Zolmitriptan (oral)

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# Overview
Zolmitriptan (oral) is a serotonin (5-HT)1B/1D receptor agonist that is FDA approved for the treatment of migraine with or without aura.   Common adverse reactions include neck/throat/jaw pain/tightness/pressure, dizziness, paresthesia, asthenia, somnolence, warm/cold sensation, nausea, heaviness sensation, and dry mouth.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- ZOMIG is indicated for the acute treatment of migraine with or without aura in adults.
- The recommended starting dose of ZOMIG is 1.25 mg or 2.5 mg. The 1.25 mg dose can be achieved by manually breaking the functionally-scored 2.5 mg tablet in half. The maximum recommended single dose of ZOMIG is 5 mg.
- In controlled clinical trials, a greater proportion of patients had headache response following a 2.5 mg or 5 mg dose than following a 1 mg dose. There was little added benefit from the 5 mg dose compared to the 2.5 mg dose, but adverse reactions were more frequent with the 5 mg dose.
- If the migraine has not resolved by 2 hours after taking ZOMIG, or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose. The maximum daily dose is 10 mg in any 24-hour period.
The safety of ZOMIG in the treatment of an average of more than three migraines in a 30-day period has not been established.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Zolmitriptan in adult patients.

### NonGuideline-Supported Use
- Oral zolmitriptan 10 mg.
- Dose varied according to baseline headache intensity: Zolmitriptan 1.25 mg (half tablet) for mild attacks, 2.5 mg for moderate attacks, and 5 mg (2 tablets) for severe attacks.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Zolmitriptan in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Zolmitriptan in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Zolmitriptan in pediatric patients.

# Contraindications
- Ischemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia), other significant underlying cardiovascular disease, or  coronary artery vasospasm including Prinzmetals angina.
- Wolff-Parkinson-White Syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders.
- History of stroke, transient ischemic attack (TIA), or history of hemiplegic or basilar migraine because these patients are at a higher risk of stroke.
- Peripheral vascular disease (PVD).
- Ischemic bowel disease.
- Uncontrolled hypertension.
- Recent use (i.e., within 24 hours) of another 5-HT 1 agonist, ergotamine-containing medication, or ergot-type medication (such as dihydroergotamine or methysergide).
- Concurrent administration of a monoamine oxidase (MAO)-A inhibitor or recent use of a MAO-A inhibitor (that is within 2 weeks).
- Known hypersensitivity to ZOMIG or ZOMIG ZMT (angioedema and anaphylaxis seen).

