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Zovi A, Lasala R, Ferrara F, Langella R, Vitiello A, Sabbatucci M, Musazzi UM. Anti-CGRP mAbs for the Preventive Treatment of Migraine: An Overview Review and a Cost Saving Analysis in the Global Scenario. Hosp Pharm 2024; 59:165-172. [PMID: 38450361 PMCID: PMC10913879 DOI: 10.1177/00185787231196763] [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: 03/08/2024]
Abstract
Objectives: Migraine is a neurological disease with a high frequency of incidence. The new monoclonal antibodies selective for the calcitonin gene-related peptide and its ligand (anti-CGRP mAbs) have been marketed both in the USA and EU based on the positive efficacy results in the prevention of migraine. This search has been carried out with the aim of collecting real-world evidence on the effectiveness of anti-CGRP mAbs, performing a cost-savings analysis, and comparing performances among anti-CGRP mAbs medicines marketed in the American and European market. Methods: The literature review has been performed in PubMed database on 31 December 2022; the cost of the unitary dose of anti-CGRP mAbs has been extracted consulting an American national database. Results: The results confirm efficacy and good tolerability of anti-CGRP mAbs, determining a difference in the purchase price. In fact, all extracted studies showed a protective risk factor exposure in monthly migraine days reduction for all the anti-CGRP mAbs, whereas the cost analysis showed that using eptinezumab, in a quarter there is a cost saving of at least $425 per patient, compared with the other anti-CGRP mAbs. Conclusions: With equal efficacy and equal safety, anti-CGRP mAbs should be prescribed also regard to the cost established at the negotiation, making sure to guarantee the best treatment to the patients, but at the same time impacting as little as possible to the healthcare services resources.
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Affiliation(s)
| | | | | | - Roberto Langella
- Agency for Health Protection of the Metropolitan Area of Milan, Milan, Italy
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2
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Gonzalez-Martinez A, Sanz-García A, García-Azorín D, Rodríguez-Vico J, Jaimes A, Gómez García A, Casas-Limón J, Díaz de Terán J, Sastre-Real M, Membrilla J, Latorre G, Calle de Miguel C, Gil Luque S, Trevino-Peinado C, Quintas S, Heredia P, Echavarría-Íñiguez A, Guerrero-Peral Á, Sierra Á, González-García N, Porta-Etessam J, Gago-Veiga AB. Effectiveness, tolerability, and response predictors of preventive anti-CGRP mAbs for migraine in patients over 65 years old: a multicenter real-world case-control study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:194-202. [PMID: 37847661 DOI: 10.1093/pm/pnad141] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/19/2023] [Accepted: 10/08/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE To evaluate clinical characteristics, effectiveness, and tolerability of preventive anti- calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) in the elderly. Anti-CGRP mAbs have demonstrated efficacy and safety in patients with migraine although there is limited information regarding the elderly. DESIGN We performed a multicenter case-control study of cases (patients over 65 years old) and controls (sex-matched patients under 55 years old) with migraine receiving anti-CGRP mAbs. METHODS We included the demographic characteristics, effectiveness-reduction in the number of monthly headache days (MHD) and monthly migraine days (MMD), 30%, 50%, and 75% responder rates-and treatment emergent adverse events (TEAEs). The primary endpoint was the 50% response rate regarding MHD at weeks 20-24; exploratory 50% response predictors in the elderly were evaluated. RESULTS In total, 228 patients were included: 114 cases , 114 controls-. Among cases 84.2% (96/114) were women, 79.8% (91/114) CM; mean age of cases 70.1 years old (range: 66-86); mean age of controls was 42.9 years old(range: 38-49). Cases had a higher percentage of vascular risk factors (P < .05),older age of onset (P < .001) and more reported prior preventive treatments (P < .001). Regarding effectiveness in cases, 50% response rate was achieved by 57.5% (42/73) at 20-24 weeks, with lower reduction in the MHD at 8-12 weeks (5 [7.2], 8 [9.1]; P = .001) and a higher reduction in MMD at 20-24 weeks (10.7 [9.1], 9.2 [7.7]; P = .04) compared to the control group. The percentage of TEAEs was similar in the 2 groups. Diagnosis of episodic migraine (EM) (P = .03) and lower number of MHD at baseline (P = .001) were associated with a 50% response in the elderly in univariate analysis. CONCLUSIONS Our study provides real world evidence of effectiveness and safety of anti-CGRP mAbs for migraine in patients without upper age-limit and possible predictors of anti-CGRP response in the elderly.
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Affiliation(s)
- Alicia Gonzalez-Martinez
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa, Madrid, Madrid 28006, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Madrid 28049, Spain
| | - Ancor Sanz-García
- Data Analysis Unit, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Hospital Universitario de la Princesa, Madrid, Madrid 28006, Spain
| | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Castilla y León 47003, Spain
- Department of Medicine, University of Valladolid, Valladolid, Castilla y León 47003, Spain
| | - Jaime Rodríguez-Vico
- Headache Unit, Neurology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Madrid 28040, Spain
| | - Alex Jaimes
- Headache Unit, Neurology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Madrid 28040, Spain
| | - Andrea Gómez García
- Headache Unit, Neurology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Madrid 28040, Spain
| | - Javier Casas-Limón
- Headache Unit, Neurology Department, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid 28922, Spain
| | - Javier Díaz de Terán
- Headache Unit, Neurology Department, Hospital Universitario La Paz, Madrid, Madrid 28046, Spain
| | - María Sastre-Real
- Headache Unit, Neurology Department, Hospital Universitario La Paz, Madrid, Madrid 28046, Spain
| | - Javier Membrilla
- Headache Unit, Neurology Department, Hospital Universitario La Paz, Madrid, Madrid 28046, Spain
| | - Germán Latorre
- Headache Unit, Neurology Department, Hospital Universitario de Fuenlabrada, Madrid, Madrid 28942, Spain
| | - Carlos Calle de Miguel
- Headache Unit, Neurology Department, Hospital Universitario de Fuenlabrada, Madrid, Madrid 28942, Spain
| | - Sendoa Gil Luque
- Headache Unit, Neurology Department, Hospital Universitario de Burgos, Burgos, Castilla y León 09006, Spain
| | - Cristina Trevino-Peinado
- Headache Unit, Neurology Department, Hospital Universitario Severo Ochoa, Leganés, Madrid 28914, Spain
| | - Sonia Quintas
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa, Madrid, Madrid 28006, Spain
| | - Patricia Heredia
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa, Madrid, Madrid 28006, Spain
| | - Ana Echavarría-Íñiguez
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Castilla y León 47003, Spain
| | - Ángel Guerrero-Peral
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Castilla y León 47003, Spain
- Department of Medicine, University of Valladolid, Valladolid, Castilla y León 47003, Spain
| | - Álvaro Sierra
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Castilla y León 47003, Spain
| | - Nuria González-García
- Headache Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Madrid 28040, Spain
| | - Jesús Porta-Etessam
- Headache Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Madrid 28040, Spain
| | - Ana Beatriz Gago-Veiga
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa, Madrid, Madrid 28006, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Madrid 28049, Spain
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Finelli F, Catalano A, De Lisa M, Ferraro GA, Genovese S, Giuzio F, Salvia R, Scieuzo C, Sinicropi MS, Svolacchia F, Vassallo A, Santarsiere A, Saturnino C. CGRP Antagonism and Ketogenic Diet in the Treatment of Migraine. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:163. [PMID: 38256423 PMCID: PMC10820088 DOI: 10.3390/medicina60010163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024]
Abstract
The study of migraine is based on the complexity of the pathology, both at the pathophysiological and epidemiological levels. Although it affects more than a billion people worldwide, it is often underestimated and underreported by patients. Migraine must not be confused with a simple headache; it is a serious and disabling disease that causes considerable limitations in the daily life of afflicted people, including social, work, and emotional effects. Therefore, it causes a daily state of suffering and discomfort. It is important to point out that this pathology not only has a decisive impact on the quality of life of those who suffer from it but also on their families and, more generally, on society as a whole. The clinical picture of migraine is complex, with debilitating unilateral or bilateral head pain, and is often associated with characteristic symptoms such as nausea, vomiting, photophobia, and phonophobia. Hormonal, environmental, psychological, dietary, or other factors can trigger it. The present review focuses on the analysis of the physiopathological and pharmacological aspects of migraine, up to the correct dietary approach, with specific nutritional interventions aimed at modulating the symptoms. Based on the symptoms that the patient experiences, targeted and specific therapy is chosen to reduce the frequency and severity of migraine attacks. Specifically, the role of calcitonin gene-related peptide (CGRP) in the pathogenesis of migraine is analyzed, along with the drugs that effectively target the corresponding receptor. Particularly, CGRP receptor antagonists (gepants) are very effective drugs in the treatment of migraine, given their high diffusion in the brain. Moreover, following a ketogenic diet for only one or two months has been demonstrated to reduce migraine attacks. In this review, we highlight the diverse facets of migraine, from its physiopathological and pharmacological aspects to prevention and therapy.
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Affiliation(s)
- Francesca Finelli
- U.O.C. Pediatrics -S. Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Alessia Catalano
- Department of Pharmacy-Drug Sciences, University of Bari “Aldo Moro”, 70126 Bari, Italy;
| | - Michele De Lisa
- U.O.C. Hygiene, Epidemiology and Public Health Department ASP, 85100 Potenza, Italy;
| | - Giuseppe Andrea Ferraro
- Plastic and Reconstructive Surgery Unit, Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, 80138 Naples, Italy;
| | - Sabino Genovese
- Department of Agriculture, Faculty of Viticulture and Oenology, Federico II University, 83100 Avellino, Italy;
| | - Federica Giuzio
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- U.O.C. Primary Care and Territorial Health, Social and Health Department, State Hospital, 47893 San Marino, San Marino
- Spinoff TNCKILLERS s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Rosanna Salvia
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- Spinoff XFlies s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Carmen Scieuzo
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- Spinoff XFlies s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Maria Stefania Sinicropi
- Department of Pharmacy and Health and Nutrition Sciences, University of Calabria, 87036 Arcavacata di Rende, Italy;
| | | | - Antonio Vassallo
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
- Spinoff XFlies s.r.l., University of Basilicata, 85100 Potenza, Italy
| | - Alessandro Santarsiere
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
| | - Carmela Saturnino
- Department of Sciences, University of Basilicata, 85100 Potenza, Italy; (R.S.); (C.S.); (A.V.); (A.S.); (C.S.)
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Loh NR, Whitehouse WP, Howells R. What is new in migraine management in children and young people? Arch Dis Child 2022; 107:1067-1072. [PMID: 35190383 DOI: 10.1136/archdischild-2021-322373] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/29/2022] [Indexed: 12/14/2022]
Abstract
For this narrative review, we found recent publications on the use and effectiveness of old therapies including nutraceuticals, such as riboflavin, vitamin D, magnesium, melatonin and talking therapies. Recent large trials of established conventional pharmaceuticals such as propranolol, pizotifen, topiramate and amitriptyline for childhood migraine have failed, but the use of a quasi-placebo in future trials could help. We reviewed the evidence for angiotensin antagonists including candesartan in adults, but found a lack of evidence for their use in children. There have been new developments in pharmaceuticals recently, including a more selective 5-HT1F agonist, lasmiditan, an effective acute treatment with no vasoconstrictor activity in adults, currently being tested in children. Also, a number of new calcitonin gene-related peptide (CGRP) antibodies and antagonists, with proven efficacy in acute treatment and/or prevention of migraine in adults, are undergoing trials in children. Peripheral nerve blocks and botulinum toxin are gaining popularity in adult practice, but we really need more good quality evidence for their effectiveness in children. Finally, electroceuticals, that is, therapeutic electric devices, are now marketed for acute and or preventative treatment, including an external trigeminal nerve stimulator (e-TNS), a non-invasive vagal nerve stimulator (nVNS), a single-pulse transcranial magnetic stimulator (sTMS) and a remote electrical neuromodulation device (REN). At the moment, evidence for their effectiveness in children is still lacking. So, there has been much progress, but mostly for adults. We are in urgent need of more migraine trials in children.
