MAOIs and diet: Is it necessary to restrict tyramine?

Tyramine (TIE-ruh-meen) is an amino acid that helps manage blood pressure. It's found naturally in the body. It's also found in certain foods. Medicines used to treat depression called monoamine oxidase inhibitors (MAOIs) can affect your tyramine levels.

MAOIs block an enzyme called monoamine oxidase that breaks down tyramine in the body. Blocking this enzyme helps ease symptoms of depression. But blocking this enzyme also means that your body can't get rid of tyramine.

For some people, taking an MAOI and eating high-tyramine foods can cause tyramine to quickly reach high levels in the body. This can cause a spike in blood pressure that may be serious and need emergency treatment.

If you're taking an MAOI, don't eat or drink foods and beverages that are high in tyramine. Generally, foods high in tyramine are those that are aged, fermented, overripe or spoiled. You'll likely need to stay on a low-tyramine diet until a few weeks after you stop the medicine.

Tyramine occurs naturally in small amounts in foods that have protein. As these foods age, the tyramine levels rise. Processing, storage and preparation methods can affect the amount of tyramine in foods. How much you eat of a food containing tyramine also affects how much tyramine you get. You can't lower the amount of tyramine in a food by cooking it.

Modern commercial food processes have lowered tyramine in many products that used to have higher levels. Also, different types of products and specific products vary widely in their estimated level of tyramine. Your healthcare professional can give you a list of foods and beverages to stay away from or eat only in limited amounts if you're taking an MAOI.

Examples of foods generally considered high in tyramine include:

• Artisan cheeses, which are made by hand, or aged cheeses. These include aged cheddar, Swiss and Parmesan; blue cheeses, such as Stilton and Gorgonzola; and cheese that's aged and preserved in brine, such as feta. It also includes soft and semisoft cheeses, such as Camembert and brie, and hard cheeses, such as Gruyere and Edam. Fresh cheeses made from pasteurized milk and commercially made cheeses are less likely to have high levels of tyramine. These include American cheese, cottage cheese, ricotta, fresh mozzarella and cream cheese.
• Cured meats, which are meats treated with salt and nitrate or nitrite, such as dry-type summer sausages, pepperoni and salami.
• Smoked or processed meats, such as bologna, bacon, corned beef, or smoked or cured fish.
• Pickled or fermented foods, such as sauerkraut, pickled fish, kimchi, caviar, tofu or pickles. Fermented beverages, such as kombucha and kefir, also may have higher levels of tyramine.
• Fermented sauces, such as soy sauce, shrimp sauce, fish sauce, miso, Worcestershire sauce and teriyaki sauce.
• Soybean products, such as soybean paste, especially if fermented.
• Snow peas and broad beans, also called fava beans, and their pods.
• Dried or overripe fruits, such as raisins, overripe bananas and their peels, and overripe avocados.
• Meat tenderizers or meat prepared with tenderizers.
• Yeast-extract spreads, such as Marmite, Vegemite and brewer's yeast. Commercially made sourdough bread may have lower levels of tyramine, but some artisan or homemade sourdough bread may have more.
• Alcoholic beverages, especially tap, spontaneously fermented, home-brewed or artisan beer, and home-brewed or artisan wine. Alcoholic beverages vary, but commercial wines and pasteurized bottled beers may be safe to drink in moderation. Sherry, liqueurs and some red wines may have more tyramine.
• Combination foods that include any ingredients that are high in tyramine.
• Foods that have not been properly stored or are spoiled. While you're taking an MAOI, your healthcare professional may suggest eating only fresh foods. Avoid leftovers or foods past their freshness dates.

Beverages with caffeine also may contain tyramine, so your healthcare professional may recommend limits.

MAOIs, although effective, generally have been replaced by newer antidepressants that are safer and cause fewer side effects. Still, an MAOI is a good option for some people. An MAOI may ease symptoms of depression when other treatments have failed.

Examples of MAOIs that are used for depression include:

• Isocarboxazid (Marplan).
• Phenelzine (Nardil).
• Selegiline (Emsam).
• Tranylcypromine (Parnate).

Selegiline (Emsam) in patch form delivers medicine through your skin. If you use the lowest dose of the patch, you may not need to stay away from foods with high tyramine levels. Talk with your healthcare professional to be sure.

Learn the emergency signs of a rapid and severe rise in blood pressure, called a hypertensive crisis. Symptoms may include:

• Severe headache.
• Upset stomach and throwing up.
• Neck stiffness.
• Sweating and a pale or grayish tint to the skin.
• Nosebleeds.
• Fast heartbeat.
• Chest pain.
• Changes in vision, such as being sensitive to light or having a larger than usual dark center of the eye, called the pupil.
• Shortness of breath.
• Confusion.

Contact your healthcare professional right away or go to the emergency department at a hospital if you have these symptoms. Rarely, a severe increase in blood pressure can lead to bleeding in the brain, called a stroke.

If you take an MAOI, be prepared. Ask your healthcare professional:

• For a list of foods to avoid. Make sure you know exactly what's safe for you and what isn't.
• What to do if you accidently eat or drink something with too much tyramine. Have a plan in place so you know what to do.

Your healthcare professional may ask you to keep a food diary and check your blood pressure at home during the first few weeks of taking an MAOI. This can help show how different foods affect you.

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