ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS The following adverse reactions are discussed in more detail in other sections of the labeling:oMyocardial Ischemia, Myocardial Infarction, and Prinzmetals Angina [see Warnings and Precautions (5.1)].oArrhythmias [see Warnings and Precautions (5.2)].oChest, Throat, Neck and/or Jaw Pain/Tightness/Pressure [see Warnings and Precautions (5.3)].oCerebrovascular Events [see Warnings and Precautions (5.4)].oOther Vasospasm Reactions [see Warnings and Precautions (5.5)].oMedication Overuse Headache [see Warnings and Precautions (5.6)].oSerotonin Syndrome [see Warnings and Precautions (5.7)].oIncrease in Blood Pressure [see Warnings and Precautions (5.8)].. oMyocardial Ischemia, Myocardial Infarction, and Prinzmetals Angina [see Warnings and Precautions (5.1)].. oArrhythmias [see Warnings and Precautions (5.2)].. oChest, Throat, Neck and/or Jaw Pain/Tightness/Pressure [see Warnings and Precautions (5.3)].. oCerebrovascular Events [see Warnings and Precautions (5.4)].. oOther Vasospasm Reactions [see Warnings and Precautions (5.5)].. oMedication Overuse Headache [see Warnings and Precautions (5.6)].. oSerotonin Syndrome [see Warnings and Precautions (5.7)].. oIncrease in Blood Pressure [see Warnings and Precautions (5.8)].. The most common adverse reactions in adults were (incidence >= 5% and greater than placebo): asthenia/fatigue, somnolence, pain/pressure sensation and dizziness (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Mylan at 1-877-446-3679 (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1Clinical Trials Experience Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.. Adults. Incidence in Controlled Clinical Trials Adverse reactions to rizatriptan benzoate tablets were assessed in controlled clinical trials that included over 3700 adult patients who received single or multiple doses of rizatriptan benzoate tablets. The most common adverse reactions during treatment with rizatriptan benzoate tablets (>= 5% in either treatment group and greater than placebo) were asthenia/fatigue, somnolence, pain/pressure sensation and dizziness. These adverse reactions appeared to be dose related.Table lists the adverse reactions (incidence >= 2% and greater than placebo) after single dose of rizatriptan benzoate tablets in adults.Table 1: Incidence (>= 2% and Greater than Placebo) of Adverse Reactions After Single Dose of Rizatriptan Benzoate Tablets or Placebo in AdultsAdverse Reactions% of PatientsRizatriptan Benzoate Tablets5 mg(N 977)Rizatriptan Benzoate Tablets10 mg(N 1167)Placebo(N 627)Atypical Sensations454 Paresthesia34< 2Pain and Other Pressure Sensations693 Chest Pain: tightness/pressure and/or heaviness< 231 Neck/throat/jaw: pain/tightness/pressure< 221 Regional Pain: tightness/pressure and/or heaviness< 120 Pain, location unspecified33< 2Digestive9138 Dry Mouth331 Nausea464Neurological142011 Dizziness495 Headache< 22< Somnolence484Other Asthenia/fatigue472The frequencies of adverse reactions in clinical trials did not increase when up to three doses were taken within 24 hours. Adverse reaction frequencies were also unchanged by concomitant use of drugs commonly taken for migraine prophylaxis (including propranolol), oral contraceptives, or analgesics. The incidences of adverse reactions were not affected by age or gender. There were insufficient data to assess the impact of race on the incidence of adverse reactions.. Other Events Observed in Association with the Administration of Rizatriptan Benzoate Tablets in Adults In the following section, the frequencies of less commonly reported adverse events are presented that were not reported in other sections of the labeling. Because the reports include events observed in open studies, the role of rizatriptan benzoate tablets in their causation cannot be reliably determined. Furthermore, variability associated with adverse event reporting, the terminology used to describe adverse events, limit the value of the quantitative frequency estimates provided. Event frequencies are calculated as the number of patients who used rizatriptan benzoate tablets and reported an event divided by the total number of patients exposed to rizatriptan benzoate tablets (N 3716). All reported events occurred at an incidence >= 1%, or are believed to be reasonably associated with the use of the drug. Events are further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: frequent adverse events are those defined as those occurring in at least (>) 1/100 patients; infrequent adverse experiences are those occurring in 1/100 to 1/1000 patients; and rare adverse experiences are those occurring in fewer than 1/1000 patients.General: Infrequent was facial edema. Rare were syncope and edema/swelling.Atypical Sensations: Frequent were warm sensations.Cardiovascular: Frequent was palpitation. Infrequent were tachycardia, cold extremities, and bradycardia.Digestive: Frequent were diarrhea and vomiting. Infrequent were dyspepsia, tongue edema and abdominal distention.Musculoskeletal: Infrequent were muscle weakness, stiffness, myalgia and muscle cramp/spasm.Neurological/Psychiatric: Frequent were hypoesthesia, euphoria and tremor. Infrequent were vertigo, insomnia, confusion/disorientation, gait abnormality, memory impairment, and agitation.Respiratory: Frequent was dyspnea. Infrequent was pharyngeal edema.Special Senses: Infrequent were blurred vision and tinnitus. Rare was eye swelling.Skin and Skin Appendage: Frequent was flushing. Infrequent were sweating, pruritus, rash, and urticaria. Rare were erythema and hot flashes.. Pediatric Patients to 17 Years of Age. Incidence in Controlled Clinical Trials in Pediatric Patients Adverse reactions to rizatriptan benzoate orally disintegrating tablets were assessed in controlled clinical trial in the acute treatment of migraines (Study 7) that included total of 1382 pediatric patients 6-17 years of age, of which 977 (72%) administered at least one dose of study treatment (rizatriptan benzoate orally disintegrating tablets and/or placebo) [see Clinical Studies (14.2)]. The incidence of adverse reactions reported for pediatric patients in the acute clinical trial was similar in patients who received rizatriptan benzoate orally disintegrating tablets to those who received placebo. The adverse reaction pattern in pediatric patients is expected to be similar to that in adults. Other Events Observed in Association with the Administration of Rizatriptan Benzoate Orally Disintegrating Tablets in Pediatric Patients In the following section, the frequencies of less commonly reported adverse events are presented. Because the reports include events observed in open studies, the role of rizatriptan benzoate orally disintegrating tablets in their causation cannot be reliably determined. Furthermore, variability associated with adverse event reporting, the terminology used to describe adverse events, limit the value of the quantitative frequency estimates provided.Event frequencies are calculated as the number of pediatric patients to 17 years of age who used rizatriptan benzoate orally disintegrating tablets and reported an event divided by the total number of patients exposed to rizatriptan benzoate orally disintegrating tablets (N 1068). All reported events occurred at an incidence >= 1%, or are believed to be reasonably associated with the use of the drug. Events are further classified within system organ class and enumerated in order of decreasing frequency using the following definitions: frequent adverse events are those occurring in (>) 1/100 pediatric patients; infrequent adverse experiences are those occurring in 1/100 to 1/1000 pediatric patients; and rare adverse experiences are those occurring in fewer than 1/1000 patients.General: Frequent was fatigue.Ear and Labyrinth Disorders: Infrequent was hypoacusis.Gastrointestinal Disorders: Frequent was abdominal discomfort.Nervous System Disorders: Infrequent were coordination abnormal, disturbance in attention, and presyncope.Psychiatric Disorders: Infrequent was hallucination.. 6.2Postmarketing Experience The following section enumerates potentially important adverse events that have occurred in clinical practice and which have been reported spontaneously to various surveillance systems. The events enumerated include all except those already listed in other sections of the labeling or those too general to be informative. Because the reports cite events reported spontaneously from worldwide postmarketing experience, frequency of events and the role of rizatriptan benzoate tablets in their causation cannot be reliably determined.Neurological/Psychiatric: Seizure.General: Allergic conditions including anaphylaxis/anaphylactoid reaction, angioedema, wheezing, and toxic epidermal necrolysis [see Contraindications (4)].Special Senses: Dysgeusia.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis. Oral carcinogenicity studies of rizatriptan were conducted in mice (100 weeks) and rats (106 weeks) at doses of up to 125 mg/kg/day. There was no evidence of an increase in tumor incidence related to rizatriptan in either species. Plasma exposures (AUC) at the highest dose tested were approximately 150 (mice) and 240 times (rats) that in humans at the maximum recommended human dose (MRHD) of 30 mg/day. Mutagenesis. Rizatriptan was neither mutagenic nor clastogenic in battery of in vitro and in vivo genetic toxicity studies, including: the microbial mutagenesis (Ames) assay, in vitro mammalian cell mutagenesis and chromosomal aberration assays, and the in vivo chromosomal aberration assay in mouse.. Impairment of Fertility. Oral administration of rizatriptan (0, 2, 10, or 100 mg/kg/day) to female rats prior to and during mating and continuing throughout gestation and lactation resulted in no effect on fertility; however, altered estrous cyclicity and delays in time to mating were observed at the highest dose tested. Plasma exposure at the no-effect dose (10 mg/kg/day) for reproductive toxicity was approximately 15 times that in humans at the MRHD.Oral administration of rizatriptan (0, 5, 35, or 250 mg/kg/day) to male rats prior to and during mating resulted in no impairment of fertility or reproductive performance. Plasma exposure (AUC) at the highest dose tested was approximately 550 times that in humans at the MRHD.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Rizatriptan binds with high affinity to human cloned 5-HT1B/1D receptors. Rizatriptan presumably exerts its therapeutic effects in the treatment of migraine headache by binding to 5-HT1B/1D receptors located on intracranial blood vessels and sensory nerves of the trigeminal system.. 12.3 Pharmacokinetics Absorption. Rizatriptan is completely absorbed following oral administration. The mean oral absolute bioavailability of the rizatriptan benzoate tablet is about 45%, and mean peak plasma concentrations (Cmax) are reached in approximately 1-1.5 hours (Tmax). The presence of migraine headache did not appear to affect the absorption or pharmacokinetics of rizatriptan. Food has no significant effect on the bioavailability of rizatriptan but delays the time to reach peak concentration by an hour. In clinical trials, rizatriptan benzoate tablets were administered without regard to food.The bioavailability and Cmax of rizatriptan were similar following administration of rizatriptan benzoate tablets and rizatriptan benzoate orally disintegrating tablets, but the rate of absorption is somewhat slower with rizatriptan benzoate orally disintegrating tablets, with Tmax delayed by up to 0.7 hour. AUC of rizatriptan is approximately 30% higher in females than in males. No accumulation occurred on multiple dosing.. Distribution. The mean volume of distribution is approximately 140 liters in male subjects and 110 liters in female subjects. Rizatriptan is minimally bound (14%) to plasma proteins.. Metabolism. The primary route of rizatriptan metabolism is via oxidative deamination by monoamine oxidase-A (MAO-A) to the indole acetic acid metabolite, which is not active at the 5-HT1B/1D receptor. N-monodesmethyl-rizatriptan, metabolite with activity similar to that of parent compound at the 5-HT1B/1D receptor, is formed to minor degree. Plasma concentrations of N-monodesmethyl-rizatriptan are approximately 14% of those of parent compound, and it is eliminated at similar rate. Other minor metabolites, the N-oxide, the 6-hydroxy compound, and the sulfate conjugate of the 6-hydroxy metabolite are not active at the 5-HT1B/1D receptor.. Elimination. The total radioactivity of the administered dose recovered over 120 hours in urine and feces was 82% and 12%, respectively, following single 10-mg oral administration of 14C-rizatriptan. Following oral administration of 14C-rizatriptan, rizatriptan accounted for about 17% of circulating plasma radioactivity. Approximately 14% of an oral dose is excreted in urine as unchanged rizatriptan while 51% is excreted as indole acetic acid metabolite, indicating substantial first pass metabolism.The plasma half-life of rizatriptan in males and females averages 2-3 hours. Cytochrome P450 Isoforms. Rizatriptan is not an inhibitor of the activities of human liver cytochrome P450 isoforms 3A4/5, 1A2, 2C9, 2C19, or 2E1; rizatriptan is competitive inhibitor (Ki 1400 nM) of cytochrome P450 2D6, but only at high, clinically irrelevant concentrations. Special Populations. Geriatric Rizatriptan pharmacokinetics in healthy elderly non-migraineur volunteers (age 65-77 years) were similar to those in younger non-migraineur volunteers (age 18-45 years).. Pediatric The pharmacokinetics of rizatriptan was determined in pediatric migraineurs to 17 years of age. Exposures following single dose administration of mg rizatriptan benzoate orally disintegrating tablets to pediatric patients weighing 20-39 kg (44-87 lb) or 10 mg rizatriptan benzoate orally disintegrating tablets to pediatric patients weighing >= 40 kg (88 lb) were similar to those observed following single dose administration of 10 mg rizatriptan benzoate orally disintegrating tablets to adults. Gender The mean AUC0- and Cmax of rizatriptan (10 mg orally) were about 30% and 11% higher in females as compared to males, respectively, while Tmax occurred at approximately the same time.. Hepatic Impairment Following oral administration in patients with hepatic impairment caused by mild to moderate alcoholic cirrhosis of the liver, plasma concentrations of rizatriptan were similar in patients with mild hepatic insufficiency compared to control group of subjects with normal hepatic function; plasma concentrations of rizatriptan were approximately 30% greater in patients with moderate hepatic insufficiency.. Renal Impairment In patients with renal impairment (creatinine clearance 10-60 mL/min/1.73 m2), the AUC0- of rizatriptan was not significantly different from that in subjects with normal renal function. In hemodialysis patients, (creatinine clearance 2 mL/min/1.73 m2), however, the AUC for rizatriptan was approximately 44% greater than that in patients with normal renal function.. Race Pharmacokinetic data revealed no significant differences between African American and Caucasian subjects. Drug Interactions. [See also Drug Interactions (7).]