MAO-B inhibitors: Rasagiline, Selegiline & Safinamide

Remember: Levodopa’s best friends are: Entacapone & Amantadine.

The medications discussed here (the MAO-B inhibitors) are also supposedly “friends of levodopa/dopamine”.

Except, two of them,  like the older brothers Karamazov, these medications are somewhat useful but full of flaws. These medications probably belong to an older generation. I use them very sparingly, if at all.

The newest amongst them, Safinamide, is a promising baby. Considering the reputation of its brothers, it’s difficult not to be slightly wary about it.

The flawed elder brothers: Rasagiline & Selegiline


Rasagiline & Selegiline are the bad brothers that you should probably avoid.

How do Rasagiline / Selegeline work?

Their mechanism of action is similar to Safinamide: They prevent the destruction of dopamine and therefore preserve it in the body, prolonging it’s action.


Two studies indicate that these medications may slightly slow the progression of Parkinson’s disease. However researchers and doctors have ferociously debated the results of these studies. Most doctors believe that there is either no effect, or a very minor effect that should not affect the choice of medication.

The effects of Rasagiline & Selegiline in slowing progression of Parkinson’s disease are very minimal. Many researchers believe there is no such effect.

Most doctors start by using levodopa (or rarely, the dopamine agonists) for a patient with newly diagnosed Parkinson’s disease. The thought process is as follows – Levodopa is the most potent medication for Parkinson’s disease. If I delay using levodopa, this patient will continue to have symptoms of Parkinson’s disease. Therefore, let me give him levodopa which I am sure will control most if not all of his symptoms, right now. These side-kicks are probably of no use in protecting the brain and produce too many side-effects.

It may be worthwhile, for the astute reader, to know about the details of these two studies:

  1. The ADIAGO study published in 2009 – Rasagiline at 1 mg per day seemed to slow Parkinson’s disease progression. But 2 mg per day had no beneficial effect! Many doctors believe that the positive result is just due to statistical chance, and is not real.
  2. The DATATOP study published in 1993 – Selegiline was useful in relieving the early symptoms of Parkinson’s disease, and therefore using the boss medication – levodopa – could be delayed by a few years.
    However, there was no direct comparison to the usual strategy of starting levodopa as the first medication. Although often cited as one of the studies that shows possible neuroprotection with these medications, it does not look at this question directly.


These medications have all of the same shortcomings as safinamide, except to a much greater degree.

  1. Sometimes they can cause or worsen high blood pressure
  2. They may occasionally cause liver problems.
  3. Some antidepressants including SSRIs (e.g. fluoxetine) and TCAs (e.g. amitriptyline, nortriptyline, amoxapine)
  4. Stimulants such as Amphetamine & Methlyphenidate
  5. Painkillers that contain opioids
  6. Some muscle relaxants such as cyclobenzaprine
  7. A few other medications such as the antibiotic linezolid.
  8. Fermented and pickled food e.g. fermented cheeses and Red Wine – these can cause a very uncomfortable, and occasionally serious condition called “Cheese reaction” due to accumulation of a chemical called tyramine in the body.
    The affected person has severe flushing of the skin, his/her heart starts beating faster, and he/she has a marked increase in BP. This can last hours – certainly not a good thing to go through!

    PanicAttack e1572183492876
    These medications can interact with fermented foods & cause a terrifying, very uncomfortable reaction.

    More importantly, they can interact with a large number of medications. You should avoid the following medications if you are taking rasagiline/selegiline:

The new kid on the block: Safinamide.

How does Safinamide act?

Safinamide acts just like Rasagiline and Selegiline. It inhibits an enzyme called MAO, which prevents the destruction of dopamine and keeps it in the body for a longer period of time.

It seems to be the less harmful brother of the older brothers Karamazov (Rasagiline & Selegiline), but only time will tell.

New Medication e1574183608197
This is 2019: Safinamide was released only 4 years ago. No one is perfectly sure how useful it will be.


  1. Since it is a very new medication, its uses are still being worked out. However, it seems to be effective in late-stage Parkinson's disease. Addition of Safinamide again seems to smoothen-out the effect of levodopa, so that patients experience fewer fluctuations in their functioning throughout the day.
  2. Safinamide is very unlikely to cause liver injury.
  3. Safnamide is less likely to interact with other medications. But you should probably avoid the medications mentioned above, if you can.
  4. Safinamide is less likely to interact with fermented foods. But perhaps it would be wise to avoid the foods mentioned above until we have more experience with the medications.


The side-effects of Safinamide seem to be the same as Rasagiline/Selegiline, but they occur less commonly.

