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True D, Mullin K, Croop R. Safety of Rimegepant in Adults with Migraine and Cardiovascular Risk Factors: Analysis of a Multicenter, Long-Term, Open-Label Study. Pain Ther 2024; 13:1203-1218. [PMID: 38985436 PMCID: PMC11393218 DOI: 10.1007/s40122-024-00626-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/05/2024] [Indexed: 07/11/2024] Open
Abstract
INTRODUCTION Cardiovascular (CV) risk factors can limit treatment options for migraine. Rimegepant is an orally administered small-molecule calcitonin gene-related peptide receptor antagonist that does not induce vasoconstriction. The aim of these post hoc subgroup analyses was to assess the safety of rimegepant according to CV risk. METHODS In a multicenter, long-term, open-label, phase II/III safety study, participants with a history of 2-14 migraine attacks per month of moderate or severe pain intensity self-administered rimegepant 75 mg, orally, to treat migraine up to once daily for up to 52 weeks. Uncontrolled, unstable, or recently diagnosed CV disease was part of the exclusion criteria. Safety was assessed across subgroups according to number of CV risk factors (0, 1, or ≥ 2) and Framingham Risk Score (< 10% or ≥ 10%). RESULTS Of 1800 treated participants, 28.8% had one CV risk factor and 12.1% had ≥ 2 CV risk factors; 7.0% had Framingham Risk Score ≥ 10%. Across the subgroups with 0, 1, and ≥ 2 CV risk factors and Framingham Risk Score < 10% and ≥ 10%, respectively, proportions of participants reporting adverse events (AEs; 59.6%, 61.4%, 62.2%, 59.9%, 67.5%) and serious AEs (2.7%, 2.5%, 2.3%, 2.6%, 2.4%) were consistent, and AEs leading to study drug discontinuation were low (1.9%, 3.1%, 5.5%, 2.5%, 4.8%). CONCLUSIONS Rimegepant showed favorable safety and tolerability in adults with migraine and CV risk factors, including those with moderate to high CV risk. TRIAL REGISTRATION ClinicalTrials.gov NCT03266588.
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Affiliation(s)
- David True
- Clinvest Research, 909 E Republic Rd Building D 200, Springfield, MO, 65807, USA.
| | - Kathleen Mullin
- New England Institute for Clinical Research, Stamford, CT, USA
| | - Robert Croop
- Biohaven Pharmaceuticals Inc, New Haven, CT, USA
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Mascarella D, Andrini G, Baraldi C, Altamura C, Favoni V, Lo Castro F, Pierangeli G, Vernieri F, Guerzoni S, Cevoli S. Blood pressure monitoring in elderly migraineurs starting an anti-CGRP monoclonal antibody: a real-world prospective study. Neurol Sci 2024:10.1007/s10072-024-07567-9. [PMID: 38795273 DOI: 10.1007/s10072-024-07567-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/27/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND While monoclonal antibodies (mAbs) targeting the CGRP pathway have revolutionized migraine management due to their improved tolerance and adherence, concerns remain about their potential impact on blood pressure (BP), especially in older patients, due to CGRP-mediated vasodilation blockade. Given the growing use of these therapies in older populations, assessing their cardiovascular (CV) safety is of paramount importance. METHODS This multicentric observational prospective study focused on migraine sufferers aged ≥ 60 who began erenumab, galcanezumab, or fremanezumab for prevention. Baseline, three-month, and twelve-month BP measurements were collected. Changes in antihypertensive medication and "Newly or Worsened Hypertensive" patients (NWHP) were assessed. RESULTS Among 155 patients receiving anti-CGRP mAbs (40 Erenumab, 47 Galcanezumab, 68 Fremanezumab), 42.5% had hypertension history and 39% were on antihypertensive treatment. No significant systolic or diastolic BP changes occurred at any time point compared to baseline (all p > 0.05), with no differences between the three groups. After one year, 20/155 (12.9%) patients were considered NWHP; 11/20 had prior hypertension, and 5/11 adjusted antihypertensive therapy. Among 9/20 newly hypertensive patients, 5/9 had a single measurement above the normal threshold with no requirement for new pharmacological therapy. A higher baseline BP value was associated with increased BP (p = 0.002). CONCLUSIONS The study concludes that treatment with anti-CGRP mAbs over one year does not significantly affect BP in patients aged ≥ 60, nor does it increase the incidence of hypertension compared to general population trends. Nonetheless, continuous monitoring and further long-term studies are necessary to fullya scertain the cardiovascular safety of these medications in the elderly.
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Affiliation(s)
- Davide Mascarella
- Department of Biomedical and Neuromotor Science DIBINEM, Alma Mater Studiorum Bologna, Bologna, Italy
| | - Giorgia Andrini
- Department of Biomedical and Neuromotor Science DIBINEM, Alma Mater Studiorum Bologna, Bologna, Italy
| | - Carlo Baraldi
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Valentina Favoni
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna ISNB, Bologna, Italy
| | - Flavia Lo Castro
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - Giulia Pierangeli
- Department of Biomedical and Neuromotor Science DIBINEM, Alma Mater Studiorum Bologna, Bologna, Italy
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna ISNB, Bologna, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Simona Guerzoni
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse-Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy
| | - Sabina Cevoli
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna ISNB, Bologna, Italy.
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Reuter U, Goadsby PJ, Ferrari MD, Da Silva Lima GP, Mondal S, Kalim J, Hasan F, Wen S, Arkuszewski M, Pandhi S, Stites T, Lanteri-Minet M. Efficacy and Safety of Erenumab in Participants With Episodic Migraine in Whom 2-4 Prior Preventive Treatments Had Failed: LIBERTY 3-Year Study. Neurology 2024; 102:e209349. [PMID: 38669638 DOI: 10.1212/wnl.0000000000209349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The LIBERTY study assessed the efficacy and safety of erenumab in participants with episodic migraine (EM) and 2-4 prior preventive treatment failures. The results have been presented after 3 years of erenumab exposure in its open-label extension phase (OLEP). METHODS Participants completing the 12-week double-blind treatment phase (DBTP) of the LIBERTY study could enter the OLEP and receive 140 mg of erenumab once monthly for 3 years. The main outcomes included the proportion of participants achieving ≥50% reduction in monthly migraine days (MMDs), the mean MMD change from baseline, and tolerability and safety. RESULTS Overall, 240/246 (97.6%) participants entered the OLEP and 168/240 (70.0%) completed the study (85/118 continuing erenumab [n = 1 lost during follow-up]; 83/122 switching from placebo [n = 2 lost during follow-up]). In the overall population, 79/151 participants (52.3%) with valid data points achieved ≥50% reduction in MMDs at week 168 (i.e., responders). In the continuous erenumab group, 35/117 participants (29.9%) were ≥50% responders at week 12 of the DBTP and 26/35 (74.3%) remained ≥50% responders in at least half of OLEP visits. Of the 82/117 participants (70.1%) not achieving responder status at week 12 in the continuous erenumab group, 17/82 (20.7%) converted to ≥50% responders in at least half of OLEP visits. Of 103/120 participants (85.8%) not achieving responder status at week 12 in the placebo-erenumab group, 42/103 (40.8%) converted to ≥50% responders in at least half of OLEP visits after switching to erenumab. Overall, the mean (SD) MMD change from baseline showed sustained improvement over 3 years (-4.4 [3.9] days at week 168). The most common treatment-emergent AEs (per 100 person-years) were nasopharyngitis (28.8), influenza (7.5), and back pain (5.8). Overall, 9.6% (3.9 per 100 person-years) and 6.7% (2.7 per 100 person-years) of participants reported events of treatment-emergent hypertension and constipation, respectively. The safety and tolerability profile remained consistent with earlier studies. DISCUSSION Erenumab (140 mg) showed sustained efficacy over 3 years in participants with EM and 2-4 prior preventive treatment failures. No new safety signals were observed. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT03096834.
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Affiliation(s)
- Uwe Reuter
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Peter J Goadsby
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michel D Ferrari
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Gabriel Paiva Da Silva Lima
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Subhayan Mondal
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Jawed Kalim
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Fatima Hasan
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Shihua Wen
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michal Arkuszewski
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Shaloo Pandhi
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Tracy Stites
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
| | - Michel Lanteri-Minet
- From the Department of Neurology (U.R.), Charité Universitätsmedizin Berlin; Universitätsmedizin Greifswald (U.R.), Germany; NIHR King's Clinical Research Facility (P.J.G.), King's College London, United Kingdom; Department of Neurology (P.J.G.), University of California, Los Angeles; Department of Neurology (M.D.F.), Leiden University Medical Center, the Netherlands; Amgen Inc. (G.P.D.S.L.), Thousand Oaks, CA; Novartis Healthcare Pvt. Ltd. (S.M., J.K., F.H.), Hyderabad, India; Novartis Pharmaceutical Corporation (S.W., T.S.), East Hanover, NJ; Novartis Pharma AG (M.A., S.P.), Basel, Switzerland; Pain Department and FHU InovPain (M.L.-M.), CHU Nice-Université Côte d'Azur, France; and INSERM U1107 Migraine and Trigeminal Pain (M.L.-M.), Auvergne University, Clermont-Ferrand, France
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Chhabra N, Mead-Harvey C, Dodoo CA, Iser C, Taylor H, Chaudhary H, Vanood A, Dodick DW. Blood pressure elevation in erenumab-treated patients with migraine: A retrospective real-world experience. Headache 2024; 64:233-242. [PMID: 38411625 DOI: 10.1111/head.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. OBJECTIVE To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. METHODS This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. RESULTS A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. CONCLUSION We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.
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Affiliation(s)
- Nikita Chhabra
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Carolyn Mead-Harvey
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Christopher A Dodoo
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Courtney Iser
- Department of Neurology, Mercy Clinic, Oklahoma City, Oklahoma, USA
| | - Hallie Taylor
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Hira Chaudhary
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Aimen Vanood
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
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Sorbara EE, Barbieri MA, Russo G, Cicala G, Spina E. Cardiovascular Adverse Drug Reactions of Anti-Calcitonin Gene-Related Peptide Monoclonal Antibodies for Migraine Prevention: An Analysis from the European Spontaneous Adverse Event Reporting System. BioDrugs 2024; 38:275-285. [PMID: 38402495 DOI: 10.1007/s40259-024-00651-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION Anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP-mAbs) have recently been approved for the prevention of migraine, and their safety profile is not fully characterized. OBJECTIVE The aim of this study was to evaluate the adverse drug reactions (ADRs) of anti-CGRP-mAbs through the analysis of individual case safety reports (ICSRs) collected in the EudraVigilance (EV) database, with a specific focus on cardiovascular (CV) ADRs. METHODS Data on ICSRs recorded between July 2018 and December 2022 in the EV database, involving one of the anti-CGRP-mAbs for migraine prevention-erenumab (ERE), galcanezumab (GMB), fremanezumab (FMB), and eptinezumab (EPT)-were included in the analysis. All ICSRs reporting at least one CV ADR, as identified within the MedDRA® System Organ Classes (SOCs) "cardiac disorders" or "vascular disorders," were selected for the analysis. The frequency of disproportionate reporting was expressed as the reporting odds ratio (ROR) with its 95% confidence interval (CI), to evaluate the frequency of reporting of CV ADRs for each anti-CGRP-mAb compared with all other monoclonal antibodies (mAbs). A case-by-case analysis was conducted paying particular attention to serious CV ADR reports, focusing on the type of seriousness, age group, sex, and concomitant drugs. RESULTS A total of 9441 ICSRs were recorded in the EV database from 2018 to 2022, of which more than half were related to ERE (58.9%), followed by GMB (21.4%), FMB (19.0%), and EPT (0.7%). CV ICSRs accounted for 1205 cases (12.8%), with a total of 1599 CV ADRs. The CV ICSRs were mainly related to female patients (82.6%) aged 18-64 years (73.4%). Of the reported CV ADRs, 67.5% were considered serious. Among the total number of ICSRs related to each anti-CGRP-mAb, those associated with FMB had a higher percentage of CV ADRs (n = 253; 14.1%), followed by ERE (n = 707; 12.7%), EPT (n = 8; 12.7%), and GMB (n = 237; 11.7%). A higher frequency of reporting hypertension was shown for ERE (ROR = 1.45; 95% CI = 1.14-1.85). Pallor was mainly observed with FMB (5.00; 1.68-14.89), as well as deep vein thrombosis (3.86; 1.57-9.51), hot flush (2.16; 1.43-3.25), and palpitations (1.48; 1.05-2.08). Atrial fibrillation (2.36; 1.02-5.46) and myocardial infarction (2.21; 1.37-3.58) were mostly reported for GMB. CONCLUSION The analysis of anti-CGRP-related CV ADRs was consistent with the information reported in the literature. However, hypertension with ERE, atrial fibrillation and myocardial infarction with GMB, as well as pallor, deep vein thrombosis, hot flush, and palpitations with FMB were not reported in the Summary of Product Characteristics (SmPCs). Considering this, more post-marketing analyses are needed to improve knowledge on the CV safety profiles of anti-CGRP-mAbs, especially for the last approved medication, EPT.
