What is the recommended dosage and treatment plan for Ubrelvy (ubrogepant) for acute migraine attacks in adults?

Ubrogepant (Ubrelvy) Dosage and Treatment Plan for Acute Migraine

The recommended dosage of Ubrelvy (ubrogepant) for acute migraine treatment in adults is 50 mg or 100 mg taken orally with or without food, with a maximum of 200 mg in a 24-hour period. 1

Dosing Protocol

• Initial dose: 50 mg or 100 mg taken orally at migraine onset
• Second dose: If needed, may take a second dose at least 2 hours after the initial dose
• Maximum daily dose: 200 mg within a 24-hour period
• Treatment frequency: Safety has not been established for treating more than 8 migraines in a 30-day period 1

Dosage Modifications

Concomitant Medications

• Moderate CYP3A4 inhibitors: Initial dose 50 mg; avoid second dose within 24 hours
• Weak CYP3A4 inhibitors: Initial dose 50 mg; second dose 50 mg if needed
• Strong CYP3A4 inducers: Avoid concomitant use
• Weak & Moderate CYP3A4 inducers: Initial dose 100 mg; second dose 100 mg if needed
• BCRP and/or P-gp inhibitors: Initial dose 50 mg; second dose 50 mg if needed 1

Special Populations

• Severe hepatic impairment: Initial dose 50 mg; second dose 50 mg if needed
• Severe renal impairment: Initial dose 50 mg; second dose 50 mg if needed
• End-stage renal disease: Avoid use 1

Place in Migraine Treatment Algorithm

According to the latest guidelines, Ubrelvy should be considered as a third-line treatment option:

1. First-line: NSAIDs (aspirin, ibuprofen, diclofenac) or acetaminophen for mild attacks 2
2. Second-line: Triptans, or combination of triptan with NSAID/acetaminophen 2
3. Third-line: CGRP antagonists-gepants (including ubrogepant) for patients who:
   • Do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID/acetaminophen 2
   • Have contraindications to triptans 2

Efficacy

Clinical trials demonstrated that ubrogepant is effective for:

• Pain freedom at 2 hours (21.8% with 50 mg vs 14.3% with placebo) 3
• Absence of most bothersome migraine-associated symptom at 2 hours (38.9% with 50 mg vs 27.4% with placebo) 3

Safety and Adverse Effects

• Most common adverse events (occurring in 0.4-4.1% of patients):
  • Nausea
  • Somnolence
  • Dry mouth 4
• Long-term safety studies showed no evidence of hepatotoxicity at therapeutic doses 5

Important Clinical Considerations

• Begin treatment as soon as possible after migraine onset for best efficacy 2
• Ubrogepant is not indicated for preventive treatment of migraine 1
• Contraindicated in patients with:
  • Concomitant use of strong CYP3A4 inhibitors
  • History of serious hypersensitivity to ubrogepant 1
• Medication overuse headache is a potential risk with frequent use of acute migraine treatments 2
• Can be safely used concurrently with preventive CGRP antagonists like atogepant 6

Pitfalls to Avoid

• Do not exceed 200 mg in a 24-hour period
• Do not use for more than 8 migraine attacks per month as safety hasn't been established beyond this frequency 1
• Do not use as preventive therapy
• Be cautious about potential drug interactions, particularly with CYP3A4 inhibitors or inducers
• Avoid use in end-stage renal disease 1

By following these dosing recommendations and considering the patient's specific needs and contraindications, ubrogepant can be an effective option for acute migraine treatment, especially for those who don't respond to or cannot tolerate first- and second-line therapies.