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Affiliation(s)
- Ne Ron Loh
- Paediatrics, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.,Paediatrics, Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | | | - Rachel Howells
- Royal Devon and Exeter NHS Trust, Children & Young People, Exeter, UK
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Davis L, Torphy B. Managing migraine on the frontline: Identifying disease, understanding burden, and incorporating CGRP pathway-targeting therapies in primary care. Br J Pain 2022; 16:560-573. [PMID: 36389011 PMCID: PMC9644104 DOI: 10.1177/20494637221104292] [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: 10/03/2023] Open
Abstract
Migraine is a common neurologic disorder with clinical phenotypes encompassing a variety of symptoms which all contribute to the burden felt by patients. In addition to negative impacts on a patient's quality of life, migraine has both direct medical costs and indirect costs related to missed work and decreased productivity that affect individuals as well as society at large. Unfortunately, migraine diagnoses are often missed, and many patients do not receive appropriate treatment. Primary care providers are in a key position to provide timely diagnosis and effectively manage migraine for many patients. This review aims to be a guide for improving migraine management in the primary care setting by providing strategies to overcome common challenges in migraine diagnosis; summarizing current knowledge on the mechanism of action, efficacy, and safety of calcitonin gene-related peptide (CGRP) pathway-targeting therapies; and reviewing approaches to incorporate traditional and emerging treatment options into a patient-centric migraine management strategy.
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Affiliation(s)
- Linda Davis
- Kolvita Family Medical
Group, Mission Viejo, CA, USA
| | - Brad Torphy
- Chicago Headache Center and Research
Institute, Chicago, IL, USA
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Bentivegna E, Luciani M, Ferrari V, Galastri S, Baldari F, Scarso F, Lamberti PA, Martelletti P. Recently approved and emerging drug options for migraine prophylaxis. Expert Opin Pharmacother 2022; 23:1325-1335. [PMID: 35850597 DOI: 10.1080/14656566.2022.2102420] [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: 11/04/2022]
Abstract
INTRODUCTION : Migraine occupies the first position regarding to the disability caused in female working population (15-49 years). Research in the field of prophylaxis of this pathology has made enormous strides in recent years. AREAS COVERED In this narrative review we retrace the most important scientific evidence regarding recently approved and emerging drug for prophylactic treatment of migraine. The purpose of this article is in fact to evaluate currently approved or emerging pharmacological agents for migraine prophylaxis. This review is based on literature published in peer review journal obtained through PubMed, Cochrane library, Clinicaltrials.gov and US FDA. EXPERT OPINION : Monoclonal antibodies (mAbs) that target the calcitonin gene-related peptide signalling pathway (CGRP) have marked an innovation in prophylactic migraine therapy. The combination of Onabotulinumtoxin-A (OBTA) and mAbs appears to be an effective, but costly, therapeutic option for resistant cases. New classes of molecules like gepants and ditans seem to give exceptional results. In addition, new prophylactic drugs are emerging with several targets: the pituitary adenylate cyclase-activating polypeptide (PACAP), ion channels, several receptors coupled to G proteins, orexin, and glutamate. All these therapies will implement and improve migraine management, as well as personalized medicine for each patient.
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Affiliation(s)
- Enrico Bentivegna
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | - Valeria Ferrari
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Silvia Galastri
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Francesco Baldari
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Francesco Scarso
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Piera A Lamberti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Noor N, Angelette A, Lawson A, Patel A, Urits I, Viswanath O, Yazdi C, Kaye AD. A Comprehensive Review of Zavegepant as Abortive Treatment for Migraine. Health Psychol Res 2022; 10:35506. [PMID: 35774914 DOI: 10.52965/001c.35506] [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: 02/21/2022] [Accepted: 02/21/2022] [Indexed: 11/06/2022] Open
Abstract
Migraine headache is a widespread and complex neurobiological disorder that is characterized by unilateral headaches that are often accompanied by photophobia and phonophobia. Migraine is one of the leading chief complaints in the emergency department with negative impacts on quality of life and activities of daily living. The high number of emergency presentations also results in a significant economic burden. Its risk factors include family history, genetics, sex, race, socioeconomics, the existence of comorbid conditions, and level of education. Triggers include stress, light, noise, menstruation, weather, changes in sleep pattern, hunger, dehydration, dietary factors, odors, and alcohol. The International Headache Society has defined criteria for the diagnosis of migraine with and without aura. The pathophysiology of migraine headaches is multifactorial so there are a variety of treatment approaches. The current treatment approach includes abortive medications and prophylactic medications. Abortive medications include the first-line treatment of triptans, followed by ergot alkaloids, and calcitonin gene-related peptide (CGRP) receptor antagonists along with supplemental caffeine and antiemetics. Trigeminal afferents from the trigeminal ganglion innervate most cranial tissues and many areas of the head and face. These trigeminal afferents express certain biomarkers such as calcitonin gene-related peptide (CGRP), substance P, neurokinin A, and pituitary adenylate cyclase-activating polypeptide that are important to the pain and sensory aspect of migraines. In this comprehensive review, we discuss Zavegepant, a calcitonin gene-related peptide receptor antagonist, as a new abortive medication for migraine headaches.
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Affiliation(s)
- Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center
| | - Alexis Angelette
- Department of Anesthesiology, Louisiana State University Health Sciences Center - Shreveport
| | | | | | - Ivan Urits
- Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center
| | - Omar Viswanath
- Innovative Pain and Wellness; Department of Anesthesiology, University of Arizona College of Medicine - Phoenix; Department of Anesthesiology, Creighton University School of Medicine; Department of Anesthesiology, Louisiana State University Health Sciences Center - Shreveport
| | - Cyrus Yazdi
- Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center - Shreveport
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Gonzalez-Martinez A, Pagán J, Sanz-García A, García-Azorín D, Rodriguez Vico JS, Jaimes A, Gómez García A, Díaz de Terán J, González-García N, Quintas S, Belascoaín R, Casas Limón J, Latorre G, Calle de Miguel C, Sierra Á, Guerrero-Peral ÁL, Trevino-Peinado C, Gago-Veiga AB. Machine-learning based approach to predict anti-CGRP response in patients with migraine: multicenter Spanish study. Eur J Neurol 2022; 29:3102-3111. [PMID: 35726393 DOI: 10.1111/ene.15458] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND To date, several variables have been associated with anti-CGRP receptor or ligand-antibody response with disparate results. Our objective is to determine whether machine learning (ML)-based models can predict 6, 9 and 12 months response to anti-CGRP receptor or ligand therapies among migraine patients. METHODS We performed a multicenter analysis of a prospectively collected data cohort of patients with migraine receiving anti-CGRP therapies. Demographic and clinical variables were collected. Response rate defined in the 30% to 50% range -or at least 30%-, in the 50% to 75% range -or at least 50%-, and response rate over 75% reduction in the number of headache days per month at 6, 9 and 12 months. A sequential forward feature selector was used for variable selection and ML-based predictive models response to anti-CGRP therapies at 6, 9 and 12 months, with models' accuracy not less than 70%, were generated. RESULTS A total of 712 patients were included, 93% women, aged 48 years (SD=11.7). Eighty-three percent had chronic migraine. ML models using headache days/month, migraine days/month and HIT-6 variables yielded predictions with a F1 score range of 0.70-0.97 and AUC (area under the receiver operating curve) score range of 0.87-0.98. SHAP (SHapley Additive exPlanations) summary plots and dependence plots were generated to evaluate the relevance of the factors associated with the prediction of the above-mentioned response rates. CONCLUSIONS According to our study, ML models can predict anti-CGRP response at 6, 9 and 12 months. This study provides a predictive tool to be used in a real-world setting.
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Affiliation(s)
- Alicia Gonzalez-Martinez
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Josué Pagán
- Universidad Politécnica de Madrid and Center for Computational Simulation of Universidad Politécnica de Madrid, Madrid, Spain
| | - Ancor Sanz-García
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - David García-Azorín
- Headache Unit, Neurology Department, Department of Medicine, University of Valladolid, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Alex Jaimes
- Headache Unit, Neurology Department, Fundación Jiménez Díaz, Madrid, Spain
| | | | - Javier Díaz de Terán
- Headache Unit, Neurology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Nuria González-García
- Headache Unit, Neurology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Sonia Quintas
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Rocio Belascoaín
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Javier Casas Limón
- Headache Unit Neurology Department, Hospital Universitario Fundación de Alcorcón, Alcorcón, Spain
| | - Germán Latorre
- Headache Unit, Neurology Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Carlos Calle de Miguel
- Headache Unit, Neurology Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Álvaro Sierra
- Headache Unit, Neurology Department, Department of Medicine, University of Valladolid, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ángel Luis Guerrero-Peral
- Headache Unit, Neurology Department, Department of Medicine, University of Valladolid, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Ana Beatriz Gago-Veiga
- Headache Unit, Neurology Department, Hospital Universitario de la Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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Ailani J, McAllister P, Winner PK, Chakhava G, Krog Josiassen M, Lindsten A, Sperling B, Ettrup A, Cady R. Rapid resolution of migraine symptoms after initiating the preventive treatment eptinezumab during a migraine attack: results from the randomized RELIEF trial. BMC Neurol 2022; 22:205. [PMID: 35659622 PMCID: PMC9164335 DOI: 10.1186/s12883-022-02714-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eptinezumab is an anti-calcitonin gene-related peptide (CGRP) monoclonal antibody approved for the preventive treatment of migraine. In the phase 3 RELIEF study, eptinezumab resulted in shorter time to headache pain freedom and time to absence of most bothersome symptom (MBS; including nausea, photophobia, or phonophobia) compared with placebo when administered during a migraine attack. The objective of this exploratory analysis was to examine the earliest time points that eptinezumab separated from placebo (P < .05) on headache- and migraine-associated symptoms when administered during a migraine attack. METHODS RELIEF, a multicenter, parallel-group, double-blind trial, occurred from November 7, 2019, through July 8, 2020. Adults considered candidates for preventive treatment were randomized to eptinezumab 100 mg (N = 238) or placebo (N = 242) administered intravenously over 30 min within 1-6 h of migraine onset. Outcome measures included headache pain freedom/relief and absence of MBS, patient's choice of photophobia, phonophobia, or nausea, at regular intervals from 0.5 to 48 h after infusion start. Censoring was applied at time of acute rescue medication use. RESULTS At hour 1, more eptinezumab-treated patients achieved headache pain freedom (9.7%), headache pain relief (38.7%), and absence of MBS (33.2%) versus placebo (4.1%, 26.9%, and 22.1%, respectively; P < .05 all), with separation from placebo (P < .05) through hour 48. Eptinezumab separated from placebo (P < .05) at hour 1 in absence-of-photophobia (29.4% vs 17.0%) and absence-of-phonophobia (41.2% vs 27.2%) and through hour 48. Initial separation from placebo (P < .05) in absence-of-nausea occurred at end-of-infusion (0.5 h; 36.7% vs 25.4%, respectively). CONCLUSION Preventive treatment with eptinezumab initiated during a migraine attack resulted in more patients achieving headache pain freedom/relief and absence of MBS, with separation from placebo (P < .05) as early as 0.5-1 h following the start of infusion. Rapid resolution of headache- and migraine-associated symptoms by a peripherally acting, intravenously administered antibody suggest a peripheral site of pharmacological action for CGRP blockade. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04152083 .
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Affiliation(s)
- Jessica Ailani
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
| | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, CT, USA
| | - Paul K Winner
- Palm Beach Headache Center, West Palm Beach, FL, USA
| | - George Chakhava
- Georgian Association of Medical Specialties, Multiprofile Clinic Consilium Medulla, D.Tvildiani Medical University, Tbilisi, Georgia
| | | | | | | | | | - Roger Cady
- Lundbeck LLC, Deerfield, IL, USA.
- RK Consults, Ozark, MO, USA.
