How to document an MAOI washout and the next start

Starting an MAOI is two visits: stop the outgoing drug with a dated clock, then start the MAOI after washout with diet and interaction rules. Chart which medicine stopped on which day, the wait and why, what they must not take (other antidepressants, meperidine, many OTC cold meds), tyramine counseling, the first MAOI dose, and the next appointment. Dates missing from “start phenelzine next month” are how serotonin syndrome happens on a poorly timed fill.

Keep the rest of the problem list in your usual complex med-management structure so the washout is not the only sentence in the plan.

Name the outgoing drug and why it is stopping

Drug, dose, start date, why it failed or why an MAOI is the next indicated step (often atypical depression, treatment-resistant MDD, or a prior MAOI response). List every serotonergic and sympathomimetic agent on the profile: SSRI, SNRI, TCA, vortioxetine, vilazodone, St. John’s wort, linezolid, stimulants you intend to stop, triptans, tramadol.

Write a stop date, not “taper off.” If the outgoing drug itself needs a taper (venlafaxine, paroxetine), show that taper and when the clock for MAOI washout starts (usually after the last dose, with extra time for fluoxetine).

BP and diet history belong before you promise an MAOI. Uncontrolled hypertension, inability to follow a tyramine-restricted diet, and active substance use that includes cocaine or amphetamines are reasons not to start, documented as such.

Write the washout interval and the avoid list

Typical labeled waits are on the order of 14 days after most antidepressants and other MAOIs, and 5 weeks after fluoxetine because of norfluoxetine. Confirm the labels in front of you for the two drugs you are combining in time. If you use a different interval, write why.

Give the patient a dated calendar:

Last fluoxetine 20 mg today 8/24/2026. Do not start phenelzine before 9/28/2026. No other antidepressants, no dextromethorphan, no meperidine, no tramadol, no methylene blue, no illicit stimulants. Call if you need an antibiotic (linezolid).

Document the hypertensive-crisis and serotonin-syndrome warning signs you taught: severe headache, palpitations, rigidity, fever, agitation. Where to go (ED, not “message the portal in the morning”).

Pharmacy: cancel remaining SSRI refills. A washout that leaves 90 sertraline tablets in the house is not a washout.

Chart the MAOI start visit

Confirm the last dose of the outgoing drug and that the interval was observed. Ask about any interval medicine, including ED visits. Recheck BP.

Drug (phenelzine, tranylcypromine, isocarboxazid, or selegiline patch), starting dose, titration plan, dietary instruction (tyramine: aged cheeses, cured meats, tap beer, soybean products as you actually listed them), and a written interaction list.

Selegiline patch at 6 mg/24 h has a different dietary labeling story than 9-12 mg or the oral MAOIs. Write the dose-specific counseling you gave rather than a generic “MAOI diet.”

If they became severely depressed or suicidal during the washout, that belongs in the start visit. Empty washout months are how TRD gets more dangerous. Interim care (psychotherapy, a non-serotonergic sleep plan, crisis contacts) should already be in the stop-visit plan.

Plan the first follow-up and emergencies

See them early: often 1 to 2 weeks after the first dose. BP, sleep, activation, diet slips, headache.

Who they call for a headache that might be a crisis. A wallet card or after-visit summary with the drug name helps an ED. If they need surgery or a dentist, the note should say they must tell that clinician they are on an MAOI.

Do not start a stimulant or another antidepressant “just for a few days” during this window. If something else is required, it is a new decision with a new note.

Sample washout-to-start language

8/24/2026 (stop visit)
Stop fluoxetine 40 mg today (last dose this morning). Indication for MAOI:
TRD, atypical features, failed two SSRIs, one SNRI, lithium augmentation.
Washout: 5 weeks for fluoxetine. Earliest phenelzine start 9/28/2026.
Refills of fluoxetine cancelled. Diet preview given. Bridge: weekly
therapy, hydroxyzine 25 mg HS, C-SSRS today low-moderate chronic.
Follow-up 9/28 start visit or sooner for SI.

9/28/2026 (start visit)
Last fluoxetine 8/24. No interval serotonergics. BP 122/76. Diet teaching
repeated. Start phenelzine 15 mg QAM. Next 10/5. ED for severe headache.

Questions people ask

Can I overlap a tiny SSRI dose with an MAOI if they are falling apart? No. That is the interaction. If they are falling apart, the answer is closer follow-up, a higher level of care, or a different non-serotonergic bridge, not a risky overlap.

Does transdermal selegiline skip the washout? No. You still need the outgoing-drug washout. What can change is diet counseling at 6 mg/24 h. Write the dose you used.