dihydroergotamine intranasal (Rx)

Brand and Other Names:Migranal, Trudhesa
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

intrnasal solution (Trudhesa)

  • 0.725mg/actuation

intranasal solution (Migranal)

  • 0.5mcg/actuation (4mg/ampule with intranasal sprayer)
  • Also contains caffeine (10 mg/ampule; 1.25mg/actuation)

Migraine Headache

Indicated for acute treatment of migraine with or without aura

Trudhesa

  • 1 spray (0.725 mg) in each nostril (total dose 1.45 mg)
  • If needed, may repeat dose a minimum of 1 hr after first dose
  • Not to exceed 2 doses (4 sprays)/24 hr or 3 doses (6 sprays)/week

Migranal

  • 1 spray (0.5 mg) in each nostril, repeat after 15-30 minutes for a total of 4 sprays (2 mg)
  • Not to exceed 6 sprays (3mg)/24 hr or 8 sprays (4 mg)/week

Dosing Considerations

Not intended for prophylaxis of migraine

Not for chronic, daily use

Not for management of hemiplegic or basilar migraine

Safety and efficacy not established

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Interactions

Interaction Checker

and dihydroergotamine intranasal

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      Serious - Use Alternative

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            Contraindicated (43)

            • almotriptan

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

            • atazanavir

              atazanavir will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • clarithromycin

              clarithromycin increases toxicity of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Coadministration may result in vasospasm and ischemia of the extremities and other tissues including the CNS.

            • conivaptan

              conivaptan will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • darunavir

              darunavir will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • eletriptan

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

            • elvitegravir/cobicistat/emtricitabine/tenofovir DF

              elvitegravir/cobicistat/emtricitabine/tenofovir DF increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Cobicistat is a CYP3A4 inhibitor; contraindicated with CYP3A4 substrates for which elevated plasma concentrations are associated with serious and/or life-threatening events.

            • erythromycin base

              erythromycin base will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • erythromycin ethylsuccinate

              erythromycin ethylsuccinate will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • erythromycin lactobionate

              erythromycin lactobionate will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • erythromycin stearate

              erythromycin stearate will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fosamprenavir

              fosamprenavir will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • frovatriptan

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

            • glyceryl trinitrate pr

              dihydroergotamine intranasal decreases effects of glyceryl trinitrate pr by pharmacodynamic antagonism. Contraindicated.

            • idelalisib

              idelalisib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • imatinib

              imatinib increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • indinavir

              indinavir will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • isoniazid

              isoniazid will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • itraconazole

              itraconazole will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Increased risk of ergotism leading to cerebral ischemia and/or ischemia of the extremities

            • ketoconazole

              ketoconazole will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • letermovir

              letermovir increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Coadministration of letermovir and ergot alkaloids is contraindicated due to risk of ergotism.

            • lopinavir

              lopinavir increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • mifepristone

              mifepristone increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Contraindicated with CYP3A substrates that have a narrow therapeutic index .

            • naratriptan

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

            • nefazodone

              nefazodone will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nelfinavir

              nelfinavir will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nicardipine

              nicardipine increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nitroglycerin IV

              dihydroergotamine intranasal decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin sublingual

              dihydroergotamine intranasal decreases effects of nitroglycerin sublingual by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin topical

              dihydroergotamine intranasal decreases effects of nitroglycerin topical by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin transdermal

              dihydroergotamine intranasal decreases effects of nitroglycerin transdermal by pharmacodynamic antagonism. Contraindicated.

            • nitroglycerin translingual

              dihydroergotamine intranasal decreases effects of nitroglycerin translingual by pharmacodynamic antagonism. Contraindicated.

            • posaconazole

              posaconazole will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • pseudoephedrine

              dihydroergotamine intranasal increases effects of pseudoephedrine by pharmacodynamic synergism. Contraindicated. Ergot derivatives may enhance the vasoconstricting effect of pseudoephedrine and eventually significantly increasing blood pressure.

