A randomized, open-label, 5-period crossover study evaluating the pharmacokinetics and safety of a single dose of intranasal dihydroergotamine (DHE) powder (STS101), intramuscular DHE mesylate, and liquid nasal spray DHE in healthy adults

ObjectiveTo compare the safety and pharmacokinetics (PK) of dihydroergotamine (DHE) after administration of intranasal DHE powder (STS101), liquid nasal spray (LNS) DHE mesylate, and intramuscular (IM) DHE mesylate injection in healthy participants.BackgroundDHE is an effective acute migraine treatment; however, self-administration difficulties have prevented its broader role in the management of migraine.MethodsThis randomized, active-controlled, five-period crossover study was conducted over 5 weeks separated by 1-week washout periods. Three STS101 dosage strengths (5.2, 7.0, 8.6 mg), and one dose each of LNS DHE 2.0 mg, and IM DHE 1.0 mg, were administered to 36 healthy participants. Liquid chromatography, tandem mass spectrometry was used to determine DHE (including its 8 ' OH-DHE metabolite) plasma levels and to calculate PK parameters (Cmax, Tmax, AUC0-2h, AUC0-last, AUC0-inf, and t1/2). Safety was evaluated by monitoring adverse events (AEs), vital signs, electrocardiograms, nasal examinations, and laboratory parameters.ResultsThirty-six participants (mean age 36 years; 19% Hispanic Black and 81% Hispanic White) were enrolled. DHE plasma concentrations rose rapidly after STS101 5.2, 7.0, and 8.6 mg and IM DHE injection, with mean concentrations greater than 2000 pg/mL for all STS101 dose strengths at 20 min. All STS101 dose strengths showed approximately 3-fold higher Cmax, AUC0-2h, and AUC0-inf, than the LNS DHE. The mean AUC0-inf of STS101 7.0 and 8.6 mg were comparable to IM DHE (12,600 and 13,200 vs. 13,400 h x pg/mL). All STS101 dose strengths showed substantially lower variability (CV%) compared to LNS DHE for Cmax (35%-41% vs. 87%), and AUC0-inf (37%-46% vs. 65%). STS101 was well tolerated, and all treatment-emergent AEs were mild and transient.ConclusionSTS101 showed rapid absorption and was well tolerated with mild and transient treatment-emergent AEs. Achieving effective DHE plasma concentrations within 10 min, STS101 displayed a favorable PK profile relative to the LNS with higher Cmax, AUC0-2h, and AUC0inf, and with greater response consistency. The AUC0-inf was comparable to IM DHE. This study aimed to see whether the pharmacokinetics (i.e., how the body breaks down a medication) are different among three different formulations of dihydroergotamine (DHE), a drug used to treat migraine headaches. We found that the nasal powder version reached the blood more rapidly and at higher levels than the liquid nasal spray and was comparable to the intramuscular injection form. Participants exposed to injectable DHE and the highest strengths of the DHE nasal powder reported higher rates of side effects.