Use in Adults
Gepants

​THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.

Rimegepant (Nurtec®) Click Here to Expand

Brands:

• Nurtec® ODT (rimegepant sulfate) For more complete prescribing information click here for PACKAGE INSERT

Initial Dose:

• 75 mg

​Dose Schedule: 

• 75 mg under the tongue at onset of migraine as needed for the treatment of an acute migraine attack 

​Max Daily Dose:

• 75 mg

Side Effects:

• Nausea, abdominal pain, indigestion

Headache Specialist Comments: 

• The main advantages of the gepants are their good efficacy & tolerability and minimal to no risk for medication overuse headache.  Also, they do not have a cardiovascular contraindication like the triptans.
• There is no evidence from clinical studies that gepants are more efficacious than triptans, ditans or ergots.
• The main disadvantages are their expense and need for a prior authorization in many cases. 
• Patients may need to “try and fail” 1-2 triptans before insurance approval.
• Consider their use as primary treatment of the migraine attack in following situations:
  • Patients whose triptan does not provide adequate pain relief at 2 hours
  • Patients who are intolerant of triptans
  • Patients who have medication overuse headache (e.g., those that using acute medications ≥ 10 days per month)
  • Patients in whom triptans are contraindicated, particularly for patients with cardiovascular contraindications, since the gepants do not have a cardiovascular contraindication. ​

Precautions and Risk:

• Hypersensitivity reactions

Contraindications:

• Avoid in those taking strong CYP3A4 inhibitors (see Drug Interactions)

Pregnancy and Breast-Feeding

• Click Nurtec® and navigate to #8 Use in Specific Populations (8.1 & 8.2)

Common Drug Interactions:

• Strong CYP3A4 Inhibitors: may increase serum levels of rimegepant.  Consider avoidance if taking these medications:  clarithromycin, protease inhibitors and antifungals (e.g., itraconazole and ketoconazole) among others.
• Moderate CYP3A4 Inhibitors: Avoid another dose within 48 hours when administered with a moderate CYP3A4 inhibitor. These drugs include verapamil, erythromycin, diltiazem, amiodarone, among others.
• Strong and moderate CYP3A Inducers: May decrease serum concentration of rimegepant. These include carbamazepine, phenytoin, phenobarbital, St. John’s wort and others.
• Inhibitors of P-gp or BCRP: Avoid concomitant administration. Consider avoidance if taking these medications:  amiodarone, clarithromycin, cyclosporin, colchicine, diltiazem, erythromycin, felodipine, ketoconazole, lansoprazole, omeprazole and others.

Counseling Tips:

• Keep the tablet in the blister/outer aluminum pouch until ready to use
• Allow tablet to disintegrate on or under the tongue

• Take early in the attack when the pain is mild

Ubrogepant (Ubrelvy®) Click Here to Expand

​Brands:

• Ubrelvy® (ubrogepant) For more complete prescribing information click here for PACKAGE INSERT

Initial Dose:

• 50 mg

​Dose Schedule:  

• 50 mg by mouth at onset of migraine as needed for the treatment of an acute migraine attack; may repeat dosage in two hours, if not pain free or with adequate relief
• 100 mg tablet can be used as the initial dosage if the 50 mg dosage does not provide pain freedom or adequate pain relief 

​Max Daily Dose:

• 200 mg

Side Effects:

• Nausea and somnolence

Headache Specialist Comments:

• The main advantages of the gepants are their good efficacy & tolerability and minimal to no risk for medication overuse headache.  Also, they do not have a cardiovascular contraindication like the triptans.
• There is no evidence from clinical studies that gepants are more efficacious than triptans, ditans or ergots.
• The main disadvantages are their expense and the requirement for prior authorization.  
• Patients may need to “try and fail” 1-2 triptans before insurance approval.
• Consider their use as primary treatment of the migraine attack in following situations:
  • Patients whose triptan does not provide adequate pain relief at 2 hours
  • Patients who are intolerant of triptans
  • Patients who have medication overuse headache (e.g., those who are using acute medications ≥ 10 days per month)
  • Patients where triptans are contraindicated, particularly for patients with cardiovascular contraindications, since the gepants do not have a cardiovascular contraindication. ​

Precautions and Risk:

• Avoid in patients with end stage renal disease
• Hypersensitivity reactions

Contraindications:

• Avoid in those taking strong CYP3A4 inhibitors (see Drug Interactions)

Pregnancy and Breast-Feeding:

• Click Ubrelvy® and navigate to #8 Use in Specific Populations (8.1 & 8.2)

Common Drug Interactions:

• Strong CYP3A4 Inhibitors: may increase serum levels of rimegepant.  Consider avoidance if taking these medications. These include clarithromycin, protease inhibitors and antifungals (e.g., itraconazole and ketoconazole) and others.
• Moderate CYP3A4 Inhibitors: Avoid another dose within 48 hours when administered with a moderate CYP3A4 inhibitor. These drugs include verapamil, erythromycin, diltiazem, amiodarone and others.
• Strong and moderate CYP3A Inducers: May decrease serum concentration of rimegepant. These medications include carbamazepine, phenytoin, phenobarbital, St. John’s wort and others.
• Inhibitors of P-gp or BCRP: Avoid concomitant administration.  These medications include amiodarone, clarithromycin, cyclosporin, , colchicine, diltiazem, erythromycin, felodipine, ketoconazole, lansoprazole, omeprazole and others.

​ Counseling Tips:  

• Take early in the attack when the pain is mild