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Almotriptan oral

Updated 2 Feb 2023 | Acute migraine treatment

Presentation

Tablets containing almotriptan as D,L-hydrogen maleate.

Drugs List

  • almotriptan 12.5mg tablets
  • Therapeutic Indications

    Uses

    Acute treatment of migraine attacks with or without aura

    Dosage

    Adults

    One 12.5 mg tablet to be taken as soon as possible after onset of attack. If the patient responds to the first dose but symptoms reappear within 24 hours then a second dose may be taken provided there is a minimum interval of two hours between doses. If the patient does not respond to the first dose a second dose should not be given for the same attack.
    The maximum recommended dose is two doses in any 24 hour period.

    Elderly

    One 12.5 mg tablet to be taken as soon as possible after onset of attack. If the patient responds to the first dose but symptoms reappear within 24 hours then a second dose may be taken provided there is a minimum interval of two hours between doses. If the patient does not respond to the first dose a second dose should not be given for the same attack.
    The maximum recommended dose is two doses in any 24 hour period.

    No dosage adjustment is necessary in the elderly. The safety and effectiveness of almotriptan in patients older than 65 years has not been systematically evaluated. Almotriptan may cause mild, transient increases in blood pressure, which may be more pronounced in the elderly.

    Patients with Renal Impairment

    No dosage adjustment is required in patients with mild or moderate renal impairment. Patients with severe renal impairment should not exceed one 12.5 mg tablet in any 24 hour period.

    The Renal Drug Handbook advises caution when the glomerular filtration rate is below 30 ml/minute a dose of 6.25 mg may be appropriate with a maximum daily dose of 12.5 mg.

    Contraindications

    Children under 18 years
    Suspected ischaemic heart disease
    Angina
    Coronary vasospasm
    History of cerebrovascular accident
    History of myocardial infarction
    History of transient ischaemic attack
    Ischaemic heart disease
    Peripheral vascular disease
    Pregnancy
    Prinzmetal's angina
    Severe hepatic impairment
    Severe hypertension
    Uncontrolled hypertension

    Precautions and Warnings

    Elderly
    Predisposition to ischaemic heart disease
    Breastfeeding
    Hypertension
    Mild hepatic impairment
    Renal impairment - glomerular filtration rate below 30ml/minute

    Not for prophylactic use
    Not indicated in hemiplegic, ophthalmoplegic or basilar migraine
    Advise ability to drive/operate machinery may be affected by side effects
    Evaluate patients for cardiovascular disease prior to treatment
    Exclude other potentially serious neurological conditions
    Avoid almotriptan for 24hrs after ergotamine-type medication administration
    Avoid ergotamine-type medication for 6 hrs after almotriptan administration
    Only for use where a clear diagnosis of migraine has been established
    Excessive use may increase frequency of headache, may require withdrawal
    If angina-like symptoms occur, discontinue treatment and investigate.
    Advise patient not to take St John's wort concurrently
    Advise patient grapefruit products may increase plasma level
    Patients should not exceed recommended dose

    Serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) has been reported following concomitant treatment with triptans and SSRIs/SNRIs. If concomitant treatment with almotriptan and an SSRI/SNRI is clinically warranted, appropriate observation of the patient is advised during initiation and dose increases.

    Pregnancy and Lactation

    Pregnancy

    Almotriptan is contraindicated in pregnancy.

    Safety in pregnancy has not been established, no reports describing the use of almotriptan in human pregnancy exist.
    It is not known if almotriptan crosses the human placenta however the molecular weight (about 336) suggests that the drug will cross to the foetus.
    Non-drug therapies such as relaxation are preferred when treating migraine during pregnancy. Paracetamol is the analgesic of choice. The NICE clinical knowledge summary recommends a benefit/risk analysis be performed for each therapy. If paracetamol and non-pharmacological treatments are ineffective, a triptan [sumatriptan preferred] or an NSAID [preferably ibuprofen] but not in the third trimester are suggested.

    Pregnant animal experiments with almotriptan
    Rats given doses that produced maternal exposures up to 958 times the human exposure from the maximum recommended daily dose of 25 mg have shown increased embryo deaths. Doses greater than 80 times the maximum recommended daily dose resulted in an increased incidence of foetal skeletal variations (decreased ossification). When administered to pregnant rats throughout gestation and lactation a dose 160 times the maximum recommended daily dose based on surface area resulted in an increase in gestational length and a decrease in litter size and pup birth weight. The decreased pup weight persisted throughout breastfeeding.

    In pregnant rabbits a dose 50 times the maximum recommended daily dose based on body surface area resulted in an increase in embryo deaths.

    The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

    Lactation

    Use almotriptan with caution in breastfeeding.

    No published experience exists with almotriptan during breastfeeding, alternative drugs may be preferred especially when nursing a newborn or preterm infant. Paracetamol is the analgesic of choice but if a triptan was required there is more clinical experience with use of sumatriptan in breastfeeding.

    There is no data regarding excretion of almotriptan in human milk. Studies in rats have shown that almotriptan and/or its metabolites are excreted in milk. Caution should therefore be exercised when prescribing during breastfeeding. To minimise effect on infant avoid breastfeeding for 24 hours post treatment.

    Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
    Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

    Counselling

    If patient does not respond to first dose of almotriptan, a second dose should not be taken for the same attack. Patients should be advised not to exceed the recommended dose.

    Advise patients that drowsiness may occur both during a migraine attack and as an adverse effect of almotriptan, use caution when driving or operating machinery.

    Advise patient to avoid taking St John's wort concurrently.

    Advise patient grapefruit products may increase plasma level of almotriptan.

    Side Effects

    Angioedema
    Asthenia
    Blurred vision
    Bone pain
    Chest pain
    Coronary vasospasm
    Diarrhoea
    Dizziness
    Dry mouth
    Dyspepsia
    Fatigue
    Headache
    Hypersensitivity reactions including anaphylaxis
    Increased blood pressure (transient)
    Myalgia
    Myocardial infarction
    Nausea
    Palpitations
    Paraesthesia
    Seizures
    Somnolence
    Tachycardia
    Tightness of chest and/or throat
    Tinnitus
    Visual disturbances
    Vomiting

    Overdosage

    It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

    The following number will direct the caller to the relevant local centre (0844) 892 0111

    Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

    Further Information

    Last Full Review Date: March 2014

    Reference Sources

    Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

    Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

    Joint Formulary Committee. British National Formulary. 66th ed. London: BMJ Group and Pharmaceutical Press; 2013.

    Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press https://www.medicinescomplete.com Accessed on March 6, 2014.

    Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.

    Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

    Summary of Product Characteristics: Almogran tablets. Almirall. Revised March 2013.

    The Renal Drug Handbook. 3rd edition. (2009) ed. Ashley, C and Currie, Radcliffe Publishing Ltd, Abingdon.

    NHS Evidence, NICE:Clinical Knowledge Summaries. Migraine.
    Available at: https://cks.nice.org.uk/migraine#!scenariorecommendation:17
    Last accessed: March 5, 2014.

    US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
    Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
    Almotriptan Last revised: September 7, 2013
    Last accessed: March 7, 2014.

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