Sumatriptan Explained

Sumatriptan, sold under the brand name Imitrex among others, is a medication used to treat migraine headaches and cluster headaches.[1] It is taken orally, intranasally, or by subcutaneous injection. Therapeutic effects generally occur within three hours.

Its primary effect as a serotonin 5-HT1B/5-HT1D receptor agonist[2] can create common side effects such as chest pressure, fatigue, vomiting, tingling, and vertigo. Serious side effects may include serotonin syndrome, heart attacks, strokes, and seizures. With excessive use, medication overuse headaches may occur. It is unclear if use during pregnancy or breastfeeding is safe.[3] The mechanism of action is not entirely clear.[4] It is in the triptan class of medications.[4]

Sumatriptan was patented in 1982 and approved for medical use in 1991.[5] It is on the World Health Organization's List of Essential Medicines.[6] It is available as a generic medication.[1] In 2021, it was the 109th most commonly prescribed medication in the United States, with more than 5million prescriptions.[7] [8] It is also available as the combination product sumatriptan/naproxen.

Medical uses

Sumatriptan is effective for ending or relieving the intensity of migraine and cluster headaches. It is most effective when taken early after the start of the pain.[9] Injected sumatriptan is more effective than other formulations.[10]

Oral sumatriptan can be used also in the treatment of post-dural puncture headache.[11]

Adverse effects

Overdose of sumatriptan can cause sulfhemoglobinemia, a rare condition in which the blood changes from red to green, due to the integration of sulfur into the hemoglobin molecule.[12] If sumatriptan is discontinued, the condition reverses within a few weeks.

Serious cardiac events, including some that have been fatal, have occurred following the use of sumatriptan injection or tablets. Events reported have included coronary artery vasospasm, transient myocardial ischemia, myocardial infarction, ventricular tachycardia, and ventricular fibrillation.[13]

The most common side effects[14] reported by at least 2% of patients in controlled trials of sumatriptan (25-, 50-, and 100-mg tablets) for migraine are atypical sensations (paresthesias and warm/cold sensations) reported by 4% in the placebo group and 5–6% in the sumatriptan groups, pain and other pressure sensations (including chest pain) reported by 4% in the placebo group and 6–8% in the sumatriptan groups, neurological events (vertigo) reported by less than 1% in the placebo group and less than 1% to 2% in the sumatriptan groups. Malaise/fatigue occurred in less than 1% of the placebo group and 2–3% of the sumatriptan groups. Sleep disturbance occurred in less than 1% in the placebo group to 2% in the sumatriptan group.

Interactions

Concurrent use with other triptans or ergot-containing medications within 24 hours can result in additive vasoconstriction.[15] [16] Increased systemic exposure to sumatriptan can occur if used within 2 weeks after a monoamine oxidase inhibitor. Cases of serotonin syndrome have been reported with co-administration of triptans and serotonin reuptake inhibitors.

Pharmacology

Mechanism of action

Sumatriptan is molecularly similar to serotonin (5-HT), and is a 5-HT receptor (types 5-HT1D and 5-HT1B[17]) agonist. Sumatriptan's primary therapeutic effect is related in its inhibition of the release of Calcitonin gene-related peptide (CGRP), likely through its 5-HT1D/1B receptor-agonist action.[18] This has been substantiated by the efficacy of more recently developed CGRP targeting drugs and antibodies developed for the preventive treatment of migraine.[19] How agonism of the 5-HT1D/1B receptors inhibits CGRP release is not fully understood. CGRP is believed to cause sensitization of trigeminal nociceptive neurons, contributing to the pain experienced in migraine.[20]

Sumatriptan is also shown to decrease the activity of the trigeminal nerve, which presumably accounts for sumatriptan's efficacy in treating cluster headaches. The injectable form of the drug has been shown to abort a cluster headache within 30 minutes in 77% of cases.[21]

Pharmacokinetics

Sumatriptan is administered in several forms: tablets, subcutaneous injection, and nasal spray. Oral administration (as succinate salt) has low bioavailability, partly due to presystemic metabolism—some of it gets broken down in the stomach and bloodstream before it reaches the target arteries. A rapid-release tablet formulation with the same bioavailability but a high concentration can achieve therapeutic effects on average 10–15 minutes earlier than other oral forumulations. When injected, sumatriptan is faster-acting (usually within 10 minutes), but the effect lasts for a shorter time. Sumatriptan is metabolised primarily by monoamine oxidase A into 2-acetic acid, which is then conjugated to glucuronic acid. These metabolites are excreted in the urine and bile. Only about 3% of the active drug may be recovered unchanged.

