Triptans

Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan, Zolmitriptan

  Issues for Surgery

For acute migraine / cluster headache – no symptomatic relief if omitted.

For menstrual migraine prophylaxis – risk of acute migraine if omitted.

Risk of serotonin syndrome if continued (see Interaction(s) with Common Anaesthetic Agents and Interaction(s) with other Common Medicines used in the Perioperative Period).

  Advice in the Perioperative period

Elective and Emergency Surgery
Prophylactic dosing
Continue regular prophylactic dosing;

When required dosing
In the event of an acute migraine attack on day of surgery a dose can be taken if required.

Post-operative Advice
Prophylactic dosing
Resume regular prophylactic dosing when next dose due.

When required dosing
In the event of an acute migraine attack post-operatively a dose can be taken if required.

  Interaction(s) with Common Anaesthetic Agents

CNS Excitation (Serotonin Syndrome)
Some opioids act as weak serotonin reuptake inhibitors (SRIs) and can precipitate serotonin syndrome in conjunction with other serotonergic medication e.g. triptans. Symptoms of serotonin syndrome may occur if triptans are given concomitantly with^{1, 2}: -

• fentanyl
• methadone
• pentazocine
• pethidine
• tapentadol
• tramadol

Patients should be monitored closely and the possibility of serotonin toxicity considered if altered mental state, autonomic dysfunction or neuromuscular adverse effects are observed with concomitant treatment¹.

  Interaction(s) with other Common Medicines used in the Perioperative Period

CNS Excitation (Serotonin Syndrome)
Opioids
For a discussion of opioids see under Interaction(s) with Common Anaesthetic Agents above.

Methylthioninium chloride (methylene blue)
There have been case reports of serotonin syndrome in patients taking serotonergic drugs who were also given methylthioninium chloride². The MHRA advise that methylthioninium chloride should be avoided in patients taking drugs that enhance serotonergic transmission. If concurrent use is necessary the lowest possible dose of methylthioninium chloride should be given and the patient should be closely monitored for signs of CNS toxicity for 4 hours after administration. However, this advice is contested in one report which suggests even doses as low as 1mg/kg may be sufficient to inhibit monoamine oxidase-A, thus causing a reaction².

Other medications
There is also an increased risk of developing serotonin syndrome when triptans are used concurrently with the following¹: -

• granisetron
• ondansetron
• linezolid

Monitor patients for symptoms of serotonin syndrome such as fever, tremors, diarrhoea, and agitation. Concurrent treatment should be stopped if serotonin syndrome occurs¹.

Antimicrobials
Macrolides
Clarithromycin is predicted to markedly increase, and erythromycin is predicted to moderately increase, exposure to eletriptan – manufacturer advises avoid concomitant use^{1, 2, 3}. Clarithromycin is also predicted to increase exposure to almotriptan; however, the clinical significance of this is not known^{1, 2, 4}. Frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan are not thought to be affected¹.

Ciprofloxacin
Ciprofloxacin is predicted to increase the exposure to zolmitriptan through inhibition of CYP1A2^{1, 2, 5}. Consult current product literature for maximum recommended dose of zolmitriptan if treatment with ciprofloxacin is necessary.

  Further Information

None relevant.

  References

1. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 29^th June 2021]
2. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 29^th June 2021]
3. Summary of Product Characteristics – RELPAX® (eletriptan) 20mg Film-Coated Tablets. Upjohn UK Limited. Accessed via www.medicines.org.uk 29/06/2021 [date of revision of the text January 2021]
4. Summary of Product Characteristics – Almotriptan 12.5mg Film-coated Tablets. Accord-UK Ltd. Accessed via www.medicines.org.uk 29/06/2021 [date of revision of the text February 2020]
5. Summary of Product Characteristics – Zolmitriptan 2.5 mg film-coated tablets. Accord-UK Ltd. Accessed via www.medicines.org.uk 29/06/2021 [date of revision of the text March 2020]