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Sumatriptan-Associated Ischemic Colitis: Case report and Review of the Literature and FAERS

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Abstract

Background and Aims

Ischemic colitis (IC) is being increasingly recognized, although specific etiological causes are observed in a minority of patients. While several drugs have been associated with IC, most remain anecdotal reports. We recently treated a patient with IC thought to be related to sumatriptan for migraines, and performed a literature review along with a review of the FDA Adverse Event Reporting System (FAERS) database to identify additional cases.

Methods

A MEDLINE/PubMed literature review was conducted using standard IC search terms to identify published cases of sumatriptan and other related “triptan” drug causes of IC. In addition, through a Freedom of Information Act request, we reviewed the adverse gastrointestinal events linked to sumatriptan contained in the FAERS database for the 5-year period 12 March 2008–11 March 2013, in order to determine whether unpublished cases might exist. Our case of IC was analyzed using a causality assessment tool initially developed for use in cases of alosetron (a 5-HT3 receptor antagonist)-related IC.

Results

Five published reports (containing a total of seven patients) describing sumatriptan-associated IC in the English language literature were found and reviewed. Another four published reports of related 5-HT1 receptor agonists causing IC (razitriptan n = 1 and naratriptan n = 3) were also analyzed. Among spontaneous reports of possible IC contained in the FAERS database for sumatriptan, there were 19 adverse events coded as “ischemic colitis” and another six coded as “intestinal ischemia” over a 5-year period ending March 2013, but clinical details were lacking. Similarly, five reports of possible IC from FAERS were mentioned in an earlier published report from the late 1990s. All of the published case reports of sumatriptan and related drugs were deemed to have the classic clinical findings and all recovered. There was one instance of possible recurrent IC symptoms in one patient re-exposed to sumatriptan, but not in another. We found that the IC scoring system developed for alosetron was applicable in our sumatriptan case.

Conclusions

Among drug-related causes of IC, sumatriptan joins a growing list of agents with literature reports supported by the finding of suspected cases of IC in the FAERS database. However, the true incidence of IC due to sumatriptan, as well as other causes, cannot be accurately determined because of the likelihood of under-reporting. The structured IC scoring system appears to be applicable for drug-related as well as other etiological causes of IC.

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References

  1. Brandt LJ, Feuerstat P, Blaszka MS. Anatomic patterns, patient characteristics and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology. Am J Gastroenterol. 2010;105(10):2245–52.

    Article  PubMed  Google Scholar 

  2. Gandhi SK, Hanson MM, Vernava AM, et al. Ischemic colitis. Dis Colon Rectum. 1996;39(1):88–100.

    Article  CAS  PubMed  Google Scholar 

  3. Higgins PD. Systematic review: the epidemiology of ischaemic colitis. Aliment Pharmacol Ther. 2004;19(7):729–38.

    Article  CAS  PubMed  Google Scholar 

  4. Longstreth GF, Yao JF. Epidemiology, clinical features, high-risk factors, and outcome of acute large bowel ischemia. Clin Gastroenterol Hepatol. 2009;7:1075–80.

    Article  PubMed  Google Scholar 

  5. Longstreth GF, Yao JF. Diseases and drugs that increase risk of acute large bowel ischemia. Clin Gastroenterol Hepatol. 2010;8:49–54.

    Article  PubMed  Google Scholar 

  6. Lewis JH. The risk of ischaemic colitis in irritable bowel syndrome patients treated with serotonergic therapies. Drug Saf. 2011;34:545–65.

    Article  CAS  PubMed  Google Scholar 

  7. Suh DC, Kahler KH, Choi IS, Shin H, Kralstein J, Shetzline M. Patients with irritable bowel syndrome or constipation have an increased risk for ischaemic colitis. Aliment Pharmacol Ther. 2007;25:681–92.

    Article  PubMed  Google Scholar 

  8. Knudsen JF, Friedman B, Chen M, Goldwasser JE. Ischemic colitis and sumatriptan use. Arch Intern Med. 1998;158:1946–8.

