OBJECT DRUGS
MAO Inhibitors (nonselective):
MAO-B Inhibitors:
- Rasagiline (Azilect)
- Safinamide (Xadago)
- Selegiline (Eldepryl, etc.)
PRECIPITANT DRUGS
Antidepressants, Tricyclic:
- Clomipramine (Anafranil)
- Imipramine (Tofranil, etc.)
Comment:
Linezolid appears to be a weak MAOI, but serotonin syndrome has been reported when it is combined with serotonergic agents such as clomipramine and imipramine. Selective MAO-B inhibitors theoretically should not interact with TCAs, but in some patients MAO-B inhibitors may become nonselective thus increasing the risk of serotonin syndrome. Rasagiline is metabolized by CYP1A2 so theoretically, patients on CYP1A2 inhibitors may be more likely to develop nonselective MAO inhibition due to rasagiline. (For a list of CYP1A2 inhibitors, see CYP450 Table.)
Class 2: Use only if Benefit Felt to Outweigh Risk
- Use Alternative:
- Antidepressants: If a TCA is given to patients on linezolid or MAO-B inhibitors, use a TCA other than clomipramine or imipramine. Avoiding amitriptyline, doxepin and desipramine may also be prudent, but they have suibstantially less serotonergic effect than clomipramine or imipramine.
- Linezolid: Tedizolid (Sivextro) does not appear to be a MAOI to a clinically important degree, so is unlikely to increase the risk of serotonin syndrome. Also, depending on the antibiogram, one could consider alternative antibiotics such as vancomycin or telavancin (Vibativ) for linezolid.
- Monitor: If any TCA is used with linezolid or an MAO-B inhibitor, monitor for evidence of serotonin syndrome (myoclonus, rigidity, tremor, hyperreflexia, fever, sweating, seizures, confusion, agitation, incoordination, and coma).