[kkrrhh]

I saw my pdoc today and, understandably, he doesn't want to start me on a new med for a few weeks since I just quit Marplan literally yesterday. I've read before that one good thing about inpatient is that docs will often be able to move things along more quickly with meds, since you're under close watch. Does this mean even shortening washout periods and starting a totally new med more quickly, or is that something that's too risky and off limits even in a hospital? I've been considering inpatient for months now, especially lately, but I kind of feel like I don't want to go if it'll end up wasting a lot of time. Meds wouldn't be the only reason I'd be going, but still, if I sat around the hospital for a week or more before even starting any new meds I'd feel like that time was a waste. If it's likely that they'd be able to speed things up and start me on something new sooner, I guess that'd be all the more reason to push myself and go now. But if I definitely have to wait the full washout period, I figure I could just try to wait around another week or 2 before going, so at least that's less time spent in the hospital.

Does anyone know much about how this works?

[*Laurie*]

I've been inpatient twice and in my experience, being in the hospital definitely expedited the medication stuff. In fact, the second time I was inpatient I asked to be put in specifically to change my meds more quickly.

Good luck!

[CobolCapsule]

If you plan on being an inpatient, i would no want to wait personally. Getting in and getting my meds straight would be a high priority.

Good luck

[Nammu]

Sunday is a good day to go in as it takes forever to do paperwork but starting Monday am you'd probably see your inpatient dr and start meds that day because that's what they do in hospitals.

[shadow2000]

Hi,

My opinion is that it's unlikely that any competent doctor would prescribe you a medication that interacts with Marplan (especially anything that inhibits the reuptake of serotonin) until the recommended washout period with respect to Marplan has come to an end. I could be wrong, but based on what I've read, most doctors seem to think that prescribing a medication that inhibits the reuptake of serotonin within the first two weeks of having discontinued an irreversible monoamine oxidase inhibitor (and Marplan/isocarboxazid is thought to inhibit the MAO enzymes irreversibly) poses too much of a risk of causing serotonin syndrome to actually go ahead and prescribe a medication that inhibits the reuptake of serotonin during this time period. So I'm just guessing here, but I tend to think that if you were to go inpatient and get prescribed a medication that might help with depression, the medication that the doctor would prescribe would probably be something that isn't known to interact with MAOIs, such as maybe a mood stabilizer or antipsychotic with antidepressant properties. I obviously can't say with 100-percent certainty what any doctors who would see you on an inpatient basis might do, but I think it's very likely that most doctors would see prescribing you a medication that interacts with Marplan before your washout period has ended as being too risky, given the fact that Marplan/isocarboxazid is thought to inhibit the MAO enzymes irreversibly.

[TicTacGo]

Yes, some medications need to be specifically monitored and some medications no longer used have to be completely out of the system before starting another, but I wouldn't worry about that too much as the doctor would know exactly what to do.

With inpatient is that these things can definitely happen faster, and any bad reactions can be monitored by a psych nurse and handled accordingly.
From what I understand, the nurses are also able to adjust things according to your needs and doctors usually do rounds everyday, which allows you to see them quite often in comparison to the outpatient system.

[BeyondtheRainbow]

I went on Emsam IP and went from a very low (20 mg) dose of imipramine to a day off ADs to starting Emsam. I was supposed to be off the imipramine completely when I went IP with the plan to be off it one day, admit next, start 3rd but I was too depressed to stay out and taper any further. They were very careful with my BP and I did fine.

I was going to go from Emsam to Nardil a year ago (and couldn't because of insurance) and that would have been IP as well and without a long washout period (I think a day or two between if I remember right).

So it can be done but I'm sure depends a great deal on the hospital's practices and the doctor in charge etc.

[shadow2000]

Just to clarify, the main reason why it's advised against prescribing patients medications that interact with irreversible MAOIs (especially the three irreversible MAOIs that are nonselective at any therapeutic dose: Nardil, Parnate, and Marplan) until at least two weeks have passed since they stopped taking the irreversible MAOI that they were taking is because Marplan, Nardil, and Parnate (also also selegiline, which is selective in its inhibition of monoamine oxidase B at lower doses) inhibit the monoamine oxidase enzymes irreversibly. Or in other words, the medications basically remain permanently (or perhaps semi-permanently, in the case of Parnate) bound to the MAO enzymes that they inhibit, and it isn't until the body replenishes its supply of the MAO enzymes (which is thought to take a few weeks, at least most typically) that the amount of uninhibited MAO in the brain and elsewhere in the body returns to the level that it was at before the MAOI was taken. So, there's more going on here than just getting the medications out of the system. The half-life of isocarboxazid (the generic name for Marplan) doesn't seem to be known, but the half-life of phenelzine (the generic name for Nardil, another irreversible nonselective MAOI) after a single 30-mg dose is just 11.6 hours (Parke-Davis Division of Pfizer Inc, 2009). So, if the only concern with Nardil/phenelzine was making sure that the medication cleared the system before a medication that interacts with MAOIs could be safely taken, there would be no need for the washout period of two weeks or longer. But there is a need for the washout because cases of serotonin syndrome in the transition from phenelzine (Nardil) to venlafaxine (Effexor) have been reported in patients who waited 14 days or even longer in some cases between stopping phenelzine and starting venlafaxine. Because of these reports, Yates et al. (2011) have argued that the recommended two-week washout period between stopping an irreversible MAOI and starting a medication that inhibits the reuptake of serotonin "may be insufficient." And consistent with what I've said, Yates et al. (2011) wrote that "the washout period between discontinuing an irreversible MAOI, such as phenelzine, and starting venlafaxine, or any SNRI, SSRI or TCA, is to allow for biosynthesis of MAO to replace enzyme which has been irreversibly inactivated."

