Emsam (Selegiline) Patch: Uses, Side Effects, Dosage, & More

What Is Emsam (Selegiline)?

Emsam, the brand name for the selegiline patch, is an antidepressant classified as a monoamine oxidase inhibitor (MAOI). Its primary mechanism of action involves increasing the levels of brain chemicals, such as serotonin, dopamine, and norepinephrine, which play crucial roles in regulating mood and emotions. Emsam is indicated for the treatment of major depressive disorder (MDD) in adults. It is not approved for children under the age of 12 due to the potential for dangerously high blood pressure (hypertensive crisis), and its use in adolescents aged 12 to 17 is not recommended or in patients who have pheochromocytoma unless alternatives have already been tried and failed.

The Emsam patch will provide a continuous release over a 24-hour period. It’s important to note that Emsam carries a boxed warning regarding an increased risk of suicidal thoughts and behaviors, particularly in pediatric and young adult patients, and dietary modifications are required for higher dosages to avoid potential interactions.¹

How Does Emsam Work?

Mood, energy, and emotions are regulated in the brain by certain chemical molecules, such as serotonin, dopamine, and norepinephrine. Emsam helps improve depression symptoms by blocking the breakdown of these chemicals, allowing them to stay active for longer. This helps boost mood, increase energy, and improve overall well-being, which can lead to a reduction in depression symptoms over time.¹

What Is Emsam Used to Treat?

Emsam is an FDA-approved medication indicated for the treatment of major depressive disorder (MDD) in adults. FDA approval is granted based on evidence of clinical benefit seen in large research trials. Emsam is typically prescribed after other antidepressant treatments have not provided sufficient relief. It is not recommended for use in patients under 17 years of age and is not approved for use in patients under 12 years of age. This is due to the risk of hypertensive crisis in these patient groups.

Emsam is also not recommended for use at the same time as (or within two weeks of) any other drugs that affect serotonin levels, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIS), or tricyclic antidepressants due to the risk of a severe reaction called “serotonin syndrome.”

Emsam may also be used off-label for some conditions. “Off-label use” is a recognized medical practice wherein prescribers utilize medications to treat conditions other than those that the FDA has approved. Due to its ability to increase dopamine levels, Emsam may be used off-label for the treatment of early-stage Parkinson’s disease. It has also been used off-label to treat attention-deficit hyperactivity disorder ADHD in children.^{1, 2, 3}

Is Emsam Good for Anxiety Symptoms?

Anxiety symptoms, such as panic attacks, phobias, or generalized anxiety, sometimes occur alongside depressive symptoms, as both disorders are thought to be caused by the irregularities of the same brain chemicals. Emsam is recommended to be used after the trial and failure of first-line antidepressants.^{1, 4} Emsam may be beneficial for people who have depression that’s accompanied by symptoms of anxiety, but due to the side effects of MAO inhibitors, safety is an important consideration.⁵

Side Effects of Emsam

In research trials of Emsam, various adverse reactions were observed. These reactions include temporary reactions observed as the patient adjusts to the medication as well as prolonged side effects. Common, temporary reactions may include headaches and diarrhea. Common, persistent side effects include application site reactions, insomnia, dry mouth, and other symptoms. Patients who discontinued Emsam most commonly did so because of application site reactions such as itching and dryness. Emsam rarely causes changes in sexual function or desire. Some patients may experience changes such as weight loss or gain and changes in blood pressure.

Emsam has a black box warning (the most severe FDA warning) for potentially serious concerns like suicidal thoughts and behaviors. These are more commonly reported in children and young adults. Patients should be monitored for these symptoms, especially at the beginning and during dose changes of therapy, and if noticed, these should be reported to healthcare professionals right away. Emsam has also been reported to cause serotonin syndrome (in combination with other medications or at toxic levels), blood pressure changes, and may cause or worsen manic and hypomanic episodes in patients with bipolar disorder.¹

Common Side Effects of Emsam

Application site reactions on the skin, insomnia, and diarrhea are the side effects that can be most commonly expected with Emsam. Less frequently, patients may notice weight changes, blood pressure changes, and changes in laboratory blood test values. The most common reason patients discontinued Emsam was application site reactions, such as itching. More rarely, Emsam may cause changes in sexual function or desire.

