Sumatriptan Succinate: Indications, Dosage, Precautions, Adverse Effects
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Sumatriptan Succinate - Product Information

Manufacture: Fresenius Kabi USA, LLC
Country: United States
Condition: Cluster Headaches, Headache, Migraine, Migraine Headache (Migraine)
Class: Antimigraine agents
Form: Liquid solution, Subcutaneous (SC)
Ingredients: Sumatriptan Succinate, Sodium Chloride, Water for Injection

Indications and Usage

Sumatriptan succinate injection is indicated in adults for (1) the acute treatment of migraine, with or without aura, and (2) the acute treatment of cluster headache.

Limitations of Use

  • Use only if a clear diagnosis of migraine or cluster headache has been established.
  • If a patient has no response to the first migraine attack treated with sumatriptan succinate injection, reconsider the diagnosis of migraine before sumatriptan succinate injection is administered to treat any subsequent attacks.
  • Sumatriptan succinate injection is not indicated for the prevention of migraine attacks.

Dosage and Administration

Dosing Information

The maximum single recommended adult dose of sumatriptan succinate injection for the acute treatment of migraine or cluster headache is 6 mg injected subcutaneously. For the treatment of migraine, if side effects are dose limiting, lower doses (1 to 5 mg) may be used. For the treatment of cluster headache, the efficacy of lower doses has not been established.

The maximum cumulative dose that may be given in 24 hours is 12 mg, two 6 mg injections separated by at least 1 hour. A second 6 mg dose should only be considered if some response to a first injection was observed.

Administration of Doses of Sumatriptan Succinate Injection Other than 6 mg

In patients receiving doses other than 6 mg, use the 6 mg single-dose vial. Visually inspect the vial for particulate matter and discoloration before administration. Do not use if particulates and discolorations are noted.

Dosage Forms and Strengths

Injection: 6 mg single-dose vial

Contraindications

Sumatriptan succinate injection is contraindicated in patients with:

  • Ischemic coronary artery disease (CAD) (angina pectoris, history of myocardial infarction, or documented silent ischemia) or coronary artery vasospasm, including Prinzmetal’s angina [see Warnings and Precautions].
  • Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders [see Warnings and Precautions].
  • History of stroke or transient ischemic attack (TIA) because these patients are at a higher risk of stroke [see Warnings and Precautions].
  • History of hemiplegic or basilar migraine.
  • Peripheral vascular disease [see Warnings and Precautions].
  • Ischemic bowel disease [see Warnings and Precautions].
  • Uncontrolled hypertension [see Warnings and Precautions].
  • Recent (i.e., within 24 hours) use of ergotamine-containing medication, ergot-type medication (such as dihydroergotamine or methysergide), or another 5 hydroxytryptamine1 (5-HT1) agonist [see Drug Interactions].
  • Concurrent administration of an MAO-A inhibitor or recent (within 2 weeks) use of an MAO-A inhibitor [see Drug Interactions].
  • Known hypersensitivity to sumatriptan [see Warnings and Precautions and Adverse Reactions].
  • Severe hepatic impairment.

Warnings and Precautions

Myocardial Ischemia, Myocardial Infarction, and Prinzmetal's Angina

The use of sumatriptan succinate injection is contraindicated in patients with ischemic or vasospastic CAD. There have been rare reports of serious cardiac adverse reactions, including acute myocardial infarction, occurring within a few hours following administration of sumatriptan succinate injection. Some of these reactions occurred in patients without known CAD. 5- HT1 agonists, including sumatriptan succinate injection, may cause coronary artery vasospasm (Prinzmetal’s angina), even in patients without a history of CAD.

Perform a cardiovascular evaluation in triptan-naive patients who have multiple cardiovascular risk factors (e.g., increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) prior to receiving sumatriptan succinate injection. If there is evidence of CAD or coronary artery vasospasm, sumatriptan succinate injection is contraindicated. For patients with multiple cardiovascular risk factors who have a negative cardiovascular evaluation, consider administering the first dose of sumatriptan succinate injection in a medically supervised setting and performing an electrocardiogram (ECG) immediately following sumatriptan succinate injection. For such patients, consider periodic cardiovascular evaluation in intermittent long-term users of sumatriptan succinate injection.

Evaluate patients with signs or symptoms suggestive of angina following sumatriptan succinate injection for the presence of CAD or Prinzmetal’s angina before receiving additional doses of sumatriptan succinate injection.

Arrhythmias

Life-threatening disturbances of cardiac rhythm, including ventricular tachycardia and ventricular fibrillation leading to death, have been reported within a few hours following the administration of 5-HT1 agonists. Discontinue sumatriptan succinate injection if these disturbances occur. Sumatriptan succinate injection is contraindicated in patients with Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders.