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Affiliation(s)
- Emanuela Elisa Sorbara
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | | | - Giulia Russo
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | - Giuseppe Cicala
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, 98125, Messina, Italy.
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Schweiger V, Bellamoli P, Taus F, Gottin L, Martini A, Nizzero M, Bonora E, Del Balzo G, Donadello K, Secchettin E, Finco G, Santis DD, Polati E. Anti-CGRP and Anti-CGRP Receptor Monoclonal Antibodies for Migraine Prophylaxis: Retrospective Observational Study on 209 Patients. J Clin Med 2024; 13:1130. [PMID: 38398444 PMCID: PMC10889238 DOI: 10.3390/jcm13041130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Migraine is a neurological disorder characterized by attacks of head pain with prevalent unilateral localization, moderate to high intensity and specifically associated accompanying symptoms. METHODS In this retrospective observational study, we analyzed data regarding 209 patients who had previously been diagnosed with migraine and who were prescribed, between 2019 and 2022, subcutaneous injections of anti-CGRP monoclonal antibodies (mAbs) fremanezumab or galcanezumab or anti-CGRP receptors mAb erenumab regardless of the concomitant assumption of any other acute-phase or prophylactic migraine medication. RESULTS Regarding efficacy, in the 205 analyzed patients, the change from baseline in terms of MIDAS, HIT-6, MMDs and MAD scores was statistically significant for erenumab and galcanezumab, while for fremanezumab a statistical significance was not achieved likely due to the small sample size. In the treated population, 36 patients (17.5%) reported AEs (pain during injection, transient injection site erythema, nausea, constipation and fatigue). Only 5 patients (2.4%) discontinued the treatment for AEs while 15 patients (7.3%) left for lack of efficacy. CONCLUSIONS this retrospective study comes out in favor of both significant efficacy and safety of anti-CGRP and anti-CGRP receptors mAbs in migraine patients. Further methodologically stronger studies are necessary to validate our observation.
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Affiliation(s)
- Vittorio Schweiger
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Paola Bellamoli
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Francesco Taus
- Department of Diagnostics and Public Health, Section of Statistics, University of Verona, 37124 Verona, Italy;
| | - Leonardo Gottin
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Alvise Martini
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Marta Nizzero
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Eleonora Bonora
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Giovanna Del Balzo
- Department of Diagnostics and Public Health, Section of Forensic Medicine, University of Verona, 37129 Verona, Italy;
| | - Katia Donadello
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Erica Secchettin
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
| | - Gabriele Finco
- Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy;
| | - Daniele De Santis
- Head and Neck Department, University of Verona, 37129 Verona, Italy;
| | - Enrico Polati
- Anesthesiology, Intensive Care and Pain Therapy Center, Department of Surgery, University of Verona, 37124 Verona, Italy; (P.B.); (L.G.); (A.M.); (M.N.); (E.B.); (K.D.); (E.S.); (E.P.)
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Wang K, Fenton BT, Dao VX, Guirguis AB, Anthony SE, Skanderson M, Sico JJ. Trajectory of blood pressure after initiating anti-calcitonin gene-related peptide treatment of migraine: a target trial emulation from the veterans health administration. J Headache Pain 2023; 24:108. [PMID: 37582724 PMCID: PMC10426172 DOI: 10.1186/s10194-023-01640-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Calcitonin gene-related peptide (CGRP) is involved in migraine pathophysiology and blood pressure regulation. Although clinical trials have established the cardio-cerebrovascular safety profile of anti-CGRP treatment, limited high-quality real-world evidence exists on its long-term effects on blood pressure (BP). To address this gap, we examined the safety of anti-CGRP treatment on BP in patients with migraine headache in the Veterans Health Administration (VHA). METHODS We emulated a target trial of patients who initiated anti-CGRP treatment or topiramate for migraine prevention between May 17th, 2018 and February 28th, 2023. We calculated stabilized inverse probability weights to balance between groups and then used weighted linear mixed-effect models to estimate the systolic and diastolic BP changes over the study period. For patients without hypertension at baseline, we estimated the cumulative incidence of hypertension using Kaplan-Meier curve. We also used weight mixed-effect Poisson model to estimate the number of antihypertension medications for patients with hypertension at baseline. RESULTS This analysis included 69,589 patients and 554,437 blood pressure readings. of these, 18,880 patients received anti-CGRP treatment, and they were more likely to be women, have a chronic migraine diagnosis and higher healthcare utilization than those received topiramate. Among patients without hypertension at baseline, we found no significant differences in systolic BP changes over the four-year follow-up between anti-CGRP (slope [standard error, SE] = 0.48[0.06]) and topiramate treated patients (slope[SE] = 0.39[0.04]). The incidence of hypertension was similar for anti-CGRP and topiramate group (4.4 vs 4.3 per 100 person-years). Among patients with hypertension at baseline who initiated anti-CGRP treatment, we found a small but persistent effect on exacerbating hypertension during the first four years of treatment, as evidenced by a significant annual 3.7% increase in the number of antihypertensive medications prescribed (RR = 1.037, 95%CI 1.025-1.048). CONCLUSIONS Our findings suggest that anti-CGRP treatment is safe regarding blood pressure in patients without hypertension. However, for those with baseline hypertension, anti-CGRP treatment resulted in a small but persistent increase in the number of antihypertensives, indicating an exacerbation of hypertension. Future studies are needed to evaluate the cardio-cerebrovascular safety of anti-CGRP treatment beyond the first four years.
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Affiliation(s)
- Kaicheng Wang
- Department of Veterans Affairs, Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, Orange, CT, USA.
- Yale Center for Analytical Sciences, Yale School of Public Health, 300 George St STE 511, New Haven, CT, 06511, USA.
| | - Brenda T Fenton
- Department of Veterans Affairs, Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, Orange, CT, USA
- Pain Research, Informatics, Multi-Morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Vinh X Dao
- Pharmacy Benefits Management Services, VA Minneapolis Health Care System, Minneapolis, MN, USA
- Headache Center of Excellence, VA Minneapolis Health Care System, Minneapolis, MN, USA
| | - Alexander B Guirguis
- Pharmacy Benefits Management Services, VA Connecticut Healthcare System, West Haven, CT, USA
- Headache Center of Excellence, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Sarah E Anthony
- Department of Veterans Affairs, Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, Orange, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Melissa Skanderson
- Department of Veterans Affairs, Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, Orange, CT, USA
| | - Jason J Sico
- Department of Veterans Affairs, Research, Education, Evaluation and Engagement Activities Center for Headache, Headache Centers of Excellence, Orange, CT, USA
- Headache Center of Excellence, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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8
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Schoenen J, Van Dycke A, Versijpt J, Paemeleire K. Ten open questions in migraine prophylaxis with monoclonal antibodies blocking the calcitonin-gene related peptide pathway: a narrative review. J Headache Pain 2023; 24:99. [PMID: 37528353 PMCID: PMC10391994 DOI: 10.1186/s10194-023-01637-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023] Open
Abstract
The monoclonal antibodies (mAbs) blocking the calcitonin-gene related peptide (CGRP) pathway, collectively called here "anti-CGRP/rec mAbs", have dramatically improved preventive migraine treatment. Although their efficacy and tolerability were proven in a number of randomized controlled trials (RCTs) and, maybe even more convincingly, in real world settings, a number of open questions remain. In this narrative review, we will analyze published data allowing insight in some of the uncertainties related to the use of anti-CGRP/rec mAbs in clinical practice: their differential efficacy in migraine subtypes, outcome predictors, switching between molecules, use in children and adolescents, long-term treatment adherence and persistence, effect persistence after discontinuation, combined treatment with botulinum toxin or gepants, added-value and cost effectiveness, effectiveness in other headache types, and potential contraindications based on known physiological effects of CGRP. While recent studies have already provided hints for some of these questions, many of them will not find reliable and definitive answers before larger studies, registries or dedicated RCTs are available.
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Affiliation(s)
- Jean Schoenen
- Headache Research Unit, Department of Neurology‑Citadelle Hospital, University of Liège, Boulevard du 12 ème de Ligne 1, Liège, 4000, Belgium.
| | - Annelies Van Dycke
- Department of Neurology, General Hospital Sint-Jan Bruges, Ruddershove 10, Bruges, 8000, Belgium
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, 9000, Belgium
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9
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González-Hernández A, Marichal-Cancino BA, MaassenVanDenBrink A, Villalón CM. Serotonergic Modulation of Neurovascular Transmission: A Focus on Prejunctional 5-HT Receptors/Mechanisms. Biomedicines 2023; 11:1864. [PMID: 37509503 PMCID: PMC10377335 DOI: 10.3390/biomedicines11071864] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/17/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
5-Hydroxytryptamine (5-HT), or serotonin, plays a crucial role as a neuromodulator and/or neurotransmitter of several nervous system functions. Its actions are complex, and depend on multiple factors, including the type of effector or receptor activated. Briefly, 5-HT can activate: (i) metabotropic (G-protein-coupled) receptors to promote inhibition (5-HT1, 5-HT5) or activation (5-HT4, 5-HT6, 5-HT7) of adenylate cyclase, as well as activation (5-HT2) of phospholipase C; and (ii) ionotropic receptor (5-HT3), a ligand-gated Na+/K+ channel. Regarding blood pressure regulation (and beyond the intricacy of central 5-HT effects), this monoamine also exerts direct postjunctional (on vascular smooth muscle and endothelium) or indirect prejunctional (on autonomic and sensory perivascular nerves) effects. At the prejunctional level, 5-HT can facilitate or preclude the release of autonomic (e.g., noradrenaline and acetylcholine) or sensory (e.g., calcitonin gene-related peptide) neurotransmitters facilitating hypertensive or hypotensive effects. Hence, we cannot formulate a specific impact of 5-HT on blood pressure level, since an increase or decrease in neurotransmitter release would be favoured, depending on the type of prejunctional receptor involved. This review summarizes and discusses the current knowledge on the prejunctional mechanisms involved in blood pressure regulation by 5-HT and its impact on some vascular-related diseases.
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Affiliation(s)
- Abimael González-Hernández
- Instituto de Neurobiología, Universidad Nacional Autónoma de México, Boulevard Juriquilla 3001, Queretaro 76230, Mexico
| | - Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Universidad Autónoma de Aguascalientes, Mexico City 20100, Mexico
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Calzada de los Tenorios 235, Colonia Granjas-Coapa, Delegación Tlalpan, Mexico City 14330, Mexico
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10
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Rhyne C, Cohen JM, Seminerio MJ, Carr K, Krasenbaum LJ. Burden of migraine with acute medication overuse or psychiatric comorbidities and treatment with CGRP pathway-targeted monoclonal antibodies: A review. Medicine (Baltimore) 2023; 102:e33874. [PMID: 37335663 DOI: 10.1097/md.0000000000033874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
Migraine is a complex and often debilitating neurological disease that affects more than 1 billion people worldwide. It is characterized by moderate-to-intense, throbbing headache attacks that are worsened by activity and is associated with nausea, vomiting, and sensitivity to light and sound. Migraine, ranked the second leading cause of years lived with disability by the World Health Organization, can diminish patients' quality of life and bring significant personal and economic burden. Furthermore, migraine patients with a history of acute medication overuse (AMO) or psychiatric comorbidities, such as depression or anxiety, may experience even greater impairment and burden, and their migraine may be more difficult-to-treat. Appropriate treatment of migraine is essential to reduce this burden and improve patient outcomes, especially for those with AMO or psychiatric comorbidities. There are several available preventive treatment options for migraine, though many of these are not migraine-specific and may have limited efficacy and/or poor tolerability. The calcitonin gene-related peptide pathway plays a key role in the pathophysiology of migraine, and monoclonal antibodies that target the calcitonin gene-related peptide pathway have been developed as specific preventive treatments for migraine. Four of these monoclonal antibodies have been approved for the preventive treatment of migraine after demonstrating favorable safety and efficacy profiles. These treatments offer substantial benefits for migraine patients, including those with AMO or common psychiatric comorbidities, by reducing monthly headache days and migraine days, days of acute medication use, and disability measures, as well as improving quality of life.