. Monoamine Oxidase Inhibitors Rizatriptan is principally metabolized via monoamine oxidase, subtype (MAO-A). Plasma concentrations of rizatriptan may be increased by drugs that are selective MAO-A inhibitors (e.g., moclobemide) or nonselective MAO inhibitors [type and B] (e.g., isocarboxazid, phenelzine, tranylcypromine, and pargyline). In drug interaction study, when rizatriptan benzoate tablets 10 mg were administered to subjects (n 12) receiving concomitant therapy with the selective, reversible MAO-A inhibitor, moclobemide 150 mg t.i.d., there were mean increases in rizatriptan AUC and Cmax of 119% and 41% respectively; and the AUC of the active N-monodesmethyl metabolite of rizatriptan was increased more than 400%. The interaction would be expected to be greater with irreversible MAO inhibitors. No pharmacokinetic interaction is anticipated in patients receiving selective MAO-B inhibitors [see Contraindications (4) and Drug Interactions (7.5)].. Propranolol In study of concurrent administration of propranolol 240 mg/day and single dose of rizatriptan 10 mg in healthy adult subjects (n 11), mean plasma AUC for rizatriptan was increased by 70% during propranolol administration, and 4-fold increase was observed in one subject. The AUC of the active N-monodesmethyl metabolite of rizatriptan was not affected by propranolol [see Dosage and Administration (2.4) and Drug Interactions (7.1)].. Nadolol/Metoprolol In drug interactions study, effects of multiple doses of nadolol 80 mg or metoprolol 100 mg every 12 hours on the pharmacokinetics of single dose of 10 mg rizatriptan were evaluated in healthy subjects (n 12). No pharmacokinetic interactions were observed.. Paroxetine In study of the interaction between the selective serotonin reuptake inhibitor (SSRI) paroxetine 20 mg/day for weeks and single dose of rizatriptan benzoate tablets 10 mg in healthy subjects (n 12), neither the plasma concentrations of rizatriptan nor its safety profile were affected by paroxetine [see Warnings and Precautions (5.7), Drug Interactions (7.4), and Patient Counseling Information (17)].. Oral Contraceptives In study of concurrent administration of an oral contraceptive during days of administration of rizatriptan benzoate tablets (10-30 mg/day) in healthy female volunteers (n 18), rizatriptan did not affect plasma concentrations of ethinyl estradiol or norethindrone.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES 14.1Adults The efficacy of rizatriptan benzoate tablets was established in four multicenter, randomized, placebo-controlled trials. Patients enrolled in these studies were primarily female (84%) and Caucasian (88%), with mean age of 40 years (range of 18 to 71). Patients were instructed to treat moderate to severe headache. Headache response, defined as reduction of moderate or severe headache pain to no or mild headache pain, was assessed for up to hours (Study 1) or up to hours after dosing (Studies 2, and 4). Associated symptoms of nausea, photophobia, and phonophobia and maintenance of response up to 24 hours post-dose were evaluated. second dose of rizatriptan benzoate tablets was allowed to 24 hours after dosing for treatment of recurrent headache in Studies and 2. Additional analgesics and/or antiemetics were allowed hours after initial treatment for rescue in all four studies.In all studies, the percentage of patients achieving headache response hours after treatment was significantly greater in patients who received either rizatriptan benzoate tablets or 10 mg compared to those who received placebo. In separate study, doses of 2.5 mg were not different from placebo. Doses greater than 10 mg were associated with an increased incidence of adverse effects. The results from the four controlled studies are summarized in Table 2.Table 2: Response Rates Hours Following Treatment of Initial Headache in Studies 1, 2, 3, and 4StudyPlaceboRizatriptan Benzoate Tablets5 mgRizatriptan Benzoate Tablets10 mg135%(n 304)62%p-value 0.05 in comparison with placebo. (n 458)71% p-value 0.05 in comparison with mg. (n 456)2Results for initial headache only. 37%(n 82)--77% (n 320)323%(n 80)63% (n 352)--440%(n 159)60% (n 164)67% (n 385)Comparisons of drug performance based upon results obtained in different clinical trials may not be reliable. Because studies are conducted at different times, with different samples of patients, by different investigators, employing different criteria and/or different interpretations of the same criteria, under different conditions (dose, dosing regimen, etc.), quantitative estimates of treatment response and the timing of response may be expected to vary considerably from study to study.The estimated probability of achieving an initial headache response within hours following treatment in pooled Studies 1, 2, 3, and is depicted in Figure 1.Figure 1: Estimated Probability of Achieving an Initial Headache Response by Hours in Pooled Studies 1, 2, 3, and Figure shows the Kaplan-Meier plot of the probability over time of obtaining headache response (no or mild pain) following treatment with rizatriptan benzoate tablets or placebo. The averages displayed are based on pooled data from placebo-controlled, outpatient trials providing evidence of efficacy (Studies 1, 2, 3, and 4). Patients taking additional treatment or not achieving headache response prior to hours were censored at hours.For patients with migraine-associated photophobia, phonophobia, and nausea at baseline, there was decreased incidence of these symptoms following administration of rizatriptan benzoate tablets compared to placebo.Two to 24 hours following the initial dose of study treatment, patients were allowed to use additional treatment for pain response in the form of second dose of study treatment or other medication. The estimated probability of patients taking second dose or other medication for migraine over the 24 hours following the initial dose of study treatment is summarized in Figure 2.Figure 2: Estimated Probability of Patients Taking Second Dose of Rizatriptan Benzoate Tablets or Other Medication for Migraines Over the 24 Hours Following the Initial Dose of Study Treatment in Pooled Studies 1, 2, 3, and This Kaplan-Meier plot is based on data obtained in placebo-controlled outpatient clinical trials (Studies 1, 2, 3, and 4). Patients not using additional treatments were censored at 24 hours. The plot includes both patients who had headache response at hours and those who had no response to the initial dose. Remedication was not allowed within hours post-dose.Efficacy was unaffected by the presence of aura; by the gender, or age of the patient; or by concomitant use of common migraine prophylactic drugs (e.g., beta-blockers, calcium channel blockers, tricyclic antidepressants) or oral contraceptives. In two additional similar studies, efficacy was unaffected by relationship to menses. There were insufficient data to assess the impact of race on efficacy. Figure 1: Estimated Probability of Achieving an Initial Headache Response by Hours in Pooled Studies 1, 2, 3, and 4. Figure 2: Estimated Probability of Patients Taking Second Dose of Rizatriptan Benzoate Tablets or Other Medication for Migraines Over the 24 Hours Following the Initial Dose of Study Treatment in Pooled Studies 1, 2, 3, and 4. 14.2Pediatric Patients to 17 Years of Age The efficacy of rizatriptan benzoate orally disintegrating tablets in pediatric patients to 17 years was evaluated in multicenter, randomized, double-blind, placebo-controlled, parallel group clinical trial (Study 7). Patients had to have at least 6-month history of migraine attacks (with or without aura) usually lasting hours or more (when untreated). The patient population was historically non-responsive to NSAIDs and acetaminophen therapy.Patients were instructed to treat single migraine attack with headache pain of moderate to severe intensity. The treatment phase of the study had two stages. Stage was used to identify placebo non-responders, who then entered into Stage 2, in which patients were randomized to rizatriptan benzoate orally disintegrating tablets or placebo. Using weight-based dosing strategy, patients 20 kg to 40 kg (44 lb to 88 lb) received rizatriptan benzoate orally disintegrating tablets mg or placebo, and patients >= 40 kg (88 lb) received rizatriptan benzoate orally disintegrating tablets 10 mg or placebo.The mean age for the studied patient population was 13 years. Sixty-one percent of the patients were Caucasian, and fifty-six percent of the patients were female. The percentage of patients achieving the primary efficacy endpoint of no headache pain at hours after treatment was significantly greater in patients who received rizatriptan benzoate orally disintegrating tablets, compared with those who received placebo (33% vs. 24%). Study results are summarized in Table 4.Table 4: Response Rates Hours Following Treatment of Initial Headache in Pediatric Patients to 17 Years of Age in Study 7n Number of evaluable patients with no headache pain at hours post-dose.m Number of evaluable patients in population.EndpointPlaceboRizatriptan BenzoateOrally Disintegrating Tabletsp-ValueNo headache pain at hours post-dose24%(n/m 94/388)33%(n/m 126/382)0.01The observed percentage of pediatric patients achieving no headache pain within hours following initial treatment with rizatriptan benzoate orally disintegrating tablets is shown in Figure 5.Figure 5: Observed Percentage of Patients Reporting No Headache Pain by Hours Post-Dose in Study 7The prevalence of the exploratory endpoints of absence of migraine-associated symptoms (nausea, photophobia, and phonophobia) at hours after taking the dose was not statistically significantly different between patients who received rizatriptan benzoate orally disintegrating tablets and those who received placebo. Figure 5: Observed Percentage of Patients Reporting No Headache Pain by Hours Post-Dose in Study 7.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS Rizatriptan benzoate tablets are contraindicated in patients with:oIschemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia), or other significant underlying cardiovascular disease [see Warnings and Precautions (5.1)].oCoronary artery vasospasm including Prinzmetals angina [see Warnings and Precautions (5.1)].oHistory of stroke or transient ischemic attack (TIA) [see Warnings and Precautions (5.4)].oPeripheral vascular disease (PVD) [see Warnings and Precautions (5.5)].oIschemic bowel disease [see Warnings and Precautions (5.5)].oUncontrolled hypertension [see Warnings and Precautions (5.8)].oRecent use (i.e., within 24 hours) of another 5-HT1 agonist, ergotamine-containing medication, or ergot-type medication (such as dihydroergotamine or methysergide) [see Drug Interactions (7.2 and 7.3)]. oHemiplegic or basilar migraine [see Indications and Usage (1)]. oConcurrent administration or recent discontinuation (i.e., within weeks) of MAO-A inhibitor [see Drug Interactions (7.5) and Clinical Pharmacology (12.3)]. oHypersensitivity to rizatriptan or any of the excipients (angioedema and anaphylaxis seen) [see Adverse Reactions (6.2)].. oIschemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia), or other significant underlying cardiovascular disease [see Warnings and Precautions (5.1)].. oCoronary artery vasospasm including Prinzmetals angina [see Warnings and Precautions (5.1)].. oHistory of stroke or transient ischemic attack (TIA) [see Warnings and Precautions (5.4)].. oPeripheral vascular disease (PVD) [see Warnings and Precautions (5.5)].. oIschemic bowel disease [see Warnings and Precautions (5.5)].. oUncontrolled hypertension [see Warnings and Precautions (5.8)].. oRecent use (i.e., within 24 hours) of another 5-HT1 agonist, ergotamine-containing medication, or ergot-type medication (such as dihydroergotamine or methysergide) [see Drug Interactions (7.2 and 7.3)]. oHemiplegic or basilar migraine [see Indications and Usage (1)]. oConcurrent administration or recent discontinuation (i.e., within weeks) of MAO-A inhibitor [see Drug Interactions (7.5) and Clinical Pharmacology (12.3)]. oHypersensitivity to rizatriptan or any of the excipients (angioedema and anaphylaxis seen) [see Adverse Reactions (6.2)].. oHistory of ischemic heart disease or coronary artery vasospasm (4)oHistory of stroke or transient ischemic attack (4)oPeripheral vascular disease (4)oIschemic bowel disease (4)oUncontrolled hypertension (4)oRecent (within 24 hours) use of another 5-HT1 agonist (e.g., another triptan), or of an ergotamine-containing medication (4) oHemiplegic or basilar migraine (4) oMAO-A inhibitor used in the past weeks (4) oHypersensitivity to rizatriptan or any of the excipients (4). oHistory of ischemic heart disease or coronary artery vasospasm (4). oHistory of stroke or transient ischemic attack (4). oPeripheral vascular disease (4). oIschemic bowel disease (4). oUncontrolled hypertension (4). oRecent (within 24 hours) use of another 5-HT1 agonist (e.g., another triptan), or of an ergotamine-containing medication (4) oHemiplegic or basilar migraine (4) oMAO-A inhibitor used in the past weeks (4) oHypersensitivity to rizatriptan or any of the excipients (4).