    Article  CAS  PubMed  Google Scholar 

  9. Caekebeke JF, Ferrari MD, Zwetsloot CP, Jansen J, Saxena PR. Antimigraine drug sumatriptan increases blood flow velocity in large cerebral arteries during migraine attacks. Neurology. 1992;42:1522–6.

    Article  CAS  PubMed  Google Scholar 

  10. Friberg L, Olesen J, Iversen HK, Sperling B. Migraine pain associated with middle cerebral artery dilatation: reversal by sumatriptan. Lancet. 1991;338:13–7.

    Article  CAS  PubMed  Google Scholar 

  11. Naik M, Potluri R, Almasri E, Arnold G. Sumatriptan-associated ischemic colitis. Dig Dis Sci. 2002;47:2015–6.

    Article  PubMed  Google Scholar 

  12. Moawad FJ, Goldkind L. An unusual case of colonic ischemia. South Med J. 2009;102:405–7.

    Article  PubMed  Google Scholar 

  13. Hodge JA, Hodge KD. Ischemic colitis related to sumatriptan overdose. JABFM. 2010;23:124–7.

    Article  PubMed  Google Scholar 

  14. Liu JJ, Ardolf JC. Sumatriptan-associated mesenteric ischemia. Ann Intern Med. 2000;132:597.

    Article  CAS  PubMed  Google Scholar 

  15. Alkhatib AA, Gangotena F, Peterson KA. Rizatriptan induced acute on top of chronic ischemic colitis. Am J Gasterolenterol. 2009;104:2643–4.

    Article  Google Scholar 

  16. Schwartz DC, Smith DJ. Colonic ischemia associated with naratriptan use. J Clin Gastroenterol. 2004;38:790–2.

    Article  PubMed  Google Scholar 

  17. Charles JA, Pullicino PM, Stoopack PM, Shroff Y. Ischemic colitis associated with naratriptan and oral contraceptive use. Headache. 2005;45:386–9.

    Article  PubMed  Google Scholar 

  18. Westgeest HM, Akol H, Schreuder CMA. Pure naratriptan-induced ischemic colitis: a case report. Turk J Gastroenterol. 2010;21:42–4.

    PubMed  Google Scholar 

  19. Chang L, Tong K, Ameen V. Ischemic colitis and complications of constipation associated with the use of alosetron under a risk management plan: clinical characteristics, outcomes, and incidences. Am J Gastroenterol. 2010;105:866–75.

    Article  PubMed  Google Scholar 

  20. Gallo-Torres H, Brinker A, Avigan M. Alosetron: ischemic colitis and serious complications of constipation. Am J Gastroenterol. 2006;101:1080–3.

    Article  PubMed  Google Scholar 

  21. DeBaise JK. Tegaserod-associated ischemic colitis. Pharmacotherapy. 2005;25:620–5.

    Article  Google Scholar 

  22. Cappell MS. Colonic toxicity of administered drugs and chemicals. Am J Gastroenterol. 2004;99:1175–90.

    Article  CAS  PubMed  Google Scholar 

  23. Kleespies A, Jonas S, Neuhaus P. Simulation of colon carcinoma: diuretic induced ulcerative-stricturing ischemic colitis. Dtsch Med Wochenschr. 2004;129(13):681–4.

    Article  CAS  PubMed  Google Scholar 

  24. Linder JD, Monkemuler KE, Raijman I, et al. Cocaine-associated ischemic colitis. South Med J. 2000;93:909–13.

    CAS  PubMed  Google Scholar 

  25. Montgomery EM, Riddell RH. Ischemic colitis in a young patient. Pathol Case Rev. 2004;9:93–6.

    Article  Google Scholar 

  26. Keller HW, Lorenz R, Mueller JM, Pichmaier H. Ischemic colitis following digitalis poisoning. Chirurg. 1984;55(12):830–1.