            • quinidine

              quinidine increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • ritonavir

              ritonavir will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • rizatriptan

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

            • saquinavir

              saquinavir increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • sumatriptan

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

            • sumatriptan intranasal

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

            • tipranavir

              tipranavir increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • voriconazole

              voriconazole will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • zolmitriptan

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

            Serious - Use Alternative (95)

            • abametapir

              abametapir will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. For 2 weeks after abametapir application, avoid taking drugs that are CYP3A4 substrates. If not feasible, avoid use of abametapir.

            • amobarbital

              amobarbital will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • aprepitant

              aprepitant will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • armodafinil

              armodafinil will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • artemether/lumefantrine

              artemether/lumefantrine will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • benzphetamine

              dihydroergotamine intranasal, benzphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • bosentan

              bosentan will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • brigatinib

              brigatinib will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Brigatinib induces CYP3A4 in vitro. Coadministration with CYP3A4 substrates, particularly those with a narrow therapeutic index, can result in decreased concentrations and loss of efficacy. If unable to avoid coadministration, monitor CYP3A4 substrate levels and adjust dose as needed.

            • bromocriptine

              dihydroergotamine intranasal, bromocriptine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. The concomitant use of bromocriptine with ergot alkaloids may potentially lead to ergot toxicity; therefore the combination should be avoided.

            • budesonide

              budesonide will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • butabarbital

              butabarbital will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • butalbital

              butalbital will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • carbamazepine

              carbamazepine will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cimetidine

              cimetidine will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cobicistat

              cobicistat will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • cortisone

              cortisone will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • cyclosporine

              cyclosporine will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • darifenacin

              darifenacin will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • dasatinib

              dasatinib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • dexamethasone

              dexamethasone will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • dexfenfluramine

              dihydroergotamine intranasal, dexfenfluramine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

              dexfenfluramine, dihydroergotamine intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Risk of serotonin syndrome.

            • dexmethylphenidate

              dihydroergotamine intranasal, dexmethylphenidate. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • dextroamphetamine

              dihydroergotamine intranasal, dextroamphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • DHEA, herbal

              DHEA, herbal will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • diethylpropion

              dihydroergotamine intranasal, diethylpropion. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • diltiazem

              diltiazem will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • dobutamine

              dihydroergotamine intranasal, dobutamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • dopamine

              dihydroergotamine intranasal, dopamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • dronedarone

              dronedarone will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • efavirenz

              efavirenz will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • enzalutamide

              enzalutamide will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • ephedrine

              dihydroergotamine intranasal, ephedrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • epinephrine

              dihydroergotamine intranasal, epinephrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • eslicarbazepine acetate

              eslicarbazepine acetate will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • etravirine

              etravirine will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fenfluramine

              dihydroergotamine intranasal, fenfluramine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

              fenfluramine, dihydroergotamine intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Risk of serotonin syndrome.

            • fluconazole

              fluconazole will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fludrocortisone

              fludrocortisone will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • fluvoxamine

              fluvoxamine will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • fosphenytoin

              fosphenytoin will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • grapefruit

              grapefruit will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • griseofulvin

              griseofulvin will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • hydrocortisone

              hydrocortisone will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • isocarboxazid

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

            • isoproterenol

              dihydroergotamine intranasal, isoproterenol. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • ivosidenib

              ivosidenib will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of sensitive CYP3A4 substrates with ivosidenib or replace with alternate therapies. If coadministration is unavoidable, monitor patients for loss of therapeutic effect of these drugs.

            • lapatinib

              lapatinib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • linezolid

              linezolid and dihydroergotamine intranasal 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.

            • lisdexamfetamine

              dihydroergotamine intranasal, lisdexamfetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • lumefantrine

              lumefantrine will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • marijuana

              marijuana will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • methamphetamine

              dihydroergotamine intranasal, methamphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • methylene blue

              methylene blue and dihydroergotamine intranasal 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.

