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Wu SZ, Chen L. Efficacy and safety of ubrogepant for migraine: a meta-analysis of randomized controlled studies. Int J Neurosci 2024; 134:124-130. [PMID: 35999672 DOI: 10.1080/00207454.2022.2090351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 06/10/2022] [Indexed: 10/31/2022]
Abstract
Introduction: The efficacy of ubrogepant 50 mg versus 100 mg daily for migraine remained controversial. We conducted a systematic review and meta-analysis to compare the efficacy and safety of ubrogepant 50 mg versus 100 mg daily on treatment in migraine patients.Methods: We have searched PubMed, EMbase, Web of science, EBSCO, Cochrane library databases and SCOPUS through 21 March 2022 for randomized controlled trials (RCTs) assessing the effect of ubrogepant 50 mg versus 100 mg on treatment efficacy in migraine patients. This meta-analysis was performed using the random-effect model.Results: Three RCTs were included in the meta-analysis. Overall, compared with ubrogepant 100 mg in migraine patients, ubrogepant 50 mg obtained comparable pain freedom at 2 h (OR = 0.86; 95% CI = 0.64-1.15; p = 0.310), sustained pain freedom 2-24 h (OR = 0.76; 95% CI = 0.54-1.07; p = 0.110), photophobia absence at 2 h (OR = 0.80; 95% CI = 0.63-1.02; p = 0.070), phonophobia absence at 2 h (OR = 1.07; 95% CI = 0.82-1.40; p = 0.620) and nausea absence at 2 h (OR = 1.02; 95% CI = 0.79-1.32; p = 0.880). In terms of safety, adverse events were found to be increased in ubrogepant 100 mg as compared to ubrogepant 50 mg (OR = 0.81; 95% CI = 0.67-0.99; p = 0.040), and there was no statistical difference of serious adverse events between two groups (OR = 0.87; 95% CI = 0.40-1.91; p = 0.720).Conclusions: Ubrogepant 50 mg and 100 mg may be equally effective to alleviate migraine, but ubrogepant 100 mg led to increase incidence of adverse events.
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Affiliation(s)
- Shu-Zhi Wu
- Neurology Department, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Third Affiliated Hospital of Shanghai University, Wenzhou People's Hospital, Wenzhou, Zhejiang, China
| | - Linglong Chen
- Emergency Medicine Department, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Third Affiliated Hospital of Shanghai University, Wenzhou People's Hospital, Wenzhou, Zhejiang, China
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Cao B, Gu S, Shen Z, Zhang Y, Shen Y, Chen H. Evaluating Ubrogepant-related adverse events using the FDA adverse event reporting system. Expert Opin Drug Saf 2024; 23:297-303. [PMID: 37608560 DOI: 10.1080/14740338.2023.2251390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Migraine has a high prevalence in the population and accounts for 12% of primary headaches. Ubrogepant is used for the treatment of acute migraine, and although some clinical trials have demonstrated the safety of Ubrogepant, its long-term safety in a large sample of the population remains to be investigated. METHODS We collected data from the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. We used reporting odds ratio (ROR), the proportional reporting ratio (PRR), the information component (IC) and the empirical Bayes geometric mean (EBGM) to evaluate Ubrogepant-induced adverse events (AEs). RESULTS We screened out 2,067 reports of Ubrogepant as primary suspected (PS) and 6,190 reports of Ubrogepant-induced AEs as PS. Our results showed that Ubrogepant-induced AEs targeted 4 system organ classes (SOCs), detected 32 Preferred terms (PTs) signals in 9 SOCs, including common Ubrogepant label consistent with Migraine, Nausea, Somnolence, Paraesthesia oral and Dizziness, It also includes the AEs of Hemiparesis, Mental impairment, Dysstasia, Tinnitus, Chest pain, Cold sweat, Neck pain, etc. that have not been demonstrated in previous studies. CONCLUSIONS Our study identified new AEs that have not been reported, which provides a new guidance to deepen the comprehension of the safety of Ubrogepant.
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Affiliation(s)
- Bing Cao
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Shanshan Gu
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Zhisen Shen
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Yuna Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Lihuili Hospital affiliated to Ningbo University, Ningbo, Zhejiang, China
| | - Yiming Shen
- Department of Otology and Skull Base Surgery, National Health Commission Key Laboratory of Hearing Medicine (Fudan University), Shanghai City, P. R. China
| | - Hang Chen
- Department of Thoracic surgery, The Affiliated Lihuili Hospital, Ningbo University, Ningbo, Zhejiang Province, P. R. China
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Moore E, Bell IM, Fraley ME, Burgey CS, White RB, Li CC, Regan CP, Danziger A, McGaraughty SP, Naseri Kouzehgarani G, Salvatore C, Banerjee P. Pharmacologic characterization of atogepant: A potent and selective calcitonin gene-related peptide receptor antagonist. Cephalalgia 2024; 44:3331024231226186. [PMID: 38215228 DOI: 10.1177/03331024231226186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
BACKGROUND The trigeminal sensory neuropeptide calcitonin gene-related peptide (CGRP) is identified as an essential element in migraine pathogenesis. METHODS In vitro and in vivo studies evaluated pharmacologic properties of the CGRP receptor antagonist atogepant. Radioligand binding using 125I-CGRP and cyclic adenosine monophosphate (cAMP) accumulation assays were conducted in human embryonic kidney 293 cells to assess affinity, functional potency and selectivity. Atogepant in vivo potency was assessed in the rat nitroglycerine model of facial allodynia and primate capsaicin-induced dermal vasodilation (CIDV) pharmacodynamic model. Cerebrospinal fluid/brain penetration and behavioral effects of chronic dosing and upon withdrawal were evaluated in rats. RESULTS Atogepant exhibited high human CGRP receptor-binding affinity and potently inhibited human α-CGRP-stimulated cAMP responses. Atogepant exhibited significant affinity for the amylin1 receptor but lacked appreciable affinities for adrenomedullin, calcitonin and other known neurotransmitter receptor targets. Atogepant dose-dependently inhibited facial allodynia in the rat nitroglycerine model and produced significant CIDV inhibition in primates. Brain penetration and behavioral/physical signs during chronic dosing and abrupt withdrawal were minimal in rats. CONCLUSIONS Atogepant is a competitive antagonist with high affinity, potency and selectivity for the human CGRP receptor. Atogepant demonstrated a potent, concentration-dependent exposure/efficacy relationship between atogepant plasma concentrations and inhibition of CGRP-dependent effects.
