From: Saklad@uthscsa.edu (Stephen R. Saklad)
Subject: Re: MAO-I's dietary restrictions
Date: Mon, 28 Nov 1994 23:05:01 -0600
This almost deserves to be a FAQ. I have copied the Micromedex drug consult on this from the current database.
© 1974-1994 Micromedex Inc. - All rights reserved - Vol. 82 Exp. 12/94
Q. Please review the dietary restrictions that should be observed when a patient is receiving monoamine oxidase inhibitor (MAOI) therapy?
R. Tyramine is an amino acid which is found in various foods, and is an indirect sympathomimetic that can cause a hypertensive reaction in patients receiving MAOI therapy. Monoamine oxidase is found in the gastrointestinal tract and inactivates tyramine; when drugs prevent the catabolism of exogenous tyramine, this amino acid is absorbed and displaces norepinephrine from sympathetic nerve ending and epinephrine from the adrenal glands. If a sufficient amount of pressor amines are released, a patient may experience a severe occipital or temporal headache, diaphoresis, mydriasis, nuchal rigidity, palpitations, and the elevation of both diastolic and systolic blood pressure may ensue (Anon, 1989; Da Prada et al, 1988; Brown & Bryant, 1988). On rare occasions, cardiac arrhythmias, cardiac failure, and intracerebral hemorrhage have developed in patients receiving MAOI therapy that did not observe dietary restrictions (Brown & Bryant, 1988). Therefore, dietary restrictions are required for patients receiving MAOIs. Extensive dietary restrictions previously published were collected over a decade ago and due to changes in food processing and more reliable analytical methods, new recommendations have been published (Anon, 1989; McCabe, 1986). The tyramine content of foods varies greatly due to the differences in processing, fermentation, ripening, degradation, or incidental contamination. Many foods contain small amounts of tyramine and the formation of large quantities of tyramine have been reported if products were aged, fermented, or left to spoil. Because the sequela from tyramine and MAOIs is dose-related, reactions can be minimized without total abstinence from tyramine-containing foods. Approximately 10 to 25 mg of tyramine is required for a severe reaction compared to 6 to 10 mg for a mild reaction. Foods that normally contain low amounts of tyramine may become a risk if unusually large quantities are consumed or if spoilage has occurred (McCabe, 1986). Three lists were compiled (foods to avoid, foods that may used in small quantities, and foods with insufficient evidence to restrict) to minimized the strict dietary restrictions that were previously used and improve compliance and safety of MAOI therapy. The foods to avoid list consists of foods with sufficient tyramine (in small or usual serving sizes) that would create a dangerous elevation in blood pressure and therefore should be avoided (McCabe, 1986)
Alcoholic beverages - avoid Chianti wine and vermouth. Consumption of red, white, and port wine in quantities less than 120 mL present little risk (Anon, 1989; Da Prada et al, 1988; McCabe, 1986). Beer and ale should also be avoided (McCabe, 1986), however other investigators feel major domestic (US) brands of beer is safe in small quantities (½ cup or less than 120 mL) (Anon, 1989; Da Prada, 1988), but imported beer should not be consumed unless a specific brand is known to be safe. Whiskey and liqueurs such as Drambuie and Chartreuse have caused reactions. Nonalcoholic beverages (alcohol-free beer and wines) may contain tyramine and should be avoided (Anon, 1989; Stockley, 1993).
Banana peels - a single case report implicates a banana as the causative agent, which involved the consumption of whole stewed green banana, including the peel. Ripe banana pulp contains 7 µg/gram of tyramine compared to a peel which contains 65 µg/gram and 700 µg of tyramine and dopamine, respectively (McCabe, 1986).
Bean curd - fermented bean curd, fermented soya bean, soya bean pastes contain a significant amount of tyramine (Anon, 1989).
Broad (fava) bean pods - these beans contain dopa, not tyramine, which is metabolized to dopamine and may cause a pressor reaction and therefore should not be eaten particularly if overripe (McCabe, 1986; Anon, 1989; Brown & Bryant, 1988).
Cheese - tyramine content cannot be predicted based on appearance, flavor, or variety and therefore should be avoided. Cream cheese and cottage cheese have no detectable level of tyramine (McCabe, 1986; Anon, 1989, Brown & Bryant, 1988).
