Abstract
Sublingual glyceryl trinitrate spray (Nitrolingual Pumpspray) may have a place in the management of monoamine oxidase inhibitor (MAOI) associated hypertensive crisis.
The MAOIs have been less widely used over recent years, largely because the recent antidepressant drugs have fewer troublesome side-effects. Nevertheless, tranylcypromine has a place in the management of treatment-resistant depression [1] and bipolar I depression [2]. The use of MAOIs is recommended in leading depression treatment algorithms [3–6].
Hypertensive crisis may occur when the patient ingests food rich in tyramine, which causes liberation of stored catecholamines, which cannot be deactivated. Intracranial bleeding and death can occur.
Recently, a 50-year-old woman who had been stable on tranylcypromine 60 mg daily, developed a severe frontal headache after eating smoked salmon. Her blood pressure was 240/150 and she swallowed the alphablocking drug I had prescribed for such emergencies (chlorpromazine, 50 mg). The headache persisted and half an hour later she presented at an emergency department. Here, her blood pressure was still elevated and was administered two squirts of sublingual glyceryl trinitrate spray. She immediately developed a ‘different’ headache at the back of the head, and the frontal headache disappeared. Half an hour later her blood pressure was 150/80, and a week later, 140/80.
The nitrates most likely act through the formation of nitric oxide [NO] and cyclic guanosyl monophosphate [cGMP] which reduce systolic, diastolic and mean arterial blood pressure. When administered sublingually, glyceryl trinitrate is rapidly absorbed and reaches the vascular system, bypassing the liver.
In this case, in which rapid resolution of the hypertensive crisis was noted, there was probably a beneficial interaction of the earlier ingested chlorpromazine and the sublingual glyceryl trinitrate administered in the emergency department. Nevertheless, sublingual treatment provided immediate beneficial effects. This is the usual experience of people taking such treatment for angina.
The patient has remained on tranylcypromine, but has requested and procured a Nitrolingual Pumpspray. This gives her confidence to continue with her valuable antidepressant treatment. There would appear to be no contraindication to this speedy, emergency management. Perhaps the headache induced by the nitrates could be confused with that of the hypertensive crisis itself. However, in hypertensive crisis, it is the blood pressure rather than the headache, that is the prime focus of therapeutic attention. The literature details a case of hypertensive crisis treated with sublingual nifedipine [7]. The calcium channel blockers are not without side-effects, and I could not locate a sublingual form that is widely available in Australia.
The Nitrolingual Pumpspray may be a safe and effective treatment for MAOI associated hypertensive crisis. It is widely available and a supply may provide the patient with a sense of control and security.