    CAS  PubMed  Google Scholar 

  27. Ablassmaier B, Hartmann JA. Case of severe ischaemic colitis following non- steroidal anti-inflammatory drug intake. Zentralbl Chir. 2004;129(6):510–2.

    Article  CAS  PubMed  Google Scholar 

  28. Deana DG, Dean PJ. Reversible ischemic colitis in young women in association with oral contraceptive use. Am J Surg Pathol 19 (1995): :454- 62.

    Google Scholar 

  29. Giurbuz AK, Gurbuz B, Salas L, Rosenshein NB, Donowitz M, Giardiello FM. Premarin induced ischemic colitis. J Clin Gastro. 1994;19:108–11.

    Article  Google Scholar 

  30. Preventza OA, Lazarides K, Sawyer MD. Ischemic colitis in young adults: a single-institution experience. J Gastrointest Surg. 2001;5:388–92.

    Article  CAS  PubMed  Google Scholar 

  31. Salk A, Stobaugh DJ, Deepak P, Ehrenpreis ED. Ischaemic colitis in rheumatoid arthritis patients receiving tumor necrosis factor-α inhibitors: an analysis of reports to the US FDA Adverse Event Reporting System. Drug Saf. 2013;36:329–34.

    Article  CAS  PubMed  Google Scholar 

  32. Salk A, Stobaugh DJ, Deepak P, Ehrenpreis ED. Ischemic colitis with type 1 interferons used in the treatment of hepatitis C and multiple sclerosis: an evaluation from the Food and Drug Administration Adverse Event Reporting System and review of the literature. Ann Pharmacother. 2013;47:537–42.

    Article  CAS  PubMed  Google Scholar 

  33. Rodman RE, Willson TD, Connolly MM, Podbielski FJ. Ischemic colitis secondary to ergotamine use: a case study. Case Rep Gastroenterol. 2011;5:1–4.

    Article  PubMed Central  PubMed  Google Scholar 

  34. Rashid A, Hamilton SR. Necrosis of the gastrointestinal tract in uremic patients as a result of sodium polystyrene sulfonate in sorbitol: an underrecognized condition. Am J Surg Pathol. 1997;21:60–9.

    Article  CAS  PubMed  Google Scholar 

  35. Traino A, Buckley M, Bassett M. Probable ischemic colitis caused by pseudoephedrine with tramadol as a possible contributing factor. Ann Pharmacother. 2004;38:2068–70.

    Article  PubMed  Google Scholar 

  36. Camerilli M. Is there an experimental basis for the development of ischaemic colitis as a result of 5-HT3 antagonist treatment? Neurogastroenterol Motil. 2007;19:77–84.

    Article  Google Scholar 

  37. Millson D, Sohail S, Lettis S, et al. Duration of inihibition of the flare response to intradermal 5-hydroxytryptamine in man by GR68755, an novel specific 5-HT3 receptor antagonist. Br J Clin Pharmacol. 1992;33:546–7.

    Article  Google Scholar 

  38. Limmroth V, May A, Auerbach P, Wosnitza G, Eppe T, Diener HC. Changes in cerebral blood flow velocity after treatment with sumatriptan or placebo and implications for the pathophysiology of migraine. J Neurol Sci. 1996;138(1–2):60–5.

    Article  CAS  PubMed  Google Scholar 

  39. Ringle Y, Wilson J, D’Agostino R, Lewis JH. Development and validation of an ischemic colitis clinical diagnosis assessment instrument. Gastroenterology 2005;128.4 (Suppl 2):A467.

    Google Scholar 

  40. Imitrex tablets prescribing information, 2012. GlaxoSmithKline Research Triangle Park, NC 27709. http://us.gsk.com/products/assets/us_imitrex_tablets.pdf Accessed 7 Dec 2013.

  41. Amerge (naratriptan hydrochloride) tablets prescribing information, October 2013. GlaxoSmithKline Research Triangle Park, NC 27709. http://us.gsk.com/products/assets/us_amerge.pdf. Accessed 7 Dec 2013.