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Affiliation(s)
| | - Joshua M Cohen
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA
| | | | - Karen Carr
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA
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11
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Kudrow D, Dafer R, Dodick DW, Starling A, Ailani J, Dougherty C, Kalidas K, Zhang F, Jeswani R, Patel N, Khodavirdi AC. Evaluation of vascular risk in patients with migraine with and without aura treated with erenumab: Post hoc analysis of pooled long-term clinical trial data. Headache 2023; 63:418-428. [PMID: 36942409 DOI: 10.1111/head.14485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/15/2022] [Accepted: 01/14/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To assess cardiovascular (CV) safety of erenumab in clinical trial patients associated with degree of CV risk. BACKGROUND Hypertension has been considered a theoretical risk associated with the inhibition of the calcitonin gene-related peptide pathway in migraine management, particularly in a patient population with pre-existing CV risk factors. METHODS Data pooled from four double-blind, randomized trials were used to assess blood pressure (BP) changes and CV safety in patients grouped based on 10-year risk of cardiac, cerebrovascular, and peripheral artery disease as no-risk-factors, low-risk (>0% to ≤10%), moderate-risk (>10% to ≤20%), and high-risk (>20%) categories. CV safety was assessed as ischemic cardiovascular and cerebrovascular adverse events (ICCAE). RESULTS There was no apparent difference between placebo- (N = 1032) and erenumab-treatment groups (70 mg, N = 885; 140 mg, N = 504) in clinical worsening of BP category from baseline to Months 1-3 (14% [143/1032] placebo vs. 13% [114/885] and 14% [71/504] for erenumab 70 and 140 mg, respectively) regardless of baseline BP category. The adverse event (AE) profile of erenumab was similar across CV risk categories throughout the long-term analysis. Erenumab-treated patients with high and moderate 10-year CV risk (N = 107) did not experience any ICCAEs during the double-blind treatment period; there was a single ICCAE (a cerebral dural venous sinus thrombosis) observed in the low-risk erenumab group (N = 273). There were no increases in AEs during the long-term extensions of up to 5 years (N = 2499; 3482 patient-years of exposure to erenumab) with exposure-adjusted incidence rates of cardio/cerebrovascular disorder AEs of 0.4, 0.5, 0.0, and 1.1 (per 100 patient-years) for no risk factor (N = 1805), low (N = 492), moderate (N = 121), and high (N = 81) 10-year CV risk groups, respectively. CONCLUSIONS Ischemic CV and cerebrovascular AEs were uncommon and the incidence rates were similar across the 10-year CV risk categories. This analysis helps provide more detail on the CV safety of erenumab.
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Affiliation(s)
- David Kudrow
- California Medical Clinic for Headache, Santa Monica, California, USA
| | - Rima Dafer
- Rush University Medical Center, Chicago, Illinois, USA
| | | | | | - Jessica Ailani
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Carrie Dougherty
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Feng Zhang
- Amgen Inc., Thousand Oaks, California, USA
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12
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Raffaelli B, De Icco R, Corrado M, Terhart M, Ailani J. Open-label trials for CGRP-targeted drugs in migraine prevention: A narrative review. Cephalalgia 2023; 43:3331024221137091. [PMID: 36718044 DOI: 10.1177/03331024221137091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Calcitonin gene-related peptide-targeted drugs have proven safe and effective for migraine prevention in large randomized-controlled, double-blind trials with an average duration of six months. Open-label studies may provide additional information on the long-term safety and efficacy of these substances. METHODS We searched PubMed for open-label trials with calcitonin gene-related peptide(-receptor) monoclonal antibodies and calcitonin gene-related peptide-receptor antagonists. We summarized and critically analyzed the literature in a narrative way. RESULTS Overall, 13 open-label trials were included in this review (n = 4 for erenumab, n = 4 for galcanezumab, n = 3 for fremanezumab, n = 1 for eptinezumab, n = 1 for atogepant). Open-label trial duration ranged between 12 and 264 weeks. No safety concerns emerged, and the adverse events profile was similar to the double-blind study phase. Discontinuation rates were generally low with >75% of patients remaining in the trials after one year. Efficacy data showed a sustained reduction of migraine frequency throughout the trials, along with a lasting improvement in quality of life. CONCLUSIONS The open-label study program for calcitonin gene-related peptide-targeted migraine preventives confirms the favorable safety and efficacy profile of these drugs over time. Treatment adherence appears higher than with previous unspecific migraine preventives. Real-world data and post-marketing surveillance studies may corroborate and complement open-label results.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Clinician Scientist Program, Berlin Institute of Health, Berlin, Germany
| | - Roberto De Icco
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Michele Corrado
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Maria Terhart
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica Ailani
- MedStar Georgetown University Hospital, Washington, DC, USA
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13
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Cherian L. Women and Ischemic Stroke. Neurol Clin 2023; 41:265-281. [PMID: 37030957 DOI: 10.1016/j.ncl.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Although men are at higher risk of stroke throughout most of their lifespan, the incidence of stroke in women climbs with age, increasing after menopause and rising sharply after 85 years. This, combined with women's longer life expectancy, results in most of the stroke deaths occurring in women. In addition to accounting for a larger proportion of strokes, women may also suffer a survival disadvantage, which may be due to several factors. In many families, women are the primary caretakers. When they become disabled, there may be limited options to care for them. Others suggest that some of the disparities in stroke outcomes in women may be related to age, pre-stroke functional status, and comorbidities. Regardless of the cause, the increased disability and post-stroke care requirements of women, particularly in our aging population, highlight the importance of determining successful strategies for stroke prevention, acute stroke treatments, optimization of stroke rehabilitation, and effective secondary prevention measures in women.
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14
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Raffaelli B, Terhart M, Fitzek MP, Lange KS, Mecklenburg J, Overeem LH, Siebert A, Storch E, Reuter U. Change of CGRP Plasma Concentrations in Migraine after Discontinuation of CGRP-(Receptor) Monoclonal Antibodies. Pharmaceutics 2023; 15:pharmaceutics15010293. [PMID: 36678920 PMCID: PMC9861447 DOI: 10.3390/pharmaceutics15010293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/08/2023] [Accepted: 01/13/2023] [Indexed: 01/17/2023] Open
Abstract
Discontinuation of treatment with monoclonal antibodies (mAb) targeting the Calcitonin Gene-Related Peptide (CGRP) pathway leads to an increase in migraine frequency. We aimed to assess changes in free and total CGRP plasma concentrations after the discontinuation of CGRP(-receptor) mAbs. This prospective analysis included 59 patients with migraine (n = 25 erenumab, n = 25 galcanezumab, n = 9 fremanezumab) who discontinued mAbs after ≥8 months of treatment. Patients were visited at the time of the last mAb injection (V1) and 16 weeks later (V2). For control, 30 migraine patients without preventive drug therapy were included. We measured free CGRP plasma concentrations in the erenumab and fremanezumab group and total CGRP concentrations in the galcanezumab group. Free CGRP plasma concentrations did not change after treatment discontinuation [erenumab: V1 31.2 pg/mL (IQR 25.8−45.6), V2 30.3 pg/mL (IQR 22.9−47.6), p = 0.65; fremanezumab V1 29.4 pg/mL (IQR 16.4−61.9), V2 34.4 (19.2−62.0), p = 0.86]. Controls had similar CGRP values of 32.6 pg/mL (IQR 21.3−44.6). Total CGRP concentrations in the galcanezumab group were 5439.3 pg/mL (2412.7−6338.1) at V1, and decreased to 1853.2 pg/mL (1136.5−3297.0) at V2 (p < 0.001). Cessation of treatment with CGRP(-R) mAbs did not have an impact on the free-circulating CGRP concentrations. Total CGRP decreased significantly after three months of treatment discontinuation.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité (BIH), 10117 Berlin, Germany
- Correspondence: ; Tel.: +49-(0)30-450-660888; Fax: +49-(0)30-450-560932
| | - Maria Terhart
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Mira Pauline Fitzek
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Kristin Sophie Lange
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Jasper Mecklenburg
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | | | - Anke Siebert
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Elisabeth Storch
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
- Universitätsmedizin Greifswald, 17475 Greifswald, Germany
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Adverse Events Reported with Therapies Targeting the CGRP Pathway During the First 6 Months Post-launch: A Retrospective Analysis Using the FDA Adverse Events Reporting System. Adv Ther 2023; 40:445-459. [PMID: 36350532 PMCID: PMC9898337 DOI: 10.1007/s12325-022-02346-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Through 2018, three calcitonin gene-related peptide pathway-targeted monoclonal antibodies (CGRP mAbs) had received US Food and Drug Administration (FDA) approval for migraine prevention: erenumab, fremanezumab, and galcanezumab. METHODS This retrospective analysis evaluated adverse events (AEs) spontaneously reported to the FDA Adverse Event Reporting System (FAERS) safety surveillance database during the first 6 months post-approval of erenumab (May 2018 to November 2018), fremanezumab (September 2018 to March 2019), and galcanezumab (September 2018 to March 2019). Reporting rates (RR) per 1000 exposed patients were calculated from number of reported events (when product classified as "primary suspect") in each AE category and estimated number of treated patients based on de-identified prescription data (IQVIA database) and were ranked on the basis of frequency for each product. RESULTS RR per 1000 exposed patients for "migraine" (erenumab, 4.89; fremanezumab, 1.01; galcanezumab, 2.99), "headache" (3.32, 1.27, 3.07), and "drug ineffective" (3.68, 1.14, 1.69) were commonly reported for all three products, as were migraine-associated symptoms ("nausea": 2.94, 0.91, 1.09) and "injection-site" reactions ("pain": 2.94, 0.8, 4.9; "swelling": 0.56, 0.53, 1.25; "pruritus": 0.26, 0.63, 1.14; "erythema": 0.58, 0.71, 1.58). "Constipation" ranked second for erenumab (4.90) but did not make the top ten events for fremanezumab (0.46) or galcanezumab (0.76); cardiovascular events did not rank in the top ten AEs for any product. The frequency of serious outcomes was low, with ≤ 2% of AEs categorized as serious across the CGRP mAbs. CONCLUSION These results aid in supporting the safety profile of CGRP mAbs in the real-world setting and may provide clinicians and patients with additional insight when considering migraine preventive treatments.
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George N, Tepper SJ. Novel Migraine Treatments: A Review. J Oral Facial Pain Headache 2023; 37:25-32. [PMID: 36917235 PMCID: PMC10586574 DOI: 10.11607/ofph.3163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 08/29/2022] [Indexed: 03/16/2023]
Abstract
Aims: To present a review of the mechanisms of action, available clinical data, and safety profiles of novel migraine therapeutics to inform practice. Methods: PubMed, Medline, and Google Scholar were searched for randomized controlled trials (24 publications), review articles (15 publications), and other pertinent literature (16 publications) discussing the novel migraine therapeutics available between the years 2010 and 2021. All publications were reviewed to assess the mechanism of action, relevant clinical data, and side effect profile for each novel treatment. Therapeutic gain was also recorded in studies that included a placebo arm. Results: A total of 55 studies were included in the final analysis. In the preventive treatment of migraine, novel medications target calcitonin gene-related peptide (CGRP) and fall into either the monoclonal anti-CGRP or gepant class. For the acute treatment of migraine, novel medications fall into either the ditan or gepant class. Several medical devices have been developed for the acute and preventive treatment of migraine. Conclusion: Novel therapeutics are available for both the prevention and acute treatment of migraine headaches. These new medications and neuromodulatory devices appear overall to be safe and effective in the management of migraine headaches.
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17
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Bedrin K, Ailani J, Dougherty C. Raynaud's phenomenon associated with calcitonin gene-related peptide receptor antagonists case report. Headache 2022; 62:1419-1423. [PMID: 36426766 DOI: 10.1111/head.14417] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Calcitonin gene-related peptide (CGRP) is a potent vasodilator that regulates the cerebrovascular and peripheral circulation. A new class of migraine therapies decreases CGRP through various mechanisms. One unknown off-target effect is the impact decreasing CGRP will have on the peripheral circulation. The following cases report new onset Raynaud's phenomenon (RP) following the use of CGRP receptor antagonists (-gepants) for both the acute and preventive treatment of migraine. These cases describe the development of RP in two individuals after using each of the currently available gepant medications. To our knowledge these are the first cases reported of RP associated with the use of gepants. RP has previously been reported in association with monoclonal antibodies to the CGRP ligand and CGRP receptor indicated in the prevention of migraine. CASE PRESENTATION One case involved oral CGRP receptor antagonists for acute treatment inducing RP. In this case, rimegepant and ubrogepant used separately for different migraine attacks each led to RP in the digits. The other case involved oral CGRP receptor antagonist, atogepant, used as a preventive treatment and induced RP in the digits. This patient had a prior history of areolar tissue RP while breastfeeding, but never in her fingers. In both cases, the offending medications were discontinued, and the patients reported no further episodes of RP. CONCLUSION Two cases are reported of people with migraine with new onset digital RP while taking CGRP receptor antagonists (rimegepant, ubrogepant, atogepant) for acute and preventive treatment.