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Viudez-Martínez A, Pascual-Carrasco A, Beltrán-Blasco I, Hernandez-Lorido R, F Ruiz de Apodaca R. Effectiveness and safety of erenumab and galcanezumab in the prevention of chronic and episodic migraine: A retrospective cohort study. J Clin Pharm Ther 2022; 47:814-823. [PMID: 35212025 DOI: 10.1111/jcpt.13620] [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: 01/16/2022] [Revised: 01/25/2022] [Accepted: 02/01/2022] [Indexed: 01/08/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE?: Erenumab and galcanezumab have shown great results for migraine prevention. However, strict inclusion criteria, absence of concomitant medication and selective outcome report of clinical trials may sometimes be barely representative of the real-world daily practice. Therefore, this study was designed to evaluate effectiveness and safety of these two monoclonal antibodies targeting calcitonin gene-related peptide in real-world patients. METHODS: This observational, retrospective study evaluated the effectiveness and safety of erenumab 140 mg and galcanezumab 120 mg in 142 real-world patients who had previously not responded to three well-established pharmacological alternatives for migraine prevention. To do so, a combination of objective parameters (monthly headache days and acute migraine-specific medication days) and subjective measurements (Migraine Disability Assessment questionnaire, Headache Impact Test and Visual Analogue Scale), validated for clinical research in migraine, were assessed during clinical interview. RESULTS AND DISCUSSION: Findings here reported show that erenumab and galcanezumab reduced monthly headache days, acute migraine specific medication days per month, Headache Impact Test score, Migraine Disability Assessment Test score and Visual Analogue Scale score after 3 and 6 doses (p < 0.01). Additionally, more than 25% of the patients enrolled in the study experienced a reduction by a half in monthly headache days, and more than 50% of the patients also reported a reduction by a half in the number of migraine specific medication days. Both treatments exhibited a great safety profile, rarely leading to discontinuation because of poor tolerance. WHAT IS NEW AND CONCLUSIONS?: Altogether, these results support previous real-life studies regarding effectiveness and safety and provide an interesting insight in how these preventive therapies are also effective in patients diagnosed with difficult to treat migraine who have previously failed, at least, three different drug classes stablished by current neurology guidelines for migraine prevention. Moreover, these data may suggest that erenumab and galcanezumab are able to not only diminish frequency, but also migraine intensity, and that it should be also considered as an effectiveness measure in line with other authors suggestion.
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11
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Schiano di Cola F, Caratozzolo S, Venturelli E, Balducci U, Sidoti V, Pari E, Costanzi C, di Summa A, Sixt GJ, D'Adda E, Liberini P, Rao R, Padovani A. Erenumab Discontinuation After 12-Month Treatment: A Multicentric, Observational Real-Life Study. Neurol Clin Pract 2022; 11:e834-e839. [PMID: 34992966 DOI: 10.1212/cpj.0000000000001112] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/10/2021] [Indexed: 11/15/2022]
Abstract
Objective To assess migraine outcome after 12-month treatment with erenumab and compare patients who underwent 3-month erenumab discontinuation following the first treatment cycle with those who continued monthly administrations. Methods This is a multicentric observational study in patients with migraine in treatment with erenumab. After a full 12-month treatment cycle (T12), patients could either continue or discontinue erenumab for at least 3 months. Patients who underwent treatment discontinuation were assessed after 3 months (T15) to decide whether to start retreatment. Patients were then assessed following at T16 and T18. Results Thirty consecutive patients were enrolled. Nineteen patients underwent treatment suspension at T12 up to T15, whereas 11 continued prophylaxis. At T15, patients who discontinued treatment documented significantly more migraine days (17.06 ± 6.5 vs 4.8 ± 2.5; p < 0.0001) and analgesics consumption (14.8 ± 9.2 vs 4.6 ± 2.5; p = 0.002), compared with those who continued treatment. After retreatment, at T16, patients who had previously undergone discontinuation documented a significant improvement in terms of migraine days (9.01 ± 4.4 vs 17.06 ± 6.5; p < 0.0001) and analgesics consumption (9.6 ± 7.3 vs 14.8 ± 9.2; p = 0.004). Such improvement was even greater at T18, comparable with T12. Conclusion After treatment discontinuation, a rapid migraine worsening was found, despite the high clinical response during treatment and at retreatment, which might be secondary to an untimely interruption of a potentially disease-modifying pharmacologic intervention. Although clinical improvement was documented after retreatment, given the high frequency and degree of worsening during discontinuation, it seems plausible-even ethical-to re-evaluate current timing of discontinuation. Classification of Evidence This study provides Class III evidence that people with migraine discontinuing erenumab migraine prophylaxis after 12 months were more likely to have an increase in nonresponder status and migraine days than those who continued treatment.
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Affiliation(s)
- Francesca Schiano di Cola
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Salvatore Caratozzolo
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Elisabetta Venturelli
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Ubaldo Balducci
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Vincenzo Sidoti
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Elisa Pari
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Chiara Costanzi
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Alfonsina di Summa
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Gabriele Johanna Sixt
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Elisabetta D'Adda
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Paolo Liberini
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Renata Rao
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
| | - Alessandro Padovani
- Neurology Unit, Clinical and Experimental Sciences Department (FSC, SC, PL, RR, AP), University and Spedali Civili, Brescia; Neurology Unit (EV), ASST Papa Giovanni XXIII, Bergamo; Neurology Unit (UB, VS), ASST Franciacorta, P.O. Chiari; Neurology Unit (EP, CC), Ospedale di Cremona, ASST Cremona; Neurology Unit (AS, GJS), Ospedale Centrale di Bolzano, Azienda Sanitaria dell'Alto Adige; and Neurology Unit (EDA), Ospedale Maggiore di Crema, ASST Crema, Italy
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12
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Kim YJ, Granstein RD. Roles of calcitonin gene-related peptide in the skin, and other physiological and pathophysiological functions. Brain Behav Immun Health 2021; 18:100361. [PMID: 34746878 PMCID: PMC8551410 DOI: 10.1016/j.bbih.2021.100361] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 10/01/2021] [Accepted: 10/02/2021] [Indexed: 01/05/2023] Open
Abstract
Skin immunity is regulated by many mediator molecules. One is the neuropeptide calcitonin gene-related peptide (CGRP). CGRP has roles in regulating the function of components of the immune system including T cells, B cells, dendritic cells (DCs), endothelial cells (ECs), and mast cells (MCs). Herein we discuss actions of CGRP in mediating inflammatory and vascular effects in various cutaneous models and disorders. CGRP can help to recruit immune cells through endothelium-dependent vasodilation. CGRP plays an important role in the pathogenesis of neurogenic inflammation. Functions of many components in the immune system are influenced by CGRP. CGRP regulates various inflammatory processes in human skin by affecting different cell-types.
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Affiliation(s)
- Yee Jung Kim
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, WGC9, New York, NY, 10021, USA
| | - Richard D Granstein
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, WGC9, New York, NY, 10021, USA
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13
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Choquet H, Yin J, Jacobson AS, Horton BH, Hoffmann TJ, Jorgenson E, Avins AL, Pressman AR. New and sex-specific migraine susceptibility loci identified from a multiethnic genome-wide meta-analysis. Commun Biol 2021; 4:864. [PMID: 34294844 PMCID: PMC8298472 DOI: 10.1038/s42003-021-02356-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 06/04/2021] [Indexed: 02/06/2023] Open
Abstract
Migraine is a common disabling primary headache disorder that is ranked as the most common neurological cause of disability worldwide. Women present with migraine much more frequently than men, but the reasons for this difference are unknown. Migraine heritability is estimated to up to 57%, yet much of the genetic risk remains unaccounted for, especially in non-European ancestry populations. To elucidate the etiology of this common disorder, we conduct a multiethnic genome-wide association meta-analysis of migraine, combining results from the GERA and UK Biobank cohorts, followed by a European-ancestry meta-analysis using public summary statistics. We report 79 loci associated with migraine, of which 45 were novel. Sex-stratified analyses identify three additional novel loci (CPS1, PBRM1, and SLC25A21) specific to women. This large multiethnic migraine study provides important information that may substantially improve our understanding of the etiology of migraine susceptibility.
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Affiliation(s)
- Hélène Choquet
- Division of Research, Kaiser Permanente Northern California (KPNC), Oakland, CA, USA.
| | - Jie Yin
- Division of Research, Kaiser Permanente Northern California (KPNC), Oakland, CA, USA
| | | | - Brandon H Horton
- Division of Research, Kaiser Permanente Northern California (KPNC), Oakland, CA, USA
| | - Thomas J Hoffmann
- Institute for Human Genetics, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Eric Jorgenson
- Division of Research, Kaiser Permanente Northern California (KPNC), Oakland, CA, USA
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California (KPNC), Oakland, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Alice R Pressman
- Sutter Health, Walnut Creek, CA, USA.
- Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, CA, USA.
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14
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Efficacy of calcitonin gene-related peptide (CGRP) receptor blockers in reducing the number of monthly migraine headache days (MHDs): A network meta-analysis of randomized controlled trials. J Neurol Sci 2021; 427:117505. [PMID: 34082147 DOI: 10.1016/j.jns.2021.117505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 12/11/2022]
Abstract
The Global burden of disease study ranked migraine as the sixth most common disorder worldwide in 2016, with significant social and economic sequelae. In this study, we assessed the efficacy of different Calcitonin gene-related peptide (CGRP) receptor blockers as potential pharmacological approaches and compare them to placebo using the systematic review (SR) and network meta-analysis (NMA) approach. We performed a computerized search of SCOPUS, PubMed, Cochrane central, and Embase databases through January 2019 and included randomized controlled trials (RCTs), which were performed on episodic and chronic migraine patients who used Erenumab, Eptinezumab, Fremanezumab, or Galcanezumab. The combined analysis revealed that after six, eight, and twelve weeks of intervention, the medications with the most potent effects in comparison to placebo were Fremanezumab 900 mg, (SMD = -0.55, 95% CI [-0.97, -0.12]); Erenumab 140 mg, (SMD = -0.51, 95% CI [-0.61, 0.41]); and Erenumab 140 mg, (SMD = -0.48, 95% CI [-0.571, 0.39]), respectively. For chronic migraine patients, Fremanezumab 900 mg, Erenumab 140 mg, in addition to Erenumab 70 mg, were associated with the highest efficacy after 6, 8, and 12 weeks, correspondingly. The analysis of combined groups data (Chronic and Episodic) showed that Fremanezumab was the most effective drug after six weeks, where Erenumab was the most effective after 8 and 12 weeks. The current evidence retrieved from this NMA suggests that Fremanezumab was the most effective anti-migraine medication in decreasing MHDs per month after six weeks in both chronic and episodic patients.
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15
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Lu J, Zhang Q, Guo X, Liu W, Xu C, Hu X, Ni J, Lu H, Zhao H. Calcitonin Gene-Related Peptide Monoclonal Antibody Versus Botulinum Toxin for the Preventive Treatment of Chronic Migraine: Evidence From Indirect Treatment Comparison. Front Pharmacol 2021; 12:631204. [PMID: 34012392 PMCID: PMC8126691 DOI: 10.3389/fphar.2021.631204] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/15/2021] [Indexed: 12/25/2022] Open
Abstract
Background: The previously approved botulinum toxin and nowadays promising calcitonin gene-related peptide (CGRP) monoclonal antibody have shown efficacy for preventing chronic migraine (CM). However, there is no direct evidence for their relative effectiveness and safety. In this study, we conducted an indirect treatment comparison to compare the efficacy and safety of CGRP monoclonal antibody with botulinum toxin for the preventive treatment of chronic migraine. Methods: Up to August 31, 2020, we systematically searched PubMed, Embase, and Cochrane Library Central Register of Controlled Trials (Central). Weighted mean difference (WMD) and relative risk (RR) were used to evaluate clinical outcomes. Indirect treatment comparison (ITC) software was used to conduct indirect treatment comparison. Results: Ten studies were pooled with 6,325 patients in our meta-analysis. Both botulinum toxin and CGRP monoclonal antibody demonstrated favorable efficacy in the change of migraine days, headache days, HIT-6 score, and 50% migraine responder rate compared with placebo. In indirect treatment comparison, CGRP monoclonal antibody was superior to botulinum toxin in the frequency of acute analgesics intake (WMD = −1.31, 95% CI: −3.394 to 0.774, p = 0.02113), the rate of treatment-related adverse events (AEs) (RR = 0.664, 95% CI: 0.469 to 0.939, p = 0.04047), and the rate of treatment-related serious adverse events (RR = 0.505, 95% CI: 0.005 to 46.98, p < 0.001). Conclusion: For chronic migraine patients, CGRP monoclonal antibody was slightly better than botulinum toxin in terms of efficacy and safety. In the future, head-to-head trials would be better to evaluate the efficacy and safety between different medications in the prevention of chronic migraine.