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Cho S, Kim BK. Update of Gepants in the Treatment of Chronic Migraine. Curr Pain Headache Rep 2023; 27:561-569. [PMID: 37656319 DOI: 10.1007/s11916-023-01167-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Despite the unmet therapeutic needs of patients with chronic migraine (CM) and/or medication overuse, available treatment options are limited. Recently, four calcitonin gene-related peptide receptor antagonists, known as gepants, have been approved for the treatment of migraine. This review focuses on the preventive treatment of CM with gepants and highlights recent findings. RECENT FINDINGS Two randomized controlled trials (RCTs) have shown promising results for rimegepant and atogepant as preventive treatments for CM. In an RCT targeting patients with CM, atogepant demonstrated a significant reduction in the mean monthly migraine days, irrespective of acute medication overuse. Moreover, the patients reported no significant safety concerns and exhibited good tolerance to treatment. These findings highlight the potential of gepants as a new and effective therapeutic option for patients with CM and/or medication overuse. Gepant use will help improve the management and quality of life of individuals with this debilitating condition.
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Affiliation(s)
- Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea.
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Dong G, Kjærgaard NA, Shakibfar S, Sessa M. Ubrogepant and rimegepant: systematic review, meta-analysis, and meta-regression of clinical studies. Expert Opin Drug Saf 2023; 22:59-70. [PMID: 36737057 DOI: 10.1080/14740338.2023.2177270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study aimed at providing pooled estimates of the incidence of adverse drug reactions (ADRs) of ubrogepant and rimegepant and to use meta-regression to identify correlations between the occurrence of selected ADRs, socio-demographic, and clinical characteristics from data published in clinical studies. METHODS Ovid MEDLINE (up to 03/02/2022) was searched along with the references listed in the reviews identified with the research query. Random intercept and slope logistic regression models were used to estimate the logit transformation of the pooled incidence. To examine how selected clinical and socio-demographic characteristics correlated with the pooled incidence rates, we performed random-effects meta-regression. RESULTS Significant heterogeneity of incidence estimates was observed in clinical studies along with correlations between ADRs and the sociodemographic and clinical characteristics of patients exposed to ubrogepant. In particular, we observed a correlation between ubrogepant dosage and muscle strain and between Body Mass Index (BMI) and liver function values. For rimegepant, significant correlations were observed between age and infections and having aura symptoms at baseline and nausea/dizziness/diarrhea/muscle strain. CONCLUSION This study provided pooled incidence estimates of ubrogepant and rimegepant's ADRs and highlighted new safety aspects of the pharmacological treatment with ubrogepants and rimigepants from correlations obtained from the meta-regression.
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Affiliation(s)
- Guojun Dong
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Naoko Adachi Kjærgaard
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Saeed Shakibfar
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW The aim of this review is to aid in choosing safe options when assessing potential risks of acute migraine treatments based on known mechanisms of action and anticipated safety concerns. RECENT FINDINGS Part 1 highlights safety issues associated with commonly used medications to treat acute migraine attacks. Strategies to mitigate cardiovascular and gastrointestinal risks of nonsteroidal anti-inflammatory drugs, evaluation of cardiovascular risks of triptan and ergot alkaloids, and precautions with use of antiemetics and the novel drugs gepants and ditans are discussed to help practitioners in clinical decision-making. When available, we included recommendations from professional societies and data from pharmacovigilance systems. While guidelines on efficacy are available, one must also consider the possible risks and adverse effects of a drug when creating treatment plans.
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Affiliation(s)
- Yulia Y Orlova
- University of Florida, 1149 Newell Dr., L3-100, Gainesville, 32611, USA.
| | - Sandhya Mehla
- Ayer Neurosciences Institute, Hartford Health Care Medical Group, University of Connecticut School of Medicine, Norwich, CT, USA
| | - Abigail L Chua
- Geisinger Health Systems, 1000 E. Mountain Boulevard, Wilkes-Barre, PA, 18702, USA
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Watkins PB. Quantitative Systems Toxicology and Drug Development: The DILIsym Experience. Methods Mol Biol 2022; 2486:181-96. [PMID: 35437723 DOI: 10.1007/978-1-0716-2265-0_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
DILIsym® is a Quantitative Systems Toxicology (QST) model that has been developed over the last decade by a public-private partnership to predict the liver safety liability in new drug candidates. DILIsym integrates the quantitative abilities of parent and relevant metabolites to cause oxidative stress, mitochondrial dysfunction, and alter bile acid homeostasis. Like the prediction of drug-drug interactions, the data entered into DILIsym are assessed in the laboratory in human experimental systems, and combined with estimates of liver exposure to predict the outcome. DILIsym is now frequently used in decision-making within the pharmaceutical industry and its modeling results are increasingly included in regulatory communications and NDA submissions. DILIsym can be used to identify dominant mechanisms underlying liver toxicity and this information is increasingly being used to identify patient-specific risk factors, including certain disease states. DILIsym is also increasingly used to optimize the interpretation of liver injury biomarkers. DILIsym provides an example of how QST modeling can help speed the delivery of safer new drugs to the patients who need them.