  1. Just like its brothers, Safinamide can cause or worsen high blood pressure.


Caution: This information is not a substitute for professional care. Do not change your medications/treatment without your doctor's permission.
Dr. Siddharth Kharkar

Dr. Siddharth Kharkar

Dr. Siddharth Kharkar has been recognized as one of the best neurologists in Mumbai by Outlook India magazine and India today Magazine. He is a board certified (American Board of Psychiatry & Neurology certified) Neurologist.

Dr. Siddharth Kharkar is a Epilepsy specialist in Mumbai & Parkinson's specialist in Mumbai, Maharashtra, India.

He has trained in the best institutions in India, US and UK including KEM hospital in Mumbai, Johns Hopkins University in Baltimore, University of California at San Francisco (UCSF), USA & Kings College in London.

Call 022-4897-1800

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NeuroPlus Epilepsy & Parkinson's Clinic - Dr. Kharkar IconNeuroPlus Epilepsy & Parkinson's Clinic - Dr. Kharkar

near LIC, Dr Balabhai Nanavati hospital, near LIC, SV Road, LIC Colony, Vile Parle

4.5 77 reviews

  • Avatar Paras Prabhu ★★★★★ a month ago
    Out patient is epileptic from about 10 years and her seizure gotten worse during the past year with the frequency of about 3-4 times a week.So we consulted … More Dr. Kharkar. He tried a few medicines, and within 1.5-2 months now the patient is feeling very well now. There are no seizures for 14 days currently.Dr. tried to keep medicines as minimum as possible. He also tried to keep the cost of the treatment minimum.When some of the medicines started showing side-effects, he was quick to switch the medicines to the better options.Overall I think we are getting a best of the available treatments. We thank you very much Dr. Kharkar.
  • Avatar Sanjay Pradhan ★★★★★ 2 months ago
    Dr. Kharkar is truly exceptional. He is extremely knowledgeable. But simultaneously, he is extremely patient and kind - taking the time and care to respond … More to all the questions. It is rare to come across a doctor who is not in a hurry to get on to the next patient, but instead, focuses on the one in front with full attention, expertise and compassion. A great experience.
  • Avatar Pinakin Shah ★★★★★ in the last week
    One of the best Dr. Gives complete attention and time to listen to patient's history, issues. Explains various options of treatment with pros and … More cons.
  • Avatar Manish Ranjan ★★★★★ 3 months ago
    I have been visiting Dr Kharkar for treatment of my father. He is a very friendly doctor. He listens to our concerns with lot of patience. He also explains … More the issue in much greater details. He has really been of great help. My father is much better now.
  • Avatar aman ul hauq Khan ★★★★ 2 months ago
    Dr Kharkar gives you all the time you need to hear you out in complete detail. He probes in depth to ensure he has managed to gain all data points to find … More the best way forward medically for you. He is an authority on the subject. After 4 years of suffering I have found my go to doctor
  • Avatar N N ★★★★★ 2 months ago
    We visited Dr. Kharkhar for treatment regarding my mum - who is a multi-stroke patient and has aphasia. Certain medications were creating complications … More with her condition and Dr. Kharkhar was able to help mitigate the issue. We found him and his approach to be incredibly compassionate, considerate, individualized and patient-friendly. He advice is astute, up-to-date and empathetic. His treatment always comes from a deeply human place and is about seeing how to help the patient and their caregivers feel more at ease. Something that is quite rare and refreshing within the medical community.We feel that he genuinely cares about the patients that he is treating and is always kind and respectful in his communication. Moreover, his admin team is very efficient and prompt and it's a pleasure to deal with them.Would highly recommend Dr Kharkhar himself - though we must say our experience with Nanavati hospital itself has been less than ideal.Hope this helps.
  • Avatar Lawrence Castellino ★★★★★ 2 months ago
    Exceptional experience with an expert,Dr. Kharkar is a knowledge house. It is rare nowadays to find doctors with patience, knowledge, and a flair for … More handling patient’s questions, besides Dr. Kharkar’s bedside manners are exemplary. I am privileged to be treated by such an amazing soul. I have told him and will repeat it here that “I am advancing my move back to India although I am a US Citizen, because I know I am in good hands and will be well taken care of. Thanks Dr. Kharkar for your selfless service!
  • Avatar Hemant Kansara ★★★★★ 4 months ago
    Great doctor!! Really appreciate.The doctor diagnosed to my sister correctly and start treatment, she has good improvement after taking medicine prescribed … More by doctor as no epilepsy attake. We have good experience with the doctor. Thank you
  • Avatar Anil Chinchulkar ★★★★★ 4 months ago
