What foods should you avoid on an MAOI?

Summary of the FDA label quoted below. The label groups these as high-tyramine foods.

• Level E MAOIs including EMSAM combined with a high tyramine diet may cause a hypertensive crisis. EMSAM (selegiline transdermal system), FDA-approved label, sections 2.3 and 7.2 (Table 5)
• Level E Air dried, aged and fermented meats, sausages and salamis (including cacciatore, hard salami and mortadella) EMSAM (selegiline transdermal system), FDA-approved label, sections 2.3 and 7.2 (Table 5)
• Level E Concentrated yeast extract (e.g., Marmite), sauerkraut, most soybean products (including soy sauce and tofu) EMSAM (selegiline transdermal system), FDA-approved label, sections 2.3 and 7.2 (Table 5)
• Level E The FDA label for transdermal selegiline (EMSAM) at 9 mg/24 h or more lists aged cheeses as foods to avoid and processed cheeses, mozzarella, ricotta, cottage cheese and yogurt as acceptable. EMSAM (selegiline transdermal system), FDA-approved label, sections 2.3 and 7.2 (Table 5)

Text in quotation marks is word for word from the official source. Level E means the position of an expert body or a drug label. How we grade evidence.

Evidence behind the advice

• Level B Sensitivity to dietary tyramine depends on which drug a person takes, with a tyramine sensitivity factor of 17.3 on phenelzine and 2.5 on selegiline against 1.5 on placebo. J Clin Pharmacol, 2010
• Level B Taking moclobemide and selegiline together raised tyramine pressor sensitivity 8.4-fold in healthy adults, against 2.4-fold and 1.3-fold for each drug alone, so tyramine-rich food stays restricted on that combination. Eur J Clin Pharmacol, 1996
• Level D Across 121 sauerkraut samples, tyramine averaged 174 mg per kg with very wide variation, and the lowest concentrations were found in home-made sauerkraut. Food Chem, 1999

The other side and the limits

• Level C Meals carrying roughly 400 mg of tyramine from aged cheeses produced no clinically significant cardiovascular change in 12 healthy men wearing a 6 mg per 24 hour selegiline patch. CNS Spectr, 2007
• Level B Tyramine challenges of 50 to 75 mg caused no clinically significant blood pressure reaction in Parkinson patients taking the selective MAO-B inhibitor rasagiline at 0.5 to 2 mg daily. Mov Disord, 2006
• Level C Tyramine swallowed with a meal reached the blood 53 percent lower in total exposure and 72 percent lower at peak than the same 200 mg dose taken after an overnight fast. J Clin Pharmacol, 2003

Levels: A is a meta-analysis of trials, B a randomized trial, C an observational study, D lab work or case reports, E an expert position. How we grade evidence.

The EMSAM avoid list is built around aged and fermented foods: aged cheeses, dry salami, sauerkraut and soy sauce, while fresh cheeses such as mozzarella, ricotta and cottage cheese are listed as acceptable.

The same food can vary a lot. In one lab study, tyramine in sauerkraut ranged widely between samples, so one safe-seeming jar does not prove the next one is.

Drinks count too. NIAAA warns that MAOIs such as tranylcypromine and phenelzine combined with alcohol may cause serious heart-related side effects, and it names beer and red wine as sources of tyramine.

Your drug sets the rules. Studies below show sensitivity to tyramine differs between MAOIs, and the EMSAM list itself applies only from the 9 mg/24 h dose up. Get the diet list for your own medicine from your prescriber or pharmacist and keep it on the fridge.

Evidence behind this note

1. Level B Sensitivity to dietary tyramine depends on which drug a person takes, with a tyramine sensitivity factor of 17.3 on phenelzine and 2.5 on selegiline against 1.5 on placebo. J Clin Pharmacol, 2010
2. Level D Across 121 sauerkraut samples, tyramine averaged 174 mg per kg with very wide variation, and the lowest concentrations were found in home-made sauerkraut. Food Chem, 1999
3. Level E The US alcohol institute (NIAAA) says MAOI antidepressants such as tranylcypromine and phenelzine combined with alcohol may cause serious heart-related side effects, and that the risk of dangerously high blood pressure rises when MAOIs are mixed with tyramine, which it says is found in red wine and beer. NIAAA, Harmful Interactions: Mixing Alcohol with Medicines (brochure, revised 2014)

Written from the positions and data on this page, reviewed by the Bioma editorial system. How we verify.

• Cheddar cheese: what the research says
• Blue cheese: what the research says
• Parmesan cheese: what the research says
• Salami: what the research says
• Sauerkraut: what the research says
• Soy sauce: what the research says
• Tofu: what the research says
• Miso: what the research says