Plasma Concentrations of Tranylcypromine in Depressed Patients With Chronic Kidney Disease: Two Case Reports

PURPOSE

The prevalence of comorbid depression and chronic kidney disease (CKD) is high. The aim of this brief report was to review 2 cases of treatment with tranylcypromine (TCP) in patients with treatment-resistant depression (TRD) and CKD. Tests of the plasma concentration of TCP were included.

METHODS

Medical and psychiatric notes of the 2 patients were reviewed with plasma concentrations of TCP as a key aspect of the discussion. The data are evaluated in the context of relevant medical and pharmacokinetic literature.

FINDINGS

Plasma concentrations of TCP are highly variable both in patients with and without CKD. Plasma concentrations of TCP were not increased in the 2 cases with CKD as compared with literature data of patients without CKD. No signs of intoxication were detected in 2 cases with CKD that impaired continuous treatment of depression with TCP.

IMPLICATIONS

TCP may be considered in selected cases of TRD with concomitant CKD. More clinical data and tests of plasma concentrations of TCP are needed in patients with CKD.

The Prescriber's Guide to the MAOI Diet-Thinking Through Tyramine Troubles

This review article features comprehensive discussions on the dietary restrictions issued to patients taking a classic monoamine oxidase inhibitor (phenelzine, tranylcypromine, isocarboxazid), or high-dose (oral or transdermal) selegiline. It equips doctors with the knowledge to explain to their patients which dietary precautions are necessary, and why that is so: MAOIs alter the capacity to metabolize certain monoamines, like tyramine, which causes dose-related blood pressure elevations. Modern food production and hygiene standards have resulted in large reductions of tyramine concentrations in most foodstuffs and beverages, including many cheeses. Thus, the risk of consequential blood pressure increases is considerably reduced-but some caution remains warranted. The effects of other relevant biogenic amines (histamine, dopamine), and of the amino acids L-dopa and L-tryptophan are also discussed. The tables of tyramine data usually presented in MAOI diet guides are by nature unhelpful and imprecise, because tyramine levels vary widely within foods of the same category. For this reason, it is vital that doctors understand the general principles outlined in this guide; that way, they can tailor their instructions and advice to the individual, to his/her lifestyle and situation. This is important because the pressor response is characterized by significant interpatient variability. When all factors are weighed and balanced, the conclusion is that the MAOI diet is not all that difficult. Minimizing the intake of the small number of risky foods is all that is required. Many patients may hardly need to change their diet at all.

Some Effects of Tranylcypromine and Trifluoperazine on Electrocortical Activity (EEG Activation)

In the deafferented cat devoid of the complicating effect of extraneous pharmacological agents (anaesthesia, muscle relaxants) the intra-innominate administration of tranylcypromine elicits immediate EEG activation. With high doses (7.5 mg/kg), EEG activation is immediate, intense, and persists for several hours. With lower doses (2.5 mg/kg) this effect is transient (20 seconds), giving way to a long period of deactivation (35–45 minutes), which in turn is followed by a secondary period of activation.

The immediate EEG activating response of tranylcypromine appears to be a direct effect, the secondary delayed phase of EEG activation appears to be an indirect action, such as might be expected from the retarded inactivation of central amines.

Trifluoperazine (2 mg/kg) elicits EEG deactivation with characteristics similar to those observed following the administration of “equi-deactivating” doses of chlorpromazine (5 mg/kg). When both trifluoperazine (2 mg/kg) and tranylcypromine (7.5 mg/kg) are introduced simultaneously, the activating effects of the latter dominate the earlier phases of the recording.

Preliminary experiments in some preparations in which gross unilateral lesions have been made in the mesencephalic tegmentum raises the possibility that this subcortical area may be a possible site for the arousal effect observed following the administration of tranylcypromine.

Free-Hand Copying of a Geometric Pattern as a Test for Sensory-Motor Disturbance

Detailed measurements of freehand copies of a geometric figure were made in order to assess the utility of such drawings for reflecting changes in skilled manual performance. For normal Ss, reliability was satisfactory only for short time-intervals and for certain parameters. However, measures of size of drawings and the placement of spiral lines appeared to show differential sensitivity to stimulant, tranquilizer, and stress conditions.

Effect of sympathomimetic amines on the blocking action of guanethidine, bretylium and xylocholine

Experiments were carried out in which the adrenergic neurone blocking activity of xylocholine, bretylium and guanethidine was studied by the use of the inhibitory responses of the isolated rabbit ileum to lumbar sympathetic nerve stimulation, and the contractions of the nictitating membrane of the anaesthetized cat in response to stimulation of the cervical sympathetic nerves. In both these preparations, after blockade of the effects of sympathetic nerve stimulation had been produced with xylocholine, bretylium or guanethicdine, the sympathomimetic amines, dexamphetamine, mephentermine, hydroxyamphetamine, ephedrine and phenethylamine, reversed the blockade; if these amines were given first, then the adrenergic neurone blocking agents were ineffective. Tyramine and dopamine were effective on the isolated rabbit ileum but not on the cat's nictitating membrane. Effective antagonism of the adrenergic neurone blocking drugs was also shown by some substances which inhibit mono-amine oxidase but only those which in addition possess sympathomimetic effects. Thus phenelzine, pheniprazine and tranylcypromine were effective whereas iproniazid and nialamide were not. Since xylocholine, bretylium and guanethidine were all antagonized by the same agents, it seems likely that they all produce sympathetic blockade by a similar mechanism. The possibility is discussed that the sympathomimetic amines which antagonize the adrenergic neurone blocking drugs are competing with these substances for the same receptor sites.

