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Symbravo
meloxicam/ rizatriptan
Black Box Warnings .
Cardiovascular Thrombotic Event
NSAIDs incr. risk of serious and potentially fatal cardiovascular thrombotic events, incl. MI and stroke; risk may occur early in tx and may incr. w/ duration of use; contraindicated in CABG periop setting
GI Bleeding, Ulceration, and Perforation
NSAIDs incr. risk of serious and potentially fatal GI adverse events incl. bleeding, ulcer, and stomach or intestine perforation; GI events may occur at any time during use and w/o warning sx; elderly pts and pts w/ hx of PUD or GI bleeding at greater risk for serious GI events
Adult Dosing .
Dosage forms: TAB: 20 mg/10 mg
Special Note
- [formulation clarification]
- Info: not interchangeable w/ other meloxicam or rizatriptan products; do not substitute on a mg to mg basis
migraine, acute
- [1 tab PO x1]
- Max: 1 tab/day; Info: use shortest effective tx duration; do not cut/crush/chew tab
renal dosing
- [see below]
- moderate-severe impairment: avoid use; moderate-severe impairment w/ volume depletion: contraindicated
- HD: contraindicated; PD: not defined
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised
Peds Dosing .
Peds dosing is currently unavailable or not applicable for this drug.
Contraindications / Cautions .
- hypersensitivity to drug or ingredient
- hypersensitivity to ASA
- hypersensitivity to NSAIDs
- MAO inhibitor use w/in 14 days
- asthma, ASA-induced
- asthma, NSAID-induced
- urticaria, ASA-induced
- urticaria, NSAID-induced
- aspirin triad
- ischemic heart dz
- coronary vasospasm
- CABG surgery periop use
- MI, recent
- CHF, severe
- WPW syndrome
- arrhythmia, cardiac accessory conduction pathway disorder-associated
- stroke hx
- TIA hx
- migraine, basilar
- migraine, hemiplegic
- ischemic bowel dz
- GI bleeding, active
- PVD
- HTN, uncontrolled
- renal impairment, moderate-severe
- renal dz, advanced
- CYP2C9 poor metabolizers
- pregnancy starting at 30 wk gestation
- caution: pregnancy at <30 wk gestation
- caution: elderly pts
- caution: debilitated pts
- caution: renal impairment
- caution: hepatic impairment
- caution: asthma
- caution: cardiovascular dz
- caution: cardiac dz risk
- caution: HTN
- caution: CHF
- caution: fluid retention
- caution: GI bleeding hx
- caution: PUD hx
- caution: coagulation disorder
- caution: dehydration
- caution: hypovolemia
- caution: smokers
- caution: alcohol use, concurrent
- caution: pts of childbearing potential trying to conceive
Drug Interactions .