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Affiliation(s)
- Jiajie Lu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Quanquan Zhang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoning Guo
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei Liu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chunyang Xu
- Department of Neurology, Traditional Chinese Medicine Hospital of Kunshan, Kunshan, China
| | - Xiaowei Hu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianqiang Ni
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haifeng Lu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hongru Zhao
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
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Moody TW, Jensen RT. Pituitary adenylate cyclase-activating polypeptide/vasoactive intestinal peptide (Part 2): biology and clinical importance in central nervous system and inflammatory disorders. Curr Opin Endocrinol Diabetes Obes 2021; 28:206-213. [PMID: 33481421 PMCID: PMC7961158 DOI: 10.1097/med.0000000000000621] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW To discuss recent advances of vasoactive intestinal peptide/pituitary adenylate cyclase-activating polypeptide (VIP/PACAP) receptors in the selected central nervous system (CNS) and inflammatory disorders. RECENT FINDINGS Recent studies provide evidence that PACAP plays an important role in a number of CNS disorders, particularly the pathogenesis of headaches (migraine, etc.) as well as posttraumatic stress disorder and drug/alcohol/smoking addiction. VIP has important therapeutic effects in a number of autoimmune/inflammatory disorder such as rheumatoid arthritis. In some cases, these insights have advanced to therapeutic trials. SUMMARY Recent insights from studies of VIP/PACAP and their receptors in both CNS disorders (migraine, posttraumatic stress disorder, addiction [drugs, alcohol, smoking]) and inflammatory disorders [such as rheumatoid arthritis] are suggesting new treatment approaches. The elucidation of the importance of VIP/PACAP system in these disorders combined recent development of specific drugs acting on this system (i.e., monoclonal VIP/PACAP antibodies) will likely lead to importance novel treatment approaches in these diseases.
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Affiliation(s)
- Terry W Moody
- Department of Health and Human services, National Cancer Institute, Center for Cancer Training. Bethesda, Maryland, USA
| | - Robert T Jensen
- National Institutes of Health, National Institute of Diabetes, Digestive and Kidney Diseases, Digestive Diseases Branch, Bethesda, Maryland, USA
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Kudrow D, Cady RK, Allan B, Pederson SM, Hirman J, Mehta LR, Schaeffler BA. Long-term safety and tolerability of eptinezumab in patients with chronic migraine: a 2-year, open-label, phase 3 trial. BMC Neurol 2021; 21:126. [PMID: 33740902 PMCID: PMC7977171 DOI: 10.1186/s12883-021-02123-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/18/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Eptinezumab, an anti-calcitonin gene-related peptide monoclonal antibody recently approved in the United States for preventive treatment of migraine in adults, was found to be well tolerated in double-blind, placebo-controlled studies in patients with episodic and chronic migraine. The objective of the PREVAIL study was to evaluate the long-term safety, immunogenicity, and impact on patient-reported outcomes of repeat doses of eptinezumab in patients with chronic migraine. METHODS PREVAIL was an open-label, phase 3 trial comprising a 48-week treatment phase followed by a second 48-week treatment phase. Adults with chronic migraine received eptinezumab 300 mg by 30-min intravenous administration every 12 weeks for up to 8 doses. Patients were followed for 20 weeks after the final infusion (end-of-study visit at week 104). RESULTS Overall, 128 adults (mean age, 41.5 years) with chronic migraine were included. During the 2 years, the most frequently reported treatment-emergent adverse events were nasopharyngitis (14.1%), upper respiratory tract infection (7.8%), sinusitis (7.8%), influenza (6.3%), bronchitis (5.5%), and migraine (5.5%). The rate of study-drug discontinuation due to adverse events was 6.3%, which included 3 patients with infusion-related hypersensitivity. The incidence of anti-eptinezumab antibodies peaked at week 24 and declined despite continued dosing, to nondetectable levels at week 104. Improvements in patient-reported outcomes were observed at first assessment (week 4) and generally sustained through week 104. CONCLUSION In adults with chronic migraine, eptinezumab 300 mg demonstrated a favorable safety profile, limited long-term immunogenicity, early and sustained reductions in migraine-related burden, and improvements in health-related quality of life over 2 years. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT02985398 ).
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Affiliation(s)
- David Kudrow
- California Medical Clinic for Headache, 2001 Santa Monica Blvd, Santa Monica, CA, 90404, USA.
| | - Roger K Cady
- Lundbeck La Jolla Research Center, 10035 Road to the Cure, Suite 250, San Diego, CA, USA
| | - Brent Allan
- Alder BioPharmaceuticals, Inc. (CKA Lundbeck Seattle BioPharmaceuticals, Inc.), 11804 North Creek Parkway South, Bothell, WA, USA
| | - Susan M Pederson
- Lundbeck La Jolla Research Center, 10035 Road to the Cure, Suite 250, San Diego, CA, USA
| | - Joe Hirman
- Pacific Northwest Statistical Consulting, 18133 154th Ave NE, Woodinville, WA, USA
| | - Lahar R Mehta
- Lundbeck La Jolla Research Center, 10035 Road to the Cure, Suite 250, San Diego, CA, USA
| | - Barbara A Schaeffler
- Lundbeck La Jolla Research Center, 10035 Road to the Cure, Suite 250, San Diego, CA, USA
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González-Hernández A, Condés-Lara M, García-Boll E, Villalón CM. An outlook on the trigeminovascular mechanisms of action and side effects concerns of some potential neuropeptidergic antimigraine therapies. Expert Opin Drug Metab Toxicol 2021; 17:179-199. [DOI: 10.1080/17425255.2021.1856366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Miguel Condés-Lara
- Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México
| | - Enrique García-Boll
- Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México
| | - Carlos M. Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Ciudad de México, México
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Ingram Z, Patkar A, Oh D, Zhang KK, Chung C, Lin-Cereghino J, Lin-Cereghino GP. Overcoming Obstacles in Protein Expression in the Yeast Pichia pastoris: Interviews of Leaders in the Pichia Field. PACIFIC JOURNAL OF HEALTH (STOCKTON, CALIF.) 2021; 4:2. [PMID: 36213698 PMCID: PMC9536841 DOI: 10.56031/2576-215x.1010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The yeast Pichia pastoris (also known as Komagataella pastoris) has been used for over 30 years to produce thousands of valuable, heterologous proteins, such as insulin to treat diabetes and antibodies to prevent migraine headaches. Despite its success, there are some common, stubborn problems encountered by research scientists when they try to use the yeast to produce their recombinant proteins. In order to provide those working in this field with strategies to overcome these common obstacles, nine experts in P. pastoris protein expression field were interviewed to create a written review and video (https://www.youtube.com/watch?v=Q1oD6k8CdG8). This review describes how each respected scientist addressed a specific challenge, such as identifying high expression strains, improving secretion efficiency and decreasing hyperglycosylation. Their perspective and practical advice can be a tool to help empower others to express challenging proteins in this popular recombinant host.
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20
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Fattori V, Ferraz CR, Rasquel-Oliveira FS, Verri WA. Neuroimmune communication in infection and pain: Friends or foes? Immunol Lett 2020; 229:32-43. [PMID: 33248166 DOI: 10.1016/j.imlet.2020.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/02/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022]
Abstract
Clinically, a variety of micro-organisms cause painful infections. Before seen as bystanders in the context of infections, recent studies have demonstrated that, as immune cells, nociceptors can sense pathogen-derived products. Nociceptors and immune cells, therefore, have evolved to communicate with each other to control inflammatory and host responses against pathogens in a complementary way. This interaction is named as neuroimmune communication (or axon-axon immune reflex) and initiates after the release of neuropeptides, such as CGRP and VIP by neurons. By this neurogenic response, nociceptors orchestrate the activity of innate and adaptive immune cells in a context-dependent manner. In this review, we focus on how nociceptors sense pathogen-derived products to shape the host response. We also highlight the new concept involving the resolution of inflammation, which is related to an active and time-dependent biosynthetic shift from pro-inflammatory to pro-resolution mediators, the so-called specialized pro-resolving lipid mediators (SPMs). At very low doses, SPMs act on specific receptors to silence nociceptors, limit pain and neurogenic responses, and resolve infections. Furthermore, stimulation of the vagus nerve induces SPMs production to regulate immune responses in infections. Therefore, harnessing the current understanding of neuro-immune communication and neurogenic responses might provide the bases for reprogramming host responses against infections through well balanced and effective immune response and inflammation resolution.
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Affiliation(s)
- Victor Fattori
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Pathology, Londrina State University, Londrina, PR, Brazil; Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Camila R Ferraz
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Pathology, Londrina State University, Londrina, PR, Brazil
| | - Fernanda S Rasquel-Oliveira
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Pathology, Londrina State University, Londrina, PR, Brazil
| | - Waldiceu A Verri
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Pathology, Londrina State University, Londrina, PR, Brazil.
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21
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Zhao Z, Zhang Z, Li J, Dong Q, Xiong J, Li Y, Lan M, Li G, Zhu B. Sustained TNF-α stimulation leads to transcriptional memory that greatly enhances signal sensitivity and robustness. eLife 2020; 9:61965. [PMID: 33155547 PMCID: PMC7704108 DOI: 10.7554/elife.61965] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/05/2020] [Indexed: 12/11/2022] Open
Abstract
Transcriptional memory allows certain genes to respond to previously experienced signals more robustly. However, whether and how the key proinflammatory cytokine TNF-α mediates transcriptional memory are poorly understood. Using HEK293F cells as a model system, we report that sustained TNF-α stimulation induces transcriptional memory dependent on TET enzymes. The hypomethylated status of transcriptional regulatory regions can be inherited, facilitating NF-κB binding and more robust subsequent activation. A high initial methylation level and CpG density around κB sites are correlated with the functional potential of transcriptional memory modules. Interestingly, the CALCB gene, encoding the proven migraine therapeutic target CGRP, exhibits the best transcriptional memory. A neighboring primate-specific endogenous retrovirus stimulates more rapid, more strong, and at least 100-fold more sensitive CALCB induction in subsequent TNF-α stimulation. Our study reveals that TNF-α-mediated transcriptional memory is governed by active DNA demethylation and greatly sensitizes memory genes to much lower doses of inflammatory cues. Genes are the instruction manuals of life and contain the information needed to build the building blocks that keep cells alive. To read these instructions, cells use specific signals that activate genes. The process, known as gene expression, is tightly controlled and for the most part, fairly stable. But gene expression can be modified in various ways. Epigenetics is a broad term for describing reversible changes made to genes to switch them on and off. Sometimes, certain genes even develop a kind of ‘transcriptional memory’ where over time, their expression is enhanced and speeds up with repeated activation signals. But this may also have harmful effects. For example, the signalling molecule called tumour necrosis factor α (TNF-α) is an essential part of the immune system. But it is also implicated in chronic inflammatory diseases, such as rheumatoid arthritis. In these conditions, cell signalling pathways triggering inflammation are overactive. One possibility is that TNF-α could be inducing the transcriptional memory of certain genes, amplifying their expression. But little is known about which fraction of genes exhibits transcriptional memory, and what differentiates memory genes from genes with stable expression. Here, Zhao et al. treated cells grown in the laboratory with TNF-α to investigate its role in transcriptional memory and find out what epigenetic features might govern the process. The experiments showed that mimicking a sustained inflammation by stimulating TNF-α, triggered a transcriptional memory in some genes, and enabled them to respond to much lower levels of TNF-α on subsequent exposure. Zhao et al. also discovered that genes tagged with methyl groups are more likely to show transcriptional memory when stimulated by TNF-α. However, they also found that these groups must be removed to consolidate any transcriptional memory. This work shows how TNF-α influences can alter the expression of certain genes. It also suggests that transcriptional memory, stimulated by TNF-α, may be a possible mechanism underlying chronic inflammatory conditions. This could help future research in identifying more genes with transcriptional memory.
