Hypertensive Crisis Risk Calculator
WARNING: LIFE-THREATENING INTERACTION
Combining ADHD stimulants with MAOIs can cause hypertensive crisis (blood pressure >180/110 mmHg) leading to stroke, heart attack, or death. This calculator estimates your risk based on specific medications and doses. NEVER combine these medications without explicit specialist guidance.
Combining ADHD stimulants with MAOIs isn’t just a bad idea-it’s potentially life-threatening. If you’re taking one of these medications, or know someone who is, this isn’t theoretical. This is real, documented danger that has sent people to the ER, caused strokes, and even led to death. The FDA, major psychiatric associations, and top clinical centers all agree: ADHD stimulants and MAOIs should not be used together. But why? And what happens if someone ignores this warning?
What Happens When These Medications Mix?
ADHD stimulants like Adderall, Vyvanse, and Ritalin work by boosting dopamine and norepinephrine in the brain. That’s how they improve focus and reduce impulsivity. MAOIs-like phenelzine, tranylcypromine, and selegiline-work differently. They block an enzyme called monoamine oxidase, which normally breaks down excess neurotransmitters and tyramine (a compound found in aged foods). When MAOIs are active, these chemicals build up in your body. Put them together, and you get a dangerous double hit. The stimulant pushes more norepinephrine into your system. The MAOI stops your body from clearing it out. The result? A runaway surge in blood pressure. Systolic readings can spike above 180 mmHg. Diastolic can hit 110 or higher. That’s not high blood pressure-it’s a hypertensive crisis. At this level, your blood vessels are under extreme stress. You’re at risk for stroke, heart attack, aortic dissection, or brain bleeding.Which MAOIs Are the Most Dangerous?
Not all MAOIs are the same. The older ones-tranylcypromine and phenelzine-are irreversible inhibitors. That means they permanently disable the enzyme until your body makes new ones. That takes about two weeks. These carry the highest risk. Tranylcypromine, in particular, has been linked to multiple cases of severe hypertension when combined with stimulants. One 2023 case report described a 42-year-old patient whose systolic blood pressure hit 210 mmHg after mixing tranylcypromine with dextroamphetamine. Transdermal selegiline (Emsam patch) is different. At low doses (6 mg/24h), it mainly blocks MAO-B in the skin, not MAO-A in the gut. That means less interference with tyramine metabolism. The FDA says hypertensive reactions are rare at this dose. But even then, combining it with stimulants isn’t risk-free. Higher doses of the patch (above 6 mg/24h) lose this safety advantage and become just as dangerous as oral MAOIs.Which ADHD Medications Are Riskiest?
Amphetamines-like Adderall and Vyvanse-are more dangerous than methylphenidate-based drugs like Ritalin or Focalin. Why? Because amphetamines cause a much stronger release of norepinephrine. Methylphenidate mainly blocks reuptake, which is a gentler effect. A 2005 review found amphetamines increase norepinephrine levels nearly twice as much as methylphenidate. That’s why Vyvanse carries a higher interaction risk than Ritalin, even though both are stimulants. Even low doses can be risky. One 2017 study from Massachusetts General Hospital gave patients with treatment-resistant depression and ADHD lisdexamfetamine starting at just 10 mg/day. They monitored blood pressure every week. No hypertensive crises occurred. But that was under strict supervision, with no other risk factors. This doesn’t mean it’s safe to try at home.Why Do Some Doctors Still Try This Combination?
It’s rare, but it happens. Some psychiatrists working with treatment-resistant depression and severe ADHD see patients who haven’t responded to anything else. In these extreme cases, they may consider combining an MAOI with a stimulant-only after exhausting every other option. Dr. Richard Friedman at Weill Cornell Medicine says he’s treated over 200 patients this way without incident. But he emphasizes strict conditions: low stimulant doses, no tyramine-rich foods, no other serotonergic drugs, and daily blood pressure checks. He’s not recommending this-he’s documenting what some clinicians do in desperation. The problem? These are outliers. Most doctors won’t touch this combo. The American Psychiatric Association’s 2022 guidelines list it as a "strong recommendation against" with "high quality of evidence." The FDA’s black box warning on all stimulants says concomitant use can cause death.
The Washout Period: Why 14 Days Isn’t Optional
If you’re switching from an MAOI to a stimulant-or vice versa-you can’t just stop one and start the other the next day. The enzyme needs time to regenerate. That’s why the standard is a 14-day washout period. Some MAOIs linger longer in your system. Stopping phenelzine doesn’t mean the enzyme is back to normal after seven days. It takes two weeks. Many patients don’t realize this. They stop their MAOI because they feel better, then start Vyvanse for ADHD. Two days later, they get a pounding headache, blurred vision, chest pain. By then, it’s too late. Emergency rooms see this pattern every year. The delay isn’t a suggestion-it’s a medical necessity.What About Food? Tyramine and the Hidden Danger
MAOIs already require dietary restrictions. You can’t eat aged cheese, cured meats, soy sauce, tap beer, or fermented foods. Why? Because tyramine builds up when MAO-A is blocked. It triggers massive norepinephrine release. Add a stimulant on top, and your body can’t handle the overload. Even if you’re on the low-dose Emsam patch, you’re not completely safe. The FDA still warns of rare reactions. One patient in a 2022 study ate a slice of blue cheese and took Adderall. Their blood pressure jumped from 120/80 to 205/115 within an hour. They ended up in the ICU. There’s no safe threshold. One bite of salami, one glass of red wine-enough to trigger a crisis when MAOIs and stimulants are both active.Who Should Never Try This?