# Warnings

### Precautions
- Myocardial Ischemia, Myocardial Infarction, and Prinzmetal Angina
- ZOMIG is contraindicated in patients with ischemic or vasospastic coronary artery disease (CAD). There have been rare reports of serious cardiac adverse reactions, including acute myocardial infarction, occurring within a few hours following administration of ZOMIG. Some of these reactions occurred in patients without known CAD. 5-HT1 agonists including ZOMIG may cause coronary artery vasospasm (Prinzmetal 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 ZOMIG. Do not administer ZOMIG if there is evidence of CAD or coronary artery vasospasm . For patients with multiple cardiovascular risk factors who have a negative cardiovascular evaluation, consider administrating the first ZOMIG dose in a medically-supervised setting and performing an electrocardiogram (ECG) immediately following ZOMIG administration. For such patients, consider periodic cardiovascular evaluation in intermittent long-term users of ZOMIG.
- Arrhythmias
- Lifethreatening 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 ZOMIG if these disturbances occur. ZOMIG is contraindicated in patients with Wolff-Parkinson-White Syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders.
- Chest, Throat, Neck and Jaw Pain/Tightness/Pressure
- As with other 5-HT1 agonists, sensations of tightness, pain, and pressure in the chest, throat, neck, and jaw commonly occur after treatment with ZOMIG and is usually non-cardiac in origin. However, perform a cardiac evaluation if these patients are at high cardiac risk. 5-HT1 agonists including ZOMIG are contraindicated in patients with CAD or 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.
- As with other acute migraine therapies, before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with symptoms atypical for migraine, exclude other potentially serious neurological conditions. ZOMIG is contraindicated in patients with a history of stroke or transient ischemic attack.
- Other Vasospasm Reactions
- 5-HT1 agonists, including ZOMIG, 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 Raynauds syndrome. In patients who experience symptoms or signs suggestive of a vasospastic reaction following the use of any 5-HT1 agonist, rule out a vasospastic reaction before receiving additional ZOMIG doses.
- 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, or a 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 ZOMIG, particularly during co-administration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors. 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 rapidly occurs within minutes to hours of receiving a new or a greater dose of a serotonergic medication. Discontinue ZOMIG if serotonin syndrome is suspected.
- Increase in Blood Pressure
- Significant elevations in systemic blood pressure have been reported in patients treated with 5-HT1 agonists including patients without a history of hypertension; very rarely, these increases in blood pressure have been associated with serious adverse reactions. In healthy subjects treated with 5 mg of ZOMIG, an increase of 1 and 5 mm Hg in the systolic and diastolic blood pressure, respectively, was seen. In a study of patients with moderate to severe liver impairment, 7 of 27 patients experienced 20 to 80 mm Hg elevations in systolic and/or diastolic blood pressure after a dose of 10 mg of ZOMIG.
- As with all triptans, blood pressure should be monitored in ZOMIG-treated patients. ZOMIG is contraindicated in patients with uncontrolled hypertension.
- Risks in Patients with Phenylketonuria
- Phenylalanine can be harmful to patients with phenylketonuria (PKU). ZOMIG-ZMT orally disintegrating tablets contain phenylalanine (a component of aspartame). Each 2.5 mg and 5 mg orally disintegrating tablet contains 2.81 and 5.62 mg of phenylalanine, respectively. ZOMIG tablets do not contain phenylalanine.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
- In a long-term, open-label study where patients were allowed to treat multiple migraine attacks for up to 1 year, 8% (167 out of 2,058) withdrew from the trial because of adverse reaction.
- The most common adverse reactions (5% and > placebo) in these trials were neck/throat/jaw pain, dizziness, paresthesia, asthenia, somnolence, warm/cold sensation, nausea, heaviness sensation, and dry mouth.
- Table 1 lists the adverse reactions that occurred in  2% of the 2,074 patients in any one of the ZOMIG 1 mg, 2.5 mg, or 5 mg dose groups in the controlled clinical trials of ZOMIG in patients with migraines (Studies 1, 2, 3, 4, and 5). Only adverse reactions that were at least 2% more frequent in a ZOMIG group compared to the placebo group are included.
- Several of the adverse reactions appear dose related, notably paresthesia, sensation of heaviness or tightness in chest, neck, jaw, and throat, dizziness, somnolence and possibly asthenia and nausea.
- There were no differences in the incidence of adverse reactions in controlled clinical trials in the following subgroups: gender, weight, age, use of prophylactic medications, or presence of aura. There were insufficient data to assess the impact of race on the incidence of adverse reactions.
- Less Common Adverse Reactions with ZOMIG Tablets:
- In the paragraphs that follow, the frequencies of less commonly reported adverse clinical reactions are presented. Because the reports include reactions observed in open and uncontrolled studies, the role of ZOMIG in their causation cannot be reliably determined. Furthermore, variability associated with adverse reaction reporting, the terminology used to describe adverse reactions, etc., limit the value of the quantitative frequency estimates provided. Adverse reaction frequencies were calculated as the number of patients who used ZOMIG tablets and reported a reaction divided by the total number of patients exposed to ZOMIG tablets (n=4,027). Reactions were further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: infrequent adverse reactions (those occurring in 1/100 to 1/1,000 patients) and rare adverse reactions (those occurring in less than 1/1,000 patients).
Infrequent were allergic reactions.
Infrequent were arrhythmias, hypertension, and syncope. Rare was tachycardia.
Infrequent were agitation, anxiety, depression, emotional lability and insomnia; Rare were amnesia, hallucinations, and cerebral ischemia.
Infrequent were pruritus, rash and urticaria.
Infrequent were polyuria, urinary frequency and urinary urgency.
- Adverse Reactions with ZOMIG-ZMT Oral Disintegrating Tablets
- The adverse reaction profile seen with ZOMIG-ZMT oral disintegrating tablets was similar to that seen with ZOMIG tablets.