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Affiliation(s)
- Zuodong Zhao
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
| | - Zhuqiang Zhang
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
| | - Jingjing Li
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China.,College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Qiang Dong
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
| | - Jun Xiong
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
| | - Yingfeng Li
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China
| | - Mengying Lan
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China.,College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Gang Li
- Faculty of Health Sciences, University of Macau, Macau, China
| | - Bing Zhu
- National Laboratory of Biomacromolecules, CAS Center for Excellence in Biomacromolecules, Institute of Biophysics, Chinese Academy of Sciences, Beijing, China.,College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
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Slepukhina MA, Ivashchenko DV, Sheina MA, Muradian AA, Blagovestnov DA, Sychev DA. Pain pharmacogenetics. Drug Metab Pers Ther 2020; 35:dmpt-2020-2939. [PMID: 32776897 DOI: 10.1515/dmpt-2020-2939] [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: 10/15/2019] [Accepted: 03/16/2020] [Indexed: 11/15/2022]
Abstract
Pain is a significant problem in medicine. The use of PGx markers to personalize postoperative analgesia can increase its effectiveness and avoid undesirable reactions. This article describes the mechanisms of nociception and antinociception and shows the pathophysiological mechanisms of pain in the human body. The main subject of this article is pharmacogenetic approach to the selection of anesthetics. Current review presents data for local and general anesthetics, opioids, and non-steroidal anti-inflammatory drugs. None of the anesthetics currently has clinical guidelines for pharmacogenetic testing. This literature review summarizes the results of original research available, to date, and draws attention to this area.
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Affiliation(s)
| | - Dmitriy V Ivashchenko
- Child Psychiatry and Psychotherapy Department, Department of Personalized Medicine, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Maria A Sheina
- Department of Anesthesiology and Intensive Care, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | | | - Dmitriy A Sychev
- Department of Clinical Pharmacology and Therapeutics, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
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23
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Schoenen J, Manise M, Nonis R, Gérard P, Timmermans G. Monoclonal antibodies blocking CGRP transmission: An update on their added value in migraine prevention. Rev Neurol (Paris) 2020; 176:788-803. [PMID: 32758365 DOI: 10.1016/j.neurol.2020.04.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/28/2020] [Indexed: 12/29/2022]
Abstract
The avenue of effective migraine therapies blocking calcitonin gene-related peptide (CGRP) transmission is the successful outcome of 35 years of translational research. Developed after short-acting, the small antagonists of the CGRP receptor (the "gepants"), the monoclonal antibodies blocking CGRP or its receptor (CGRP/rec mAbs) have changed the paradigm in migraine treatment. Contrary to the classical acute medications like triptans or nonsteroidal anti-inflammatory drugs (NSAIDs) with a transient effect, they act for long durations exclusively in the peripheral portion of the trigeminovascular system and can thus be assimilated to a durable attack treatment, unlike the classical preventives that chiefly act upstream on the central facets of migraine pathophysiology. Randomized controlled trials (RCT) of eptinezumab, erenumab, fremanezumab and galcanezumab have included collectively several thousands of patients, making them the most extensively studied class of preventive migraine treatments. Their results clearly indicate that CGRP/rec mAbs are significantly superior to placebo and have been comprehensively reviewed by Dodick [Cephalalgia 2019;39(3):445-458]. In this review we will briefly summarize the placebo-subtracted outcomes and number-needed-to-treat (NNT) of these pivotal RCTs and analyze new and post-hoc studies published afterwards focusing on effect size, effect onset and sustainability, response in subgroups of patients, safety and tolerability, and cost-effectiveness. We will also summarize our limited real-world experience with one of the CGRP/rec mAbs. Although methodological differences and lack of direct comparative trials preclude any reliable comparison, the overall impression is that there are only minor differences in efficacy and tolerability profiles between the four monoclonals: the average placebo-subtracted 50% responder rates for reduction in migraine headaches are 21.4% in episodic migraine (NNTs: 4-5), 17.4% in chronic migraine (NNTs: 4-8). Patients with an improvement exceeding 50% are rare, chronic migraineurs with continuous headache are unlikely to be responders and migraine auras are not improved. The effect starts within the first week after administration and is quasi maximal at one month. It is sustained for long time periods and may last for several months after treatment termination. CGRP/rec mAbs are effective even after prior preventive treatment failures and in patients with medication overuse, but the effect size might be smaller. They significantly reduce disability and health care resource utilization. The adverse effect profile of CGRP/rec mAbs is close to that of placebo with few minor exceptions and despite concerns related to the safeguarding role of CGRP in ischemia, no treatment-related vascular adverse events have been reported to date. Putting the CGRP/rec mAbs in perspective with available preventive migraine drug treatments, their major advantage seems not to be chiefly their superior efficacy but their unprecedented efficacy over adverse event ratio. Regarding cost-effectiveness, preliminary pharmaco-economic analyses of erenumab suggest that it is cost-effective for chronic migraine compared to no treatment or to onabotulinumtoxinA, but likely not for episodic migraine unless attack frequency is high, indirect costs are considered and its price is lowered.
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Affiliation(s)
- J Schoenen
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium.
| | - M Manise
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
| | - R Nonis
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
| | - P Gérard
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
| | - G Timmermans
- Headache Research Unit, Department of Neurology, University of Liège, Citadelle Hospital, 4000 Liège, Belgium
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Raut S, Singh U, Sarmah D, Datta A, Baidya F, Shah B, Bohra M, Jagtap P, Sarkar A, Kalia K, Borah A, Dave KR, Yavagal DR, Bhattacharya P. Migraine and Ischemic Stroke: Deciphering the Bidirectional Pathway. ACS Chem Neurosci 2020; 11:1525-1538. [PMID: 32348103 DOI: 10.1021/acschemneuro.0c00137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Migraine and stroke are common, disabling neurological conditions with several theories being proposed to explain this bidirectional relationship. Migraine is considered as a benign neurological disorder, but research has revealed a connection between migraine and stroke, predominantly those having migraine with aura (MA). Among migraineurs, females with MA are more susceptible to ischemic stroke and may have a migrainous infarction. Migrainous infarction mostly occurs in the posterior circulation of young women. Although there are several theories about the potential relationship between MA and stroke, the precise pathological process of migrainous infarction is not clear. It is assumed that cortical spreading depression (CSD) might be one of the essential factors for migrainous infarction. Other factors that may contribute to migrainous infarction may be genetic, hormonal fluctuation, hypercoagulation, and right to left cardiac shunts. Antimigraine drugs, such as ergot alkaloids and triptans, are widely used in migraine care. Still, they have been found to cause severe vasoconstriction, which may result in the development of ischemia. It is reported that patients with stroke develop migraines during the recovery phase. Both experimental and clinical data suggest that cerebral microembolism can act as a potential trigger for MA. Further studies are warranted for the treatment of migraine, which may lead to a decline in migraine-related stroke. In this present article, we have outlined various potential pathways that link migraine and stroke.
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Affiliation(s)
- Swapnil Raut
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Upasna Singh
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Deepaneeta Sarmah
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Aishika Datta
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Falguni Baidya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Birva Shah
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Mariya Bohra
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Priya Jagtap
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Ankan Sarkar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Kiran Kalia
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Anupom Borah
- Cellular and Molecular Neurobiology Laboratory, Department of Life Science and Bioinformatics, Assam University, Silchar, Assam 788011, India
| | - Kunjan R. Dave
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136, United States
| | - Dileep R. Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida 33136, United States
| | - Pallab Bhattacharya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
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Garcia-Martinez LF, Raport CJ, Ojala EW, Dutzar B, Anderson K, Stewart E, Kovacevich B, Baker B, Billgren J, Scalley-Kim M, Karasek C, Allison D, Latham JA. Pharmacologic Characterization of ALD403, a Potent Neutralizing Humanized Monoclonal Antibody Against the Calcitonin Gene-Related Peptide. J Pharmacol Exp Ther 2020; 374:93-103. [DOI: 10.1124/jpet.119.264671] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022] Open
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Martin V, Samaan KH, Aurora S, Pearlman EM, Zhou C, Li X, Pallay R. Efficacy and Safety of Galcanezumab for the Preventive Treatment of Migraine: A Narrative Review. Adv Ther 2020; 37:2034-2049. [PMID: 32319039 PMCID: PMC7467458 DOI: 10.1007/s12325-020-01319-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Indexed: 01/09/2023]
Abstract
Migraine is a debilitating neurologic disease. People who experience migraine can have substantial disability, impaired functioning and a decreased quality of life (QoL). Expert recommendations suggest that people with frequent migraine attacks or severe impairment related to attacks may benefit from preventive treatment. Despite these recommendations and the existence of evidence-based guidelines for the use of preventive medication, many people who are candidates for preventive therapies do not receive them. Thus, there is still a substantial unmet need for preventive migraine treatment. Calcitonin gene-related peptide (CGRP) has a demonstrated role in the pathophysiology of migraine. Galcanezumab-gnlm (galcanezumab) is a humanized monoclonal antibody that binds to the CGRP ligand and prevents binding to its receptor. It is administered as a once-monthly subcutaneous injection. The aim of this review is to present a comprehensive overview of the existing short- and long-term efficacy and safety data for galcanezumab in patients with migraine. Data from the phase 3, randomized, double-blind, placebo-controlled EVOLVE-1, EVOLVE-2 and REGAIN studies show that galcanezumab treatment for 3 or 6 months results in overall reduction in mean monthly migraine headache days in patients with episodic (EVOLVE-1 and EVOLVE-2) and chronic (REGAIN) migraine. Greater proportions of patients with episodic migraine receiving galcanezumab versus placebo demonstrated a ≥ 50%, ≥ 75% and 100% response to therapy and reported a lower level of disability and an improvement in functioning and QoL. Similarly, when compared with placebo, greater proportions of patients with chronic migraine treated with galcanezumab demonstrated a ≥ 50% and ≥ 75% response and reported improved functioning. A 12-month open-label study demonstrated the continued efficacy of galcanezumab for up to 12 months. In all studies galcanezumab was well tolerated. In conclusion, data from pivotal studies show that galcanezumab may fulfill an unmet need in the treatment of patients with migraine who require preventive therapy. Migraine is a significant contributor to the global burden of disease. Migraine symptoms can lead to substantial disability and can significantly impact an individual’s ability to perform everyday tasks and their overall quality of life. While individuals with infrequent migraine attacks might have success with acute treatments alone, those with more frequent attacks or who have severe migraine-related impairment may require preventive treatment. Although recommendations on the use of preventive treatment exist, only about one-third of individuals who qualify for preventive therapy actually receive it, resulting in a substantial unmet need. Calcitonin gene-related peptide (CGRP) has a demonstrated role in migraine. Galcanezumab is a humanized monoclonal antibody that binds to the CGRP ligand and prevents receptor binding. In clinical trials of patients with ≥ 4 migraine headache days per month, treatment with galcanezumab was associated with a reduction in the average number of migraine headache days per month. The majority of galcanezumab groups had greater responder rates compared with the placebo groups, and levels of disability and daily functioning were generally improved. Galcanezumab was well tolerated, with the most common adverse events being injection site reactions. The results from the clinical trials of galcanezumab suggest that this drug may fulfill an unmet need in the treatment of individuals with migraine who require preventive therapy.