            • methylenedioxymethamphetamine

              dihydroergotamine intranasal, methylenedioxymethamphetamine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • methylphenidate

              dihydroergotamine intranasal, methylphenidate. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • methylprednisolone

              methylprednisolone will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • metronidazole

              metronidazole will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • miconazole vaginal

              miconazole vaginal will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • midodrine

              dihydroergotamine intranasal, midodrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • modafinil

              modafinil will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • nevirapine

              nevirapine will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nifedipine

              nifedipine will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • nilotinib

              nilotinib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • nilutamide

              nilutamide will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • norepinephrine

              dihydroergotamine intranasal, norepinephrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • oxcarbazepine

              oxcarbazepine will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • pentobarbital

              pentobarbital will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • phendimetrazine

              dihydroergotamine intranasal, phendimetrazine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenelzine

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

            • phenobarbital

              phenobarbital will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • phentermine

              dihydroergotamine intranasal, phentermine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenylephrine

              dihydroergotamine intranasal, phenylephrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenylephrine PO

              dihydroergotamine intranasal, phenylephrine PO. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • phenytoin

              phenytoin will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • prednisone

              prednisone will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • primidone

              primidone will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • procarbazine

              procarbazine and dihydroergotamine intranasal both increase serotonin levels. Avoid or Use Alternate Drug.

            • propylhexedrine

              dihydroergotamine intranasal, propylhexedrine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • quinupristin/dalfopristin

              quinupristin/dalfopristin will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rifabutin

              rifabutin will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rifampin

              rifampin will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • rifapentine

              rifapentine will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • rufinamide

              rufinamide will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • secobarbital

              secobarbital will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • sotorasib

              sotorasib will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If use is unavoidable, refer to the prescribing information of the CYP3A4 substrate for dosage modifications

            • St John's Wort

              St John's Wort will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • topiramate

              topiramate will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • tranylcypromine

              tranylcypromine and dihydroergotamine intranasal both increase serotonin levels. Avoid or Use Alternate Drug.

            • triamcinolone acetonide injectable suspension

              triamcinolone acetonide injectable suspension will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            • tucatinib

              tucatinib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid concomitant use of tucatinib with CYP3A substrates, where minimal concentration changes may lead to serious or life-threatening toxicities. If unavoidable, reduce CYP3A substrate dose according to product labeling.

            • verapamil

              verapamil will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.

            • voxelotor

              voxelotor will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Voxelotor increases systemic exposure of sensitive CYP3A4 substrates. Avoid coadministration with sensitive CYP3A4 substrates with a narrow therapeutic index. Consider dose reduction of the sensitive CYP3A4 substrate(s) if unable to avoid.

            • xylometazoline

              dihydroergotamine intranasal, xylometazoline. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • yohimbine

              dihydroergotamine intranasal, yohimbine. Mechanism: pharmacodynamic synergism. Contraindicated. Additive vasospasm; risk of hypertension.

            • zafirlukast

              zafirlukast will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug.

            Monitor Closely (73)

            • 5-HTP

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

            • almotriptan

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

            • amitriptyline

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

            • amoxapine

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

            • axitinib

              dihydroergotamine intranasal increases levels of axitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • belzutifan

              belzutifan will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. If unable to avoid coadministration of belzutifan with sensitive CYP3A4 substrates, consider increasing the sensitive CYP3A4 substrate dose in accordance with its prescribing information.

            • buspirone

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

            • citalopram

              citalopram and dihydroergotamine intranasal both increase serotonin levels. Use Caution/Monitor. Combination may increase risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions.

            • clomipramine

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

            • cocaine

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

            • crizotinib

              crizotinib increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Coadministration of crizotinib with CYP3A substrates with narrow therapeutic indices should be avoided.

            • dabrafenib

              dabrafenib will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely.

            • deferasirox

              deferasirox will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Use ergot alkaloids with caution with less potent CYP3A4 inhibitors.

