MAOIs may also interact with specific anesthetic drugs used during surgery. Cancer patients in particular may frequently undergo surgical procedures and should alert their anesthesiologist of all medications. Postoperative pain should not be treated with meperidine HCl. MAOIs should neither be taken with procarbazine, a chemotherapeutic agent used in the treatment of lymphomas and brain tumors, nor used with other antidepressants.
The FDA approved a transdermal antidepressant that may have particular value in the treatment of the depressed cancer patient who is unable to swallow or take medications by mouth. The antidepressant selegiline (sold under the trade name EMSAM) is an irreversible MAOI. The drug has not been evaluated for the treatment of depression in cancer patients.
Many of the usual dietary restrictions (low-tyramine diet) and drug-drug interactions (the product should not be used with meperidine, propoxyphone, or methadone) are germane to selegiline (see Table 4 below). However, according to the package insert, the 20-mg skin patch (which delivers 6 mg of selegiline in a 24-hour period) can be used without the dietary restrictions found on all MAOIs marketed to date. This recommendation is supported by clinical trials and other evidence submitted to the FDA. The two higher doses (a 30-mg patch that delivers 9 mg in 24 hours and a 40-mg patch that delivers 12 mg in 24 hours) carry the usual dietary warning. This drug has not been evaluated in cancer patients for safety and efficacy.
Table 4. Tyramine-Containing Foodsa
OTC = over-the-counter.
a Adapted from the EMSAM Medication Guide. The foods and beverages listed above should be avoided beginning on the first day of treatment with selegiline 9 mg/24 h or 12 mg/24 h and should continue to be avoided for 2 weeks after a dose reduction to 6 mg/24 h or following the discontinuation of selegiline 9 mg/24 h or 12 mg/24 h.
|Class of Food and Beverage
||Tyramine-Rich Foods and Beverages To Avoid
||Acceptable Foods Containing Little or No Tyramine
|Meat, poultry, and fish
||Air-dried, aged, and fermented meats, sausages, and salamis (including cacciatore, hard salami, and mortadella); pickled herring; and any spoiled or improperly stored meat, poultry, and fish (e.g., foods that have undergone changes in color or odor or that have become moldy); spoiled or improperly stored animal livers
||Fresh meat, poultry, and fish, including fresh processed meats (e.g., lunch meats, hot dogs, breakfast sausage, and cooked sliced ham)
||Broad bean pods (fava bean pods)
||All other vegetables
||Processed cheeses, mozzarella, ricotta cheese, cottage cheese, and yogurt
||All varieties of tap beer, and beers that have not been pasteurized so as to allow for ongoing fermentation
||As with other antidepressants, concomitant use of alcohol with selegiline is not recommended. (Bottled and canned beers and wines contain little or no tyramine.)
||Concentrated yeast extract (e.g., Marmite), sauerkraut, most soybean products (including soy sauce and tofu); OTC supplements containing tyramine
||Brewer's yeast, baker's yeast, soy milk, commercial chain-restaurant pizzas prepared with cheeses low in tyramine