By Danita Acquafredda and George Hunter
This Diet Summary is comprised of various references in an attempt to
provide knowledge regarding food restrictions and possible adverse
reactions. It may be beneficial to know that the references have not agreed
on all restricted tyramine foods; thus, it is not the purpose of this writer
to contradict or formulate any opinions or conclusions; but rather to
provide the information as written by the various references including the
various contradictions. All persons who are receiving an MAO inhibitor,
such as Procarbazine, should be given a diet by their physician, or
dietitian, of which to follow.
Procarbazine is an monoamine oxidase inhibitor (MAOI). Well known drug and
food interactions involve drugs that inhibit monoamine oxidase, such as
Procarbazine. Monoamine oxidase is in the gastrointestinal tract and
inactivates tyramine, an amino acid, which is found various foods.
Procarbazine, a MAO inhibitor, interfers with the inactivation of tyramine
found in various foods. When drugs, such as Procarbazine (MAOI) prevent the
inactivation of tyramine, adverse and serious events may occur when one
consumes foods that contain tyramine, such as follows:
- Elevation of blood pressure, headaches, chest pains
- diaphoresis (perspiration associated with fever), palpitations.
- In severe cases, the crisis can result in intracranial hemorrhage,
cardiac arrhythmias and cardiac failure.
The tyramine content in foods differ greatly due to different processing,
aging, fermentation, ripening and/or contamination. Many foods that contain
small amounts of tyramine have developed large amounts of tyramine, if the
food products were left to spoil, age (not fresh), or fermented.
During a telephone interview with a Dietitian whom prepares diets for
patients receiving MAO inhibitors, she strongly emphasized the importance of
"fresh foods", that fruits that are permissible should still be very fresh,
to avoid left overs kept in the refrigerator especially meats, to check all
frozen, dry packaged mixes and can products (prepared foods) for yeast
extracts, protein extracts, which many contain and to avoid those entirely;
however the yeast found in breads is acceptable. Furthermore, regarding the
controversy of "bananas", she also agreed that the reported adverse event
involving a banana included the stewing of the banana and banana peel;
however, overripe bananas increase in tyramine content, thus, overripe
bananas should be avoided.
FOODS THAT MUST BE COMPLETELY AVOIDED:
Cheeses: All aged and mature cheeses, since it is impossible to know the
tyramine content all cheeses should be avoided. Including but not limited
cheddar, swiss, blue cheese, mozzarella, parmesan, romano, cheese spreads,
cheese casseroles or any foods made with cheese.
Only Exceptions: Ricotta, cottage cheese, cream cheese
and processed cheese slices.(per the ADA)
Note: The American Dietetic Association is the only reference
below that has included "processed cheese slices"
Yeast, Brewers and Extracts Includes brewers yeast, extracts such as
marmite, yeast vitamin supplements, sourdough and fresh homemade yeast
leavened breads; yeast found in prepared foods, soups, can foods, frozen
foods, should be checked for the addition of yeast abstracts and should be
Note: Breads that ARE NOT sourdough, fresh homemade yeast
leavened breads are permissible.
Meats/Fish All smoked, aged, picked, fermented, or marinated meats must be
avoided. Including but not limited to picked fish, Shrimp paste, picked
herring, meat extracts, livers, Non-fresh meats, (such as leftovers), Wild
game, Dry sausages or prepared, such as salamoni, bologna, pepperoni,
frankfurters, bacon, bologna, liverwurst and ham.
Note: Any smoked, picked, fermented, aged meat or spoiled food may contain
high levels of tyramine and must be avoided. Caution should be used in
restaurants. Any protein food that is improperly stored or mishandled can
contain high levels of tyramine, chicken and beef liver, liver pate and game
usually contain high levels due to mishandling. Freshness of food is a key
issue while taking an MAOI in order to prevent a potential hypertensive
crisis. Thus, eat perishable foods within two days after purchase.
Protein Extracts Includes liquid and powdered protein dietary supplements
Fruits and Vegetables.
Banana Peels (also overripe bananas must be avoided as the tyramine
becomes high as the banana ages)
Sauerkraut (since the tyramine contents in sauerkraut differ widely all
Note: All overripe and spoiled fruits should be avoided.
Limit intake of 1/2 cup (4oz) of only one
per day, providing same is fresh of the
following: avocados, bananas, canned
figs, raisins, rasberries, red plums.
Beans Includes Broad fava beans, Italian beans, chinese pea pods, beans
pastes, fermented bean curds, fermented soya beans, soya sauce, soya bean
pastes, Tofu, Miso soup.
Condiments/Seasonings In that protein and yeast extracts are found in
various condiments and seasonings and should be avoided, those to be avoided
includes but are not limited to bouillion cubes/powder, meat tenderizers,
dry packaged and canned soups, gravy, sauces, stew mixes, instant soup dry
powder bases, Soy Sauce and Teriyaki.
Soy Sauce (has been reported to contain high levels of tyramine and
reactions have been reported with Teriyaki)
Soups Prepared, can, frozen, dry packaged, restaurant soups should be
avoided as Protein Extracts, bouillions may be present; furthermore, Miso
Soup is prepared from fermented beans and contain high leveles of tyramine,
additionally bouillons should also be avoided.
Beverages/Alcholic and Non Includes Beer, Ales, domestic and imported,
Wines, especially Chianti vermouth, Whiskey and liqueurs, such as Drambuie
and Chartreuse. Nonalcoholic varieties of beers and wines should also be
Ginseng Some preparations have resulted in adverse reactions and should be
FOODS TO USE WITH CAUTION:
Note: The foods to use with caution, listed below, have been
reported to cause adverse events. Adverse reactions may occur
if foods are over ripe, contaminated, not handled propertly, near
expiration date, or eaten in large qualities, such as more than 1/2 cup.
Furthermore, the ADA has advised that only one (1) of these foods
may be eaten per day.
Avocados Overripe should be completely avoided; however, if not overripe,
small amounts, 1/2 cup, may be safe.
Raspberries Contain tyramine; however small amounts, 1/2 cup, may be safe
Nuts Large amounts of Peanuts, coconuts and brazil nuts have been implicated
in a hypertensive reaction.
Chocolate May be safe unless consumed in large amounts.
Spinach Large amounts of New Zealand or hot weather variety, have resulted
in a reaction.
Caffeine Such as coffee, tea, cokes; large amounts may cause a reaction.
The ADA suggests restricting these beverages to two 8oz servings per day.
Dairy Products Limit servings of Buttermilk, yogurt and sour cream
to 1/2 cup. Dairy products from unpasteurized milk should be avoided.
Note: Cream cheese, cottage cheese or milk
should pose little risk, providing, these
products have been properly stored
and handled and the products should be
avoided if close to the expiration date.
FOODS WITH INSUFFICIENT EVIDENCE
- Fresh Fish
- Sweet Corn
- Fresh Pineapple
- Worcestershire Sauce
- Tomato Juice
- Curry Powder
- Boiled Egg
- Cookies (English Biscuit)
- Cottage Cheese
- Cream Cheese
Physicians' Desk Reference, 48th ed.(1994):1941-2
Matulane Tong, Theodore G., "Foods to Avoid on MAO Inhibitors", Revised by DRUGDEX
Editorial Staff 1/94(DC2763)http://www.lycaeum.org/drugs/plants/maoi/maoi.foods.html (20 Jan 99)
Mahan, L. Kathleen, Krause's food, nutrition, and diet therapy 9th
ed.(1996)392-3 "Monoamine Oxidase Inhibitors"
Supplement to the Manual of Clinical Dietetics, The American Dietetic
Association, (1996) "Tyramine-Controlled Diet"