What is the recommended use of Nurtec (rimegepant) for migraine treatment?

Recommended Use of Nurtec (Rimegepant) for Migraine Treatment

Nurtec ODT (rimegepant) should be used as a second-line therapy for moderate to severe acute episodic migraine in nonpregnant adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen. 1

Indications

• Nurtec ODT is FDA-approved for two distinct uses:
  • Acute treatment of migraine with or without aura in adults 2
  • Preventive treatment of episodic migraine in adults 2

Treatment Algorithm for Acute Migraine

First-Line Therapy

• Begin with NSAIDs, acetaminophen, or their combination for mild to moderate migraine attacks 1
• For moderate to severe attacks, use a triptan (such as sumatriptan) combined with an NSAID or acetaminophen 1

Second-Line Therapy

• Consider Nurtec (rimegepant) for patients who:
  • Do not tolerate triptans and NSAIDs/acetaminophen combination therapy 1
  • Have inadequate response to triptans and NSAIDs/acetaminophen combination therapy 1
  • Have contraindications to first-line therapies 1

Dosing for Acute Treatment

• The recommended dose is 75 mg taken orally as needed 2
• Maximum dose: 75 mg in a 24-hour period 2
• Safety limit: No more than 18 doses in a 30-day period 2

Dosing for Preventive Treatment

• The recommended dose is 75 mg taken orally every other day 2
• This preventive regimen has shown sustained benefits over 52 weeks with continued improvement in monthly migraine days 3

Administration Instructions

• Use dry hands when opening the blister pack 2
• Place the orally disintegrating tablet on or under the tongue 2
• The tablet will dissolve in saliva without additional liquid 2
• Take immediately after opening the blister pack 2

Efficacy Considerations

• Rimegepant has demonstrated efficacy for both acute treatment and prevention of migraine 4
• It is effective in patients with insufficient response to triptans, making it valuable for those who failed previous triptan therapy 5
• Long-term data shows sustained and increasing treatment benefits over 52 weeks for preventive use 3

Safety Considerations

• Most common adverse reaction for acute treatment: nausea 2
• Most common adverse reactions for preventive treatment: nausea and abdominal pain/dyspepsia 2
• Hypersensitivity reactions, including dyspnea and rash, can occur days after administration 2
• Avoid use in patients with severe hepatic impairment (Child-Pugh C) 2, 6

Drug Interactions

• Avoid concomitant use with strong CYP3A4 inhibitors 2
• With moderate CYP3A4 inhibitors, avoid another dose within 48 hours 2
• Avoid concomitant use with strong or moderate CYP3A inducers 2
• With potent P-gp inhibitors, avoid another dose within 48 hours 2

Special Populations

• Safe to use in patients already taking preventive migraine medications 7
• Not recommended in patients with severe hepatic impairment due to significantly increased drug exposure 2, 6

Clinical Pearls and Caveats

• Nurtec is the first dual agent approved for both acute treatment and prevention of migraine 4
• When used for prevention, patients can still use Nurtec as needed on non-scheduled dosing days for breakthrough migraines 3
• Be aware of medication overuse headache risk - defined as headache occurring on 15 or more days per month for at least 3 months due to overuse of acute medication 1
• Consider cost implications - CGRP antagonists like Nurtec have significantly higher costs compared to traditional migraine treatments 1