## Postmarketing Experience
- The following adverse reactions were identified during post approval use of ZOMIG. 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.
- Hypersensitivity Reactions:
- As with other 5HT1B/1D agonists, there have been reports of anaphylaxis, anaphylactoid, and hypersensitivity reactions including angioedema in patients receiving ZOMIG. ZOMIG is contraindicated in patients with a history of hypersensitivity reaction to ZOMIG.

# 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 ZOMIG within 24 hours of each other is contraindicated.
- MAO-A Inhibitors
- MAO-A inhibitors increase the systemic exposure of zolmitriptan and its active N-desmethyl metabolite. Therefore, the use of ZOMIG in patients receiving MAO-A inhibitors is contraindicated.
- 5-HT1B/1D agonists
- Concomitant use of other 5-HT1B/1D agonists (including triptans) within 24 hours of ZOMIG treatment is contraindicated because the risk of vasospastic reactions may be additive.
- Selective Serotonin Reuptake Inhibitors and Serotonin Norepinephrine Reuptake Inhibitors
- Cases of life-threatening serotonin syndrome have been reported during co-administration of triptans and selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs).
- Cimetidine
- Following administration of cimetidine, the half-life and blood levels of zolmitriptan and its active N-desmethyl metabolite were approximately doubled. If cimetidine and ZOMIG are used concomitantly, limit the maximum single dose of ZOMIG to 2.5 mg, not to exceed 5 mg in any 24-hour period.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):
- Pregnancy Category C
- There are no adequate and well- controlled studies in pregnant women; therefore, ZOMIG should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. In reproductive toxicity studies in rats and rabbits, oral administration of zolmitriptan to pregnant animals resulted in embryolethality and fetal abnormalities (malformations and variations) at clinically relevant exposures.
- When zolmitriptan was administered to pregnant rats during the period of organogenesis at oral doses of 100, 400, and 1200 mg/kg/day (plasma exposures (AUCs) 280, 1100, and 5000 times the human AUC at the maximum recommended human dose (MRHD) of 10 mg/day), there was a dose-related increase in embryolethality. A no-effect dose for embryolethality was not established. When zolmitriptan was administered to pregnant rabbits during the period of organogenesis at oral doses of 3, 10, and 30 mg/kg/day (plasma AUCs 1, 11, and 42 times the human AUC at the MRHD), there were increases in embryolethality and in fetal malformations and variations. The no-effect dose for adverse effects on embryo-fetal development was associated with a plasma AUC similar to that in humans at the MRHD. When female rats were given zolmitriptan during gestation, parturition, and lactation at oral doses of 25, 100, and 400 mg/kg/day (plasma AUCs 70, 280, and 1100 times that in human at the MRHD), an increased incidence of hydronephrosis was found in the offspring. The no-effect dose was associated with a plasma AUC 280 times that in humans at the MRHD.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Zolmitriptan in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Zolmitriptan during labor and delivery.

### Nursing Mothers
- It is not known whether zolmitriptan is excreted in human milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants from ZOMIG, 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. In rats, oral dosing with zolmitriptan resulted in levels in milk up to 4 times higher than in plasma.

