Can Nurtec (rimegepant) or Ubrelvy (ubrogepant) be used in patients with Chronic Kidney Disease (CKD) on hemodialysis?

Use of Nurtec (Rimegepant) or Ubrelvy (Ubrogepant) in CKD Patients on Hemodialysis

Nurtec (rimegepant) should be avoided in patients with end-stage renal disease on hemodialysis, while there is insufficient data on Ubrelvy (ubrogepant) in this population, making both medications not recommended for hemodialysis patients.

Rimegepant (Nurtec) in Hemodialysis

According to the FDA label for rimegepant:

• No dosage adjustment is required for mild, moderate, or severe renal impairment
• However, Nurtec ODT has not been studied in patients with end-stage renal disease or in patients on dialysis
• The FDA specifically recommends avoiding use of Nurtec ODT in patients with end-stage renal disease (CLcr < 15 mL/min) 1
• Rimegepant is unlikely to be significantly removed by dialysis because of high serum protein binding 1

Pharmacokinetic Considerations

The pharmacokinetic properties of rimegepant that are relevant for hemodialysis patients include:

• High protein binding, making it unlikely to be removed effectively by dialysis 1
• While specific data on ubrogepant in hemodialysis is not provided in the evidence, similar concerns would apply to other CGRP antagonists
• Patients with end-stage renal disease often have altered drug metabolism and distribution, which can affect medication safety and efficacy 2

Management of Medications in Hemodialysis Patients

For patients with CKD on hemodialysis, medication management requires special consideration:

• Dosing adjustments are critical for patients with renal impairment to prevent adverse effects 2
• Patients on dialysis are at higher risk for drug accumulation and toxicity 3
• Protein-bound uremic toxins can compete with medications for albumin binding sites, potentially altering drug availability and efficacy 3

Alternative Approaches

For migraine management in hemodialysis patients:

1. Consider medications with established safety profiles in ESRD
2. Consult with nephrology before initiating any new migraine therapy
3. Monitor for drug-drug interactions, particularly with other medications commonly used in CKD patients
4. Evaluate the timing of medication administration in relation to dialysis sessions

Conclusion

Based on the available evidence, particularly the FDA label recommendations, rimegepant (Nurtec) should be avoided in patients with end-stage renal disease on hemodialysis. While specific data on ubrogepant (Ubrelvy) in hemodialysis patients was not provided in the evidence, similar caution would be warranted given the lack of studies in this specific population.