Overview
meloxicam
NSAID
- CYP2C9 substrate
- affects growth hormone diagnostic test results
- alters gallbladder contraction/motility
- antiplatelet effects
- decreases renal perfusion/fxn
- GI mucosal injury/bleeding risk
- hyperkalemia
- hypertensive effects
- hyponatremia
- lowers seizure threshold
- thrombogenic effects
rizatriptan
5-HT1 agonist
- MAO substrate
- CNS depression
- hypertensive effects
- serotonergic effects
- add MAO inhibitor to Interaction Check if recent (14 days) use
Contraindicated
- almotriptan
- dihydroergotamine
- eletriptan
- ergotamine
- frovatriptan
- isocarboxazid
- ketorolac
- linezolid
- methylene blue oral
- methylergonovine
- naratriptan
- phenelzine
- procarbazine
- propranolol
- rizatriptan
- selegiline transdermal
- sumatriptan
- tranylcypromine
- yohimbe
- zolmitriptan
Avoid/Use Alternative
- adagrasib
- alfentanil
- amikacin
- amiodarone
- amphetamine
- asciminib
- aspirin
- bumetanide
- buprenorphine
- buspirone
- butorphanol
- celecoxib
- citalopram
- clofarabine
- clomipramine
- clonidine
- codeine
- cyclobenzaprine
- desipramine
- desvenlafaxine
- dextroamphetamine
- diclofenac
- diclofenac topical
- diflunisal
- dihydrocodeine
- doxylamine
- duloxetine
- efavirenz
- enoxaparin
- epinephrine inhaled
- escitalopram
- ethanol
- etodolac
- fenoprofen
- fentanyl
- fluconazole
- fluorouracil
- fluoxetine
- flurbiprofen
- fluvoxamine
- fondaparinux
- furosemide
- gepirone
- granisetron
- hydrocodone
- hydromorphone
- ibuprofen
- ibuprofen lysine
- indomethacin
- isoniazid
- kava
- ketoprofen
- kratom
- levomilnacipran
- levorphanol
- lisdexamfetamine
- lisinopril
- lithium
- macimorelin
- magnesium salicylate
- meclofenamate
- mefenamic acid
- meloxicam
- meperidine
- metaxalone
- methadone
- methamphetamine
- methotrexate
- metoclopramide
- miconazole oropharyngeal
- midazolam
- midodrine
- milk thistle
- milnacipran
- mirtazapine
- morphine
- nabumetone
- nalbuphine
- naproxen
- nitisinone
- nortriptyline
- oliceridine
- olmesartan medoxomil
- ondansetron
- opium
- oxaprozin
- oxybate
- oxycodone
- oxymorphone
- paroxetine
- pemetrexed
- pentazocine
- perindopril
- piroxicam
- potassium chloride
- potassium phosphate
- pralatrexate
- promethazine
- rasagiline
- remifentanil
- ropeginterferon alfa-2b
- safinamide
- salsalate
- selegiline
- sertraline
- St. John's wort
- sufentanil
- sulindac
- tacrolimus
- tapentadol
- tenofovir disoproxil
- thalidomide
- tolmetin
- tramadol
- tranexamic acid
- trimethobenzamide
- trimipramine
- vaccinia immune globulin
- valsartan
- venlafaxine
- vilazodone
- vortioxetine
- willow bark
- ziprasidone
- zuranolone
Monitor/Modify Tx
- 5-HTP
- abemaciclib
- abiraterone acetate
- abrocitinib
- acalabrutinib
- acebutolol
- acyclovir
- adefovir dipivoxil
- ado-trastuzumab emtansine
- afatinib
- aflibercept
- albuterol
- albuterol inhaled
- aldesleukin
- alendronate
- aliskiren
- alprazolam
- alteplase
- amikacin inhaled
- amiloride
- aminocaproic acid
- amitriptyline
- amlodipine
- amoxapine
- amphotericin
- anacaulase topical
- anagrelide
- angiotensin II
- anthrax immune globulin
- anti-inhibitor coagulant complex
- antihemophilic factor (factor VIII)/von Willebrand factor complex
- antithrombin
- apixaban
- aprocitentan
- arformoterol inhaled
- argatroban
- armodafinil