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Affiliation(s)
- Kate Bedrin
- Medstar Georgetown Headache Center, Department of Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Jessica Ailani
- Medstar Georgetown Headache Center, Department of Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Carrie Dougherty
- Medstar Georgetown Headache Center, Department of Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
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18
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de Vries Lentsch S, van der Arend BW, Maassen VanDenBrink A, Terwindt GM. Blood Pressure in Patients With Migraine Treated With Monoclonal Anti-CGRP (Receptor) Antibodies: A Prospective Follow-up Study. Neurology 2022; 99:e1897-e1904. [PMID: 36195452 PMCID: PMC9620812 DOI: 10.1212/wnl.0000000000201008] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/09/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Anti-calcitonin gene-related peptide (CGRP) (receptor) antibodies are approved as preventive treatment for migraine. Recent concerns have been raised after a retrospective analysis of postmarketing case reports of elevated blood pressure (BP) associated with erenumab. In this prospective follow-up study, we aimed to assess the safety regarding BP in a real-world setting. METHODS All people with migraine who were treated with erenumab and fremanezumab at the Leiden Headache Center between January 2019 and January 2021 were included. BP measurements were collected from baseline (T0) until 12 months of follow-up, with a 3-month interval (T1-T4). Mixed linear models were fitted with time as a fixed effect and the patient as a random effect. RESULTS Both systolic and diastolic BP were increased at all time points T1-T4 compared with T0 (p < 0.001). The maximum estimated increase in the mean systolic BP was 5.2 mm Hg (95% CI 3.1-7.5). The maximum estimated increase in the mean diastolic BP was 3.5 mm Hg (95% CI 2.0-4.9). In the erenumab group (n = 109), both systolic and diastolic BP were increased at all time points compared with T0 (all p < 0.001). For fremanezumab (n = 87), systolic but not diastolic BP was increased compared with T0 at T1 (p = 0.006) and T2 (p = 0.004). Four patients (3.7%) with normal BP at T0 required antihypertensive treatment after erenumab was started. DISCUSSION The mean systolic and diastolic BP increased after anti-CGRP (receptor) antibodies were started. The majority of patients remained within the normal BP limits, but some patients required antihypertensive treatment. Physicians should be aware that people with migraine may be at risk of developing hypertension when treated with anti-CGRP (receptor) antibodies, and this should be added to (inter)national treatment guidelines. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that anti-CGRP (receptor) antibodies increase BP when used to treat patients with migraine.
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Affiliation(s)
- Simone de Vries Lentsch
- From the Department of Neurology (S.d.V.L., B.W.H.v.d.A., G.M.T.), Leiden University Medical Centre; and Division of Vascular Medicine and Pharmacology (B.W.H.v.d.A., A.M.V.D.B.), Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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19
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Kaltseis K, Indelicato E, Broessner G, Boesch S. Case report: Monoclonal CGRP-antibody treatment in a migraine patient with a mutation in the mitochondrial single-strand binding protein (SSBP1). Front Neurol 2022; 13:958463. [PMID: 36203974 PMCID: PMC9531672 DOI: 10.3389/fneur.2022.958463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThere is a growing body of mitochondrial disorders that are associated with headaches, albeit only one of them is currently listed in the latest International Classification of Headache Disorders, 3rd edition (ICHD-3). Headache frequency and headache presentation can vary widely in this respective patient group. Acute and preventive migraine treatment can be quite challenging—the use of several established medications is often limited due to their side effects in the setting of mitochondrial dysfunction and multi-organ disease.Case presentationAlong with a review of the literature on treatment options in patients with mitochondrial disorders and migraine headaches, we present the case of a 23-year-old male with a homozygous mutation in the mitochondrial single-strand binding protein (SSBP1) with chronic migraine with aura. After failing several standard of care prophylactics due to either side effects or inefficacy, he was successfully treated with a monoclonal anti-CGRP-antibody as a preventive migraine treatment. The monoclonal antibody was well tolerated and showed adequate efficacy with a sustained > 50% reduction in monthly headache days after 3 years of treatment.ConclusionMigraine is often challenging to treat in patients with mitochondriopathy due to therapy-limiting comorbidities. Monoclonal CGRP-antibodies might be a safe treatment option in the prevention of migraine headaches in patients with a mitochondrial disorder.
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20
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Altamura C, Brunelli N, Marcosano M, Fofi L, Vernieri F. Gepants - a long way to cure: a narrative review. Neurol Sci 2022; 43:5697-5708. [PMID: 35650458 PMCID: PMC9159895 DOI: 10.1007/s10072-022-06184-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/28/2022] [Indexed: 01/01/2023]
Abstract
Calcitonin gene-related peptide (CGRP) is probably the most potent vasodilator in cerebral circulation. Forty years after its discovery, the new CGRP-targeted therapy monoclonal antibodies, and the small molecule gepants, are now available for clinical practice. While randomized controlled trials and real-world experience consistently demonstrated the high efficacy and tolerability of monoclonal antibodies, limited evidence is available to characterize gepants fully. Depending on pharmacokinetics, these CGRP receptor antagonists can be used for acute (ubrogepant, rimegepant, and the not yet approved zavegepant) or preventive (atogepant and rimegepant) migraine treatment. Randomized placebo-controlled trials demonstrated gepants efficacy in treating acute attacks to obtain 2 h pain freedom in about 20% of patients and pain relief in about 60%, while up to 60% of treated patients with episodic migraine may experience a 50% reduction in monthly migraine days. The most common treatment-related emergent adverse events were gastrointestinal (nausea, constipation) for the acute or preventive use. No vascular or hepatic concerns have emerged so far. More studies are ongoing to investigate gepant tolerability and safety also if associated with monoclonal antibodies targeting CGRP and other therapeutic classes. Gepants are also under investigation to treat other painful and non-painful conditions. Real-life studies are necessary to confirm the trials’ findings and investigate more practical clinical aspects.
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Affiliation(s)
- Claudia Altamura
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy.
| | - Nicoletta Brunelli
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Marilena Marcosano
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Luisa Fofi
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Universitario Campus Bio-Medico Di Roma, 00128, Rome, Italy
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21
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Lampl C, Kraus V, Lehner K, Loop B, Chehrenama M, Maczynska Z, Ritter S, Klatt J, Snellman J. Safety and tolerability of erenumab in individuals with episodic or chronic migraine across age groups: a pooled analysis of placebo-controlled trials. J Headache Pain 2022; 23:104. [PMID: 35978286 PMCID: PMC9386939 DOI: 10.1186/s10194-022-01470-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Erenumab, a fully human monoclonal antibody that targets the calcitonin gene-related peptide receptor, has demonstrated efficacy and safety in the prevention of episodic and chronic migraine. There exists an unmet need to establish the safety of erenumab in older individuals, in view of existing multiple comorbidities, polypharmacy, and age-related physiological changes. This pooled analysis of five large migraine-prevention studies examined the safety of erenumab stratified across age groups, particularly in older populations. METHODS Pooled and age-stratified analysis of safety data from the 12-week double-blind treatment phase (DBTP) of five randomized, placebo-controlled Phase 2 and 3 studies of erenumab in participants with episodic or chronic migraine across the age groups < 40 years, 40-49 years, 50-59 years, and ≥ 60 years was completed. The safety of erenumab across age groups was determined by assessing safety endpoints including treatment-emergent adverse events (AEs), serious AEs, and events leading to study drug discontinuation. RESULTS Overall, 3345 participants across five studies were randomized to receive either placebo (n = 1359), erenumab 70 mg (n = 1132) or erenumab 140 mg (n = 854); 3176 (94.9%) completed the DBTP, and 169 (5.1%) discontinued, mainly due to participant decision (110; 3.3%). Overall, 1349 (40.6%), 1122 (33.8%), and 850 (25.6%) participants received at least one dose of placebo, erenumab 70 mg, and erenumab 140 mg, respectively. Incidence of treatment-emergent AEs was similar across all age groups for both doses of erenumab (70 mg or 140 mg) and placebo (< 40 years, 44.0% vs 44.4%; 40-49 years, 42.5% vs 49.2%; 50-59 years, 46.5% vs 41.6%; ≥ 60 years, 43.8% vs 59.4%). Incidence of treatment-emergent serious AEs overall, and stratified by age groups for both doses and placebo was low (< 40 years, 0.9% vs 1.2%; 40-49 years, 1.7% vs 1.9%; and 50-59 years, 1.6% vs 1.1%), with no serious AEs reported in participants aged ≥ 60 years. No deaths were reported. CONCLUSIONS Erenumab (70 mg or 140 mg) exhibited a similar safety profile compared with placebo across age groups in individuals with episodic or chronic migraine, with no increased emergence of events due to age. Erenumab was well tolerated in older participants with multiple comorbidities, polypharmacy, and age-related physiological changes. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifiers: NCT02066415, NCT02456740, NCT02483585, NCT03096834, NCT03333109.
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Affiliation(s)
- Christian Lampl
- Department of Neurology, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Austria.
| | - Viktoria Kraus
- Department of Neurology, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Austria
| | - Katrina Lehner
- Department of Neurology, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, 4020, Linz, Austria
| | - Brett Loop
- Novartis Pharmaceuticals, Cambridge, MA, USA
| | | | | | - Shannon Ritter
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
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22
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Ogunlaja OI, Goadsby PJ. Headache: Treatment update. eNeurologicalSci 2022; 29:100420. [PMID: 36636337 PMCID: PMC9830470 DOI: 10.1016/j.ensci.2022.100420] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 08/10/2022] [Indexed: 01/16/2023] Open
Abstract
Primary headache disorders in particular migraine are one of the most common causes of disability worldwide. Given the high burden of migraine in terms of disability, there has been an effort to develop migraine specific therapies that has led to the availability of new drugs including 5HT1F receptor agonists-ditans (lasmiditan), small molecule calcitonin gene-related peptide (CGRP) receptor antagonists-gepants: (ubrogepant, rimegepant, atogepant) and anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab and eptinezumab). However, some of these treatments incur a high cost and may not be a feasible option for most patients in resource limited settings. Lasmiditan and the gepants are a good option for patients with moderate-severe migraine attacks who cannot use triptans due variously to poor tolerability, or cardio- or cerebrovascular disease. For practical purposes, the new anti-CGRP monoclonal antibodies are best reserved for patients who have failed to have efficacy or had intolerable side effects from multiple traditional oral preventives.
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Affiliation(s)
- Oyindamola I. Ogunlaja
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College London, UK
| | - Peter J. Goadsby
- NIHR King's Clinical Research Facility and SLaM Biomedical Research Centre, King's College London, UK,Department of Neurology, University of California, Los Angeles, CA, USA,Corresponding author at: Wellcome Foundation Building, King's College Hospital, London SE5 9PJ, UK.
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23
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Reducing the Burden of Migraine: Safety and Efficacy of CGRP Pathway-Targeted Preventive Treatments. J Clin Med 2022; 11:jcm11154359. [PMID: 35955976 PMCID: PMC9369309 DOI: 10.3390/jcm11154359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Migraine is a highly disabling and often chronic neurological disease that affects more than one billion people globally. Preventive migraine treatment is recommended for individuals who have frequent and/or disabling attacks; however, many of the medications used for migraine prevention (e.g., antiepileptics, antidepressants, antihypertensives) were not specifically developed for migraine, and often have limited efficacy or poor tolerability. Four monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway, which is believed to play a crucial role in the pathophysiology of migraine, have been approved by the US Food and Drug Administration for the preventive treatment of migraine in adults. All four migraine-specific treatments have demonstrated efficacy based on reductions in monthly days with migraine for patients with both episodic and chronic migraine, including those with comorbidities. They have also demonstrated favorable safety and tolerability profiles. Based on these accounts, CGRP pathway-targeted monoclonal antibodies have the potential to revolutionize preventive treatment for patients with migraine.
