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Reassessing the contraindication of zolmitriptan and serotonin reuptake inhibitors: an evidence‐based pharmacotherapeutic case report
Author(s) -
Boutilier A. S. W.,
Gardner D. M.
Publication year - 2003
Publication title -
journal of clinical pharmacy and therapeutics
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.622
H-Index - 73
eISSN - 1365-2710
pISSN - 0269-4727
DOI - 10.1046/j.1365-2710.2003.00453.x
Subject(s) - pharmacy , nova scotia , contraindication , medicine , library science , psychology , family medicine , alternative medicine , sociology , computer science , ethnology , pathology
Zolmitriptan is a selective agonist at specific serotonin receptors, namely 5-HT1B and 5-HT1D receptors, which is believed to account for its antimigraine effects through vasoconstriction of extracerebral blood vessels and a reduction of neurogenic inflammation in the brain (1). This proposed mechanism of action applies to all triptan antimigraine compounds, however, they differ in some relevant pharmacokinetic properties including lipophilicity (1–3). Zolmitriptan is also an agonist at 5-HT1A, a serotonin autoreceptor (see Table 1). Paroxetine is also serotonergic, although rather non-specific. Like other selective serotonin reuptake inhibitors (SSRI), it exerts its pharmacologic effects by increasing synaptic serotonin concentrations resultant to its blockade of the presynaptic serotonin transporter (2). Use of zolmitriptan and paroxetine are contraindicated due to the theoretical risk of a serotonin syndrome (4). This syndrome is believed to be caused by overstimulation of 5HT1A receptors (5) and is characterized by a wide range of neuromuscular and neuropsychiatric symptoms and autonomic dysfunction (3, 6). Serotonin syndrome can be severe and may even result in death (7). As first-line treatment options, triptans and SSRIs are in common use in individuals suffering from migraines and depression, respectively. It is also common that many of these individuals suffer from both of these prevalent diseases concurrently. Numerous studies have demonstrated high rates of depression in individuals suffering from migraines and vice versa (8–10). Thus, there is significant potential to coprescribe these agents. On an individual basis, the contraindication against their concurrent use could either prevent harm, by avoiding a serotonin syndrome, or deny a potentially effective therapy. As the contraindication between zolmitriptan and SSRIs is theoretically, not empirically, based and the opportunity to coprescribe these agents is likely to be frequent, a re-evaluation of the contraindication is justified. The following case provided this opportunity.