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MAOI to other antidepressants: switching in adults

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Topics: IsocarboxazidMental health and illnessPhenelzine · SwitchingTranylcypromine ·

Switching between or from a monoamine oxidase inhibitor (MAOI) is a complex switch and requires support from a specialist. General principles are described.

Contents
  1. Advice for all antidepressants
  2. Specific advice when switching from MAOIs
    1. Agomelatine
    2. Mirtazapine
    3. Moclobemide
    4. Another MAOI
    5. Selective serotonin reuptake inhibitors (SSRIs)
    6. Serotonin and noradrenaline reuptake inhibitors (SNRIs)
    7. Trazodone
    8. Tricyclic antidepressants (TCAs)
    9. Vortioxetine
  3. More advice on individual switches
  4. Update history

Advice for all antidepressants

You should read our advice for all antidepressant switching for the treatment of depression before applying that to individual MAOI switches below.

Specific advice when switching from MAOIs

Strategies for switching from MAOIs to other antidepressants are outlined below.

Agomelatine

Cross-taper with specialist advice

Cross-tapering can usually be undertaken cautiously over 2 to 4 weeks, the speed is determined by individual tolerability. The specialist will advise on how to cross-taper on a case-by-case basis taking into consideration the MAOI being switched from.

There is limited experience with this switch so extra caution is required. Although interactions are not expected, agomelatine is not expected to mitigate discontinuation reactions from stopping MAOI.

Mirtazapine

Taper, washout and switch with specialist advice

Gradually reduce the dose of the MAOI and stop; wait 14 days before starting mirtazapine. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being switched from.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

Moclobemide

Taper, washout and switch with specialist advice

Gradually reduce the dose of the MAOI and then stop; wait 14 days before starting moclobemide. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being switched from.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

Another MAOI

Taper, washout and switch with specialist advice

Gradually reduce the dose of the MAOI and stop; wait 14 days before starting the new MAOI. If switching to tranylcypromine, you should consider starting it at half the usual dose for the first week of treatment. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being switched from and the MAOI being started.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

Selective serotonin reuptake inhibitors (SSRIs)

Taper, washout and switch with specialist advice

Gradually reduce the dose of the MAOI and stop; wait 14 days before starting the SSRI. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being switched from and the antidepressant being started.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

Serotonin and noradrenaline reuptake inhibitors (SNRIs)

Taper, washout and switch with specialist advice

Gradually reduce the dose of the MAOI and stop; wait 14 days before starting the SNRI. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being switched from and the antidepressant being started.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

Trazodone

Taper, washout and switch with specialist advice

Gradually reduce the dose of the MAOI and stop; wait 14 days before starting trazodone. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being switched from.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

Tricyclic antidepressants (TCAs)

Switching to dosulepin requires specialist advice and should not be done in primary care due to the increased cardiac risk and toxicity in overdose.

Taper, washout and switch with specialist advice

For any MAOI, you should gradually reduce the dose and stop. You will then need to wait for a period, dependent on the antidepressant being switched to (see below), before starting low dose TCA. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being stopped.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

To all except clomipramine or imipramine

After stopping the MAOI, wait 14 days before starting low dose TCA.

To clomipramine or imipramine

After stopping the MAOI, wait 21 days before starting low dose clomipramine or imipramine.

Vortioxetine

Taper, washout and switch with specialist advice

Gradually reduce the dose of the MAOI and stop; wait 14 days before starting vortioxetine. The specialist will advise on the duration of the washout period on a case-by-case basis taking into consideration the MAOI being switched from.

Cross-tapering is not recommended due to the high risk of serotonin syndrome.

There is limited experience with this switch so extra caution is required to avoid serotonin syndrome.

More advice on individual switches

We have further advice on how to switch between individual antidepressants of different types. Browse our collection below.

Update history

  1. Headings adjusted and bibliography removed.
  1. Published