Chest, Throat, Neck, and/or Jaw Pain/Tightness/Pressure

As with other 5- HT1 agonists, sensations of tightness, pain, pressure, and heaviness in the precordium, throat, neck, and jaw commonly occur after treatment with sumatriptan succinate injection and are usually non- cardiac in origin. However, perform a cardiac evaluation if these patients are at high cardiac risk. The use of sumatriptan succinate injection is contraindicated in patients shown to have CAD and those with Prinzmetal’s variant angina.

Cerebrovascular Events

Cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with 5-HT1 agonists, and some have resulted in fatalities. In a number of cases, it appears possible that the cerebrovascular events were primary, the 5 -HT1 agonist having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine when they were not. Also, patients with migraine may be at increased risk of certain cerebrovascular events (e.g., stroke, hemorrhage, TIA). Discontinue sumatriptan succinate injection if a cerebrovascular event occurs.

As with other acute migraine therapies, before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions. Sumatriptan succinate injection is contraindicated in patients with a history of stroke or TIA.

Other Vasospasm Reactions

5-HT1 agonists, including sumatriptan succinate injection, may cause non- coronary vasospastic reactions, such as peripheral vascular ischemia, gastrointestinal vascular ischemia and infarction (presenting with abdominal pain and bloody diarrhea), splenic infarction, and Raynaud’s syndrome. Until further evaluation, sumatriptan succinate injection is contraindicated in patients who experience symptoms or signs suggestive of non-coronary vasospasm reaction following the use of any 5-HT1 agonist.

Reports of transient and permanent blindness and significant partial vision loss have been reported with the use of 5-HT1 agonists. Since visual disorders may be part of a migraine attack, a causal relationship between these events and the use of 5-HT1 agonists have not been clearly established.

Medication Overuse Headache

Overuse of acute migraine drugs (e.g., ergotamine, triptans, opioids, combination of drugs for 10 or more days per month) may lead to exacerbation of headache (medication overuse headache). Medication overuse headache may present as migraine-like daily headaches, or as a marked increase in frequency of migraine attacks. Detoxification of patients, including withdrawal of the overused drugs, and treatment of withdrawal symptoms (which often includes a transient worsening of headache) may be necessary.

Serotonin Syndrome

Serotonin syndrome may occur with triptans, including sumatriptan succinate injection, particularly during coadministration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors [see Drug Interactions].. Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). The onset of symptoms usually occurs within minutes to hours of receiving a new or a greater dose of a serotonergic medication. Discontinue sumatriptan succinate injection if serotonin syndrome is suspected.

Increase in Blood Pressure

Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, has been reported on rare occasions in patients treated with 5 -HT1 agonists, including patients without a history of hypertension. Monitor blood pressure in patients treated with sumatriptan succinate. Sumatriptan succinate injection is contraindicated in patients with uncontrolled hypertension.

Anaphylactic/Anaphylactoid Reactions

Anaphylactic/anaphylactoid reactions have occurred in patients receiving sumatriptan. Such reactions can be life threatening or fatal. In general, anaphylactic reactions to drugs are more likely to occur in individuals with a history of sensitivity to multiple allergens. Sumatriptan succinate injection is contraindicated in patients with prior serious anaphylactic reaction.

Seizures

Seizures have been reported following administration of sumatriptan. Some have occurred in patients with either a history of seizures or concurrent conditions predisposing to seizures. There are also reports in patients where no such predisposing factors are apparent. Sumatriptan succinate injection should be used with caution in patients with a history of epilepsy or conditions associated with a lowered seizure threshold.

Adverse Reactions

The following adverse reactions are discussed in more detail in other sections of the labeling:

  • Myocardial ischemia, myocardial infarction, and Prinzmetal’s angina [see Warnings and Precautions]
  • Arrhythmias [see Warnings and Precautions]
  • Chest, throat, neck, and/or jaw pain/tightness/pressure [see Warnings and Precautions]
  • Cerebrovascular events [see Warnings and Precautions]
  • Other vasospasm reactions [see Warnings and Precautions]
  • Medication overuse headache [see Warnings and Precautions]
  • Serotonin syndrome [see Warnings and Precautions]
  • Increase in blood pressure [see Warnings and Precautions]
  • Anaphylactic/anaphylactoid reactions [see Warnings and Precautions]
  • Seizures [see Warnings and Precautions]

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Migraine Headache

Table 1 lists adverse reactions that occurred in 2 US placebo-controlled clinical trials in migraine subjects [Studies 2 and 3] following either a single 6 mg dose of sumatriptan succinate injection or placebo. Only reactions that occurred at a frequency of 2% or more in groups treated with sumatriptan succinate injection 6 mg and that occurred at a frequency greater than the placebo group are included in Table 1.

