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Internal Medicine

Cheese reaction

Acute hypertensive crisis associated with monoamine oxidase inhibitor (MAOI) drugs taken with cheese, caused by an interaction of the MAOI with tyramine, formed in ripe cheese when bacteria provide an enzyme that reacts with the amino acid tyrosine in the cheese.

Introduction

Acute hypertensive crisis associated with monoamine oxidase inhibitor (MAOI) drugs taken with cheese, caused by an interaction of the MAOI with tyramine, formed in ripe cheese when bacteria provide an enzyme that reacts with the amino acid tyrosine in the cheese.

The mechanism of potentiation of cardiovascular effects of tyramine, the cheese reaction, and NE release and metabolism after MAO-A inhibition. | Youdim, M. B. H., & Riederer, P. F. (2004). A review of the mechanisms and role of monoamine oxidase inhibitors in Parkinson’s disease. Neurology, 63(7 suppl 2), S32 LP-S35. https://doi.org/10.1212/WNL.63.7_suppl_2.S32

History:

The tyramine connection was discovered by a British pharmacist whose wife was taking an monoamine oxidase inhibitors (MAOI). He noticed that every time they had a meal with cheese, she would get a severe headache. Cheese, especially aged cheese, contains substantial amount of tyramine. For this reason, persons taking MAOI antidepressants are cautioned to avoid foods that are rich in tyramine so that the hypertensive crises can be avoided. However, the road to understanding the neurochemical mechanism of this phenomenon was rather a long and tortuous one. Hypertensive crises due to phenelzine were reported by Dally and Tailor in 1962 but these episodes are commoner with tranylcypromine. Barry Blackwell systematically described these side-effects in 12 patients and 10 of these were women. Eleven patients were receiving tranylcypromine and one, phenelzine. In majority that had the reaction, cooked or raw cheese was the precipitating agent. Increases in blood pressure (BP) ranged from 160/90 to 220/115 mm Hg. The onset of the episode was usually one to two hours after the food intake. Headache was the main symptom associated with heart pounding and palpitations and the complications included subarachnoid hemorrhage, hemiplegia, intracranial hemorrhage, cardiac arrhythmias, cardiac failure, pulmonary edema, and death.


Management

  • Phentolamine (DOC)

Dietary management:

Other foods and drinks that produce the same effect include pickled herring, yeast extract, and certain red wines. Also called the cheese reaction.
Transdermal selegiline – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/46_tbl3_6224555 [accessed 16 Dec, 2020]

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