sumatriptan intranasal (Rx)

Brand and Other Names:Imitrex Intranasal, Onzetra Xsail, more...Tosymra
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

intranasal spray

  • 5mg/actuation (Imitrex Intranasal)
  • 10mg/actuation (Tosymra)
  • 20mg/actuation (Imitrex Intranasal)

intranasal powder (Onzetra Xsail)

  • 11mg/capsule in disposable nosepiece

Migraine Headache

Indicated for acute treatment of migraine headache with or without aura

Intranasal spray

  • Individualized dose of 5 mg, 10 mg, or 20 mg intranasally once
  • Administer 5 mg, 10 mg, or 20 mg dose into 1 nostril
  • If headache returns, may repeat dose once after 2 hr; not to exceed 40 mg/day

Intranasal powder

  • 22 mg (2 nosepieces) administered using the Xsail breath-powered delivery device (see Administration)
  • A second 22-mg dose may be administered if the migraine has not resolved by 2 hr after taking the first dose, or returns after a transient improvement
  • Not to exceed 2 doses in 24 hr (ie, 44 mg/4 nosepieces) or 1 dose of Onzetra Xsail and 1 dose of another sumatriptan product, separated by at least 2 hr

Dosing Considerations

Safety not established for treating >4 headaches/30 days

<18 years: Safety and efficacy not established

Next:

Interactions

Interaction Checker

and sumatriptan intranasal

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    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

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            Contraindicated (14)

            • almotriptan

              almotriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • bromocriptine

              bromocriptine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • cabergoline

              cabergoline, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • dihydroergotamine

              dihydroergotamine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • dihydroergotamine intranasal

              dihydroergotamine intranasal, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • eletriptan

              eletriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • ergoloid mesylates

              ergoloid mesylates, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • ergotamine

              ergotamine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • frovatriptan

              frovatriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • methylergonovine

              methylergonovine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • naratriptan

              naratriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • procarbazine

              sumatriptan intranasal and procarbazine both increase serotonin levels. Contraindicated. Combination is contraindicated within 2 weeks of MAOI use.

              procarbazine increases levels of sumatriptan intranasal by serotonin levels. Contraindicated. If procarbazine is required, naratriptan, eletriptan or frovatriptan may be a suitable 5-HT1D agonist to employ. Monitor for the development of serotonin toxicity/serotonin syndrome during such therapy.

            • rizatriptan

              rizatriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            • zolmitriptan

              sumatriptan intranasal, zolmitriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.

            Serious - Use Alternative (18)

            • citalopram

              citalopram, sumatriptan intranasal. Mechanism: unknown. Avoid or Use Alternate Drug. Combination may increase risk of serotonin syndrome. If concomitant treatment with citalopram and a triptan is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases.

            • cyclobenzaprine

              sumatriptan intranasal and cyclobenzaprine both increase serotonin levels. Avoid or Use Alternate Drug.

            • desvenlafaxine

              sumatriptan intranasal and desvenlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.

            • dolasetron

              dolasetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.

            • granisetron

              granisetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.

            • isocarboxazid

              sumatriptan intranasal and isocarboxazid both increase serotonin levels. Avoid or Use Alternate Drug.

              isocarboxazid increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated.

            • linezolid

              sumatriptan intranasal and linezolid both increase serotonin levels. Avoid or Use Alternate Drug. Linezolid may increase serotonin as a result of MAO-A inhibition. If linezolid must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last linezolid dose or after 2 weeks of monitoring, whichever comes first.

              linezolid increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated.

            • lorcaserin

              sumatriptan intranasal and lorcaserin both increase serotonin levels. Avoid or Use Alternate Drug.

            • methylene blue

              sumatriptan intranasal and methylene blue both increase serotonin levels. Avoid or Use Alternate Drug. Methylene blue may increase serotonin as a result of MAO-A inhibition. If methylene blue must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last methylene blue dose or after 2 weeks of monitoring, whichever comes first.

            • netupitant/palonosetron

              netupitant/palonosetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.

            • ondansetron

              ondansetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.

            • ozanimod

              ozanimod increases toxicity of sumatriptan intranasal by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug. Because the active metabolite of ozanimod inhibits MAO-B in vitro, there is a potential for serious adverse reactions, including hypertensive crisis. Therefore, coadministration of ozanimod with drugs that can increase norepinephrine or serotonin is not recommended. Monitor for hypertension with concomitant use.

