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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by cubbybear on August 15, 2003, at 4:07:03
I take Parnate regularly and know that when I need a dental injectioin, I have to tell the dentist to give me a shot without epinephrine. It's really no big deal (except that the analgesic quality of the injection doesn't seem to be as strong or last as long as the shot with epinephrine.) I don't know anything about anaesthesia (localized or major) for surgeries, colonoscopies, etc. but I would imagine that they'd be contraindicated with Parnate.The patient insert states that you have to discontinue the drug two weeks (?) before elective surgery. But what about emergencies? Are there any anesthetics out there that are safe to be administered while you're taking Parnate?
Posted by Ame Sans Vie on August 15, 2003, at 11:29:24
In reply to Parnate and Anaesthesia, posted by cubbybear on August 15, 2003, at 4:07:03
From what I understand, there *are* some *relatively* safe methods of inducing general anesthesia in a patient on MAOIs, but only, like you said, in an emergency. Phencyclidine (PCP) and ketamine can be used, along with other anesthetics, though the whole waking up tripping thing is pretty much a turn-off when considering these options.
Most commonly employed is a combination of an opioid anesthetic (i.e. Alfenta, Sufenta, Ultiva) with a barbiturate (i.e. thiopental, methohexital) or Versed, along with oxygen, nitrous oxide, and monitored anesthesia care. Even this is risky though, as opioids are very much cautioned against while on MAOI therapy. The key for the anesthetist is to start low and go slow.
Posted by cubbybear on August 16, 2003, at 7:12:41
In reply to Re: Parnate and Anaesthesia, posted by Ame Sans Vie on August 15, 2003, at 11:29:24
Thanks very much for the interesting info. I've seen your name a lot on this board and you seem like "the" expert on everything!
Posted by Caleb462 on August 16, 2003, at 13:58:12
In reply to Re: Parnate and Anaesthesia, posted by Ame Sans Vie on August 15, 2003, at 11:29:24
> From what I understand, there *are* some *relatively* safe methods of inducing general anesthesia in a patient on MAOIs, but only, like you said, in an emergency. Phencyclidine (PCP) and ketamine can be used, along with other anesthetics, though the whole waking up tripping thing is pretty much a turn-off when considering these options.
>
> Most commonly employed is a combination of an opioid anesthetic (i.e. Alfenta, Sufenta, Ultiva) with a barbiturate (i.e. thiopental, methohexital) or Versed, along with oxygen, nitrous oxide, and monitored anesthesia care. Even this is risky though, as opioids are very much cautioned against while on MAOI therapy. The key for the anesthetist is to start low and go slow.Why *is* anesthesia + MAOI risky? I don't understand the mechanisms behind this - care to enlighten me?
Also - you say opiods are cautioned against while on MAOI therapy, but it was my understanding that only those which also block monoanime reuptake (Demerol, Ultram, etc) need to be avoided. For instance, I see no reason why MAOI + hydrocodone would be a problem.
Posted by Ame Sans Vie on August 16, 2003, at 14:54:50
In reply to Re: Parnate and Anaesthesia » Ame Sans Vie, posted by cubbybear on August 16, 2003, at 7:12:41
You're welcome, and thanks for the compliment. :-) Actually, there are plenty of people on here who know more than I do about all this -- it's just that I'm currently unemployed and visit Babble about a dozen times a day, so I tend to post way too often, lol.
Posted by Ame Sans Vie on August 16, 2003, at 15:36:15
In reply to Re: Parnate and Anaesthesia, posted by Caleb462 on August 16, 2003, at 13:58:12
> Why *is* anesthesia + MAOI risky? I don't understand the mechanisms behind this - care to enlighten me?
That's a good question... I believe that it may be due to the danger of life-threatening hypotension. I'll see if I can find some more info for you.
> Also - you say opiods are cautioned against while on MAOI therapy, but it was my understanding that only those which also block monoanime reuptake (Demerol, Ultram, etc) need to be avoided. For instance, I see no reason why MAOI + hydrocodone would be a problem.
Once again, good question. Demerol should definitely be avoided while on MAO inhibitors, but sources seem to vary in their opinions on the use of other narcotics concomitantly with MAOIs. Here are a few examples of what these sources say with regard to specific narcotics together with MAO inhibitors:
"Mosby's Drug Guide for Nurses":
alfentanil -- do not use [MAOIs] within 2 wk of alfentanil
buprenorphine -- do not use [MAOIs] 2 wk before buprenorphine
butorphanol -- do not use [MAOIs] 2 wk before butorphanol
codeine -- use with caution
fentanyl -- do not use [MAOIs] 2 wk before fentanyl
hydrocodone -- do not use [MAOIs] for 2 wk before taking hydrocodone
hydromorphone -- serious reactions; dosage should be reduced
levorphanol -- increases respiratory depression
meperidine -- do not use [MAOIs] for 2 wk before taking meperidine
methadone -- do not use [MAOIs] for 2 wk before taking methadone
morphine -- reduce dosage; unpredictable reaction may occur
oxycodone -- do not use [MAOIs] for 2 wk before oxycodone
oxymorphone -- do not use [MAOIs] for 2 wk before oxymorphone
pentazocine -- use cautiously; results are unpredictable
propoxyphene -- use decreased dosage; reaction is unpredictable
remifentanil -- (no interactions listed for MAOIs)
sufentanil -- do not use [MAOIs] 2 wk before sufentanil
tramadol -- inhibition of serotonin and norepinephrine reuptake; use together with cautionhttp://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202054.html
Medline only warns against the use of meperidine with MAOIs; it never even makes mention of the others.
http://www.nursespdr.com/members/database/ndrhtml/phenelzinesulfate.html
Just says that all narcotics should be used with caution while on MAOI therapy. It also lists general anesthetics as causing an increased hypotensive effect, so I suppose I was correct in my earlier assumption.
http://www.sma.org/smj/97aug14.htm
"ADVERSE INTERACTIONS between the monoamine oxidase inhibitors (MAOIs) and anesthetic drugs are well recognized. Although controversial, the most current recommendation pertaining to patients who, while taking MAOIs, require surgery and anesthesia suggests that the MAOI can be continued perioperatively as long as meperidine is avoided."
So it's pretty obvious that there's no real consensus yet as to which narcotics are "okay" while on MAOIs. Though it seems to me that "Mosby's Drug Guide for Nurses" may be a little overly conservative, as I've personally spoken with an anesthetist about this very issue, and he says he's never had any problems inducing anesthesia on MAOI patients with morphine, fentanyl, alfentanil, or sufentanil; and though the book says not to use hydrocodone or propoxyphene during MAOI therapy, I used them with no problems while on very high-dose Nardil. I imagine this means I also could have used oxycodone, codeine, and probably methadone (since it's related to propoxyphene) with no problems.
I guess the important thing is to avoid meperidine at all costs, and to just take it slow with any other narcotic.
Posted by cubbybear on August 17, 2003, at 2:28:33
In reply to Re: Parnate and Anaesthesia » Ame Sans Vie, posted by Ame Sans Vie on August 16, 2003, at 14:54:50
> You're welcome, and thanks for the compliment. :-) Actually, there are plenty of people on here who know more than I do about all this -- it's just that I'm currently unemployed and visit Babble about a dozen times a day, so I tend to post way too often, lol.
Uh-oh, I wonder if there's a 12-step program for anyone whose addicted to Psychobabble.
This is the end of the thread.
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