The preclinical discovery and development of atogepant for migraine prophylaxis

Variant angina associated with a CGRP receptor antagonist: a case report

BACKGROUND

Calcitonin gene-related peptide (CGRP) plays a pivotal role in migraine pathophysiology, and CGRP receptor antagonists are increasingly used for acute and preventive treatment. While considered to have minimal cardiovascular risk, real-world safety data remain limited, particularly in patients with cardiovascular comorbidities. We report a rare case of variant angina associated with atogepant, a novel oral CGRP receptor antagonist.

CASE PRESENTATION

A 57-year-old woman presented with new-onset, paroxysmal chest pain over three days, described as a squeezing sensation with diaphoresis, typically occurring during early morning hours and relieved by sublingual nitroglycerin. She had a history of hypertension and IgA nephropathy and had been using zolmitriptan for chronic migraine for several years. Atogepant 60 mg once daily was initiated four days prior to reduce triptan use. On symptom onset, troponin I was mildly elevated but normalized by admission. Coronary angiography revealed no fixed stenosis or thrombosis. Given the clear clinical presentation, further spasm provocation testing was not performed, and variant angina was diagnosed. As no other causes of coronary vasospasm were identified, atogepant was discontinued, and diltiazem with a long-acting nitrate was prescribed. She remained symptom-free during follow-up.

CONCLUSIONS

This case suggests that atogepant may be associated with coronary vasospasm in patients with cardiovascular risk factors. Given CGRP's role as a potent vasodilator, its blockade may predispose to vasospasm in vulnerable individuals. Caution and close monitoring are warranted when prescribing CGRP receptor antagonists, particularly in those with cardiovascular comorbidities.

Identifying signals of disproportionate reporting for calcitonin gene-related peptide inhibitors: real-world evidence from the FDA adverse event reporting system

BACKGROUND

Calcitonin gene-related peptide (CGRP) inhibitors have been FDA-approved for migraine prophylaxis and relief. However, their safety profile remains uncertain. This study analyzes adverse events (AEs) and signals of disproportionate reporting (SDRs) using the FDA Adverse Event Reporting System (FAERS).

RESEARCH DESIGN AND METHODS

We analyzed FAERS reports from approval through Q2 2023, standardizing terms using preferred terminology and system organ class (SOCs) classifications. Disproportionality analyses (ROR, PRR, IC) identified SDRs and inclusion in FDA prescribing information was reviewed. Additional analyses included comparisons with other migraine drugs, indication-based sensitivity analyses and causality assessment using the Bradford Hill framework.

RESULTS

Galcanezumab showed strong signals for underdose (ROR 47.4; 95% CI 43.79-51.3), alopecia (5.72; 5.09-6.43), and constipation (6.01; 5.35-6.75), while fremanezumab exhibited notable associations with alopecia (6.9; 5.72-8.33) and weight increased (6.34; 5.18-7.76). Among gepants, rimegepant was linked to somnolence (4.52; 3.57-5.73) and dizziness (3.73; 3.15-4.42) and atogepant showed a strong signal for therapy interruption (16.58; 12.86-21.38).

CONCLUSIONS

This study highlights CGRP inhibitor-associated AEs, underscoring the need for clinical monitoring and risk identification. Early detection of AEs and SDRs can inform protective measures to enhance patient safety.

Single-centre, randomised and double-blind clinical trial on the efficacy of transcutaneous auricular vagus nerve stimulation in preventing and treating primary headache in children and adolescents: a study protocol

INTRODUCTION

Primary headaches pose a significant burden on children and adolescents, highlighting the need for effective non-pharmacological interventions. Transcutaneous auricular vagus nerve stimulation (taVNS) is a non-invasive modality that has demonstrated efficacy in adult populations with primary headaches and has shown safety in adolescents with mental health disorders. However, its effectiveness in managing acute headache episodes and preventing recurrences in paediatric populations remains underexplored. This study aims to evaluate the immediate analgesic effects of taVNS during acute headache episodes and its preventive efficacy over a 4-week period. Additionally, we will investigate potential biomarkers associated with primary headaches and elucidate the underlying mechanisms of taVNS through electromyography (EMG) and electrocardiography (ECG) assessments.