Table 1. Advers e Reactions Reported by at Leas t 2% of Subjects and at a Greater Frequency than Placebo in 2 Placebo-Controlled Migraine Clinical Trials (Studies 2 and 3)a
Advers e Reaction  Percent of Subjects Reporting
Sumatriptan Succinate Injection
6 mg
Subcutaneous (n = 547)
Placebo
(n=370)
Atypical sensations 42 9
  Tingling 14 3
  Warm/hot sensation 11 4
  Burning sensation 7 < 1
  Feeling of heaviness 7 1
  Pressure sensation 7 2
  Feeling of tightness 5 < 1
 Numbness 5 2
  Feeling strange 2 < 1
  Tight feeling in head 2 < 1
Cardiovascular    
  Flushing 7 2
Chest discomfort 5 1
  Tightness in chest 3 < 1
  Pressure in chest 2 < 1
Ear, nose, and throat    
  Throat discomfort 3 < 1
  Discomfort: nasal cavity/sinuses 2 < 1
Injection site reactionb 59 24
Miscellaneous    
  Jaw discomfort 2 0
Musculoskeletal    
  Weakness 5 < 1
  Neck pain/stiffness 5 < 1
  Myalgia 2 < 1
Neurological    
  Dizziness/vertigo 12 4
  Drowsiness/sedation 3 2
  Headache 2 < 1
Skin    
  Sweating 2 1

a The sum of the percentages cited is greater than 100% because subjects may have experienced more than 1 type of adverse reaction. Only reactions that occurred at a frequency of 2% or more in groups treated with sumatriptan succinate injection and occurred at a frequency greater than the placebo groups are included.

b Includes injection site pain, stinging/burning, swelling, erythema, bruising, bleeding.

The incidence of adverse reactions in controlled clinical trials was not affected by gender or age of the subjects. There were insufficient data to assess the impact of race on the incidence of adverse reactions.

Cluster Headache

In the controlled clinical trials assessing the efficacy of sumatriptan succinate injection as a treatment for cluster headache, no new significant adverse reactions were detected that had not already been identified in trials of sumatriptan succinate in subjects with migraine.

Overall, the frequency of adverse reactions reported in the trials of cluster headache was generally lower than in the migraine trials. Exceptions include reports of paresthesia (5% sumatriptan succinate, 0% placebo), nausea and vomiting (4% sumatriptan succinate, 0% placebo), and bronchospasm (1% sumatriptan succinate, 0% placebo).

Other Adverse Reactions

In the paragraphs that follow, the frequencies of less commonly reported adverse reactions are presented. Reaction frequencies were calculated as the number of subjects reporting a reaction divided by the total number of subjects (N = 6,218) exposed to subcutaneous sumatriptan succinate injection. All reported reactions are included except those already listed in the previous table. Reactions are further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: frequent are defined as those occurring in at least 1/100 subjects, infrequent are those occurring in 1/100 to 1/1,000 subjects, and rare are those occurring in fewer than 1/1,000 subjects.

Cardiovascular

Infrequent were hypertension, hypotension, bradycardia, tachycardia, palpitations, and syncope. Rare was arrhythmia.

Gastrointestinal

Frequent was abdominal discomfort.

Musculoskeletal

Frequent were muscle cramps.

Neurological

Frequent was anxiety. Infrequent were mental confusion, euphoria, agitation, tremor. Rare were myoclonia, sleep disturbance, and dystonia.

Respiratory

Infrequent was dyspnea.

Skin

Infrequent were erythema, pruritus, and skin rashes.

Miscellaneous

Infrequent was “serotonin agonist effect”.

Adverse Events Observed with Other Formulations of Sumatriptan Succinate

The following adverse events occurred in clinical trials with sumatriptan succinate tablets and sumatriptan succinate nasal spray. Because the reports include events observed in open and uncontrolled trials, the role of sumatriptan succinate in their causation cannot be reliably determined. All reported events are included except those already listed, those too general to be informative, and those not reasonably associated with the use of the drug.

Cardiovascular

Angina, cerebrovascular lesion, heart block, peripheral cyanosis, phlebitis, thrombosis.

Gastrointestinal

Abdominal distention and colitis.

Neurological

Convulsions, hallucinations, syncope, suicide, and twitching.