### Pediatric Use
- The safety and effectiveness in pediatric patients have not been established. Therefore, ZOMIG is not recommended for use in patients under 18 years of age.
- One randomized, placebo-controlled clinical trial of ZOMIG tablets (2.5, 5 and 10 mg) evaluated 696 pediatric patients (aged 12-17 years) with migraines. This study did not demonstrate the efficacy of ZOMIG compared to placebo in the treatment of migraine in adolescents. Adverse reactions in the adolescent patients treated with ZOMIG were similar in nature and frequency to those reported in clinical trials in adults treated with ZOMIG. ZOMIG has not been studied in pediatric patients less than 12 years old.
- In the postmarketing experience with triptans, including ZOMIG, there were no additional adverse reactions seen in pediatric patients that were not seen in adults.

### Geriatic Use
- Clinical studies of ZOMIG 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 patients. 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 coronary artery disease) prior to receiving ZOMIG,
- The pharmacokinetics of zolmitriptan were similar in geriatric patients (aged > 65 years) compared to younger patients.

### Gender
There is no FDA guidance on the use of Zolmitriptan with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Zolmitriptan with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Zolmitriptan in patients with renal impairment.

### Hepatic Impairment
- After oral ZOMIG administration, zolmitriptan blood levels were increased in patients with moderate to severe hepatic impairment, and significant elevation in blood pressure was observed in some of these patients. Therefore, adjust the ZOMIG dose and administer with caution in patients with moderate or severe hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Zolmitriptan in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Zolmitriptan in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Oral

### Monitoring
There is limited information regarding Monitoring of Zolmitriptan in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Zolmitriptan in the drug label.

# Overdosage

## Acute Overdose

### Signs and Symptoms
- There is no experience with acute overdose of ZOMIG. Clinical study subjects who received single 50 mg oral doses of ZOMIG commonly experienced sedation.

### Management
- There is no specific antidote to ZOMIG. In cases of severe intoxication, intensive care procedures are recommended, including establishing and maintaining a patent airway, ensuring adequate oxygenation and ventilation, and monitoring and support of the cardiovascular system.
- The elimination half-life of ZOMIG is 3 hours;therefore, monitor patients after overdose with ZOMIG for at least 15 hours or until symptoms or signs resolve. It is unknown what effect hemodialysis or peritoneal dialysis has on the plasma concentrations of zolmitriptan.

## Chronic Overdose
There is limited information regarding Chronic Overdose of Zolmitriptan in the drug label.

# Pharmacology

## Mechanism of Action
- Zolmitriptan binds with high affinity to human recombinant 5-HT1D and 5HT1B receptors, and moderate affinity for 5-HT1A receptors. The N-desmethyl metabolite also has high affinity for 5HT1B/1D and moderate affinity for 5HT1A receptors.
- Migraines are likely due to local cranial vasodilatation and/or to the release of sensory neuropeptides (vasoactive intestinal peptide, substance P and calcitonin gene-related peptide) through nerve endings in the trigeminal system. The therapeutic activity of ZOMIG for the treatment of migraine headache is thought to be due to the agonist effects at the 5HT1B/1D receptors on intracranial blood vessels (including the arterio-venous anastomoses) and sensory nerves of the trigeminal system which result in cranial vessel constriction and inhibition of pro-inflammatory neuropeptide release.

## Structure
- ZOMIG (zolmitriptan) tablets and ZOMIG-ZMT (zolmitriptan) orally disintegrating tablets contain zolmitriptan, which is a selective 5hydroxytryptamine1B/1D (5-HT1B/1D) receptor agonist. Zolmitriptan is chemically designated as (S)-4--1H-indol-5-yl]methyl]-2-oxazolidinone and has the following chemical structure:
- The empirical formula is C16H21N3O2, representing a molecular weight of 287.36. Zolmitriptan is a white to almost white powder that is readily soluble in water.
- ZOMIG tablets are available as 2.5 mg (yellow and functionally-score) and 5 mg (pink, not scored) film coated tablets for oral administration. The film coated tablets contain anhydrous lactose NF, microcrystalline cellulose NF, sodium starch glycolate NF, magnesium stearate NF, hydroxypropyl methylcellulose USP, titanium dioxide USP, polyethylene glycol 400 NF, yellow iron oxide NF (2.5 mg tablet), red iron oxide NF (5 mg tablet), and polyethylene glycol 8000 NF.
- ZOMIG-ZMT orally disintegrating tablets are available as 2.5 mg and 5 mg white uncoated tablets. The orally disintegrating tablets contain mannitol USP, microcrystalline cellulose NF, crospovidone NF, aspartame NF, sodium bicarbonate USP, citric acid anhydrous USP, colloidal silicon dioxide NF, magnesium stearate NF and orange flavor SN 027512.

