eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Monoamine Oxidase Inhibitor: Follow-up

Author: Soumya Ganapathy, MD, Consulting Staff, Department of Emergency Medicine, Union Memorial Hospital
Coauthor(s): Frank A Maffei, MD, FAAP, Associate Professor of Pediatrics, Temple University School of Medicine; Director of Medical Student Affairs, Geisinger Health System; Pediatric Critical Care Attending Physician, Janet Weis Children's Hospital at Geisinger Medical Center
Contributor Information and Disclosures

Updated: Jan 23, 2008

Follow-up

Further Inpatient Care

  • Patients with monoamine oxidase inhibitor (MAOI) overdoses should be admitted to the hospital primarily because of the prolonged latent stage.
  • All patients with suspected MAOI ingestion require 24 hours of ICU care or frequent monitoring in an inpatient facility.

Inpatient & Outpatient Medications

  • Avoid indirect sympathomimetics and foods that contain tyramine.
  • Avoid drugs such as meperidine, dextromethorphan, and SSRIs (eg, fluoxetine, sertraline) because they can lead to a hyperserotonergic state.
  • Avoid ketamine.

Transfer

  • Any child with evidence of MAOI toxicity should be stabilized and transferred to a tertiary pediatric center.

Deterrence/Prevention

  • Keep medications and other ingestible substances locked or safely stored where children cannot reach them.

Complications

  • Pulmonary edema
  • Coma
  • Myocardial ischemia
  • Intracerebral hemorrhage
  • Rhabdomyolysis
  • Acute renal failure
  • Disseminated intravascular coagulation
  • Hemolysis
  • Subarachnoid hemorrhage
  • Serotonin syndrome

Prognosis

  • Mortality and morbidity are dependent on the time of presentation, the occurrence of co-ingestions, and the status of the patient upon his or her arrival in the emergency department.
  • Most patients recover without sequelae when given careful supportive care.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to properly manage the airway during decontamination is a pitfall.
  • Failure to monitor patients is a pitfall, even if they are initially asymptomatic. Signs of MAOI toxicity may be delayed as long as 24 hours after the ingestion.5
  • Failure to avoid the use of indirect sympathomimetics and serotonergic drugs is a pitfall.
 


More on Toxicity, Monoamine Oxidase Inhibitor

Overview: Toxicity, Monoamine Oxidase Inhibitor
Differential Diagnoses & Workup: Toxicity, Monoamine Oxidase Inhibitor
Treatment & Medication: Toxicity, Monoamine Oxidase Inhibitor
Follow-up: Toxicity, Monoamine Oxidase Inhibitor
References
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References

  1. Dawson JK, Earnshaw SM, Graham CS. Dangerous monoamine oxidase inhibitor interactions are still occurring in the 1990s. J Accid Emerg Med. Mar 1995;12(1):49-51. [Medline].

  2. Jarrott B, Vajda FJ. The current status of monoamine oxidase and its inhibitors. Med J Aust. Jun 15 1987;146(12):634-8. [Medline].

  3. Larsen JK. MAO inhibitors: pharmacodynamic aspects and clinical implications. Acta Psychiatr Scand Suppl. 1988;345:74-80. [Medline].

  4. Stewart JW, Thase ME. Treating DSM-IV depression with atypical features. J Clin Psychiatry. Apr 2007;68(4):e10. [Medline].

  5. Bosse GM, Matyunas NJ. Delayed toxidromes. J Emerg Med. Jul-Aug 1999;17(4):679-90. [Medline].

  6. Dilsaver SC. Monoamine oxidase inhibitor withdrawal phenomena: symptoms and pathophysiology. Acta Psychiatr Scand. Jul 1988;78(1):1-7. [Medline].

  7. Feinberg SS. Combining stimulants with monoamine oxidase inhibitors: a review of uses and one possible additional indication. J Clin Psychiatry. Nov 2004;65(11):1520-4. [Medline].

  8. Frazer A, Conway P. Pharmacologic mechanisms of action of antidepressants. Psychiatr Clin North Am. Sep 1984;7(3):575-86. [Medline].

  9. Gillman PK. Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. Br J Anaesth. Oct 2005;95(4):434-41. [Medline].

  10. Hyman Rapaport M. Translating the evidence on atypical depression into clinical practice. J Clin Psychiatry. 2007;68 Suppl 3:31-6. [Medline].

  11. Krishnan KR. Revisiting monoamine oxidase inhibitors. J Clin Psychiatry. 2007;68 Suppl 8:35-41. [Medline].

  12. Linden CH, Rumack BH, Strehlke C. Monoamine oxidase inhibitor overdose. Ann Emerg Med. Dec 1984;13(12):1137-44. [Medline].

  13. Lucena MI, Carvajal A, Andrade RJ, Velasco A. Antidepressant-induced hepatotoxicity. Expert Opin Drug Saf. May 2003;2(3):249-62. [Medline].

  14. Sarko J. Antidepressants, old and new. A review of their adverse effects and toxicity in overdose. Emerg Med Clin North Am. Nov 2000;18(4):637-54. [Medline].

  15. Siberry GK, Iannone R, eds. The Harriet Lane Handbook. In: A Manual for Pediatric House Officers. 15th ed. Mosby-Year Book: 2000.

  16. Siderowf A, Kurlan R. Monoamine oxidase and catechol-O-methyltransferase inhibitors. Med Clin North Am. Mar 1999;83(2):445-67. [Medline].

  17. Tollefson GD. Monoamine oxidase inhibitors: a review. J Clin Psychiatry. Aug 1983;44(8):280-8. [Medline].

  18. Wax P, Hoffman J, Keyes CD. Neuroleptics, lithium, and monoamine oxidase inhibitors. In: Rosen P, Barkin R, eds. Emergency Medicine. 3rd ed. 1992:2624-2628.

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Further Reading

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Keywords

monoamine oxidase inhibitor, antidepressant overdose, antidepressant poisoning, antidepressant overdoses, antidepressant poisonings, antidepressant-induced hepatotoxicity, childhood ingestions, MAO antidepressant, MAO antidepressant overdose, MAO antidepressant toxicity, MAO antidepressant poisoning, MAOI, MAOIs, MAOI overdose, MAOI toxicity, MAOI poisoning, monoamine oxidase A, MAO-A, monoamine oxidase B, MAO-B, phenelzine, tranylcypromine, isocarboxazid, Parkinson disease, methicillin-resistant Staphylococcus aureus, hypertension, tachycardia, hyperpexia, mydriasis, diaphoresis, rhabdomyolysis, renal failure, pulmonary edema, myocardial infarction, disseminated intravascular coagulopathy, serotonin syndrome

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Contributor Information and Disclosures

Author

Soumya Ganapathy, MD, Consulting Staff, Department of Emergency Medicine, Union Memorial Hospital
Soumya Ganapathy, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Frank A Maffei, MD, FAAP, Associate Professor of Pediatrics, Temple University School of Medicine; Director of Medical Student Affairs, Geisinger Health System; Pediatric Critical Care Attending Physician, Janet Weis Children's Hospital at Geisinger Medical Center
Frank A Maffei, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Michael E Mullins, MD, Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine
Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Clinical Assistant Professor of Pediatrics, University of North Dakota, School of Medicine and Health Sciences; Consulting Staff, Altru Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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