What is the recommended protocol for transferring a patient from Ajovy (fremanezumab) to Nurtec (rimegepant)?

Transitioning from Ajovy (Fremanezumab) to Nurtec (Rimegepant) for Migraine Management

When transitioning from Ajovy (fremanezumab) to Nurtec (rimegepant), no washout period is required, and Nurtec can be initiated immediately after the last Ajovy dose with a recommended dosing of 75mg every other day for prevention or 75mg as needed for acute treatment.

Understanding the Medications

Ajovy (Fremanezumab)

• CGRP monoclonal antibody used for migraine prevention
• Administered subcutaneously monthly (225mg) or quarterly (675mg) 1
• Has a long half-life of approximately 29 days 1

Nurtec (Rimegepant)

• CGRP receptor antagonist with dual indication:
  • Acute treatment: 75mg as needed (maximum once daily)
  • Preventive treatment: 75mg every other day 2
• First medication approved for both acute and preventive migraine treatment 2

Transition Protocol

Step 1: Timing

• No washout period is required between discontinuing Ajovy and starting Nurtec
• Nurtec can be initiated immediately following the last scheduled dose of Ajovy

Step 2: Dosing Selection

• For prevention: Start Nurtec 75mg every other day
• For acute treatment only: Use Nurtec 75mg as needed (maximum once daily)
• For dual therapy (both prevention and acute treatment): Use Nurtec 75mg every other day for prevention, with additional doses as needed for acute attacks (ensuring at least 24 hours between doses)

Step 3: Monitoring

• Assess efficacy after 4 weeks of preventive treatment
• Full preventive effect may take up to 12 weeks to develop 3
• Monitor for treatment response with headache diary tracking:
  • Monthly migraine days
  • Headache severity
  • Functional impairment
  • Medication use

Efficacy Considerations

• Rimegepant has demonstrated efficacy in reducing monthly migraine days by approximately 4.3 days compared to 3.5 days for placebo in clinical trials 3
• The 2023 VA/DoD Clinical Practice Guideline indicates there is insufficient evidence to recommend for or against rimegepant for migraine prevention (neither for nor against recommendation) 4
• However, the same guideline suggests rimegepant for the short-term treatment of migraine (weak for recommendation) 4

Safety and Compatibility

• Studies have demonstrated that rimegepant can be safely used concurrently with CGRP monoclonal antibodies like fremanezumab 5
• In a study of 13 patients using both rimegepant and CGRP monoclonal antibodies (including fremanezumab), no safety issues were identified 5
• Most common adverse events with rimegepant are mild and include nausea and urinary tract infection 6

Special Considerations

Potential Benefits of Transition

• Oral administration may be preferred over injections
• Dual indication for both acute and preventive treatment
• No evidence of hepatotoxicity or cardiovascular toxicity in clinical trials 2

Monitoring for Adverse Events

• Most common adverse events are mild and include nausea
• No special laboratory monitoring is required
• Unlike some preventive medications, no titration period is needed

Follow-up Recommendations

1. Schedule follow-up at 4 weeks after transition to assess initial response
2. Comprehensive evaluation at 12 weeks to determine full preventive effect
3. Assess patient satisfaction with oral administration versus previous injectable therapy
4. Document changes in migraine frequency, intensity, and disability scores

Remember that while the transition itself does not require a washout period, the full preventive effect of rimegepant may take up to 12 weeks to develop, so patience with the new regimen is important.