So, I'm not making the argument that absolutely no medications can be taken in the two-week period following the discontinuation of Marplan/isocarboxazid or any of the other irreversible MAOIs. But I am saying that the recommended washout period -- especially as it pertains to transitioning from Marplan, Nardil, or Parnate to any medication that inhibits the reuptake of serotonin -- is there for a good reason. If the case reports that Yates et al. (2011) discussed are to be believed, serotonin syndrome can result from starting a medication that inhibits the reuptake of serotonin even more than two weeks following the discontinuation of an irreversible nonselective MAOI -- and most certainly before the recommended two-week period has come to an end. And again, this is thought to be because the irreversible inhibition of MAO-A by Marplan, Nardil, and Parnate continues to interfere with the breakdown of serotonin until enough MAO-A is replenished to make up for the MAO-A that was lost to irreversible inhibition. Some medication transitions involving MAOIs are likely to be riskier than others, but as far as transitioning from Marplan, Nardil, or Parnate to a medication that inhibits the reuptake of serotonin is concerned, I think that the evidence from the case studies that Yates et al. (2011) discussed would support the idea that starting a medication that inhibits the reuptake of serotonin within two weeks of having discontinued an irreversible nonselective MAOI isn't safe.

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REFERENCES

Parke-Davis Division of Pfizer Inc. (2009). Nardil (R) (Phenelzine sulfate tablets, USP), labeling information. Retrieved February 19, 2017, from Pfizer.com, https://www.pfizer.com/files/products/uspi_nardil.pdf

Yates, S.J., Ahuja, N., Gartside, S.E., & McAllister-Williams, R.H. (2011). Serotonin syndrome following introduction of venlafaxine following withdrawal of phenelzine: Implications for drug washout periods. Therapeutic Advances in Psychopharmacology, 1, 125-127. Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736920/

[kkrrhh]

Thank you all! So, sounds like it's possible but will probably depend a lot on the doc. I've still been feeling like I should go, but just can't push myself to do it. Maybe, if things don't change this week, I can try to push myself to commit to Sunday then if that's a good day to go in. We'll see...
Thank you, Shadow2000, for the detailed replies. That makes sense, I hadn't even thought about the fact that washout is even more necessary after MAOIs for those reasons.
I'd considered going on Nardil again, and would almost tell my pdoc I want to do that just to start on something sooner, but I'd probably regret not trying everything I could to avoid going back on Nardil.
(edit: Wait, I thought I'd read before that an MAOI to MAOI switch could be done without washout, and my pdoc had me do that a couple times before, now google's telling me otherwise... Woops, might explain why it went so roughly before.)

[BeyondtheRainbow]

Be careful with thinking Sunday is a good day to go in. I did that once and spent 30 hours in the psych ER because there were no beds for psych in the whole city. It may be different elsewhere but I'll never go in on a Sunday again. 30 hours is a long wait and since people are usually only there a few hour they serve the same freezing cold hamburger for lunch and supper and lunch the next day. I didn't eat hamburgers for a good 6 months after that. It's also just not set up to be "home" for so long and so it's loud and chaotic. There are worse things but that was not my favorite IP experience (yet not their fault; they would even have sent me to another city if a bed were open; I just hit a very bad weekend.) But I was told that this happens on Sundays sometimes and so from now I'll be going on Friday (when most people get discharged, even though it means a long 2 days waiting for treatment) or Monday if I have to go in through the ER.

[shadow2000]

Originally Posted by kkrrhh

Thank you all! So, sounds like it's possible but will probably depend a lot on the doc. I've still been feeling like I should go, but just can't push myself to do it. Maybe, if things don't change this week, I can try to push myself to commit to Sunday then if that's a good day to go in. We'll see...
Thank you, Shadow2000, for the detailed replies. That makes sense, I hadn't even thought about the fact that washout is even more necessary after MAOIs for those reasons.
I'd considered going on Nardil again, and would almost tell my pdoc I want to do that just to start on something sooner, but I'd probably regret not trying everything I could to avoid going back on Nardil.
(edit: Wait, I thought I'd read before that an MAOI to MAOI switch could be done without washout, and my pdoc had me do that a couple times before, now google's telling me otherwise... Woops, might explain why it went so roughly before.)

I just wanted to respond to wish you luck with going inpatient if you decide to do that before you go in to see your psychiatrist again. There are definitely medications with antidepressant properties that you can safely take within two weeks of having discontinued Marplan, and since I've already made it very clear that I don't think that medications that inhibit the reuptake of serotonin are among those medications, I won't say any more about that here. From what I've read about switching from one MAOI to another, a washout does seem to be recommended when doing this, even though Fiedorowicz & Swartz (2004) cited reports of patients having been safely transitioned from one MAOI to another with a gap of eight days or less. It might not make the most sense for you to switch from one MAOI to another without waiting a full two weeks, considering that having done that in the past sounded like it didn't go well for you, but at the same time, doing this doesn't sound like it would involve the same level of risk as switching from an MAOI to something with SRI properties without waiting at least two weeks before starting the medication that inhibits the reuptake of serotonin. So, maybe some doctors might be willing to have you start taking another MAOI before the end of the two-week washout period, assuming that they'd monitor you closely, if it's decided that another MAOI will end up being the next medication that you'll take.

At any rate, I wish you luck with getting your medication situation sorted out and with going inpatient, if you end up doing that.

=====

REFERENCE

Fiedorowicz, J.G., & Swartz, K.L. (2004). The role of monoamine oxidase inhibitors in current psychiatric practice. Journal of Psychiatric Practice, 10, 239-248. Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2075358/