## Pharmacodynamics
There is limited information regarding Pharmacodynamics of Zolmitriptan in the drug label.

## Pharmacokinetics
- Absorption
- Zolmitriptan is well absorbed after oral administration for both ZOMIG tablets and the ZOMIG-ZMT orally disintegrating tablets. Zolmitriptan displays linear kinetics over the dose range of 2.5 to 50 mg.
- The AUC and Cmax of zolmitriptan are similar following administration of ZOMIG tablets and ZOMIG-ZMT orally disintegrating tablets, but the Tmax is somewhat later with ZOMIGZMT, with a median Tmax of 3 hours for ZOMIGZMT orally disintegrating tablet compared with 1.5 hours for the ZOMIG tablet. The AUC, Cmax,and Tmax for the active Ndesmethyl metabolite are similar for the two formulations.
- During a moderate to severe migraine attack, mean AUC0-4 and Cmax for zolmitriptan, dosed as a ZOMIG tablet, were decreased by 40% and 25%, respectively, and mean Tmax was delayed by onehalf hour compared to the same patients during a migraine free period.
- Food has no significant effect on the bioavailability of zolmitriptan. No accumulation occurred on multiple dosing.
- Distribution
- Mean absolute bioavailability is approximately 40%. The mean apparent volume of distribution is 7.0 L/kg. Plasma protein binding of zolmitriptan is 25% over the concentration range of 10- 1000 ng/mL.
- Metabolism
- Zolmitriptan is converted to an active N-desmethyl metabolite; the metabolite concentrations are about two-thirds that of zolmitriptan. Because the 5HT1B/1D potency of the metabolite is 2 to 6 times that of the parent compound, the metabolite may contribute a substantial portion of the overall effect after ZOMIG administration.
- Excretion
- Total radioactivity recovered in urine and feces was 65% and 30% of the administered dose, respectively. About 8% of the dose was recovered in the urine as unchanged zolmitriptan. Indole acetic acid metabolite accounted for 31% of the dose, followed by N-oxide (7%) and N-desmethyl (4%) metabolites. The indole acetic acid and N-oxide metabolites are inactive.
- Mean total plasma clearance is 31.5 mL/min/kg, of which one-sixth is renal clearance. The renal clearance is greater than the glomerular filtration rate suggesting renal tubular secretion.
- Special Populations
- Hepatic Impairment
- In patients with severe hepatic impairment, the mean Cmax, Tmax, and AUC0- of zolmitriptan were increased 1.5-fold, 2-fold (2 vs. 4 hours), and 3-fold, respectively, compared to subjects with normal hepatic function. Seven out of 27 patients experienced 20 to 80 mm Hg elevations in systolic and/or diastolic blood pressure after a 10 mg ZOMIG dose. Adjust the ZOMIG Dose in patients with moderate or severe hepatic impairment.
- Renal Impairment
- Clearance of zolmitriptan was reduced by 25% in patients with severe renal impairment (Clcr  5  25 mL/min) compared to subjects with normal renal function (Clcr > = 70 mL/min); no significant change in clearance was observed in patients with moderate renal impairment (Clcr  26  50 mL/min).
- Age
- Zolmitriptan pharmacokinetics in healthy elderly non-migraineur volunteers (age 6576 years) was similar to those in younger non-migraineur volunteers (age 18 - 39 years).
- Sex
- Mean plasma concentrations of zolmitriptan were up to 1.5-fold higher in females than males.
- Race
- Retrospective analysis of pharmacokinetic data between Japanese and Caucasians revealed no significant differences.
- Hypertensive Patients
- No differences in the pharmacokinetics of zolmitriptan or its effects on blood pressure were seen in mild to moderate hypertensivevolunteers compared with normotensive controls.
- Drug Interaction Studies
- All drug interaction studies were performed in healthy volunteers using a single 10 mg dose of ZOMIG and a single dose of the other drug except where otherwise noted.
- MAO Inhibitors
- Following one week of administration of moclobemide (150 mg twice daily), a specific MAO-A inhibitor, there was an increase of about 25% in both Cmax and AUC for zolmitriptan and a 3fold increase in the Cmax and AUC of the active N-desmethyl metabolite of zolmitriptan. MAO inhibitors are contraindicated in ZOMIG-treated patients.
- Selegiline, a selective MAO-B inhibitor, at a dose of 10 mg/day for 1 week, had no effect on the pharmacokinetics of zolmitriptan and its metabolite.
- Cimetidine
- Following the administration of cimetidine, the halflife and AUC of zolmitriptan (5 mg dose), and its active metabolite, were approximately doubled.
- Fluoxetine
- The pharmacokinetics of zolmitriptan, as well as its effect on blood pressure, were unaffected by 4 weeks of pretreatment with oral fluoxetine (20 mg/day).
- Propranolol
- Cmax and AUC of zolmitriptan were increased 1.5-fold after one week of dosing with propranolol (160 mg/day). Cmax and AUC of the N-desmethyl metabolite were reduced by 30% and 15%, respectively. There were no changes in blood pressure or pulse rate following administration of propranolol with ZOMIG.
- Acetaminophen
- A single 1 gram dose of acetaminophen did not alter the pharmacokinetics of zolmitriptan and its N-desmethyl metabolite. However, ZOMIG administration delayed the Tmax of acetaminophen by one hour.
- Metoclopramide
- A single 10 mg dose of metoclopramide had no effect on the pharmacokinetics of zolmitriptan or its metabolites.
- Oral Contraceptives
- Retrospective analysis of pharmacokinetic data across studies indicated that mean Cmax and AUC of zolmitriptan were increased by 30% and 50%, respectively, and Tmax was delayed by one-half hour in women taking oral contraceptives. The effect of ZOMIG on the pharmacokinetics of oral contraceptives has not been studied.

