hey all welcome back to the real life pharmacology podcast i'm your host pharmacist eric christensen and i thank you so much for listening today go check out reallifepharmacology.com you can get a free 31-page pdf great study guide quick summary review of the top 200 drugs clinical practice pearls as well as things that show up on board exams a lot same thing if you're in pharmacy school med school nursing school and taking pharmacology you're going to see a lot of the information there potentially show up on pharmacology exams throughout your career too so again based on my experience things i've seen in practice as well as thoughts from others in academia as well so go check that out subscribe i get that absolutely for free reallifepharmacology.com we also give you updates as to when we have new podcasts and content episodes available there as well so go do that at reallifepharmacology.com and with that let's get into the drug of the day today and that is sumatriptin uh primary brand name you're going to hear in clinical practice is immatrax i definitely see this medication used periodically by far the most common situation i see it used for is acute migraine treatment with that said i have seen it used for cluster headaches as well if you remember in cluster headaches oxygen is an important treatment but i have seen tryptans used in combination uh specifically sumatriptan used in combination for relieving some of the symptoms of cluster headache as well mechanistically this is classified as a tryptan and it is a serotonin agonist and specifically as an agonist at the 5 ht 1b and 1d receptors and primarily what's going to result from this and what's likely theorized to be the benefit is vasoconstriction and reduction of inflammation which could obviously make headaches worse that vasodilation has been thought to cause headache pain or be associated with that with that said it's a lot of theories in the migraine world the brain is complicated structure and so i i don't think it's 100 percent figured out exactly how a migraine happens why a migraine happens what causes a migraine uh there there's a lot to learn still but the the theories there that vasoconstriction from these drugs and reduction of inflammation may help manage that migraine and abort a migraine or reduce the the pain and severity there i did want to mention tryptons generally aren't used first in migraine therapy unless it's kind of more moderate to severe for those milder cases we're going to generally use simple analgesics like acetaminophen and nsaids and as those don't work or as the progression of of migraine gets more severe then we start to lean into the tryptans other important things that i think to pay attention to we generally want to avoid using uh no more than uh nine doses per month kind of that magic number is 10 is probably easier to remember so less than 10 days per month we want to use a board of therapy these drugs maybe more so other drugs can cause rebound headaches or excuse me medication overuse headaches where we use too too much of the medication and then the headache uh remains and and continues to linger and potentially even get worse in some situations so again we we don't want to use abortive short-term acute migraine treatment on a chronic basis because that's going to potentially lead to more problems than it does good there dosing of sumatriptan 50 to 100 milligrams and we can repeat that dose two hours or later if the patient is still struggling with migraine symptoms so generally a max of 200 milligrams per day and depending upon the patient they're going to use a 50 milligram dose or 100 milligram dose pharmacokinetics is important there are multiple dosage forms of sumatriptin uh we've got oral we've got nasal we've got subq so this is going to be selected based upon pretty much what the patient likes and what's beneficial to them and also ease of administration of course so a good example of a patient that you you might avoid the oral root is a patient that has a lot of nausea and vomiting associated with their migraine if they're vomiting they're throwing that pill right back up they're not gonna get the dose and they're not gonna get the relief um with that said if somebody has nausea and vomiting might lean on more nasal administration or sub-q administration okay i did want to mention pharmacokinetics and this generally holds true i think for for any medication and any medication administration orals generally going to be slower nasal is a little bit quicker and sub-q and obviously iv is the fastest route of administration for a medication so specifically with sumatriptan oral is approximately 30 minutes for the onset nasal is 15 to 30 minutes in that ballpark sub q is is 10 minute onset approximately all right let's talk about adverse effects so first thing i want you to think of is vasoconstriction so that's one of the key characteristics in potential benefit in using a drug like sumatriptin in migraine treatment but vasoconstriction is generally not a good thing when it comes to other vessels and particularly you think of the heart and brain and situations like that vasoconstriction is a bad bad thing and can lead to heart attacks and strokes and things like that and indeed that is a potential concern with the use of tryptins now younger patients at low cardiovascular risk we typically aren't going to worry about that as much now if you've got a patient with multiple heart attack history stroke history tia history this is a concern and probably a situation where we're going to avoid tryptins and they are contraindicated in situations like that according to the package insert so really got to look at cardiovascular risks if you you know are struggling