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Moreno-Ajona D, Villar-Martínez MD, Goadsby PJ. New Generation Gepants: Migraine Acute and Preventive Medications. J Clin Med 2022; 11:jcm11061656. [PMID: 35329982 PMCID: PMC8953732 DOI: 10.3390/jcm11061656] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Migraine is a debilitating disease whose clinical and social impact is out of debate. Tolerability issues, interactions, contraindications, and inefficacy of the available medications make new options necessary. The calcitonin-gene-related peptide (CGRP) pathway has shown its importance in migraine pathophysiology and specific medications targeting this have become available. The first-generation CGRP receptor antagonists or gepants, have undergone clinical trials but their development was stopped because of hepatotoxicity. The new generation of gepants, however, are efficacious, safe, and well tolerated as per recent clinical trials. This led to the FDA-approval of rimegepant, ubrogepant, and atogepant. The clinical trials of the available gepants and some of the newer CGRP-antagonists are reviewed in this article.
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Affiliation(s)
- David Moreno-Ajona
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 9PJ, UK; (D.M.-A.); (M.D.V.-M.)
- NIHR-Wellcome Trust King’s Clinical Research Facility/SLaM Biomedical Research Centre, King’s College Hospital, London SE5 9RS, UK
| | - María Dolores Villar-Martínez
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 9PJ, UK; (D.M.-A.); (M.D.V.-M.)
- NIHR-Wellcome Trust King’s Clinical Research Facility/SLaM Biomedical Research Centre, King’s College Hospital, London SE5 9RS, UK
| | - Peter J. Goadsby
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 9PJ, UK; (D.M.-A.); (M.D.V.-M.)
- NIHR-Wellcome Trust King’s Clinical Research Facility/SLaM Biomedical Research Centre, King’s College Hospital, London SE5 9RS, UK
- Department of Neurology, University of California, Los Angeles, CA 90095, USA
- Correspondence:
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Lo Castro F, Guerzoni S, Pellesi L. Safety and Risk of Medication Overuse Headache in Lasmiditan and Second-Generation Gepants: A Rapid Review. Drug Healthc Patient Saf 2021; 13:233-240. [PMID: 34849034 PMCID: PMC8627250 DOI: 10.2147/dhps.s304373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/15/2021] [Indexed: 11/23/2022] Open
Abstract
The treatment of migraine is often complicated by insufficient headache relief, a miscellany of side effects and the risk of developing Medication Overuse Headache (MOH). Novel acute therapies have been recently developed and are now in the early post-marketing phase. Lasmiditan is a highly selective serotonin receptor agonist that binds to the 5-HT1F receptor, while ubrogepant and rimegepant antagonize the calcitonin gene-related peptide receptor. All three medications are now prescribed in a real-world setting, and an adequate level of knowledge is the starting point for rational use. In this rapid systematic review, we have established what is known about lasmiditan, ubrogepant and rimegepant, highlighting the most relevant safety aspects available from published studies and speculating about their risk of MOH.
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Affiliation(s)
- Flavia Lo Castro
- Medical Toxicology, Headache and Drug Abuse Research Center, Department of Specialized Medicine, AOU Policlinico di Modena, Modena, Italy
| | - Simona Guerzoni
- Medical Toxicology, Headache and Drug Abuse Research Center, Department of Specialized Medicine, AOU Policlinico di Modena, Modena, Italy
| | - Lanfranco Pellesi
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Correspondence: Lanfranco Pellesi Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, DenmarkTel +45 53 80 30 56 Email
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Yang CP, Huang KT, Chang CM, Yang CC, Wang SJ. Acute Treatment of Migraine: What has Changed in Pharmacotherapies? Neurol India 2021; 69:S25-S42. [PMID: 34003146 DOI: 10.4103/0028-3886.315995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Migraine is the most prevalent neurological disorder and the leading cause of disability in individuals under 50 years of age. Two types of migraine therapies have been defined: acute therapy (abortive or symptomatic treatment), the purpose of which is to interrupt migraine attacks, and preventive treatment (prophylactic treatment), the purpose of which is to reduce the frequency and severity of migraine attacks. Objective This paper reviews research advances in new agents for acute therapy of migraine. Material and Methods This review provides an overview of emerging new drugs for acute treatment of migraine based on clinical evidence and summarizes the milestones of different stages of clinical development. Results Two new formulations of sumatriptan, DFN-11 (3 mg doses of subcutaneous sumatriptan) and DFN-02 (a nasal spray of sumatriptan 10 mg and a permeation-enhancing excipient), have been developed, and both of them showed a fast-onset action with efficacy for acute treatment of migraine with fewer adverse events. New drug discovery programs shifted the focus to the development of ditans, a group of antimigraine drugs targeting 5-HT1F receptors. Only lasmiditan has progressed to phase III clinical trials and was finally approved by the Food and Drug Administration (FDA) for acute migraine treatment. The other target for acute therapy is CGRP receptor antagonists, namely, gepants. Ubrogepant and rimegepant demonstrated statistically significant efficacy, and both were recently approved by the FDA. These 5-HT1F receptor agonists and CGRP receptor antagonists did not cause vasoconstriction, offering advantages over the current mainstay of specific acute migraine treatment. Conclusions Overall, these new agents have expanded the available acute therapies for migraine treatment and will likely change the strategy with which we treat patients with migraine in the future.
