Should Ubrelvy (Ubrogepant) be held prior to anesthesia?

Management of Ubrelvy (Ubrogepant) Prior to Anesthesia

Ubrelvy (ubrogepant) should be held on the day of surgery when anesthesia is planned.

Background on Ubrelvy

Ubrelvy (ubrogepant) is an oral calcitonin gene-related peptide (CGRP) receptor antagonist approved for the acute treatment of migraine with or without aura in adults 1. Unlike traditional triptans, it belongs to the newer "gepant" class of medications that work by blocking CGRP receptors 2.

Perioperative Considerations

Classification and Comparison to Other Migraine Medications

Ubrelvy (ubrogepant) is structurally and mechanistically different from:

• Triptans (serotonin 5-HT1B/1D receptor agonists)
• Ergotamine (ergot alkaloid with serotonin receptor agonist effects)
• Preventive CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)

Recommendation Based on Guidelines

The Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement provides specific recommendations for various migraine medications 3:

• Triptans: Hold on the day of operation
• Ergotamine: Hold at least 2 days prior to operation
• CGRP monoclonal antibodies (preventive agents): Can be taken throughout the perioperative period

While Ubrelvy (ubrogepant) is not specifically mentioned in the SPAQI guidelines, the recommendation for triptans provides the most appropriate parallel due to their similar acute use pattern. Both are used for acute migraine treatment rather than prevention.

Rationale for Holding Ubrelvy on Day of Surgery

1. Timing of use: Ubrelvy is an acute medication taken as needed for migraine attacks, not a daily preventive medication 4, 5. This makes it easier to hold without risk of withdrawal.

2. Potential for drug interactions: Although specific anesthetic drug interactions with ubrogepant have not been extensively studied, the prudent approach is to minimize potential interactions during anesthesia.

3. Guideline alignment: The SPAQI consensus recommends holding triptans (another acute migraine treatment) on the day of surgery 3, suggesting a similar approach for other acute migraine treatments.

4. Pharmacokinetics: Ubrogepant has a half-life of approximately 5-7 hours 2, so holding it on the day of surgery would allow sufficient clearance before anesthesia.

Important Considerations

• No withdrawal risk: Unlike medications that require continuous use (such as butalbital, which requires gradual weaning to avoid withdrawal seizures), there is no risk of withdrawal when holding Ubrelvy for a single day 3.

• Alternative options: If a patient experiences a migraine on the day of surgery, discuss with the anesthesiologist about alternative treatments that can be safely administered.

• Resumption: Ubrelvy can typically be resumed once the patient is fully recovered from anesthesia and able to take oral medications.

Caveat

If the patient is taking other medications for migraine prevention (such as CGRP monoclonal antibodies like erenumab, fremanezumab, or galcanezumab), these can be continued throughout the perioperative period as recommended by the SPAQI consensus 3.

Summary

For patients taking Ubrelvy (ubrogepant) for acute migraine treatment who are scheduled for anesthesia:

• Hold Ubrelvy on the day of surgery
• No tapering is required
• Inform the anesthesiologist about the patient's migraine history and medication use
• Resume Ubrelvy after recovery from anesthesia when oral medications are permitted