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Atzumi
dihydroergotamine nasal
Black Box Warnings .
Peripheral Ischemia w/ Concomitant Strong CYP3A4 Inhibitor Use
serious and/or life-threatening peripheral ischemia possible when given in combo w/ strong CYP3A4 inhibitors incl. protease inhibitors and macrolide antibiotics; CYP3A4 inhibition incr. serum levels and risk for vasospasm leading to cerebral ischemia and/or ischemia of extremities; concomitant use w/ strong CYP3A4 inhibitors contraindicated
Adult Dosing .
Dosage forms: PWDR: 5.2 mg per device
migraine, acute
- [5.2 mg intranasally x1]
- Max: 10.4 mg/day; Info: may repeat dose x1 after 1h; safety not established w/ doses >20.8 mg/wk or >62.4 mg/mo
renal dosing
- [see below]
- mild-moderate impairment: not defined; severe impairment: contraindicated
- HD/PD: not defined
hepatic dosing
- [see below]
- mild-moderate impairment: not defined; severe impairment: contraindicated
Peds Dosing .
Peds dosing is currently unavailable or not applicable for this drug.
Contraindications / Cautions .
- hypersensitivity to drug or ingredient
- pregnancy
- renal impairment, severe
- hepatic impairment, severe
- ischemic heart dz
- coronary vasospasm
- HTN, uncontrolled
- peripheral arterial dz
- migraine, basilar
- migraine, hemiplegic
- vascular surgery, recent
- sepsis
- daily use, prolonged
- avoid: breastfeeding during tx and x3 days after D/C
- caution: elderly pts
- caution: CAD risk
Drug Interactions .
Overview
dihydroergotamine
ergot alkaloid
- CYP3A4 substrate
- 5-HT2B receptor agonist, potent
- hypertensive effects
- serotonergic effects
Contraindicated
- adagrasib
- almotriptan
- atazanavir
- ceritinib
- chloramphenicol
- clarithromycin
- cobicistat
- darunavir
- dobutamine
- dopamine
- eletriptan
- ephedra
- ephedrine injection
- ephedrine oral
- epinephrine
- epinephrine inhaled
- ergotamine
- erythromycin
- fosamprenavir
- frovatriptan
- idelalisib
- itraconazole
- ketoconazole
- letermovir
- levoketoconazole
- lonafarnib
- lopinavir/ritonavir
- methylergonovine
- midodrine
- mifepristone
- naratriptan
- nefazodone
- nelfinavir
- norepinephrine
- phenylephrine
- phenylephrine injection
- posaconazole
- pseudoephedrine
- ribociclib
- ritonavir
- rizatriptan
- sumatriptan
- tipranavir
- tucatinib
- vasopressin
- voriconazole
- zolmitriptan
Avoid/Use Alternative
- alfentanil
- amphetamine
- aprepitant
- avacopan
- berotralstat
- buprenorphine
- butorphanol
- ciprofloxacin
- citalopram
- clofazimine
- clomipramine
- codeine
- conivaptan
- crizotinib
- cyclobenzaprine
- cyclosporine
- danazol
- desipramine
- desvenlafaxine
- dextroamphetamine
- dihydrocodeine
- dihydroergotamine
- diltiazem
- dronedarone
- duloxetine
- duvelisib
- escitalopram
- fedratinib
- fentanyl
- fluconazole
- fluoxetine
- fluvoxamine
- furosemide
- gepirone
- granisetron
- hydrocodone
- hydromorphone
- imatinib
- isavuconazonium
- isocarboxazid
- isoniazid
- isosorbide dinitrate
- isosorbide mononitrate
- landiolol
- lefamulin
- lenacapavir
- levomilnacipran
- levorphanol
- linezolid
- lisdexamfetamine
- lithium
- meperidine
- metaxalone
- methadone
- methamphetamine
- methylene blue injection
- methylene blue oral
