MCQ Quiz: Monoamine Oxidase Inhibitors (MAOIs)

MCQ Quiz: Monoamine Oxidase Inhibitors (MAOIs)

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Monoamine Oxidase Inhibitors (MAOIs) are a potent class of antidepressants with a storied history in psychopharmacology. While their use is limited today due to a significant potential for severe drug and food interactions, they remain an important option for treatment-resistant depression. For pharmacists, a meticulous understanding of their mechanism, dietary restrictions, and interaction profile is a critical safety competency. This quiz for PharmD students will test your knowledge on the pharmacology, management, and risks associated with this unique class of medications.

1. What is the primary mechanism of action for traditional, non-selective MAOIs?

  • They block the reuptake of serotonin and norepinephrine.
  • They are antagonists at the dopamine D2 receptor.
  • They irreversibly inhibit the monoamine oxidase enzyme, increasing the levels of serotonin, norepinephrine, and dopamine.
  • They enhance the effects of GABA.

Answer: They irreversibly inhibit the monoamine oxidase enzyme, increasing the levels of serotonin, norepinephrine, and dopamine.

2. The monoamine oxidase (MAO) enzyme exists in two main forms. MAO-A preferentially metabolizes __________, while MAO-B preferentially metabolizes __________.

  • Dopamine; Serotonin and Norepinephrine
  • Serotonin and Norepinephrine; Dopamine
  • Acetylcholine; Histamine
  • Histamine; Acetylcholine

Answer: Serotonin and Norepinephrine; Dopamine

3. Which of the following is a traditional, non-selective, irreversible MAOI?

  • Selegiline
  • Moclobemide
  • Phenelzine
  • Sertraline

Answer: Phenelzine

4. The most famous and life-threatening interaction associated with MAOIs is the “cheese effect,” which occurs when a patient consumes foods high in:

  • Vitamin K
  • Tyramine
  • Tryptophan
  • Phenylalanine

Answer: Tyramine

5. The ingestion of tyramine-rich foods by a patient taking a traditional MAOI can lead to a:

  • Serotonergic syndrome.
  • Hypertensive crisis.
  • Severe skin rash.
  • Sedative state.

Answer: Hypertensive crisis.

6. A patient taking an MAOI should be counseled to avoid which of the following foods?

  • Fresh fruits and vegetables.
  • Aged cheese, cured meats, and fermented products like sauerkraut.
  • Freshly baked bread.
  • Pasteurized milk and yogurt.

Answer: Aged cheese, cured meats, and fermented products like sauerkraut.

7. How does tyramine cause a hypertensive crisis in a patient on an MAOI?

  • Tyramine is normally broken down by MAO in the gut; without this, it is absorbed and acts as an indirect sympathomimetic, causing a massive release of norepinephrine.
  • It directly stimulates alpha-1 receptors.
  • It blocks the reuptake of serotonin.
  • It inhibits the metabolism of the MAOI itself.

Answer: Tyramine is normally broken down by MAO in the gut; without this, it is absorbed and acts as an indirect sympathomimetic, causing a massive release of norepinephrine.

8. The concurrent use of an MAOI with a Selective Serotonin Reuptake Inhibitor (SSRI) is strictly contraindicated due to the high risk of:

  • Agranulocytosis.
  • A hypertensive crisis.
  • Serotonin Syndrome.
  • Tardive dyskinesia.

Answer: Serotonin Syndrome.

9. When switching from an SSRI like fluoxetine to an MAOI, a long “washout period” of up to 5 weeks is required. This is due to fluoxetine’s:

  • Short half-life.
  • Long half-life and the half-life of its active metabolite.
  • Potent D2 blockade.
  • High cost.

Answer: Long half-life and the half-life of its active metabolite.

10. Selegiline is an MAOI that, at low oral doses, is selective for inhibiting:

  • MAO-A
  • MAO-B
  • Both MAO-A and MAO-B equally
  • Cytochrome P450 enzymes

Answer: MAO-B

11. Due to its MAO-B selectivity at low doses, oral selegiline is used as an adjunct therapy for which neurologic condition?

