# A client on levodopa-carbidopa is being evaluated for new severe depression. Which medication on the medication reconciliation list most warrants a discussion with the provider before initiation?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391756&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A client on levodopa-carbidopa is being evaluated for new severe depression. Which medication on the medication reconciliation list most warrants a discussion with the provider before initiation?

## Option

1. Sertraline (SSRI)
2. Bupropion at the manufacturer-recommended dose
3. Mirtazapine
4. Phenelzine (nonselective MAOI) **✔ Correct answer**

**Correct answer: 4**

## Explanation

Correct (2): Nonselective MAOIs (phenelzine, tranylcypromine, isocarboxazid) are contraindicated with levodopa — they prevent breakdown of peripheral dopamine and norepinephrine causing severe hypertensive crisis. Wash-out of 14 days required before/after. (1) SSRIs require monitoring (rare serotonin syndrome with selegiline) but not absolute contraindication. (3) Mirtazapine is generally safe. (4) Bupropion requires caution but not absolute contraindication.

## In-depth explanation

Memory Tip Levodopa + Nonselective MAOI = Hypertensive Crisis. Selegiline and rasagiline (selective MAO-B) at therapeutic doses are PD adjuncts; switching from a nonselective MAOI requires a 14-day washout before levodopa.

## Clinical scenario

Scenario 70-year-old male, Parkinson disease on levodopa-carbidopa, evaluated for new severe major depression. New medications considered.

## Key concepts

- **Nonselective MAOI** — Phenelzine, tranylcypromine — block both MAO-A and MAO-B; contraindicated with levodopa.
- **Hypertensive crisis** — Severe BP elevation from unopposed monoamine accumulation; potentially fatal.
- **MAOI washout** — 14-day drug-free interval required before and after nonselective MAOI use.

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