Miscellaneous

Edema, hypersensitivity, swelling of extremities, and swelling of face.

Postmarketing Experience

The following adverse reactions have been identified during postapproval use of sumatriptan succinate tablets, sumatriptan succinate nasal spray, and sumatriptan succinate injection. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reactions have been chosen for inclusion due to either their seriousness, frequency of reporting, or causal connection to sumatriptan succinate or a combination of these factors.

Blood

Hemolytic anemia, pancytopenia, thrombocytopenia.

Ear, Nose, and Throat

Deafness.

Eye

Ischemic optic neuropathy, retinal artery occlusion, retinal vein thrombosis.

Neurological

Central nervous system vasculitis, cerebrovascular accident, serotonin syndrome, subarachnoid hemorrhage.

Non-Site Specific

Angioedema, cyanosis, temporal arteritis.

Skin

Exacerbation of sunburn, hypersensitivity reactions (allergic vasculitis, erythema, pruritus, rash, shortness of breath, urticaria), photosensitivity. Following subcutaneous administration of sumatriptan succinate, pain, redness, stinging, induration, swelling, contusion, subcutaneous bleeding, and, on rare occasions, lipoatrophy (depression in the skin) or lipohypertrophy (enlargement or thickening of tissue) have been reported.

Urogenital

Acute renal failure.

Drug Interactions

Ergot-Containing Drugs

Ergot-containing drugs have been reported to cause prolonged vasospastic reactions. Because these effects may be additive, use of ergotamine-containing or ergot-type medications (like dihydroergotamine or methysergide) and sumatriptan succinate injection within 24 hours of each other is contraindicated.

Monoamine Oxidase-A Inhibitors

MAO-A inhibitors increase systemic exposure by 2-fold. Therefore, the use of sumatriptan succinate injection in patients receiving MAO-A inhibitors is contraindicated.

Other 5-HT1 Agonists

Because their vasospastic effects may be additive, coadministration of sumatriptan succinate injection and other 5-HT1 agonists (e.g., triptans) within 24 hours of each other is contraindicated.

Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors and Serotonin Syndrome

Cases of serotonin syndrome have been reported during coadministration of triptans and SSRIs, or SNRIs, SNRIs, TCAs, and MAO inhibitors [see Warnings and Precautions].

Use in Specific Populations

Pregnancy

Pregnancy Category C

There are no adequate and well-controlled trials of sumatriptan succinate injection in pregnant women. Sumatriptan succinate injection should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

When sumatriptan was administered intravenously to pregnant rabbits daily throughout the period of organogenesis, embryolethality was observed at doses at or close to those producing maternal toxicity. These doses were less than the maximum recommended human dose (MRHD) of 12 mg/day on a mg/m2 basis. Oral administration of sumatriptan to rabbits during organogenesis was associated with increased incidences of fetal vascular and skeletal abnormalities. The highest no-effect dose for these effects was 15 mg/kg/day. The intravenous administration of sumatriptan to pregnant rats throughout organogenesis at doses that are approximately 10 times the MRHD on a mg/m2 basis, did not produce evidence of embryolethality. The subcutaneous administration of sumatriptan to pregnant rats prior to and throughout pregnancy did not produce evidence of embryolethality or teratogenicity.

Nursing Mothers

It is not known whether sumatriptan is excreted in human breast milk following subcutaneous administration. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants from sumatriptan succinate, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use

Safety and effectiveness of sumatriptan succinate injection in pediatric patients under 18 years of age have not been established; therefore, sumatriptan succinate injection is not recommended for use in patients under 18 years of age.

Two controlled clinical trials evaluated sumatriptan succinate nasal spray (5 to 20 mg) in 1,248 adolescent migraineurs aged 12 to 17 years who treated a single attack. The trials did not establish the efficacy of sumatriptan succinate nasal spray compared with placebo in the treatment of migraine in adolescents. Adverse reactions observed in these clinical trials were similar in nature to those reported in clinical trials in adults.

Five controlled clinical trials (2 single-attack trials, 3 multiple-attack trials) evaluating oral sumatriptan succinate (25 to 100 mg) in pediatric subjects aged 12 to 17 years enrolled a total of 701 adolescent migraineurs. These trials did not establish the efficacy of oral sumatriptan succinate compared with placebo in the treatment of migraine in adolescents. Adverse reactions observed in these clinical trials were similar in nature to those reported in clinical trials in adults. The frequency of all adverse reactions in these subjects appeared to be both dose- and age-dependent, with younger subjects reporting reactions more commonly than older adolescents.