            • palonosetron

              palonosetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.

            • phenelzine

              sumatriptan intranasal and phenelzine both increase serotonin levels. Avoid or Use Alternate Drug.

              phenelzine increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated.

            • tedizolid

              tedizolid, sumatriptan intranasal. Either increases effects of the other by Mechanism: pharmacodynamic synergism. Avoid or Use Alternate Drug. both increase serotonin levels; increased risk of serotonin syndrome.

            • tranylcypromine

              sumatriptan intranasal and tranylcypromine both increase serotonin levels. Avoid or Use Alternate Drug. Concomitant use or use within 2 wks following the discontinuation of tranylcypromine is contraindicated.

              tranylcypromine increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated.

            • vilazodone

              sumatriptan intranasal, vilazodone. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. Concomitant therapy should be discontinued immediately if signs or symptoms of serotonin syndrome emerge and supportive symptomatic treatment should be initiated. .

            • vortioxetine

              sumatriptan intranasal, vortioxetine. Either increases effects of the other by serotonin levels. Avoid or Use Alternate Drug.

            Monitor Closely (84)

            • 5-HTP

              sumatriptan intranasal and 5-HTP both increase serotonin levels. Use Caution/Monitor.

            • almotriptan

              almotriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.

            • amitriptyline

              sumatriptan intranasal and amitriptyline both increase serotonin levels. Modify Therapy/Monitor Closely.

            • amoxapine

              sumatriptan intranasal and amoxapine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • aripiprazole

              sumatriptan intranasal, aripiprazole. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • asenapine

              sumatriptan intranasal, asenapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • benzhydrocodone/acetaminophen

              benzhydrocodone/acetaminophen, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration of drugs that affect the serotonergic neurotransmitter system may result in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.

            • buspirone

              sumatriptan intranasal and buspirone both increase serotonin levels. Modify Therapy/Monitor Closely.

            • cariprazine

              sumatriptan intranasal, cariprazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • clomipramine

              sumatriptan intranasal and clomipramine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • clozapine

              sumatriptan intranasal, clozapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • cocaine topical

              sumatriptan intranasal and cocaine topical both increase serotonin levels. Modify Therapy/Monitor Closely.

            • cyproheptadine

              cyproheptadine decreases effects of sumatriptan intranasal by pharmacodynamic antagonism. Use Caution/Monitor. Cyproheptadine may diminish the serotonergic effect of serotonin agonists.

            • desipramine

              sumatriptan intranasal and desipramine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • dexfenfluramine

              sumatriptan intranasal and dexfenfluramine both increase serotonin levels. Use Caution/Monitor.

            • dextroamphetamine

              sumatriptan intranasal and dextroamphetamine both increase serotonin levels. Use Caution/Monitor.

            • dextromethorphan

              sumatriptan intranasal and dextromethorphan both increase serotonin levels. Modify Therapy/Monitor Closely.

            • dihydroergotamine

              sumatriptan intranasal and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.

            • dihydroergotamine intranasal

              sumatriptan intranasal and dihydroergotamine intranasal both increase serotonin levels. Use Caution/Monitor.

            • dosulepin

              sumatriptan intranasal and dosulepin both increase serotonin levels. Modify Therapy/Monitor Closely.

            • doxepin

              sumatriptan intranasal and doxepin both increase serotonin levels. Modify Therapy/Monitor Closely.

            • droxidopa

              sumatriptan intranasal and droxidopa both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. May increase risk for supine hypertension

            • duloxetine

              sumatriptan intranasal and duloxetine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • eletriptan

              eletriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.

            • ergotamine

              sumatriptan intranasal and ergotamine both increase serotonin levels. Use Caution/Monitor.

            • escitalopram

              sumatriptan intranasal and escitalopram both increase serotonin levels. Modify Therapy/Monitor Closely.

            • fenfluramine

              sumatriptan intranasal and fenfluramine both increase serotonin levels. Use Caution/Monitor.

              fenfluramine, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration with drugs that increase serotoninergic effects may increase the risk of serotonin syndrome.

            • fluoxetine

              sumatriptan intranasal and fluoxetine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • fluphenazine

              sumatriptan intranasal, fluphenazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • fluvoxamine

              fluvoxamine and sumatriptan intranasal both increase serotonin levels. Modify Therapy/Monitor Closely.