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Affiliation(s)
- Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital; Department of Nutrition, Huang-Kuang University, Taichung, Taiwan
| | - Kuo-Ting Huang
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ching-Mao Chang
- Center for Traditional Medicine, Neurological Institute, Taipei Veterans General Hospital; Faculty of Medicine, National Yang Ming Chiao Tung University; Institute of Traditional Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Chia Yang
- Department of Healthcare Administration, Asia University, Taichung, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital; National Yang Ming Chiao Tung University, School of Medicine; Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Ailani J, Lipton RB, Hutchinson S, Knievel K, Lu K, Butler M, Yu SY, Finnegan M, Severt L, Trugman JM. Long-Term Safety Evaluation of Ubrogepant for the Acute Treatment of Migraine: Phase 3, Randomized, 52-Week Extension Trial. Headache 2021; 60:141-152. [PMID: 31913519 PMCID: PMC7004213 DOI: 10.1111/head.13682] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2019] [Indexed: 12/17/2022]
Abstract
Objective To evaluate the long‐term safety and tolerability of ubrogepant for the acute treatment of migraine. Background Ubrogepant is an oral, calcitonin gene–related receptor antagonist in development for the acute treatment of migraine. The efficacy of ubrogepant was demonstrated in 2 phase 3 trials in which a significant improvement was observed in migraine headache pain, migraine‐associated symptoms, and ability to function. Methods This was a phase 3, multicenter, randomized, open‐label, 52‐week extension trial. Adults with migraine with or without aura entered the trial after completing one of 2 phase 3 lead‐in trials and were re‐randomized 1:1:1 to usual care, ubrogepant 50 mg, or ubrogepant 100 mg. Randomization to ubrogepant dose was blinded. Those randomized to usual care continued to treat migraine attacks with their own medication. The usual care arm was included in this trial to capture background rates of hepatic laboratory parameters and contextualize hepatic safety assessments. Safety and tolerability were the primary outcome measures. The safety population for the ubrogepant arms included all randomized participants who received at least 1 dose of treatment. All cases of alanine aminotransferase (ALT)/aspartate aminotransferase (AST) elevations of ≥3 times the upper limit of normal were adjudicated by an independent panel of liver experts who were blinded to dose. Results The safety population included 1230 participants (404 in the ubrogepant 50‐mg group, 409 in the ubrogepant 100‐mg group, and 417 in the usual care group). Participants were on average 42 years of age, 90% (1106/1230) female and 85% (1043/1230) white, with an average BMI of 30 kg/m2. Throughout the trial, 21,454 migraine attacks were treated with 31,968 doses of ubrogepant. Treatment‐emergent adverse events (TEAEs) were reported by 268/404 (66%) participants receiving ubrogepant 50 mg and 297/409 (73%) receiving ubrogepant 100 mg. The most commonly reported TEAE was upper respiratory tract infection (<12%); findings were similar across dose groups. Treatment‐related TEAEs were reported by 42/404 (10%) participants in the ubrogepant 50‐mg group and 43/409 (11%) in the ubrogepant 100‐mg group. Serious adverse events (SAEs) were reported by 9/404 (2%) participants in the ubrogepant 50‐mg group and 12/409 (3%) participants in the ubrogepant 100‐mg group. Twenty cases of ALT/AST levels of ≥3 times the upper limit of normal were reported and reviewed by an independent clinical adjudication committee of liver experts. There were no cases of Hy’s Law. Conclusions Long‐term intermittent use of ubrogepant 50 and 100 mg given as 1 or 2 doses per attack for the acute treatment of migraine was safe and well tolerated, as indicated by a low incidence of treatment‐related TEAEs and SAEs and discontinuations due to adverse events in this 1‐year trial.
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Affiliation(s)
- Jessica Ailani
- Medstar Georgetown University Hospital, Washington, DC, USA
| | - Richard B Lipton
- Albert Einstein College of Medicine and Montefiore Headache Center, Bronx, NY, USA
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Abstract
OBJECTIVES To discuss headache secondary to cerebrovascular disease. BACKGROUND Headache is an important symptom in cerebrovascular diseases. In some conditions, headache is the leading symptom. Migraine is associated with an increased risk of stroke. METHODS The authors undertook a literature search for the terms "headache" and "cerebrovascular diseases". RESULTS We report studies on headache in subarachnoidal hemorrhage, intracerebral hemorrhage, ischemic stroke, TIA, basilar artery thrombosis, cervical artery dissection, cerebellar stroke, arteritis and cerebral sinus venous thrombosis. In addition, we discuss migraine and stroke and thunderclap headache. CONCLUSIONS Headache is a leading symptom in many cerebrovascular diseases. Headache in combination with focal neurological deficits requires immediate diagnosis and treatment.