  42. Maxalt (rizatriptan benzoate) prescribing information, January 2013. Merck & Co. Whitehouse Station, NJ 08889. http://www.merck.com/product/usa/pi_circulars/m/maxalt/maxalt_pi.pdf. Accessed 7 Dec 2013.

  43. Relpax (eletriptan hydrobromide) tablets prescribing information, May 2008; Roerig Division of Pfizer, NY,NY 10017. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=986dc112-b97b-44a3-bfaf-074f906f8bb2. Accessed 7 Dec 2013.

  44. Axert (almotriptan malate) tablets prescribing information, April 2011; Ortho-McNeil Neurologics, Titusville, NJ 08560. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=b13ba9bf-1661-456a-8eae-6d110ea08c94. Accessed 7 Dec 2013.

  45. Frova (frovatriptan succinate) prescribing information, April 2007; Endo Pharmaceuticals, Inc. 100 Endo Blvd, Chadds Ford, PA 19317. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=294d60f3-005b-40d9-a404-cdd77f62b820. Accessed 7 Dec 2013.

  46. Zomig (zolmitriptan) prescribing information, September 2012; AstraZeneca/Impax Pharmaceuticals, Hawward, CA 94544. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=294d60f3-005b-40d9-a404-cdd77f62b820. Accessed 7 Dec 2013.

  47. Personal communication, JP Nicandro. Data on file with Prometheus Laboratories, San Diego, CA.

  48. Loder E. Triptan therapy in migraine. N Engl J Med. 2010;363:63–70.

    Article  CAS  PubMed  Google Scholar 

  49. Tfelt-Hansen P, De Vries P, Saxena PR. Triptans in migraine: a comparative review of pharmacology, pharmacokinetics and efficacy. Drugs. 2000;60:1259–87.

    Article  CAS  PubMed  Google Scholar 

  50. Bax WA, Renzenbrink GJ, Van Heuven-Nolsen D, Thijssen EJ, Bos E, Saxena PR. 5-HT receptors mediating contractions of the isolated human coronary artery. Eur J Pharmacol. 1993;239:203–10.

    Article  CAS  PubMed  Google Scholar 

  51. Connor HE, Feniuk W, Humphrey PP. 5-Hydroxytryptamine contracts human coronary arteries predominantly via 5-HT2 receptor activation. Eur J Pharmacol. 1989;161:91–4.

    Article  CAS  PubMed  Google Scholar 

  52. Jamieson DG. The safety of triptans in the treatment of patients with migraine. Am J Med. 2002;112:135–40.

    Article  CAS  PubMed  Google Scholar 

  53. Szarfman A, Machado SG, O’Neill RT. Use of screening algorithms and computer systems to efficiently signal higher-than-expected combinations of drugs and events in the US FDA’s spontaneous reports database. Drug Saf. 2002;25(6):381–92.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The authors thank Adrien Mazer, MD (Department of Medicine) for his assistance with managing the patient, and Bhaskar Kallakury, MD (Department of Pathology) for his help in preparing the pathology photomicrographs.

Author Contributions

Thuc Quyen Nguyen drafted the manuscript. James H. Lewis conceived, drafted, and critically revised the manuscript.

Disclosures

No sources of funding were used to assist in the preparation of this study. Thus Quyen Nguyen and James H. Lewis have no conflicts of interest that are directly relevant to the content of this study.

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  1. Division of Gastroenterology, Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC, 20007, USA

    Thuc Quyen Nguyen & James H. Lewis

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  1. Thuc Quyen Nguyen
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Correspondence to James H. Lewis.

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Nguyen, T.Q., Lewis, J.H. Sumatriptan-Associated Ischemic Colitis: Case report and Review of the Literature and FAERS. Drug Saf 37, 109–121 (2014). https://doi.org/10.1007/s40264-013-0134-7

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