Case+2

=== Ms. S. states she has started taking a new medication for her depression, iproniazid. Ms. S. has come from a social event where she had two glasses of wine and different cheeses that she states were “wonderful". Fifteen minutes into the appointment, Ms. S. states she is experiencing a severe headache and nausea and ask for you to stop treatment. You take her blood pressure and it is 230/160 mm Hg so you activate EMS. ===

What interaction has occurred to cause the symptoms Ms. S is experiencing? Be very specific and think broad because there are many layers of interactions occurring here.
====Iproniazid is a hydrazine drug and used as an antidepressent. It was widely discontinued in most of the world, but is still currently used in France. The drug was originally intended for treatment of tuberculosis. It was approved originally in 1958, but was withdrawn in 1961 due to high rate of hepatitis diagnosed on patients taking these drugs. It acts as an irreversible and non-selective monoamine oxidase inhibitor. Monoamine Oxidase inhibitors inhibit the catabolism of amines and norepinephrine. Since it is irreversible the body cannot use monoamine oxidase until it is replaced by the body, which takes approximately 2 weeks. Thus, Ms. S experienced an adverse reaction ( an increase in blood pressure) to iproniazid when she decided to drink two glasses of wine after taking the new medication.====

====There are two types of Monoamine oxidase: MAO-A and MAO-B. MAO-A breaks down serotonin, epinephrine, and norepinephrine. MAO-B breaks down dopamine and phenethylamine. Since Iproniazid is an antidepression medication it targets both MAO-A and MAO-B, reducing their ability to break down serotonin, epinephrine, and norepinephrine, dopamine and phenethylamine. As stated above, iproniazid is a monoamine oxidase inhibitor. MAOIs reduce the function of the enzyme monoamine oxidase. Monoamine oxidase is responsible for the breakdown of tyramine in the body. Too much food consumed with high content of tyramine, for examples: aged-cheese and red wine, while taking an MAIOs will experience an increase in blood pressure. Thus, this was what Ms. S was experiencing with a BP of 230/160 mm Hg. Stopping the treatment and activating EMS was a proper protocol because an excess in tyramine in the blood can trigger a stroke and in some cases death.====

====The most likely cause of Ms. S's hypertension is due to "Cheese Syndrome." Cheese syndrome is a condition associated with the accumulation of tyramine. Tyramine is a naturally occuring amino acid that help regulate blood pressure. Tyramine is present in various food, such as cheese (aged-cheese) and wine. According to the [|www.mayo.com], Thyramine can also result from the bacterial breakdown of protein in foods as they aged. Tyramine is a monoamine which causes the release of catecholamines such as dopamine, epinephrine, and norepinephrine. When tyramine is prevented from breaking down due to the MAO inhibitors, it can cause a hypertensive crisis which would explain the headache, nausea, and elevated blood pressure. It is thought that tyramine causes the release of norepinephrine from storage sites in the body, which cannot be broken down due to the MAOI, causing vasoconstriction and increased heart rate. With MAOI's it requires 10-25 mg of tyramine to cause a severe reaction (6-10 mg for a mild reaction).====

====When foods containing Tryptophan are consumed the individual may suffer from hypertensive crisis. So maybe if Ms. S. took this medication prior to attending this party, the medication and the foods containing tryptophan reduced the breakdown of the serotonin or epinephrine, and then mixed to create a hypertensive crisis and because her blood pressure was 230/160, this lead to her feeling like she was experiencing a headache, and nausea feeling, but could actually have had a heart attack. Wondering why the Doctor had prescribed this prescription to her knowing that it has been discontinued.====

The following are symptoms of the above given drug: 1. increase heart rate, shivering, sweating, dilated pupils, overresponsive reflexes, high blood pressure, and hypoththermia.

 * ~ Systematic ([|IUPAC]) name ||
 * = //N'//-isopropylisonicotinohydrazide ||
 * = //N'//-isopropylisonicotinohydrazide ||