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Ashina M, Saper J, Cady R, Schaeffler BA, Biondi DM, Hirman J, Pederson S, Allan B, Smith J. Eptinezumab in episodic migraine: A randomized, double-blind, placebo-controlled study (PROMISE-1). Cephalalgia 2020; 40:241-254. [PMID: 32075406 PMCID: PMC7066477 DOI: 10.1177/0333102420905132] [Citation(s) in RCA: 203] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of eptinezumab, a humanized anti-calcitonin gene-related peptide monoclonal antibody, in the preventive treatment of episodic migraine. METHODS The PRevention Of Migraine via Intravenous ALD403 Safety and Efficacy-1 (PROMISE-1) study was a phase 3, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. Adults with episodic migraine were randomized to eptinezumab 30 mg, 100 mg, 300 mg, or placebo for up to four intravenous (IV) doses administered every 12 weeks. The primary endpoint was change from baseline in monthly migraine days (MMDs) over weeks 1-12. RESULTS A total of 888 patients received treatment across 84 study sites. Mean MMDs at baseline was ∼8.6 across treatment groups. Eptinezumab 100 mg and 300 mg met the primary endpoint, significantly reducing MMDs across weeks 1-12 compared with placebo (30 mg, -4.0; 100 mg, -3.9, p = 0.0182; 300 mg, -4.3; placebo, -3.2, p = 0.0001). Treatment-emergent adverse events were reported by 58.4% (30 mg), 63.2% (100 mg), 57.6% (300 mg), and 59.5% (placebo) of patients. Treatment-emergent adverse events reported by ≥2% of eptinezumab-treated patients at an incidence greater than placebo included: upper respiratory tract infection (30 mg, 11.4%; 100 mg, 9.9%; 300 mg, 10.3%; placebo, 7.2%), and fatigue (30 mg, 2.3%; 100 mg, 3.6%; 300 mg, 3.6%; placebo, <1%). CONCLUSION Eptinezumab (100 mg or 300 mg) significantly reduced migraine frequency, was well tolerated, and had an acceptable safety profile when used for the preventive treatment of migraine in adults with episodic migraine. ClinicalTrials.gov identifier: NCT02559895.
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Affiliation(s)
- Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Joel Saper
- Michigan Headache & Neurological Institute, Ann Arbor, MI, USA
| | - Roger Cady
- Lundbeck Seattle BioPharmaceuticals, Inc., Bothell, WA, USA
| | | | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Inc., Woodinville, WA, USA
| | - Susan Pederson
- Lundbeck Seattle BioPharmaceuticals, Inc., Bothell, WA, USA
| | - Brent Allan
- Alder BioPharmaceuticals, Inc., Bothell, WA, USA
| | - Jeff Smith
- Lundbeck Seattle BioPharmaceuticals, Inc., Bothell, WA, USA
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Xu M, Bennett DLH, Querol LA, Wu LJ, Irani SR, Watson JC, Pittock SJ, Klein CJ. Pain and the immune system: emerging concepts of IgG-mediated autoimmune pain and immunotherapies. J Neurol Neurosurg Psychiatry 2020; 91:177-188. [PMID: 30224548 DOI: 10.1136/jnnp-2018-318556] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/18/2018] [Accepted: 07/30/2018] [Indexed: 12/30/2022]
Abstract
The immune system has long been recognised important in pain regulation through inflammatory cytokine modulation of peripheral nociceptive fibres. Recently, cytokine interactions in brain and spinal cord glia as well as dorsal root ganglia satellite glia have been identified important- in pain modulation. The result of these interactions is central and peripheral sensitisation of nociceptive processing. Additionally, new insights and the term 'autoimmune pain' have emerged through discovery of specific IgGs targeting the extracellular domains of antigens at nodal and synaptic structures, causing pain directly without inflammation by enhancing neuronal excitability. Other discovered IgGs heighten pain indirectly by T-cell-mediated inflammation or destruction of targets within the nociceptive pathways. Notable identified IgGs in pain include those against the components of channels and receptors involved in inhibitory or excitatory somatosensory synapses or their pathways: nodal and paranodal proteins (LGI1, CASPR1, CASPR2); glutamate detection (AMPA-R); GABA regulation and release (GAD65, amphiphysin); glycine receptors (GLY-R); water channels (AQP4). These disorders have other neurological manifestations of central/peripheral hyperexcitabability including seizures, encephalopathy, myoclonus, tremor and spasticity, with immunotherapy responsiveness. Other pain disorders, like complex regional pain disorder, have been associated with IgGs against β2-adrenergic receptor, muscarinic-2 receptors, AChR-nicotinic ganglionic α-3 receptors and calcium channels (N and P/Q types), but less consistently with immune treatment response. Here, we outline how the immune system contributes to development and regulation of pain, review specific IgG-mediated pain disorders and summarise recent development in therapy approaches. Biological agents to treat pain (anti-calcitonin gene-related peptide and anti-nerve growth factor) are also discussed.
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Affiliation(s)
- Min Xu
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Xuan wu Hospital Capital Medical University, Beijing, China
| | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Luis Antonio Querol
- Neuromuscular Diseases Unit-Neuromuscular Lab Neurology Department, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Long-Jun Wu
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarosh R Irani
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - James C Watson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Pain Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA .,Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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Vécsei L, Lukács M, Tajti J, Fülöp F, Toldi J, Edvinsson L. The Therapeutic Impact of New Migraine Discoveries. Curr Med Chem 2019; 26:6261-6281. [PMID: 29848264 DOI: 10.2174/0929867325666180530114534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 04/18/2018] [Accepted: 05/03/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Migraine is one of the most disabling neurological conditions and associated with high socio-economic costs. Though certain aspects of the pathomechanism of migraine are still incompletely understood, the leading hypothesis implicates the role of the activation of the trigeminovascular system. Triptans are considered to be the current gold standard therapy for migraine attacks; however, their use in clinical practice is limited. Prophylactic treatment includes non-specific approaches for migraine prevention. All these support the need for future studies in order to develop innovative anti-migraine drugs. OBJECTIVE The present study is a review of the current literature regarding new therapeutic lines in migraine research. METHODS A systematic literature search in the database of PUBMED was conducted concerning therapeutic strategies in a migraine published until July 2017. RESULTS Ongoing clinical trials with 5-HT1F receptor agonists and glutamate receptor antagonists offer promising new aspects for acute migraine treatment. Monoclonal antibodies against CGRP and the CGRP receptor are revolutionary in preventive treatment; however, further long-term studies are needed to test their tolerability. Preclinical studies show positive results with PACAP- and kynurenic acid-related treatments. Other promising therapeutic strategies (such as those targeting TRPV1, substance P, NOS, or orexin) have failed to show efficacy in clinical trials. CONCLUSION Due to their side-effects, current therapeutic approaches are not suitable for all migraine patients. Especially frequent episodic and chronic migraine represents a therapeutic challenge for researchers. Clinical and preclinical studies are needed to untangle the pathophysiology of migraine in order to develop new and migraine-specific therapies.
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Affiliation(s)
- László Vécsei
- Department of Neurology, University of Szeged, Szeged, Hungary.,MTASZTE Neuroscience Research Group, Szeged, Hungary
| | - Melinda Lukács
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - János Tajti
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Ferenc Fülöp
- Institute of Pharmaceutical Chemistry and MTA-SZTE Research Group for Stereochemistry, University of Szeged, Szeged, Hungary
| | - József Toldi
- Department of Physiology, Anatomy and Neuroscience, University of Szeged, Szeged, Hungary
| | - Lars Edvinsson
- Department of Clinical Sciences, Division of Experimental Vascular Research, Lund University, Lund, Sweden.,Department of Clinical Experimental Research, Copenhagen University, Glostrup Hospital, Copenhagen, Denmark
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Edvinsson L. The CGRP Pathway in Migraine as a Viable Target for Therapies. Headache 2019; 58 Suppl 1:33-47. [PMID: 29697153 DOI: 10.1111/head.13305] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 12/22/2022]
Abstract
The neuropeptide calcitonin gene-related peptide is well established as a key player in the pathogenesis of migraine. Clinical studies show calcitonin gene-related peptide levels correlate with migraine attacks, and decreases in this neuropeptide can indicate antimigraine therapy effectiveness. Research has revealed a wide distribution of expression sites for calcitonin gene-related peptide in the central and peripheral nervous system. Of these, the calcitonin gene-related peptide receptor, which binds calcitonin gene-related peptide with high affinity, has attracted growing interest as a viable target for antimigraine therapies. An incentive to pursue such research is the continuing unmet medical need of patients. Triptans have offered some clinical benefit, but many patients do not respond and these drugs have important safety considerations. Initial calcitonin gene-related peptide-focused research led to development of the "gepant" small-molecule calcitonin gene-related peptide receptor blockers. Positive efficacy reports concerning the gepants have been tempered by safety findings which led to the discontinuation of some of these agents. Currently, there is considerable excitement regarding monoclonal antibodies against calcitonin gene-related peptide (eptinezumab, galcanezumab, fremanezumab) and the calcitonin gene-related peptide receptor (erenumab). To date, these monoclonal antibodies have shown promising efficacy in clinical trials, with no major safety concerns. If ongoing long-term studies show that their efficacy can be maintained, this may herald a new era for effective antimigraine therapies.
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Affiliation(s)
- Lars Edvinsson
- Institute of Clinical Sciences, Lund University, Lund, Sweden
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31
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Abstract
Introduction: Calcitonin Gene-Related Peptide (CGRP) plays a crucial role in migraine pathophysiology. A novel specific treatment strategy for the prevention of migraine incorporates monoclonal antibodies (mAbs) against CGRP and its canonical receptor. Eptinezumab, fremanezumab and galcanezumab block CGRP mediated effects by binding to the peptide, while erenumab blocks the CGRP receptor.Areas covered: Following a brief overview of pharmacological characteristics, we will review phase III trials for the use of CGRP mAbs in the prevention of episodic and chronic migraine.Expert opinion: All four CGRP mAbs demonstrated an excellent safety, tolerability and efficacy profile in migraine patients. Across all trials mAbs showed superior efficacy for the reduction of monthly migraine days compared to placebo with a net benefit of 2.8 days. Neither cardiovascular nor immunological safety concerns have emerged from clinical trials. Fremanezumab, galcanezumab, and erenumab are approved in the USA and Europe. Based on trial data there is no reason why these mAbs should not become first-line therapies in future. For now, we advocate for the use of mAbs in migraine prevention for patients who failed a minimum of two standard oral treatments based on the novelty and costs of this approach. mAbs are also effective in patients with medication overuse and with comorbid depression or anxiety disorders. Taken together, mAbs are likely to usher in a new era in migraine prevention and provide significant value to patients.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Clinician Scientist Programm, Berlin Institute of Health (BIH), Berlin, Germany
| | - Lars Neeb
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Silberstein SD, Stauffer VL, Day KA, Lipsius S, Wilson MC. Galcanezumab in episodic migraine: subgroup analyses of efficacy by high versus low frequency of migraine headaches in phase 3 studies (EVOLVE-1 & EVOLVE-2). J Headache Pain 2019; 20:75. [PMID: 31253091 PMCID: PMC6734504 DOI: 10.1186/s10194-019-1024-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/11/2019] [Indexed: 12/20/2022] Open
Abstract
Background Patients with high-frequency episodic migraine (HFEM) have a greater disease burden than those with low-frequency episodic migraine (LFEM). Acute treatment overuse increases the risk of migraine chronification in patients with HFEM. Galcanezumab, a humanized monoclonal antibody binding calcitonin gene-related peptide (CGRP), is effective for migraine prevention with a favorable safety profile. Here, we investigate whether there are differences in galcanezumab efficacy in patients with LFEM or with HFEM. Methods Data were pooled from two double-blind, placebo-controlled phase 3 trials; EVOLVE-1 and EVOLVE-2. Patients were 18–65 years old, experienced 4–14 monthly migraine headache days (MHDs) for ≥1 year prior, with onset at < 50 years of age. Migraine headaches were tracked via electronic patient-reported outcome system and randomization was stratified by low (LFEM; 4–7 monthly MHDs) or high (HFEM; 8–14 monthly MHDs) frequency. Subgroup analysis compared the HFEM and LFEM subgroups with a linear or generalized linear mixed model repeated measures approach. Results The intent-to-treat patients (N = 1773) had a mean age of 41.3 years, were mostly white (75%), female (85%), and 66% of patients had HFEM. In both the LFEM and HFEM subgroups, the overall (Months 1–6) and monthly changes from baseline in monthly MHDs and monthly MHDs with acute medication use compared with placebo were statistically significantly reduced for galcanezumab 120-mg and 240-mg. Galcanezumab (120-mg and 240-mg) significantly decreased the overall and monthly MHDs with nausea and/or vomiting, and with photophobia and phonophobia versus placebo in patients with LFEM or HFEM. In both subgroups, the mean overall (Months 1–6) and monthly percentages of patients with ≥50%, ≥75%, and 100% reduction in monthly MHDs from baseline were statistically significantly greater in patients receiving either dose of galcanezumab versus placebo. Galcanezumab (120-mg and 240-mg) significantly improved the Migraine-Specific Quality of Life Questionnaire role function-restrictive domain score as well as the Migraine Disability Assessment total score versus placebo for patients with LFEM or HFEM. There were no significant subgroup-by-treatment interactions. Conclusions Galcanezumab was as effective in patients with HFEM as in those with LFEM. Associated symptoms, quality of life, and disability were similarly improved in patients with HFEM or LFEM. Trial registration NCT02614183, NCT02614196.