- asparaginase
- atenolol
- atidarsagene autotemcel
- atogepant
- atomoxetine
- atropine ophthalmic
- auranofin
- avapritinib
- avatrombopag
- axitinib
- azilsartan medoxomil
- baclofen intrathecal
- balsalazide
- baricitinib
- bazedoxifene
- benazepril
- benzphetamine
- betamethasone
- betaxolol
- bevacizumab
- binimetinib
- bismuth subsalicylate
- bisoprolol
- bivalirudin
- botulism immune globulin
- brentuximab vedotin
- brigatinib
- brolucizumab
- bromelain
- bromfenac ophthalmic
- bromocriptine
- budesonide
- bupropion
- butalbital
- C1 esterase inhibitor
- cabazitaxel
- cabozantinib
- caffeine
- caffeine citrate
- calaspargase
- candesartan cilexetil
- cangrelor
- cannabis
- capecitabine
- caplacizumab
- captopril
- carbamazepine
- carboplatin
- carfilzomib
- carvedilol
- chlordiazepoxide
- chlorothiazide
- chlorpromazine
- chlorthalidone
- chorionic gonadotropin
- cidofovir
- cilostazol
- cinacalcet
- cisplatin
- clevidipine
- clindamycin
- clobazam
- clonazepam
- clopidogrel
- clorazepate
- clozapine
- coagulation factor IX
- coagulation factor VIIa
- coagulation factor XIII A-subunit
- cocaine
- colistimethate
- collagenase clostridium histolyticum
- concizumab
- copanlisib
- corticotropin
- cortisone
- creatine
- cyclophosphamide
- cyclosporine
- cysteamine
- cytomegalovirus immune globulin
- dabigatran
- dalteparin
- danazol
- danshen
- darbepoetin alfa
- daridorexant
- dasatinib
- decitabine
- deferasirox
- deferoxamine
- defibrotide
- deflazacort
- desflurane
- desmopressin
- desogestrel (contraceptive)
- deuruxolitinib
- dexamethasone
- dexmedetomidine
- dexmedetomidine injection
- dexmethylphenidate
- dextromethorphan
- diazepam
- diclofenac ophthalmic
- dienogest (contraceptive)
- diethylpropion
- diltiazem
- dimethyl fumarate
- diosmin
- dipyridamole
- diroximel fumarate
- dobutamine
- donepezil
- dopamine
- doxapram
- doxazosin
- doxepin
- doxepin topical
- dronabinol
- droperidol
- drospirenone (contraceptive)
- drospirenone (hormone replacement)
- droxidopa
- edoxaban
- eltrombopag
- enalapril
- enalaprilat
- encorafenib
- enzalutamide
- ephedra
- ephedrine injection
- ephedrine oral
- epinephrine
- epirubicin
- eplerenone
- epoetin alfa
- epoprostenol
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- eptinezumab
- erenumab
- erlotinib
- esketamine
- esmolol
- estazolam
- estetrol (contraceptive)
- estradiol (contraceptive)
- estradiol (hormone replacement)
- estrogens, conjugated (hormone replacement)
- estrogens, esterified (hormone replacement)
- eszopiclone
- etelcalcetide
- ethacrynic acid
- ethanol (in some formulations)
- ethinyl estradiol (contraceptive)
- ethinyl estradiol (hormone replacement)
- ethynodiol (contraceptive)
- etomidate
- etonogestrel (contraceptive)
- etrasimod
- evening primrose oil
- everolimus
- exenatide
- factor XIII concentrate
- faricimab
- fedratinib
- felodipine
- fenfluramine
- fenofibrate
- fenofibric acid
- fenoldopam
- fenugreek
- finerenone
- fingolimod
- fitusiran
- flucytosine
- fludrocortisone
- fluphenazine
- flurazepam
- flurbiprofen ophthalmic
- follitropin
- formoterol inhaled
- foscarnet
- fosinopril
- fostamatinib
- fremanezumab
- fruquintinib
- gabapentin
- gabapentin enacarbil
- galantamine
- galcanezumab
- ganciclovir
- garlic
- gefitinib
- gemtuzumab ozogamicin