Postmarketing experience documents that serious adverse reactions have occurred in the pediatric population after use of subcutaneous, oral, and/or intranasal sumatriptan succinate. These reports include reactions similar in nature to those reported rarely in adults, including stroke, visual loss, and death. A myocardial infarction has been reported in a 14-year-old male following the use of oral sumatriptan succinate; clinical signs occurred within 1 day of drug administration. Since clinical data to determine the frequency of serious adverse reactions in pediatric patients who might receive subcutaneous, oral, or intranasal sumatriptan succinate are not presently available, the use of sumatriptan succinate in patients under 18 years of age is not recommended.

Geriatric Use

Clinical trials of sumatriptan succinate injection did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy.

A cardiovascular evaluation is recommended for geriatric patients who have other cardiovascular risk factors (e.g., diabetes, hypertension, smoking, obesity, strong family history of CAD) prior to receiving sumatriptan succinate injection [see Warnings and Precautions].

Overdosage

No gross overdoses in clinical practice have been reported. Coronary vasospasm was observed after intravenous administration of sumatriptan succinate injection [see Contraindications]. Overdoses would be expected from animal data (dogs at 0.1 g/kg, rats at 2 g/kg) to possibly cause convulsions, tremor, inactivity, erythema of the extremities, reduced respiratory rate, cyanosis, ataxia, mydriasis, injection site reactions (desquamation, hair loss, and scab formation), and paralysis.

The elimination half- life of sumatriptan is about 2 hours, and therefore monitoring of patients after overdose with sumatriptan succinate injection should continue for at least 10 hours or while symptoms or signs persist. It is unknown what effect hemodialysis or peritoneal dialysis has on the serum concentrations of sumatriptan.

How Supplied/Storage and Handling

Sumatriptan succinate injection contains sumatriptan (base) as the succinate salt and is supplied as a clear, colorless to pale yellow, sterile, nonpyrogenic solution as follows:

Product No. NDC No. Strength
271301 63323-273-01 6 mg (sumatriptan) 0.5 mL 0.5 mL single dose vial, packaged individually.

Store between 2° and 25°C (36° and 77°F). Protect from light.

The container closure is not made with natural rubber latex.

Patient Counseling Information

See FDA-approved patient labeling (Consumer Medicine Information).

Risk of Myocardial Ischemia and/or Infarction, Prinzmetal’s Angina, Other Vasospasm-Related Events, Arrhythmias, and Cerebrovascular Events

Inform patients that sumatriptan succinate injection may cause serious cardiovascular side effects such as myocardial infarction or stroke. Although serious cardiovascular events can occur without warning symptoms, patients should be alert for the signs and symptoms of chest pain, shortness of breath, irregular heartbeat, significant rise in blood pressure, weakness, and slurring of speech and should ask for medical advice when observing any indicative sign or symptoms. Patients should be apprised of the importance of this follow-up [see Warnings and Precautions].

Anaphylactic/Anaphylactoid Reactions

Inform patients that anaphylactic/anaphylactoid reactions have occurred in patients receiving sumatriptan succinate injection. Such reactions can be life threatening or fatal. In general, anaphylactic reactions to drugs are more likely to occur in individuals with a history of sensitivity to multiple allergens [see Warnings and Precautions].

Medication Overuse Headache

Inform patients that use of acute migraine drugs for 10 or more days per month may lead to an exacerbation of headache and encourage patients to record headache frequency and drug use (e.g., by keeping a headache diary) [see Warnings and Precautions].

Pregnancy

Inform patients that sumatriptan succinate injection should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus [see Use in Specific Populations].

Nursing Mothers

Advise patients to notify their healthcare provider if they are breastfeeding or plan to breastfeed [see Use in Specific Populations]..

Ability to Perform Complex Tasks

Since migraines or treatment with sumatriptan succinate injection may cause somnolence and dizziness, instruct patients to evaluate their ability to perform complex tasks during migraine attacks and after administration of sumatriptan succinate injection.

Serotonin Syndrome

Patients should be cautioned about the risk of serotonin syndrome with the use of sumatriptan succinate injection or other triptans, particularly during combined use with SSRIs, SNRIs, TCAs, and MAO inhibitors [see Warnings and Precautions and Drug Interactions].

How to Use Sumatriptan Succinate Injection

Provide patients instruction on the proper use of sumatriptan succinate injection if they are able to self-administer sumatriptan succinate injection in medically unsupervised situation.

Inform patients that the injection is intended to be given subcutaneously and intramuscular or intravascular delivery should be avoided. Instruct patients to use injection sites with an adequate skin and subcutaneous thickness to accommodate the length of the needle.