DESCRIPTION SECTION.

11 DESCRIPTION Rizatriptan benzoate tablets, USP contain rizatriptan benzoate, selective 5-hydroxytryptamine1B/1D (5-HT1B/1D) receptor agonist.Rizatriptan benzoate is described chemically as: 3-[2-(Dimethylamino)ethyl]-5-(1H-1,2,4-triazol-1-ylmethyl)indole monobenzoate and its structural formula is:Its molecular formula is C15H19N5oC7H6O2, representing molecular weight of the free base of 269.4. Rizatriptan benzoate, USP is cream to white powder that is soluble in water at about 42 mg per mL (expressed as free base) at 25C.Rizatriptan benzoate tablets are available for oral administration in strengths of and 10 mg (corresponding to 7.265 mg or 14.53 mg of the benzoate salt, respectively). Each compressed tablet contains the following inactive ingredients: lactose monohydrate, magnesium stearate, microcrystalline cellulose, pregelatinized starch (corn) and red iron oxide.. Rizatriptan Benzoate Structural Formula.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION oAdults: or 10 mg single dose; separate repeat doses by at least hours; maximum dose in 24-hour period: 30 mg (2.1) oPediatric patients to 17 years: mg single dose in patients less than 40 kg (88 lb); 10 mg single dose in patients 40 kg (88 lb) or more (2.2)oAdjust dose if co-administered with propranolol (2.4). oAdults: or 10 mg single dose; separate repeat doses by at least hours; maximum dose in 24-hour period: 30 mg (2.1) oPediatric patients to 17 years: mg single dose in patients less than 40 kg (88 lb); 10 mg single dose in patients 40 kg (88 lb) or more (2.2). oAdjust dose if co-administered with propranolol (2.4). 2.1Dosing Information in Adults The recommended starting dose of rizatriptan benzoate tablets is either mg or 10 mg for the acute treatment of migraines in adults. The 10-mg dose may provide greater effect than the 5-mg dose, but may have greater risk of adverse reactions [see Clinical Studies (14.1)].. Redosing in Adults. Although the effectiveness of second dose or subsequent doses has not been established in placebo-controlled trials, if the migraine headache returns, second dose may be administered hours after the first dose. The maximum daily dose should not exceed 30 mg in any 24-hour period. The safety of treating, on average, more than four headaches in 30-day period has not been established.. 2.2Dosing Information in Pediatric Patients (Age to 17 Years) Dosing in pediatric patients is based on the patients body weight. The recommended dose of rizatriptan benzoate tablets is mg in patients weighing less than 40 kg (88 lb), and 10 mg in patients weighing 40 kg (88 lb) or more.The efficacy and safety of treatment with more than one dose of rizatriptan benzoate tablets within 24 hours in pediatric patients to 17 years of age have not been established.. 2.4Dosage Adjustment for Patients on Propranolol Adult Patients. In adult patients taking propranolol, only the 5-mg dose of rizatriptan benzoate tablets is recommended, up to maximum of doses in any 24-hour period (15 mg) [see Drug Interactions (7.1) and Clinical Pharmacology (12.3)].. Pediatric Patients. For pediatric patients weighing 40 kg (88 lb) or more, taking propranolol, only single 5-mg dose of rizatriptan benzoate tablets is recommended (maximum dose of mg in 24-hour period). Rizatriptan benzoate tablets should not be prescribed to propranolol-treated pediatric patients who weigh less than 40 kg (88 lb) [see Drug Interactions (7.1) and Clinical Pharmacology (12.3)].