- gentamicin
- ginkgo
- guanfacine
- heparin
- hepatitis B immune globulin
- hoodia
- hydralazine
- hydrochlorothiazide
- hydrocortisone
- hydroxyzine
- ibandronate
- ibrutinib
- icosapent ethyl
- ifosfamide
- iloprost inhaled
- imatinib
- imipramine
- immune globulin
- indapamide
- iohexol
- iomeprol
- iopamidol
- irbesartan
- isoflurane
- isradipine
- itraconazole
- ketamine
- ketorolac ophthalmic
- labetalol
- landiolol
- lanreotide
- lanthanum
- lasmiditan
- lazertinib
- leflunomide
- lemborexant
- lenalidomide
- lenvatinib
- levalbuterol inhaled
- levonorgestrel (contraceptive)
- levonorgestrel (hormone replacement)
- licorice
- lifileucel
- liraglutide
- lorazepam
- lorlatinib
- losartan
- lumacaftor/ivacaftor
- luspatercept
- lusutrombopag
- lutetium Lu 177 vipivotide tetraxetan
- magnesium citrate
- mannitol
- medroxyprogesterone (contraceptive)
- medroxyprogesterone (hormone replacement)
- megestrol
- menotropins
- mesalamine
- mesalamine rectal
- methohexital
- methoxy polyethylene glycol-epoetin beta
- methyl salicylate topical
- methyldopa
- methylene blue injection
- methylphenidate
- methylprednisolone
- methyltestosterone
- metolazone
- metoprolol
- minoxidil
- mirabegron
- mitomycin
- mitotane
- modafinil
- moexipril
- momelotinib
- monomethyl fumarate
- mycophenolate mofetil
- mycophenolic acid
- nadolol
- nattokinase
- naxitamab
- nebivolol
- necitumumab
- nefazodone
- nelarabine
- neomycin
- nepafenac ophthalmic
- niacin (vitamin B3)
- nicardipine
- nifedipine
- nilotinib
- nimodipine
- nintedanib
- niraparib
- nisoldipine
- norelgestromin (contraceptive)
- norepinephrine
- norethindrone (contraceptive)
- norethindrone acetate (hormone replacement)
- norgestimate (contraceptive)
- norgestimate (hormone replacement)
- norgestrel (contraceptive)
- nusinersen
- olanzapine
- olaparib
- olodaterol inhaled
- olsalazine
- omega-3-acid
- opicapone
- osilodrostat
- ospemifene
- oxaliplatin
- oxazepam
- oxybutynin
- oxymetazoline nasal
- oxytocin
- ozanimod
- pacritinib
- palonosetron
- pamidronate
- paromomycin
- pazopanib
- pegaspargase
- penicillamine
- penicillin G
- pentamidine
- pentobarbital
- pentosan polysulfate sodium
- pentostatin
- pentoxifylline
- perphenazine
- pexidartinib
- phendimetrazine
- phenobarbital
- phenoxybenzamine
- phentermine
- phentolamine
- phenylephrine
- phenylephrine injection
- phenylephrine nasal
- phenylephrine ophthalmic
- phenylephrine rectal
- pindolol
- piperacillin
- pirtobrutinib
- plasminogen, human
- plazomicin
- polyethylene glycol
- polyethylene glycol/electrolytes
- polymyxin B
- pomalidomide
- ponatinib
- ponesimod
- porfimer
- potassium acid phosphate
- potassium bicarbonate
- potassium citrate
- potassium iodide
- pralsetinib
- prasugrel
- prazosin
- prednisolone
- prednisone
- pregabalin
- primidone
- progesterone (hormone replacement)
- progesterone vaginal (hormone replacement)
- propofol
- prothrombin complex concentrate (human)
- protriptyline
- pseudoephedrine
- pyridostigmine
- quazepam
- quetiapine
- quinapril
- raloxifene
- ramipril
- ramucirumab
- ranibizumab
- regorafenib
- remimazolam
- resveratrol
- reteplase
- revakinagene taroretcel
- Rho(D) immune globulin
- rimegepant
- ripretinib
- risedronate
- ritlecitinib
- rituximab
- rivaroxaban
- rivastigmine
- romiplostim