There is no simple, direct relationship between sumatriptan concentration (pharmacokinetics) per se in the blood and its anti-migraine effect (pharmacodynamics). This paradox has, to some extent, been resolved by comparing the rates of absorption of the various sumatriptan formulations, rather than the absolute amounts of drug that they deliver.[22] [23]

History

In 1991, Glaxo received approval for sumatriptan, which was the first available triptan.

In July 2009, the US FDA approved a single-use jet injector formulation of sumatriptan. The device delivers a subcutaneous injection of sumatriptan, without the use of a needle. Autoinjectors with needles have been previously available in Europe and North America.[24]

Phase III studies with an iontophoretic transdermal patch (Zelrix/Zecuity) started in July 2008. This patch uses low voltage controlled by a pre-programmed microchip to deliver a single dose of sumatriptan through the skin within 30 minutes.[25] [26] Zecuity was approved by the US FDA in January 2013.[27] Sales of Zecuity have been stopped following reports of skin burns and irritation.[28]

Society and culture

Legal status

In the United States, it is available only by medical prescription. It is available over the counter in many states in Australia. The product requires labelling by a pharmacist and is only available in packs of two without a medical prescription.[29] However, it can be bought over the counter in the UK[30] and Sweden.[31]

In Russia, versions of sumatriptan which are not registered in the State Register of Medicines may be regarded as narcotic drugs (derivatives of dimethyltryptamine).[32]

Generics

Glaxo patents for sumatriptan expired in February 2009. At that time, Imitrex sold for about $25 a pill.[33] Par Pharmaceutical then introduced generic versions of sumatriptan injection (sumatriptan succinate injection) 4- and 6-mg starter kits and 4- and 6-mg filled syringe cartridges, and 6-mg vials soon after.[34]

Mylan Laboratories Inc., Ranbaxy Laboratories, Sandoz (a subsidiary of Novartis), Dr. Reddy's Laboratories, and other companies have been producing generic versions of sumatriptan tablets in 25-, 50-, and 100-mg doses. Generic forms of the drug are available in U.S. and European markets after Glaxo's patent protections expired in the respective countries. A nasal spray form of sumatriptan known as AVP-825 has been developed by Avanir and is generically available in some countries.[35]

Controversy

According to the American Headache Society, "Patients frequently state that they have difficulty accessing triptans prescribed to them." In the U.S. triptans cost from $12 to $120 each, and more than 80% of U.S. health insurance plans place a limit on the amount of pills available to a patient per month, which has been called "arbitrary and unfair."

