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4.1 Contraindications
Isocarboxazid is contra-indicated in patients with any impairment of hepatic function, cerebrovascular disorders or severe cardiovascular disease, and in those with actual or suspected phaeochromocytoma.
Selective serotonin reuptake inhibitors (SSRIs): Cases of serious and sometimes fatal reactions (serotonin syndrome) have been reported in patients receiving monoamine oxidase inhibitors (MAOIs) in combination with SSRIs, and in patients who have recently discontinued an SSRI and have been started on a MAOI. Treatment with SSRIs should only be started 2 weeks after discontinuation of Isocarboxazid.
Conversely, treatment with Isocarboxazid should not be started until at least a week after stopping a SSRI or related anti-depressant (at least 5 weeks for fluoxetine).
4.1 Interaction with other medicinal products and other forms of interaction
Like other monoamine oxidase inhibitors, Isocarboxazid potentiates the action of a number of drugs and foods. Patients being treated with a monoamine oxidase inhibitor should not receive indirectly-acting sympathomimetic agents such as amphetamines, metaraminol, fenfluramine or similar anorectic agents, ephedrine or phenylpropanolamine (contained in many proprietary 'cold-cure' medications), dopamine or levodopa. Patients should also be warned to avoid foodstuffs and beverages with a high tyramine content: mature cheeses (including processed cheeses), hydrolysed yeast or meat extracts, alcoholic beverages, particularly heavy red wines such as Chianti, non-alcoholic beers, lagers and wines, and other foods which are not fresh and are fermented, pickled, 'hung', 'matured' or otherwise subject to protein degradation before consumption. Broad bean pods (which contain levodopa) and banana skins may also present a hazard. In extreme cases interactions may result in severe hypertensive episodes. Isocarboxazid should therefore be discontinued immediately upon the occurrence of palpitations or frequent headaches.
Pethidine should not be given to patients receiving monoamine oxidase inhibitors as serious, potentially fatal reactions, including central excitation, muscle rigidity, hyperpyrexia, circulatory collapse, respiratory depression and coma, can result. Such reactions are less likely with morphine, but experience of the interaction of Isocarboxazid with narcotic analgesics other than pethidine is limited and extreme caution is therefore necessary when administering morphine to patients undergoing therapy with Isocarboxazid.
Isocarboxazid should not be administered together with other monoamine oxidase inhibitors, selective serotonin reuptake inhibitors (SSRIs) or most tricyclic antidepressants (clomipramine, desipramine, imipramine, butriptyline, nortriptyline or protriptyline). Although there is no proof that combined therapy will be effective, refractory cases of depression may be treated with Isocarboxazid in combination with amitriptyline or trimipramine, provided appropriate care is taken. Hypotensive and other adverse reactions are likely to be increased.
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