Skip to content
My WebMD Sign In, Sign Up

Announcements

Visit our Crisis Assistance Link for resources. For immediate help, get to the ER.

*No Dr Outside Contact Please*
Includes Expert Content
Dr. G - MAOI Dosage
avatar
ddnos posted:
Hi Dr. G.

I have been a little confused about what I think I have read in every document about Nardil - this is about the dosage of Nardil. I constantly read that you should start with a certain dose, increase, and then reduce dosage as low as 15mg daily or even every other day. Say what? lol I'm sure I couldn't realisticall do that since i've been on Nardil so many years, but to your knowledge, is it ever done the following way?

"Initial dose: The usual starting dose of NARDIL (phenelzine) is one tablet (15 mg) three times a day.
Early phase treatment: Dosage should be increased to at least 60 mg per day at a fairly rapid pace consistent with patient tolerance. It may be necessary to increase dosage up to 90 mg per day to obtain sufficient MAO inhibition. Many patients do not show a clinical response until treatment at 60 mg has been continued for at least 4 weeks.
Maintenance dose: After maximum benefit from NARDIL (phenelzine) is achieved, dosage should be reduced slowly over several weeks. Maintenance dose may be as low as one tablet, 15 mg, a day or every other day, and should be continued for as long as is required."
http://www.rxlist.com/nardil-drug/indications-dosage.htm

Thank you
Debbie
Forgiveness is letting go of the hope that the past could have been any different --Unknown
Reply
 
avatar
ddnos responded:
bump
Forgiveness is letting go of the hope that the past could have been any different --Unknown
 
avatar
ddnos replied to ddnos's response:
bumpy
Forgiveness is letting go of the hope that the past could have been any different --Unknown
 
avatar
Joseph F Goldberg, MD responded:
Debbie,

During long-term treatment with Nardil, the dose CAN be lowered to just 1 tab (15 mg)/day with good effect, but there is no automatic need to do so.

Dr. G.
 
avatar
ddnos replied to Joseph F Goldberg, MD's response:
Dr. G.

Do you think it could slowly be done with me, who has been on Nardil for 22 years, or is it too late because I've been on it for so long?

Thank you

Debbie
Forgiveness is letting go of the hope that the past could have been any different --Unknown
 
avatar
Joseph F Goldberg, MD replied to ddnos's response:
Dear Debbie,

My own credo is "ain't broke don't fix."

Why fiddle?

Dr. G.
 
avatar
ddnos replied to Joseph F Goldberg, MD's response:
Hi Dr. G.

....but it IS broken! My Normetanephrines levels are and have been through the roof since Sept. 2008. Before I went off Nardil 4 years ago, my Normetanephrines levels were 1182. When I was completely off Nardil for about 2-3 months, they were within normal range and the symptoms of the high levels went completely away. I was then put on EmSam, and within 3 months, my normetane levels were climbing up again at 836. Then I went back on Nardil and after being on it for 4 months (in Sept 2010), my "N" levels were at 1037. I was just tested again and they are at 1229! My doctor had me reduce nardil by a half a pill earlier this week (which I had just increased a couple months ago). I can barely tolerate the effects of this level of Normetanephrines anymore, and I wonder if because of how MAOI's work, maintainence on 15mg or less a day is how it's supposed to be done to lessen the chances or inevitibilty of eventual high Normetanephrines levels? I don't know how much my body can handle of this. My doctor looked at me and said that we have to do something lest I blast off into space (she was playing, but serious).

Maybe I was supposed to be on Nardil the way I have seen it written in every medical publication I've read. Because I have been on it for so long, I wonder if it's even possible to go backwards in my dosage and still maintain its anti-depressant effect.

So yes, "it is broke," and I'm wondering if in your opinion, you think it's too late to make the above changes (or similar) and if so, would it need to be done slowly? As I may have said before, I became very ill when I went off Nardil before, titrating a 1/2 a pill a week (with a 1 month break in between because of anxiety worse than I've ever experienced on or off medication.) This method of taking an anti-depressant seems so foriegn to me and doesn't make sense; but I've read about it over the years many times, wondering why I wasn't taking it that way. I asked my then doctor, but she just brushed it off as something that was obsurd; so I never mentioned it to her again.

Thank you for your input!

Debbie
Forgiveness is letting go of the hope that the past could have been any different --Unknown
 
avatar
Joseph F Goldberg, MD replied to ddnos's response:
Dear Debbie,

Why is your doctor measuring normetanephrine levels? And, assuming you don't have high blood pressure or suspicion that you have an adrenal tumor, why does she think the levels are clinically relevant?

Dr. G.
 
avatar
ddnos replied to Joseph F Goldberg, MD's response:
Dr. G.

The reason for initial testing of normetanephrine levels back in 2008, my blood pressure was progressively spiking really high on a daily basis. I was temporarily seeing a different doc at the time. Anyway, because of concern, I went to the doctor and he did several tests to rule out heart issues and whatever else he was ruling out. Because of my symptoms, and after looking at several things over the span of about 9 months to a year, he thought that maybe I had an adrenal tumor (because, among other testing, he had at that point tested my "N" levels and they were high. He ordered a CT Scan adn it showed no adrenal gland tumor. After then confering with another doctor, it was determined that the cause of the blood pressure spikes was the high "N" levels, which was caused by the MAOI (Nardil). So it was determined that I should go off Nardil and try a non-MAOI medication because he was concerned about my increasing and excessively high blood pressure spikes. So I was sent to one of the Psychiatrists to be in charge of that part of the treatment since that was her specialty, not his. Once I was completely weaned off Nardil, my "N" levels completely went down to within normal range, and my bp stopped spiking, as well as all of the other symptoms I had. As soon as (within 3 months) I got back on an MAOI (EmSam), my "N" levels started to go up again as did my blood pressure. I went back on Nardil because EmSam wasn't working for me anyway and by that time, I had been so sick from the whole ordeal, that for my mental and physical health, I didn't have much choice. My "N" levels continued to climb to where they are today (the highest they've ever been.

