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Tyramine Restricted Diet
Depression can be treated with many drugs, including tranquilizers or monoamine oxidase inhibitors (MAOI's). Alcohol should never be ingested with tranquilizers to prevent possible increased central nervous system depression. The combination can cause excessive drowsiness, posing a hazard for those individuals who drive. Monoamine oxidase metabolizes tyramine in the gut. MAOI's prevent this breakdown, and norepinephrine is released in response to the intact tyramine. Symptoms depend on the MAOI dosage and the quantity of tyramine-containing food that was ingested. This drug-food combination may cause: palpitations, a nosebleed, severe headache, or a severe hypertensive crisis resulting in intracranial bleeding and sometimes death.
Tyramine Foods to avoid, if taking MAOI's for depression:
Ripened cheese Sausage (fermented) Beef liver Chicken liver Chianti Meats (canned) Soysauce Yeast concentrates Bologna Salami Pickled and dried, salted herring
Foods to consume with caution if taking MAOI'S for depression:
Red wine Beans Beer Sherry Banana Avocado Figs (canned) Chocolate Yogurt Vanilla Processed cheese (American) Gouda
Coffee, hot chocolate, and cola drink (consume only 1-3 cups per day)
Tyramine is an amino acid, which is found in various foods and is an indirect sympathomimetic that can cause a hypertensive reaction among patients receiving MAOI therapy.
Monoamine oxidase is found in the gastrointestinal tract and inactivates tyramine; when drugs prevent the catabolism of exogenous tyramine, it is absorbed and displaces norepinephrine and epinephrine from the adrenal glands, disrupting the nervous system. Patients may experience a severe occipital or temporal headache, even cardiac arrhythmias, cardiac failure, and intracerebral hemorrhage have developed in patients receiving MAOI therapy that did not observe dietary restrictions (Brown & Bryant, 1988). Therefore, dietary restrictions are required for patients receiving MAOIs.
The tyramine content of foods varies greatly due to the differences in processing, fermentation, ripening, degradation, or incidental contamination. Foods that normally contain low amounts of tyramine may become a risk if unusually large quantities are consumed or if spoilage has occurred (McCabe, 1986). Because the side effects, from tyramine and MAOIs, are dose-related, reactions can usually be avoided without total abstinence from tyramine-containing foods. Approximately 10 to 25 mg of tyramine is required for a severe reaction compared to 6 to 10 mg for a mild reaction.
Three lists were compiled:
Foods to avoid
Foods to use with caution
Foods with insufficient evidence for restriction
Foods to Avoid
This list consists of foods with sufficient tyramine (in small or usual serving sizes) to create a dangerous elevation in blood pressure and which therefore should be avoided (McCabe, 1986).
Alcoholic beverages - especially Chianti wine and vermouth. Consumption of red, white, and port wine in quantities less than 120 ml present little risk. Nonalcoholic beverages (alcohol- free beer and wines) may also contain tyramine and should be avoided.
Banana peels have been implicated, although they do not usually constitute a food item in the United States.
Bean curd - fermented bean curd, fermented soya bean, soya bean pastes contain a significant amount of tyramine.
Broad (fava) bean pods - these beans contain dopa, not tyramine, which is metabolized to dopamine and may cause a pressor reaction and therefore should not be eaten particularly if overripe.
Cheeses - tyramine content cannot be predicted based on appearance, flavor, or variety and therefore should be avoided except for cream and cottage cheese, which have no detectable level of tyramine.
Fish - Smoked, fermented, pickled (Herring) and otherwise aged fish, meat, or any spoiled food may contain high levels of tyramine and should be. Fresh fish and vacuum- packed pickled fish, or caviar, contain only small amounts of tyramine and are safe if consumed promptly or refrigerated for short periods; longer storage may be dangerous.
Ginseng - some preparations have resulted in a headache, tremulousness and manic-like symptoms. Ephedrine (as in the Chinese herb Ma Huang) is also contra-indicated.
Protein extracts - meat extracts should be avoided. Avoid liquid and powdered protein dietary supplements.