            • frovatriptan

              frovatriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.

            • haloperidol

              sumatriptan intranasal, haloperidol. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • hydrocodone

              hydrocodone, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration of drugs that affect the serotonergic neurotransmitter system may result in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.

            • iloperidone

              sumatriptan intranasal, iloperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • imipramine

              sumatriptan intranasal and imipramine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • isoniazid

              sumatriptan intranasal and isoniazid both increase serotonin levels. Use Caution/Monitor.

            • L-tryptophan

              sumatriptan intranasal and L-tryptophan both increase serotonin levels. Use Caution/Monitor.

            • levodopa

              sumatriptan intranasal and levodopa both increase serotonin levels. Use Caution/Monitor.

            • levomilnacipran

              sumatriptan intranasal and levomilnacipran both increase serotonin levels. Modify Therapy/Monitor Closely.

            • lisdexamfetamine

              sumatriptan intranasal and lisdexamfetamine both increase serotonin levels. Use Caution/Monitor.

            • lithium

              sumatriptan intranasal and lithium both increase serotonin levels. Use Caution/Monitor.

            • lofepramine

              sumatriptan intranasal and lofepramine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • loxapine

              sumatriptan intranasal, loxapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • loxapine inhaled

              sumatriptan intranasal, loxapine inhaled. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • lsd

              sumatriptan intranasal and lsd both increase serotonin levels. Use Caution/Monitor.

            • lurasidone

              sumatriptan intranasal, lurasidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • maprotiline

              sumatriptan intranasal and maprotiline both increase serotonin levels. Modify Therapy/Monitor Closely.

            • meperidine

              sumatriptan intranasal and meperidine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • milnacipran

              sumatriptan intranasal and milnacipran both increase serotonin levels. Modify Therapy/Monitor Closely.

            • mirtazapine

              sumatriptan intranasal and mirtazapine both increase serotonin levels. Use Caution/Monitor.

            • molindone

              sumatriptan intranasal, molindone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • morphine

              sumatriptan intranasal and morphine both increase serotonin levels. Use Caution/Monitor.

            • naratriptan

              naratriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.

            • nefazodone

              sumatriptan intranasal and nefazodone both increase serotonin levels. Modify Therapy/Monitor Closely.

            • nortriptyline

              sumatriptan intranasal and nortriptyline both increase serotonin levels. Modify Therapy/Monitor Closely.

            • olanzapine

              sumatriptan intranasal, olanzapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • oliceridine

              sumatriptan intranasal, oliceridine. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely.

            • paliperidone

              sumatriptan intranasal, paliperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • paroxetine

              sumatriptan intranasal and paroxetine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • pentazocine

              sumatriptan intranasal and pentazocine both increase serotonin levels. Use Caution/Monitor.

            • perphenazine

              sumatriptan intranasal, perphenazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • pimavanserin

              sumatriptan intranasal, pimavanserin. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • pimozide

              sumatriptan intranasal, pimozide. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • protriptyline

              sumatriptan intranasal and protriptyline both increase serotonin levels. Modify Therapy/Monitor Closely.

            • quetiapine

              sumatriptan intranasal, quetiapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • rasagiline

              sumatriptan intranasal and rasagiline both increase serotonin levels. Modify Therapy/Monitor Closely.

            • remifentanil

              remifentanil increases toxicity of sumatriptan intranasal by serotonin levels. Modify Therapy/Monitor Closely. Increases risk of serotonin syndrome.

            • risperidone

              sumatriptan intranasal, risperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • rizatriptan

              rizatriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.

            • SAMe

              sumatriptan intranasal and SAMe both increase serotonin levels. Use Caution/Monitor.

            • selegiline

              sumatriptan intranasal and selegiline both increase serotonin levels. Modify Therapy/Monitor Closely.

            • selegiline transdermal

              sumatriptan intranasal and selegiline transdermal both increase serotonin levels. Modify Therapy/Monitor Closely.

            • sertraline

              sumatriptan intranasal and sertraline both increase serotonin levels. Modify Therapy/Monitor Closely.

            • St John's Wort

              sumatriptan intranasal and St John's Wort both increase serotonin levels. Modify Therapy/Monitor Closely.

            • sufentanil SL

              sufentanil SL, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration of drugs that affect the serotonergic neurotransmitter system may result in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.