So that's the reason my "N" levels have been measured, and beacuse it's the MAOI that is causing my levels to be high, my bp starting to spike again, and the other physical symptoms I'm having, yes, it's very clinically relevant in my maybe unusual case.

If there was another way of lowering my "N" levels (which maybe there is and my dr doesn't know it) then we would do that; but at this point, the only way to do that seems to be the lowering of my Nardil intake. I wondered about my initial question to you re the dosage because it seems that if I could get on a much lower dose of Nardil if that would still be effective for me re depression, and it lowered my "N" levels, then that would be the ideal scenerio for me. I just can't imagine going down even 15mgs lower right now because I've been on the med so long and I seem to react significantly to the reduced dosage (or at least I did 4 years ago). When I had to wean off Nardil prior to 4 years ago (twice) I didn't react so severely, so it's possible that would be the case should I have to do that again. I suppose the thing we could do is try, and if that doesn't work, increase the med again. I don't know. My dr is the one in charge of what we do here, I'm just trying to do my part of being proactive in my own health. My doc obviously won't do or not do something based on my input, but I know that she will at least look at it and consider any input I have.

Thank you for your time and input

Debbie
Forgiveness is letting go of the hope that the past could have been any different --Unknown
 
avatar
ddnos replied to ddnos's response:
bump
Forgiveness is letting go of the hope that the past could have been any different --Unknown
 
avatar
Joseph F Goldberg, MD replied to ddnos's response:
Dear Debbie,

MAOIs like Nardil -- as well as many other medicines, such as SNRIs (eg, Effexor, Pristiq, Cymbalta) and tricyclics (e.g., desipramine, nortriptyline) can artificially raise metanephrine levels (meaning, metanephrine is usually made by the adrenal glands), so the clinical relevance of high metanephrine levels is to make sure there isn't an adrenal tumor (ie, pheochromocytoma) responsible for the levels....which for you apparently has been ruled out, which is reassuring. High metanephrine levels can mimic the symptoms of pheochromocytoma -- sudden blood pressure spikes that can last for minutes to hours, drenching sweats, palpitations. If blood pressure increases are substantially high and these types of symptoms Sounds like that was confidently determined for you.

There isn't any medical literature on remedies to counteract high metanephrine levels or medicines to treat their effects (ie, blood pressure spikes etc) so a general recommendation is to change to a different medicine that doesn't cause this problem. This is actually a difficult and complex question for your doctor and you to think through, since, on the one hand, if you've been living with this consequence of the Nardil for many years and if the BP spikes have not been tremendously high, it's conceivably possible that this is a livable side effect, albeit with the need for close monitoring. Lowering the dose (by increments of 15 mg) might diminish the effect, since the degree of inhibition of monoamine oxidase is dose-related, and the build-up of norepinephrine (which is desirable from a depression standpoint, but potentially hazardous from a blood pressure standpoint), would expectably be less on a lower dose -- which may or may not translate to fewer side effects such as these. Another possible, though unusual, strategy might be to consult with a very knowledgeable cardiologist about whether adding a beta blocker could offset the blood pressure consequences of the high metanpehrine levels. This would be quite novel -- I haven't seen anything in the medical literature describing such a strategy, but plausible in terms of mechanisms of how these medicines work on what's called the autonomic nervous system (ie, the part of the nervous system that controls blood pressire). Outright changing to a different type of ("non-noradrenergic") medicine in order to eliminate the problem carries with it the uncertainty of its desired effect on mood.

Show this post to your doctor...I would be curious what his thoughts are. This is a complex and medically interesting puzzle worth sorting through wih the right psychiatric and cardiology expertise.

Dr. G.
 
avatar
ddnos replied to Joseph F Goldberg, MD's response:
Thank you Dr. G!

I definitely plan on sharing this post with my doctor when I see her next Friday. Thank you for your explanation!

Yes, this is a complicated situation and hope to get it resolved or at least minimized eventually. I have often wondered if any other people who have been on Nardil long term have also experienced the same thing with the high metanpehrine levels and subsequent symptoms - I certainly can't be the only one. I guess that would make me "special" if so, eh? lol

Thanks again for sticking with me on this topic as you have! I appreciate it very much! I will get back to you re any course of action my doctor may take after reading what you have to say.

Debbie
Forgiveness is letting go of the hope that the past could have been any different --Unknown


Featuring Experts

Joseph F. Goldberg, MD, is a Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. He also maintains a private prac...More

Helpful Tips

Screen out people who can't seem to "get it"....
There are some people who can't or won't understand at all. My wife is bipolar, and some people are more understanding than others. We ... More
Was this Helpful?
34 of 40 found this helpful

Related News

There was an error with this newsfeed

Related Drug Reviews

  • Drug Name User Reviews

Report Problems With Your Medications to the FDA

FDAYou are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.