MAOI + Tyramine Hypertensive Emergency/Adrenergic Storm

Discussion in 'Heart, Heart Rate, Blood Pressure' started by zanolachino, Apr 28, 2019.

  1. zanolachino

    zanolachino Member

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    This post concerns a hypothetical medical emergency involving “Bob”. He has been to the ER and is under the care of multiple doctors. He is discouraged by their lack of understanding of root causes. He is simply looking for other ideas, not medical advice.

    Just over three weeks ago Bob went to a Chinese doctor to ask for an herbal formula to help his severe insomnia.

    Three weeks ago he suffered a hypertensive crisis as the result of combining the herbal formula he was prescribed, which he only later discovered contained potent monoamine oxidase inhibitors (MAOIs), with high-tyramine foods.

    He was in the ER after just two days on the herbs, where they told him he was at imminent risk of stroke. They used IV hydralazine to lower his blood pressure. All tests were normal. They sent him home with hydrochlorothiazide, a diuretic, and told him to follow up with his regular doctor the next day.

    That doctor prescribed Benicar (olmesartan, an angiotensin II receptor antagonist, plus hydrochlorothiazide). Neither that doctor nor the next two doctors Bob consulted much cared about what caused the hypertensive crisis. They treated Bob as someone who “just has hypertension now”.

    This did not sit right with Bob. His blood pressure had been normal before the MAOI/tyramine interaction. It seemed to him that the doctors were not attacking the root of the problem: an adrenergic storm with an unambiguous cause. Calm that storm, solve the problem.

    Bob never took the herbs again after the initial two days. Once he figured out — through his own research, as the doctors were no help — what had happened, he was careful to avoid tyramine in his diet. This latter bit was complicated somewhat by the incomplete and sometimes contradictory information online about what is and is not high in tyramine.

    He expected his blood pressure to drop steadily over the following days or weeks. He is no longer in hypertensive crisis, but three weeks later his blood pressure continues to range from slightly high to very high — particularly worrisome in light of his family history of stroke and heart attack. He was particularly discouraged after the two-week mark, as MAOIs are often said to persist in their effects for two weeks, and he was optimistic that that would be a turning point.

    Beyond the tyramine concern, starting a few days ago Bob limited his diet much further, as he was astonished to learn how many foods contain MAOIs. In fact, it’s hard to find anything in the vegetable kingdom that does not. (For example, good old orange juice is rich in quercetin and other flavonoids which are MAOIs.). Perhaps this will prove to be key moving forward. Bob thought the MAOIs were out of his system by now, yet he was continuing to introduce them unknowingly in food.

    He has not yet started the olmesartan, as he is not convinced it is the right drug for the job, but will do so very soon if he cannot otherwise get his blood pressure under control, The continued elevation is simply too risky.

    When he researched adrenergic storm, he learned that diazepam/Valium is the standard treatment, plus beta blockers. (Interestingly, the ER doctor did not administer diazepam, and the antihypertensive they used was not a beta blocker.) Bob does not have access to diazepam but has access to chlordiazepoxide/Librium. He has taken 25mg of Librium a total of five times, only when he felt especially bad. While it improved both blood pressure readings and subjective symptoms, it did not put a permanent stop to the adrenergic storm. Perhaps he did not take enough, or for long enough, but he is concerned about the addictive potential — a very real concern given Librium's reputation as the most addictive of the benzodiazepines, and his own experience of strong rebound effect upon its wearing off.

    Significantly, his body is voracious for magnesium. He has used and loved Magnoil since its release. Normally, applying more than 25-30 drops exceeds his bowel tolerance. Now he is applying up to 200 drops per day without any diarrhea whatsoever. This seems a major clue that the doctors have completely disregarded.

    Beyond Magnoil, many of Haidut’s more exotic products look promising for calming the nervous system. Bob is researching what would be most appropriate to consider here but could use some help.

    Does anyone have thoughts for addressing this hypothetical problem at its root?

    Thanks to everyone who read this long message.
     
  2. JudiBlueHen

    JudiBlueHen Member

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    First, I have a question. I have looked up Adrenergic Storm, and every definition seems to copy Wikipedia, so is not totally helpful. Can you provide a brief description of the term (most online definitions are related to drug overdose or traumatic brain injury). Second, how do you distinguish between Adrenergic Storm and Thyroid Storm?

    Your scenario is potentially relevant to me in that I have episodes of SVT, usually accompanied by episodic HBP. Thanks!
     
  3. OP
    zanolachino

    zanolachino Member

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    I'm afraid I don't know anything about differential diagnosis between adrenergic storm and thyroid storm.

    The reason the situation in the OP is fairly certain to be an adrenergic storm is that the sort of hypertensive crisis caused by MAOIs plus tyramine is very well-documented, and tyramine causes the hypertensive crisis through an adrenergic storm: a runaway surge in adrenaline and norepinephrine.
     
  4. JudiBlueHen

    JudiBlueHen Member

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    You might be interested in the writings of Dr. Ken Gillman, Psychotropical Research. He has many articles on MAOIs; one describes the hypotensive effect of MAOIs. He is an expert in Serotonin Toxicity.

    MAOIs and Blood Pressure (Anti-Hypertensive Effect) - Psychotropical

    Lowering of Blood Pressure: a Therapeutic Effect of MAOIs
    On reading this you may understand why it is frustrating to read much of what is written about MAOIs. Many doctors still believe that MAOIs raise blood pressure. Back in the 1960s they were more widely used as anti-hypertensive drugs than they were as antidepressants: the following references attest to that (1-10).​

    Regarding foods eaten with MAOIs, he discusses the reaction with tyramine (but he does not specifically discuss supplements). It would be interesting to know if "Bob" had these specific symptoms.

    MAOI Diet Abbreviated 3.3 - Psychotropical
    • The increased blood pressure reaction that can result from excess tyramine ingestion is proportional to the amount of tyramine ingested
    • Nowadays very few foods or drinks have tyramine levels sufficiently high that a small amount (i.e. 50 grams or ml, or less) is likely to cause a problematic degree of hypertension
    • All modern cheeses are safe in healthy-sized portions (25-50 grams). Only a very few matured cheeses can sometimes have higher tyramine concentrations, so a little care and awareness is still needed
    • Reaction to modern foods are likely to be mild and to last less than 2 hrs. The chance of coming to serious harm is remote
    • The symptoms of a reaction are: a thumping forceful heartbeat (usually a slower than normal pulse rate), paleness (pallor), rapid onset severe headache, tightness in the chest. Pulse may drop as low as 40 beats per minute
    • The variability of sensitivity to tyramine between individuals means that a small percentage of people may notice mild reactions with smaller doses
     
  5. fractalpi

    fractalpi Member

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    It is when one takes MAOI inhibitors, that a hypertensive crisis occurs, if one eats food high in tyramine, like aged cheese and brewer's yeast.

    Examples of MAOIs that are used for depression include:

    • Isocarboxazid (Marplan)
    • Phenelzine (Nardil)
    • Selegiline (Emsam)
    • Tranylcypromine (Parnate)
    Avoid the combination of high-tyramine foods and MAOIs
     
  6. methylenewhite

    methylenewhite Member

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    Another proof that traditional medicines are a placebo based voodoo. They have no idea what they mix in.
     
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