- milnacipran
- mirtazapine
- morphine
- nalbuphine
- netupitant
- nilotinib
- nirogacestat
- nitroglycerin
- nortriptyline
- oliceridine
- ondansetron
- opium
- oxycodone
- oxymetazoline nasal
- oxymorphone
- paroxetine
- pentazocine
- phenelzine
- phenylephrine nasal
- phenylephrine ophthalmic
- phenylephrine rectal
- procarbazine
- rasagiline
- remifentanil
- safinamide
- selegiline
- selegiline transdermal
- sertraline
- sufentanil
- tapentadol
- tramadol
- tranylcypromine
- trimipramine
- venlafaxine
- verapamil
- vilazodone
- vortioxetine
- yohimbe
- ziprasidone
Monitor/Modify Tx
- 5-HTP
- abiraterone acetate
- acebutolol
- albuterol
- albuterol inhaled
- aliskiren
- amiloride
- amitriptyline
- amlodipine
- amoxapine
- angiotensin II
- aprocitentan
- arformoterol inhaled
- armodafinil
- asciminib
- atenolol
- atogepant
- atomoxetine
- atropine ophthalmic
- axitinib
- azilsartan medoxomil
- benazepril
- benzphetamine
- betamethasone
- betaxolol
- bevacizumab
- bismuth subsalicylate
- bisoprolol
- black cohosh
- brigatinib
- bromocriptine
- budesonide
- bumetanide
- bupropion
- buspirone
- cabozantinib
- caffeine
- caffeine citrate
- candesartan cilexetil
- cannabis
- captopril
- carbamazepine
- carfilzomib
- carvedilol
- celecoxib
- chlorothiazide
- chlorthalidone
- clevidipine
- clonidine
- cocaine
- copanlisib
- corticotropin
- cortisone
- darbepoetin alfa
- deflazacort
- desmopressin
- dexamethasone
- dexmethylphenidate
- dextromethorphan
- diclofenac
- diclofenac topical
- diethylpropion
- diflunisal
- doxapram
- doxazosin
- doxepin
- doxepin topical
- dronabinol
- droxidopa
- enalapril
- enalaprilat
- enzalutamide
- eplerenone
- epoetin alfa
- eptinezumab
- erenumab
- esketamine
- esmolol
- estetrol (contraceptive)
- estradiol (contraceptive)
- ethacrynic acid
- ethinyl estradiol (contraceptive)
- etodolac
- etrasimod
- felodipine
- fenfluramine
- fenoldopam
- fenoprofen
- fingolimod
- fludrocortisone
- flurbiprofen
- formoterol inhaled
- fosinopril
- fostamatinib
- fremanezumab
- fruquintinib
- galcanezumab
- guanfacine
- hoodia
- hydralazine
- hydrochlorothiazide
- hydrocortisone
- ibrutinib
- ibuprofen
- imipramine
- indapamide
- indomethacin
- irbesartan
- isradipine
- ketamine
- ketoprofen
- ketorolac
- labetalol
- lanreotide
- lasmiditan
- leflunomide
- lenvatinib
- levalbuterol inhaled
- licorice
- lisinopril
- lorlatinib
- losartan
- lumacaftor/ivacaftor
- luspatercept
- magnesium salicylate
- meclofenamate
- mefenamic acid
- meloxicam
- methoxy polyethylene glycol-epoetin beta
- methyldopa
- methylphenidate
- methylprednisolone
- methyltestosterone
- metoclopramide
- metolazone
- metoprolol
- minoxidil
- mirabegron
- modafinil
- moexipril
- nabumetone
- nadolol
- naproxen
- naxitamab
- nebivolol
- nicardipine
- nifedipine
- nimodipine
- niraparib
- nisoldipine
- olmesartan medoxomil
- olodaterol inhaled
- osilodrostat
- oxaprozin
- oxytocin
- ozanimod
- palbociclib
- palonosetron
- pazopanib
- perindopril
- pexidartinib
- phendimetrazine
- phenoxybenzamine
- phentermine
- phentolamine
- pindolol
- piroxicam
- ponatinib
- ponesimod
- pralsetinib
- prazosin
- prednisolone
- prednisone
- propranolol
- protriptyline
