What is the recommended dosage and treatment plan for Nurtec (rimegepant) in adults with migraine attacks?

Recommended Dosage and Treatment Plan for Nurtec (Rimegepant) in Adults with Migraine Attacks

The recommended dosage of Nurtec (rimegepant) for acute treatment of migraine in adults is a single 75 mg orally disintegrating tablet taken as needed, with a maximum of one dose per 24-hour period. 1

Dosing Regimens

Acute Treatment

• Dose: 75 mg orally disintegrating tablet (ODT)
• Frequency: As needed for migraine attacks
• Maximum dosing: One 75 mg dose in a 24-hour period
• Safety limitation: No more than 18 doses in a 30-day period 1

Preventive Treatment

• Dose: 75 mg orally disintegrating tablet
• Frequency: Every other day
• Purpose: Prevention of episodic migraine 1

Administration Instructions

1. Proper handling:

   • Use dry hands when opening the blister pack
   • Peel back foil covering and gently remove the tablet
   • Do not push the tablet through the foil

2. Taking the medication:

   • Place the ODT on or under the tongue immediately after opening
   • Allow the tablet to disintegrate in saliva
   • No additional liquid is required for administration
   • Take immediately after opening (do not store outside blister pack) 1

Treatment Algorithm for Migraine

First-Line Options (Start Here)

• NSAIDs (ibuprofen 400-800 mg, aspirin 650-1000 mg) or acetaminophen
• If inadequate relief, add a triptan to NSAID/acetaminophen 2

Second-Line Options

• Triptans (sumatriptan, rizatriptan, zolmitriptan, etc.)
• Consider combination therapy with NSAIDs for better efficacy 2

Third-Line Options (When to Use Nurtec)

• Use Nurtec when:
  • Patient does not tolerate or has inadequate response to combination therapy of triptan plus NSAID/acetaminophen
  • Patient has contraindications to triptans 2, 3

Important Medication Interactions

Avoid Concomitant Use With:

• Strong CYP3A4 inhibitors: Complete avoidance recommended
• Moderate CYP3A4 inhibitors: Avoid another dose of Nurtec within 48 hours
• Strong or moderate CYP3A inducers: May lead to loss of efficacy
• Potent P-gp inhibitors: Avoid another dose of Nurtec within 48 hours 1

Special Populations

Hepatic Impairment

• Severe impairment (Child-Pugh C): Avoid use due to significantly higher drug exposure
• Mild to moderate impairment: No dosage adjustment needed 1

Efficacy and Safety Profile

• Efficacy: Rimegepant has demonstrated effectiveness for pain freedom and relief from most bothersome migraine symptoms at 2 hours post-dose 4, 5
• Effectiveness in triptan non-responders: Rimegepant is effective in patients with history of insufficient response to one or multiple triptans 3
• Common adverse events: Nausea (1-2%), urinary tract infection (1%), and protein in urine (1%) 6, 4
• Long-term safety: Well-tolerated with no signals of hepatotoxicity, drug abuse potential, or medication-overuse headache during extended use 7

Important Clinical Considerations

• Begin treatment as soon as possible after migraine onset for optimal efficacy 2
• Be aware of medication overuse headache risk (occurs when acute medications are used too frequently)
• For triptans, medication overuse threshold is ≥10 days per month 2
• Consider preventive treatment if migraine attacks are frequent or acute treatment provides inadequate response 2

Common Pitfalls to Avoid

1. Exceeding recommended dosage: Never exceed one 75 mg dose in 24 hours
2. Medication overuse: Monitor for overuse (>18 doses in 30 days)
3. Drug interactions: Carefully screen for CYP3A4 inhibitors/inducers and P-gp inhibitors
4. Improper administration: Ensure proper handling of the orally disintegrating tablet
5. Using in severe hepatic impairment: Avoid in patients with Child-Pugh C liver disease

By following these guidelines, healthcare providers can optimize the use of Nurtec (rimegepant) for effective management of migraine attacks in adult patients.