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS Rizatriptan Benzoate Tablets: Rizatriptan Benzoate Tablets, USP are available containing 7.265 mg or 14.53 mg of rizatriptan benzoate, USP equivalent to mg or 10 mg of rizatriptan, respectively.oThe mg tablets are light pink, oval, unscored tablets debossed with RN5 on one side of the tablet and plain on the other side. oThe 10 mg tablets are light pink, oval, unscored tablets debossed with RN10 on one side of the tablet and plain on the other side.. oThe mg tablets are light pink, oval, unscored tablets debossed with RN5 on one side of the tablet and plain on the other side. oThe 10 mg tablets are light pink, oval, unscored tablets debossed with RN10 on one side of the tablet and plain on the other side.. oRizatriptan Benzoate Tablets: and 10 mg (3). oRizatriptan Benzoate Tablets: and 10 mg (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS 7.1Propranolol The dose of rizatriptan benzoate tablets should be adjusted in propranolol-treated patients, as propranolol has been shown to increase the plasma AUC of rizatriptan by 70% [see Dosage and Administration (2.4) and Clinical Pharmacology (12.3)].. 7.2Ergot-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 rizatriptan benzoate tablets within 24 hours is contraindicated [see Contraindications (4)].. 7.3Other 5-HT1 Agonists Because their vasospastic effects may be additive, co-administration of rizatriptan benzoate tablets and other 5-HT1 agonists within 24 hours of each other is contraindicated [see Contraindications (4)].. 7.4SSRIs/SNRIs and Serotonin Syndrome Cases of serotonin syndrome have been reported during co-administration of triptans and selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) [see Warnings and Precautions (5.7)].. 7.5Monoamine Oxidase Inhibitors Rizatriptan benzoate tablets are contraindicated in patients taking MAO-A inhibitors and non-selective MAO inhibitors. specific MAO-A inhibitor increased the systemic exposure of rizatriptan and its metabolite [see Contraindications (4) and Clinical Pharmacology (12.3)].

GERIATRIC USE SECTION.

8.5 Geriatric Use Clinical studies of rizatriptan benzoate tablets 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.Although the pharmacokinetics of rizatriptan were similar in elderly (aged >= 65 years) and in younger adults (n 17), in general, dose selection for an elderly patient should be cautious, starting at the low end of the dosing range. This reflects the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.Geriatric patients who have other cardiovascular risk factors (e.g., diabetes, hypertension, smoking, obesity, strong family history of coronary artery disease) should have cardiovascular evaluation prior to receiving rizatriptan benzoate tablets [see Warnings and Precautions (5.1)].

HEPATIC IMPAIRMENT SUBSECTION.

Hepatic Impairment Following oral administration in patients with hepatic impairment caused by mild to moderate alcoholic cirrhosis of the liver, plasma concentrations of rizatriptan were similar in patients with mild hepatic insufficiency compared to control group of subjects with normal hepatic function; plasma concentrations of rizatriptan were approximately 30% greater in patients with moderate hepatic insufficiency.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING Rizatriptan Benzoate Tablets, USP are available containing 7.265 mg or 14.53 mg of rizatriptan benzoate, USP equivalent to mg or 10 mg of rizatriptan, respectively.The mg tablets are light pink, oval, unscored tablets debossed with RN5 on one side of the tablet and plain on the other side. They are available as follows:NDC 0378-1403-96bottles of 12 tabletsThe 10 mg tablets are light pink, oval, unscored tablets debossed with RN10 on one side of the tablet and plain on the other side. They are available as follows:NDC 0378-1404-96bottles of 12 tabletsStorage: Store at 20 to 25C (68 to 77F). [See USP Controlled Room Temperature.]Dispense in tight, light-resistant container as defined in the USP using child-resistant closure.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE Rizatriptan benzoate tablets are indicated for the acute treatment of migraine with or without aura in adults and in pediatric patients to 17 years old.Limitations of Use:oRizatriptan benzoate tablets should only be used where clear diagnosis of migraine has been established. If patient has no response for the first migraine attack treated with rizatriptan benzoate tablets, the diagnosis of migraine should be reconsidered before rizatriptan benzoate tablets are administered to treat any subsequent attacks. oRizatriptan benzoate tablets are not indicated for use in the management of hemiplegic or basilar migraine [see Contraindications (4)]. oRizatriptan benzoate tablets are not indicated for the prevention of migraine attacks. oSafety and effectiveness of rizatriptan benzoate tablets have not been established for cluster headache.. oRizatriptan benzoate tablets should only be used where clear diagnosis of migraine has been established. If patient has no response for the first migraine attack treated with rizatriptan benzoate tablets, the diagnosis of migraine should be reconsidered before rizatriptan benzoate tablets are administered to treat any subsequent attacks. oRizatriptan benzoate tablets are not indicated for use in the management of hemiplegic or basilar migraine [see Contraindications (4)]. oRizatriptan benzoate tablets are not indicated for the prevention of migraine attacks. oSafety and effectiveness of rizatriptan benzoate tablets have not been established for cluster headache.. Rizatriptan benzoate tablets are serotonin (5-HT)1B/1D receptor agonist (triptan) indicated for the acute treatment of migraine with or without aura in adults and in pediatric patients to 17 years of age (1)Limitations of Use:oUse only after clear diagnosis of migraine has been established (1)oNot indicated for the prophylactic therapy of migraine (1)oNot indicated for the treatment of cluster headache (1). oUse only after clear diagnosis of migraine has been established (1). oNot indicated for the prophylactic therapy of migraine (1). oNot indicated for the treatment of cluster headache (1).

RENAL IMPAIRMENT SUBSECTION.

Renal Impairment In patients with renal impairment (creatinine clearance 10-60 mL/min/1.73 m2), the AUC0- of rizatriptan was not significantly different from that in subjects with normal renal function. In hemodialysis patients, (creatinine clearance 2 mL/min/1.73 m2), however, the AUC for rizatriptan was approximately 44% greater than that in patients with normal renal function.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved patient labeling (Patient Information).Risk of Myocardial Ischemia and/or Infarction, Prinzmetals Angina, Other Vasospasm-Related Events, and Cerebrovascular Events: Inform patients that rizatriptan benzoate tablets may cause serious cardiovascular side effects such as myocardial infarction or stroke. Although serious cardiovascular events can occur without warning symptoms, patients should be alert for the signs and symptoms of chest pain, shortness of breath, weakness, slurring of speech, and should ask for medical advice when observing any indicative sign or symptoms. Patients should be apprised of the importance of this follow-up [see Warnings and Precautions (5.1, 5.2, 5.4, 5.5)].Serotonin Syndrome: Patients should be cautioned about the risk of serotonin syndrome with the use of rizatriptan benzoate tablets or other triptans, particularly during combined use with selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) [see Warnings and Precautions (5.7), Drug Interactions (7.4), and Clinical Pharmacology (12.3)]. Pregnancy: Inform patients that rizatriptan benzoate tablets should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus [see Use in Specific Populations (8.1)]. Lactation: Advise patients to notify their healthcare provider if they are breastfeeding or plan to breastfeed [see Use in Specific Populations (8.2)]. Ability to Perform Complex Tasks: Since migraines or treatment with rizatriptan benzoate tablets may cause somnolence and dizziness, instruct patients to evaluate their ability to perform complex tasks during migraine attacks and after administration of rizatriptan benzoate tablets.Medication Overuse Headache: Inform patients that use of acute migraine drugs 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 headache diary) [see Warnings and Precautions (5.6)].

LACTATION SECTION.

8.2 Lactation Risk Summary. There are no data on the presence of rizatriptan or any active metabolites in human milk, or on the effects of rizatriptan on the breastfed infant, or on milk production.Rizatriptan was excreted in rat milk, with levels in milk approximately times those in maternal plasma.The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for rizatriptan benzoate tablets and any potential adverse effects on the breastfed infant from rizatriptan benzoate tablets or from the underlying maternal condition.. Data. Following oral administration of rizatriptan to lactating rats at dose of 100 mg/kg/day, drug concentrations of rizatriptan in milk samples exceeded maternal plasma drug concentrations by approximately 6-fold.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action Rizatriptan binds with high affinity to human cloned 5-HT1B/1D receptors. Rizatriptan presumably exerts its therapeutic effects in the treatment of migraine headache by binding to 5-HT1B/1D receptors located on intracranial blood vessels and sensory nerves of the trigeminal system.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenesis. Oral carcinogenicity studies of rizatriptan were conducted in mice (100 weeks) and rats (106 weeks) at doses of up to 125 mg/kg/day. There was no evidence of an increase in tumor incidence related to rizatriptan in either species. Plasma exposures (AUC) at the highest dose tested were approximately 150 (mice) and 240 times (rats) that in humans at the maximum recommended human dose (MRHD) of 30 mg/day. Mutagenesis. Rizatriptan was neither mutagenic nor clastogenic in battery of in vitro and in vivo genetic toxicity studies, including: the microbial mutagenesis (Ames) assay, in vitro mammalian cell mutagenesis and chromosomal aberration assays, and the in vivo chromosomal aberration assay in mouse.. Impairment of Fertility. Oral administration of rizatriptan (0, 2, 10, or 100 mg/kg/day) to female rats prior to and during mating and continuing throughout gestation and lactation resulted in no effect on fertility; however, altered estrous cyclicity and delays in time to mating were observed at the highest dose tested. Plasma exposure at the no-effect dose (10 mg/kg/day) for reproductive toxicity was approximately 15 times that in humans at the MRHD.Oral administration of rizatriptan (0, 5, 35, or 250 mg/kg/day) to male rats prior to and during mating resulted in no impairment of fertility or reproductive performance. Plasma exposure (AUC) at the highest dose tested was approximately 550 times that in humans at the MRHD.