Even under supervision, this combo isn’t for everyone. Avoid it if you have:- Any history of high blood pressure
- Heart disease, arrhythmias, or prior stroke
- Liver or kidney problems
- History of substance abuse
- Use of other antidepressants, opioids, or migraine meds like triptans
What Are the Alternatives?
If you need both ADHD and depression treatment, there are safer paths:- Bupropion (Wellbutrin): An NDRI that helps with both ADHD and depression. No MAOI risk.
- SSRIs or SNRIs: Combined with stimulants. These are standard, well-studied combos.
- Non-stimulant ADHD meds: Atomoxetine (Strattera) or guanfacine (Intuniv) can be used with MAOIs safely.
- Therapy: CBT and DBT help manage both conditions without medication.
The Bigger Picture: Why MAOIs Are Rare Today
MAOIs made up 5% of antidepressant prescriptions in 2000. By 2023, that number dropped to less than 1%. Why? Safety. Side effects. The rise of SSRIs and SNRIs. And the fact that combining them with stimulants is so dangerous. Meanwhile, ADHD prescriptions in the U.S. jumped 23% from 2018 to 2022-92 million total. More people are on stimulants. More people are being prescribed antidepressants. The chance of accidental overlap is rising. Doctors are getting better at checking for drug interactions. But patients? Many don’t know what MAOI stands for. They hear "antidepressant" and think it’s safe with their Adderall. That’s where the real danger lies.What to Do If You’re Already Taking Both
If you’re currently taking an MAOI and a stimulant, do not stop either abruptly. Sudden withdrawal from an MAOI can cause rebound depression or withdrawal symptoms. Stopping a stimulant suddenly can cause fatigue, depression, or suicidal thoughts. Call your prescribing doctor immediately. Tell them exactly what you’re taking-name, dose, frequency. Ask for a plan to transition safely. That plan will likely include:- Stopping the stimulant first
- Waiting 14 days
- Starting a non-stimulant ADHD medication
- Re-evaluating antidepressant options
Bottom Line: It’s Not Worth the Risk
There’s no safe way to combine ADHD stimulants and MAOIs. Even the most careful, experienced clinicians agree: the potential for death outweighs any possible benefit. The data is clear. The warnings are loud. The consequences are irreversible. If you’re struggling with both ADHD and depression, there are other options. Safer options. Effective options. You don’t need to risk your life to feel better. Talk to your doctor. Ask about alternatives. And never, ever mix these two drugs without explicit, written guidance from a specialist who understands the full risk.Can you take Adderall with an MAOI?
No. Taking Adderall with an MAOI like phenelzine or tranylcypromine can cause a life-threatening hypertensive crisis. The combination causes dangerous spikes in blood pressure that can lead to stroke, heart attack, or death. The FDA and all major psychiatric guidelines strictly prohibit this combination.
How long should I wait after stopping an MAOI before starting a stimulant?
You must wait at least 14 days after stopping any MAOI before starting a stimulant. This is because MAOIs irreversibly block the enzyme that breaks down neurotransmitters, and your body needs two weeks to produce new enzymes. Starting a stimulant too soon can trigger a hypertensive emergency.
Is the Emsam patch safer than oral MAOIs when combined with stimulants?
At the lowest dose (6 mg/24h), the Emsam patch carries less risk than oral MAOIs because it mainly blocks MAO-B in the skin, not MAO-A in the gut. But it’s still not safe to combine with stimulants. Even low-dose Emsam has caused hypertensive reactions when paired with amphetamines. The FDA does not approve this combination under any circumstances.
What are the signs of a hypertensive crisis from this interaction?
Symptoms include severe headache, blurred vision, chest pain, shortness of breath, nausea, vomiting, nosebleeds, and extreme anxiety. Blood pressure may spike above 180/110 mmHg. If you experience any of these while taking both medications, seek emergency care immediately. Do not wait.
Can I take Vyvanse and selegiline together if my doctor says it’s okay?
Even if a doctor suggests it, this combination is not approved by the FDA and carries serious, documented risks. There are no large-scale studies proving it’s safe. Only a handful of case reports exist, and they involve extreme monitoring. For nearly all patients, the risk far outweighs any potential benefit. Safer alternatives exist.
Are there any stimulants that are safe to take with MAOIs?
No. All FDA-approved ADHD stimulants-including methylphenidate, amphetamines, and lisdexamfetamine-carry the same risk when combined with MAOIs. The mechanism of interaction is the same regardless of the specific stimulant. There is no safe stimulant to pair with an MAOI.
What should I do if I accidentally took both drugs?
Call 911 or go to the nearest emergency room immediately. Do not wait for symptoms. Hypertensive crisis can develop within minutes to hours. Bring the medication bottles with you. Tell the staff exactly what you took and when. Time is critical.