            • desipramine

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

            • dexfenfluramine

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

            • dextroamphetamine

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

            • dextromethorphan

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

            • doxepin

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

            • duloxetine

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

            • duvelisib

              duvelisib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. will increase the level or effect of

            • elagolix

              elagolix will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Elagolix is a weak-to-moderate CYP3A4 inducer. Monitor CYP3A substrates if coadministered.

            • eletriptan

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

            • encorafenib

              encorafenib, dihydroergotamine intranasal. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Encorafenib both inhibits and induces CYP3A4 at clinically relevant plasma concentrations. Coadministration of encorafenib with sensitive CYP3A4 substrates may result in increased toxicity or decreased efficacy of these agents.

            • ergotamine

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

            • escitalopram

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

            • fenfluramine

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

              dihydroergotamine intranasal decreases effects of fenfluramine by pharmacodynamic antagonism. Use Caution/Monitor. Potent serotonin receptor antagonists may decrease fenfluramine efficacy. If coadministered, monitor appropriately.

            • finerenone

              dihydroergotamine intranasal will increase the level or effect of finerenone by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Monitor serum potassium during initiation and dosage adjustment of either finererone or weak CYP3A4 inhibitors. Adjust finererone dosage as needed.

            • fluoxetine

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

            • fluvoxamine

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

            • frovatriptan

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

            • iloperidone

              iloperidone increases levels of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Iloperidone is a time-dependent CYP3A inhibitor and may lead to increased plasma levels of drugs predominantly eliminated by CYP3A4.

            • imipramine

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

            • isoniazid

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

            • istradefylline

              istradefylline will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Istradefylline 40 mg/day increased peak levels and AUC of CYP3A4 substrates in clinical trials. This effect was not observed with istradefylline 20 mg/day. Consider dose reduction of sensitive CYP3A4 substrates.

            • L-tryptophan

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

            • levodopa

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

            • levomilnacipran

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

            • lithium

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

            • lofepramine

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

            • lomitapide

              dihydroergotamine intranasal increases levels of lomitapide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. Lomitapide dose should not exceed 30 mg/day.

            • lsd

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

            • maprotiline

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

            • meperidine

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

            • milnacipran

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

            • mirtazapine

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

            • mitotane

              mitotane will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • morphine

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

            • naratriptan

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

            • nefazodone

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

            • nitroglycerin rectal

              nitroglycerin rectal will increase the level or effect of dihydroergotamine intranasal by Other (see comment). Use Caution/Monitor. Oral administration of nitroglycerin markedly decreases the first-pass metabolism of dihydroergotamine and consequently increases its oral bioavailability. Ergotamine is known to precipitate angina pectoris. Therefore the possibility of ergotism in patients receiving nitroglycerin should be considered.

            • nortriptyline

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

            • paroxetine

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

            • pentazocine

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

            • protriptyline

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

            • rasagiline

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

            • ribociclib

              ribociclib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • rizatriptan

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

            • rucaparib

              rucaparib will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dosage of CYP3A4 substrates, if clinically indicated.

            • SAMe

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

            • schisandra

              schisandra will increase the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • selegiline

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

            • selegiline transdermal

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

            • sertraline

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

            • St John's Wort

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

            • stiripentol

              stiripentol, dihydroergotamine intranasal. affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Stiripentol is a CYP3A4 inhibitor and inducer. Monitor CYP3A4 substrates coadministered with stiripentol for increased or decreased effects. CYP3A4 substrates may require dosage adjustment.

            • sumatriptan

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

            • sumatriptan intranasal

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

            • tazemetostat

              tazemetostat will decrease the level or effect of dihydroergotamine intranasal by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.

            • tramadol

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

            • trazodone

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

            • trimipramine

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

            • venlafaxine

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

            • zolmitriptan

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

            Minor (20)

            • acebutolol

              dihydroergotamine intranasal, acebutolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • atenolol

              dihydroergotamine intranasal, atenolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • betaxolol

              dihydroergotamine intranasal, betaxolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • bisoprolol

              dihydroergotamine intranasal, bisoprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • carvedilol

              dihydroergotamine intranasal, carvedilol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • celiprolol

              dihydroergotamine intranasal, celiprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • esmolol

              dihydroergotamine intranasal, esmolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • green tea

              green tea increases levels of dihydroergotamine intranasal by enhancing GI absorption. Applies only to oral form of both agents. Minor/Significance Unknown. Due to caffeine content.

