Imitrex
enUKsumatriptan succinate
Pharmacologic class: Selective 5-hydroxytryptamine1 (5-HT1) agonist
Therapeutic class: Vascular headache suppressant
Pregnancy risk category C
Action
Selectively activates vascular 5-HT1 receptor sites, causing vasoconstriction in intracranial arteries
Availability
Injection: 6 mg/0.5-ml prefilled syringes, 0.6 mg/0.5-ml single-dose vials; 6 mg/0.5-ml prefilled, single-dose, needle-free subcutaneous delivery system; 4- and 6-mg STATdose system containing two prefilled single-dose syringe cartridges and one STATdose Pen; 4-and 6-mg kits containing two prefilled single-dose syringe cartridges and one autoinjector pen
Nasal spray: 5 mg in 100-mcl unit dose spray device (package of six), 20 mg in 100-mcl unit dose spray device (package of six)
Tablets: 25 mg, 50 mg, 100 mg
Indications and dosages
➣ Acute migraine, cluster headaches
Adults: Initially, 25 mg P.O.; if response inadequate after 2 hours, may give up to 100 mg P.O. If migraine recurs, repeat dose q 2 hours, not to exceed 200 mg/day. Or 6 mg subcutaneously, repeated as needed after 1 hour, not to exceed 12 mg in 24 hours. If P.O. therapy will follow subcutaneous injection, additional P.O. sumatriptan may be given q 2 hours, not to exceed 100 mg/day. Or a single dose of 5, 10, or 20 mg intranasally in one nostril, repeated p.r.n. in 2 hours, not to exceed 40 mg in 24 hours.
Dosage adjustment
• Hepatic impairment
Contraindications
• Hypersensitivity to drug
• Hemiplegic or basilar migraine headache
• Ischemic cardiac, cerebrovascular, or peripheral vascular disease (such as a history of myocardial infarction, stroke, angina, or ischemic bowel)
• Uncontrolled hypertension
• Severe hepatic impairment
• MAO inhibitor use within past 14 days
• Use of other 5-HT1 agonists, ergotamine-containing drugs, or ergot-type products within past 24 hours
Precautions
Use cautiously in:
• patients with cardiovascular risk factors (hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history of cardiovascular disease, men over age 40, menopausal women)
• elderly patients
• women of childbearing age
• pregnant or breastfeeding patients
• children younger than age 18 (safety not established).
Administration
• Be aware that parenteral form is for subcutaneous use only.
• Be aware that an autoinjection device is available for use with the 4- and 6-mg prefilled syringe cartridges to facilitate patient self-administration using the 4- or 6-mg dose. For patients receiving doses other than 4 or 6 mg, only the 6-mg single-dose vial dosage form should be used.
See If patient has risk factors for coronary artery disease, know that first dose should be given in medical setting with emergency equipment at hand.
See Don't give within 14 days of MAO inhibitors.
See Don't administer within 24 hours of other 5-HT1 agonists, ergotamine-containing drugs, or ergot-type products.
Adverse reactions
CNS: headache, malaise, dizziness, drowsiness, fatigue, vertigo, anxiety, tight feeling in head, numbness
CV: angina, chest pressure or tightness, transient hypertension, ECG changes, coronary vasospasm, myocardial infarction
EENT: vision changes, nasal sinus discomfort, throat discomfort
GI: abdominal discomfort, dysphagia
Musculoskeletal: jaw discomfort, muscle cramps, myalgia, neck pain or stiffness
Skin: flushing; tingling; warm, cool or, burning sensation
Other: injection site reaction, feeling of heaviness or tightness
Interactions
Drug-drug. Dihydroergotamine, ergotamine, methysergide: increased risk of vasospastic reaction
Lithium, MAO inhibitors, selective serotonin reuptake inhibitors: weakness, hyperreflexia, incoordination
Drug-herbs. Horehound: enhanced serotonergic effects
Patient monitoring
See Monitor cardiovascular status closely. Be aware that drug may cause serious and possibly fatal cardiac disorders.
• Watch for neurologic and vision changes. Institute safety measures as needed to prevent injury.
• Monitor patient's response to drug. Assess need for repeat doses.
• Watch for injection site reaction, which should subside within 1 hour.
Patient teaching
• Instruct patient to take as soon as possible after migraine onset.
See Teach patient to recognize and immediately report serious cardiovascular reactions.
• Explain proper drug use. Tell patient it doesn't prevent migraine.
• With subcutaneous use, instruct patient to follow directions in the patient leaflet carefully before injecting drug and to inject dose subcutaneously using spring-loaded injector system or needle-free subcutaneous delivery system included in package. If headache recurs after dose, tell him he may take a second dose, but should wait at least 1 hour after initial dose and shouldn't exceed two 6-mg injections in a 24-hour period. Instruct him to report injection site reaction that doesn't subside within 1 hour.
