Contraindications. Phaeochromocytoma, hypertension, cerebrovascular disease, severe cardiovascular disease, liver disease, severe kidney impairment, use with other antidepressants (especially clomipramine and imipramine), sympathomimetics, pethidine, tramadol, dextromethorphan, buspirone, triptans, stimulants or levodopa, a planned general anaesthetic within 10 days, children under 18 years.
Serious adverse effects. Boxed-warning-level risk of suicidal thinking and behaviour in under 25 years, and hypertensive crisis. Serotonin syndrome, orthostatic hypotension, hepatotoxicity (uncommon), mania, seizures, dependence with high doses, withdrawal syndrome.
Common adverse effects. Insomnia, agitation, dizziness on standing, dry mouth, headache, palpitations, sweating, weight loss.
Interactions. Tyramine-rich foods (mature cheese, cured and fermented meats, fermented soya products, yeast extracts, broad beans, tap or unpasteurised beer) can cause hypertensive crisis. Khat contains cathinone and must be avoided. Pseudoephedrine, ephedrine, amphetamines and methylphenidate can cause crisis. SSRIs, SNRIs, tricyclics, tramadol, pethidine and dextromethorphan can cause serotonin syndrome.
Common prescribing errors. Not providing written food and drug warnings; combining with a tricyclic antidepressant; prescribing in uncontrolled hypertension; dosing late in the day.
Special groups.
- Pregnancy: avoid; limited data.
- Breastfeeding: avoid; no safety data.
- Children: not advised in under 18 years.
- Older adults: start low; orthostatic hypotension and falls.
- Kidney impairment: avoid in severe impairment.
- Liver impairment: contraindicated.