- quetiapine
- quinapril
- ramipril
- ramucirumab
- regorafenib
- rimegepant
- ripretinib
- ropinirole
- rotigotine transdermal
- salmeterol inhaled
- salsalate
- SAMe
- selpercatinib
- siponimod
- solriamfetol
- sorafenib
- spironolactone
- St. John's wort
- sulindac
- sunitinib
- tacrolimus
- tagraxofusp
- telmisartan
- terazosin
- terbutaline
- teriflunomide
- testosterone
- timolol
- tivozanib
- tolmetin
- torsemide
- trametinib
- trandolapril
- trazodone
- triamcinolone
- triamterene
- ubrogepant
- vadadustat
- valsartan
- vamorolone
- vilanterol inhaled
- viloxazine
- zavegepant
- ziv-aflibercept
Caution Advised
- alprazolam
- amiodarone
- atorvastatin
- belumosudil
- berberine
- bicalutamide
- capivasertib
- chlorzoxazone
- cilostazol
- cimetidine
- daridorexant
- demeclocycline
- diosmin
- doxycycline
- entrectinib
- eravacycline
- everolimus
- finerenone
- flibanserin
- fosaprepitant
- gepotidacin
- ginkgo
- givosiran
- glecaprevir
- goldenseal
- grazoprevir
- istradefylline
- ivacaftor
- kratom
- lapatinib
- larotrectinib
- lazertinib
- lomitapide
- lovastatin
- lurasidone
- maribavir
- mavorixafor
- minocycline
- nicotine
- omadacycline
- peppermint
- pibrentasvir
- pirtobrutinib
- quercetin
- ranolazine
- remdesivir
- resveratrol
- ritlecitinib
- rucaparib
- sarecycline
- stiripentol
- tetracycline
- ticagrelor
- tigecycline
- tolvaptan
- treosulfan
- trofinetide
- vonoprazan
- voxelotor
- zileuton
Adverse Reactions .
Serious Reactions
- coronary vasospasm
- myocardial ischemia
- MI
- ventricular tachycardia
- ventricular fibrillation
- HTN, severe
- cerebral ischemia
- stroke
- cerebral hemorrhage
- subarachnoid hemorrhage
- intestinal ischemia
- peripheral vascular ischemia
- gangrene
- medication overuse headache (use >10 days/mo)
Common Reactions
- local irritation
- rhinitis
- nausea
- taste changes
- application site rxn
- dizziness
- vomiting
- pharyngitis
- somnolence
- diarrhea
- paresthesia
Safety/Monitoring .
Monitoring Parameters
Cr at baseline; cardiovascular eval. at baseline, then if long-term use in pts w/ CAD risk, cont. periodically; ECG after 1st dose if CAD risk
Pregnancy/Lactation .
Pregnancy
Clinical Summary
contraindicated during pregnancy; no known risk of teratogenicity, though risk of preterm birth based on limited human data; possible risk of decr. fetal wt and delayed skeletal ossification based on animal data at 0.4-1.2x MRHD; risk of fetal hypoxia based on drug's mechanism of action
Lactation
Clinical Summary
avoid breastfeeding during tx and x3 days after D/C; no human data available to assess risk of infant harm, though possible drug excretion into milk based on drug properties; no human data available, though theoretical decr. milk production based on decr. prolactin levels
Pharmacology .
Metabolism: liver extensively; CYP450: 3A4 substrate; Info: active metabolite
Excretion: bile/feces primarily, urine (2-7% unchanged); Half-life: 10-13h
Subclass: Headache/Migraine
Mechanism of Action
activates vascular serotonin 5-HT1D receptors, constricting cranial and peripheral blood vessels (ergot alkaloid)
Formulary .
No Formulary Selected
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