2646 Ischemic Colitis Secondary to Sumatriptan Overuse Along With Estrogen

Abstract

INTRODUCTION: Sumatriptan, a 5-HT1B/1D (5-hydroxytryptamine-1B/1D) receptor agonist is the first line medication currently available for migraine and cluster headaches. The drug acts by selectively constricting the intracranial blood vessels. Also, studies have shown that estrogen modifies the levels of MAO-A (Monoamine oxidase-A) in the body thereby decreasing the metabolism of sumatriptan. In the past few decades, there has been a handful of reported cases of coronary vasospasm, myocardial infarction and ischemic colitis associated with sumatriptan use. We report a 57-year-old female who developed ischemic colitis in the setting of usage of increasing doses of sumatriptan along with estrogen. CASE DESCRIPTION/METHODS: A 57-year-old woman with a history of migraine headache, fibromyalgia, hypertension, diet-controlled diabetes mellitus, diverticulitis presented to the emergency room with sudden onset of left sided abdominal pain and 5 episodes of Bright red blood per rectum for one day. Medications included sumatriptan, estradiol, enalapril, venlafaxine, aspirin, and atorvastatin. On examination, left lumbar and left iliac quadrants tenderness was noted. Negative for peritoneal signs. Labs showed WBC 19.6 [3.7–10.6 cells/ul], Hb 15 [11.5–15.5 cells/ul], glucose 106 [70–139 mg/dL], lactic acid 3.2 [0.5–2.2 mmol/L], ESR 18 [<=30 mm/hr], CRP 10.2 [0.3–1.0 mg/dL]. CT abdomen and pelvis revealed findings suggestive of colitis extending from the hepatic flexure to sigmoid colon. Of note, she was using increasing doses of sumatriptan [100 mg tabs, at least 3 to 4 times a day] in the past few weeks for increased frequency of migraine headaches. Endoscopic findings are suggestive of ischemic colitis versus the others. Pathology of the mucosal biopsy showed hallmarks of ischemic colitis. Sumatriptan and estrogen were discontinued. The patient was followed up for a few weeks to months. She reported remarkable improvement of symptoms without any recurrence. DISCUSSION: Sumatriptan is a commonly prescribed abortive medicine for migraine, while ischemic colitis is one of its rare side effects. We aim to emphasize the synergistic effect of increasing doses of sumatriptan along with estrogen in causing ischemic colitis. Physicians should consider the diagnosis of sumatriptan-induced ischemic colitis in patients taking increased doses of this medication with concurrent estrogen usage, who develop severe abdominal pain, hematochezia and potentially counsel patient on cautious use of 5HT1 receptor agonist.