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Affiliation(s)
- John F Rothrock
- Department of Neurology, George Washington University School of Medicine, MFA Building, Department of Neurology, Washington, DC, USA
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Essen, Germany
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Zhang Z, Shu Y, Diao Y, Du Y, Chen L, Liu Y, Du B. Calcitonin gene-related peptide receptor antagonist ubrogepant for the treatment of acute migraine: A meta-analysis. Medicine (Baltimore) 2021; 100:e24741. [PMID: 33663087 PMCID: PMC7909234 DOI: 10.1097/md.0000000000024741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/16/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The objective of this study is to systematically evaluate the efficacy and safety of the calcitonin gene-related peptide (CGRP) receptor antagonist ubrogepant for the treatment of acute migraine. METHODS Randomized controlled trials (RCTs) of ubrogepant for treatment of acute migraine were identified in PubMed, MEDLINE, EMBASE, and the Cochrane Library from database establishment to June 2020; we also searched ClinicalTrials.gov manually during the same period. Then, RevMan 5.3 software was used to perform a meta-analysis on each outcome measure. RESULTS A total of 5 RCTs involving 4903 patients were included; there were 3358 cases in the ubrogepant group and 1545 cases in the placebo group. The meta-analysis showed the following results: at 2 hours postdose, the percentages of participants reporting pain relief and the absence of photophobia, nausea, and phonophobia were significantly higher in the ubrogepant group than in the placebo group (odds ratio [OR] = 1.71, 95%CI: 1.48-1.97, P < .00001; OR = 1.33, 95%CI: 1.22-1.45, P < .00001; OR = 1.07, 95%CI: 1.03-1.11, P = .0006; OR = 1.21, 95%CI: 1.14-1.28, P < .00001). The incidence of common adverse events was similar between the 2 groups (P > .05). CONCLUSION Ubrogepant is effective and safe for the treatment of acute migraine. REGISTRATION NUMBER PROSPERO CRD42019145286.
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Affiliation(s)
- Zizhen Zhang
- School of Pharmacy, Southwest Medical University, Luzhou Sichuan
| | - Yunfeng Shu
- School of Pharmacy, Southwest Medical University, Luzhou Sichuan
| | - Yun Diao
- School of Pharmacy, North Sichuan Medical College, Nanchong Sichuan
| | - Yang Du
- Department of Psychosomatic Medicine
| | - Lizhi Chen
- School of Pharmacy, Southwest Medical University, Luzhou Sichuan
| | - Ying Liu
- School of Pharmacy, North Sichuan Medical College, Nanchong Sichuan
| | - Biao Du
- Department of Pharmacy, the Affiliated Three Gorges Hospital of Chongqing University, Chongqing, China
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Moreno-Ajona D, Pérez-Rodríguez A, Goadsby PJ. Gepants, calcitonin-gene-related peptide receptor antagonists: what could be their role in migraine treatment? Curr Opin Neurol 2021; 33:309-315. [PMID: 32251023 DOI: 10.1097/wco.0000000000000806] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Migraine is the second leading cause of years lived with disability after back pain. Poor tolerability, contraindications, drug-drug interactions and efficacy limited to a subpopulation make new approaches necessary for the acute and preventive treatment of migraine. The study of the calcitonin-gene-related peptide (CGRP) pathway over the last decades is a good example of translational medicine leading to directed therapies for patients. RECENT FINDINGS After some of the first-generation CGRP receptor antagonists, gepants, were not fully developed because of hepatotoxicity, the second generation of gepants have shown efficacy, safety and tolerability in recent clinical trials. SUMMARY Both rimegepant and ubrogepant have published positive randomized placebo-controlled clinical trials data. Vazegepant is the first intranasal gepant for the acute treatment of migraine and has announced a positive phase II/III study. Daily rimegepant use has preliminary data to suggest efficacy. Atogepant has shown efficacy in migraine prevention in a phase II/III study. Most importantly, hepatotoxicity has not been reported in specifically designed phase I studies or long-term extension studies, with rimegepant or ubrogepant, or in a preventive study with atogepant. Given the preventive effect, it seems likely that gepants will not lead to medication overuse headache. They will likely have no cardiovascular warnings. Because of the particular benefit gepants may represent for these groups of patients, specific studies in patients with medication overuse headache, as well as those with comorbid cardiovascular diseases, would be of considerable interest.
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Affiliation(s)
- David Moreno-Ajona
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London.,NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Abigail Pérez-Rodríguez
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London.,NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK.,Department of Neurology, Hospital Nuestra Señora Del Rosario, Calle del Príncipe de Vergara, Madrid, Spain
| | - Peter J Goadsby
- Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London.,NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
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Edinoff AN, Casey CA, Colon MA, Zaheri AR, Gregoire CM, Bourg MM, Kaye AD, Kaye JS, Kaye AM, Kaye RJ, Tirumala SR, Viswanath O, Urits I. Ubrogepant to Treat Acute Migraine in Adults. Neurol Int 2021; 13:32-45. [PMID: 33525313 PMCID: PMC7931025 DOI: 10.3390/neurolint13010004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/10/2021] [Accepted: 01/16/2021] [Indexed: 11/16/2022] Open
Abstract
Migraine is a neurobiological headache disorder that affects around 16% of adults in the United States. Medical treatment of mild to moderate migraines include non-prescription non-steroidal anti-inflammatory drugs, acetaminophen, or aspirin and caffeine-containing combination analgesics. Additionally, moderate to severe migraines and those that are mild to moderate that have not responded to analgesics can be treated with triptans, which are drugs specific for migraine treatment. Non-pharmacological treatments include cognitive behavioral therapy and relaxation training. Medications for the prevention of migraines have also been developed since they are more affective in offsetting the symptoms. Ubrogepant's high specificity and selectivity for calcitonin gene-related peptide (CGRP) sets it apart from certain other drugs, which previously limited the treatment of migraines with or without aura due to their decreased selectivity. The most frequently reported side effects are oropharyngeal pain, nasopharyngitis, and headache. Most studies found that participants receiving Ubrogepant were free from pain within 2 h when compared to placebo. Patients taking Ubrogepant should avoid taking it when pregnant or with end stage renal disease. In summary, Ubrogepant has good tolerability and an overall favorable safety profile. It appears to hold promise for the acute treatment of migraines with or without aura in adults.
