Is it logical to take Nurtec (rimegepant) every other day in combination with Emgality (galcanezumab)?

Combination of Nurtec (Rimegepant) and Emgality (Galcanezumab) for Migraine Management

Yes, it is logical to take Nurtec (rimegepant) every other day in combination with Emgality (galcanezumab) for migraine management, as these medications work through complementary mechanisms and have been shown to be safe when used together. 1

Mechanism of Action and Rationale

• Emgality (galcanezumab): A monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) ligand, administered monthly as a preventive treatment 2
• Nurtec (rimegepant): A CGRP receptor antagonist that can be used for both acute treatment and prevention when taken every other day 3

These medications work through different but complementary mechanisms in the CGRP pathway:

• Emgality binds directly to the CGRP ligand
• Nurtec blocks the CGRP receptor

Evidence Supporting Combined Use

A safety study specifically examining this combination found that using rimegepant as an acute treatment in patients already on CGRP monoclonal antibodies (including galcanezumab) was well-tolerated with no identified safety issues 1. In this study:

• 13 patients simultaneously used rimegepant and either erenumab, fremanezumab, or galcanezumab
• Only 5 patients (38%) reported any adverse events, most of which were mild
• No serious adverse events were reported
• No patients discontinued due to adverse events

Guidelines and Recommendations

The VA/DoD Clinical Practice Guideline (2023) provides relevant recommendations:

• Suggests galcanezumab for the prevention of episodic cluster headache (weak for recommendation) 4
• States there is insufficient evidence to recommend for or against rimegepant for the prevention of episodic migraine (neither for nor against) 4
• Suggests rimegepant for the short-term treatment of migraine (weak for recommendation) 4

According to Praxis Medical Insights, rimegepant 75mg every other day may be considered as a later treatment option for migraine prevention after failure of first and second-line treatments 5.

Practical Considerations

When using this combination:

• Dosing schedule:

  • Emgality: Monthly subcutaneous injection
  • Nurtec: 75mg orally every other day for prevention

• Efficacy expectations:

  • Galcanezumab has demonstrated reduction in monthly migraine days in both episodic and chronic migraine 2, 6
  • Rimegepant has shown efficacy in reducing monthly migraine days by approximately 4.3 days compared to 3.5 days for placebo 5

• Monitoring:

  • Watch for common side effects of rimegepant which include nausea, urinary tract infection, and dizziness 7
  • Monitor for injection site reactions with galcanezumab

Clinical Considerations

• This combination may be particularly beneficial for patients who:

  • Have inadequate response to a single preventive agent
  • Experience breakthrough migraines despite preventive therapy
  • Need both acute and preventive treatment options

• The Mayo Clinic consensus statement indicates that CGRP receptor antagonists like galcanezumab can be taken throughout treatment periods without interruption, making them compatible with other migraine treatments 4

Potential Pitfalls and Caveats

• Cost considerations: Both medications are expensive, and insurance coverage for combination therapy may be limited
• Limited long-term data: While short-term safety has been demonstrated, long-term effects of combination therapy are not yet well-established
• Some patients may not need both medications - evaluate response to monotherapy before adding the second agent

In conclusion, the combination of Nurtec every other day with Emgality is logical and supported by safety data, though it represents a later-line approach after trying first and second-line preventive options.