            • labetalol

              dihydroergotamine intranasal, labetalol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • metoprolol

              dihydroergotamine intranasal, metoprolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nadolol

              dihydroergotamine intranasal, nadolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nebivolol

              dihydroergotamine intranasal, nebivolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nicotine inhaled

              dihydroergotamine intranasal, nicotine inhaled. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • nicotine intranasal

              dihydroergotamine intranasal, nicotine intranasal. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • penbutolol

              dihydroergotamine intranasal, penbutolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • pindolol

              dihydroergotamine intranasal, pindolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • propranolol

              dihydroergotamine intranasal, propranolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • ruxolitinib

              dihydroergotamine intranasal will increase the level or effect of ruxolitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Minor/Significance Unknown.

            • sotalol

              dihydroergotamine intranasal, sotalol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

            • timolol

              dihydroergotamine intranasal, timolol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Additive vasospasm.

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            Adverse Effects

            >10%

            Rhinitis (26%)

            1-10%

            Nausea (10%)

            Altered taste (8%)

            Application site reactions (6%)

            Vomiting (4%)

            Somnolence (3%)

            Paraesthesia (2%)

            Pharyngitis (3%)

            Diarrhea (2%)

            Sinusitis (1%)

            Hot flashes (1%)

            Fatigue (1%)

            Asthenia (1%)

            Dry mouth (1%)

            Stiffness (1%)

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            Warnings

            Black Box Warnings

            Serious and/or life-threatening peripheral ischemia has been reported with coadministration of this drug with potent CYP3A4 inhibitors (including protease inhibitors and macrolide antibiotics)

            Because CYP3A4 inhibition elevates the serum ergotamine levels, the risk of vasospasm leading to cerebral ischemia and/or ischemia of the extremities is increased

            Concurrent use of these potent CYP3A4 inhibitors are contraindicated

            Contraindications

            Hypersensitivity

            Peripheral vascular disease, severe hepatic/renal impairment, ischemic heart disease, uncontrolled hypertension, sepsis, pregnancy, breastfeeding women

            Recent vascular surgery

            Hemiplegic or basilar migraine

            Coadministration with potent CYP3A4 inhibitors

            Peripheral or central vasoconstrictors

            Cautions

            Coadministration with less potent CYP3A4 inhibitors

            Fibrotic complications reported (pleural and retroperitoneal fibrosis with prolonged parenteral use)

            May cause coronary vasospasm

            Avoid in patients with unrecognized CAD (ie, patient with risk factors)

            May cause vasospastic reactions including myocardial, peripheral vascular, and colonic ischemia

            May elevate blood pressure

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            Pregnancy & Lactation

            Pregnancy Category: X

            Lactation: Contraindicated; excreted in human milk and is known to inhibit prolactin

            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

            Binds with high affinity to 5-HT-1Dα and 5-HT-1Dβ; also bind to serotonin 5-HT-1A, -2A, and -2C receptors, noradrenaline α2A, α2B, and alpha receptors, and dopamine D2L and D3 receptors

            Therapeutic activity attributed to agonist effect at 5-HT-1D receptors, which includes vasoconstriction of intracranial blood vessels, or activation of 5-HT1D may inhibit proinflammatory neuropeptide release

            Absorption

            Bioavailability: 32%

            Distribution

            Protein bound: 93%

            Vd: 800 L

            Metabolism

            Metabolites: 8'-β-hydroxydihydroergotamine (active); metabolites represent 20-30% of plasma AUC

            Elimination

            Half-life: 10 hr

            Renal clearance: 0.1 L/min

            Total body clearance: 1.5 mL/min

            Excretion: Major excretory route is in the bile and feces; urine 2%

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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.
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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.