What are the precautions when taking Rizatriptan (a triptan) with Propranolol (a beta blocker)?

Precautions When Taking Rizatriptan with Propranolol

When prescribing rizatriptan to patients taking propranolol, only the 5 mg dose of rizatriptan should be used, with a maximum of 3 doses in any 24-hour period (15 mg total daily maximum). 1

Pharmacokinetic Interaction

• Propranolol significantly increases rizatriptan plasma concentrations by approximately 67% (AUC) and peak concentration by approximately 75% 2
• This interaction occurs through propranolol's inhibition of monoamine oxidase-A (MAO-A), which metabolizes rizatriptan 2
• The interaction is specific to propranolol and does not occur with other beta-blockers such as metoprolol or nadolol 2

Dosing Recommendations

Adult Patients

• For adults taking propranolol: only the 5 mg dose of rizatriptan is recommended 1
• Maximum of 3 doses of rizatriptan (15 mg total) in any 24-hour period for adults on propranolol 1
• Without propranolol, the standard rizatriptan dosing would be 5-10 mg with a maximum of 30 mg in 24 hours 1

Pediatric Patients

• For pediatric patients weighing ≥40 kg (88 lb) taking propranolol: only a single 5 mg dose of rizatriptan is recommended (maximum 5 mg in 24 hours) 1
• Rizatriptan should not be prescribed to propranolol-treated pediatric patients who weigh less than 40 kg (88 lb) 1

Safety Considerations

• Despite the pharmacokinetic interaction, no serious adverse events have been reported specifically due to the rizatriptan-propranolol combination in clinical studies 2
• However, caution is still warranted due to the increased rizatriptan exposure 2
• Common side effects of rizatriptan include dizziness, somnolence, asthenia/fatigue, and pain/pressure sensations 3
• Both medications can cause cardiovascular effects, with propranolol causing bradycardia and hypotension, while rizatriptan can cause chest pressure or heaviness 4

Clinical Monitoring

• Monitor for increased triptan-related side effects such as dizziness, somnolence, and chest pressure 3
• Be aware that propranolol may mask some of the early warning signs of hypoglycemia (such as tachycardia and tremor) 5
• If a patient experiences unpleasant sensory disturbances with the combination, consider alternative migraine prophylaxis options that don't interact with rizatriptan 4

Important Contraindications

• Both medications are contraindicated in patients with:
  • Ischemic heart disease 4
  • Uncontrolled hypertension 4
  • Vasospastic coronary disease 4
• Propranolol is also contraindicated in patients with asthma, obstructive airway disease, and decompensated heart failure 5

Alternative Beta-Blockers

• If a patient requires both a beta-blocker for migraine prophylaxis and triptans for acute treatment, consider using metoprolol or nadolol instead of propranolol 2
• These alternative beta-blockers do not significantly alter rizatriptan pharmacokinetics and do not require dose adjustment 2