## Nonclinical Toxicology
- Carcinogenesis
- Zolmitriptan was administered to mice and rats at doses up to 400 mg/kg/day. Mice were dosed for 85 weeks (males) and 92 weeks (females); rats were dosed for 101 weeks (males) and 86 weeks (females). There was no evidence of drug-induced tumors in mice at plasma exposures (AUC) up to approximately 700 times that in humans at the maximum recommended human dose (MRHD) of 10 mg/day. In rats, there was an increase in the incidence of thyroid follicular cell hyperplasia and thyroid follicular cell adenomas in male rats receiving 400 mg/kg/day. No increase in tumors was observed in rats at 100 mg/kg/day, a dose associated with a plasma AUC approximately 700 times that in humans at the MRHD.
- Mutagenesis
- Zolmitriptan was positive in an in vitro bacterial reverse mutation (Ames) assay and in an in vitro chromosomal aberration assay in human lymphocytes. Zolmitriptan was negative in an in vitro mammalian gene cell mutation (CHO/HGPRT) assay and in oral in vivo mouse micronucleus assays in mouse and rat.
- Impairment of Fertility
- Studies of male and female rats administered zolmitriptan prior to and during mating and up to implantation showed no impairment of fertility at oral doses up to 400 mg/kg/day. The plasma exposure (AUC) at this dose was approximately 3000 times that in humans at the MRHD.