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Affiliation(s)
- Amber N. Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.A.C.); (M.A.C.)
| | - C. Austin Casey
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.A.C.); (M.A.C.)
| | - Marc A. Colon
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.A.C.); (M.A.C.)
| | - Alexa R. Zaheri
- Shreveport School of Medicine, Louisiana State University, Shreveport, LA 71103, USA; (A.R.Z.); (C.M.G.); (M.M.B.)
| | - Courtney M. Gregoire
- Shreveport School of Medicine, Louisiana State University, Shreveport, LA 71103, USA; (A.R.Z.); (C.M.G.); (M.M.B.)
| | - Margaret M. Bourg
- Shreveport School of Medicine, Louisiana State University, Shreveport, LA 71103, USA; (A.R.Z.); (C.M.G.); (M.M.B.)
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (S.R.T.); (O.V.); (I.U.)
| | - Jessica S. Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA; (J.S.K.); (A.M.K.)
| | - Adam M. Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA; (J.S.K.); (A.M.K.)
| | - Rachel J. Kaye
- School of medicine, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Sridhar R. Tirumala
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (S.R.T.); (O.V.); (I.U.)
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (S.R.T.); (O.V.); (I.U.)
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ 85004, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE 68124, USA
- Valley Anesthesiology and Pain Consultants—Envision Physician Services, Phoenix, AZ 85004, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Shreveport, Shreveport, LA 71103, USA; (A.D.K.); (S.R.T.); (O.V.); (I.U.)
- Southcoast Health, Southcoast Physicians Group Pain Medicine, Wareham, MA 02571, USA
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16
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Szkutnik-Fiedler D. Pharmacokinetics, Pharmacodynamics and Drug-Drug Interactions of New Anti-Migraine Drugs-Lasmiditan, Gepants, and Calcitonin-Gene-Related Peptide (CGRP) Receptor Monoclonal Antibodies. Pharmaceutics 2020; 12:pharmaceutics12121180. [PMID: 33287305 PMCID: PMC7761673 DOI: 10.3390/pharmaceutics12121180] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 02/08/2023] Open
Abstract
In the last few years, there have been significant advances in migraine management and prevention. Lasmiditan, ubrogepant, rimegepant and monoclonal antibodies (erenumab, fremanezumab, galcanezumab, and eptinezumab) are new drugs that were launched on the US pharmaceutical market; some of them also in Europe. This publication reviews the available worldwide references on the safety of these anti-migraine drugs with a focus on the possible drug–drug (DDI) or drug–food interactions. As is known, bioavailability of a drug and, hence, its pharmacological efficacy depend on its pharmacokinetics and pharmacodynamics, which may be altered by drug interactions. This paper discusses the interactions of gepants and lasmiditan with, i.a., serotonergic drugs, CYP3A4 inhibitors, and inducers or breast cancer resistant protein (BCRP) and P-glycoprotein (P-gp) inhibitors. In the case of monoclonal antibodies, the issue of pharmacodynamic interactions related to the modulation of the immune system functions was addressed. It also focuses on the effect of monoclonal antibodies on expression of class Fc gamma receptors (FcγR).
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Affiliation(s)
- Danuta Szkutnik-Fiedler
- Department of Clinical Pharmacy and Biopharmacy, Poznań University of Medical Sciences, Św. Marii Magdaleny 14 St., 61-861 Poznań, Poland
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18
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Abstract
Small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists have demonstrated therapeutic efficacy for the treatment of migraine. However, previously investigated CGRP receptor antagonists, telcagepant and MK-3207, were discontinued during clinical development because of concerns about drug-induced liver injury. A subsequent effort to identify novel CGRP receptor antagonists less likely to cause hepatotoxicity led to the development of ubrogepant. The selection of ubrogepant, following a series of mechanistic studies conducted with MK-3207 and telcagepant, was focused on key structural modifications suggesting that ubrogepant was less prone to forming reactive metabolites than previous compounds. The potential for each drug to cause liver toxicity was subsequently assessed using a quantitative systems toxicology approach (DILIsym) that incorporates quantitative assessments of mitochondrial dysfunction, disruption of bile acid homeostasis, and oxidative stress, along with estimates of dose-dependent drug exposure to and within liver cells. DILIsym successfully modeled liver toxicity for telcagepant and MK-3207 at the dosing regimens used in clinical trials. In contrast, DILIsym predicted no hepatotoxicity during treatment with ubrogepant, even at daily doses up to 1000 mg (10-fold higher than the approved clinical dose of 100 mg). These predictions are consistent with clinical trial experience showing that ubrogepant has lower potential to cause hepatotoxicity than has been observed with telcagepant and MK-3207.
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Affiliation(s)
| | | | - Paul B Watkins
- Eshelman School of Pharmacy and Institute for Drug Safety Sciences, University
of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Faculty of Health and Medical
Sciences, University of Copenhagen, København, Denmark
| | | | | | - Peter J Goadsby
- NIHR-Wellcome Trust King’s Clinical Research Facility, SLaM Biomedical Research
Centre, King’s College London, London, UK
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19
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Moreno-ajona D, Pérez-rodríguez A, Goadsby PJ. Small-molecule CGRP receptor antagonists: A new approach to the acute and preventive treatment of migraine. Medicine in Drug Discovery 2020; 7:100053. [DOI: 10.1016/j.medidd.2020.100053] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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20
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Chiang CC, Schwedt TJ. Calcitonin gene-related peptide (CGRP)-targeted therapies as preventive and acute treatments for migraine-The monoclonal antibodies and gepants. Prog Brain Res 2020; 255:143-70. [PMID: 33008505 DOI: 10.1016/bs.pbr.2020.06.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022]
Abstract
Calcitonin Gene-Related Peptide (CGRP) plays a pivotal role in migraine pathophysiology. Two types of CGRP function-blocking modalities, monoclonal antibodies, and small molecules (gepants), have been developed to target the CGRP ligands and CGRP receptors. Four CGRP monoclonal antibodies have received FDA approval for the prevention of migraine: erenumab, fremanezumab, galcanezumab, and eptinezumab. Two gepants have been approved by the FDA for the acute treatment of migraine: ubrogepant and rimegepant. Multiple clinical trials of the CGRP monoclonal antibodies and gepants, and now some open-label long-term extension data, established their efficacy, safety, and tolerability. In this chapter, we summarize the major clinical trials, pharmacokinetic insights, safety and tolerability profiles, and real-world data (if available) of the CGRP monoclonal antibodies and gepants.