    We have visited the hospital and meet the Dr. S. Kharkar. And my personal experience is very much better and exilent. My father is very well recover as … More we thought. Thanks to Nanavati Hospital and Dr. S. Kharkar.
  • Avatar MAMTA YADAV ★★★★★ 4 months ago
    The services that I received from doctor Siddharth kharkar is excellent ,and the other doctor is also very good who had taken initial discussion with me … More ...and the staff are friendly and ensure that I am properly informed about my health and care and would highly recommend to anyone..
  • Avatar Khushi Valia ★★★★★ 4 months ago
    Had very Severe migraine attacks for years and suddenly my migraine had triggered for continuous 5 days thats when I contact Dr Siddharth and was fortunate … More to have a effective medication which help me reduced my triggers and headaches..Lucky in few months I have very less days of headache in a month and can do my Daily life with much ease.
  • Avatar JAIKUMAR MANI ★★★★★ 9 months ago
    My experience with Dr Siddharth Kharkar was really awesome. It’s always great to be in the presence of someone who is a renowned expert in his field & … More it brings peace of mind that the advice will obviously be the correct one. In addition, his ability to convey complex workings of the human brain in such simple terms that a layman like me could easily understand was something I really appreciated. I heartily Thank Dr Kharkar for his astute advice & gladly recommend him to anyone who needs a neurologist.
  • Avatar Rohit shetye ★★★★★ 10 months ago
    Best Dr. we have ever meet. Dr. Listened to us patiently and gave us the proper solution. No unnecessary test or didn’t frighten us. Thank you so much … More Dr.
  • Avatar Ashish Patil ★★★★★ 10 months ago
    Great doctor!! Really appreciate.The doctor diagnosed me correctly and start treatment that will help me a lots to improve my condition. The doctor is … More really good, calm and his nature is down to earth, gives confidence to patient!!! Thank you!!!
  • Avatar Bianca D'silva ★★★★★ 9 months ago
    We had been looking for a specialist in parkinsons for a while now, for my father and when we found Dr. Siddharth Kharka's details on Google, we were … More partly relieved. Partly because, we were all very anxious not knowing how would our visit turn out. I appreciate Dr. Kharkar and his team. He was very clear in his explanations, his knowledge about parkinsons. He took the time to answer the questions we had, went over the diagnosis and started necessary treatment immediately. The only drawback we experienced was the waiting time. Overall, we left the clinic satisfied, knowing much more than when we walked in. We would highly recommend him to anyone looking for a specialist.
  • Avatar Neelam Satghare ★★★★★ 10 months ago
    I have visited the doctor clinic for the first timeBut he gave good advice and helped me overcomeMy doubts and queries. It was a good experience.I am very … More thankful for cooperation.
  • Avatar Nitin Ghotge ★★★★★ 10 months ago
    Dr.Sidharth Kharkar is one of the best neurologist i came across ....He is really genuine and focused .....We really satisfied after consultancy...
  • Avatar Krishna kumari Radhakrishnan ★★★★★ 11 months ago
    Hi Sharing my experience with Dr KharkarI had consulted with dr regarding my husband’sProblems of tremors. Dr immediately diagnosed on video consultation … More and could help him to control the tremors s of Parkinson’s disease.I found him genuinely polite and free to talk n patiently listening to the patients problem.Now my husband regained his balance n tremors controlled. Many many thanks to Dr Kharkar
  • Avatar a kumar ★★★★★ 10 months ago
    Dr kharkar is very nice doctor, sir explained each and every thing very nicely, and i am thankful for Dr kharkar for his treatment .
  • Avatar Nidhi Sonawane ★★★★★ a year ago
    I had a positive experience with the doctor. He was very sympathetic. His communication skills were good and listened with patience.
  • Avatar Ujwala Sawant ★★★★★ 10 months ago
    Because of Dr.kharkar sir my husband got new life. Tnx sir.
  • Avatar Mythili Balasubramanian ★★★★★ a year ago
    Consultation with the doctor was a very satisfying experience. Was empathetic in his approach, and responded positively to all the queries we had. Thank … More you doctor!
  • Avatar Govind Patel ★★★★★ 11 months ago
    Doctor explained very Good nice person give length time to check body
  • Avatar Sharmila Kumawat ★★★★★ a year ago
    Dr Siddharth is one of the best Dr I have ever met. He is kind, polite, helpful and very selfless person. I have migraine and I am his patient since more … More than 2 years. The staff is always helpful and Dr Siddharth is just beyond words for me. Thank you for ur selfless service and kindness u give to all ur patients.

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India Today Magazine - 2021Noted as one of the Best Neurologists in Mumbai