Fish - fresh fish (Anon, 1989; McCabe, 1986) and vacuum-packed pickled fish or caviar contain only small amounts of tyramine and are safe if consumed promptly or refrigerated for short periods; longer storage may be dangerous (Anon, 1989). Smoked, fermented, pickled (Herring) and otherwise aged fish, meat, or any spoiled food may contain high levels of tyramine and should be avoided (Anon, 1989; Brown & Bryant, 1988).
Ginseng - some preparations have resulted in a headache, tremulousness, and manic-like symptoms (Anon, 1989).
Protein extracts - three brands of meat extract contained 95, 206, and 304 µg/gram of tyramine and therefore meat extracts should be avoided (McCabe, 1986). Avoid liquid and powdered protein dietary supplements (Anon, 1989).
Meat, nonfresh or liver - no detectable levels identified in fresh chicken livers; high tyramine content found in spoiled or unfresh livers (McCabe, 1986). Fresh meat is safe, caution suggested in restaurants (Anon, 1989; Da Prada et al, 1988).
Sausage, bologna, pepperoni and salami contain large amounts of tyramine (Anon, 1989; Da Prada et al, 1988; McCabe, 1986). No detectable tyramine levels were identified in country cured ham (McCabe, 1986).
Sauerkraut - tyramine content has varied from 20 to 95 µg/gram and should be avoided (McCabe, 1986).
Shrimp paste - contain a large amount of tyramine (Anon, 1989).
Soups - should be avoided as protein extracts may be present; miso soup is prepared from fermented bean curd and contain tyramine in large amounts and should not be consumed (Anon, 1989).
Yeast, Brewer's or extracts - yeast extracts (Marmite) which are spread on bread or mixed with water, Brewer's yeast, or yeast vitamin supplements should not be consumed. Yeast used in baking is safe (Anon, 1989; Da Prada et al, 1988; McCabe, 1986).
The foods to use with caution list categorizes foods that have been reported to cause a hypertensive crisis if foods were consumed in large quantities, stored for prolong periods, or if contamination occurred. Small servings (½ cup, or less than 120 mL) of the following foods are not expected to pose a risk for patients on MAOI therapy (McCabe, 1986).
Alcoholic beverages - see under foods to avoid.More than 200 foods contain tyramine in small quantities and have been implicated in reactions with MAOI therapy, however the majority of the previous reactions were due to the consumption of spoiled food. Evidence does not support the restriction of the following foods listed if the food is fresh (McCabe, 1986).
Avocados - contain tyramine, particularly overripe (Anon, 1989) but may be used in small amounts if not overripened (McCabe, 1986).
Caffeine - contains a weak pressor agent, large amounts may cause a reaction (Anon, 1989).
Chocolate - is safe to ingest for most patients, unless consumed in large amounts (Anon, 1989; McCabe, 1986).
Dairy products - Cream, sour cream, cottage cheese, cream cheese, yogurt, or milk should pose little risk unless prolonged storage or lack of sanitation standards exists (Anon, 1989; McCabe, 1986). Products should not be used if close to the expiration date (McCabe, 1986).
Nuts - large quantities of peanuts were implicated in a hypertensive reaction and headache. Coconuts and brazil nuts have also been implicated, however no analysis of the tyramine content was performed (McCabe, 1986).
Raspberries - contain tyramine and small amounts are expected to be safe (McCabe, 1986).
Soy sauce - has been reported to contain large amounts of tyramine and reactions have been reported with teriyaki (Anon, 1989), however analysis of soy sauce reveals a tyramine level of 1.76 µg/mL and fermented meat may have contributed to the previously reported reactions (McCabe, 1986).
Spinach, New Zealand prickly or hot weather - large amounts have resulted in a reaction (Anon, 1989; McCabe, 1986).
With appropriate dietary restrictions, the incidence of hypertensive crises has decreased to approximately 4% (Zisook, 1985). Treatment of a hypertensive reactions includes the=7F administration of phentolamine (Anon, 1989) 2.5 to 5 milligrams intravenously (slow) titrated against blood pressure (Zisook,=7F 1985; Lippman & Nash, 1990). One report has suggested that the use of sublingual nifedipine 10 milligrams was effective in treating 2 hypertensive reactions following the ingestion of a tyramine-containing food in a patient receiving MAOI therapy (Clary & Schweizerr, 1987). Chlorpromazine also has alpha-blocking properties and has been recommended as an agent for discretionary use (patient-initiated treatment) in the setting of dietary indiscretion (Lippman & Nash, 1990).
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