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21
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Holland PR, Saengjaroentham C, Sureda-gibert P, Strother LC. Medication overuse headache: Divergent effects of new acute antimigraine drugs. Cephalalgia 2020; 40:889-91. [DOI: 10.1177/0333102420938655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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22
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Abstract
The pivotal role of calcitonin gene-related peptide (CGRP) in migraine pathophysiology was identified over 30 years ago, but the successful clinical development of targeted therapies has only recently been realized. This Perspective traces the decades long evolution of medicinal chemistry required to advance small molecule CGRP receptor antagonists, also called gepants, including the current clinical agents rimegepant, vazegepant, ubrogepant, and atogepant. Providing clinically effective blockade of CGRP signaling required surmounting multiple challenging hurdles, including defeating a sizable ligand with subnanomolar affinity for its receptor, designing antagonists with an extended confirmation and multiple pharmacophores while retaining solubility and oral bioavailability, and achieving circulating free plasma levels that provided near maximal CGRP receptor coverage. The clinical efficacy of oral and intranasal gepants and the injectable CGRP monoclonal antibodies (mAbs) are described, as are recent synthetic developments that have benefited from new structural biology data. The first oral gepant was recently approved and heralds a new era in the treatment of migraine.
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Affiliation(s)
- Gene M Dubowchik
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
| | - Charles M Conway
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
| | - Alison W Xin
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
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23
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Wattiez AS, Sowers LP, Russo AF. Calcitonin gene-related peptide (CGRP): role in migraine pathophysiology and therapeutic targeting. Expert Opin Ther Targets 2020; 24:91-100. [PMID: 32003253 DOI: 10.1080/14728222.2020.1724285] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: The neuropeptide calcitonin gene-related peptide (CGRP) is recognized as a critical player in migraine pathophysiology. Excitement has grown regarding CGRP because of the development and clinical testing of drugs targeting CGRP or its receptor. While these drugs alleviate migraine symptoms in half of the patients, the remaining unresponsive half of this population creates an impetus to address unanswered questions that exist in this field.Areas covered: We describe the role of CGRP in migraine pathophysiology and CGRP-targeted therapeutics currently under development and in use. We also discuss how a second CGRP receptor may provide a new therapeutic target.Expert opinion: CGRP-targeting drugs have shown a remarkable safety profile. We speculate that this may reflect the redundancy of peptides within the CGRP family and a second CGRP receptor that may compensate for reduced CGRP activity. Furthermore, we propose that an inherent safety feature of peptide-blocking antibodies is attributed to the fundamental nature of peptide release, which occurs as a large bolus in short bursts of volume transmission. These facts support the development of more refined CGRP therapeutic drugs, as well as drugs that target other neuropeptides. We believe that the future of migraine research is bright with exciting advances on the horizon.
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Affiliation(s)
- Anne-Sophie Wattiez
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA
| | - Levi P Sowers
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA
| | - Andrew F Russo
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA.,Department of Neurology, University of Iowa, Iowa City, IA, USA
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Abstract
INTRODUCTION Migraine is a neurovascular disorder involving neurogenic inflammation and transmission of trigeminovascular nociceptive pathways mediated by Calcitonin Gene-Related Peptide (CGRP). Several small molecules antagonizing the CGRP receptor have been developed as migraine-specific acute medications. The CGRP receptor antagonist ubrogepant, also known as MK-1602, has been recently evaluated in phase III clinical trials for clinical efficacy and long-term safety as an abortive migraine treatment. AREAS COVERED This paper discusses the pharmacodynamics, pharmacokinetics, clinical efficacy, safety, and tolerability profile of ubrogepant for the acute treatment of migraine with or without aura. EXPERT OPINION Ubrogepant, a selective CGRP antagonist belonging to the gepants family, has been evaluated in large short- and long-term Phases 2 and 3 clinical trials aimed to assess clinical efficacy and safety as acute migraine medication. It did not significantly affect liver function and was not associated with other serious adverse events. Long-term non-serious adverse events were similar between placebo and ubrogepant. The efficacy was evaluated in large placebo-controlled studies and ubrogepant 50 mg and 100 mg was superior, even if the therapeutic gain seems to be low. Nevertheless, the favorable safety profile compared to other abortive drugs makes ubrogepant a promising option for the acute treatment of migraine.
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Affiliation(s)
- Martina Curto
- Department of Human Neurosciences, Sapienza University of Rome , Rome, Italy.,International Mood & Psychotic Disorders Research Consortium, Mailman Research Center, McLean Hospital , Belmont, Massachusetts, USA.,Department of Mental Health, ASL Roma 3 , Rome, Italy
| | - Matilde Capi
- Mass Spectrometry Lab-Clinical Biochemistry Unit, Sant'Andrea University Hospital , Rome, Italy
| | - Fabiola Cipolla
- Department of Clinical and Molecular Medicine, Sapienza University of Rome , Rome, Italy
| | - Giusy Ylenia Cisale
- Department of Physiology and Pharmacology, Sapienza University , Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome , Rome, Italy
| | - Luana Lionetto
- Mass Spectrometry Lab-Clinical Biochemistry Unit, Sant'Andrea University Hospital , Rome, Italy
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Abstract
Ubrogepant (Ubrelvy™) is an orally administered, small molecule, highly-selective, calcitonin gene-related peptide (CGRP) antagonist that was developed by Allergan under license to Merck & Co. as an acute treatment for migraine. In December 2019, ubrogepant received its first global approval in the USA for the acute treatment of migraine (± aura) in adults. This article summarizes the milestones in the development of ubrogepant leading to its first global approval for the acute treatment of migraine (± aura) in adults.
