OBJECT DRUGS

MAO Inhibitors (Nonselective):

• Furazolidone (Furoxone)
• Isocarboxazid
• Methylene Blue
• Phenelzine (Nardil)
• Tranylcypromine (Parnate)

PRECIPITANT DRUGS

Serotonergic Drugs:

• Bupropion (Wellbutrin, etc.)
• Buspirone (BuSpar)
• Citalopram (Celexa)
• Cyclobenzaprine (Felxeril, etc.)
• Desvenlafaxine (Pristiq, etc.)
• Dextromethorphan
• Duloxetine (Cymbalta)
• Escitalopram (Lexapro)
• Fentanyl (Sublimaze, etc.)
• Fluoxetine (Prozac, etc.)
• Fluvoxamine (Luvox, etc.)
• Meperidine (Demerol)
• Milnacipran (Savella)
• Mirtazapine (Remeron, etc.)
• Paroxetine (Paxil, etc.)
• Propoxyphene^*
• Sertraline (Zoloft)
• Tapentadol (Nucynta, etc.)
• Tetrabenazine (Xenazine)
• Tramadol (Ultram, etc.)
• Trazodone (Desyrel)
• Venlafaxine (Effexor)
• Vilazodone (Viibryd)

^* Propoxyphene (Darvon) was withdrawn from the US market.

Comment:

Nonselective MAO inhibitors (MAOI) may produce serotonin syndrome when combined with serotonergic drugs. Serotonin syndrome can be life-threatening. [Note: Concurrent use of 2 or more serotonergic drugs (from the 2 right columns above) may increase the risk of serotonin syndrome, but only isolated cases have been reported.] Bupropion is not generally considered a serotonergic drug, but purportedly may increase MAO inhibitor toxicity; the combination is considered contraindicated in the product information.

Class 1: Avoid Combination

• Avoid: Avoid serotonergic drugs in patients receiving MAOI. At least 14 days (preferably 18-20 days) should elapse after stopping an MAOI before starting a serotonergic drug. At least 5 weeks should elapse after stopping fluoxetine before starting an MAOI. If such combinations are used, monitor for evidence of serotonin syndrome (myoclonus, rigidity, tremor, hyperreflexia, fever, sweating, seizures, confusion, agitation, incoordination, and coma).