Shivang Joshi, MD, MPH, RPh, FAHS, outlines essential counseling points on dosing, timing, contraindications, and rebound headache risks when dispensing Symbravo.
In an interview with Pharmacy Times®, Shivang Joshi, MD, MPH, RPh, FAHS, director of headache medicine and clinical research at Community Neuroscience Services in Westborough, Massachusetts, and assistant professor of neurology at UMass Chan Medical School in Worcester, Massachusetts, emphasizes the critical counseling points pharmacists should provide when dispensing the combination of meloxicam and rizatriptan (Symbravo; Axsome Therapeutics). He explains that the medication should be taken once daily at migraine onset and limited to 2 or 3 days per week to avoid rebound headache, noting that triptans and nonsteroidal anti-inflammatory drugs differ in how easily they can trigger medication overuse.
Joshi highlights the fixed-dose combination of 10 mg rizatriptan and 20 mg meloxicam and stresses that Symbravo should not be used in patients with contraindications to either component, such as uncontrolled hypertension, coronary artery disease, gastrointestinal ulcers, or significant cardiovascular disease. He also underscores the importance of educating patients about boxed warnings and reassessing the diagnosis if the medication is not providing adequate benefit.
Pharmacy Times: From your experience, how important is timing in acute migraine therapy, and how might that apply when using a combination agent such as Symbravo?
Shivang Joshi, MD, MPH, RPh, FAHS: Timing is very important. Ideally, earlier is better. But we have a unique circumstance here. There [are] data suggesting that medications affecting both peripheral and central sensitization may still help later in an attack. We know triptans do not reduce allodynia when taken 4 hours after onset. However, NSAIDs may reduce pain and allodynia even when taken at 4 hours, due to their effect on prostaglandin E2.
What’s unique about Symbravo is its MoSEIC (Molecular Solubility Enhanced Inclusion Complex) technology. This uses a cyclodextrin carrier molecule with a hydrophilic outer surface and lipophilic cavity to improve the solubility of meloxicam. Normally, a significant portion of meloxicam is not absorbed; even though meloxicam has a long half-life, you can’t benefit from it if it’s not absorbed. MoSEIC technology also includes a pH-modifying buffer. Together with rizatriptan, this leads to quicker absorption and better solubility of both components, along with the advantage of meloxicam’s long half-life of about 18 hours. So, taking it early is ideal, but with this combination, there is some flexibility due to the NSAID component. Still, we advise taking it early.
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