None of these side effects required medical care in clinical trials. The only reason patients stopped taking Emsam was due to application site reactions, such as itching. Reactions will vary by individual, and serious reactions should be reported to a healthcare professional.¹

Common side effects of Emsam include:*¹

• Application site reactions of the skin (itching)
• Diarrhea
• Insomnia
• Headaches
• Weight gain/loss
• Blood pressure changes

*This is not a complete list of possible side effects with Emsam. You should talk with your healthcare prescriber or pharmacist about the potential risks of Emsam before starting the medication.

Serious Side Effects of Emsam

Rarely, Emsam may cause serious side effects, which require immediate medical care. If experiencing these side effects, patients should immediately seek urgent care or call 911. In toxic doses or in combination with other medications, Emsam may cause serotonin syndrome. Signs of serotonin syndrome include sweating, tremors, large pupils, hallucinations, and agitation. Emsam has a block box warning for the increase of suicidal thoughts and behaviors, especially in children, adolescents, and young adults. Patients should monitor this and contact a provider if noticed.

Emsam also carries a warning for dietary-induced blood pressure crisis. Tyramine, a molecule found in foods such as meat, poultry, and fermented foods, interacts with Emsam to raise blood pressure to dangerous levels. Patients taking Emsam must follow dietary restrictions to avoid this interaction.¹

Serious side effects of Emsam may include:*¹

• Serotonin syndrome
• Blood pressure crisis
• Suicidal thoughts and actions

*All medications, including Emsam, can cause side effects which can be mild or serious. This is not a comprehensive list of all possible side effects. You should talk with your provider or pharmacist about any questions you have and to understand the potential side effects and benefits of any medication.

Antidepressant Discontinuation

Most antidepressants, including MAOI inhibitors like selegiline, require a taper at discontinuation. Tapering means gradually decreasing the dose of medication over a period of time to avoid antidepressant discontinuation syndrome. Emsam, which is a transdermal patch, will slowly leave the body on its own due to the patch form of the drug. After removal of the last patch, leftover drug in the layers of the skin slowly releases and allows the body to adjust gradually. Patients on high doses of the patch may require additional tapering by utilizing a lower-dose patch for a period of time before completely stopping. If this method is used, a prescriber may decrease the patch dose by 3mg per 24 hours every week or two. Slowly tapering the dose when stopping the medication prevents symptoms of antidepressant withdrawal.¹

Allergic Reactions to Emsam

Some patients may be allergic to Emsam or the products contained within the patch system itself. An allergy related to the drug itself may manifest as a widespread rash, hives, swelling, itching, and in severe cases, anaphylaxis and swelling of the face, lips, or tongue. Patients who notice any of these symptoms should contact their provider or pharmacist right away. Patients who notice very severe rashes or swelling of the facial area should call 911 immediately.

Emsam patches do not contain latex. The adhesive layer of the patch is made from acrylic, and the patch itself also contains polyurethane and silicone. Patients who are allergic to these substances may experience a localized rash, swelling, itching, or hives. This is different from an application site reaction, which is usually limited to mild itching and irritation directly at the site.¹

Allergic reactions to Emsam may include:¹

• Rashes or hives
• Itching
• Swelling
• Fever
• Swelling of the facial area

Emsam can include mild allergic reactions such as itching, rashes, or hives. It may also cause severe allergic reactions, such as severe rashes and anaphylaxis. Any signs of allergy should be reported immediately to your provider. Patients who experience mild, local reactions to Emsam may continue treatment with the application of topical steroids (e.g. Cortisone) or oral antihistamines (e.g. Benadryl). Patients with severe reactions will likely be switched to another MAOI or explore other options for depression treatment.¹

Emsam Warnings & Precautions

There are several warnings and precautions associated with Emsam usage. Emsam has been associated with an increased risk of suicidal thoughts and behaviors, especially in adolescents and young adults. Monitor closely for these during the initial months of treatment and when dosage adjustments are made.

Secondly, a potentially life-threatening condition called serotonin syndrome can occur when Emsam is used in combination with other serotonin-altering drugs (e.g. SSRIs). This syndrome can lead to a range of symptoms, including agitation or severe headaches, large pupils, sweating, tremors, severe nausea and vomiting, seizures, coma, and death. For this same reason, patients with pheochromocytoma (specific tumor type) must not take Emsam. Prompt medical attention is required if any signs of serotonin syndrome emerge.

