What is the proper protocol for prescribing Nurtec (rimegepant)?

From the Guidelines

Nurtec ODT (rimegepant) is prescribed for acute migraine treatment and prevention in adults, with a typical dose of 75 mg taken orally as needed for acute attacks, not exceeding one dose per 24 hours, or 75 mg every other day for prevention. For acute treatment, patients should take one tablet at the first sign of migraine, placing it on or under the tongue where it dissolves without requiring water. For preventive therapy, the every-other-day regimen helps maintain therapeutic levels in the system. Nurtec works as a calcitonin gene-related peptide (CGRP) receptor antagonist, blocking the CGRP pathway involved in migraine pain transmission. Patients should be advised that Nurtec can be taken with or without food, but they should avoid grapefruit products which may increase drug levels. Common side effects include nausea and stomach pain. Prescribers should check for potential drug interactions, particularly with strong CYP3A4 inhibitors, and use caution in patients with severe hepatic or renal impairment, as noted in the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1. Additionally, the guideline suggests that rimegepant is a weak for recommendation for the short-term treatment of migraine, and there is insufficient evidence to recommend for or against rimegepant for the prevention of episodic migraine 1. It is also important to consider the patient's individual needs and medical history when prescribing Nurtec, as well as alternative treatment options such as aspirin-acetaminophen-caffeine, which has a strong for recommendation for the short-term treatment of migraine 1. Overall, the use of Nurtec should be based on a thorough evaluation of the patient's condition and medical history, and in accordance with the most recent clinical practice guidelines, as outlined in the 2023 VA/DoD headache guidelines 1.

From the FDA Drug Label

The safety of NURTEC ODT for the acute treatment of migraine in adults has been evaluated in a randomized, double-blind, placebo-controlled trial (Study 1) in 682 patients with migraine who received one 75 mg dose of NURTEC ODT The safety of NURTEC ODT for the preventive treatment of episodic migraine in adults has been established in a randomized, double-blind, placebo-controlled trial with an open-label extension (Study 2) using a different oral dosage form of rimegepant

Prescription Information for NURTEC

• Acute Treatment of Migraine: 75 mg dose of NURTEC ODT
• Preventive Treatment of Episodic Migraine: 75 mg dose of rimegepant every other day Important Considerations
• Concomitant administration of NURTEC ODT with strong inhibitors of CYP3A4 should be avoided
• Concomitant administration of NURTEC ODT with moderate inhibitors of CYP3A4 may result in increased exposure of rimegepant, avoid another dose of NURTEC ODT within 48 hours
• Concomitant administration of NURTEC ODT with strong or moderate inducers of CYP3A can result in a significant reduction in rimegepant exposure, which may lead to loss of efficacy of NURTEC ODT
• Concomitant administration of NURTEC ODT with potent inhibitors of P-gp may result in increased exposure of rimegepant, avoid another dose of NURTEC ODT within 48 hours 2

From the Research

Prescribing Nurtec (Rimegepant)

To prescribe Nurtec, consider the following:

• Nurtec is an oral calcitonin gene-related peptide receptor antagonist for the acute treatment of migraine 3.
• The recommended dose of Nurtec is 75 mg orally, taken as needed 3.
• Efficacy of Nurtec has been demonstrated in clinical trials, with a higher percentage of patients achieving pain freedom and freedom from their most bothersome symptom compared to placebo 3, 4.

Patient Selection

When selecting patients for Nurtec treatment, consider:

• Adults with a history of migraine and at least 2 migraine attacks of moderate or severe intensity per month 3.
• Patients who have had an insufficient response to triptans or other migraine treatments may still benefit from Nurtec 4.
• Patients with cardiovascular risk factors may be candidates for Nurtec, as it does not have vasoconstrictive properties 5.

Administration and Monitoring

When administering Nurtec, consider:

• Nurtec should be taken orally, as needed, at the onset of a migraine attack 3.
• Patients should be monitored for adverse events, such as nausea and urinary tract infection, which are common with Nurtec treatment 3.
• Efficacy and safety of Nurtec should be evaluated in individual patients, with adjustments to treatment as needed 6, 7.