OVERDOSAGE SECTION.

10 OVERDOSAGE No overdoses of rizatriptan benzoate tablets were reported during clinical trials in adults.Some adult patients who received 40 mg of rizatriptan benzoate tablets either single dose or as two doses with 2-hour interdose interval had dizziness and somnolence.In clinical pharmacology study in which 12 adult subjects received rizatriptan benzoate tablets, at total cumulative doses of 80 mg (given within hours), two of the subjects experienced syncope, dizziness, bradycardia including third degree AV block, vomiting, and/or incontinence.In the long-term, open label study, involving 606 treated pediatric migraineurs 12 to 17 years of age (of which 432 were treated for at least 12 months), 151 patients (25%) took two 10-mg doses of rizatriptan benzoate orally disintegrating tablets within 24-hour period. Adverse reactions for of these patients included abdominal discomfort, fatigue, and dyspnea.In addition, based on the pharmacology of rizatriptan benzoate tablets, hypertension or myocardial ischemia could occur after overdosage. Gastrointestinal decontamination, (i.e., gastric lavage followed by activated charcoal) should be considered in patients suspected of an overdose with rizatriptan benzoate tablets. Clinical and electrocardiographic monitoring should be continued for at least 12 hours, even if clinical symptoms are not observed.The effects of hemo- or peritoneal dialysis on serum concentrations of rizatriptan are unknown.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL 5 mg NDC 0378-1403-96RizatriptanBenzoateTablets, USP5 mgRx only 12 TabletsEach tablet contains7.265 mg of rizatriptan benzoate, USPequivalent to mg of rizatriptan.Usual Dosage: See accompanyingprescribing information.Keep this and all medication out ofthe reach of children.Store at 20 to 25C (68 to 77F). [SeeUSP Controlled Room Temperature.]Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.Made in IndiaMylan.comRMX1403ES1Dispense in tight, light-resistantcontainer as defined in the USPusing child-resistant closure.Keep container tightly closed.Code No.: MH/DRUGS/25/NKD/89. Rizatriptan Benzoate Tablets mg Bottle Label.

PEDIATRIC USE SECTION.

8.4 Pediatric Use Safety and effectiveness in pediatric patients under years of age have not been established.The efficacy and safety of rizatriptan benzoate orally disintegrating tablets in the acute treatment of migraine in patients aged to 17 years was established in an adequate and well-controlled study [see Clinical Studies (14.2)].The incidence of adverse reactions reported for pediatric patients in the acute clinical trial was similar in patients who received rizatriptan benzoate orally disintegrating tablets to those who received placebo. The adverse reaction pattern in pediatric patients is expected to be similar to that in adults.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics Absorption. Rizatriptan is completely absorbed following oral administration. The mean oral absolute bioavailability of the rizatriptan benzoate tablet is about 45%, and mean peak plasma concentrations (Cmax) are reached in approximately 1-1.5 hours (Tmax). The presence of migraine headache did not appear to affect the absorption or pharmacokinetics of rizatriptan. Food has no significant effect on the bioavailability of rizatriptan but delays the time to reach peak concentration by an hour. In clinical trials, rizatriptan benzoate tablets were administered without regard to food.The bioavailability and Cmax of rizatriptan were similar following administration of rizatriptan benzoate tablets and rizatriptan benzoate orally disintegrating tablets, but the rate of absorption is somewhat slower with rizatriptan benzoate orally disintegrating tablets, with Tmax delayed by up to 0.7 hour. AUC of rizatriptan is approximately 30% higher in females than in males. No accumulation occurred on multiple dosing.. Distribution. The mean volume of distribution is approximately 140 liters in male subjects and 110 liters in female subjects. Rizatriptan is minimally bound (14%) to plasma proteins.. Metabolism. The primary route of rizatriptan metabolism is via oxidative deamination by monoamine oxidase-A (MAO-A) to the indole acetic acid metabolite, which is not active at the 5-HT1B/1D receptor. N-monodesmethyl-rizatriptan, metabolite with activity similar to that of parent compound at the 5-HT1B/1D receptor, is formed to minor degree. Plasma concentrations of N-monodesmethyl-rizatriptan are approximately 14% of those of parent compound, and it is eliminated at similar rate. Other minor metabolites, the N-oxide, the 6-hydroxy compound, and the sulfate conjugate of the 6-hydroxy metabolite are not active at the 5-HT1B/1D receptor.. Elimination. The total radioactivity of the administered dose recovered over 120 hours in urine and feces was 82% and 12%, respectively, following single 10-mg oral administration of 14C-rizatriptan. Following oral administration of 14C-rizatriptan, rizatriptan accounted for about 17% of circulating plasma radioactivity. Approximately 14% of an oral dose is excreted in urine as unchanged rizatriptan while 51% is excreted as indole acetic acid metabolite, indicating substantial first pass metabolism.The plasma half-life of rizatriptan in males and females averages 2-3 hours. Cytochrome P450 Isoforms. Rizatriptan is not an inhibitor of the activities of human liver cytochrome P450 isoforms 3A4/5, 1A2, 2C9, 2C19, or 2E1; rizatriptan is competitive inhibitor (Ki 1400 nM) of cytochrome P450 2D6, but only at high, clinically irrelevant concentrations. Special Populations. Geriatric Rizatriptan pharmacokinetics in healthy elderly non-migraineur volunteers (age 65-77 years) were similar to those in younger non-migraineur volunteers (age 18-45 years).. Pediatric The pharmacokinetics of rizatriptan was determined in pediatric migraineurs to 17 years of age. Exposures following single dose administration of mg rizatriptan benzoate orally disintegrating tablets to pediatric patients weighing 20-39 kg (44-87 lb) or 10 mg rizatriptan benzoate orally disintegrating tablets to pediatric patients weighing >= 40 kg (88 lb) were similar to those observed following single dose administration of 10 mg rizatriptan benzoate orally disintegrating tablets to adults. Gender The mean AUC0- and Cmax of rizatriptan (10 mg orally) were about 30% and 11% higher in females as compared to males, respectively, while Tmax occurred at approximately the same time.. Hepatic Impairment Following oral administration in patients with hepatic impairment caused by mild to moderate alcoholic cirrhosis of the liver, plasma concentrations of rizatriptan were similar in patients with mild hepatic insufficiency compared to control group of subjects with normal hepatic function; plasma concentrations of rizatriptan were approximately 30% greater in patients with moderate hepatic insufficiency.. Renal Impairment In patients with renal impairment (creatinine clearance 10-60 mL/min/1.73 m2), the AUC0- of rizatriptan was not significantly different from that in subjects with normal renal function. In hemodialysis patients, (creatinine clearance 2 mL/min/1.73 m2), however, the AUC for rizatriptan was approximately 44% greater than that in patients with normal renal function.. Race Pharmacokinetic data revealed no significant differences between African American and Caucasian subjects. Drug Interactions. [See also Drug Interactions (7).]. Monoamine Oxidase Inhibitors Rizatriptan is principally metabolized via monoamine oxidase, subtype (MAO-A). Plasma concentrations of rizatriptan may be increased by drugs that are selective MAO-A inhibitors (e.g., moclobemide) or nonselective MAO inhibitors [type and B] (e.g., isocarboxazid, phenelzine, tranylcypromine, and pargyline). In drug interaction study, when rizatriptan benzoate tablets 10 mg were administered to subjects (n 12) receiving concomitant therapy with the selective, reversible MAO-A inhibitor, moclobemide 150 mg t.i.d., there were mean increases in rizatriptan AUC and Cmax of 119% and 41% respectively; and the AUC of the active N-monodesmethyl metabolite of rizatriptan was increased more than 400%. The interaction would be expected to be greater with irreversible MAO inhibitors. No pharmacokinetic interaction is anticipated in patients receiving selective MAO-B inhibitors [see Contraindications (4) and Drug Interactions (7.5)].. Propranolol In study of concurrent administration of propranolol 240 mg/day and single dose of rizatriptan 10 mg in healthy adult subjects (n 11), mean plasma AUC for rizatriptan was increased by 70% during propranolol administration, and 4-fold increase was observed in one subject. The AUC of the active N-monodesmethyl metabolite of rizatriptan was not affected by propranolol [see Dosage and Administration (2.4) and Drug Interactions (7.1)].. Nadolol/Metoprolol In drug interactions study, effects of multiple doses of nadolol 80 mg or metoprolol 100 mg every 12 hours on the pharmacokinetics of single dose of 10 mg rizatriptan were evaluated in healthy subjects (n 12). No pharmacokinetic interactions were observed.. Paroxetine In study of the interaction between the selective serotonin reuptake inhibitor (SSRI) paroxetine 20 mg/day for weeks and single dose of rizatriptan benzoate tablets 10 mg in healthy subjects (n 12), neither the plasma concentrations of rizatriptan nor its safety profile were affected by paroxetine [see Warnings and Precautions (5.7), Drug Interactions (7.4), and Patient Counseling Information (17)].. Oral Contraceptives In study of concurrent administration of an oral contraceptive during days of administration of rizatriptan benzoate tablets (10-30 mg/day) in healthy female volunteers (n 18), rizatriptan did not affect plasma concentrations of ethinyl estradiol or norethindrone.

PREGNANCY SECTION.