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Affiliation(s)
| | - Virginia L Stauffer
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, Indiana, USA
| | - Katie A Day
- Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, Indiana, USA
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33
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Erenumab and galcanezumab in chronic migraine prevention: effects after treatment termination. J Headache Pain 2019; 20:66. [PMID: 31159727 PMCID: PMC6734267 DOI: 10.1186/s10194-019-1018-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/27/2019] [Indexed: 11/24/2022] Open
Abstract
Background Monoclonal antibodies (mAbs) targeting the CGRP pathway are safe and efficacious therapies for the prevention of migraine. In this study we assessed the effects of discontinuation of preventive erenumab and galcanezumab treatment in patients with chronic migraine. Methods This retrospective pooled analysis included completers of the open-label extension study phase for the preventive treatment of chronic migraine with galcanezumab (NCT02614261; 9 months) and erenumab (NCT02174861; 12 months) in a single headache center. We compare migraine data until week 12 after open-label treatment completion, when patients did not have any pharmacological preventive medication, to study baseline values of the double-blind trial period, and to the last 4 weeks of the open-label extension. The assessment included changes in monthly migraine days, headache hours, days with severe headache and acute headache medication use. Results Data from 16 patients after galcanezumab (n = 9) and erenumab (n = 7) open-label treatment completion were analyzed. The mean number of monthly migraine days was 18.38 ± 3.74 at baseline, and 12.19 ± 4.53 in the last 4 weeks of the open-label extension (p < 0.001). Monthly migraine days remained significantly reduced compared to baseline during the entire 12-week observation period after open-label termination (p = 0.002), with a reduction of 5.38 ± 4.92 in weeks 1–4 (p = 0.001), 4.75 ± 4.15 in weeks 5–8 (p = 0.001), and 3.93 ± 5.45 in weeks 9–12 (p = 0.014). There was no significant difference in monthly migraine days between the 12 weeks after open-label termination and the last 4 weeks of the open-label phase (p = 0.228). All other analyses revealed numerical improvement through week 12 in comparison to baseline. Conclusions In this small, self-selected cohort, the results indicate a therapeutic effect of monoclonal antibodies targeting the CRGP pathway in chronic migraine prevention after treatment termination up to 12 weeks.
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34
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Pomes LM, Guglielmetti M, Bertamino E, Simmaco M, Borro M, Martelletti P. Optimising migraine treatment: from drug-drug interactions to personalized medicine. J Headache Pain 2019; 20:56. [PMID: 31101004 PMCID: PMC6734220 DOI: 10.1186/s10194-019-1010-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/05/2019] [Indexed: 11/16/2022] Open
Abstract
Migraine is the most disabling and expensive chronic disorders, the etiology of which is still not fully known. The neuronal systems, (glutammatergic, dopaminergic, serotoninergic and GABA-ergic) whose functionality is partly attributable to genetically determined factors, has been suggested to play an important role. The treatment of acute attacks and the prophylactic management of chronic forms include the use of different category of drugs, and it is demonstrated that not each subject has the same clinical answer to them. The reason of this is to be searched in different functional capacity and quantity of phase I enzymes (such as different isoforms of CYP P450), phase II enzymes (such as UDP-glucuronosyltransferases), receptors (such as OPRM1 for opioids) and transporters (such as ABCB1) involved in the metabolic destiny of each drug, all of these dictated by DNA and RNA variations. The general picture is further exacerbated by the need for polytherapies, often also to treat comorbidities, which may interfere with the pharmacological action of anti-migraine drugs. Personalized medicine has the objective of setting the optimal therapies in the light of the functional biochemical asset and of the comorbidities of the individual patient, in order to obtain the best clinical response. Novel therapeutic perspectives in migraine includes biotechnological drugs directed against molecules (such as CGRP and its receptor) that cause vasodilatation at the peripheral level of the meningeal blood vessels and reflex stimulation of the parasympathetic system. Drug-drug interactions and the possible competitive metabolic destiny should be studied by the application of pharmacogenomics in large scale. Drug-drug interactions and their possible competitive metabolic destiny should be studied by the application of pharmacogenomics in large scale.
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Affiliation(s)
- Leda Marina Pomes
- Residency Program in Laboratory Medicine, Gabriele d'Annunzio University, Chieti, Italy
| | - Martina Guglielmetti
- Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy.,Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Enrico Bertamino
- Residency Program in Hygiene and Preventive Medicine, Sapienza University of Rome, Rome, Italy
| | - Maurizio Simmaco
- Department of Neurosciences, Mental Health and Sensory Organs, Sapienza University of Rome, Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Marina Borro
- Department of Neurosciences, Mental Health and Sensory Organs, Sapienza University of Rome, Rome, Italy.,Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Paolo Martelletti
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy. .,Internal Medicine and Emergency Medicine Unit, Sant'Andrea Hospital, Rome, Italy.
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35
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Silberstein SD, McAllister P, Ning X, Faulhaber N, Lang N, Yeung P, Schiemann J, Aycardi E, Cohen JM, Janka L, Yang R. Safety and Tolerability of Fremanezumab for the Prevention of Migraine: A Pooled Analysis of Phases 2b and 3 Clinical Trials. Headache 2019; 59:880-890. [PMID: 30977520 DOI: 10.1111/head.13534] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Presentation of pooled analysis of safety data for fremanezumab in patients with chronic (CM) or episodic migraine (EM) from 4 placebo-controlled phase 2b and phase 3 studies. BACKGROUND There is a need for an effective, safe, and well-tolerated preventive therapy that specifically targets the pathophysiology of migraine to reduce the frequency and severity of migraine attacks in patients with CM or EM who experience 4 or more migraine days per month. Fremanezumab is a fully humanized monoclonal antibody that targets calcitonin gene-related peptide, a neuropeptide involved in the pathophysiology of migraine. DESIGN/METHODS The 4 placebo-controlled phases 2b and 3 studies included in this analysis were 16-week, multicenter, randomized, double-blind, placebo-controlled, and parallel-group studies consisting of a screening visit, a 28-day pretreatment baseline period, and a 12-week treatment period with a final evaluation 4 weeks after the final dose of the study drug. Safety endpoints included adverse events (AEs) and immunogenicity. RESULTS A total of 2566 patients were randomized across all studies (fremanezumab, n = 1704; placebo, n = 862), and 2563 patients were treated. Common reasons for study discontinuation were withdrawal by patient (n = 78), patient lost to follow-up (n = 60), and AE (n = 50). The mean (standard deviation) duration of exposure was 83.8 (13.6) days for the patients who received fremanezumab, with a total exposure of 390.4 patient years and maximum exposure of 181 days. AEs were mostly mild to moderate in severity and were reported among 48-69% of patients in all treatment groups, and most were injection site reactions (pain, induration, and erythema). Two deaths occurred (chronic obstructive pulmonary disease and intentional overdose of diphenhydramine), both of which were deemed unrelated to study drug by the investigators and sponsor. Cardiovascular adverse events, abnormal liver function tests, and hypersensitivity were uncommon and occurred at similar rates between the placebo and fremanezumab groups. CONCLUSIONS Fremanezumab is a generally safe and well-tolerated preventive therapy for migraine in adults.
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Affiliation(s)
| | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, CT, USA
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Maasumi K, Michael RL, Rapoport AM. CGRP and Migraine: The Role of Blocking Calcitonin Gene-Related Peptide Ligand and Receptor in the Management of Migraine. Drugs 2019; 78:913-928. [PMID: 29869205 DOI: 10.1007/s40265-018-0923-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Migraine is a highly prevalent, complex neurological disorder. The burden of disease and the direct/indirect annual costs are enormous. Thus far, treatment options have been inadequate and mostly based on trial and error, leaving a significant unmet need for effective therapies. While the underlying pathophysiology of migraine is incompletely understood, blocking the calcitonin gene-related peptide (CGRP) using monoclonal antibodies targeting CGRP or its receptor and small molecule CGRP receptor antagonists (gepants) have emerged as a promising therapeutic opportunity for the management of migraine. In this review, we discuss new concepts in the pathophysiology of migraine and the role of CGRP, the current guidelines for treating migraine preventively, the medications that are being used, and their limitations. We then discuss small molecule CGRP receptor antagonists, monoclonal antibodies to CGRP ligand and receptor, as well as the detailed results of Phase II and III trials involving these novel treatments. We conclude with a discussion of the implications of blocking CGRP and its receptor.
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Affiliation(s)
- Kasra Maasumi
- Department of Neurology, University of California, San Francisco, USA.
| | - Rebecca L Michael
- Department of Neurology, University of California, San Francisco, USA
| | - Alan M Rapoport
- Department of Neurology, University of California, Los Angeles, USA
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37
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Abstract
PURPOSE OF REVIEW The purpose of the following review is to summarize the most recent understanding of migraine pathophysiology, as well as of basic and clinical science pharmacologic literature regarding the development of calcitonin gene receptor peptide (CGRP) antagonists as a novel therapeutic modality for the treatment of migraine headaches. A review is provided of erenumab, the first of its class FDA approved CGRP antagonist. RECENT FINDINGS Despite its high prevalence, the occurrence and treatment of migraine headaches is poorly understood. Erenumab and CGRP antagonists as a whole significantly reduce the average number of migraine days experienced in migraine sufferers. CGRP antagonists appear to significantly improve treatment outcomes in patients who suffer from episodic and chronic migraines. Erenumab is the first CGRP antagonist to be FDA approved for public use; however, further development of biologics in this class is underway.
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Munksgaard SB, Ertsey C, Frandsen E, Bendtsen L, Tekes K, Jensen RH. Circulating nociceptin and CGRP in medication-overuse headache. Acta Neurol Scand 2019; 139:269-275. [PMID: 30457160 DOI: 10.1111/ane.13053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 11/09/2018] [Accepted: 11/23/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Previous studies found low serum levels of nociceptin in migraine patients but high serum levels of calcitonin gene-related peptide (CGRP). CGRP can elicit migraine-like headache. Medication-Overuse Headache (MOH) often has migraine features and can mimic chronic migraine. We therefore hypothesized that as in migraine, serum levels of nociceptin would be lower and CGRP serum levels higher in MOH patients compared with those in healthy volunteers. We hypothesized that the serum levels would normalize after detoxification. METHODS Seventeen MOH patients, hereof 70.6% with chronic migraine and MOH, and 30 sex and age matched headache-free controls were included. MOH patients underwent a 2-month outpatient detoxification program and after 6 months, 10 patients and 19 controls were retested. Blood samples were analyzed blinded. RESULTS We found no differences in the levels of nociceptin and CGRP between MOH patients and controls (P = 0.65 and P = 0.59). The mean headache frequency reduction was 43% and 70% of patients reverted to episodic headache after 6 months, but the levels of nociceptin and CGRP were unchanged (P = 0.71 and P = 0.82). CONCLUSION In contrast to previous findings in migraine patients, we found normal serum levels of nociceptin and CGRP in MOH patients. Thus, we find no evidence that the increased headache frequency of MOH patients could be caused by altered nociceptin and CGRP levels. This underlines the importance of identifying medication overuse in chronic headache and treating the MOH.