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Affiliation(s)
- Lesley J Scott
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Ankrom W, Bondiskey P, Li CC, Palcza J, Liu W, Dockendorf MF, Matthews C, Panebianco D, Reynders T, Wagner JA, Jakate A, Mesens S, Kraft WK, Marcantonio EE. Ubrogepant Is Not Associated With Clinically Meaningful Elevations of Alanine Aminotransferase in Healthy Adult Males. Clin Transl Sci 2020; 13:462-472. [PMID: 31899602 PMCID: PMC7214647 DOI: 10.1111/cts.12728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/20/2019] [Indexed: 11/28/2022] Open
Abstract
Ubrogepant is a novel, oral calcitonin gene-related peptide (CGRP) receptor antagonist intended for the acute treatment of migraine attacks. Ubrogepant has a chemical structure distinct from previous small-molecule CGRP receptor antagonists that were associated with elevated serum alanine aminotransferase (ALT) in clinical trials. Here, we report overall and hepatic safety data from two placebo-controlled phase I trials of ubrogepant, spray-dried oral compressed tablet (SD-OCT) in healthy male volunteers. Trial A was a pharmacokinetic (PK) trial of single (100-400 mg) and multiple (40-400 mg) ascending doses. Trial B was a dedicated hepatic safety trial assessing daily use of ubrogepant 150 mg for 28 days. Serum ALT (as hepatotoxicity biomarker) and PK data are reported. Ubrogepant was well-tolerated in both trials, with a low incidence of adverse events that did not differ greatly from placebo. Changes in mean ALT levels were minimal and similar to placebo. Over 28 days of treatment, the mean percentage change in ALT from baseline was < 5% at all time points. No participant in either trial demonstrated ALT ≥ 3× upper limit of normal at any time. Ubrogepant SD-OCT demonstrated linear PK appropriate for acute treatment of migraine, with rapid uptake (time of maximum plasma concentration (tmax ): 2-3 hours) and no accumulation with daily use. Overall, there was no evidence of ubrogepant-associated hepatotoxicity with daily doses up to 400 mg for 10 days or with daily ubrogepant 150 mg for 28 days. Supratherapeutic dosing is a useful strategy for characterizing hepatic safety in early drug development.
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Affiliation(s)
- Wendy Ankrom
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Phung Bondiskey
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Chi-Chung Li
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - John Palcza
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Wen Liu
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Marissa F Dockendorf
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Catherine Matthews
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | - Deborah Panebianco
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | - John A Wagner
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
| | | | | | - Walter K Kraft
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eugene E Marcantonio
- Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey, USA
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Goadsby PJ, Tepper SJ, Watkins PB, Ayele G, Miceli R, Butler M, Severt L, Finnegan M, Szegedi A, Trugman JM, Jakate A. Safety and tolerability of ubrogepant following intermittent, high-frequency dosing: Randomized, placebo-controlled trial in healthy adults. Cephalalgia 2019; 39:1753-1761. [PMID: 31537107 PMCID: PMC6900570 DOI: 10.1177/0333102419869918] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ubrogepant is a novel, oral calcitonin gene-related peptide (CGRP) receptor antagonist in development for the acute treatment of migraine. This trial evaluated the safety and tolerability of ubrogepant, focusing on hepatic safety, when administered intermittently with high-frequency dosing to healthy participants. METHODS In this phase 1, multicenter, double-blind, parallel-group trial, healthy adults (age 18-50 years) were randomized 1:1 to placebo or ubrogepant. Ubrogepant was dosed at 100 mg (2 × 50 mg tablets) on 2 consecutive days followed by 2 consecutive days of placebo, alternating for 8 weeks. Primary outcome measures were safety and tolerability. RESULTS Of participants randomized (n = 518), 516 were included in the safety population (n = 260 placebo; n = 256 ubrogepant). Treatment-emergent adverse events were reported in 45% of placebo and 44% of ubrogepant participants. The most common was headache (10% placebo; 11% ubrogepant). Overall, seven cases of alanine aminotransferase and/or aspartate aminotransferase levels ≥ 3 × the upper limit of normal (five placebo, two ubrogepant) were reported and adjudicated by a panel of independent liver experts blinded to treatment. Four cases were judged unlikely related to treatment. Two cases (one placebo, one ubrogepant) were judged possibly related, and one (ubrogepant) probably related. Alanine aminotransferase increases to ≥ 3 × the upper limit of normal in the two ubrogepant cases (possibly or probably related) were transient and resolved with continued dosing; both cases were asymptomatic, with no concurrent bilirubin elevation. CONCLUSION Ubrogepant was well tolerated following intermittent, high-frequency dosing in healthy participants, with no clinically relevant signal of hepatotoxicity. TRIAL REGISTRATION NA.
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Affiliation(s)
- Peter J Goadsby
- NIHR-Wellcome Trust King's Clinical
Research Facility, SLaM Biomedical Research Centre, King's College London, London,
UK
| | | | - Paul B Watkins
- Institute for Drug Safety Sciences,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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