Advising patients about a low tyramine diet
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My recent paper published in the Journal of Neural Transmission (1) is the only paper in the literature, in the last 30 years, that thoroughly reviews the current best evidence concerning tyramine levels in a wide variety of foods. All the other papers published are a reworking of out-of-date material from the 1980s. This is important, because the existing literature is not only unfounded in scientific fact and outdated, but also relies on single case reports of an unreliable nature to extrapolate into general advice. That practice is unreliable and unscientific: it leads to a ragbag of chaotic warnings, few of which have been replicated even once in 50 years, but which produce confusion and uncertainty for doctors and patients.
For some time, I have offered information sheets that patients and doctors can download from my website, concerning tyramine in food, and drug interactions involving MAOIs: these can be found in this section.
I had ‘discussions’ with the editors and referees of my recent paper concerning my presentation of the tyramine data: they wanted me to make a ‘simple table’, even though I told them at the beginning that in my opinion that was not useful or possible (and, after a great deal of wasted time and effort, they came round to my view). I wished that I had never accepted the invitation to contribute a paper for them. Insofar as a table might be possible, it would not be simple; and insofar as it was simple, it would not be useful.
That reminds me of the riposte to a question at the end of a lecture ‘Dr, what is the take-home message’: to which the answer was, ‘pay attention next time you come to a lecture’.
Science is not the practice of ‘sound-bites’.
The practical and logical nature of my position was reinforced to me recently when an enquiry included the caveat that the medico-legal risk-perception is different in different countries and different areas. In addition, individual doctors and individual patients have different perceptions and choices of what constitutes an appropriate risk, in their particular experience and circumstances, and depending on illness severity and other factors. Such individual informed choices by doctors and patients must be respected, and no guidelines, lists, or other authority, should be allowed to interfere with that choice. The above encapsulates my main objections to guidelines in general, which seem to me to do more harm than good, partly because of the authoritarian and dictatorial tone in which they are written, and partly because of the way they are interpreted. Almost all patients who contact me via the website complain that doctors will not contemplate giving treatments that are not ‘in the guidelines’ — it is turning medicine into the equivalent of a fascist state. Too often it seems to be forgotten that evidence-based medicine (EBM) should adhere to certain basic tenets which require, “integrating … the best available external clinical evidence from systematic research…[with] the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice… [without which] even excellent external evidence may be inapplicable to or inappropriate for an individual patient.” (2).
The role of the specialist physician is to advise and educate individual patients according to their circumstances and dietary habits. This can only be done if specialists are in possession of accurate information about how tyramine is produced in food, and which foods are likely to have significant levels, combined with an understanding of what the possible risks of an episode of elevated blood pressure might be. This information is in my published papers and is summarised on this website.
The interpretation of scientific information such as this, and its explanation to patients so that they can participate in the decision about the treatment, is a significant part of the raison d’être of all specialist physicians. That is why we are called experts, and that is what we are paid for. Otherwise, all of you can be replaced with a computer algorithm.
Furthermore, the magnitude of the risk of adverse outcomes, if significant amounts of tyramine are ingested, is also something that has been reassessed I have written extensively about this in the light of various more recent evidence, and best practice. In essence, the levels of tyramine in all foods are now much lower than they used to be, and the risk of acute ‘hypertensive urgency’, or the more severe ‘hypertensive emergency’ (the term ‘hypertensive crisis’ is now less used) is lower than previously estimated [add link].
I therefore advise that individual physicians using MAOIs will be much more comfortable doing so if they update themselves with the latest evidence and use their individual interpretation of that to modify the general advice I issue on my website, in order to make it suitable for their particular patients and their circumstances.
There are two main sources of detailed tyramine information: first, the Journal of Neural Transmission paper and supplement; second, the hundred-page monograph available as a PDF from the menu, ‘MAOI Diet Drug Interactions 2017 PDF’. It is entitled ‘Monoamine oxidase inhibitors: A review concerning dietary tyramine and drug inter-actions’. That contains much more detail about drug interactions and discussion of things like changing directly from one MAOI to another.
If you utilise that material in your professional work, your conscience may impel you to make a donation to help the work of my PsychoTropical website, from which you are directly benefiting.
- Gillman, PK, A reassesment of the safety profile of monoamine oxidase inhibitors: elucidating tired old tyramine myths. J Neural Transm (Vienna), 2018. 125(11): p. 1707-1717.
- Sackett, DL, Rosenberg, WM, Gray, JA, Haynes, RB, et al., Evidence based medicine: what it is and what it isn’t. BMJ, 1996. 312(7023): p. 71-2.