METHODS AND ANALYSIS

This study will employ a double-blind, randomised clinical trial design involving 288 children and adolescent participants diagnosed with primary headaches. The study will consist of two substudies: the acute period (AP) study and the preventive period (PP) study. Participants will be randomly allocated to receive either taVNS or sham stimulation. The primary outcome for the AP study will be the reduction of pain intensity 2 hours after treatment, as measured by the visual analogue scale, while the PP study will assess the change in the headache attack days over the treatment period. Secondary outcomes will include EMG and ECG parameters.

ETHICS AND DISSEMINATION

The study will adhere to the principles outlined in the Declaration of Helsinki and has received ethical approval from the Medical Ethics Committee of Nanfang Hospital, Southern Medical University (NFEC-2024-057), on 2 January 2024. Informed consent will be obtained from all participants or their guardians. The findings will be disseminated through peer-reviewed journals and presented at relevant scientific conferences.

TRIAL REGISTRATION NUMBER

NCT06277063.

Health Technology Assessment: Evaluation of 8 CGRP-Targeted Therapy Drugs for the Treatment of Migraine

Purpose

In order to scientifically evaluate the clinical value of the comprehensive attributes of Calcitonin gene-related peptide (CGRP) inhibitor drugs, a comprehensive literature-based clinical evaluation of CGRP-targeted therapy drugs was conducted using the drug evaluation method modified by expert discussion in the Rapid Guide for Drug Evaluation and Selection in Chinese Medical Institutions (Second Edition).

Methods

Based on evidence-based data and the relevant elements and weighting in the "Selection Guidelines" quantification record form for drug evaluation and selection in medical institutions, adjustments were made according to the characteristics of CGRP-targeted therapy drugs. We systematically evaluated erenumab, galcanezumab, fremanezumab, eptinezumab, rimegepant, ubrogepant, atogepant, zavegepant for safety, efficacy, economy, and pharmacological properties.

Results

The final assessment result scores from highest to lowest were rimegepant (84.5 points), erenumab (75.78 points), galcanezumab (74.02 points), fremanezumab (73.93 points), atogepant (72.64 points), eptinezumab (71.69 points), ubrogepant (70.37 points), zavegepant (56.44 points).

Conclusion

Rimegepant, erenumab, fremanezumab, atogepant, galcanezumab, eptinezumab, ubrogepant can be entered into the medication list of medical institutions as strongly recommended drugs.

Antimicrobial Neuropeptides and Their Receptors: Immunoregulator and Therapeutic Targets for Immune Disorders

The interaction between the neuroendocrine system and the immune system plays a key role in the onset and progression of various diseases. Neuropeptides, recognized as common biochemical mediators of communication between these systems, are receiving increasing attention because of their potential therapeutic applications in immune-related disorders. Additionally, many neuropeptides share significant similarities with antimicrobial peptides (AMPs), and evidence shows that these antimicrobial neuropeptides are directly involved in innate immunity. This review examines 10 antimicrobial neuropeptides, including pituitary adenylate cyclase-activating polypeptide (PACAP), vasoactive intestinal peptide (VIP), α-melanocyte stimulating hormone (α-MSH), ghrelin, adrenomedullin (AM), neuropeptide Y (NPY), urocortin II (UCN II), calcitonin gene-related peptide (CGRP), substance P (SP), and catestatin (CST). Their expression characteristics and the immunomodulatory mechanisms mediated by their specific receptors are summarized, along with potential drugs targeting these receptors. Future studies should focus on further investigating antimicrobial neuropeptides and advancing the development of related drugs in preclinical and/or clinical studies to improve the treatment of immune-related diseases.

Combining treatments for migraine prophylaxis: the state-of-the-art

Combination treatments for migraine prophylaxis present a promising approach to addressing the diverse and complex mechanisms underlying migraine. This review explores the potential of combining oral conventional prophylactics, onabotulinumtoxin A, monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway, and small molecule CGRP receptor antagonists (gepants). Among the most promising strategies, dual CGRP inhibition through mAbs and gepants may enhance efficacy by targeting both the CGRP peptide and its receptor, while the combination of onabotulinumtoxin A with CGRP treatments offers synergistic pain relief. Oral non-CGRP treatments, which are accessible and often prescribed for patients with comorbid conditions, provide an affordable and practical option in combination regimens. Despite the potential of these combinations, there is a lack of evidence to support their widespread inclusion in clinical guidelines. The high cost of certain combinations, such as onabotulinumtoxin A with a CGRP mAb or dual anti-CGRP mAbs, presents feasibility challenges. Further large-scale trials are needed to establish safe and effective combination protocols and solidify their role in clinical practice, particularly for treatment-resistant patients.