- ropinirole
- rotigotine transdermal
- ruxolitinib
- ruxolitinib topical
- salmeterol inhaled
- SAMe
- saw palmetto
- segesterone (contraceptive)
- selpercatinib
- selumetinib
- sevoflurane
- sincalide
- siponimod
- sipuleucel-T
- sirolimus
- sirolimus albumin-bound
- sitagliptin
- sodium tetradecyl sulfate
- solriamfetol
- sorafenib
- sotatercept
- sparsentan
- spironolactone
- streptomycin
- streptozocin
- sulfate bowel prep
- sunitinib
- suvorexant
- tagraxofusp
- tamoxifen
- telavancin
- telmisartan
- temazepam
- temsirolimus
- tenecteplase
- tenofovir alafenamide
- terazosin
- terbutaline
- teriflunomide
- testosterone
- thioridazine
- thiothixene
- ticagrelor
- timolol
- tiopronin
- tipranavir
- tirofiban
- tisotumab vedotin
- tivozanib
- tobramycin
- tobramycin inhaled
- tocilizumab
- tofacitinib
- tolvaptan
- toremifene
- torsemide
- tovorafenib
- trametinib
- trandolapril
- trazodone
- treprostinil
- tretinoin
- triamcinolone
- triamterene
- triazolam
- trimethoprim
- ubrogepant
- upadacitinib
- vadadustat
- valacyclovir
- valganciclovir
- valoctocogene roxaparvovec
- valproic acid
- vamorolone
- vancomycin
- vandetanib
- varicella zoster immune globulin
- vasopressin
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- vilanterol inhaled
- viloxazine
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- voclosporin
- von Willebrand factor
- vorapaxar
- voriconazole
- vorinostat
- warfarin
- zaleplon
- zanubrutinib
- zavegepant
- ziconotide
- ziv-aflibercept
- zoledronic acid
- zolpidem
- zonisamide
Caution Advised
- allopurinol
- amantadine
- apomorphine
- apraclonidine ophthalmic
- aripiprazole bimonthly injection
- aripiprazole lauroxil
- aripiprazole monthly injection
- aripiprazole oral
- asenapine
- baclofen
- brexpiprazole
- brimonidine ophthalmic
- brimonidine topical
- brivaracetam
- brompheniramine
- cannabidiol
- carbinoxamine
- cariprazine
- carisoprodol
- cenobamate
- cetirizine
- chamomile, German
- chlophedianol
- chlorpheniramine
- chlorzoxazone
- ciprofloxacin
- clemastine
- cyproheptadine
- dantrolene
- darifenacin
- delafloxacin
- deutetrabenazine
- dexbrompheniramine
- dexchlorpheniramine
- dichlorphenamide
- difelikefalin
- difenoxin
- dimenhydrinate
- diphenhydramine
- diphenoxylate
- domperidone
- emtricitabine
- entacapone
- entrectinib
- eslicarbazepine acetate
- ethosuximide
- felbamate
- fesoterodine
- flibanserin
- foslevodopa
- fosphenytoin
- ganaxolone
- glofitamab
- glycopyrrolate
- haloperidol
- hyoscyamine
- iloperidone
- lacosamide
- lamotrigine
- levetiracetam
- levocetirizine
- levodopa
- levofloxacin
- lofexidine
- loxapine
- lumateperone
- lurasidone
- meclizine
- melatonin
- meprobamate
- methocarbamol
- methsuximide
- metyrapone
- metyrosine
- molindone
- mosunetuzumab
- moxifloxacin
- naltrexone
- ofloxacin
- orphenadrine
- oxcarbazepine
- paliperidone
- passion flower
- perampanel
- pheniramine
- phenytoin
- pimozide
- pramipexole
- prochlorperazine
- pyrilamine
- ramelteon
- repotrectinib
- risperidone
- rufinamide
- scopolamine
- selinexor
- solifenacin
- stiripentol
- tasimelteon
- tetrabenazine
- thiotepa
- tiagabine
- tizanidine
- tolcapone
- tolterodine
- topiramate
- trifluoperazine
- trihexyphenidyl
- triprolidine
- trospium
- valbenazine
- valerian
- vigabatrin
Adverse Reactions .
