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Hypertensive Crisis: The most important reaction associated with PARNATE (tranylcypromine) is the occurrence of hypertensive crises which have sometimes been fatal.
These crises are characterized by some or all of the following symptoms: occipital headache which may radiate frontally, palpitation, neck stiffness or soreness, nausea or vomiting, sweating (sometimes with fever and sometimes with cold, clammy skin), and photophobia. Either tachycardia or bradycardia may be present, and associated constricting chest pain and dilated pupils may occur Intracranial bleeding, sometimes fatal in outcome, has been reported in association with the paradoxical increase in blood pressure.
In all patients taking PARNATE (tranylcypromine) , blood pressure should be followed closely to detect evidence of any pressor response. It is emphasized that full reliance should not be placed on blood pressure readings, but that the patient should also be observed frequently.
Therapy should be discontinued immediately upon the occurrence of palpitation or frequent headaches during therapy with PARNATE (tranylcypromine) . These signs may be prodromal of a hypertensive crisis.
Important: Recommended treatment in hypertensive crises
If a hypertensive crisis occurs, PARNATE (tranylcypromine) should be discontinued and therapy to lower blood pressure should be instituted immediately. Headache tends to abate as blood pressure is lowered. On the basis of present evidence, phentolamine is recommended. (The dosage reported for phentolamine is 5 mg IV.) Care should be taken to administer this drug slowly in order to avoid producing an excessive hypotensive effect. Fever should be managed by means of external cooling. Other symptomatic and supportive measures may be desirable in particular cases. Do not use parenteral reserpine.
Hypotension: Hypotension has been observed during therapy with PARNATE (tranylcypromine) . Symptoms of postural hypotension are seen most commonly but not exclusively in patients with pre-existent hypertension; blood pressure usually returns rapidly to pretreatment levels upon discontinuation of the drug. At doses above 30 mg daily, postural hypotension is a major side effect and may result in syncope. Dosage increases should be made more gradually in patients showing a tendency toward hypotension at the beginning of therapy. Postural hypotension may be relieved by having the patient lie down until blood pressure returns to normal.
Also, when PARNATE (tranylcypromine) is combined with those phenothiazine derivatives or other compounds known to cause hypotension, the possibility of additive hypotensive effects should be considered.
There have been reports of drug dependency in patients using doses of tranylcypromine significantly in excess of the therapeutic range. Some of these patients had a history of previous substance abuse. The following withdrawal symptoms have been reported: restlessness, anxiety, depression, confusion, hallucinations, headache, weakness, and diarrhea.
Drugs which lower the seizure threshold, including MAO inhibitors, should not be used with Amipaque®*. As with other MAO inhibitors, PARNATE (tranylcypromine) should be discontinued at least 48 hours before myelography and should not be resumed for at least 24 hours postprocedure.
MAO inhibitors may have the capacity to suppress anginal pain that would otherwise serve as a warning of myocardial ischemia.
The usual precautions should be observed in patients with impaired renal function since there is a possibility of cumulative effects in such patients.
Older patients may suffer more morbidity than younger patients during and following an episode of hypertension or malignant hyperthermia. Older patients have less compensatory reserve to cope with any serious adverse reaction. Therefore, PARNATE (tranylcypromine) should be used with caution in the elderly population.
Although excretion of PARNATE (tranylcypromine) is rapid, inhibition of MAO may persist up to 10 days following discontinuation.
Because the influence of PARNATE (tranylcypromine) on the convulsive threshold is variable in animal experiments, suitable precautions should be taken if epileptic patients are treated.
Some MAO inhibitors have contributed to hypoglycemic episodes in diabetic patients receiving insulin or oral hypoglycemic agents. Therefore, PARNATE (tranylcypromine) should be used with caution in diabetics using these drugs.
PARNATE (tranylcypromine) may aggravate coexisting symptoms in depression, such as anxiety and agitation.
Use PARNATE (tranylcypromine) with caution in hyperthyroid patients because of their increased sensitivity to pressor amines.
PARNATE (tranylcypromine) should be administered with caution to patients receiving Antabuse®†. In a single study, rats given high intraperitoneal doses of d or l isomers of tranylcypromine sulfate plus disulfiram experienced severe toxicity including convulsions and death. Additional studies in rats given high oral doses of racemic tranylcypromine sulfate (PARNATE (tranylcypromine) ) and disulfiram produced no adverse interaction.
Information for Patients: Prescribers or other health professionals should inform patients, their families, and their caregivers about the benefits and risks associated with treatment with PARNATE (tranylcypromine) and should counsel them in its appropriate use. A patient Medication Guide about “Antidepressant Medicines, Depression and Other Serious Mental Illnesses, and Suicidal Thoughts or Actions” is available for PARNATE (tranylcypromine) . The prescriber or health professional should instruct patients, their families, and their caregivers to read the Medication Guide and should assist them in understanding its contents. Patients should be given the opportunity to discuss the contents of the Medication Guide and to obtain answers to any questions they may have. The complete text of the Medication Guide is reprinted at the end of this document.
Patients should be advised of the following issues and asked to alert their prescriber if these occur while taking PARNATE (tranylcypromine) .
Clinical Worsening and Suicide Risk: Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Families and caregivers of patients should be advised to look for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt. Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. Symptoms such as these may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication.
Pediatric Use: Safety and effectiveness in the pediatric population have not been established (see BOX WARNING and WARNINGS - Clinical Worsening and Suicide Risk). Anyone considering the use of PARNATE (tranylcypromine) in a child or adolescent must balance the potential risks with the clinical need.
*metrizamide, The Sanofi-Aventis Group.
†disulfiram, Odyssey Pharmaceuticals, Inc.
Last reviewed on RxList: 6/11/2010
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