Additionally, Emsam can elevate blood pressure dangerously and lead to a blood pressure crisis, particularly when consuming foods rich in tyramine, such as fermented meats and sausage, other fermented foods, tap beer, and soybeans. Symptoms include neck stiffness or soreness, nausea, vomiting, sweating, and light sensitivity. Adherence to a low tyramine diet is important. For patients with bipolar disorder, caution is advised, as treatment with Emsam could potentially trigger a manic or hypomanic episode. Pregnant or lactating patients should consult their providers to assess the risks and benefits of using Emsam during pregnancy. Last, exposure to external heat sources like heating pads or saunas can affect the absorption of Emsam. Patients should avoid such heat sources to ensure the proper functioning of Emsam.¹

Providers and pharmacists play a key role in monitoring and managing these potential risks to ensure well-being during the course of treatment.

Precautions for taking Emsam include:¹

• Use during pregnancy and breastfeeding: Emsam showed increases in animal fetal abnormalities at extremely high doses (24-60 times the recommended maximum daily dosage) but not at lower dosages. There is no evidence that Emsam is present in human breast milk.
• Tyramine-induced hypertensive crisis: Consuming too much tyramine increases the risk for blood pressure crisis in combination with Emsam.
• Serotonin syndrome: In combination with other serotonin-altering drugs (e.g. SSRIs), or in toxic doses, Emsam may precipitate the development of serotonin syndrome. All other serotonergic drugs, including some herbs like St John’s wort, should be avoided before, during, and for at least two weeks after treatment with Emsam.
• Manic/hypomanic episodes: Emsam may cause or worsen manic/hypomanic episodes in patients with bipolar disorder.

Interactions With Emsam

Emsam can have several dangerous interactions with other medications and herbs. In combination with other medications, Emsam can cause serotonin syndrome. This interaction is also possible with various herbs such as St John’s wort and tryptophan. In combination with tyramine, a molecule found in various foods, Emsam can precipitate a blood pressure crisis. It is not recommended to take carbamazepine, buspirone, and amphetamines in combination with Emsam due to this same risk. This is not a comprehensive list. A pharmacist will be most helpful in identifying potential drug interactions with Emsam.¹

8 substances you should avoid while taking Emsam include:¹

• Other antidepressants (SSRIs, SNRIs, TCAs, other MAOIs, buspirone, bupropion)
• Tyramine
• Tryptophan
• St. John’s wort
• Medications for Parkinson’s disease or restless leg syndrome
• Carbamazepine
• OTC cough/cold medications (e.g. decongestants)
• Weight loss medications (e.g. phentermine)

Emsam Dosages for FDA-Approved Treatment

Emsam is FDA-approved for the treatment of MDD. Emsam patches come in three different strengths: 6 milligrams, 9 milligrams, and 12 milligrams per 24 hours. The recommended starting dose is 6 mg per 24 hours. For patients older than 65, this is also the maximum daily dose. For other patients, including adolescents aged 12 to 17, the maximum daily dose is 12mg in a 24-hour period.

Emsam is not recommended for use in the adolescent population due to its lack of effectiveness. Dosages will be adjusted by no more than 3 mg/24 hours in every two-week period. Emsam has not been studied in patients with severe liver disease, but no dose adjustments are required for mild or moderate liver disease. Emsam does not require dose adjustments for any stage of kidney disease. Tyramine-rich foods must be avoided at any dose greater than or equal to 9 milligrams in 24 hours and for two weeks after decreasing the dose or stopping Emsam.¹

Emsam may also be used off-label for the treatment of Parkinson’s disease and ADHD. Off-label use is an acceptable medical practice wherein prescribers utilize a medication for a condition for which it has not been fully FDA-evaluated.^{1, 2, 3}

Emsam Forms & Strengths

Emsam is available only as a transdermal patch which releases a consistent amount of drug over 24 hours. The patch doses available are 6 milligrams, 9 milligrams, and 12 milligrams released over the 24-hour period. All patients will start at a dose of 6 milligrams, which may be increased to higher doses based on response to treatment and side effects. Due to patient individuality, the dose is not always correlated to the severity of symptoms.

Prescribers may choose the Emsam patch over oral forms of selegiline due to a more tolerable side effect profile, as a patch provides more consistent dosing than oral tablets. Patients will likely notice the first signs and possibly side effects of Emsam within a week of beginning, and it may take up to 12 weeks to achieve full therapeutic effect.¹

Emsam is available in the following forms and strengths:¹

• 6 mg/24 hours patch
• 9 mg/24 hours patch
• 12mg/24 hours patch

Be sure to take all your medications as prescribed. Follow your provider’s instructions on how to use Emsam properly. For additional information, consult your pharmacist.