Notes and References

  1. Book: British National Formulary: BNF 76. 2018. Pharmaceutical Press. 9780857113382. 474. 76.
  2. Syed YY . Sumatriptan/Naproxen Sodium: A Review in Migraine . Drugs . 76 . 1 . 111–121 . January 2016 . 26628293 . 10.1007/s40265-015-0521-8 . 25060147 .
  3. Web site: Sumatriptan Use During Pregnancy . Drugs.com . 3 March 2019 .
  4. Web site: Sumatriptan Monograph for Professionals . Drugs.com . American Society of Health-System Pharmacists . 3 March 2019 .
  5. Book: Fischer J, Ganellin CR . Analogue-based Drug Discovery . 2006 . John Wiley & Sons . 9783527607495 . 531 .
  6. Book: ((World Health Organization)) . World Health Organization model list of essential medicines: 22nd list (2021) . 2021 . 10665/345533 . World Health Organization . World Health Organization . Geneva . WHO/MHP/HPS/EML/2021.02 . free .
  7. Web site: The Top 300 of 2021 . ClinCalc . 14 January 2024 . 15 January 2024 . https://web.archive.org/web/20240115223848/https://clincalc.com/DrugStats/Top300Drugs.aspx . live .
  8. Web site: Sumatriptan - Drug Usage Statistics . ClinCalc . 14 January 2024.
  9. Derry CJ, Derry S, Moore RA . Sumatriptan (all routes of administration) for acute migraine attacks in adults - overview of Cochrane reviews . The Cochrane Database of Systematic Reviews . 2014 . 5 . CD009108 . May 2014 . 24865446 . 6469574 . 10.1002/14651858.CD009108.pub2 .
  10. Dahlöf CG . Sumatriptan: pharmacological basis and clinical results . Current Medical Research and Opinion . 17 . s35–s45 . 2001 . Suppl 1 . 12463276 . 10.1185/0300799039117010 . 16 July 2016 . live . 2355125 . dmy-all . https://web.archive.org/web/20170217060845/http://www.medscape.com/viewarticle/429671_4 . 17 February 2017 .
  11. Shaat AM, Abdalgaleil MM . 1 January 2021. Is theophylline more effective than sumatriptan in the treatment of post-dural puncture headache? A randomized clinical trial. Egyptian Journal of Anaesthesia. 37. 1. 310–316. 10.1080/11101849.2021.1949195. 1110-1849. free.
  12. News: Patient bleeds dark green blood . 8 June 2007 . BBC News . 6 March 2010 . live . https://web.archive.org/web/20100805042210/http://news.bbc.co.uk/2/hi/health/6733203.stm . 5 August 2010 . dmy-all .
  13. Kelly KM . Cardiac arrest following use of sumatriptan . Neurology . 45 . 6 . 1211–1213 . June 1995 . 7783891 . 10.1212/wnl.45.6.1211 . 35168945 .
  14. Web site: Tablets . fda.gov . 19 February 2018 .
  15. Web site: DailyMed - SUMATRIPTAN- sumatriptan succinate tablet tablet . 2024-05-03 . dailymed.nlm.nih.gov.
  16. Web site: Drugs for Migraine The Medical Letter Inc. . 2024-05-03 . en.
  17. Razzaque Z, Heald MA, Pickard JD, Maskell L, Beer MS, Hill RG, Longmore J . Vasoconstriction in human isolated middle meningeal arteries: determining the contribution of 5-HT1B- and 5-HT1F-receptor activation . British Journal of Clinical Pharmacology . 47 . 1 . 75–82 . January 1999 . 10073743 . 2014192 . 10.1046/j.1365-2125.1999.00851.x .
  18. Juhasz G, Zsombok T, Jakab B, Nemeth J, Szolcsanyi J, Bagdy G . Sumatriptan causes parallel decrease in plasma calcitonin gene-related peptide (CGRP) concentration and migraine headache during nitroglycerin induced migraine attack . Cephalalgia . 25 . 3 . 179–183 . March 2005 . 15689192 . 10.1111/j.1468-2982.2005.00836.x . 13007101 .
  19. Tso AR, Goadsby PJ . Anti-CGRP Monoclonal Antibodies: the Next Era of Migraine Prevention? . Current Treatment Options in Neurology . 19 . 8 . 27 . August 2017 . 28653227 . 5486583 . 10.1007/s11940-017-0463-4 .
  20. Giniatullin R, Nistri A, Fabbretti E . Molecular mechanisms of sensitization of pain-transducing P2X3 receptors by the migraine mediators CGRP and NGF . Molecular Neurobiology . 37 . 1 . 83–90 . February 2008 . 18459072 . 10.1007/s12035-008-8020-5 . 25689799 .
  21. Ekbom K, Waldenlind E, Richard L, Andersson B, Boivie J, Dizdar N, etal . Treatment of acute cluster headache with sumatriptan . The New England Journal of Medicine . 325 . 5 . 322–326 . August 1991 . 1647496 . 10.1056/NEJM199108013250505 . Sumatriptan Cluster Headache Study Group . free .
