Shivang Joshi, MD, MPH, RPh, FAHS, discusses how Symbravo’s multi-mechanistic fixed-dose design may address gaps in acute migraine therapy for patients who do not respond to single-agent treatments.
In an interview with Pharmacy Times®, Shivang Joshi, MD, MPH, RPh, FAHS, director of Headache Medicine and Clinical Research at Community Neuroscience Services and assistant professor of neurology at UMass Chan Medical School, explains how the fixed-dose combination of meloxicam and rizatriptan (Symbravo; Axsome Therapeutics) offers a multi-mechanistic approach that differs from using each agent separately.
Joshi highlights how triptans and non-steroidal anti-inflammatory drugs (NSAIDs) target distinct but complementary pathways in migraine pathophysiology and notes the value of using the MTAC assessment tool to evaluate real-world treatment effectiveness. Joshi also describes persistent unmet needs among patients who do not achieve pain freedom, sustained relief, or tolerability with current acute options, and he outlines how Symbravo may help fill gaps in the acute migraine landscape, particularly for individuals who have not found adequate benefit with triptans, NSAIDs, gepants, or ditans alone.
Pharmacy Times: From a pharmacy perspective, what are the key differences between using two separate medications versus a fixed-dose single tablet like Symbravo?
Shivang Joshi, MD, MPH, PRh, FAHS: That's an excellent question. First, when we look at the multi-mechanistic approach, that is a key difference. Triptans affect CGRP release and bind to 5-HT1B and 5-HT1D receptors, while meloxicam affects prostaglandin E2 and the inflammatory cascade. These pathways are involved in both peripheral and central sensitization.
The other thing I'd like to mention is something called MTAC, which is a tool used to evaluate the effectiveness of a migraine treatment. We ask questions such as, "After taking your migraine medicine, do you have pain freedom within two hours of most attacks? Does the medication relieve the headache and keep it away for 24 hours? Can you return to normal activities? Is it well tolerated?"
There are patients who do not experience these benefits whether they’re taking a triptan alone, an NSAID, or another class of medication. So you have to think about unmet needs and individualized therapy. In that scenario, I do see a role for this combination for patients who are not getting what they need from current therapy.
Pharmacy Times: How do you see Symbravo filling gaps in treatment guidance for acute migraine, especially from a pharmacy perspective?
Joshi: That's an excellent question. Going back to unmet needs, you have many patients who may or may not be diagnosed with migraine. Some are self-treating with over-the-counter medications, which can lead to medication overuse headache. You have patients who are not doing well on their current triptan—either due to tolerability or duration—and patients who use NSAIDs, gepants, or ditans.
Not everyone responds to every treatment for every headache. So this combination fits well for someone who is not finding benefit with their current acute therapy.
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