Relative activity of some inhibitors of mono-amine oxidase in potentiating the action of tryptamine in vitro and in vivo

Several known inhibitors of mono-amine oxidase (iproniazid, isocarboxazid, nialamide, phenelzine, pheniprazine and tranylcypromine) were tested for their ability to (i) inhibit the mono-amine oxidase activity of a rat brain mitochondrial preparation in vitro; (ii) potentiate the action of tryptamine on the isolated rat fundal strip preparation; and (iii) potentiate the acute toxicity of tryptamine in mice. There was some correlation between the order of potency of the drugs in the three tests, particularly in inhibiting the enzyme activity in the Warburg and in the tryptamine toxicity test in mice. Exceptions to this were isocarboxazid which had unexpectedly high activity on the rat fundal strip preparation, and tranylcypromine which was devoid of tryptamine-potentiation action on the rat fundus preparation although it inhibited rat brain mono-amine oxidase in vitro and potentiated the action of tryptamine in vivo. Tranylcypromine was considerably less active in inhibiting the mono-amine oxidase of rat fundus than rat brain tissue in vitro, while iproniazid and isocarboxazid had about the same potency on the enzyme from the two tissues.

MONOAMINE OXIDASE INHIBITORS: AUGMENTATION OF PRESSOR EFFECTS OF PERORAL TYRAMINE

Monoamine oxidase inhibitors markedly enhance the oral pressor potency of tyramine by preventing it from being destroyed by the monoamine oxidase normally present in liver and intestine. Since certain types of cheese contain high concentrations of tyramine, they should not be eaten by patients during treatment with a monoamine oxidase inhibitor.

THE 5-HYDROXYTRYPTAMINE CONTENT OF THE PLACENTA AND FOETUS DURING PREGNANCY IN MICE

5-Hydroxytryptamine (5HT) levels were measured in blood and tissues from pregnant mice. Blood levels remained constant during pregnancy and were the same as those in nonpregnant female mice. Placental levels of 5HT increased throughout pregnancy as did the foetal levels. The maternal blood volume of the placenta also increased with advancing gestation. 5HT levels were measured after treatment of the mother with 5HT, and the critical placental level of 5HT observed at about the time of death of the foetus was determined. The levels of 5HT in the placenta and foetus after treatment of the mother with several monoamine oxidase inhibitors were measured, and found to show no significant increase above the normal levels in these tissues. Treatment with cyproheptadine, a 5HT antagonist, did not delay parturition.

Advertising, computers, and pharmacy liability. A Michigan court's decision has ramifications for pharmaceutical care

Arbor Drugs, Inc., advertised that its computer could detect dangerous drug interactions. A pharmacist failed to warn a patient accordingly and the patient suffered a stroke as a result of an interaction between tranylcypromine and a decongestant. The Michigan Court of Appeals held that this failure to warn was actionable under the theories of negligence and fraud as well as under the Michigan Consumer Protection Act. The court's basic message is that pharmacies may be held legally responsible for preventing harm when they represent themselves as being capable of doing so.

Description of a clinical case]

The author reports a patient, treated with tranylcipromine as antidepressant (a MAO inhibitor), who underwent an operation for abdominal aortic aneurysm. The antidepressant was stopped five days only, for neurological problems. The anesthesia was a combination among general anesthesia (Diprivan and Tracrium), epidural anaesthesia (lidocaine and clonidine) and electro-acupuncture. The cardio-circulatory, ventilatory and metabolic parameters were very stable both in the perioperative and in the postoperative period.

Description of a clinical case]

The Authors report a collapsial reaction during general anaesthesia for total hip replacement in a patient treated with tranylcipromine, an inhibitor of MAO, as antidepressant agent. She had discontinued drug intake eight days before. Nevertheless a serious collapsial reaction appeared in association with general anaesthesia. It would be suitable, in their opinion, to stop antidepressant therapy with tranylcipromine at least three weeks (like with other IMAO) before general anaesthesia.

[Effect of acute and chronic ethanol consumption on rat brain and liver monoamine oxidase activity]

Monoamine oxidase (MAO) activity was studied in hyporthalamus, midbrain, brain stem and liver tissue of rats after single and repeated administration of ethanol using noradrenaline and dopamine as MAO substrates. Small, but statistically significant decrease in the activity MAO of the "A" type was found in rat liver tissue after repeated administration of alcohol. Both single and repeated administrations of ethanol did not affect the enzymatic activity in the brain. Prolonged administration of the MAO inhibitor parnate simultaneously with alcoholization of rats led to inhibition of the MAO activity to the same degree as in control animals treated with the parnate only.

A case of tranylcypromine ('Parnate') addiction

A case of addiction to tranylcypromine is described where tolerance occurred and a severe withdrawal illness followed discontinuation of the drug. Previous reports in the literature of similar cases are reviewed and comparisons made, and the implications for management are discussed.

L-tryptophan in depression

L-tryptophan, the amino acid precursor of serotonin, was administered to 16 depressive patients in a double-blind study of its potential antidepressant efficacy. Antidepressant responses were observed in one of ten unipolar patients and in three of six bipolar patients. These results are discussed in the context of possible interactions of amines with electrolyte systems in the etiology of affective illness.

Anxiety state or masked depression? A study based on the action of monoamine oxidase inhibitors

In 1959, West and Dally reported the effects of iproniazid in depressive syndromes, drawing attention to the greater therapeutic effectiveness of this drug in ‘atypical’ or ‘hysterical’ depressive states than in endogenous depression. Later, Sargant and Dally (1962) found a group of patients with good previous personalities, showing obvious features of depression, whose anxiety symptoms responded to phenelzine alone, but in view of the response of other patients with anxiety they questioned whether monoamine oxidase inhibitors were really antidepressant, or whether they were essentially drugs acting against anxiety. These findings prompted this study, intended to compare other parts of the clinical pictures of anxiety states responsive to monoamine oxidase inhibitors with those of depressive illnesses.