Food-Drug Interaction: Tyramine

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The food-drug interaction between monoamine oxidase inhibitors (MAOIs) and high tyramine containing foods is one of the most dangerous combinations. In today’s post, I will discuss where you can find tyramine and the most common MAOIs out there that interact. I will also discuss alternatives for foods containing tyramine.

What happens when you consume foods with tyramine while taking a MAOI medication? Foods high in tyramine, “the decarboxylated product of the amino acid tyrosine”1, can cause a hypertensive crisis when on MAOI therapy. A hypertensive crisis is also known as dangerously high blood pressure which can lead to stroke and even death. Blood pressure readings during a hypertensive crisis are higher than 180/110 mmHg.2 MAOI medications block the enzyme monoamine oxidase which is what helps naturally break down tyramine consumed. Even after stopping the medication, it is important to follow at low tyramine diet for 2-3 weeks as the medication can still be present in the bloodstream.

Most MAOI medications are used for severe depression when other medications fail (usually a last resort scenario). The following medications are considered MAOIs:

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

Selegiline (Emsam) is provided as a topical patch and may not require a low tyramine diet at lower doses (usually 6 mg).5 If you take this medication, it’s important to check with your doctor to see if you need to follow a low tyramine diet.3

Other medications requiring a low tyramine diet:

  • Linezolid (Zyvox) – an antibiotic
  • Pargyline hydrochloride (Eutonyl) – to treat moderate to severe hypertension
  • Procarbazine hydrochloride (Matulane) – used to treat advanced Hodgkin lymphoma

Foods which contain high tyramine and must be avoided include:

  • Aged and fermented cheeses (aged cheddar, swiss, parmesan, bleu cheese, gorgonzola, stilton)
  • Dried sausages (summer sausage, salami, pepperoni)
  • Smoked meats (bacon, corned beef, chorizo)
  • Fermented and pickled foods (pickles, sauerkraut, kimchee, caviar, tofu)
  • Some sauces (soy sauce, shrimp sauce, fish sauce, miso, teryaki)
  • Fermenterd soybeans and fermented soy bean products
  • Snow peas, fava beans and their pods
  • Overripe fruits (overripe bananas or avocados more commonly)
  • Meat tenderizers
  • Yeast extracts (Marmite, brewer’s yeast, sour dough bread)
  • Alcoholic beverages (tap and home brewed beer, more than 2-4 oz daily of red and white wine)
  • Caffeinated food and beverages (cola, coffee, tea)
  • Spoiled foods (sounds like a no-brainer but accidents happen!)
  • Other fermented or aged food products

Similar foods/alternatives which are allowed on a low tyramine diet:

  • Non-fermented cheeses (cream cheese, cottage cheese, american cheese, ricotta cheese)
  • Yogurt and milk
  • Eggs, nuts, legumes
  • Chicken, turkey, beef, pork, fish (not smoked)
  • Fresh, frozen, or canned vegetables
  • Fresh, canned, or frozen fruits
  • Decaf coffee and decaf tea
  • Caffeine-free soft drinks
  • Small amounts of chocolate

If you do accidentally consume high tyramine foods while taking an MAOI, DON’T PANIC! Monitor your blood pressure every hour for 24 hours after consuming the food item and seek medical attention if higher than normal for you. Normal blood pressure is 120/80 mmHg.Other side effects of consuming high tyramine include headache, heart palpitations, confusion, visual disturbances, nausea, or vomiting.If you experience any of these symptoms after consuming tyramine, seek medical attention immediately.

To avoid accidental consumption of spoiled foods, consume fresh produce and meats or make sure they are properly frozen. Avoid foods in which you do not know how they were stored.

Sources

1 Food Medication Interactions. 18th edition. Zaneta M. Pronsky, MS, RD, LDN, FADA; Dean Elbe, BSC (Pharm), BCPP, Pharm D; Keith Ayoob Ed D, RD, FADA. pp 395, 403.

The Facts About High Blood Pressure. https://www.heart.org/HEARTORG/Conditions/HighBloodPressure/GettheFactsAboutHighBloodPressure/The-Facts-About-High-Blood-Pressure_UCM_002050_Article.jsp

3 Monoamine oxidase Inhibitors (MAOIs). http://www.mayoclinic.org/diseases-conditions/depression/in-depth/maois/art-20043992

4 Low tyramine diet. UW Health. http://www.uwhealth.org/healthfacts/nutrition/154.pdf

EmSam. FDA Medication Guide. p 3. https://www.fda.gov/downloads/drugs/drugsafety/ucm088589.pdf