            • tapentadol

              sumatriptan intranasal and tapentadol both increase serotonin levels. Modify Therapy/Monitor Closely.

            • thiothixene

              sumatriptan intranasal, thiothixene. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • tramadol

              sumatriptan intranasal and tramadol both increase serotonin levels. Use Caution/Monitor.

            • trazodone

              sumatriptan intranasal and trazodone both increase serotonin levels. Modify Therapy/Monitor Closely.

            • trifluoperazine

              sumatriptan intranasal, trifluoperazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • trimipramine

              sumatriptan intranasal and trimipramine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • venlafaxine

              sumatriptan intranasal and venlafaxine both increase serotonin levels. Modify Therapy/Monitor Closely.

            • ziprasidone

              sumatriptan intranasal, ziprasidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).

            • zolmitriptan

              sumatriptan intranasal and zolmitriptan both increase serotonin levels. Use Caution/Monitor.

            Minor (9)

            • duloxetine

              duloxetine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • escitalopram

              escitalopram, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • fluoxetine

              fluoxetine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • milnacipran

              milnacipran, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • nefazodone

              nefazodone, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • paroxetine

              paroxetine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • sertraline

              sertraline, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • trazodone

              trazodone, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

            • venlafaxine

              venlafaxine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.

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            Adverse Effects

            >10%

            Bad/unusual taste (13.5-24.5%)

            Gastrointestinal: nausea/vomiting (11-13.5%)

            1-10%

            Disorder/discomfort of nasal cavity/sinuses (2.5-3.8%)

            Throat discomfort (0.8-2.4%)

            Dizziness/vertigo (1-1.7%)

            Burning sensation (0.4-1.4%)

            Frequency Not Defined

            Atypical Sensations: Tingling, numbness, pressure sensation, cold sensation, feeling of tightness

            Cardiovascular: Flushing, hypertension, palpations, tachycardia, arrhythmia, edema

            Chest tightness/discomfort, chest pressure/heaviness

            Disturbance of hearing, ear infections

            Eye irritation and visual disturbances

            Gastrointestinal: Abdominal discomfort, diarrhea, dysphagia, GERD, dry mouth, thirst

            Musculoskeletal: Neck pain/stiffness, backache, weakness, joint symptoms, arthritis, myalgia, muscle cramps

            Neurological: Drowsiness/sedation, anxiety, sleep disturbances, tremors, syncope, chills, depression, agitation, confusion

            Respiratory: Dyspnea, lower respiratory infection

            Skin: Rash/skin eruption, pruritus, erythema

            Urogenital: Dysuria, dysmenorrhea

            Postmarketing Reports

            Blood: Hemolytic anemia, pancytopenia, thrombocytopenia

            Cardiovascular: Atrial fibrillation, cardiomyopathy, colonic ischemia, Prinzmetal variant angina, pulmonary embolism, shock, thrombophlebitis

            Ear, nose, throat: Deafness

            Eye: Ischemic optic neuropathy, retinal artery occlusion, retinal vein thrombosis, loss of vision

            Gastrointestinal: Ischemic colitis, dry mouth

            Hepatic: Elevated LFTs

            Neurological: CNS vasculitis, cerebrovascular accident, dysphasia, serotonin syndrome, subarachnoid hemorrhage

            Psychiatric: Panic disorder

            Respiratory: bronchospasm in patients with or without a history of asthma

            Skin: exacerbation of sunburn, hypersensitivity reactions (erythema, pruritus, rash), photosensitivity

            Urogenital: acute renal failure

            Nonspecific: Angioneurotic edema, cyanosis, death, temporal arteritis

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            Warnings

            Contraindications

            Ischemic coronary artery disease (CAD) (eg, angina pectoris, history of myocardial infarction, or silent ischemia) or coronary artery vasospasm, including Prinzmetal’s angina or in patients with other significant underlying cardiovascular diseases

            Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders

            History of stroke, transient ischemic attack (TIA), or history of hemiplegic or basilar migraine

            Peripheral vascular disease

            Ischemic bowel

            Uncontrolled hypertension

            Recent use (eg, within 24 hours) of ergotamine-containing medication, ergot-type medication (such as dihydroergotamine or methysergide), or another 5-hydroxytryptamine1 (5-HT1) agonist