• With oral use, tell patient he may take a second dose 2 hours after first dose if migraine recurs. Tell him he may repeat oral doses every 2 hours as needed, up to 200 mg in a 24-hour period.
• With intranasal use, tell patient to spray 5, 10, or 20 mg into one nostril, as prescribed. Tell him he may repeat dose after 2 hours but shouldn't exceed 40 mg in a 24-hour period.
• Advise patient not to use drug for more than four episodes per month.
• Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and herbs mentioned above.
SUMAtriptan
(soo-ma-trip-tan) sumatriptan,Alsuma
(trade name),Imitrex
(trade name),Imitrex STATdose
(trade name),Sumavel DosePro
(trade name),Zecuity
(trade name)Classification
Therapeutic: vascular headache suppressantsPharmacologic: five ht1 agonists
Indications
Action
Therapeutic effects
Pharmacokinetics
Time/action profile (relief of migraine)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | within 30 min | 2–4 hr | up to 24 hr |
| Subcut | 30 min | up to 2 hr | up to 24 hr |
| Nasal | within 60 min | 2 hr | unknown |
| TD | unknown | 2 hr | unknown |
Contraindications/Precautions
Adverse Reactions/Side Effects
All adverse reactions are less common after oral administrationCentral nervous system
- dizziness (most frequent)
- vertigo (most frequent)
- anxiety
- drowsiness
- fatigue
- feeling of heaviness
- feeling of tightness
- headache
- malaise
- strange feeling
- tight feeling in head
- weakness
Ear, Eye, Nose, Throat
- alterations in vision
- nasal sinus discomfort
- throat discomfort
Cardiovascular
- mi (life-threatening)
- angina
- chest pressure
- chest tightness
- coronary vasospasm
- ECG changes
- transient hypertension
Gastrointestinal
- abdominal discomfort
- dysphagia
Dermatologic
- tingling (most frequent)
- warm sensation (most frequent)
- burning sensation
- contact dermatitis (patch only)
- cool sensation
- flushing
Local
- injection site reaction (most frequent)
Musculoskeletal
- jaw discomfort
- muscle cramps
- myalgia
- neck pain
- neck stiffness
Neurologic
- numbness
Interactions
Drug-Drug interaction
The risk of vasospastic reactions may be ↑ by concurrent use of ergotamine or dihydroergotamine (avoid within 24 hr of each other).Avoid concurrent use with other 5HT1 agonists.MAO inhibitors may ↑ levels (do not use within 2 wk of discontinuing MAO inhibitor).↑ risk of serotonin syndrome when used with SSRI or SNRI antidepressants.↑ risk of serotonergic side effects including serotonin syndrome with St. John’s wort and SAMe.Route/Dosage
Hepatic Impairment
Oral (Adults) 25 mg initially; if response is inadequate at 2 hr, up to 50 mg may be given (initial doses of 25–50 mg may be more effective than 25 mg). If headache recurs, doses may be repeated q 2 hr (not to exceed 300 mg/day). If PO therapy is to follow subcut injection, additional PO sumatriptan may be taken q 2 hr (not to exceed 200 mg/day); no single oral dose should exceed 50 mg.Availability (generic available)
Nursing implications
Nursing assessment
- Assess pain location, intensity, duration, and associated symptoms (photophobia, phonophobia, nausea, vomiting) during migraine attack.
- Give initial subcut dose under observation to patients with potential for coronary artery disease including postmenopausal women, men >40 yr, patients with risk factors for coronary artery disease such as hypertension, hypercholesterolemia, obesity, diabetes, smoking, or family history. Monitor BP before and for 1 hr after initial injection. If angina occurs, monitor ECG for ischemic changes.
- Monitor for serotonin syndrome in patients taking SSRIs or SNRIs concurrently with sumatriptan.
Potential Nursing Diagnoses
Acute pain (Indications)Implementation
- Do not confuse sumatriptan with sitagliptin or zolmitriptan.
- Oral: Tablets should be swallowed whole; do not crush, break, or chew. Tablets are film-coated to prevent contact with tablet contents, which have an unpleasant taste and may cause nausea and vomiting.
- Subcutaneous: Administer as a single injection just below the skin. Solution is clear and colorless or pale yellow; do not use if dark-colored or cloudy or if beyond expiration date.
- Sumavel DosePro: The snap-off tip should sit firmly on the end of the clear medication chamber; do not use if tip tilted or broken off upon removal from packaging. Administer only in abdomen or thigh.
- Intranasal: 10-mg dose may be administered as 2 sprays of 5 mg in 1 nostril or 1 spray in each nostril.