Serious Reactions
- MI
- myocardial ischemia
- coronary vasospasm
- GI bleeding
- GI perforation
- GI ulcer
- ventricular tachycardia
- ventricular fibrillation
- arrhythmia, life-threatening
- stroke
- thromboembolism
- hypersensitivity rxn
- angioedema
- anaphylaxis
- exfoliative dermatitis
- Stevens-Johnson syndrome
- toxic epidermal necrolysis
- drug rxn w/ eosinophilia and systemic sx
- generalized bullous fixed drug eruption
- peripheral vascular ischemia
- intestinal ischemia
- splenic infarction
- Raynaud phenomenon
- blindness, transient or permanent
- vision loss, partial
- hepatotoxicity
- HTN, severe
- hypertensive crisis
- renal papillary necrosis
- nephrotoxicity
- hyperkalemia
- anemia
- medication overuse headache (use >10 days/mo)
- serotonin syndrome
Common Reactions
- dizziness
- somnolence
- chest pain or discomfort
- jaw pain or discomfort
- neck pain or discomfort
- throat pain or discomfort
Safety/Monitoring .
Monitoring Parameters
Cr at baseline, then if renal or hepatic impairment, CHF, dehydration, or hypovolemia cont. periodically; BP at baseline, then periodically; cardiovascular eval. at baseline if risk factors, then periodically during long-term tx; consider ECG after 1st dose if cardiac risk factors; CBC, chemistry profile if long-term tx
Pregnancy/Lactation .
Pregnancy
Clinical Summary
meloxicam: weigh risk/benefit if <30 wk gestation, esp. at 20-29 wk gestation, avoid use starting at 30 wk gestation; if must use at 20-29 wk gestation, limit dose and duration, and consider monitoring amniotic fluid if use >48h; no human data available, though risk of embryo-fetal toxicity and death low in 1st trimester based on conflicting human data w/ NSAID class; risk of fetal harm, incl. renal dysfxn and oligohydramnios, starting at 20 wk gestation and premature ductus arteriosus closure, starting at 30 wk gestation, based on human data w/ NSAID class and drug's mechanism of action
rizatriptan: weigh risk/benefit during pregnancy; risk of fetal harm low based on limited human data; risk of decr. fetal wt based on animal data at >15x MRHD; risk of vasoconstriction based on drug's mechanism of action
Individuals of Reproductive Potential
weigh risk/benefit in pts of childbearing potential trying to conceive, esp. if long-term use; NSAIDs may reversibly delay ovulation during tx based on limited human or animal data and drug's mechanism of action
Lactation
Clinical Summary
meloxicam: weigh risk/benefit while breastfeeding, consider short-acting NSAID; no human data available to assess risk of infant harm or effects on milk production
rizatriptan: weigh risk/benefit while breastfeeding; no human data available to assess risk of infant harm, though drug excreted into milk; no human data available to assess effects on milk production
Pharmacology .
Metabolism: for meloxicam: liver extensively; CYP450: 2C9 (primary), 3A4 substrate; for rizatriptan: liver; CYP450: none; Info: active metabolite
Excretion: for meloxicam: urine (0.2% unchanged), feces (1.6% unchanged); Half-life: 15-22h; for rizatriptan: urine 82% (14% unchanged), feces 12%; Half-life: 2-3h
Subclass: Headache/Migraine ; Nonsteroidal Anti-inflammatory Drugs (NSAIDs) ; Serotonin 5-HT1B/1D Receptor Agonists (Triptans)
Mechanism of Action
meloxicam's exact mechanism of action unknown; inhibits cyclooxygenase, reducing prostaglandin and thromboxane synthesis; rizatriptan activates serotonin 5-HT1B/1D receptors, producing cranial vasoconstriction and inhibiting pro-inflammatory neuropeptide release
Formulary .
No Formulary Selected
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