A 79-year-old female with severe cardiosclerosis is also suffering from anxiety and depressive symp

Fråga: A 79-year-old female with severe cardiosclerosis is also suffering from anxiety and depressive symptoms. She has been treated with moclobemide (Aurorix 750 mg x2) with insufficient effect. She is currently being treated with digoxin, salicylic acid, isosorbid, captopril, furosemide, diltiazem, alprazolam and oestriolum. The questioner wants to change the medication from moclobemide to citalopram. Is there any recommendation in the literature for a drug-free period before changing the treatment from moclobemide to citalopram?

Sammanfattning: We have not found any documentation recommending a wash-out period when treatment with reversible monoamine oxidase A inhibitors is stopped to avoid interaction with selective serotonin reuptake inhibitors. However, in this case we suggest waiting a day before starting with citalopram, which should be enough as the half-life of moclobemide is one to three hours (3).

Svar: No documentation has been found in the literature concerning the question about a drug-free period when changing therapy from the reversible monoamine oxidase A inhibitor moclobemide to citalopram, a highly selective serotonin reuptake inhibitor. However, it is well documented that an enhanced serotonergic effect may result from receiving combination therapy of selective serotonin reuptake inhibitors and irreversible monoamine oxidase inhibitors concurrently or within a short interval of each other. The result can be a potentially lethal, toxic hyperserotonergic state called the serotonin syndrome. There is a case report in the British Medical Journal (1) where the serotonin syndrome developed when the serotonin reuptake inhibitor clomipramine was changed to moclobemide. A 76-year-old woman with depression and Parkinson´s disease developed impaired general condition and mental status, fever, increased muscle stiffness, widespread myoclonus and intermittent convulsive attacks the day after her treatment with clomipramine had been changed to moclobemide. These symptoms fulfilled the diagnostic criteria described as the serotonin syndrome suggested by Sternbach (2). Clomipramine has a half-life varying between 22 and 84 hours, indicating that slow metabolisers could retain pharmacologically active amounts of the drug for one to two weeks after withdrawal of the drug. The authors recommend that serotonin reuptake inhibitors should be discontinued for some time (depending on the half-life of the drug and its metabolites) before treatment with moclobemide is started.