  • Alzheimer’s disease
  • Epilepsy
  • Parkinson’s disease
  • Multiple sclerosis

Answer: Parkinson’s disease

12. The transdermal patch formulation of selegiline (Emsam®) is unique because at the lowest strength, it does not require the full tyramine dietary restriction. This is because:

  • The patch does not work.
  • It bypasses first-pass metabolism, inhibiting MAO in the brain with less inhibition of MAO in the gut.
  • It is a different chemical than oral selegiline.
  • The FDA has waived the restriction for this product.

Answer: It bypasses first-pass metabolism, inhibiting MAO in the brain with less inhibition of MAO in the gut.

13. A patient taking an MAOI should avoid over-the-counter decongestants like pseudoephedrine and phenylephrine due to the risk of:

  • Severe sedation.
  • A hypertensive crisis.
  • Liver damage.
  • Kidney failure.

Answer: A hypertensive crisis.

14. A common side effect of MAOIs, unrelated to dietary interactions, is:

  • Orthostatic hypotension.
  • Weight loss.
  • Insomnia.
  • Both A and C are common.

Answer: Both A and C are common.

15. Due to their significant risk profile, MAOIs are generally reserved for which place in therapy for depression?

  • First-line for all patients.
  • Second-line after an SSRI fails.
  • Treatment-resistant depression after other alternatives have failed.
  • Only for mild depression.

Answer: Treatment-resistant depression after other alternatives have failed.

16. From a “neurologic and psychiatric principles” perspective, the action of MAOIs provides evidence for which hypothesis of depression?

  • The neuroinflammatory hypothesis.
  • The HPA-axis hypothesis.
  • The monoamine hypothesis.
  • The neuroplasticity hypothesis.

Answer: The monoamine hypothesis.

17. A pharmacist dispensing a new prescription for an MAOI has a critical professional responsibility to:

  • Provide comprehensive counseling on all dietary and drug restrictions.
  • Assume the patient has already been educated by their physician.
  • Fill the prescription as quickly as possible without speaking to the patient.
  • Delegate the counseling to a pharmacy technician.

Answer: Provide comprehensive counseling on all dietary and drug restrictions.

18. After a patient stops taking a traditional, irreversible MAOI, the dietary and drug restrictions must be continued for approximately:

  • 24 hours.
  • 3-5 days.
  • 2 weeks, to allow for regeneration of the MAO enzyme.
  • 1 month.

Answer: 2 weeks, to allow for regeneration of the MAO enzyme.

19. Which of the following is NOT an MAOI?

  • Tranylcypromine
  • Isocarboxazid
  • Selegiline
  • Mirtazapine

Answer: Mirtazapine

20. A key leadership practice for a pharmacist in a mental health clinic is to:

  • Advocate for a clear policy and procedure for initiating and monitoring patients on high-risk drugs like MAOIs.
  • Defer all monitoring decisions to the physician.
  • Focus only on the dispensing of MAOIs.
  • Avoid counseling patients on MAOIs to save time.

Answer: Advocate for a clear policy and procedure for initiating and monitoring patients on high-risk drugs like MAOIs.

21. A “Clinical Decision Support” alert in an EHR should be considered a “hard stop” when a physician attempts to prescribe:

  • An SSRI for a patient currently taking an MAOI.
  • Acetaminophen for a patient on an MAOI.
  • A statin for a patient on an MAOI.
  • A multivitamin for a patient on an MAOI.

Answer: An SSRI for a patient currently taking an MAOI.

22. A patient on phenelzine presents with a severe occipital headache, palpitations, and a blood pressure of 210/120 mmHg. The pharmacist should suspect:

  • A normal side effect.
  • A hypertensive crisis, and ask the patient about their recent food intake.
  • Serotonin syndrome.
  • An opioid overdose.

Answer: A hypertensive crisis, and ask the patient about their recent food intake.

23. The combination of an MAOI and the opioid meperidine is particularly dangerous and should be avoided due to the risk of:

  • Severe serotonin syndrome.
  • A hypertensive crisis.
  • Severe sedation and respiratory depression.
  • All of the above.

Answer: All of the above.

24. A patient’s adherence to the dietary restrictions for an MAOI is a critical component of:

  • Medication safety.
  • Therapeutic efficacy.
  • The cost of the medication.
  • The half-life of the drug.

Answer: Medication safety.