The prodrome of migraine: mechanistic insights and emerging therapeutic strategies

Migraine is a common clinical chronic neurovascular disease characterized by recurrent, mostly unilateral, moderate or severe, pulsatile headache. It can be divided into four clinical stages: premonitory (prodrome), aura, headache and postdrome. The early warning value of the prodrome in migraine has been largely verified in various studies. In fact, the prodrome of migraine has received increasing attention as it can serve as an ideal therapeutic window for early intervention and effective treatment of migraine. In recent years, the pathophysiological and molecular biological mechanisms in the prodromal stage of migraine have been extensively studied, and great progress has been made in understanding the disease. This review paper aims to provide an overview of recent studies mainly focused on the prodrome of migraine, discuss the biological mechanisms underlying the clinical profile, and reveal novel therapeutic strategies for preventing or blocking migraine onset during its prodrome.

Atogepant for migraine prevention: a meta-analysis of safety and efficacy in adults

Background

Migraine is a neurological condition marked by frequent headaches, which tends to be accompanied by nausea and vomiting in severe instances. Injectable therapies for migraine, such as monoclonal antibodies that target calcitonin gene-related peptide (CGRP), have proven to be effective and safe. While various oral drugs are available, none have been developed for migraines. Patients prefer oral therapies because they are easier to use, making atogepant, an orally accessible small-molecule CGRP receptor antagonist, a possible alternative.

Objectives

This systematic review and meta-analysis compared the safety and effectiveness of atogepant with placebo in treating migraine.

Methods

Adhering to the PRISMA guidelines, we meticulously gathered randomized controlled trials (RCTs) from databases including the Cochrane Library, PubMed, Science Direct, and ClinicalTrials.gov. Studies comparing atogepant with placebo and reporting monthly migraine days (MMDs) as the primary outcome along with secondary outcomes such as monthly headache days and acute medication use days were included. Two independent reviewers conducted the data extraction and quality assessment. Statistical analyses were carried out using RevMan, utilizing risk ratios for dichotomous outcomes and mean differences for continuous outcomes, and a random-effects model.

Results

Our primary outcome was the change in MMDs over 12 weeks, which showed a significant reduction with atogepant at dosages of 10, 30, and 60 mg. Secondary outcomes, such as monthly headache days, proportion of patients achieving a ≥ 50% reduction in MMDs, acute medication use days, and patient-reported outcomes, consistently showed that atogepant outperformed placebo, highlighting its effectiveness in reducing the migraine burden.

Conclusion

Higher doses of atogepant are more effective in lowering migraine and headache-related days and increasing quality of life metrics. However, this is accompanied by an increased incidence of adverse events, suggesting the need for careful dose optimization to balance the benefits and risks.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=563395. Unique Identifier: CRD42024563395.

Adverse events associated with Atogepant: a FAERS-based pharmacovigilance analysis

BACKGROUND

Migraine, a prevalent neurovascular disorder, can significantly disrupt an individual's daily life. Atogepant (AGN-241689), an orally administered small-molecule drug classified as a calcitonin gene-related peptide receptor antagonist, is utilized for prophylactic migraine treatment. The objective of this study was to investigate adverse events (AEs) associated with atogepant through data mining in the FDA Adverse Event Reporting System (FAERS) to enhance clinical safety.

METHODS

Data for atogepant were obtained from the FAERS database covering Q3 2021 through Q4 2023. Disproportionality analysis was employed to quantify relevant AEs associated with atogepant. Reported Ratio of Ratios (ROR) was utilized for identifying risk signals within the FAERS data. This methodology relies on the System Organ Class (SOC) and Preferred Terminology (PT) of the Medical Dictionary for Regulatory Activities (MedDRA).

RESULTS

From the FAERS database, a collection of 7,991,243 reports was obtained. Among these reports, a subset of 3015 was identified as 'primary suspected (PS)' AEs specifically related to atogepant. AEs induced by atogepant were observed across 27 organ systems. A total of 48 significantly disproportionate Preferred Terminologies (PTs) meeting all four algorithms were identified.

CONCLUSION

Our study has identified adverse events (AEs) associated with atogepant, potentially providing crucial support for the clinical monitoring and risk identification of atogepant.