's and also why we are less likely to use it for depression.

 

[shan564]

Quick question for the group:

We know that clozapine is a reasonable/best option for TR Schizophrenia after 2 full adequate trials of an AP. STARD gave us multiple combo/switch strategies with diminishing returns. Knowing that, it seems ECT should be a discussion long before we get to an MAOI, no?

Yes. I'd say that most people offer ECT before offering an MAOI... I have more MAOI patients than 90% of the doctors who answered this poll, and they were all offered ECT first. One of them is on concurrent ECT, one didn't have insurance to pay for ECT (but public funding will pay for her meds), and one just didn't want to try ECT. I just offered an MAOI to another patient (didn't start it yet, but might end up doing that in the future) because she has severe COPD that would likely make anesthesia quite dangerous.

 

[splik]

Because selegiline perferentially inhibits MAO-B, while Parnate and Nardil inhibit MAO-A. MAO-A has combined serotonin/norepinephrine/dopamine activity, while MAO-B is mostly dopaminergic. That's why selegiline is better for Parkinson's and also why we are less likely to use it for depression.

parnate and nardil inhibit both MAO isoforms. At doses used in depression, selegiline inhibits both MAO-A and -B. If using oral selegiline dose for parkisons is 5mg bid, for depression it is 15-30mg bid. I have treated patients with 60mg selegiline daily. It has a more favorable side-effect profile than the older MAOIs. I haven't used EMSAM yet because it's been cheaper for my patients to take the oral version.

 

[cookymonster]

Does it really have to be two weeks on an inpatient basis if the patient isn't on Prozac? You could monitor them for side effects more closely....

I don't have the experience to know if it's safe or not, nor do I know anyone who does. You really don't know unless your patient is able to do it without developing serotonin syndrome, which isn't usually a mild or gradual-onset kind of thing. Until then, it's taking a leap and holding your breath.

As I alluded to earlier, unless there's evidence that an MAO-I is more effective or affordable than (in variable order): 1. Multiple SSRIs and SNRIs, 2. Bupropion, 3. Remeron, 4. Viibryd, 5. Brintellix, 6. at least one TCA, 7, Nefazodone, 8. ECT or TMS I'm not sure why I'd use one first. So it would have to be the 9th or 10th med I'd try in most insured patients. The only one I might frequently skip is TCAs for patients with a high ingestion risk

 

[keifernny2]

Emsam at low dosages doesn't require a restrictive diet. I can't recall a patient that I didn't recommend ECT for prior to starting an maoi. Very few of my patients are willing to try ECT, I think mainly due to limited ECT options in my geographic area which would require them to travel 3-4 hours each way for each treatment. So, when they refuse ECT, then we start talking about MAOI and usually Emsam due to its safety compared to others.


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[Shikima]

It's not only the restrictive diet, there are potential problems in managing physical health too with medications by primary care and other specialists.

 

[whopper]

Does it really have to be two weeks on an inpatient basis if the patient isn't on Prozac? You could monitor them for side effects more closely...

Do you really have to wait a week to raise an SSRI? I sometimes raise it on day 5 or 6 in severe cases. I of course do tell the patient why I'm not following the FDA guidelines.

You don't have to follow the guidelines and of course then you will be open to all the liabilities that can accompany doing that. Given the problems with MAO-Is could be fatal I would follow them.

 

[notdeadyet]

I've started MAOIs, most often selegiline and doxepin. I've used other MAOIs, but less frequently.

In my opinion, psychiatrists tend to have disproportionately high thresholds to start MAOIs and low thresholds to start antipsychotics.

 

[shan564]

I've started MAOIs, most often selegiline and doxepin. I've used other MAOIs, but less frequently.

In my opinion, psychiatrists tend to have disproportionately high thresholds to start MAOIs and low thresholds to start antipsychotics.

Doxepin is a TCA...

 

[notdeadyet]

Sorry, I've noticed I've got a bunch of crossed wires the past few weeks. I blame cramming for boards.