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24
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Perino J, Corand V, Laurent E, Théophile H, Miremont-Salamé G, Pariente A, Colas JL, Couffinhal T, Salvo F. Myocardial infarction associated with erenumab: A case report. Pharmacotherapy 2022; 42:585-589. [PMID: 35620946 PMCID: PMC9541222 DOI: 10.1002/phar.2706] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 12/28/2022]
Abstract
Background Monoclonal antibodies acting on the calcitonin gene‐related peptide or its receptor (CGRP‐mabs) are novel drugs for resistant migraine prophylaxis. As CGRP‐mabs cause inhibition of vasodilatation, their use is reserved to patients with no recent history of cardiovascular diseases. We report a case of myocardial infarction associated with erenumab. Case A 57‐year‐old woman with a familial history of coronaropathy was first treated with erenumab 70 mg for 6 months and then increased to 140 mg. Almost 5 months after, the patient presented chest pain, increased troponin, and abnormal electrocardiogram. A myocardial infarction without coronarography abnormality was diagnosed through MRI. Conclusion Further evidence is needed to assess the risk of myocardial infarction in patients treated with a CGRP‐mab. In patients over 40 years of age, the risk of coronary or cardiovascular events should be assessed using risk tables or algorithms to take into account cardiovascular risk factors. This may be complemented by appropriate examinations to measure the burden of coronary atherosclerosis, if necessary.
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Affiliation(s)
- Justine Perino
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM, BPH, U1219, Bordeaux, France
| | - Virginie Corand
- Pain Center of Bordeaux, Department of Clinical Neurosciences, University Hospital of Bordeaux, Bordeaux, France
| | - Elise Laurent
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France
| | - Hélène Théophile
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France
| | - Ghada Miremont-Salamé
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France
| | - Antoine Pariente
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM, BPH, U1219, Bordeaux, France
| | - Jean-Laurent Colas
- Department of Cardiology, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - Thierry Couffinhal
- Univ. Bordeaux, INSERM, Biology of Cardiovascular Diseases, U1034, CHU de Bordeaux, Bordeaux, France
| | - Francesco Salvo
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM, BPH, U1219, Bordeaux, France
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25
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Eller M, Cheng S. Migraine management: an update for the 2020s. Intern Med J 2022; 52:1123-1128. [PMID: 35879242 PMCID: PMC9545433 DOI: 10.1111/imj.15843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/19/2022] [Indexed: 12/11/2022]
Abstract
Migraine is a common malady cutting across socioeconomic and ethnic divides in Australia. It is typically diagnosed late with significant impact on quality of life. Management options have emerged over the past several years that promise simpler treatment regimens with less potential for side‐effects. The development of rationally designed migraine preventives is the most significant advance in treatment since the development of the triptans and delivers significant hope to many headache sufferers.
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Affiliation(s)
- Michael Eller
- Monash Medical Centre and Monash University, Melbourne, Victoria, Australia
| | - Shuli Cheng
- Alfred Health, Melbourne, Victoria, Australia
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26
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Gonzalez-Martinez A, Bose G, Chitnis T. Anti-CGRP therapies for migraine in multiple sclerosis patients. Mult Scler 2022; 28:2149-2150. [PMID: 35575242 DOI: 10.1177/13524585221096353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alicia Gonzalez-Martinez
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Gauruv Bose
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tanuja Chitnis
- Translational Neuroimmunology Research Center (TNRC), Ann Romney Center for Neurologic Diseases (ARCND), Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.,Brigham Multiple Sclerosis Center, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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27
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Gérard AO, Merino D, Van Obberghen EK, Rocher F, Destere A, Lantéri-Minet M, Drici MD. Calcitonin gene-related peptide-targeting drugs and Raynaud's phenomenon: a real-world potential safety signal from the WHO pharmacovigilance database. J Headache Pain 2022; 23:53. [PMID: 35505285 PMCID: PMC9066820 DOI: 10.1186/s10194-022-01424-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Migraine is responsible for significant disability and societal burden. Recently, drugs targeting the calcitonin gene-related peptide (CGRP) pathway raised new hopes. CGRP, a potent vasodilator, plays a key role in the pathogenesis of migraine attacks. The deficiency of CGRP is involved in Raynaud's phenomenon, which consists of abnormal vasoconstriction of the digits. We aimed to assess the potential association of Raynaud's phenomenon with CGRP-targeting drugs, analyzing real-world data from the World Health Organization (VigiBase®). METHODS We queried all reports of Raynaud's phenomenon involving a CGRP-targeting drug. We sought disproportionate reporting of Raynaud's phenomenon with these drugs. For this purpose, we relied on the calculation of the Information Component (IC). A positive lower end of the 95% confidence interval (CI) of the IC defines a statistically significant association. As migraine patients are prone to Raynaud's phenomenon, we also calculated the IC of Raynaud's phenomenon with CGRP-targeting drugs compared to 5HT1B/D agonists (triptans), and beta-blockers used in the treatment of migraine. RESULTS Overall, 99 reports of Raynaud's phenomenon involving CGRP-targeting drugs have been yielded in VigiBase®. The most reported CGRP-targeting drug was erenumab, with 56 reports (56.6%). The median time to onset was 84 days. No fatality was notified, but one patient suffered from gangrene and extremity necrosis. As a whole, CGRP-targeting drugs were significantly associated with Raynaud's phenomenon, with an IC of 3.3 (95%CI: 3.0-3.5). There was a disproportionate reporting of Raynaud's phenomenon with CGRP-targeting drugs compared to triptans (IC 0.4; 95%CI: 0.1-0.6) and to beta-blockers (IC 0.5; 95%CI: 0.2-0.7) as well. CONCLUSIONS There is a significant disproportionality signal of Raynaud's phenomenon with CGRP-targeting. This signal stands out when CGRP-targeting drugs are compared to other drugs used in patients with migraine. This study is limited by missing data in pharmacovigilance reports. CGRP-targeting drugs may be subject to Weber effect and reporting bias. Nonetheless, CGRP blockade might be the last straw that disrupts the physiological balance of vascular response in patients at-risk of Raynaud's phenomenon. Pending further data regarding vascular safety of CGRP-targeting drugs, caution is warranted in these patients.
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Affiliation(s)
- Alexandre O Gérard
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
- Department of Nephrology-Dialysis-Transplantation, University Hospital Center of Nice, Nice, France
- Laboratory of Molecular Physio Medicine (LP2M), UMR 7370, CNRS, University Côte d'Azur, Nice, France
| | - Diane Merino
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Elise K Van Obberghen
- Pain Department and FHU InovPain, University Hospital Center of Nice and Côte d'Azur University, Nice, France
| | - Fanny Rocher
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Alexandre Destere
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France
| | - Michel Lantéri-Minet
- Pain Department and FHU InovPain, University Hospital Center of Nice and Côte d'Azur University, Nice, France
- Migraine and Trigeminal Pain, UMR 1107, INSERM, Auvergne University, Clermont-Ferrand, France
| | - Milou-Daniel Drici
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital Center of Nice, Nice, France.
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28
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Cohen F, Yuan H, Silberstein SD. Calcitonin Gene-Related Peptide (CGRP)-Targeted Monoclonal Antibodies and Antagonists in Migraine: Current Evidence and Rationale. BioDrugs 2022; 36:341-358. [PMID: 35476215 PMCID: PMC9043885 DOI: 10.1007/s40259-022-00530-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/25/2022]
Abstract
Calcitonin gene-related peptide (CGRP), a 37 amino-acid neuropeptide found mostly in peptidergic sensory C-fibers, has been suggested to be implicated in the pathogenesis of migraine, which is one of the most common neurological disorders seen in medical practice, affecting almost 16% of the US population. While previously thought to be a vascular condition, migraine attacks are the result of neurogenic inflammation and peripheral/central sensitization through dysfunctional activation of the trigeminovascular system. To date, two classes of therapeutic agents have been developed to interrupt the function of CGRP: CGRP-targeted monoclonal antibodies (mAbs) and small-molecule antagonists (gepants). There are currently four CGRP-targeted mAbs and three gepants that are US Food and Drug Administration (FDA) approved for the treatment of migraine. Multiple phase II and III studies have established the efficacies and tolerability of these treatments. Previously, we reviewed the fundamental role of CGRP in migraine pathogenesis. Here, we discuss in depth the clinical evidence (randomized controlled trials and real-world studies), safety, and tolerability of CGRP-targeted mAbs and gepants for treating migraine.
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Affiliation(s)
- Fred Cohen
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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Kubota GT. It is time anti-CGRP monoclonal antibodies be considered first-line prophylaxis for migraine. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:218-226. [PMID: 35976302 PMCID: PMC9491437 DOI: 10.1590/0004-282x-anp-2022-s112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
The result of more than thirty years of research, anti-CGRP monoclonal antibodies are currently the state of the art for migraine preventive therapy. Their efficacy and safety, supported by an already large and growing body of evidence, are added by many other advantages: an early onset of action, favorable posology, negligible pharmacological interaction, and a broad-reaching efficacy in many challenging clinical contexts. When compared to standard prophylactics, these novel medications seem at least as efficacious, clearly more tolerable and, consequently, with a superior adherence profile. Furthermore, recently published analyses indicate that they are cost-effective, especially among those with chronic migraine. Yet, current guidelines endorse their use only after multiple other preventives have failed or have been deemed not tolerable. Although this recommendation may have been sensible at first, the now available data strongly point that time has come for anti-CGRP monoclonal antibodies to be acknowledged as first-line treatments for migraine patients with severe disability. For these individuals, delaying treatment until several other alternatives have failed incurs in significant losses, both economically and to many relevant aspects of their lives.
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Affiliation(s)
- Gabriel Taricani Kubota
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brazil
- Instituto do Câncer do Estado de São Paulo, São Paulo SP, Brazil
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De Matteis E, Sacco S, Ornello R. Migraine Prevention with Erenumab: Focus on Patient Selection, Perspectives and Outcomes. Ther Clin Risk Manag 2022; 18:359-378. [PMID: 35411146 PMCID: PMC8994624 DOI: 10.2147/tcrm.s263825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/14/2022] [Indexed: 01/13/2023] Open
Abstract
Erenumab is a monoclonal antibody targeting the calcitonin gene-related peptide (CGRP) receptor suitable for episodic and chronic migraine prevention. Randomized clinical trials proved the superiority of erenumab to placebo in a strictly selected population, while real-world studies confirmed treatment efficacy in more severe forms of disease – most patients suffered from chronic migraine with medication overuse headache, had prior treatment failures, and long disease duration. According to guidelines, anti-CGRP pathway monoclonal antibodies should be reserved to patients who failed or have contraindication to several classes of preventive treatments. However, their ease of use, tolerability and efficacy make these monoclonal antibodies ideally suitable for most patients with migraine; cost-effectiveness needs to be considered when looking at expanding current prescription criteria. Also, data from open label extensions of randomized control trials confirmed sustained benefits of prolonged treatment up to 5 consecutive years without significant risk of adverse events. Further studies will provide insights on optimal treatment duration to achieve migraine remission and predictors of treatment response. In the present work, we aimed at reviewing design and results of the main studies on erenumab and discussing treatment use in the current migraine prevention scenario; we also summarized the main ongoing research projects and provided clinical perspectives for the future.
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Affiliation(s)
- Eleonora De Matteis
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
- Correspondence: Simona Sacco, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio, L’Aquila, 67100, Italy, Tel +39 0862433561; +39 0863499734, Email
| | - Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
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Dominguez-Moreno R, Do TP, Ashina M. Calcitonin gene-related peptide and pituitary adenylate cyclase-activating polypeptide in migraine treatment. Curr Opin Endocrinol Diabetes Obes 2022; 29:225-231. [PMID: 35066541 DOI: 10.1097/med.0000000000000717] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To review the latest advances in migraine management with a focus on medications specifically developed for the treatment of migraine. RECENT FINDINGS Randomized clinical trials demonstrated the efficacy of calcitonin gene-related peptide (CGRP) mAbs for the preventive treatment of migraine and the small molecule CGRP receptor antagonist gepants for acute abortion and prevention of migraine attacks. Pituitary adenylate cyclase-activating polypeptide (PACAP) is another signaling molecule of interest and represents a potential new drug class of mechanism-based migraine medications. Drugs targeting PACAP are currently undergoing clinical trials, and the coming years will reveal whether this class of drugs will expand our therapeutic armamentarium. SUMMARY Here, we summarize the role of CGRP and PACAP in migraine pathophysiology and discuss novel therapies targeting the CGRP and PACAP signaling pathways.
