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58-year-old woman comes to the office because of depression. After talking extensively about her symptoms, she is started on a trial of medication. She is informed to watch her diet and to be careful about the medications she takes concomitantly because she may experience some serious side effects. A few weeks later, she develops a cold and an earache, and because she had to fly on a business trip she purchases something to ease the congestion. Once she arrives at the business meeting, she develops a severe headache and flushing. This was most likely caused by a reaction between the decongestant and which of the following medications?
A. Alprazolam
B. Bupropion
C. Mirtazapine
D. Phenelzine
E. Venlafaxine
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what is this pt experiencing
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seems to be serotonin syndrome.but as none of the drugs is an SSRI I marked phenelzine considering MAO reaction a remote possibility.
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The correct answer is D. MAO inhibitors such as phenelzine may have potentiated action when used with medications containing epinephrine, such as nose drops or local anesthetics. Hypertensive crisis, cardiac arrhythmias, and strokes can occur.
Alprazolam (choice A) is a benzodiazepine that has been tried in the past for treatment of depression and anxiety disorders. Given its high addiction potential and lack of efficacy in treatment of depression, it is not used in this case. It should not be used with the inhibitors of cytochrome P-450 3A3/4.
Bupropion (choice B) is not specifically contraindicated with over-the-counter sympathicomimetics. It is contraindicated with MAO inhibitors, L-dopa, and medications that lower seizure threshold.
Mirtazapine (choice C) is not specifically contraindicated with over-the-counter sympathicomimetics; however, it is contraindicated with MAO inhibitors and should be avoided with benzodiazepines and alcohol.
Venlafaxine (choice E) is contraindicated with MAO inhibitors, but not specifically contraindicated with over-the-counter sympathicomimetics. It may cause a slow rise in blood pressure in patients who are already hypertensive; however, a hypertensive crisis is unlikely in a patient without previous severe hypertension.