            Concurrent administration of an MAO-A inhibitor or recent use (within 2 weeks) of an MAO-A inhibitor

            Hypersensitivity to sumatriptan (angioedema and anaphylaxis seen)

            Severe hepatic impairment

            Cautions

            Local irritation of nose and throat reported

            Sensations of tightness, pain, pressure, and heaviness in chest, throat, neck, and jaw commonly occur after treatment with 5-HT1 agonists including other products containing sumatriptan and are usually non-cardiac in origin; however, perform a cardiac evaluation if these patients are at high cardiac risk; therapy is contraindicated in patients with known CAD and those with Prinzmetal’s variant angina

            Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, reported on rare occasions in patients treated with 5-HT1 agonists, including patients without a history of hypertension; monitor blood pressure in patients treated with this drug; therapy is contraindicated in patients with uncontrolled hypertension

            Hypersensitivity reactions, including angioedema and anaphylaxis, have occurred in patients receiving sumatriptan; such reactions can be life-threatening or fatal; in general, anaphylactic reactions to drugs are more likely to occur in individuals with a history of sensitivity to multiple allergens; therapy is contraindicated in patients with history of hypersensitivity reaction to this drug

            Seizures reported following administration of therapy; some have occurred in patients with either a history of seizures or concurrent conditions predisposing to seizures; there are also reports in patients where no such predisposing factors are apparent; this drug should be used with caution in patients with a history of epilepsy or conditions associated with a lowered seizure threshold

            Medication Overuse Headache

            • Overuse of acute migraine drugs (eg, ergotamine, triptans, opioids, nonsteroidal anti-inflammatory drugs or combinations of these drugs for 10 or more days per month) may lead to exacerbation of headache (medication overuse headache)
            • Medication overuse headache may present as migraine-like daily headaches or as a marked increase in frequency of migraine attacks
            • Detoxification of patients, including withdrawal of overused drugs, and treatment of withdrawal symptoms (which often includes a transient worsening of headache) may be necessary

            Arrhythmias

            • Life-threatening disturbances of cardiac rhythm, including ventricular tachycardia and ventricular fibrillation leading to death, reported within a few hours following administration of therapy
            • Discontinue therapy if these disturbances occur; therapy is contraindicated in patients with Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders

            Myocardial Ischemia, myocardial Infarction, and Prinzmetal’s angina

            • There are rare reports of serious cardiac adverse reactions, including acute myocardial infarction, occurring within a few hours following administration of therapy; some occurred in patients without known CAD
            • 5-HT1 agonists may cause coronary artery vasospasm (Prinzmetal’s angina), even in patients without a history of CAD
            • Perform a cardiovascular evaluation in triptan-naïve patients who have multiple cardiovascular risk factors (e.g., increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) prior to receiving therapy
            • If there is evidence of CAD or coronary artery vasospasm, therapy is contraindicated; for patients with multiple cardiovascular risk factors who have a negative cardiovascular evaluation, consider administering the first dose in a medically supervised setting and performing an electrocardiogram (ECG) immediately following administration
            • For such patients, consider periodic cardiovascular evaluation in intermittent long-term users of the drug

            Cardiovascular events

            • Cerebral hemorrhage, subarachnoid hemorrhage, stroke, and other cerebrovascular events have occurred in patients treated with 5-HT1 agonists including other products containing sumatriptan, and some have resulted in fatalities
            • In some cases, it appears possible that the cerebrovascular events were primary, the 5-HT1 agonist having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine when they were not
            • Patients with migraine may be at increased risk of certain cerebrovascular events (eg, stroke, hemorrhage, TIA); therapy is contraindicated in patients with a history of stroke or TIA; discontinue therapy if a cerebrovascular event occurs
            • Before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions

            Other vasospasm reactions

            • 5-HT1 agonists may cause non-coronary vasospastic reactions, such as peripheral vascular ischemia, gastrointestinal vascular ischemia and infarction (presenting with abdominal pain and bloody diarrhea), splenic infarction, and Raynaud’s syndrome
            • In patients who experience symptoms or signs suggestive of a non-coronary vasospastic reaction following use of any 5-HT1 agonist, rule out a vasospastic reaction before using this drug
            • Transient and permanent blindness and significant partial vision loss have been reported with the use of 5-HT1 agonists including this drug
            • Since visual disorders may be part of a migraine attack, a causal relationship between these events and the use of 5-HT1 agonists have not been clearly established