  22. Fox AW . February 2004 . Onset of effect of 5-HT1B/1D agonists: a model with pharmacokinetic validation . Headache . 44 . 2 . 142–147 . 10.1111/j.1526-4610.2004.04030.x . 14756852 . 25587940.
  23. Freidank-Mueschenborn E, Fox AW . June 2005 . Resolution of concentration-response differences in onset of effect between subcutaneous and oral sumatriptan . Headache . 45 . 6 . 632–637 . 10.1111/j.1526-4610.2005.05129a.x . 15953294 . 20755695.
  24. Brandes JL, Cady RK, Freitag FG, Smith TR, Chandler P, Fox AW, Linn L, Farr SJ . Needle-free subcutaneous sumatriptan (Sumavel DosePro): bioequivalence and ease of use . Headache . 49 . 10 . 1435–1444 . 2009 . 19849720 . 10.1111/j.1526-4610.2009.01530.x . 25696109 .
  25. Web site: SmartRelief -electronically assisted drug delivery (iontophoresis) . nupathe.com . 19 February 2018 . live . https://web.archive.org/web/20160107062814/http://www.nupathe.com/description.php?secid=3&subsecid=7#_ELECTRONIC_DRUG . 7 January 2016 . dmy-all .
  26. Pierce M, Marbury T, O'Neill C, Siegel S, Du W, Sebree T . Zelrix: a novel transdermal formulation of sumatriptan . Headache . 49 . 6 . 817–825 . June 2009 . 19438727 . 10.1111/j.1526-4610.2009.01437.x . 205683188 . free .
  27. Web site: Zecuity Approved by the FDA for the Acute Treatment of Migraine . nupathe.com . 19 February 2018 . live . https://web.archive.org/web/20160107062814/http://ir.nupathe.com/press-releases/nupathe-s-zecuity-approved-by-the-fda-for-the-acut-nasdaq-path-975802NuPathe's . 7 January 2016 . dmy-all .
  28. Web site: Teva pulls migraine patch Zecuity on reports of burning, scarring . FiercePharma . 13 June 2016 . 10 April 2017. live. https://web.archive.org/web/20170321022606/http://www.fiercepharma.com/pharma/teva-pulls-migraine-patch-zecuity-reports-burning-scarring. 21 March 2017.
  29. Web site: Poisons Standard June 2017 . 22 July 2017 . 18 May 2017 . live . https://web.archive.org/web/20170731114704/https://www.legislation.gov.au/Details/F2017L00605/Html/Text#_Toc471222305 . 31 July 2017 . dmy-all .
  30. Web site: Press release: First Over The Counter (OTC) migraine pill made available . Medicines and Healthcare Products Regulatory Agency . 28 January 2015 . http://webarchive.nationalarchives.gov.uk/20141205150130/http://www.mhra.gov.uk/NewsCentre/Pressreleases/CON2023768 . 5 December 2014 .
  31. Web site: European Medicines Agency . European Medicines Agency . Assessment Report: Sumatriptan Galpharm 50 mg Tablets . European Medicines Agency . 28 January 2015 . 20 . 23 November 2011 . live . https://web.archive.org/web/20160107062816/http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Public_assessment_report/human/002140/WC500122862.pdf . 7 January 2016 . dmy-all .
  32. Web site: Постановление Правительства РФ от 30 июня 1998 г. N 681 "Об утверждении перечня наркотических средств, психотропных веществ и их прекурсоров, подлежащих контролю в Российской Федерации" (с изменениями и дополнениями). ДМТ (диметилтриптамин) и его производные, за исключением производных, включенных в качестве самостоятельных позиций в перечень. Гарант. 28 April 2019. ru.
  33. Web site: GlaxoSmithKline sets out to dupe migraine sufferers with Treximet smoke and mirrors . 24 April 2008 . Community Catalyst . 22 March 2019.
  34. News: Par Pharmaceutical begins shipment of sumatriptan injection . https://web.archive.org/web/20081210132734/http://www.parpharm.com/media/NR_20081106.jsp . dead . 10 December 2008 . Par Pharmaceutical . 6 November 2008 . 25 November 2008 . dmy-all .
  35. News: LaMattina J . If You 'Want To Make A Good Drug Great' Cost Must Be Factored In . 13 February 2017 . Forbes . 2 March 2015 . live . https://web.archive.org/web/20170214105140/http://www.forbes.com/sites/johnlamattina/2015/03/03/if-you-want-to-make-a-good-drug-great-cost-must-be-factored-in/ . 14 February 2017 . dmy-all .

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