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Affiliation(s)
- Signe B Munksgaard
- Department of Neurology, Rigshospitalet-Glostrup, Danish Headache Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Csaba Ertsey
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Erik Frandsen
- Department of Diagnostics, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bendtsen
- Department of Neurology, Rigshospitalet-Glostrup, Danish Headache Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kornelia Tekes
- Department of Pharmacodynamics, Semmelweis University, Budapest, Hungary
| | - Rigmor H Jensen
- Department of Neurology, Rigshospitalet-Glostrup, Danish Headache Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
BACKGROUND AND PURPOSE Migraine headache is an enormous health care burden resulting in billions of dollars in workforce revenue lost and millions of lost workdays per year. Migraine headaches and depression are common comorbidities and require expertise in treatment and prevention. METHODS The aim of this article is to update the nurse practitioner (NP) on best clinical practices for managing the patient with migraine and previously diagnosed depression. This will include an overview of the pathophysiology of migraine, as well as criteria for diagnosis, treatment, prevention, and patient teaching. CONCLUSIONS Migraine and depression are commonly linked and require expertise in treatment to achieve the best patient outcomes. IMPLICATIONS FOR PRACTICE Patients with migraine are more likely to have depression than the general population. Both conditions require optimal treatment and patient education to reduce overall disease burden. A better understanding of the relationship between depression and migraine will enable the NP to better manage patients with migraine and comorbid depression.
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Ashish K, Faisaluddin M, Bandyopadhyay D, Dhaduk K, Baral A. Therapeutic role of monoclonal antibodies in Migraine: A new paradigm. Eur J Intern Med 2018; 57:e9-e10. [PMID: 30031595 DOI: 10.1016/j.ejim.2018.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Affiliation(s)
| | | | | | - Kartik Dhaduk
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Anupam Baral
- Albert Einstein Medical Center, Philadelphia, PA, USA
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42
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Cowan RP. The Future of Migraine Prevention. Headache 2018; 58 Suppl 3:291-297. [DOI: 10.1111/head.13418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2018] [Indexed: 11/30/2022]
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Straube A, Ruscheweyh R. [Pain - The most interesting new findings in the last ten years]. MMW Fortschr Med 2018; 160:111-115. [PMID: 30421182 DOI: 10.1007/s15006-018-1137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Andreas Straube
- Neurologie, Klinikum Großhadern, Ludwig-Maximilians Universität, Marchioninistraße 15, D-81377, München, Deutschland.
| | - Ruth Ruscheweyh
- Neurologie, Klinikum Großhadern, Ludwig-Maximilians Universität, Marchioninistraße 15, D-81377, München, Deutschland
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Szperka CL, VanderPluym J, Orr SL, Oakley CB, Qubty W, Patniyot I, Lagman-Bartolome AM, Morris C, Gautreaux J, Victorio MC, Hagler S, Narula S, Candee MS, Cleves-Bayon C, Rao R, Fryer RH, Bicknese AR, Yonker M, Hershey AD, Powers SW, Goadsby PJ, Gelfand AA. Recommendations on the Use of Anti-CGRP Monoclonal Antibodies in Children and Adolescents. Headache 2018; 58:1658-1669. [PMID: 30324723 DOI: 10.1111/head.13414] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Christina L Szperka
- Division of Neurology, Children's Hospital of Philadelphia & Departments of Neurology & Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Serena L Orr
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Cynthia Morris
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Jessica Gautreaux
- Lousiana State University Health Science Center and Children's Hospital New Orleans, New Orleans, LA, USA
| | | | | | - Sona Narula
- Division of Neurology, Children's Hospital of Philadelphia & Departments of Neurology & Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meghan S Candee
- University of Utah, Primary Children's Hospital, Salt Lake City, UT, USA
| | | | - Rashmi Rao
- Lousiana State University Health Science Center and Children's Hospital New Orleans, New Orleans, LA, USA
| | | | - Alma R Bicknese
- Feinberg School of Medicine at Northwestern University & Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Andrew D Hershey
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Scott W Powers
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Orr SL, Kabbouche MA, O’Brien HL, Kacperski J, Powers SW, Hershey AD. Paediatric migraine: evidence-based management and future directions. Nat Rev Neurol 2018; 14:515-527. [DOI: 10.1038/s41582-018-0042-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Reuter U. A Review of Monoclonal Antibody Therapies and Other Preventative Treatments in Migraine. Headache 2018; 58 Suppl 1:48-59. [DOI: 10.1111/head.13302] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/16/2018] [Accepted: 03/18/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Uwe Reuter
- Charité - Universitätsmedizin Berlin, Charitéplatz 1; 10117 Berlin Germany
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Peripheral GABA A receptor-mediated signaling facilitates persistent inflammatory hypersensitivity. Neuropharmacology 2018; 135:572-580. [PMID: 29634983 DOI: 10.1016/j.neuropharm.2018.04.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/30/2018] [Accepted: 04/06/2018] [Indexed: 01/26/2023]
Abstract
Unlike in the central nervous system (CNS), in the adult peripheral nervous system (PNS), activation of GABAA receptors (GABAAR) is excitatory because of the relatively high concentration of intracellular chloride in these neurons. Indeed, exogenous GABA and muscimol, a GABAAR agonist, exacerbate acute inflammatory hypersensitivity in rodents. However, it remains unclear whether peripheral GABAAR and the endogenous GABA play an important role in persistent inflammatory hypersensitivity. In this study, we thus investigated how peripheral GABAAR affects pain hypersensitivity by using the complete Freund's adjuvant (CFA)-induced persistent inflammatory pain mouse model. We found that intraplantar (i.pl.) administration of GABAAR antagonists, picrotoxin, and 1(S),9(R)-(-)-bicuculline methiodide significantly inhibited both spontaneous nociceptive (paw licking and flinching) behavior and mechanical hypersensitivity in CFA-injected mice at day 3 (D3), but not in naïve mice. Interestingly, CFA-induced mechanical hypersensitivity was significantly reversed by anti-GABA antibody (anti-GABA, i.pl.). In addition, RT-qPCR revealed that glutamate decarboxylase Gad1 (GAD 67) and Gad2 (GAD 65) mRNA expression was also upregulated in the ipsilateral hind paw of CFA-injected mice at D3. Finally, 5α-pregnan-3α-ol-20-one (3α,5α-THP), a selective positive allosteric modulator of GABAAR, produced mechanical hypersensitivity in naïve mice in a dose-dependent manner. Taken together, our results indicate that peripheral GABAAR and endogenous GABA, possibly produced by the inflamed tissue, potentiate CFA-induced persistent inflammatory hypersensitivity, suggesting that they can be used as a therapeutic target for alleviating inflammatory pain.
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Raffaelli B, Reuter U. The Biology of Monoclonal Antibodies: Focus on Calcitonin Gene-Related Peptide for Prophylactic Migraine Therapy. Neurotherapeutics 2018; 15:324-335. [PMID: 29616494 PMCID: PMC5935651 DOI: 10.1007/s13311-018-0622-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) is 37-amino-acid neuropeptide, crucially involved in migraine pathophysiology. Four monoclonal antibodies (mAbs) targeting the CGRP pathway are currently under evaluation for the prevention of episodic and chronic migraine: eptinezumab (ALD403), fremanezumab (TEV-48125), galcanezumab (LY2951742), and erenumab (AMG334). As reviewed in this article, all 4 antibodies have been proven effective, tolerable, and safe as migraine prophylactic treatments in phase II clinical trials. The mean decrease in migraine days per month was between 3.4 and 6.3 days/month after 8 to 12 weeks of treatment, and the placebo subtracted benefit ranged from 1 to 2.18 days. Notably, up to 32% of subjects experienced total migraine freedom after drug administration. Substance class-specific adverse events and treatment-related serious adverse event did not occur. Further long-term and large-scale trials are currently under way to verify the safety and efficacy profile of mAbs. In particular, the potential risk of vascular adverse events and the role of anti-drug antibodies deserve special attention. Anti-CGRP peptide and anti-CGRP receptor antibodies are the first effective treatments, which were specifically developed for the prevention of migraine. Their site of action in migraine prevention is most likely peripheral due to large molecule size, which prevents the penetration through the blood-brain barrier and thereby shows that peripheral components play a pivotal role in the pathophysiology of a CNS disease.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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González-Hernández A, Marichal-Cancino BA, MaassenVanDenBrink A, Villalón CM. Side effects associated with current and prospective antimigraine pharmacotherapies. Expert Opin Drug Metab Toxicol 2018; 14:25-41. [PMID: 29226741 DOI: 10.1080/17425255.2018.1416097] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Migraine is a neurovascular disorder. Current acute specific antimigraine pharmacotherapies target trigeminovascular 5-HT1B/1D, 5-HT1F and CGRP receptors but, unfortunately, they induce some cardiovascular and central side effects that lead to poor treatment adherence/compliance. Therefore, new antimigraine drugs are being explored. Areas covered: This review considers the adverse (or potential) side effects produced by current and prospective antimigraine drugs, including medication overuse headache (MOH) produced by ergots and triptans, the side effects observed in clinical trials for the new gepants and CGRP antibodies, and a section discussing the potential effects resulting from disruption of the cardiovascular CGRPergic neurotransmission. Expert opinion: The last decades have witnessed remarkable developments in antimigraine therapy, which includes acute (e.g. triptans) and prophylactic (e.g. β-adrenoceptor blockers) antimigraine drugs. Indeed, the triptans represent a considerable advance, but their side effects (including nausea, dizziness and coronary vasoconstriction) preclude some patients from using triptans. This has led to the development of the ditans (5-HT1F receptor agonists), the gepants (CGRP receptor antagonists) and the monoclonal antibodies against CGRP or its receptor. The latter drugs represent a new hope in the antimigraine armamentarium, but as CGRP plays a role in cardiovascular homeostasis, the potential for adverse cardiovascular side effects remains latent.
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Affiliation(s)
| | - Bruno A Marichal-Cancino
- b Departamento de Fisiología y Farmacología, Universidad Autónoma de Aguascalientes , Ciudad Universitaria , Aguascalientes , México
| | - Antoinette MaassenVanDenBrink
- c Division of Vascular Medicine and Pharmacology, Department of Internal Medicine , Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Carlos M Villalón
- d Departamento de Farmacobiología , Cinvestav-Coapa , Ciudad de México , México
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Cohen JM, Dodick DW, Yang R, Newman LC, Li T, Aycardi E, Bigal ME. Fremanezumab as Add-On Treatment for Patients Treated With Other Migraine Preventive Medicines. Headache 2017; 57:1375-1384. [DOI: 10.1111/head.13156] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Joshua M. Cohen
- Medical Affairs, Teva Pharmaceutical Industries; Frazer PA USA
| | | | - Ronghua Yang
- Biostatistics; Teva Pharmaceutical Industries; Frazer PA USA
| | - Lawrence C. Newman
- Department of Neurology; New York University Medical Center; New York NY USA
| | - Thomas Li
- Biostatistics; Teva Pharmaceutical Industries; Frazer PA USA
| | - Ernesto Aycardi
- Clinical Development; Teva Pharmaceutical Industries; Frazer PA USA
| | - Marcelo E. Bigal
- Clinical Development; Teva Pharmaceutical Industries; Frazer PA USA
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