8.1 Pregnancy Risk Summary. Available human data on the use of rizatriptan benzoate tablets in pregnant women are not sufficient to draw conclusions about drug-associated risk for major birth defects and miscarriage.In animal studies, developmental toxicity was observed following oral administration of rizatriptan during pregnancy (decreased fetal body weight in rats) or throughout pregnancy and lactation (increased mortality, decreased body weight, and neurobehavioral impairment in rat offspring) at maternal plasma exposures greater than that expected at therapeutic doses in humans [see Animal Data].In the U.S. general population, the estimated background risk of major birth defects and of miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. The reported rate of major birth defects among deliveries to women with migraine range from 2.2% to 2.9% and the reported rate of miscarriage was 17%, which are similar to rates reported in women without migraine.. Clinical Considerations. Disease-Associated Maternal and/or Embryo/Fetal Risk In women with migraine, there is an increased risk of adverse perinatal outcomes in the mother, including pre-eclampsia and gestational hypertension.. Data. Human Data The Pregnancy Registry for rizatriptan benzoate tablets did not identify any pattern of congenital anomalies or other adverse birth outcomes over the period of 1998 to 2018. However, the lack of identification of any pattern should be viewed with caution, as the number of prospective reports with outcome information was low and did not provide sufficient power to detect an increased risk of individual birth defects associated with the use of rizatriptan benzoate tablets. Additionally, there was significant loss to follow-up in the prospective pregnancy reports, further complicating this assessment of an association between rizatriptan benzoate tablets and any pattern of congenital anomalies or other adverse birth outcomes.In study using data from the Swedish Medical Birth Register, live births to women who reported using triptans or ergots during pregnancy were compared with those of women who did not. Of the 157 births with first-trimester exposure to rizatriptan, infants were born with malformations (relative risk 1.01 [95% CI: 0.40 to 2.08]). study using linked data from the Medical Birth Registry of Norway to the Norwegian Prescription Database compared pregnancy outcomes in women who redeemed prescriptions for triptans during pregnancy, as well as migraine disease comparison group who redeemed prescriptions for triptans before pregnancy only, compared with population control group. Of the 310 women who redeemed prescriptions for rizatriptan during the first trimester, 10 had infants with major congenital malformations (OR 1.03 [95% CI: 0.55 to 1.93]), while for the 271 women who redeemed prescriptions for rizatriptan before, but not during, pregnancy, 12 had infants with major congenital malformations (OR 1.48 [95% CI: 0.83 to 2.64]), each compared with the population comparison group.. Animal Data When rizatriptan (0, 2, 10, or 100 mg/kg/day) was administered orally to pregnant rats throughout organogenesis, decrease in fetal body weight was observed at the highest doses tested. At the mid dose (10 mg/kg/day), which was no-effect dose for adverse effects on embryofetal development, plasma exposure (AUC) was approximately 15 times that in humans at the maximum recommended human dose (MRHD) of 30 mg/day. When rizatriptan (0, 5, 10, or 50 mg/kg/day) was administered orally to pregnant rabbits throughout organogenesis, no adverse fetal effects were observed. Plasma exposure (AUC) at the highest dose tested was 115 times that in humans at the MRHD. Placental transfer of drug to the fetus was demonstrated in both species.Oral administration of rizatriptan (0, 2, 10, or 100 mg/kg/day) to female rats prior to and during mating and continuing throughout gestation and lactation resulted in reduced body weight in offspring from birth and throughout lactation at all but the lowest dose tested (2 mg/kg/day). Plasma exposure (AUC) at the no-effect dose (2 mg/kg/day) for adverse effects on postnatal development was similar to that in humans at the MRHD.Oral administration of rizatriptan (0, 5, 100, or 250 mg/kg/day) throughout organogenesis and lactation resulted in neonatal mortality, reduced body weight (which persisted into adulthood), and impaired neurobehavioral function in offspring at all but the lowest dose tested. Plasma exposure (AUC) at the no-effect dose for adverse effects on postnatal development (5 mg/kg/day) was approximately times that in humans at the MRHD.

RISKS.

Risk Summary. Available human data on the use of rizatriptan benzoate tablets in pregnant women are not sufficient to draw conclusions about drug-associated risk for major birth defects and miscarriage.In animal studies, developmental toxicity was observed following oral administration of rizatriptan during pregnancy (decreased fetal body weight in rats) or throughout pregnancy and lactation (increased mortality, decreased body weight, and neurobehavioral impairment in rat offspring) at maternal plasma exposures greater than that expected at therapeutic doses in humans [see Animal Data].In the U.S. general population, the estimated background risk of major birth defects and of miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. The reported rate of major birth defects among deliveries to women with migraine range from 2.2% to 2.9% and the reported rate of miscarriage was 17%, which are similar to rates reported in women without migraine.

SPL PATIENT PACKAGE INSERT SECTION.

