Shivang Joshi, MD, MPH, RPh, FAHS, highlights Symbravo’s non-substitutability, multi-mechanistic design, and key safety considerations for pharmacists across care settings.
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, underscores several key points pharmacists should keep in mind when encountering the combination of meloxicam and rizatriptan (Symbravo; Axsome Therapeutics) in practice.
Joshi explains that the product is not substitutable with individual rizatriptan and meloxicam components and emphasizes its multi-mechanistic design targeting CGRP, serotonin, and prostaglandin pathways, supported by MoSEIC technology for improved absorption. Joshi also reiterates the importance of being aware of boxed warnings and contraindications tied to both triptans and non-steroidal anti-inflammatory drugs (NSAIDs). He encourages pharmacists to recognize signs of medication overuse headache, guide patients toward comprehensive migraine management strategies, and leverage resources from organizations such as the American Migraine Foundation and the Association of Migraine Disorders.
Pharmacy Times: What is the most important message you’d want pharmacy colleagues to take away about Symbravo when they see it on the shelf or being used in their health system?
Shivang Joshi, MD, MPH, PRh, FAHS: In terms of practicality, one unique aspect is that the package insert states that Symbravo is not substitutable with its individual components. So you cannot substitute separate rizatriptan and over-the-counter meloxicam. Second, this is a multi-mechanistic approach. Migraine is a complex neurological disorder involving CGRP, serotonin, and prostaglandins. The MoSEIC technology improves absorption and may translate into better clinical outcomes. And of course, pharmacists should be aware of the standard warnings, including the black box warnings for both triptans and NSAIDs. If a patient has a contraindication to either component, they cannot use this medication.
Pharmacy Times: Is there anything else that you would like to add?
Joshi: Pharmacists are among the most trusted healthcare professionals, and patients come to you for advice. When you see patients coming in for early refills or using large quantities of over-the-counter analgesics, think about medication overuse headache and unmet needs. There are multiple options available for patients, and this is one of the newest. Migraine management is multi-mechanistic—acute treatment, prevention, dietary triggers, and lifestyle modification. Pharmacists are well positioned to direct patients to a headache specialist when needed. There are credible resources available, such as the American Migraine Foundation and the Association of Migraine Disorders. Collaboration is important, and I always welcome pharmacist involvement, questions, and participation in educational programs.
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