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

              sumatriptan intranasal and cocaine 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

            Current/history of: ischemic cardiac, cerebrovascular, or peripheral vascular syndromes (angina, MI, stroke, TIA, ischemic bowel disease)

            Uncontrolled hypertension

            Coadministration of MAO-A inhibitors or use within 2 weeks after discontinuing MAO-A inhibitors

            Use within 24 hr of any ergotamine-containing or ergot-type medication (eg, dihydroergotamine or methysergide)

            Use within 24 hr of other 5-HT1 agonists

            Hypersensitivity

            Severe hepatic impairment

            Not indicated for basilar or hemiplegic migraine

            Cautions

            Clear diagnosis of migraine headache has been established

            Overuse of acute migraine drugs (eg, ergotamine, triptans, opioids, or combination of these drugs for ≥10 days/month) may lead to exacerbation of headache (medication overuse headache)

            Serious cardiac and cerebrovascular events, including cerebral hemorrhage, subarachnoid hemorrhage, stroke, acute MI, arrhythmias, and death reported within a few hours after administration

            Chest discomfort and jaw or neck tightness reported infrequently following intranasal administration (relatively common following SC injection)

            Not for use with unrecognized CAD as predicted by risk factors (eg, hypertension, hypercholesterolemia, smoking, obesity, diabetes, strong family history of CAD, female with surgical or physiological menopause, male aged >40 yr)

            Serotonin syndrome may occur, particularly when coadministered with SSRIs (eg, fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram) or SNRIs (eg, venlafaxine, duloxetine) Increased blood pressure, including hypertensive crisis reported (rare)

            Local irritation of nose and throat reported

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            Pregnancy & Lactation

            Pregnancy Category: C

            Reproductive toxicity studies for sumatriptan by intranasal route have not been conducted; embryolethality and blood vessel abnormalities observed with PO or IV doses in pregnant rabbits during organogenesis

            Lactation: Excreted in human breast milk in very low levels (NLM Toxnet); minimize infant to potential exposure by avoiding breastfeeding for 8-12 hr after administration

            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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            • View the formulary and any restrictions for each plan.
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            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            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.