How Should I Take Emsam?

Emsam patches should be applied to an area of clean, dry skin on the upper torso, upper thigh, or outer arm once a day. Peel off the protective back layering to expose the adhesive, and place the patch firmly on the skin. Do not cut the patches or use more than one patch at a time. Patches should not be covered; if the patch falls off, place a new one on. Hair or oil on the skin may compromise the adhesive of the patch.

After 24 hours, carefully remove the patch by peeling it off, folding it in half, and throwing it in the trash. Patches may be worn in the shower while avoiding direct streams of very hot water on the patch. Take medications as directed by a prescriber, and consult a pharmacist with additional questions.¹

What Should I Do If I Miss a Dose of Emsam?

Do not stop taking Emsam without first consulting a provider or pharmacist. Emsam should be tapered properly if therapy is to be discontinued. If you miss applying a patch, simply place a new patch on the skin as soon as you remember. If it has been several days since you applied a patch, contact your provider or pharmacist prior to reapplying another patch. Never apply more than one patch at a time, or attempt to catch up on missed doses.¹

Can You Overdose on Emsam?

Yes, you can overdose on Emsam. Overdosing on Emsam can be dangerous. Signs and symptoms of an overdose on Emsam vary and might include restlessness, confusion, agitation, hallucinations, fast heart rate, high blood pressure, severe headache, nausea, vomiting, sweating, and even seizures. Since Emsam inhibits the breakdown of brain chemicals, an excessive accumulation of these can potentially result in an over-activation of the brain, leading to these symptoms.

An Emsam overdose could be life-threatening, particularly if it triggers a blood pressure crisis, which is a dangerous spike in blood pressure. Therefore, it is crucial to adhere to the prescribed dosage and promptly seek medical attention if any signs of overdose are suspected. If you or someone you know is experiencing potential overdose symptoms, it is imperative to contact a healthcare professional or 911 immediately.¹

What Should You Do If You Take Too Much Emsam?

If someone takes too much Emsam or suspects an overdose, seek immediate medical attention. Contacting your healthcare provider, poison control center (800-222-1222), or emergency services (such as 911) is recommended. It’s important to provide information about the medication taken, the dosage, and the time of ingestion.

While waiting for professional assistance, closely monitor the patient’s symptoms and stay with them. Do not induce vomiting; Emsam is absorbed through the skin, and this will have no effect. The response to an Emsam overdose will require individualized medical intervention. Fast and appropriate action is necessary to ensure the patient receives the necessary medical care.¹

Questions to Ask Your Healthcare Provider About Emsam (Selegiline)

Individuals might want to learn about Emsam when seeking treatment for major depressive disorder, particularly if other treatments have proven ineffective. When consulting one’s doctor, pharmacist, psychiatrist, or therapist, one should inquire about the potential benefits, risks, and side effects of Emsam, as well as its compatibility with one’s medical history and current medications. One should also discuss any concerns about dietary restrictions or interactions with certain foods due to Emsam’s MAOI nature.

In cases where changing prescribers becomes necessary, online psychiatry services can offer a convenient and accessible option to help ensure a smooth transition and minimize disruptions in their mental health care.¹

Questions to ask your care team about Emsam include:¹

• How long will it take for me to adjust to taking Emsam?
• Am I at risk for more severe symptoms if I am already taking other anxiety /depression medications?
• What is the best dosage to ensure fewer side effects?
• When should I reach out to you if I am experiencing sexual side effects?
• Is there anything I should tell my therapist about this new medication?
• How do I use this patch?
• Will my insurance cover this patch?
• Do my other medications interact with Emsam?
• What if my patch falls off?
• If I forget to put on my patch, how long is enough that I should call you before I put a new one on?

In My Experience

In my experience, Emsam is a good option for adult patients who have tried other antidepressants without success. The patch allows for a different type of absorption in the body compared to an oral tablet or capsule. I do not see Emsam used in children or adolescents in my practice, but I do see it used in adults. Emsam has the potential to interact with many different medications. Therefore, other antidepressants are usually chosen before Emsam. If you would like to try the Emsam patch, talk to your provider or pharmacist about the potential risks and benefits of trying this medication as it relates to your medical history and current medication list. It is important to your healthcare providers about this topic and follow their guidance.