25. A pharmacist providing MTM for a patient on an MAOI must perform a meticulous review of:

  • All prescription medications.
  • All over-the-counter medications, including decongestants.
  • All herbal supplements.
  • All of the above.

Answer: All of the above.

26. The “forging ahead” mindset in pharmacy means that while MAOIs are old drugs, a modern pharmacist must:

  • Understand their niche place in therapy and be able to manage them safely.
  • Forget about them as they are no longer used.
  • Advocate for their return as first-line agents.
  • Refuse to learn about any drug that is not brand new.

Answer: Understand their niche place in therapy and be able to manage them safely.

27. A key “human factors” issue with MAOIs is that:

  • The complexity of the dietary and drug restrictions creates a high potential for patient error.
  • The medication is very easy and safe to use.
  • Patient education is not an important factor in their safe use.
  • The design of the tablet prevents overdose.

Answer: The complexity of the dietary and drug restrictions creates a high potential for patient error.

28. A “difficult conversation” for a pharmacist would be:

  • Explaining the significant lifestyle modifications required to safely take an MAOI to a patient.
  • Handing a patient their refill for a multivitamin.
  • Taking a patient’s blood pressure.
  • Explaining the pharmacy’s hours.

Answer: Explaining the significant lifestyle modifications required to safely take an MAOI to a patient.

29. The use of a “Dashboard Presentation” in a mental health clinic could be used to track:

  • The number of patients on MAOIs to ensure appropriate follow-up and monitoring.
  • The clinic’s daily profit.
  • The schedule for the clinic’s administrative staff.
  • The number of visitors to the clinic.

Answer: The number of patients on MAOIs to ensure appropriate follow-up and monitoring.

30. The ultimate reason a pharmacist must have a deep understanding of MAOIs is to:

  • Prevent potentially fatal drug-food and drug-drug interactions.
  • Impress physicians with their knowledge of older drugs.
  • Because they are the most commonly prescribed antidepressants.
  • Fulfill a continuing education requirement.

Answer: Prevent potentially fatal drug-food and drug-drug interactions.

31. Which of the following is NOT a monoamine neurotransmitter?

  • Serotonin
  • Dopamine
  • Norepinephrine
  • Acetylcholine

Answer: Acetylcholine

32. The “advocacy” role of a pharmacist is demonstrated when they:

  • Take extra time to ensure a patient on an MAOI truly understands all the necessary precautions.
  • Refuse to fill a prescription for an MAOI because it is too much work.
  • Only provide a warning leaflet with the medication.
  • Tell the patient to look up the diet online.

Answer: Take extra time to ensure a patient on an MAOI truly understands all the necessary precautions.

33. In a “business plan” for a new advanced patient care service in psychiatry, a protocol for managing high-risk drugs like MAOIs would be a key component of the:

  • Marketing plan.
  • Operations plan, demonstrating a commitment to safety.
  • Financial plan.
  • Executive summary.

Answer: Operations plan, demonstrating a commitment to safety.

34. The “antidotal therapy” for a tyramine-induced hypertensive crisis would involve:

  • Administering a rapid-acting vasodilator like phentolamine or nifedipine.
  • Giving the patient more of the MAOI.
  • Administering naloxone.
  • Supportive care only.

Answer: Administering a rapid-acting vasodilator like phentolamine or nifedipine.

35. A pharmacist’s knowledge of “toxicology” is essential for:

  • Recognizing the signs and symptoms of a hypertensive crisis or serotonin syndrome.
  • Dosing a common antibiotic.
  • Managing a pharmacy’s inventory.
  • Counseling on the use of a spacer.

Answer: Recognizing the signs and symptoms of a hypertensive crisis or serotonin syndrome.

36. From a “policy” perspective, the numerous and severe interaction warnings for MAOIs have influenced:

  • Prescribing guidelines to place them as later-line agents.
  • The DEA’s decision to make them Schedule I drugs.
  • Their over-the-counter availability.
  • Their use as first-line agents in all patients.

Answer: Prescribing guidelines to place them as later-line agents.

37. Which “practice setting” would be most likely to initiate and manage a patient on an MAOI?

  • A busy community pharmacy.
  • A specialty psychiatric clinic or an inpatient psychiatric unit.
  • A mail-order pharmacy.
  • A supermarket pharmacy.

