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On May 16, 2006, the Food and Drug Administration (FDA) approved a new drug, rasagiline, for the treatment of Parkinson's disease (PD). Rasagiline, which will be sold under the name of Azilect® in the United States, is taken once a day. The manufacturer, Teva Pharmaceuticals, intends to have two strengths of this drug available for sale in the US later this year.

The FDA approved rasagiline as a stand-alone treatment for early PD and in combination with levodopa, a commonly used drug to treat PD, for the signs and symptoms of moderate to advanced PD. These approvals were based on the results of three clinical studies.

The first study included 404 participants who had early PD and were not taking any dopamine-like drugs for the treatment of PD. The study lasted for 26 weeks. The results showed that rasagiline was better than placebo at controlling the symptoms of PD, as measured by the Unified Parkinson Disease Rating Scale (UPDRS). The UPDRS is a tool that doctors often use in research studies to measure the effects of PD.

A total of 1,159 people with moderate to severe PD participated in the second two studies. These people were taking levodopa and had motor fluctuations, dyskinesias, or both. They kept a diary at home and recorded the amount of "off" time that they had each day. Both studies found that the addition of rasagiline to the subjects' usual medications reduced the amount of off time, as compared with before they started taking rasagiline. In addition, some people were able to decrease their dose of levodopa.

Additional studies will be conducted to evaluate the impact of dietary tyramine on people taking rasagiline (see the information below on monoamine oxidase inhibitors) and whether taking rasagiline increases a person's risk of developing melanoma. In the studies of rasagiline that have been completed, the rate of melanoma was slightly higher in those taking rasagiline, but it is not clear whether this was due to the drug or happened by chance and was not related to the drug. For now, people taking rasagiline should follow a diet that does not include foods that contain tyramine and should undergo regularly scheduled examinations of their skin to look for melanomas.

Monoamine Oxidase Inhibitors

Azilect is in a class of drugs known as monoamine oxidase inhibitors (MAOIs). These drugs affect chemicals in the brain known as monoamines--serotonin, dopamine, and norepinephrine. Monoamines are involved in the transmission of messages between nerve cells. Dopamine is particularly important in regulating messages related to movement. People with PD have a decreased amount of dopamine in their brains.

After monoamines perform their jobs as messengers, they are broken down by a type of protein known as an oxidase. Rasagiline, like other MAOIs, limits or is an inhibitor of oxidation (which is the process of combining oxygen with some other substance). Because they inhibit oxidation, MAOIs increase the level of monoamines, including dopamine, in the brain.

Unfortunately, MAOIs also inhibit or prevent the breakdown of a naturally occurring substance known as tyramine. When tyramine builds up in the body, it can cause extremely high blood pressure, leading to rupture of blood vessels in the brain or even death. Many prescription and over-the-counter medications, such as antidepressants and cough-and-cold medicines, and dietary supplements contain tyramine or also interfere with the breakdown of tyramine. Therefore, if you are taking rasagiline, make sure that you are aware of these substances and that every healthcare provider who cares for you, including the person administering your anesthesia if you are having an operation, knows that you are taking an MAOI.

A wide variety of foods also contain tyramine, and the level of tyramine increases in protein-based or processed foods as the protein breaks down. Eating the freshest possible meats and other protein-based foods is very important. Therefore, it's a good idea if you are taking an MAOI to eat only food that is freshly prepared--let someone else finish off the leftovers, and you may want to steer clear of the buffet line at a restaurant. Some foods should be limited because they contain small amounts of tyramine, and others should be avoided completely (see the Table below). Be sure to check with your doctor for a complete listing of foods and medications that you should avoid. People with liver problems should also not take MAOIs.

People who take MAOIs should be aware of the symptoms of high levels of tyramine, including severe headache, blurred vision, difficulty thinking, seizures, chest pain, unexplained nausea or vomiting, or signs or symptoms of a stroke. Patients and caregivers should seek immediate medical attention for patients who develop any severe headache or other atypical or unusual symptoms not previously experienced.

Tyramine-rich Foods and Beverages to Avoid

Class of food or beverage
Specific foods or beverages to avoid

Meat, poultry, and fish
Air dried, aged, and fermented meats, sausages, and salamis (including cacciatore, hard salami and mortadella); pickled herring; and any spoiled or improperly stored meat, poultry and fish (e.g., foods that have undergone changes in coloration, odor, or become moldy); spoiled or improperly stored animal livers

Vegetables
Broad bean pods

Dairy
Aged cheeses

Beverages
Red wines and all varieties of tap beer and beers that have not been pasteurized

Miscellaneous
Over-the-counter supplements containing tyramine
Concentrated yeast extract
Sauerkraut
Most soybean products (including soy sauce and tofu)

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