In Collaboration With

THERAPEUTICS

Brands

• Aurorix
• Arima
• Manerix
• see index for additional brand names

Generic?

• No

Class

• Reversible inhibitor of monoamine oxidase A (MAO-A) (RIMA)

Commonly Prescribed For

• (bold for FDA approved)
• Depression
• Social anxiety disorder

How The Drug Works

• Reversibly blocks MAO-A from breaking down norepinephrine, dopamine, and serotonin
• This presumably boosts noradrenergic, serotonergic, and dopaminergic neurotransmission
• MAO-A inhibition predominates unless significant concentrations of monoamines build up (e.g., due to dietary tyramine), in which case MAO-A inhibition is theoretically reversed

How Long Until It Works

• Onset of therapeutic actions usually not immediate, but often delayed 2 to 4 weeks
• If it is not working within 6 to 8 weeks, it may require a dosage increase or it may not work at all
• May continue to work for many years to prevent relapse of symptoms

If It Works

• The goal of treatment is complete remission of current symptoms as well as prevention of future relapses
• Treatment most often reduces or even eliminates symptoms, but not a cure since symptoms can recur after medicine stopped
• Continue treatment until all symptoms are gone (remission)
• Once symptoms gone, continue treating for 1 year for the first episode of depression
• For second and subsequent episodes of depression, treatment may need to be indefinite
• Use in anxiety disorders may also need to be indefinite

If It Doesn’t Work

• Many patients only have a partial response where some symptoms are improved but others persist (especially insomnia, fatigue, and problems concentrating)
• Other patients may be nonresponders, sometimes called treatment-resistant or treatment-refractory
• Consider increasing dose, switching to another agent or adding an appropriate augmenting agent
• Consider psychotherapy
• Consider evaluation for another diagnosis or for a comorbid condition (e.g., medical illness, substance abuse, etc.)
• Some patients may experience apparent lack of consistent efficacy due to activation of latent or underlying bipolar disorder, and require antidepressant discontinuation and a switch to a mood stabilizer

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Augmentation of MAOIs has not been systematically studied, and this is something for the expert, to be done with caution and with careful monitoring, but may be somewhat less risky with moclobemide than with other MAO inhibitors
• A stimulant such as d-amphetamine or methylphenidate (with caution; may activate bipolar disorder and suicidal ideation)
• Lithium
• Mood stabilizing anticonvulsants
• Atypical antipsychotics (with special caution for those agents with monoamine reuptake blocking properties, such as ziprasidone and zotepine)

Tests

• Patients should be monitored for changes in blood pressure