- Transdermal: Apply to dry, non-irritated, intact skin of upper arm or thigh. Site must be relatively free of hair and without scars, tattoos, abrasions, eczema, psoriasis, melanoma, or contact dermatitis. After application, push activation button within 15 min and red light emitting diode (LED) will turn on. Secure patch with medical tape if needed. System stops operating when dosing complete; activation light turns off signaling system can be removed. System cannot be reactivated when completed. If light turns off before 4 hr, dosing has stopped and patch can be removed. Fold patch so adhesive sides stick together and discard away from children and pets; contains lithiummanganese dioxide batteries; dispose in accordance with state and local regulations.
- If headache is not completely relieved, may retreat no sooner than 2 hr in a different site; use no more than 2 patches in 24 hr. Rotate sites; do not apply to a previous site until site is free from erythema for at least 3 days.
Patient/Family Teaching
- Inform patient that sumatriptan should be used only during a migraine attack. It is meant to be used for relief of migraine attacks but not to prevent or reduce the number of attacks.
- Instruct patient to administer sumatriptan as soon as symptoms of a migraine attack appear, but it may be administered at any time during an attack. If migraine symptoms return, a second injection may be used. Allow at least 1 hr between doses, and do not use more than 2 injections in any 24-hr period. Additional sumatriptan doses are not likely to be effective, and alternative medications may be used. If no relief from 1st dose, unlikely 2nd dose will provide relief. Advise patient to read Patient Information prior to using and with each Rx refill; new information may be available.
- Advise patient that lying down in a darkened room after sumatriptan administration may further help relieve headache.
- Advise patient that overuse (use more than 10 days/mo) may lead to exacerbation of headache (migraine-like daily headaches, or as a marked increase in frequency of migraine attacks). May require gradual withdrawal of sumatriptan and treatment of symptoms (transient worsening of headache).
- Advise patient to notify health care professional before next dose of sumatriptan if pain or tightness in chest occurs during use. If pain is severe or does not subside, notify health care professional immediately. If wheezing; heart throbbing; swelling of eyelids, face, or lips; skin rash; skin lumps; or hives occur, notify health care professional immediately, and do not take more sumatriptan without approval of health care professional. If usual dose fails to relieve 3 consecutive headaches, or if frequency and/or severity increases, notify health care professional. If feelings of tingling, heat, flushing, heaviness, pressure, drowsiness, dizziness, tiredness, or sickness develop, discuss with health care professional at next visit.
- Sumatriptan may cause dizziness or drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
- Advise patient to avoid alcohol, which aggravates headaches, during sumatriptan use.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications Patients concurrently taking SSRI or SNRI antidepressants should notify health care professional promptly if signs of serotonin syndrome (mental status changes: agitation, hallucinations, coma; autonomic instability: tachycardia, labile BP, hyperthermia; neuromuscular aberrations: hyper-reflexia, incoordination; and/or gastrointestinal symptoms: nausea, vomiting, diarrhea) occur.
- Caution patient not to use sumatriptan if pregnant, suspects pregnancy, or plans to become pregnant. Adequate contraception should be used during therapy.
- Subcutaneous: Instruct patient on the proper technique for loading, administering, and discarding the autoinjector or for using Sumavel DosePro. Patient information pamphlet is provided. Instructional video is available from the manufacturer.
- Inform patient that pain or redness at the injection site usually lasts less than 1 hr.
- Intranasal: Instruct patient in proper technique for intranasal administration. Usual dose is a single spray in 1 nostril. If headache returns, a 2nd dose may be administered in ≥2 hr. Do not administer 2nd dose if no relief was provided by 1st dose without consulting health care professional.
- Transdermal: Instruct patient to read Patient Information and Instructions for Use before starting and with each Rx refill, in case of changes.
- Advise patient not to bathe, shower, or swim while wearing patch.
- Inform patient that skin redness under patch site that disappears within 24 hr is common. If signs and symptoms of allergic contact dermatitis (itching, redness, irritation, blistering or peeling, warmth or tenderness of skin, blisters that ooze, drain, or crust over) occur, stop using sumatriptan transdermal and notify health care professional.
- Advise patient referred for MRI test to discuss patch with referring health care professional and MRI facility to determine if removal of patch is necessary prior to test and for directions for replacing patch.
- Advise patient not to use more than 4 times/mo without consulting health care professional.
Evaluation/Desired Outcomes
- Relief of migraine attack.
Imitrex
(ĭm′ĭ-trĕks′)Imitrex®
Sumatriptan succinate, see there.Patient discussion about Imitrex
Q. What can i do other than taking Imitrex for my reccuring migraine headaches?