Fresh meat is safe, however, while there are no detectable levels in fresh chicken livers, a high tyramine content exists in spoiled or unfresh livers.
Sausage, bologna, pepperoni and salami contain large amounts of tyramine. No detectable tyramine levels were identified in country cured ham.
Sauerkraut - should be avoided.
Shrimp paste - should be avoided.
Soups - should be avoided, as protein extracts may be present; miso soup is prepared from fermented bean curd and should not be consumed.
Yeast, Brewer's or extracts - yeast extracts (Marmite) which are spread on bread or mixed with water, should not be consumed. Yeast used in baking is safe.
Foods to Use with Caution
This list categorizes foods that have been reported to cause a hypertensive crisis if foods were consumed in large quantities or stored for prolonged periods, or if contamination occurred.
Small servings (1/2 cup or less) of the following foods are not expected to pose a risk for patients on MAOI therapy.
Avocados - contain tyramine, particularly overripe (Anon, 1989) but may be used in small amounts if not overripened (McCabe, 1986).
Caffeine - contains a weak pressor agent, large amounts may cause a reaction.
Chocolate - is safe to ingest for most patients, unless consumed in large amounts.
Dairy products - Cream, sour cream, cottage cheese, cream cheese, yogurt, or milk should pose little risk unless prolonged storage, or lack of sanitation standards exists. Products should not be used if close to the expiration date.
Nuts - large quantities of peanuts were implicated in a hypertensive reaction and headache. Coconuts and brazil nuts have also been implicated, however no analysis of the tyramine content was performed.
Raspberries - contain tyramine but small amounts are expected to be safe.
Soy sauce - has been reported to contain large amounts of tyramine and reactions have been reported with Teriyaki.
Spinach - large amounts have resulted in a reaction.
Foods with Insufficient Evidence for Restriction
More than 200 foods contain tyramine in small quantities and have been implicated in reactions with MAOI therapy. However, the majority were due to spoiled food. Evidence does not support the restriction of the following foods listed if the food is fresh:
Anchovies Beetroot Chips with vinegar Coca Cola Cockles Coffee Corn, sweet Cottage cheese Cream cheese Cucumbers Egg, boiled Figs, canned Fish, canned Junket Mushrooms Pineapple, fresh Raisins Salad dressings Snails Tomato juice Wild game Worcestershire sauce Yeast-leavened bread
Any protein food, improperly stored or handled, can form pressor amines through protein breakdown. Chicken and beef liver, liver pate and game generally contain high amine levels due to frequent mishandling. Game is often allowed to partially decompose as part of its preparation.
Low Purine Diet
Low purine diet is designed to restrict the intake of purine-rich foods, thereby decreasing uric acid levels and joint inflammation.
Foods to be restricted in a Low Purine Diet:
Meat Soybean Fish Asparagus Poultry, especially goose Anchovies Mackerel Sardines* Mussels Brains Fish roe Veal sweetbread Scallops* Beef liver Dried beans Heart Green peas Kidney* Lentils Mincemeat* Mushrooms Gravy* Spinach Baker's yeast Celery Brewer's yeast*
*Foods extremely high in purines are never to be consumed by individuals with gout.
Care should be taken to include one serving per day in the following category: meat, fish, milk, cheese, eggs or poultry; otherwise the diet will be deficient in iron, niacin and thiamine. The individual is encouraged to drink plenty of fluids to help the kidney flush uric acid from the body. The individual would benefit by incorporating elements of the Alkaline Ash Diet into the Low Purine Diet.
Alkaline ash diet is composed primarily of fruits and vegetables, increases the alkalinity of the urine. Cranberries, plums, prunes and corn are excluded from this recommendation because they are acid-forming. Milk and milk products, olives, molasses, chestnuts, almonds and coconut are all considered alkaline-forming foods.
The serum levels of vitamin B-12, fat, carotene, sodium, potassium, lactose, nitrogen and cholesterol should be monitored periodically. Supplements should be prescribed if deficiencies arise. In general, antigout drugs decrease the absorption of fat-soluble vitamins; therefore, supplements should be prescribed for the user.
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