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Affiliation(s)
- Rogelio Dominguez-Moreno
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Thien Phu Do
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Danish Knowledge Center on Headache Disorders, Glostrup, Denmark
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Tepper SJ, Sheikh HU, Dougherty CO, Nahas SJ, Winner PK, Karanam AK, Blumenfeld AM, Abdrabboh A, Rasmussen S, Weiss JL, Ailani J. Erenumab dosage for migraine prevention: An evidence‐based narrative review with recommendations. Headache 2022; 62:420-435. [DOI: 10.1111/head.14266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 12/28/2021] [Accepted: 12/31/2021] [Indexed: 01/02/2023]
Affiliation(s)
- Stewart J. Tepper
- Department of Neurology Geisel School of Medicine at Dartmouth Hanover New Hampshire USA
| | - Huma U. Sheikh
- Department of Neurology Mt. Sinai‐Icahn School of Medicine New York New York USA
| | - Carrie O. Dougherty
- Department of Neurology Medstar Georgetown University Hospital Washington DC USA
| | - Stephanie J. Nahas
- Department of Neurology Thomas Jefferson University, Jefferson Headache Center Philadelphia Pennsylvania USA
| | - Paul K. Winner
- Premiere Research Institute Nova Southeastern University West Palm Beach Florida USA
| | | | - Andrew M. Blumenfeld
- The Los Angeles Headache Center Los Angeles California USA
- The San Diego Headache Center San Diego California USA
| | - Ahmad Abdrabboh
- Novartis Pharmaceuticals Corporation East Hanover New Jersey USA
| | | | - Jamie L. Weiss
- Novartis Pharmaceuticals Corporation East Hanover New Jersey USA
| | - Jessica Ailani
- Department of Neurology Medstar Georgetown University Hospital Washington DC USA
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Diener HC, McAllister P, Jürgens TP, Kessler Y, Ning X, Cohen JM, Campos VR, Barash S, Silberstein SD. Safety and tolerability of fremanezumab in patients with episodic and chronic migraine: a pooled analysis of phase 3 studies. Cephalalgia 2022; 42:769-780. [PMID: 35331009 PMCID: PMC9218411 DOI: 10.1177/03331024221076485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Fremanezumab, a fully humanized monoclonal antibody that selectively targets calcitonin gene-related peptide, has demonstrated efficacy for preventive treatment of episodic and chronic migraine. Since calcitonin gene-related peptide is expressed within the cardio- and cerebrovascular system and may have cardioprotective effects, it is critical to understand the cardio- and cerebrovascular safety of fremanezumab. Methods This was a pooled analysis of three randomized, double-blind, placebo-controlled, phase 3, 12-week trials in which patients with episodic migraine or chronic migraine received quarterly fremanezumab, monthly fremanezumab, or placebo. Incidences of overall and serious adverse events were analyzed. Cardio- and cerebrovascular adverse events (CVAEs) were analyzed in subgroups stratified by cardio- and cerebrovascular medical history, cardiovascular risk factors (CVRFs), and use of cardio- and cerebrovascular medications or triptans. Results Two thousand, eight hundred and forty-two patients were included in the study. Overall (58–65%) and serious adverse events (<1–2%) occurred in similar proportions across fremanezumab and placebo groups. CVAEs were infrequent, regardless of cardio- and cerebrovascular medical history (2–6%). CVAEs occurred in low, similar proportions of patients with CVRFs and those using cardio- and cerebrovascular medications or triptans. No cardio- and cerebrovascular signals were identified. Conclusion Fremanezumab demonstrated a favorable overall and cardio- and cerebrovascular safety profile in more than 2800 patients with episodic migraine or chronic migraine, regardless of cardio- and cerebrovascular medical history, CVRFs, or medication use. Trial Registrations: NCT02629861 (HALO EM, https://clinicaltrials.gov/ct2/show/NCT02629861), NCT02621931 (HALO CM, https://clinicaltrials.gov/ct2/show/NCT02621931), NCT03308968 (FOCUS, https://clinicaltrials.gov/ct2/ show/NCT03308968)
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Affiliation(s)
- Hans Christoph Diener
- Institute for Medical Informatics, Biometry, and Epidemiology, Medical Faculty of the University Duisburg-Essen, Essen, Germany
| | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, CT, USA
| | - Tim P Jürgens
- Headache Center North-East, Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Yoel Kessler
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Xiaoping Ning
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | - Joshua M Cohen
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
| | | | - Steve Barash
- Teva Branded Pharmaceutical Products R&D, Inc., West Chester, PA, USA
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Datta A, Gupta S, Maryala S, Aggarwal V, Chopra P, Jain S. Erenumab for episodic migraine. Pain Manag 2022; 12:587-594. [PMID: 35313740 DOI: 10.2217/pmt-2021-0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
In this review, the authors provide an overview of erenumab, a monoclonal antibody used for the preventative treatment of episodic migraine by targeting the CGRP pathway. Randomized controlled trials have shown that erenumab is associated with a statistically significant decrease in monthly migraine days in patients with episodic migraine at monthly doses of 70 or 140 mg when given for a period of 9-12 weeks. Post hoc analyses have also shown long-term maintenance of efficacy. Clinical trials have found erenumab at doses of both 70 and 140 mg to have a favorable safety profile. Erenumab faces significant limitations because of its high financial cost. Additional long-term real-world data are needed to understand the role of erenumab in the treatment of migraine.
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Affiliation(s)
| | - Sahil Gupta
- Southern Illinois Healthcare, Carbondale, IL 62901, USA
| | - Shashi Maryala
- Gandhi Medical College, Secunderabad, Telangana, 500003, India
| | | | - Pooja Chopra
- Bux Pain Management, 217 3rd St., Danville, KY 40422, USA
| | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, AR 72205, USA
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35
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Liang D, Sessa M. Post-marketing safety surveillance of erenumab: new insight from Eudravigilance. Expert Opin Drug Saf 2022; 21:1205-1210. [PMID: 35236231 DOI: 10.1080/14740338.2022.2049231] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND We aimed at evaluating adverse drug reactions during the post-marketing phase with erenumab as the suspected/interacting drug in Eudravigilance, with the final goal of investigating the consistency of the disproportionality signals (DS) for erenumab in Eudravigilance and the American Food and Drug Administration Adverse Event Reporting System (FDA FAERS) and undetected disproportionality signals from Eudravigilance. RESEARCH DESIGN AND METHODS Eudravigilance was screened in the period from October 2019 to October 2020. Disproportionality measure was performed using the Reporting Odds Ratio (ROR) according to the guidelines by the European Medicine Agency and using sumatriptan as the control group. RESULTS 3381 cases were reported in the study period. Forty DS were identified both in Eudravigilance and FAERS. Sixteen DS were not identified in FAERS, 10 DS were found to have a biological probability and six DS were considered false-positive and potentially related to confounding by indication. The three system organ classes with the highest proportion of adverse events were general disorders and administration site conditions (16.12%), nervous system disorders (15.95%), and gastrointestinal disorders (13.59%). CONCLUSIONS Adverse events reports were mostly reported as non-serious. The co-analysis of multiple spontaneous reported databases unveiled undetected disproportionality signals for erenumab in individual databases. Future studies should be conducted to confirm the associations and potential clinical implications.
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Affiliation(s)
- David Liang
- Ferring Pharmaceuticals, Kay Fiskers Pl. 11, 2300 København, Copenhagen, Denmark
| | - Maurizio Sessa
- Pharmacovigilance Research Center, Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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36
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Belskaya G, Kiryanova E, Krasnikov A, Prokopovich M, Sakharova E. Efficiency of erenumab in neurologist’s real practice. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:74-80. [DOI: 10.17116/jnevro202212207174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Liu Y, Yang T, Li J, Xu H, Li S, Xiong L. Breakthroughs on the clinical management of headache and questions that need to be solved. IBRAIN 2021; 7:298-308. [PMID: 37786564 PMCID: PMC10529177 DOI: 10.1002/ibra.12003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 10/04/2023]
Abstract
Headache is a common refractory disorder among adults, especially in females, which can lower the quality of life in patients and increase medical costs. Nearly 90% of people have been affected by headache disorders during their lifetime. The severe situation of headaches has drawn the attention of researchers in recent years. Although the mechanism of headache has not been fully understood by us, there are many effective preventive drugs and treatments available. This review is aimed to sum up the progress in clinical trials of headaches in the past 5 years.
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Affiliation(s)
- Yu‐Cong Liu
- School of AnesthesiologyZunyi Medical UniversityZunyiGuizhouChina
| | - Ting‐Ting Yang
- School of AnesthesiologyZunyi Medical UniversityZunyiGuizhouChina
| | - Jing Li
- School of AnesthesiologyZunyi Medical UniversityZunyiGuizhouChina
| | - Hui‐Chan Xu
- School of AnesthesiologyZunyi Medical UniversityZunyiGuizhouChina
| | - Shun‐Lian Li
- School of AnesthesiologyZunyi Medical UniversityZunyiGuizhouChina
| | - Liu‐Lin Xiong
- Department of AnesthesiologyAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
- Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
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Blumenfeld A, Durham PL, Feoktistov A, Hay DL, Russo AF, Turner I. Hypervigilance, Allostatic Load, and Migraine Prevention: Antibodies to CGRP or Receptor. Neurol Ther 2021; 10:469-497. [PMID: 34076848 PMCID: PMC8571459 DOI: 10.1007/s40120-021-00250-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 04/09/2021] [Indexed: 01/03/2023] Open
Abstract
Migraine involves brain hypersensitivity with episodic dysfunction triggered by behavioral or physiological stressors. During an acute migraine attack the trigeminal nerve is activated (peripheral sensitization). This leads to central sensitization with activation of the central pathways including the trigeminal nucleus caudalis, the trigemino-thalamic tract, and the thalamus. In episodic migraine the sensitization process ends with the individual act, but with chronic migraine central sensitization may continue interictally. Increased allostatic load, the consequence of chronic, repeated exposure to stressors, leads to central sensitization, lowering the threshold for future neuronal activation (hypervigilance). Ostensibly innocuous stressors are then sufficient to trigger an attack. Medications that reduce sensitization may help patients who are hypervigilant and help to balance allostatic load. Acute treatments and drugs for migraine prevention have traditionally been used to reduce attack duration and frequency. However, since many patients do not fully respond, an unmet treatment need remains. Calcitonin gene-related peptide (CGRP) is a vasoactive neuropeptide involved in nociception and in the sensitization of peripheral and central neurons of the trigeminovascular system, which is implicated in migraine pathophysiology. Elevated CGRP levels are associated with dysregulated signaling in the trigeminovascular system, leading to maladaptive responses to behavioral or physiological stressors. CGRP may, therefore, play a key role in the underlying pathophysiology of migraine. Increased understanding of the role of CGRP in migraine led to the development of small-molecule antagonists (gepants) and monoclonal antibodies (mAbs) that target either CGRP or the receptor (CGRP-R) to restore homeostasis, reducing the frequency, duration, and severity of attacks. In clinical trials, US Food and Drug Administration-approved anti-CGRP-R/CGRP mAbs were well tolerated and effective as preventive migraine treatments. Here, we explore the role of CGRP in migraine pathophysiology and the use of gepants or mAbs to suppress CGRP-R signaling via inhibition of the CGRP ligand or receptor.
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Affiliation(s)
- Andrew Blumenfeld
- The Headache Center of Southern California, The Neurology Center, Carlsbad, CA, USA.
| | - Paul L Durham
- Department of Biology, Center for Biomedical and Life Sciences, Missouri State University, Springfield, MO, USA
| | | | - Debbie L Hay
- School of Biological Sciences, The University of Auckland, Auckland, New Zealand
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
| | - Andrew F Russo
- Departments of Molecular Physiology and Biophysics, Neurology, University of Iowa, Iowa City, IA, USA
- Center for the Prevention and Treatment of Visual Loss, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Ira Turner
- Island Neurological Associates, Plainview, NY, USA
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Dodick DW, Tepper SJ, Ailani J, Pannacciulli N, Navetta MS, Loop B, Zhang F, Khodavirdi AC, Mann A, Abdrabboh A, Kalim J. Risk of hypertension in erenumab-treated patients with migraine: Analyses of clinical trial and postmarketing data. Headache 2021; 61:1411-1420. [PMID: 34591982 PMCID: PMC9293040 DOI: 10.1111/head.14208] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022]
Abstract
Objective To assess the risk of hypertension in patients with migraine who received erenumab in clinical trials and in the postmarketing setting. Background Erenumab is a monoclonal antibody for migraine prevention that targets the calcitonin gene‐related peptide (CGRP) receptor. Hypertension is a theoretical risk for inhibitors of the CGRP pathway. Although no evidence of an association between erenumab treatment and hypertension was observed during the clinical development program, adverse events (AEs) of hypertension have been identified in the postmarketing setting. Methods Safety data from four phase 2 and phase 3 clinical trials were used to perform a pooled analysis of hypertension AEs in patients with migraine receiving erenumab. Postmarketing AEs of hypertension were identified from the Amgen Global Safety database from May 17, 2018, through January 31, 2020. Results In the pooled analysis of clinical trials, hypertension AEs (placebo, 9/1043 [0.9%]; erenumab 70 mg, 7/893 [0.8%]; erenumab 140 mg, 1/507 [0.2%]) and percentage of patients initiating medication to treat hypertension (12/1043 [1.2%], 7/893 [0.8%], 1/507 [0.2%], respectively) were similar across treatment groups. A total of 362 AEs of hypertension were identified from the postmarketing setting, 26.2% (95/362) of which were serious, >245,000 patient‐years of exposure. The exposure‐adjusted incidence of hypertension was 0.144 per 100 patient‐years. Conclusions Clinical trials did not demonstrate an increased risk of hypertension with erenumab compared with placebo, and AE rates of hypertension reported with erenumab in the postmarketing setting were generally low. Additional data are needed to fully characterize the extent to which hypertension is a risk associated with erenumab.