to kind of gauge that assessment and what other options we have for migraine treatment that type of thing it may help to get cardiology involved and see what their take is on their cardiovascular risk but again if you see that patient history you see them on anti-platelet agents anticoagulant type agents for prevention of strokes preventions of heart attack things like that that that is a concern with tryptans that it may increase that risk another thing cardiovascular-wise cardiac-wise i guess qt prolongation um so there has been a risk associated with using the tryptans in prolonging that qt interval so if you've got a patient at baseline that's already at risk due to other risk factors and if you go back to the amiodarone podcast i talk about a lot of those risks uh that may increase the risk for qt prolongation um definitely go go check that out but tryptons like sumatriptan can cause that issue or potentially make a cardiovascular event uh more probable there other adverse effects dizziness drowsiness um you know those are kind of more nuisance things in general and then we've got to remember the serotonin action agonist action so serotonin syndrome is a consideration there as well and then if you think about each of those individual dosage forms uh so local irritation injection site reactions things like that can happen obviously with the sub-q nasal discomfort nasal irritation can happen with the nasal dosage form gi upset can happen maybe more so with the the oral administration there so again all those adverse effects kind of go along with the way we're giving that drug all right so let's take a quick break from our sponsor and we'll wrap up with drug interactions if you're in the market for pharmacist board certification study material like bcps bcacp bcmtms a geriatric certification naplex exam go check out metadata101.com 101.com store s-t-o-r-e if you're a nurse dietitian med student physician nurse practitioner pa we've got all sorts of books audible books as well metad101.com store latest and greatest has been perils of polypharmacy a lot of people liked it i've been getting a lot of good reviews on that book a lot of experiences from my practice in primarily geriatrics and polypharmacy reducing meds i talk about strategies there as well as the prescribing cascade a lot of common examples there so again go check that out parallel poly pharmacy it's on amazon but yeah all those links you're going to find at meta101.com store s-t-o-re and as i finish up on drug interactions i want to of course mention my two books i've got a food drug interaction book that you can find at meta101.com store and i've got a common drug interactions in primary care book as well and they've they've both been been fairly highly rated i've been fortunate to have a lot of people enjoy and i think benefit from those books so again go check those out metadata101.com store okay so getting into our drug interactions uh there aren't a ton of drug interactions with tryptons uh as far as you know thinking about like enzymes like sip 2d6 or 3a4 that type of thing usually that's not terribly concerning with sumatriptin but there definitely are a few to consider and the two primary things are maois which again aren't used terribly often they're an older school agent that can be used for refractory depression but certainly we have some serotonin risks and things like that with that class and then the other serotonergic agents we can have some additive effects so ssris tcas tramadol snris these can all potentially increase the role of serotonin in the brain and increase the risk for serotonin syndrome okay and so when i think about these type of drug interactions i think about that cumulative effect so if i've got a patient on let's say snri like duloxetine 30 milligrams am i really worried about serotonin syndrome if a patient takes a trip down a couple times a month uh no probably not okay um now do i have a patient on a tca and maybe they're taking tramadol and their higher dosages and now we're taking more more and more frequent sumatriptan use that's a situation where it probably should be coming a little bit more into focus and we maybe should think about that a little bit further so again serotonin syndrome is extremely extremely rare i've only seen a couple of cases in 10 plus years of practice but it is you know relatively serious as well so it's important to think about but you know in general you want to look at the dosages look at the medications they're on how frequently they're taking it and really kind of do that risk assessment all right so i think that's going to wrap up the podcast for today thank you so much for listening leave us a rating review on itunes or wherever you're listening greatly appreciated for those of you that have already done that it helps us grow this podcast another way to help grow this podcast is shoot a friend an email with the podcast link url or reallifepharmacology.com help them get better at medication management medication safety and just learning pharmacology in general so again rating review on itunes and sharing it via email or whatever else you want to do so social media that has been greatly appreciative and it has grown the podcast uh far beyond anything i have ever imagined uh if you want to help keep this podcast free go to real life uh excuse me go to meded101.com store s-c-o-r-e your purchases there go directly to support this podcast if you want to track me down suggestions comments questions about study materials anything like that med education 101 gmail.com or you can track me down eric christensen pharmd bcgp bcps on linkedin all right thank you guys so much for listening uh take care hope you have a great rest of your day