Patient Information Rizatriptan Benzoate Tablets, USP(rye za trip tan ben zoe ate)Read this Patient Information before you start taking rizatriptan benzoate tablets and each time you get refill. There may be new information. This information does not take the place of talking to your doctor about your medical condition or your treatment.Unless otherwise stated, the information in this Patient Information leaflet applies to both rizatriptan benzoate tablets and to rizatriptan benzoate orally disintegrating tablets.What is rizatriptan benzoateRizatriptan benzoate is prescription medicine that belongs to class of medicines called Triptans. Rizatriptan benzoate is available as traditional tablet and as an orally disintegrating tablet. Rizatriptan benzoate tablets and rizatriptan benzoate orally disintegrating tablets are used to treat migraine attacks with or without aura in adults and in children to 17 years of age.Rizatriptan benzoate is not to be used to prevent migraine attacks.Rizatriptan benzoate is not for the treatment of hemiplegic or basilar migraines.It is not known if rizatriptan benzoate is safe and effective for the treatment of cluster headaches.It is not known if taking more than dose of rizatriptan benzoate in 24 hours is safe and effective in children to 17 years of age.It is not known if rizatriptan benzoate is safe and effective in children under years of age.Who should not take rizatriptan benzoate tablets Do not take rizatriptan benzoate tablets if you:ohave or have had heart problemsohave or have had stroke or transient ischemic attack (TIA)ohave or have had blood vessel problems including ischemic bowel diseaseohave uncontrolled high blood pressureohave taken other Triptan medicines in the last 24 hoursohave taken ergot-containing medicines in the last 24 hoursohave hemiplegic or basilar migrainesotake monoamine oxidase (MAO) inhibitor or have taken MAO inhibitor within the last weeksoare allergic to rizatriptan benzoate or any of the ingredients in rizatriptan benzoate tablets. See the end of this leaflet for complete list of ingredients in rizatriptan benzoate tablets.Talk to your doctor before taking this medicine if you have any of the conditions listed above or if you are not sure if you take any of these medicines.What should tell my doctor before taking rizatriptan benzoate tablets Before you take rizatriptan benzoate tablets, tell your doctor if you:ohave or have had heart problems, high blood pressure, chest pain, or shortness of breathohave any risk factors for heart problems or blood vessel problems such as:ohigh blood pressureohigh cholesterolosmokingoobesityodiabetesofamily history of heart problemsoyou are post menopausaloyou are male over 40 ohave kidney or liver problems ohave any other medical condition oare pregnant or plan to become pregnant. It is not known if rizatriptan benzoate tablets will harm your unborn baby. If you become pregnant while taking rizatriptan benzoate tablets, talk to your healthcare provider. oare breastfeeding or plan to breastfeed. It is not known if rizatriptan passes into your breast milk. Talk to your doctor about the best way to feed your baby if you take rizatriptan benzoate tablets.Tell your doctor about all the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements.Rizatriptan benzoate tablets and other medicines may affect each other causing side effects. Rizatriptan benzoate tablets may affect the way other medicines work, and other medicines may affect how rizatriptan benzoate tablets work.Especially tell your doctor if you take:opropranolol containing medicines such as Inderal(R), Inderal(R) LA, or Innopran(R) XL omedicines used to treat mood disorders, including selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs).Ask your doctor or pharmacist for list of these medicines, if you are not sure.Know the medicines you take. Keep list of them to show your doctor and pharmacist when you get new medicine.How should take rizatriptan benzoate tabletsoTake rizatriptan benzoate tablets exactly as your doctor tells you to take them. oYour doctor will tell you how many rizatriptan benzoate tablets to take and when to take them. oIf your headache comes back after your first rizatriptan benzoate tablets dose:oFor adults: second dose may be taken hours after the first dose. Do not take more than 30 mg of rizatriptan benzoate tablets in 24-hour period (for example, do not take more than 10-mg tablets in 24-hour period).oFor children to 17 years of age: It is not known if taking more than dose of rizatriptan benzoate tablets in 24 hours is safe and effective. Talk to your doctor about what to do if your headache does not go away or comes back.oIf you take too many rizatriptan benzoate tablets, call your doctor or go to the nearest hospital emergency room right away.What should avoid while taking rizatriptan benzoate tabletsRizatriptan benzoate tablets may cause dizziness, weakness, or fainting. If you have these symptoms, do not drive car, use machinery, or do anything that needs you to be alert.What are the possible side effects of rizatriptan benzoate tabletsRizatriptan benzoate tablets may cause serious side effects. Call your doctor or go to the nearest hospital emergency room right away if you think you are having any of the serious side effects of rizatriptan benzoate tablets including:oheart attack. Symptoms of heart attack may include:ochest discomfort in the center of your chest that lasts for more than few minutes or that goes away and comes backochest discomfort that feels like uncomfortable pressure, squeezing, fullness or painopain or discomfort in your arms, back, neck, jaw or stomachoshortness of breath with or without chest discomfortobreaking out in cold sweatonausea or vomitingofeeling lightheaded ostroke. Symptoms of stroke may include the following sudden symptoms:onumbness or weakness in your face, arm or leg, especially on one side of your bodyoconfusion, problems speaking or understandingoproblems seeing in or both of your eyesoproblems walking, dizziness, loss of balance or coordinationosevere headache with no known cause oblood vessel problems. Symptoms of blood vessel problems may include:ostomach painobloody diarrheaovision problemsocoldness and numbness of hands and feet oserotonin syndrome. condition called serotonin syndrome can happen when Triptan medicines such as rizatriptan benzoate tablets are taken with certain other medicines. Symptoms of serotonin syndrome may include:oagitationohallucinationsocomaofast heartbeatofast changes in your blood pressureoincreased body temperatureomuscle spasmoloss of coordinationonausea, vomiting or diarrhea oincreased blood pressure.The most common side effects of rizatriptan benzoate tablets in adults include:ofeeling sleepy or tiredopain or pressure in your chest or throatodizzinessTell your doctor if you have any side effect that bothers you or that does not go away.If you take rizatriptan benzoate tablets too often, this may result in you getting chronic headaches. In such cases, you should contact your doctor, as you may have to stop taking rizatriptan benzoate tablets.These are not all the possible side effects of rizatriptan benzoate tablets. For more information, ask your doctor or pharmacist.Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should store rizatriptan benzoate tabletsoStore rizatriptan benzoate tablets at room temperature between 20 to 25C (68 to 77F). oSafely throw away medicine that is out of date or no longer needed.Keep rizatriptan benzoate tablets and all medicines out of the reach of children.General information about the safe and effective use of rizatriptan benzoate tablets.Medicines are sometimes prescribed for purposes other than those listed in Patient Information leaflet. Do not use rizatriptan benzoate tablets for condition for which they were not prescribed. Do not give rizatriptan benzoate tablets to other people, even if they have the same symptoms that you have. They may harm them.This Patient Information leaflet summarizes the most important information about rizatriptan benzoate tablets. If you would like more information, talk to your doctor. You can ask your pharmacist or doctor for information about rizatriptan benzoate tablets that is written for health professionals.For more information, call Mylan at 1-877-446-3679 (1-877-4-INFO-RX).What are the ingredients in rizatriptan benzoate tabletsActive ingredient in rizatriptan benzoate tablets: rizatriptan benzoate.Inactive ingredients in rizatriptan benzoate tablets: lactose monohydrate, magnesium stearate, microcrystalline cellulose, pregelatinized starch (corn) and red iron oxide.This Patient Information has been approved by the U.S. Food and Drug Administration.The brands listed are trademarks of their respective owners.Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.Manufactured by: Mylan Laboratories Limited Hyderabad -- 500 096, India75070485Revised: 11/2019MX:RZTP:R3. ohave or have had heart problems. ohave or have had stroke or transient ischemic attack (TIA). ohave or have had blood vessel problems including ischemic bowel disease. ohave uncontrolled high blood pressure. ohave taken other Triptan medicines in the last 24 hours. ohave taken ergot-containing medicines in the last 24 hours. ohave hemiplegic or basilar migraines. otake monoamine oxidase (MAO) inhibitor or have taken MAO inhibitor within the last weeks. oare allergic to rizatriptan benzoate or any of the ingredients in rizatriptan benzoate tablets. See the end of this leaflet for complete list of ingredients in rizatriptan benzoate tablets.. ohave or have had heart problems, high blood pressure, chest pain, or shortness of breath. ohave any risk factors for heart problems or blood vessel problems such as:ohigh blood pressureohigh cholesterolosmokingoobesityodiabetesofamily history of heart problemsoyou are post menopausaloyou are male over 40 ohigh blood pressure. ohigh cholesterol. osmoking. oobesity. odiabetes. ofamily history of heart problems. oyou are post menopausal. oyou are male over 40 ohave kidney or liver problems ohave any other medical condition oare pregnant or plan to become pregnant. It is not known if rizatriptan benzoate tablets will harm your unborn baby. If you become pregnant while taking rizatriptan benzoate tablets, talk to your healthcare provider. oare breastfeeding or plan to breastfeed. It is not known if rizatriptan passes into your breast milk. Talk to your doctor about the best way to feed your baby if you take rizatriptan benzoate tablets.. opropranolol containing medicines such as Inderal(R), Inderal(R) LA, or Innopran(R) XL omedicines used to treat mood disorders, including selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs).. oTake rizatriptan benzoate tablets exactly as your doctor tells you to take them. oYour doctor will tell you how many rizatriptan benzoate tablets to take and when to take them. oIf your headache comes back after your first rizatriptan benzoate tablets dose:oFor adults: second dose may be taken hours after the first dose. Do not take more than 30 mg of rizatriptan benzoate tablets in 24-hour period (for example, do not take more than 10-mg tablets in 24-hour period).oFor children to 17 years of age: It is not known if taking more than dose of rizatriptan benzoate tablets in 24 hours is safe and effective. Talk to your doctor about what to do if your headache does not go away or comes back.. oFor adults: second dose may be taken hours after the first dose. Do not take more than 30 mg of rizatriptan benzoate tablets in 24-hour period (for example, do not take more than 10-mg tablets in 24-hour period).. oFor children to 17 years of age: It is not known if taking more than dose of rizatriptan benzoate tablets in 24 hours is safe and effective. Talk to your doctor about what to do if your headache does not go away or comes back.. oIf you take too many rizatriptan benzoate tablets, call your doctor or go to the nearest hospital emergency room right away.. oheart attack. Symptoms of heart attack may include:ochest discomfort in the center of your chest that lasts for more than few minutes or that goes away and comes backochest discomfort that feels like uncomfortable pressure, squeezing, fullness or painopain or discomfort in your arms, back, neck, jaw or stomachoshortness of breath with or without chest discomfortobreaking out in cold sweatonausea or vomitingofeeling lightheaded ochest discomfort in the center of your chest that lasts for more than few minutes or that goes away and comes back. ochest discomfort that feels like uncomfortable pressure, squeezing, fullness or pain. opain or discomfort in your arms, back, neck, jaw or stomach. oshortness of breath with or without chest discomfort. obreaking out in cold sweat. onausea or vomiting. ofeeling lightheaded. ostroke. Symptoms of stroke may include the following sudden symptoms:onumbness or weakness in your face, arm or leg, especially on one side of your bodyoconfusion, problems speaking or understandingoproblems seeing in or both of your eyesoproblems walking, dizziness, loss of balance or coordinationosevere headache with no known cause onumbness or weakness in your face, arm or leg, especially on one side of your body. oconfusion, problems speaking or understanding. oproblems seeing in or both of your eyes. oproblems walking, dizziness, loss of balance or coordination. osevere headache with no known cause. oblood vessel problems. Symptoms of blood vessel problems may include:ostomach painobloody diarrheaovision problemsocoldness and numbness of hands and feet ostomach pain. obloody diarrhea. ovision problems. ocoldness and numbness of hands and feet. oserotonin syndrome. condition called serotonin syndrome can happen when Triptan medicines such as rizatriptan benzoate tablets are taken with certain other medicines. Symptoms of serotonin syndrome may include:oagitationohallucinationsocomaofast heartbeatofast changes in your blood pressureoincreased body temperatureomuscle spasmoloss of coordinationonausea, vomiting or diarrhea oagitation. ohallucinations. ocoma. ofast heartbeat. ofast changes in your blood pressure. oincreased body temperature. omuscle spasm. oloss of coordination. onausea, vomiting or diarrhea. oincreased blood pressure.. ofeeling sleepy or tired. opain or pressure in your chest or throat. odizziness. oStore rizatriptan benzoate tablets at room temperature between 20 to 25C (68 to 77F). oSafely throw away medicine that is out of date or no longer needed.

SPL UNCLASSIFIED SECTION.

