Selegiline ($ EMSAM)

MAOI antidepressant (dopamine, norepinephrine, serotonin enzyme inhibitor (MAO-B and -A)

Dosing

6-12 mg/day as patch. Tell patient to rotate the patch on shoulders, thighs according to picture in med box (this reduces skin irritation, also can use Rx hydrocortisone cream for that). Response is dose-dependent, most patients go to 12mg/d. Oral selegiline 30 mg/d = 9 mg/day EMSAM.

Management

MAOIs have greater risk of mania than other antidepressants. Preferred for atypical depression, and also have high effect size in social phobia.

Selegiline does not work in treatment resistant depression as well as oral MAOIs. At doses above 6 mg/d, has same food interactions as oral MAOIs. Has same drug interactions at all doses. That means the oral versions a better choice (since most patients need > 6 mg anyway). If switching from one MAOI to another, need to wait a week for the previous MAOI to wash out.

TOLERABILITY: Mild activation feelings, skin irritation.

RISKS: Serotonin syndrome with drug interactions. Hypertensive crisis with food interactions. Hypotension.

Must stop antidepressants (including other MAOIs) for 1-2 weeks before starting MAOI (except fluoxetine is 4-6 week wait, vortioxetine 2-3 weeks).

May be able to combine MAOIs with non-serotonergic antidepressants: some tricyclics (desipramine, trimipramine, and doxepin), bupropion, mirtazapine, trazodone, and pramipexole.

EMR Text