NURTEC (Rimegepant): A Comprehensive Overview
NURTEC ODT (rimegepant) is an FDA-approved calcitonin gene-related peptide (CGRP) receptor antagonist used in adults for both acute treatment of migraine attacks with or without aura and preventive treatment of episodic migraine. 1
Medication Classification and Mechanism
- NURTEC belongs to the "gepant" class of medications (CGRP receptor antagonists) that work by blocking calcitonin gene-related peptide receptors involved in migraine pathophysiology 1
- Available as a 75 mg orally disintegrating tablet (ODT) that can be placed on or under the tongue without requiring water 1
- The active ingredient rimegepant is described chemically as (5S,6S,9R)-5-amino-6-(2,3-difluorophenyl)-6,7,8,9-tetrahydro-5H-cyclohepta[b]pyridin-9-yl 4-(2-oxo-2,3-dihydro-1H-imidazo[4,5-b]pyridin-1-yl)-1-piperidinecarboxylate hemisulfate sesquihydrate 1
FDA-Approved Indications
- Acute treatment of migraine attacks with or without aura in adults 1
- Preventive treatment of episodic migraine in adults 1
- NURTEC is the first dual agent approved for both treatment and prevention of migraine 2
Clinical Efficacy
For Acute Treatment:
- In clinical trials, rimegepant demonstrated significantly higher rates of pain freedom at 2 hours compared to placebo (19.6% vs 12.0%) 3
- Freedom from most bothersome migraine symptom at 2 hours was also significantly better with rimegepant versus placebo (37.6% vs 25.2%) 3
- The 2023 VA/DoD Clinical Practice Guidelines give rimegepant a "weak for" recommendation for acute migraine treatment 4
For Preventive Treatment:
- When used every other day, rimegepant significantly reduced monthly migraine days compared to placebo (-4.3 vs -3.5 days) 1
- 49.1% of patients achieved at least 50% reduction in moderate to severe monthly migraine days versus 41.5% with placebo 1
- Benefits in reducing migraine frequency and improving quality of life were maintained for up to 52 weeks in longer-term studies 2
Dosing and Administration
- For acute treatment: 75 mg taken once per day as needed, with no more than 1 tablet in 24 hours 1
- For preventive treatment: 75 mg taken once every other day 1
- Administration instructions:
- Use dry hands when opening the blister pack
- Peel back foil covering and gently remove tablet (do not push through foil)
- Place on or under the tongue immediately after opening
- Tablet will dissolve without requiring water 1
Place in Therapy
- According to current guidelines, rimegepant is generally positioned as a third-line therapy for acute migraine treatment 5
- The recommended treatment algorithm is:
Safety Profile and Adverse Effects
- Most common side effects for acute treatment: nausea 1
- Most common side effects for preventive treatment: nausea, stomach pain, and indigestion 1
- Serious potential adverse effect: allergic reactions (including trouble breathing, rash, swelling of face/mouth/tongue/throat) 1
- No evidence of hepatotoxicity or cardiovascular toxicity was observed in clinical trials 2
- Unlike triptans, rimegepant does not have cardiovascular contraindications, making it suitable for patients with cardiovascular risk factors 2, 6
Special Considerations and Contraindications
- Contraindicated in patients allergic to rimegepant or any ingredients in NURTEC ODT 1
- Not recommended for use in adults with severe hepatic impairment, as exposure increases 2.0 to 3.9-fold 7
- Use caution in patients with liver or kidney problems 1
- Pregnancy: It is not known if NURTEC will harm an unborn baby; a pregnancy registry (MONITOR) exists to collect information 1
- Breastfeeding: Very small amounts pass into breast milk; discuss with healthcare provider 1
Storage Requirements
- Store at room temperature between 68°F to 77°F (20°C to 25°C) 1
- Keep in the original blister package until ready to use 1
NURTEC represents an important addition to migraine management options, particularly for patients who cannot tolerate or have inadequate response to traditional treatments like triptans or have cardiovascular contraindications to triptans.