OBJECT DRUGS

MAO Inhibitors (nonselective):

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

PRECIPITANT DRUGS

Antidepressants, Tricyclic:

• Clomipramine (Anafranil)
• Imipramine (Tofranil, etc.)

Comment:

Nonselective MAO inhibitors (MAOI) may produce serotonin syndrome when combined with tricyclic antidepressants (TCAs), especially TCAs with substantial serotonergic effects such as clomipramine and imipramine. Nonselective MAOI and TCAs have been used safely with careful monitoring in experienced hands, but serotonin syndrome can be life-threatening. Avoiding amitriptyline, doxepin and desipramine may also be prudent, but they have suibstantially less serotonergic effect than clomipramine or imipramine.

Class 1: Avoid Combination

• Avoid: Avoid clomipramine and imipramine in patients receiving nonselective MAOI. Avoiding amitriptyline, doxepin, and desipramine would also be prudent although the risk is probably less. At least 14 days (preferably 18-20 days) should elapse after stopping an MAOI before starting clomipramine or imipramine. If a TCA is to be used, use those with less serotonergic effects and monitor for evidence of serotonin syndrome (myoclonus, rigidity, tremor, hyperreflexia, fever, sweating, seizures, confusion, agitation, incoordination, and coma).