# Clinical Studies
- The efficacy of ZOMIG tablets in the acute treatment of migraine headaches was demonstrated in five randomized, double-blind, placebo-controlled studies (Studies 1, 2, 3, 4, and 5), of which two utilized the 1 mg dose, two utilized the 2.5 mg dose and four utilized the 5 mg dose. In Study 1, patients treated their headaches in a clinic setting. In the other studies, patients treated their headaches as outpatients. In Study 4, patients who had previously used sumatriptan were excluded, whereas in the other studies no such exclusion was applied.
- Patients enrolled in these 5 studies were predominantly female (82%) and Caucasian (97%) with a mean age of 40 years (range 12-65). Patients were instructed to treat a moderate to severe headache. Headache response, defined as a reduction in headache severity from moderate or severe pain to mild or no pain, was assessed at 1, 2, and, in most studies, 4 hours after dosing. Associated symptoms such as nausea, photophobia, and phonophobia were also assessed. Maintenance of response was assessed for up to 24 hours post-dose. A second dose of ZOMIG tablets or other medication was allowed 2 to 24 hours after the initial treatment for persistent and recurrent headache. The frequency and time to use of these additional treatments were also recorded. In all studies, the effect of ZOMIG was compared to placebo in the treatment of a single migraine attack.
- In all five studies, the percentage of patients achieving headache response 2 hours after treatment was significantly greater among patients who received ZOMIG tablets at all doses (except for the 1 mg dose in the smallest study) compared to those who received placebo. In Studies 1 and 3, there was a statistically significant greater percentage of patients with headache response at 2 hours in the higher dose groups (2.5 and/or 5 mg) compared to the 1 mg dose group. There were no statistically significant differences between the 2.5 and 5 mg dose groups (or of doses up to 20 mg) for the primary end point of headache response at 2 hours in any study. The results of these controlled clinical studies are summarized in Table 2.
- The estimated probability of achieving an initial headache response by 4 hours following treatment in pooled Studies 2, 3, and 5 is depicted in Figure 1.
- In this KaplanMeier plot, the averages displayed are based on pooled data from 3 placebo controlled, outpatient trials. Patients not achieving headache response or taking additional treatment prior to 4 hours were censored at 4 hours.
- For patients with migraine associated photophobia, phonophobia, and nausea at baseline, there was a decreased incidence of these symptoms following administration of ZOMIG tablets as compared with placebo.
- Two to 24 hours following the initial dose of study treatment, patients were allowed to use additional treatment for pain relief in the form of a second dose of study treatment or other medication. The estimated probability of patients taking a second dose or other medication for migraine over the 24 hours following the initial dose of study treatment is summarized in Figure 2.
- In this Kaplan-Meier plot, patients not using additional treatments were censored at 24 hours. The plot includes both patients who had headache response at 2 hours and those who had no response to the initial dose. The studies did not allow taking additional doses of study medication within 2 hours post-dose.
- The efficacy of ZOMIG was unaffected by presence of aura; duration of headache prior to treatment; relationship to menses; gender, age, or weight of the patient; pre-treatment nausea or concomitant use of common migraine prophylactic drugs.
- The efficacy of ZOMIG-ZMT 2.5 mg orally disintegrating tablets was demonstrated in a randomized, placebo-controlled trial (Study 6) that was similar in design to the trials of ZOMIG tablets. Patients were instructed to treat a moderate to severe headache. Of the 471 patients treated in Study 6, 87% were female and 97% were Caucasian, with a mean age of 41 years (range 18-62).
- At 2 hours post-dosing, there was a statistically significant greater percentage of patients treated with ZOMIG-ZMT 2.5 mg with a headache response (reduction in headache severity from moderate or severe pain to mild or no headache) compared to patients treated with placebo (63% vs. 22%). The estimated probability of achieving an initial headache response by 2 hours following treatment with ZOMIG-ZMT orally disintegrating tablets is depicted in Figure 3.
- In this Kaplan-Meier plot patients taking additional treatment or not achieving headache response prior to 2 hours were censored at 2 hours.
- For patients with migraine-associated photophobia, phonophobia and nausea at baseline, there was a decreased incidence of these symptoms following administration of ZOMIG-ZMT as compared to placebo.
- Two to 24 hours following the initial dose of study treatment, patients were allowed to use additional treatment in the form of a second dose of study treatment or other medication. The estimated probability of patients taking a second dose or other medication for migraine over the 24 hours following the initial dose of study treatment in Study 6 is summarized in Figure 4.
- In this Kaplan-Meier plot, patients not taking additional treatments were censored at 24 hours. The plot includes both patients who had headache response at 2 hours and those who had no response to the initial dose. Taking another dose of study medication was allowed 2 hours post-dose in Study 6. In contrast to studies of ZOMIG tablets (Studies 1, 2, 3, 4, and 5), Study 6 allowed re-dosing of ZOMIG-ZMT oral disintegrating tablets prior to 4 hours.