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Affiliation(s)
- David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Stewart J Tepper
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Jessica Ailani
- Georgetown Headache Center, Medstar Georgetown University, Washington, DC, USA
| | | | | | - Brett Loop
- Global Patient Safety, Amgen Inc., Cambridge, Massachusetts, USA
| | - Feng Zhang
- Global Medical Amgen Inc., Thousand Oaks, California, USA
| | | | - Allison Mann
- Medical Safety, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Ahmad Abdrabboh
- Medical Safety, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Jawed Kalim
- Medical Safety, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
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Breen ID, Mangold AR, VanderPluym JH. The evolving understanding of risk with calcitonin gene-related peptide monoclonal antibodies based on real-world data: A focus on hypertension and Raynaud phenomenon. Headache 2021; 61:1274-1276. [PMID: 34364313 DOI: 10.1111/head.14198] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/14/2021] [Accepted: 06/29/2021] [Indexed: 01/26/2023]
Affiliation(s)
- Ilana D Breen
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
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Yang Y, Chen M, Wu D, Sun Y, Jiang F, Chen Z, Wang Z. Optimal dose of erenumab for preventive treatment of episodic migraine: a systematic review and meta-analysis. Curr Neuropharmacol 2021; 20:460-470. [PMID: 34429056 PMCID: PMC9413785 DOI: 10.2174/1570159x19666210823104916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/09/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Erenumab is a novel monoclonal calcitonin gene-related peptide receptor antibody that is used for the preventive treatment of migraine. Objectives: This study aimed to evaluate the overall safety, efficacy, and dose-response relationship of erenumab in patients with episodic migraine and patients with prior migraine treatment failures. Methods: We searched randomized clinical trials on PUBMED, EMBASE database, and Cochrane Library database. A pair-wise meta-analysis and Bayesian network analysis were performed. Results: For efficacy outcomes, the network meta-analysis suggests that in comparison to erenumab 70 mg, participants who received erenumab 140 mg reported a significant decrease in monthly acute Migraine-Specific Medication Days (MSMD) and 50% increase in response rate, and erenumab was most likely to be ranked first for Monthly Migraine Days (MMD), MSMD, and 50% response rate. For safety outcomes, the network meta-analysis has found no significant difference between the 70 mg group and the 140 mg group measured by adverse events and serious adverse events. In the 140 mg erenumab group, a significant decreased in MMD and MSMD and 50% and 75% increased in response rate were reported in patients with ≥ 2 treatment failures compared to placebo. For safety outcomes, no significant difference was found between the 140 mg erenumab group and the placebo group. Conclusion: Erenumab was effective in patients with episodic migraine. A total of 140 mg erenumab was associated with better efficacy outcomes without any increased risk for developing adverse events compared to 70 mg erenumab. Furthermore, 140 mg erenumab was effective in patients with prior migraine treatment failures.
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Affiliation(s)
- Yanbo Yang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006. China
| | - Mingjia Chen
- Department of Neurology and National Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040. China
| | - Da Wu
- Department of Neurosurgery, Yixing People's Hospital, Yixing 214200. China
| | - Yue Sun
- School of Biology and Basic Medical Science of Soochow University, Suzhou, Jiangsu Province, 215006. China
| | - Fan Jiang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006. China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006. China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, 215006. China
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Marto JP, Strambo D, Livio F, Michel P. Drugs Associated With Ischemic Stroke: A Review for Clinicians. Stroke 2021; 52:e646-e659. [PMID: 34404236 DOI: 10.1161/strokeaha.120.033272] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Certain drugs may increase the risk of ischemic stroke (IS). Our goal was to review associations between frequently used drugs and IS. We created an initial list of frequently used drugs to search Pubmed/MEDLINE from 1966 to 2020 and reviewed phase III and IV data, case series, and drug authorities' safety warnings to assess a potential association with IS. Drugs were grouped according to the World Health Organization Anatomical Therapeutic Chemical Classification System. Predefined criteria were applied to establish a level of evidence for an association, from A (high level of evidence of association) to E (high level of evidence of absence of association). In addition, we assessed relative risks and reviewed potential mechanisms of IS facilitation. We assessed 81 drugs or drug classes from 11 World Health Organization Anatomical Therapeutic Chemical Groups. We identified a high level of association for erythropoietin, combined contraceptives, oral estrogen replacement therapy, bevacizumab, tamoxifen, and antipsychotics and a moderate level for ponatinib, nilotinib, darunavir, and gonadotropin-releasing hormone agonists. Drug dose and treatment duration may modify the risk. For a substantial number of drugs, we found no association, and for others, there were insufficient data to categorize risk. We identified a high level of association of IS with a limited number of drugs, a potential association with some, and a lack of data for others. The summarized information may help clinicians to estimate the contribution of a drug to an IS, to better assess drug benefit-risk ratios, and to support decisions about using specific drugs.
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Affiliation(s)
- João Pedro Marto
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service (J.P.M., D.S., P.M.), Lausanne University Hospital, Switzerland.,Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (J.P.M.)
| | - Davide Strambo
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service (J.P.M., D.S., P.M.), Lausanne University Hospital, Switzerland
| | - Francoise Livio
- Service of Clinical Pharmacology, Department of Laboratories (F.L.), Lausanne University Hospital, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Stroke Centre, Neurology Service (J.P.M., D.S., P.M.), Lausanne University Hospital, Switzerland
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Mavridis T, Deligianni CI, Karagiorgis G, Daponte A, Breza M, Mitsikostas DD. Monoclonal Antibodies Targeting CGRP: From Clinical Studies to Real-World Evidence-What Do We Know So Far? Pharmaceuticals (Basel) 2021; 14:ph14070700. [PMID: 34358126 PMCID: PMC8308667 DOI: 10.3390/ph14070700] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 02/06/2023] Open
Abstract
Now more than ever is the time of monoclonal antibody use in neurology. In headaches, disease-specific and mechanism-based treatments existed only for symptomatic management of migraines (i.e., triptans), while the standard prophylactic anti-migraine treatments consist of non-specific and repurposed drugs that share limited safety profiles and high risk for interactions with other medications, resulting in rundown adherence rates. Recent advances in headache science have increased our understanding of the role of calcitonin gene relate peptide (CGRP) and pituitary adenylate cyclase-activating polypeptide (PACAP) pathways in cephalic pain neurotransmission and peripheral or central sensitization, leading to the development of monoclonal antibodies (mAbs) or small molecules targeting these neuropeptides or their receptors. Large scale randomized clinical trials confirmed that inhibition of the CGRP system attenuates migraine, while the PACAP mediated nociception is still under scientific and clinical investigation. In this review, we provide the latest clinical evidence for the use of anti-CGRP in migraine prevention with emphasis on efficacy and safety outcomes from Phase III and real-world studies.
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Affiliation(s)
- Theodoros Mavridis
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.D.); (M.B.); (D.D.M.)
- Correspondence: ; Tel.: +30-694-149-2121
| | | | | | - Ariadne Daponte
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.D.); (M.B.); (D.D.M.)
| | - Marianthi Breza
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.D.); (M.B.); (D.D.M.)
| | - Dimos D. Mitsikostas
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.D.); (M.B.); (D.D.M.)
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Deligianni CI, Mitsikostas DD, Ashina M. Safety and tolerability evaluation of erenumab for the preventive treatment of migraine. Expert Opin Drug Saf 2021; 20:867-876. [PMID: 34037500 DOI: 10.1080/14740338.2021.1933941] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Erenumab, a monoclonal antibody targeting the receptor of calcitonin gene related peptide (CGRP), is the first disease-specific and mechanism-based treatment approved for the prevention of migraine. Although the safety and tolerability data from randomized trials are clear, the physiological effects of CGRP rise reasonable concerns. We aimed to evaluate the current evidence for safety and tolerability related to erenumab use in migraine. Areas covered: This review outlines the severe adverse events (AEs), common AEs, AEs leading to treatment discontinuation and AEs of special interest, reported in all phase 2, phase 3, open label, and observational studies with erenumab in migraine. Individual safety reports were also included in the systematic review of evidence. Expert opinion: No safety and tolerability flags were detected in this review. The most common AE are local skin reactions and constipation. No severe AEs, or frequent AEs leading to treatment discontinuation were detected. Treatment is well tolerated. The only AE of interest that may play a role in decision making and treatment monitoring is constipation. These findings are in line with previous safety reports, further highlighting the substantial tolerability and safety profile of the modern anti-CGRP monoclonal antibodies for the prevention of migraine.
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Affiliation(s)
- Christina I Deligianni
- Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Dimos D Mitsikostas
- 1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Messoud Ashina
- Danish Headache Center, Rigshospitalet Glostrup, University of Copenhagen, Copenhagen, Denmark
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Caponnetto V, Deodato M, Robotti M, Koutsokera M, Pozzilli V, Galati C, Nocera G, De Matteis E, De Vanna G, Fellini E, Halili G, Martinelli D, Nalli G, Serratore S, Tramacere I, Martelletti P, Raggi A. Comorbidities of primary headache disorders: a literature review with meta-analysis. J Headache Pain 2021; 22:71. [PMID: 34261435 PMCID: PMC8278743 DOI: 10.1186/s10194-021-01281-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background Primary headache disorders are common and burdensome conditions. They are associated to several comorbidities, such as cardiovascular or psychiatric ones, which, in turn, contribute to the global burden of headache. The aim of this study is to provide a comprehensive description of the pooled prevalence of comorbidities of primary headache disorders using a meta-analytical approach based on studies published between 2000 and 2020. Methods Scopus was searched for primary research (clinical and population studies) in which medical comorbidities were described in adults with primary headache disorders. Comorbidities were extracted using a taxonomy derived from the Global Burden of Disease (GBD) study. We compared prevalence of comorbidities among headache sufferers against general population using GBD-2019 estimates, and compared comorbidities’ proportions in clinical vs. population studies, and by age and gender. Results A total of 139 studies reporting information on 4.19 million subjects with primary headaches were included: in total 2.75 million comorbidities were reported (median per subject 0.64, interquartile range 0.32–1.07). The most frequently addressed comorbidities were: depressive disorders, addressed in 51 studies (pooled proportion 23 %, 95 % CI 20–26 %); hypertension, addressed in 48 studies (pooled proportion 24 %, 95 % CI 22–26 %); anxiety disorders addressed in 40 studies (pooled proportion 25 %, 95 % CI 22–28 %). For conditions such as anxiety, depression and back pain, prevalence among headache sufferers was higher than in GBD-2109 estimates. Associations with average age and female prevalence within studies showed that hypertension was more frequent in studies with higher age and less females, whereas fibromyalgia, restless leg syndrome, and depressive disorders were more frequent in studies with younger age and more female. Conclusions Some of the most relevant comorbidities of primary headache disorders – back pain, anxiety and depression, diabetes, ischemic heart disease and stroke – are among the most burdensome conditions, together with headache themselves, according to the GBD study. A joint treatment of headaches and of these comorbidities may positively impact on headache sufferers’ health status and contribute to reduce the impact of a group of highly burdensome diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-021-01281-z.
