1. Monoamine Oxidase Inhibitor Nardil
Jessica Swartz
SN, BSN
Psychiatric Nursing

2. Goals and Objectives Goal
To impart information about the MAOI Nardil to a target audience of first year nursing students that have completed one semester of pharmacology and one semester of psychiatric nursing
Objectives
Learner will be able to:
identify high risk patients for whom the use of Nardil is contraindicated
describe signs and symptoms and two causes of a hypertensive crisis
list at least 10 foods that are high in tyramine

3. Nursing considerations are underlined and in bold font throughout the presentation.

4. Indications for use
Nardil, generic name phenelzine, is a monoamine oxidase inhibitor (MAOI) that is classified as an anti-depressant
Nardil is a drug of choice only for atypical depression
Nardil is a second or third choice for depression because MAOIs are considered more dangerous than SSRIs or TCAs
Used with some success for bulimia-nervosa and OCD
Can reduce panic attacks in patients with panic disorder

5. Actions
Depression is hypothesized to be a result of a deficiency of two monoamine neurotransmitters found in the brain, serotonin and norepinephrine.
Therefore a drug that inhibits the inactivation of these monoamines should be useful in treating the symptoms of depression.
Antidepressant effects of Nardil result from inhibiting the enzyme MAO in the neurons of the brain.
MAO is an enzyme found in the liver, intestinal wall, and terminals of monoamine containing neurons of the brain.
In the liver MAO inactivates tyramine.
In the brain, MAO inactivates norepinephrine, dopamine and serotonin.
Nardil, as an MAO inhibitor, prevents that inactivation of norepinephrine and serotonin in the brain, leaving more available for release, relieving depression.
The inhibitory effect of Nardil is non-selective, meaning that an increase in the levels of dopamine and tyramine occur as well.

7. Pharmacokinetics Nardil is well absorbed through the GI tract.
It can be distributed across the placenta and breast milk.
Nardil is metabolized by the liver and excreted in the urine as metabolites and an unchanged drug
The half life is 12 hours
Nardil takes about 2-4 weeks to take effect and peaks in effectiveness in about 3-6 weeks. -

8. Dosage and Routes
Nardil is an oral MAOI that is available in 15mg tablets
The initial dose is 15mg/day and is increased to a daily maintenance dose mg/day as required
Inform patients to take everyday, not PRN, and continue treatment to prevent relapse

9. Adverse Effects
CNS stimulation: can produce anxiety, agitation, insomnia, hypomania or mania
Orthostatic hypertension
Inform patients about signs of hypotension such as dizziness or lightheadedness
Inform patient to move slowly from sitting to standing
Monitor blood reassure and pulse of hospitalized patients on a regular basis. Assess while lying down and after sitting or standing for 1-2 minutes. Withhold medication and inform prescriber if blood pressure is low.

10. Hypertensive Crisis
Dietary tyramine, indirect-acting sympathomimetics, and TCAs can cause a hypertensive crisis in patients taking MAOIs
Symptoms of hypertensive crisis include severe headache, tachycardia, hypertension, nausea, vomiting, confusion and profuse sweating.
Warn patient about signs and symptoms of hypertensive crisis and to inform provider if they occur.
Warn patient to avoid foods containing tyramine and sympathomimetic drugs. Provide patient with a list of foods that contain tyramine.

11. Foods that contain tyramine
Table 1
category
unsafe foods
safe foods
vegetables
avocados, fermented bean curd, fermented soy bean, soybean paste
most vegetables
fruits
figs, bananans (esp. if overripe)
most fruits
meats
meats that are fermented, smoked or aged, spoiled meats, liver (unless very fresh)
meats that are known to be fresh
sausages
fermented varieties, salami, bologna, pepperoni
nonfermented varieties
fish
dried, cured, smoked, age or fermented fish, spoiled fish
Fresh fish
milk and milk products
practically all cheeses
milk, yogurt, cottage cheese, seam cheese
foods with yeast
yeast extract (marmite, bovril)
baked goods that contain yeast
beer, wine
some imported beers, chianti wine
major domestic brands of beer, most wine
other foods
protein dietary supplements, soups, shrimp paste, soy sauce

12. Contraindications Patients taking SSRIs or other seratogenic drugs
Patients with:
pheochromocytoma
heart disease
liver disease
severe renal impairment
cerebrovascular defect or disease
patients over the age of 60

13. Serotonin Syndrome
Combining MAOIs and serotonergic drugs poses a risk for serotonin syndrome.
Serotonin syndrome is potentially fatal and signs and symptoms include agitation, confusion, disorientation, anxiety, hallucinations, poor concentration, incoordination, myoclonus, hyperreflexia, excessive sweating, tremor and fever.
MAOIs should be discontinued for at least two weeks before taking an SSRI.

14. Adverse Interactions
Nardil remain in the body for about 2 weeks after discontinuing medication and interferes with many other drugs.
Instruct patient to avoid all prescription and non prescription medications, unless approved by prescriber.
Consumption of foods or herbs high in caffeine increase the risk of hypertension and arrhythmias
Antihypertensive drugs can intensify the hypotensive effects of Nardil.
Monitor blood pressure periodically
Meperidine (Demerol) should be avoided because it causes hyperthermia in patients taking Nardil

15. Remember
Depression carries the risk of suicide, which may increase during the initial phase of therapy.
Advise family members or caregiver to immediately reports symptoms such as anxiety, panic attacks, insomnia, hostility, hypomania and the emergence of suicidal thoughts. -

16. Summary
Nardil increases the amounts of norepinephrine and serotonin at the neuronal synapses of the brain which reduces the symptoms of depression. Due to the serious side effects and drug interactions MAOIS like Nardil are usually a second or third choice drug for depression and only a first choice for atypical depression. Patients taking Nardil must be taught the importance of a tyramine free diet, foods that have a high tyramine content and the signs and symptoms of a hypertensive crisis. Patients taking Nardil must also be aware that Nardil take a few weeks to reach therapeutic levels and that it must be taken as prescribed , not PRN, to prevent relapse. It’s also important for patients to understand that Nardil should not be combined with any other drug unless approved by prescriber. This includes OTCs and herbals. Inform patients of orthostatic hypotension and to rise slowly from laying to sitting to standing to avoid dizziness and prevent falls

17. Check your learning
Can you identify high risk patients for whom the use of Nardil would be contraindicated?
For additional help see slide 12
Can you give two causes of hypertensive crisis as well as describe signs and symptoms?
For additional help see slide 10
Can you list ten foods that contain unsafe amounts of tyramine for a patient taking Nardil?
For additional help see slide 11

18. Thanks for watching!!

19. References
Lehne, R. A. (2013). Pharmacology for nursing care. St. Louis, MO: Elsvier.