Almotriptan


Article Author:
Gursharan Sidhu


Article Editor:
Priti Patel


Editors In Chief:
Melissa Max
Danyae Lee
Manouchkathe Cassagnol


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
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Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
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Ahmad Malik
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James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/6/2019 3:29:20 PM

Indications

Almotriptan is the first FDA-approved drug used to treat migraine headaches in adults with or without an aura.[1] The drug is also useful in adolescents with a history of a migraine that, when left untreated, lasts 4 hours or longer. Certain triptan medications such as almotriptan and rizatriptan have also been shown to be effective and safe for management of acute migraines and other benign headaches in the pediatric population (less than 18 years of age).[2] 

Almotriptan has approval for use as monotherapy and in conjunction with migraine-abortive medications such as non-steroidal anti-inflammatory drugs (e.g., aceclofenac).[3] It is usually taken by mouth as a tablet.[4] Almotriptan is a white, coated circular tablet, and requires a prescription from a registered physician in the United States.[5] 

In pregnant women with migraines or headaches, triptan use is less frequent; where drugs like metoclopramide, and acetaminophen are more common choices for migraines due to their effectiveness and safety.[6] Triptans have also found to be quite effective in treating menstrual migraines in premenopausal women. Various studies have shown that among the triptans, rizatriptan has been proven to be the most beneficial in treating acute menstrual migraines in females.[7] In a randomized, placebo-controlled study it was shown that rizatriptan provided pain relief between 2 to 24 hours with an efficacy of 63 percent when compared to other classes of triptans.[7] 

Mechanism of Action

Almotriptan is a selective serotonin agonist on the 5-HT1B and 5-HT1D receptors in the cranial arteries. Activation of the 5HT receptors is associated with a reduction in neurogenic inflammation, which has been hypothesized to be involved in the migraine relief process.

Almotriptan works by narrowing the blood vessels in the brain, thereby reducing the cerebral blood flow, stopping the transmission of pain signals to the brain center.[8] The drug has a relatively short half-life of 3 hours, and the oral bioavailability was found to be 69.1%.[9] Almotriptan is excreted in the urine and metabolized predominantly by the cytochrome CYP450 system.[9] When compared with earlier generation triptans such as sumatriptan, almotriptan has a higher oral bioavailability and a shorter plasma half-life.[8]

Administration

The recommended oral dose of almotriptan is 12.5mg for the effective treatment of acute migraine attack in adults and adolescents.[9] The dose may be repeated after two hours if a headache returns. It is recommended to not administer more than two doses or more than 25 mg/day. Studies have also shown that almotriptan has a synergistic effect when combined with aceclofenac 100mg in the treatment of an acute migraine attack.[3] 

The absorption of almotriptan has not been shown to be affected by food intake; therefore, its dosing can be without regard to food intake.[9] Dosing adjustment recommended in patients with renal insufficiency. Dosing adjustment is necessary when the drug used with cytochrome P450 inducers (e.g., phenytoin, phenobarbital) and with cytochrome P450 inhibitors (e.g., antibiotics, grapefruit juice, Ketoconazole, protease inhibitors). 

Adverse Effects

The common adverse effects of almotriptan are found to be drowsiness, dizziness, headache, nausea, vomiting, chest pain and fatigue.[10] The drug is associated with a similar incidence of nausea/vomiting as compared to other classes of triptans (e.g., sumatriptan). However, it is found to have a decreased incidence of the other common adverse effects listed above, especially when compared to first generation triptans.[8][10] 

Almotriptan works on the 5HT1B receptors which are present in the coronary arteries; thus, the administration may result in coronary artery narrowing or spasms, leading to potential coronary artery vasospasm or myocardial infarction.[11] Some rare side effects of almotriptan include pulmonary vasoconstriction, serotonin syndrome, inhibition of trigeminal nerves.[12][13]

Contraindications

Almotriptan is contraindicated in patients with renal dysfunction or insufficiency. It is also contraindicated in the elderly due to a physiological decrease in renal function and renal clearance with advanced age.[9] 

Minor clearance of almotriptan occurs through the CYPP450 system (specifically, CYP3A4); therefore, other drugs metabolized through this pathway should be avoided because they may decrease almotriptan clearance. These drugs include but are not limited to verapamil, nifedipine, losartan, cyclosporine, and moclobemide.[9] It is then reasonable to assume that patients with a mutation in this specific enzyme should be cautious in dosing the drug.

Almotriptan is also contraindicated in patients with underlying cardiovascular disease due to the presence of 5HT1B receptors on the coronary arteries. Almotriptan can potentially attach to such receptors resulting in further narrowing or spasm of the arteries.[11] Patients with hypersensitivity to almotriptan should not use the drug. Almotriptan is also contraindicated in patients that may have a history of a hemiplegic or basilar migraine or a heart condition. Moreover, this medication may not be used in patients that have cerebrovascular syndromes, peripheral vascular disease, or high blood pressure. Caution is advised if dosing almotriptan within 24 hours of use of a serotonin agonist or an ergotamine-classified medication due to the vasoconstrictive effects of both drugs.[13] 

Monitoring

Patients taking almotriptan should require monitoring for the presence of side effects and response to therapy. Kidney function should be monitor when taking the drug as renal clearance may affect the drug clearance from the body, causing toxicity. Regular monitoring of the blood pressure should take place at each clinical visit due to the narrowing effect of the 5-HT1B receptors on the blood vessels, and assess the effectiveness of the drug.[13] 