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Affiliation(s)
| | - Manuela Deodato
- Department of Life Sciences, University of Trieste, Trieste, Italy. .,Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Micaela Robotti
- Centro di Diagnosi e Cura delle Cefalee, Palazzo della Salute, Gruppo San Donato, Milano, Italy.,PainClinicMilano, Centro Medico Visconti di Modrone, Milano, Italy
| | | | - Valeria Pozzilli
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Cristina Galati
- UO Neuropsichiatria Infantile, Policlinico Universitario Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Giovanna Nocera
- UO Neuropsichiatria Infantile, Policlinico Universitario Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Eleonora De Matteis
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Gioacchino De Vanna
- Clinica Neurologica, Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
| | - Emanuela Fellini
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Gleni Halili
- Department of Neurology, University Hospital Center 'Mother Teresa', Tirana, Albania
| | - Daniele Martinelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Gabriele Nalli
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Serena Serratore
- Internal Medicine Unit, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Irene Tramacere
- Dipartimento di Ricerca e Sviluppo Clinico, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Roma, Italy.,Regional Referral Headache Center, Sant'Andrea University Hospital, Roma, Italy
| | - Alberto Raggi
- UOC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Ailani J, Burch RC, Robbins MS. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache 2021; 61:1021-1039. [PMID: 34160823 DOI: 10.1111/head.14153] [Citation(s) in RCA: 288] [Impact Index Per Article: 96.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To incorporate recent research findings, expert consensus, and patient perspectives into updated guidance on the use of new acute and preventive treatments for migraine in adults. BACKGROUND The American Headache Society previously published a Consensus Statement on the use of newly introduced treatments for adults with migraine. This update, which is based on the expanded evidence base and emerging expert consensus concerning postapproval usage, provides practical recommendations in the absence of a formal guideline. METHODS This update involved four steps: (1) review of data about the efficacy, safety, and clinical use of migraine treatments introduced since the previous Statement was published; (2) incorporation of these data into a proposed update; (3) review and commentary by the Board of Directors of the American Headache Society and patients and advocates associated with the American Migraine Foundation; (4) consideration of these collective insights and integration into an updated Consensus Statement. RESULTS Since the last Consensus Statement, no evidence has emerged to alter the established principles of either acute or preventive treatment. Newly introduced acute treatments include two small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists (ubrogepant, rimegepant); a serotonin (5-HT1F ) agonist (lasmiditan); a nonsteroidal anti-inflammatory drug (celecoxib oral solution); and a neuromodulatory device (remote electrical neuromodulation). New preventive treatments include an intravenous anti-CGRP ligand monoclonal antibody (eptinezumab). Several modalities, including neuromodulation (electrical trigeminal nerve stimulation, noninvasive vagus nerve stimulation, single-pulse transcranial magnetic stimulation) and biobehavioral therapy (cognitive behavioral therapy, biofeedback, relaxation therapies, mindfulness-based therapies, acceptance and commitment therapy) may be appropriate for either acute and/or preventive treatment; a neuromodulation device may be appropriate for acute migraine treatment only (remote electrical neuromodulation). CONCLUSIONS The integration of new treatments into clinical practice should be informed by the potential for benefit relative to established therapies, as well as by the characteristics and preferences of individual patients.
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Affiliation(s)
- Jessica Ailani
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Rebecca C Burch
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Les antagonistes du CGRP, de nouveaux antimigraineux. ACTUALITES PHARMACEUTIQUES 2021. [DOI: 10.1016/j.actpha.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nowaczewska M, Straburzyński M, Meder G, Kaźmierczak W. Changes in Cerebral Blood Flow after Erenumab Treatment in Good and Non-Responders-A Pilot Study of Migraine Patients. J Clin Med 2021; 10:jcm10112523. [PMID: 34200202 PMCID: PMC8201252 DOI: 10.3390/jcm10112523] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/06/2021] [Accepted: 06/04/2021] [Indexed: 12/17/2022] Open
Abstract
Erenumab showed efficacy in migraine prevention, however we cannot identify which patients to treat by predicting efficacy response. The aim of this study was to compare changes in cerebral blood flow (CBF) reflected by transcranial Doppler (TCD) in erenumab good responders (GR) and non-responders, in order to identify a parameter that could predict the treatment response. In this study, migraineurs treated with erenumab underwent clinical and TCD evaluations before and 6 weeks after the treatment, including data on migraine type, monthly migraine days (MMD), medication overuse headache (MOH) presence, mean blood flow velocity (Vm) and pulsatility index (PI) in cerebral arteries (CA). GR were defined as reporting ≥50% reduction in MMD. Thirty women were enrolled, of mean age 40.53 years, 20 with chronic migraine, 14 with MOH, and 19 were GR. Baseline Vm values in right CA and basilar artery (BA) were significantly lower in GR as compared with non-responders. Vm values in all arteries significantly increased after the treatment as compared with corresponding baseline values, but only in GR. A significant negative correlation was observed between baseline Vm in right CA and treatment effectiveness. Baseline Vm in right CA and basilar artery is reduced in erenumab GR as compared with non-responders. This asymmetry normalizes after the treatment with significant Vm increase in CA which may reflect CBF increase in GR only. Lower baseline Vm in right CA may predict erenumab efficacy; however, these results should be replicated in a larger cohort.
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Affiliation(s)
- Magdalena Nowaczewska
- Department of Otolaryngology, Head and Neck Surgery, and Laryngological Oncology, Ludwik, Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Skłodowskiej-Curie 9, 85-090 Bydgoszcz, Poland
- Athleticomed—Pain & Sport Injury Centre with Headache & Migraine Treatment Divsion, Fordonska 144, 85-357 Bydgoszcz, Poland
- Correspondence:
| | - Marcin Straburzyński
- Headache Clinic—Terapia Neurologiczna ‘Samodzielni’, Mochnackiego 10, 02-042 Warsaw, Poland;
| | - Grzegorz Meder
- Department of Interventional Radiology, Jan Biziel University Hospital No. 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland;
| | - Wojciech Kaźmierczak
- Department of Sensory Organs Examination, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Skłodowskiej-Curie 9, 85-090 Bydgoszcz, Poland;
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Jakate A, Blumenfeld AM, Boinpally R, Butler M, Borbridge L, Contreras-De Lama J, McGeeney D, Periclou A, Lipton RB. Pharmacokinetics and safety of ubrogepant when coadministered with calcitonin gene-related peptide-targeted monoclonal antibody migraine preventives in participants with migraine: A randomized phase 1b drug-drug interaction study. Headache 2021; 61:642-652. [PMID: 33818780 PMCID: PMC8252052 DOI: 10.1111/head.14095] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/11/2021] [Accepted: 01/24/2021] [Indexed: 01/03/2023]
Abstract
Objective To evaluate the impact of two calcitonin gene–related peptide (CGRP)‐targeted monoclonal antibodies (mAbs), erenumab and galcanezumab, on the pharmacokinetic (PK) profile, safety, and tolerability of ubrogepant. Background People taking CGRP‐targeted mAbs for migraine prevention sometimes take ubrogepant, an oral small‐molecule CGRP receptor antagonist, for acute treatment of breakthrough migraine attacks. Design In this two‐arm, multicenter, open‐label, phase 1b trial, adults with migraine were randomized to arm 1 (ubrogepant ± erenumab) or arm 2 (ubrogepant ± galcanezumab). The PK profile of ubrogepant was characterized for administration before and 4 days after CGRP‐targeted mAb injection. Participants received single‐dose ubrogepant 100 mg on day 1, subcutaneous erenumab 140 mg (arm 1) or galcanezumab 240 mg (arm 2) on day 8, and ubrogepant 100 mg once daily on days 12–15. In each study arm, serial blood samples were drawn on days 1 and 12 for measurement of plasma ubrogepant concentrations. The primary outcomes were area under the plasma ubrogepant concentration–time curve (AUC) from time 0 to t post‐dose (AUC0–t) and from time 0 to infinity (AUC0–inf), and maximum plasma concentration (Cmax) of ubrogepant when ubrogepant was administered before or after a single dose of erenumab or galcanezumab. Vital signs and laboratory parameters were monitored. Results Forty participants enrolled (20 per arm; mean [standard deviation] ages, 32.2 [8.9] and 38.4 [8.8] years; 50% [10/20] and 60% [12/20] female in arms 1 and 2, respectively). There were no significant differences in ubrogepant Cmax after versus before erenumab administration (geometric least‐squares mean [LSM] ratio, 1.04 [90% CI, 0.93–1.16]), and no significant differences in AUC0–t (1.06 [0.96–1.16]) or AUC0–inf (1.05 [0.96–1.15]). Similarly, ubrogepant Cmax (1.00 [90% CI, 0.82–1.20]), AUC0–t (1.05 [0.90–1.23]), and AUC0–inf (1.05 [0.90–1.22]) geometric LSM ratios were statistically equivalent after galcanezumab versus ubrogepant alone. Treatment‐emergent adverse events (TEAEs) were similar to those reported with each treatment alone. No serious TEAEs, TEAEs leading to discontinuation, or clinically relevant changes in laboratory parameters or vital signs were reported. Conclusions The PK profile of ubrogepant was not significantly changed and no safety concerns were identified when ubrogepant was coadministered with erenumab or galcanezumab.
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Affiliation(s)
| | | | | | | | - Lisa Borbridge
- Bioanalysis, Non-clinical and Translational Sciences, AbbVie, Irvine, CA, USA
| | | | | | | | - Richard B Lipton
- The Saul R. Korey Department of Neurology, Department of Psychiatry and Behaviorial Sciences, Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Smith TR, Spierings ELH, Cady R, Hirman J, Schaeffler B, Shen V, Sperling B, Brevig T, Josiassen MK, Brunner E, Honeywell L, Mehta L. Safety and tolerability of eptinezumab in patients with migraine: a pooled analysis of 5 clinical trials. J Headache Pain 2021; 22:16. [PMID: 33781209 PMCID: PMC8008612 DOI: 10.1186/s10194-021-01227-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/12/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The humanized anti-CGRP monoclonal antibody eptinezumab has been evaluated in five large-scale clinical trials conducted in patients with migraine. This integrated analysis was conducted to evaluate the comprehensive safety and tolerability of eptinezumab in patients with migraine across these studies. METHODS Data were pooled from four randomized, double-blind, placebo-controlled studies and the first year of one open-label study. RESULTS The pooled population comprised 2867 adults with migraine: eptinezumab, n = 2076 (4797 infusions); placebo, n = 791 (1675 infusions). A total of 1137/2076 (54.8%) patients who received eptinezumab and 414/791 (52.3%) patients who received placebo experienced ≥1 treatment-emergent adverse event (TEAE); rates were similar across eptinezumab dose groups (10-1000 mg). For most patients with TEAEs, the events were mild or moderate in severity and considered unrelated to study drug by the investigators. Thirty infusion-site AEs occurred in 27/2076 (1.3%) patients who received eptinezumab and 7 in 7/791 (0.9%) patients who received placebo. Infusion-site AEs led to infusion interruption in 19/2076 (0.9%) and 5/791 (0.6%) patients in the eptinezumab and placebo groups, respectively. Nasopharyngitis occurred in ≥2% of patients in the eptinezumab 300-mg group and with an incidence of at least 2 percentage points greater than in the placebo group; however, in most patients (eptinezumab, 139/140; placebo 40/41), its occurrence was considered not related to study treatment. Adverse events coded to hypersensitivity occurred for 23/2076 (1.1%) patients treated with eptinezumab and no patients in the placebo group. If additional TEAE terms that could indicate hypersensitivity are considered (e.g., urticaria, flushing/hot flush, rash, and pruritus), hypersensitivity reactions in the two pivotal placebo-controlled phase 3 studies occurred in ≥2% of patients in the eptinezumab 100-mg and 300-mg groups, and the incidence was at least 2 percentage points greater in either of these groups than in the placebo group. Most hypersensitivity reactions were not serious and resolved with standard medical treatment or observation without treatment, usually within 1 day. CONCLUSIONS In adults with migraine, the intravenous administration of eptinezumab every 12 weeks demonstrated a favorable safety and tolerability profile. TRIAL REGISTRATION ClinicalTrials.gov (Identifiers: NCT01772524 , NCT02275117 , NCT02559895 , NCT02974153 , NCT02985398 ).
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Affiliation(s)
- Timothy R. Smith
- StudyMetrix Research, LLC, 3862 Mexico Road, St. Peters, MO 63303 USA
| | | | - Roger Cady
- Lundbeck La Jolla Research Center, San Diego, CA USA
| | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc., Woodinville, WA USA
| | | | | | - Bjørn Sperling
- grid.424580.f0000 0004 0476 7612H. Lundbeck A/S, Copenhagen, Denmark
| | - Thomas Brevig
- grid.424580.f0000 0004 0476 7612H. Lundbeck A/S, Copenhagen, Denmark
| | | | | | - Loan Honeywell
- grid.424580.f0000 0004 0476 7612H. Lundbeck A/S, Copenhagen, Denmark
| | - Lahar Mehta
- Lundbeck Seattle BioPharmaceuticals, Inc., Seattle, WA USA
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