From: dyer@spdcc.com (Steve Dyer)
Subject: Re: Help, hypotension is messing up my MAOI trial!
Organization: S.P. Dyer Computer Consulting, Cambridge MA
Date: Thu, 20 Aug 1992 07:03:34 GMT

In article <01GNS8ZDEJRO9JD83I@Meena.CC.URegina.CA> SCHOLAR@MEENA.CC.UREGINA.CA writes:
>     Anyway, drinking tonnes of water (with salt) and lowering my dose allowed
>me to survive the last few days, but if this weren't summer vacation I'd be
>dead, besides how can I work if get weak every time I bend over and have to
>move like an eighty year old to keep from fainting?

Increasing salt and water is a good first step, as you say.  Getting
to the lowest effective dose and spreading the dose out during the day
is also important.  Another possibility might be a trial of a different
MAOI, say phenelzine instead of tranylcypromine.  Phenelzine is generally
considered even more problematic than tranylcypromine when it comes to
hypotension.  However, individuals who can't tolerate one may have fewer
problems with the other.

>     So this morning I sat down with my copy of the PDR and looked to see if
>there was anything I could take with an MAOI that would help.  The only thing
>that looked safe to me was the antidiuretic desmopressin [DDAVP], a long
>lasting analog vasopressin without most of the pressor action.  I got rather
>excited because I'm under the impression that vasopressin (and its analogs) are
>the only nootropics with anything like proven action, and with my memory the
>way it is these days, I need all the help I can get to make through my next
>year of engineering classes.
>     I walked down to the library to see what I could find on vasopressin and
>on treating the side effects of MAOIs.  Here's what I found:
> 
>     ... more troubling side effect is orthostatic hypotension ... In its
>     milder forms this condition is easily controlled by adding salt to food
>     ... fludrocortisone acetate, a mineralocorticoid, may effectively maintain
>     blood pressure... .1 mg one to three times daily.  In refractory cases ...
>     methylphenidate HCL [Ritalin] or dextroamphetamine [Dexedrine] (2.5 mg per
>     day to start) can be added safely and are highly effective...
> 
>     Fludrocortisone isn't in my (out of date) PDR. I've had bad experience
>with Prednisone before (infections took over my face and gums), does
>Fludrocortisone have the same sort of immunosuppressive effect at .3 mg?

Fludrocortisone is a mineralocorticoid, affecting sodium, potassium
and water balance.  It has no glucocorticoid (prednisone-like) effects.
This might not be an unreasonable thing to try.

>     Neither Ritalin nor Dexedrin are available in Canada.  I wonder whether
>pseudophenedrine could substitute?  I've always gotten unpleasant side effects
>from Sudaphed though (anxiety, irritability, dysphoria, poor memory and finally
>burn out after taking it for a whole summer).

As you should be aware (and if you're not, your doctor is guilty of the
severest malpractice), combining any sort of sympathomimetic drug
with an MAO inhibitor is an experiment fraught with danger, and should
be attempted only under controlled medical supervision.  This includes
the central stimulants dextroamphetamine and methylphenidate (Ritalin)
or the over-the-counter decongestants pseudoephedrine, ephedrine or
phenylpropanolamine.  Ordinarily, such drugs are absolutely contraindicated
in people taking MAO inhibitors.  Parnate (tranylcypromine) is a particularly
nasty drug in this respect.  It has a checkered history of hypertensive
crises, strokes and a few deaths from its careless combination with
proscribed foods and drugs.

[Side tidbit: tranylcypromine is the generic name for the chemical
trans-phenyl-cyclopropylamine.  This is the amphetamine molecule
compressed into an energetic cyclopropyl group, which accounts for
its MAOI activity.  The drug is sometimes said to have amphetamine-
like side effects and abuse potential, but more usually the sedative/
hypotensive effects of MAO inhibition predominate.]

There are some psychiatrists who are very very experienced with these
drugs who have tried using dextroamphetamine or Ritalin to counteract
hypotension.  There has even been reports of some doctors using small
amounts of cheddar cheese to produce a controlled tyramine reaction
to raise the blood pressure.  But _DON'T TRY THIS AT HOME_.  You have
the very great chance of damaging or even killing yourself.  Some
doctors have used small doses of thyroid hormone (T3, liothyronine)
to treat the hypotension.

>     Is my DDAVP idea sound?

First rule for any patient on MAOIs: don't even consider taking a
drug without talking to your doctor who prescribed the MAOI.

>     My Dad thinks that if I build up my dose slowly enough, my body will
>eventually learn to compensate for the hypotensive side effect, is this true?
>How long could that take - I'm not particularly patient at this point.

My understanding is that this side effect of orthostatic hypotension
is rather persistent.  Some people might develop a tolerance, but
most come to an accomodation with it.  It's not likely to disappear.

Put briefly, you have to discuss this with your psychiatrist, who
should be in a position to discuss your options.  If the doctor
giving you this drug isn't up on the therapeutic possibilities
for treating postural hypotension, you should definitely contact
someone who is more experienced with prescribing this class of
drugs and has dealt with this problem before (assuming, of course,
that the drugs are working OK for you.)

-- 
Steve Dyer
dyer@ursa-major.spdcc.com aka {ima,harvard,rayssd,linus,m2c}!spdcc!dyer