Selegiline transdermal
EMSAM
Pronunciation: se-LE-ji-leen (EM-sam)
“YosEmite Sam Seals gills”
On patch: Mao Zedong → monoamine oxidase (MAO) inhibitor
What it isTransdermal selegiline, an MAOI; major depressive disorder in adults.
Why this oneAt 6 mg/24 h no tyramine diet is needed, because skin delivery spares gut MAO-A.
What limits itTyramine restriction from the first day of 9 or 12 mg/24 h and for 2 weeks after stepping down. Contraindicated with SSRIs, SNRIs, clomipramine, imipramine, meperidine, tramadol, methadone, dextromethorphan and carbamazepine.
Selegiline transdermal prescription history
Animated chart of estimated U.S. prescriptions per year, Antidepressants (1957–2026). Selegiline transdermal enters in 2006 (estimated).
FDA-approved for
- major depressive disorder in adults (2006)
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilityOrthostasis, hallucinations, dyskinesia and impulse-control symptoms; abrupt withdrawal can be hazardous.
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Major depressive disorder | Adults | 6 mg/24 h once daily | 6 mg/24 h | 12 mg/24 h |
| Major depressive disorder | Elderly (≥65 y) | 6 mg/24 h once daily | 6 mg/24 h | 6 mg/24 h |
Titration Increase in 3 mg/24 h increments at intervals of no less than 2 weeks
Renal No adjustment needed (mild, moderate, or severe); not studied in ESRD/dialysis
Hepatic No adjustment needed (mild or moderate Child-Pugh); not studied in severe
Observe washout intervals when switching to/from contraindicated drugs (≥2 weeks after stopping EMSAM; ~1 week (or 5 weeks for fluoxetine) before starting EMSAM)
Instructions
- Apply to dry, intact skin on upper torso, upper thigh, or outer upper arm once every 24 hours; rotate sites
- Avoid tyramine-rich foods/beverages at doses of 9 mg/24 h and 12 mg/24 h (and 2 weeks after reducing/stopping those doses)
- Avoid external heat (heating pads, saunas, hot tubs, prolonged sunlight) at application site
- Screen for bipolar disorder before starting
Available strengths
- patch 6, 9, 12 mg/24 hr
- cap 5 mg
- tab 5 mg
- ODT 1.25 mg
Contraindications
- Serotonergic drugs: SSRIs, SNRIs, clomipramine and imipramine, meperidine, tramadol, methadone, pentazocine, and propoxyphene; and the antitussive agent dextromethorphan — because of a risk of serotonin syndrome
- Carbamazepine (possible increased risk of hypertensive crisis)
- Patients less than 12 years of age (potential for hypertensive crisis)
- Pheochromocytoma
Cautions
- Tyramine-induced hypertensive crisis (dietary modification at 9 and 12 mg/24 h)
- Blood pressure elevation with concomitant sympathomimetics/buspirone
- Activation of mania/hypomania
- External heat may increase selegiline absorption
- Serotonin syndrome
Adverse reactions
- Application site reaction
- Headache
- Insomnia
- Diarrhea
- Dry mouth
- Dyspepsia
- Rash
- Pharyngitis
- Sinusitis
Pregnancy Insufficient human data; animal studies show malformations and developmental toxicity — potential fetal harm; weigh MAOI risks
Lactation No human data; breastfeeding not recommended during treatment and for 5 days after final dose
Cost
| Strength | #/mo | generic $/unit | brand $/unit | CostPlus | |
|---|---|---|---|---|---|
| 6 mg/24 hr | patch | per unit | — | $75.00/ea | not offered |
| 9 mg/24 hr | patch | per unit | — | $75.18/ea | not offered |
| 12 mg/24 hr | patch | per unit | — | $75.40/ea | not offered |
Other forms: Selegiline (ELDEPRYL)
Serotonin and MAOI
Provisional washout figures
Elevating mechanismMAO-A inhibitor (dose-dependent)
Evidence confidenceHigh
InterpretationEMSAM label 12.2: "at antidepressant doses, selegiline inhibits both isoenzymes... as selegiline concentration increases, this selectivity is lost with resulting dose-related inhibition of MAO-A." A tyramine-modified diet is not required at 6 mg/24 h but IS required at 9 and 12 mg/24 h. No modified diet does not establish SRI compatibility.
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Memory aids: interaction avatars
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Self-check
- Which selegiline patch dose needs no tyramine diet?
6 mg/24 h. - How long does tyramine restriction continue after stepping down from 9 or 12 mg/24 h?
2 weeks.