            Serotonin Syndrome

            • Serotonin syndrome may occur with triptans, including this drug, particularly during co-administration with selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors
            • Serotonin syndrome symptoms may include mental status changes (eg, agitation, hallucinations, coma), autonomic instability (eg, tachycardia, labile blood pressure, hyperthermia), neuromuscular abnormalities (eg, hyperreflexia, incoordination), and/or gastrointestinal symptoms (eg, nausea, vomiting, diarrhea)
            • The onset of symptoms usually occurs within minutes to hours of receiving a new or a greater dose of a serotonergic medication; discontinue therapy if serotonin syndrome is suspected
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            Pregnancy & Lactation

            Pregnancy

            Data from prospective pregnancy exposure registry and epidemiological studies of pregnant women have not detected an increased frequency of birth defects or a consistent pattern of birth defects among women exposed to sumatriptan compared with the general population

            Several studies have suggested that women with migraine may be at increased risk of preeclampsia and gestational hypertension during pregnancy

            Animal data

            • In developmental toxicity studies in rats and rabbits, oral administration to pregnant animals was associated with embryolethality, fetal abnormalities, and pup mortality; when administered by intravenous route to pregnant rabbits, sumatriptan was embryo lethal

            Lactation

            This drug is excreted in human milk following subcutaneous administration; there is no information regarding concentrations of this drug in milk from lactating women following administration of therapy

            There are no data on effects of sumatriptan on breastfed infant or effects of this drug on milk production

            The developmental and health benefits of breastfeeding should be considered along with mother's clinical need for this drug and any potential adverse effects on breastfed infants from sumatriptan or from underlying maternal condition

            Infant exposure to sumatriptan can be minimized by avoiding breastfeeding for 12 hours after treatment with this drug

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Selective 5-HT1 receptor agonist in cranial arteries; elicits vasoconstrictive and anti-inflammatory effects; associated with antidromic neuronal transmission and relief of migraine headache

            Absorption

            Bioavailability: 80-100%

            Onset: 30 min

            Peak Plasma Concentration: 5-16 ng/mL (dose dependent)

            Distribution

            Protein Bound: 14-21%

            Metabolism

            Metabolized by MAO-A

            Metabolites: indole acetic acid analogue of sumatriptan

            Elimination

            Half-life: 2 hr

            Total body clearance: 1,200 mL/min

            Excretion: urine (3% unchanged, 42% as major metabolite)

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            Administration

            Intranasal Administration

            Imitrex Intranasal Spray

            • Imitrex Intranasal
              • Administer 5 mg or 20 mg metered-spray dose into 1 nostril
              • 10 mg dose achieved by administering 5 mg in each nostril
            • Tosymra
              • Administer 10 mg metered-spray dose into 1 nostril
              • 20 mg dose achieved by administering 10 mg in each nostril

            Onzetra Xsail

            • Remove the clear device cap from the reusable delivery device, then remove a disposable nosepiece from its foil pouch and click the nosepiece into the device body
            • Fully press and promptly release the white piercing button on the device body to pierce the capsule inside the nosepiece; the white piercing button should only be pressed once and released prior to administration to each nostril
            • Insert the nosepiece is then inserted into the nostril so that it makes a tight seal; keeping the nosepiece in the nose, rotate the device to place the mouthpiece into the mouth
            • The patient blows forcefully through the mouthpiece to deliver the sumatriptan powder into the nasal cavity
            • Vibration (eg, a rattling noise) may occur, and indicates that the patient is blowing forcefully, as directed
            • Once the medication in the first nosepiece has been administered, remove and discard the nosepiece
            • The same process must then be repeated using a second 11 mg nosepiece into the other nostril to administer the remainder of the total recommended 22 mg dose

            Storage

            Imitrex Intranasal

            • Store between 36-86°F (2-30°C)
            • Protect from light

            Onzetra Xsail

            • Store at room temperature between 20-25°C (68-77°F), with excursions permitted between 15-30°C (59-86°F)
            • Do not store in the refrigerator or freezer
            • Use nosepiece immediately after removing from foil pouch
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            Images

            No images available for this drug.
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            Patient Handout

            A Patient Handout is not currently available for this monograph.
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            Formulary

            FormularyPatient Discounts

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            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.