2.1Dosing Information in Adults The recommended starting dose of rizatriptan benzoate tablets is either mg or 10 mg for the acute treatment of migraines in adults. The 10-mg dose may provide greater effect than the 5-mg dose, but may have greater risk of adverse reactions [see Clinical Studies (14.1)].. Redosing in Adults. Although the effectiveness of second dose or subsequent doses has not been established in placebo-controlled trials, if the migraine headache returns, second dose may be administered hours after the first dose. The maximum daily dose should not exceed 30 mg in any 24-hour period. The safety of treating, on average, more than four headaches in 30-day period has not been established.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS oPregnancy: Based on animal data, may cause fetal harm (8.1) oPregnancy: Based on animal data, may cause fetal harm (8.1) 8.1 Pregnancy Risk Summary. Available human data on the use of rizatriptan benzoate tablets in pregnant women are not sufficient to draw conclusions about drug-associated risk for major birth defects and miscarriage.In animal studies, developmental toxicity was observed following oral administration of rizatriptan during pregnancy (decreased fetal body weight in rats) or throughout pregnancy and lactation (increased mortality, decreased body weight, and neurobehavioral impairment in rat offspring) at maternal plasma exposures greater than that expected at therapeutic doses in humans [see Animal Data].In the U.S. general population, the estimated background risk of major birth defects and of miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. The reported rate of major birth defects among deliveries to women with migraine range from 2.2% to 2.9% and the reported rate of miscarriage was 17%, which are similar to rates reported in women without migraine.. Clinical Considerations. Disease-Associated Maternal and/or Embryo/Fetal Risk In women with migraine, there is an increased risk of adverse perinatal outcomes in the mother, including pre-eclampsia and gestational hypertension.. Data. Human Data The Pregnancy Registry for rizatriptan benzoate tablets did not identify any pattern of congenital anomalies or other adverse birth outcomes over the period of 1998 to 2018. However, the lack of identification of any pattern should be viewed with caution, as the number of prospective reports with outcome information was low and did not provide sufficient power to detect an increased risk of individual birth defects associated with the use of rizatriptan benzoate tablets. Additionally, there was significant loss to follow-up in the prospective pregnancy reports, further complicating this assessment of an association between rizatriptan benzoate tablets and any pattern of congenital anomalies or other adverse birth outcomes.In study using data from the Swedish Medical Birth Register, live births to women who reported using triptans or ergots during pregnancy were compared with those of women who did not. Of the 157 births with first-trimester exposure to rizatriptan, infants were born with malformations (relative risk 1.01 [95% CI: 0.40 to 2.08]). study using linked data from the Medical Birth Registry of Norway to the Norwegian Prescription Database compared pregnancy outcomes in women who redeemed prescriptions for triptans during pregnancy, as well as migraine disease comparison group who redeemed prescriptions for triptans before pregnancy only, compared with population control group. Of the 310 women who redeemed prescriptions for rizatriptan during the first trimester, 10 had infants with major congenital malformations (OR 1.03 [95% CI: 0.55 to 1.93]), while for the 271 women who redeemed prescriptions for rizatriptan before, but not during, pregnancy, 12 had infants with major congenital malformations (OR 1.48 [95% CI: 0.83 to 2.64]), each compared with the population comparison group.. Animal Data When rizatriptan (0, 2, 10, or 100 mg/kg/day) was administered orally to pregnant rats throughout organogenesis, decrease in fetal body weight was observed at the highest doses tested. At the mid dose (10 mg/kg/day), which was no-effect dose for adverse effects on embryofetal development, plasma exposure (AUC) was approximately 15 times that in humans at the maximum recommended human dose (MRHD) of 30 mg/day. When rizatriptan (0, 5, 10, or 50 mg/kg/day) was administered orally to pregnant rabbits throughout organogenesis, no adverse fetal effects were observed. Plasma exposure (AUC) at the highest dose tested was 115 times that in humans at the MRHD. Placental transfer of drug to the fetus was demonstrated in both species.Oral administration of rizatriptan (0, 2, 10, or 100 mg/kg/day) to female rats prior to and during mating and continuing throughout gestation and lactation resulted in reduced body weight in offspring from birth and throughout lactation at all but the lowest dose tested (2 mg/kg/day). Plasma exposure (AUC) at the no-effect dose (2 mg/kg/day) for adverse effects on postnatal development was similar to that in humans at the MRHD.Oral administration of rizatriptan (0, 5, 100, or 250 mg/kg/day) throughout organogenesis and lactation resulted in neonatal mortality, reduced body weight (which persisted into adulthood), and impaired neurobehavioral function in offspring at all but the lowest dose tested. Plasma exposure (AUC) at the no-effect dose for adverse effects on postnatal development (5 mg/kg/day) was approximately times that in humans at the MRHD. 8.2 Lactation Risk Summary. There are no data on the presence of rizatriptan or any active metabolites in human milk, or on the effects of rizatriptan on the breastfed infant, or on milk production.Rizatriptan was excreted in rat milk, with levels in milk approximately times those in maternal plasma.The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for rizatriptan benzoate tablets and any potential adverse effects on the breastfed infant from rizatriptan benzoate tablets or from the underlying maternal condition.. Data. Following oral administration of rizatriptan to lactating rats at dose of 100 mg/kg/day, drug concentrations of rizatriptan in milk samples exceeded maternal plasma drug concentrations by approximately 6-fold. 8.4 Pediatric Use Safety and effectiveness in pediatric patients under years of age have not been established.The efficacy and safety of rizatriptan benzoate orally disintegrating tablets in the acute treatment of migraine in patients aged to 17 years was established in an adequate and well-controlled study [see Clinical Studies (14.2)].The incidence of adverse reactions reported for pediatric patients in the acute clinical trial was similar in patients who received rizatriptan benzoate orally disintegrating tablets to those who received placebo. The adverse reaction pattern in pediatric patients is expected to be similar to that in adults.. 8.5 Geriatric Use Clinical studies of rizatriptan benzoate tablets 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.Although the pharmacokinetics of rizatriptan were similar in elderly (aged >= 65 years) and in younger adults (n 17), in general, dose selection for an elderly patient should be cautious, starting at the low end of the dosing range. This reflects the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.Geriatric patients who have other cardiovascular risk factors (e.g., diabetes, hypertension, smoking, obesity, strong family history of coronary artery disease) should have cardiovascular evaluation prior to receiving rizatriptan benzoate tablets [see Warnings and Precautions (5.1)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS oMyocardial ischemia, myocardial infarction, and Prinzmetals angina: Perform cardiac evaluation in patients with multiple cardiovascular risk factors (5.1)oArrhythmias: Discontinue dosing if occurs (5.2)oChest/throat/neck/jaw pain, tightness, pressure, or heaviness; Generally not associated with myocardial ischemia; Evaluate patients at high risk (5.3)oCerebral hemorrhage, subarachnoid hemorrhage, and stroke: Discontinue dosing if occurs (5.4) oGastrointestinal ischemic events, peripheral vasospastic reactions: Discontinue dosing if occurs (5.5) oMedication overuse headache: Detoxification may be necessary (5.6) oSerotonin syndrome: Discontinue dosing if occurs (5.7). oMyocardial ischemia, myocardial infarction, and Prinzmetals angina: Perform cardiac evaluation in patients with multiple cardiovascular risk factors (5.1). oArrhythmias: Discontinue dosing if occurs (5.2). oChest/throat/neck/jaw pain, tightness, pressure, or heaviness; Generally not associated with myocardial ischemia; Evaluate patients at high risk (5.3). oCerebral hemorrhage, subarachnoid hemorrhage, and stroke: Discontinue dosing if occurs (5.4) oGastrointestinal ischemic events, peripheral vasospastic reactions: Discontinue dosing if occurs (5.5) oMedication overuse headache: Detoxification may be necessary (5.6) oSerotonin syndrome: Discontinue dosing if occurs (5.7). 5.1Myocardial Ischemia, Myocardial Infarction, and Prinzmetals Angina Rizatriptan benzoate tablets should not be given to patients with ischemic or vasospastic coronary artery disease. There have been rare reports of serious cardiac adverse reactions, including acute myocardial infarction, occurring within few hours following administration of rizatriptan benzoate tablets. Some of these reactions occurred in patients without known coronary artery disease (CAD). 5-HT1 agonists, including rizatriptan benzoate tablets may cause coronary artery vasospasm (Prinzmetals Angina), even in patients without history of CAD.Triptan-naive patients who have multiple cardiovascular risk factors (e.g., increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) should have cardiovascular evaluation prior to receiving rizatriptan benzoate tablets. If there is evidence of CAD or coronary artery vasospasm, rizatriptan benzoate tablets should not be administered [see Contraindications (4)]. For patients who have negative cardiovascular evaluation, consideration should be given to administration of the first rizatriptan benzoate tablet dose in medically-supervised setting and performing an electrocardiogram (ECG) immediately following rizatriptan benzoate tablet administration. Periodic cardiovascular evaluation should be considered in intermittent long-term users of rizatriptan benzoate tablets who have cardiovascular risk factors.. 5.2Arrhythmias Life-threatening disturbances of cardiac rhythm, including ventricular tachycardia and ventricular fibrillation leading to death, have been reported within few hours following the administration of 5-HT1 agonists. Discontinue rizatriptan benzoate tablets if these disturbances occur.. 5.3Chest, Throat, Neck and/or Jaw Pain/Tightness/Pressure As with other 5-HT1 agonists, sensations of tightness, pain, pressure, and heaviness in the precordium, throat, neck and jaw commonly occur after treatment with rizatriptan benzoate tablets and are usually non-cardiac in origin. However, if cardiac origin is suspected, patients should be evaluated. Patients shown to have CAD and those with Prinzmetals variant angina should not receive 5-HT1 agonists.. 5.4Cerebrovascular Events Cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with 5-HT1 agonists, and some have resulted in fatalities. In 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 consequence of migraine, when they were not. Also, patients with migraine may be at increased risk of certain cerebrovascular events (e.g., stroke, hemorrhage, transient ischemic attack). Discontinue rizatriptan benzoate tablets if cerebrovascular event occurs.As with other acute migraine therapies, before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, care should be taken to exclude other potentially serious neurological conditions. Rizatriptan benzoate tablets should not be administered to patients with history of stroke or transient ischemic attack [see Contraindications (4)].. 5.5Other Vasospasm Reactions 5-HT1 agonists, including rizatriptan benzoate tablets, 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 non-coronary vasospasm reaction following the use of any 5-HT1 agonist, the suspected vasospasm reaction should be ruled out before receiving additional rizatriptan benzoate tablet 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 migraine attack, causal relationship between these events and the use of 5-HT1 agonists have not been clearly established.. 5.6Medication Overuse Headache Overuse of acute migraine drugs (e.g., ergotamine, triptans, opioids, or 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 marked increase in frequency of migraine attacks. Detoxification of patients, including withdrawal of the overused drugs, and treatment of withdrawal symptoms (which often includes transient worsening of headache) may be necessary.. 5.7Serotonin Syndrome Serotonin syndrome may occur with triptans, including rizatriptan benzoate tablets particularly during co-administration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors [see Drug Interactions (7.5)]. 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 can occur within minutes to hours of receiving new or greater dose of serotonergic medication. Rizatriptan benzoate tablet treatment should be discontinued if serotonin syndrome is suspected [see Drug Interactions (7.4) and Patient Counseling Information (17)].. 5.8Increase in Blood Pressure Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, has been reported on rare occasions in patients with and without history of hypertension receiving 5-HT1 agonists, including rizatriptan benzoate tablets. In healthy young adult male and female patients who received maximal doses of rizatriptan benzoate tablets (10 mg every hours for doses), slight increases in blood pressure (approximately 2-3 mmHg) were observed. Rizatriptan benzoate tablets are contraindicated in patients with uncontrolled hypertension [see Contraindications (4)].