This handout is for maoi–tyramine hypertensive crisis ("cheese effect" — severe occipital headache + htn crisis + tachycardia + diaphoresis after maoi + tyramine-rich food or sympathomimetic exposure). Your care team identified this based on: irreversible maoi (phenelzine, tranylcypromine, isocarboxazid, selegiline transdermal high-dose) + tyramine-rich food (aged cheese, cured meats, fava beans, soy sauce, draft beer, fermented foods) or sympathomimetic medication (decongestant, ephedra, otc cold med) within 30 min – 2 h (wimbiscus cleve clin j med 2010 pmid 21048054; shulman j clin psychiatry 2003 pmid 14728101).
Other reasons your team may use this plan: severe occipital headache + sbp ≥180/dbp ≥120 + diaphoresis + tachycardia + photophobia within 30 min – 2 h of maoi + tyramine/sympathomimetic exposure — classic "cheese reaction"; patient on irreversible maoi receiving meperidine, ssri, snri, tramadol, or dextromethorphan — drug-drug interaction with potential for tyramine-like surge or serotonin syndrome overlap.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| phentolamine | 5 mg IV bolus q5-15 min titrate to SBP <160; typical total 5-20 mg cumulative; can give 1-5 mg increments for fine titration | IV | PRN bolus titrated | Wimbiscus Cleve Clin J Med 2010 PMID 21048054 + Fiedorowicz 2004 PMID 15330418 — phentolamine cornerstone for tyramine crisis (reverses NE surge); same drug used for pheochromocytoma crisis (analogous catecholamine-excess physiology) |
| nicardipine | 5 mg/h IV titrate q5 min by 2.5 mg/h to max 15 mg/h | IV | continuous | AHA 2025 HTN guideline + ACC 2017 — preferred IV agent if phentolamine unavailable; titratable + autoregulation-aware; safe in MAOI patients |
| labetalol | Use ONLY AFTER alpha-blockade established with phentolamine; 10-20 mg IV q10 min, max 300 mg | IV | PRN bolus | AHA 2025 HTN — mixed alpha-beta acceptable AFTER phentolamine controls alpha component (analogous to pheochromocytoma sequencing); tiny beta component initially raises unopposed alpha concern but practical use ok with simultaneous phentolamine |
| esmolol | Use ONLY AFTER alpha-blockade with phentolamine; 500 mcg/kg IV bolus then 50-200 mcg/kg/min infusion titrate | IV | continuous infusion | Short half-life beta-blocker for HR control AFTER alpha-blockade; same logic as pheochromocytoma |
| acetaminophen | 650-1000 mg PO/IV q6h | PO/IV | q6h PRN | Non-opioid headache control; first-line analgesic in MAOI patients (avoids meperidine + tramadol risks) |
| AVOID meperidine | AVOID | N/A | N/A | FDA boxed warning — meperidine + MAOI = severe hyperthermic + hypertensive + serotonergic reactions; absolute contraindication |
| AVOID β-blocker monotherapy | AVOID monotherapy | N/A | N/A | Unopposed alpha vasoconstriction (analogous to pheochromocytoma + cocaine teaching); β-blocker only AFTER phentolamine alpha-blockade established |
| AVOID sympathomimetics (pseudoephedrine, phenylephrine, ephedra, OTC cold meds) | AVOID | N/A | long-term while on MAOI | Sympathomimetics + MAOI = recurrent tyramine-like crises; lifetime avoidance + medication card education |
| AVOID SSRI/SNRI/tramadol/dextromethorphan during MAOI + 14-d washout | AVOID without 14-d washout | N/A | long-term | Serotonin syndrome risk; mandatory 14-d washout before/after irreversible MAOI; for fluoxetine require 5-wk washout (long half-life) |
| AVOID nitroprusside | AVOID prolonged use | N/A | N/A | Cyanide accumulation with prolonged infusion; nicardipine preferred |
Plan: MAOI–tyramine HTN crisis — phentolamine IV cornerstone (alpha-blocker) + nicardipine alternative; AVOID β-blocker monotherapy (unopposed alpha); AVOID meperidine (FDA boxed warning in MAOI); strict tyramine diet + sympathomimetic-medication-avoidance education
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
COMPREHENSIVE TYRAMINE-RESTRICTED DIET EDUCATION (handout + dietitian consult; high-tyramine foods to AVOID: aged cheeses, cured meats, fava beans, soy sauce, draft beer, sauerkraut, fermented soy, miso, tempeh, marmite/vegemite, tap beer; safe-in-moderation: pasteurized cheese, fresh meat, processed cheese); MEDICATION INTERACTION LIST education (AVOID sympathomimetics — pseudoephedrine, phenylephrine, ephedra, OTC cold meds, decongestants; AVOID meperidine — FDA boxed warning; AVOID SSRI/SNRI/tramadol/dextromethorphan during MAOI + 14-d washout); psychiatry consultation re: continuing MAOI vs alternative (consider switch to MAOI-B selective transdermal selegiline if low-dose tolerated, OR switch to other antidepressant class with appropriate washout); if MAOI required to continue, dietitian referral + medication card carried + family education + MedicAlert bracelet; outpatient PCP + psychiatry follow-up within 1-2 weeks
Guideline: Wimbiscus Cleve Clin J Med 2010 (PMID 21048054) — MAOI safety + tyramine reactions + drug interactions; 2025 ACC/AHA HTN (Whelton); FDA boxed warning meperidine + MAOI