Monoamine Oxidase Inhibitor Nardil Jessica Swartz SN, BSN Psychiatric Nursing

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

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

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

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.

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. -

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 45-90 mg/day as required Inform patients to take everyday, not PRN, and continue treatment to prevent relapse

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.

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.

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

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

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.

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

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. -

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

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

Thanks for watching!!

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