Answer: A specialty psychiatric clinic or an inpatient psychiatric unit.

38. The use of an “analytics and reporting system” in a health system could be used to:

  • Create a list of all patients taking an MAOI who are also prescribed a contraindicated medication.
  • Track the total cost of MAOIs dispensed.
  • Order MAOIs from the wholesaler.
  • Generate a patient education leaflet.

Answer: Create a list of all patients taking an MAOI who are also prescribed a contraindicated medication.

39. A “negotiation” may be required between a pharmacist and a physician if:

  • The physician prescribes an interacting medication for a patient on an MAOI and is not aware of the risk.
  • A patient needs a routine refill of a non-interacting medication.
  • A patient has no questions about their MAOI.
  • The MAOI is on the hospital’s formulary.

Answer: The physician prescribes an interacting medication for a patient on an MAOI and is not aware of the risk.

40. A key “human resources” consideration for a clinic that manages patients on MAOIs is:

  • Ensuring all clinical staff are thoroughly trained on the medication’s risks and protocols.
  • The brand of computer used by the staff.
  • The clinic’s holiday party schedule.
  • The number of parking spaces available.

Answer: Ensuring all clinical staff are thoroughly trained on the medication’s risks and protocols.

41. The service of “deprescribing” an MAOI requires:

  • Abrupt discontinuation.
  • A slow and careful taper to avoid withdrawal symptoms.
  • No special precautions.
  • Switching to an SSRI the next day.

Answer: A slow and careful taper to avoid withdrawal symptoms.

42. A pharmacist’s “geriatric sensitivity” is crucial, as older adults are:

  • More susceptible to the orthostatic hypotension caused by MAOIs.
  • Less likely to be on multiple medications, reducing interaction risk.
  • The ideal candidates for first-line MAOI therapy.
  • Immune to the side effects of MAOIs.

Answer: More susceptible to the orthostatic hypotension caused by MAOIs.

43. The “Regulation” course in pharmacy school provides the foundation for understanding:

  • Why MAOIs are prescription-only.
  • The legal requirements for dispensing and labeling.
  • The FDA’s role in drug safety warnings.
  • All of the above.

Answer: All of the above.

44. A patient’s adherence to an MAOI may be challenging due to:

  • The restrictive diet and potential for side effects.
  • The fact that it is a once-yearly injection.
  • Its low cost.
  • Its lack of efficacy.

Answer: The restrictive diet and potential for side effects.

45. Which of the following drugs should be avoided with an MAOI?

  • Dextromethorphan
  • Pseudoephedrine
  • Sertraline
  • All of the above

Answer: All of the above

46. The leadership skill of __________ is vital when implementing a new safety protocol for MAOIs in a hospital.

  • Change management
  • Financial accounting
  • Marketing
  • Micromanagement

Answer: Change management

47. A “health disparity” could be exacerbated if:

  • A patient with low health literacy is not adequately educated on the complex MAOI diet.
  • All patients receive the same high-quality counseling.
  • A pharmacist uses a professional interpreter.
  • A clinic provides free medication to low-income patients.

Answer: A patient with low health literacy is not adequately educated on the complex MAOI diet.

48. An “Electronic Health Record” (EHR) improves the safety of MAOI use by:

  • Providing a platform for robust clinical decision support alerts for interactions.
  • Making it harder to access a patient’s medication list.
  • Hiding a patient’s allergy information.
  • Increasing the number of transcription errors.

Answer: Providing a platform for robust clinical decision support alerts for interactions.

49. The “clinical decision support” for an MAOI should be:

  • A passive, informational alert.
  • A “hard stop” for any contraindicated drug-drug interaction.
  • Turned off for all experienced prescribers.
  • The same as the alert for a common antibiotic.

Answer: A “hard stop” for any contraindicated drug-drug interaction.

50. The continued, niche use of MAOIs in modern psychiatry underscores the principle that:

  • A pharmacist must be an expert on all medications, not just the newest ones, to provide comprehensive care.
  • Older drugs have no place in therapy.
  • The risk of side effects is not an important consideration.
  • Patient counseling is not necessary for high-risk drugs.

Answer: A pharmacist must be an expert on all medications, not just the newest ones, to provide comprehensive care.

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