# How Supplied
- 2.5 mg Tablets - Yellow, biconvex, round, film-coated, functionally-scored tablets containing 2.5 mg of zolmitriptan identified with ZOMIG and 2.5 debossed on one side are supplied in cartons containing a blister pack of 6 tablets (NDC 64896-671-51).
- 5 mg Tablets  Pink, biconvex, round, film-coated tablets containing 5 mg of zolmitriptan identified with ZOMIG and 5 debossed on one side are supplied in cartons containing a blister pack of 3 tablets (NDC 64896-672-50).
- 2.5 mg Orally Disintegrating Tablets - White, flat-faced, round, uncoated, bevelled tablet containing 2.5 mg of zolmitriptan identified with a debossed Z on one side are supplied in cartons containing a blister pack of 6 orally disintegrating tablets (NDC 64896-691-51).
- 5 mg Orally Disintegrating Tablets - White, flat-faced, round, uncoated, bevelled tablet containing 5 mg of zolmitriptan identified with a debossed Z and 5 on one side and plain on the other are supplied in cartons containing a blister pack of 3 orally disintegrating tablets (NDC 64896-692-50).
- Store ZOMIG Tablets and ZOMIGZMT Tablets at controlled room temperature, 2025oC (6877oF) . Protect from light and moisture.

## Storage
There is limited information regarding Zolmitriptan (oral) Storage in the drug label.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Myocardial Ischemia and/or Infarction, Prinzmetals angina, Other Vasospastic Reactions, and Cerebrovascular Events
- Inform patients that ZOMIG may cause serious cardiovascular adverse reactions such as myocardial infarction or stroke, which may result in hospitalization and even death. Although serious cardiovascular reactions can occur without warning symptoms, instruct patients to be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and instruct them to ask for medical advice when observing any indicative sign or symptoms. Instruct patients to seek medical advice if they have symptoms of other vasospastic reactions.
- Medication Overuse Headache
- Inform patients that use of drugs to treat acute migraines 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).
- Serotonin Syndrome
- Inform patients about the risk of serotonin syndrome with the use of ZOMIG or other triptans, particularly during combined use with selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs).
- Pregnancy
- Inform patients that ZOMIG should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus.
- Nursing Mothers
- Advise patients to notify their healthcare provider if they are breastfeeding or plan to breastfeed.
- Handling of ZOMIG-ZMT Orally Disintegrating Tablets
- Inform patients not to break ZOMIG-ZMT oral disintegrating tablets. Inform patients that the orally disintegrating tablet is packaged in a blister. Instruct patients not to remove the oral disintegrating tablet from the blister until just prior to dosing. Instruct patients that prior to dosing, peel open the blister pack and place the orally disintegrating tablet on the tongue, where it will dissolve and be swallowed with the saliva.
- Patients with Phenylketonuria
- Inform patients with phenylketonuria (PKU) that ZOMIG-ZMT contains phenylalanine (a component of aspartame).

# Precautions with Alcohol
- Alcohol-Zolmitriptan interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- ZOMIG

# Look-Alike Drug Names
- ZOLMitriptan  sitaGLIPtin
- ZOLMitriptan  SUMAtriptan
- zolmitriptan  zolpidem

# Drug Shortage Status

# Price