Toxicity

There are no associated toxicities with almotriptan due to the limited data; although studies demonstrate increased preterm birth rates in pregnant women that received triptans for migraine relief.[14]

An analysis of several case reports of patients undergoing dual triptan-SSRI/SNRI therapy or triptan monotherapy suggested that the addition of triptans to SSRI/SNRI therapy does not necessarily increase the risk of patients developing serotonin syndrome. However, it is advisable for providers to remain cautious and vigilant of the symptoms.[15]

Enhancing Healthcare Team Outcomes

Managing the administration of almotriptan in patients with acute migraines requires an interprofessional team of healthcare professionals that include a neurologist, primary care physician, nephrologist in the case of a compromised renal function, psychiatrist, specialty-trained nursing staff, and pharmacist for appropriate dosing and safety precautions, all working collaboratively to ensure optimal patient outcomes. [Level V] A robust support system consisting of the patients' family and friends may also be beneficial in successful treatment. Consistent patient follow-up and adherence to appointment times are essential for proper monitoring of vital signs and management of any adverse effects. Moreover, it is also necessary for assessing drug effectiveness. 


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Almotriptan - Questions

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A 65-year-old patient comes into the clinic complaining of worsening headaches for the past 3 days. The patient has a history of acute migraines, diabetes mellitus type 2 and stable angina. He is currently on several medications as a form of treatment. Which drug would be appropriate for this patient at this time?



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A 14-year-old female patient comes into the clinic with her mother to discuss her treatment options for her acute migraines. The patient is afraid of injections. Which medication should be prescribed for this patient at this time?



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A 65-year-old patient walks into the pharmacy and hands you a prescription for Axert. Upon reviewing his medication profile, you find that he is currently taking Naprosyn and Nardil. What is the next step in managing his prescription?



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A 50-year-old female presents to the clinic with the complaint of acute migraine for the past two months. The patient has a history of renal failure, diabetes, depression, obesity, anemia, and hypertension. She believes that the stress is causing these migraines that she is having at work. On physical examination, her blood pressure is 130/80 mmHg, respiratory rate is 12/min, the temperature is 98 F, and the pulse is 80/min. Her current medications include fluoxetine, amlodipine, iron sulfate, and multivitamins. The provider pulls out literature before the relevant medication is prescribed. He informs her that the antidepressant would have to be switched before this medication can be prescribed, but she still has other conditions because of which this drug cannot be given to her. To which of the following conditions is the provider referring?



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Almotriptan - References

References

Formulation Approaches of Triptans for Management of Migraine., Kassem AA,, Current drug delivery, 2016     [PubMed]
Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review., Patniyot IR,Gelfand AA,, Headache, 2016 Jan     [PubMed]
Schoenen J,De Klippel N,Giurgea S,Herroelen L,Jacquy J,Louis P,Monseu G,Vandenheede M, Almotriptan and its combination with aceclofenac for migraine attacks: a study of efficacy and the influence of auto-evaluated brush allodynia. Cephalalgia : an international journal of headache. 2008 Oct;     [PubMed]
Dowson AJ, Oral almotriptan: practical uses in the acute treatment of migraine. Expert review of neurotherapeutics. 2004 May;     [PubMed]
McEnroe JD,Fleishaker JC, Clinical pharmacokinetics of almotriptan, a serotonin 5-HT(1B/1D) receptor agonist for the treatment of migraine. Clinical pharmacokinetics. 2005;     [PubMed]
Tepper SJ,Millson D, Safety profile of the triptans. Expert opinion on drug safety. 2003 Mar;     [PubMed]
Thorlund K,Toor K,Wu P,Chan K,Druyts E,Ramos E,Bhambri R,Donnet A,Stark R,Goadsby PJ, Comparative tolerability of treatments for acute migraine: A network meta-analysis. Cephalalgia : an international journal of headache. 2017 Sep;     [PubMed]
Dodick DW, Triptans and chest symptoms: the role of pulmonary vasoconstriction. Cephalalgia : an international journal of headache. 2004 Apr;     [PubMed]
Tepper SJ,Rapoport AM,Sheftell FD, Mechanisms of action of the 5-HT1B/1D receptor agonists. Archives of neurology. 2002 Jul;     [PubMed]
Eiland LS,Hunt MO, The use of triptans for pediatric migraines. Paediatric drugs. 2010 Dec 1;     [PubMed]
Sharma M,Vadhariya A,Johnson ML,Marcum ZA,Holmes HM, Association between industry payments and prescribing costly medications: an observational study using open payments and medicare part D data. BMC health services research. 2018 Apr 2;     [PubMed]
Hamilton KT,Robbins MS, Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study. Headache. 2019 Feb;     [PubMed]
Maasumi K,Tepper SJ,Kriegler JS, Menstrual Migraine and Treatment Options: Review. Headache. 2017 Feb;     [PubMed]
Soldin OP,Dahlin J,O'Mara DM, Triptans in pregnancy. Therapeutic drug monitoring. 2008 Feb;     [PubMed]
Shader RI,Greenblatt DJ, Is There Always a Right or Wrong?: Comments on the FDA Warnings About Triptans and the Serotonin Syndrome. Journal of clinical psychopharmacology. 2018 Dec;     [PubMed]

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