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Wang Y, Yang F, Chen L, Chang T, Su H, Yang C, Tu Y, Tzeng Y, Chen S, Fuh J, Lai K, Ling Y, Chen W, Wang S. Comparative effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies and onabotulinumtoxinA in chronic migraine: A multicenter, real-world study in Taiwan. Eur J Neurol 2024; 31:e16372. [PMID: 38837528 PMCID: PMC11295178 DOI: 10.1111/ene.16372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/23/2024] [Accepted: 05/14/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE To compare the real-world effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) and onabotulinumtoxinA in chronic migraine (CM) patients. METHODS This multicenter study involved retrospective analysis of prospectively collected data of CM patients treated with CGRP mAbs or onabotulinumtoxinA, including difficult-to-treat (DTT) patients (i.e., ≥3 preventive failures). Treatment outcomes were determined at 6 months based on prospective headache diaries and Migraine Disability Assessment (MIDAS). RESULTS The study included 316 (55 M/261F, mean age 44.4 ± 13.5 years) and 333 (61 M/272F, mean age 47.9 ± 13.4 years) CM patients treated with CGRP mAbs or onabotulinbumtoxinA, respectively. At 6 months, CGRP mAb treatment was associated with a greater decrease in monthly migraine days (MMDs) (-13.0 vs. -8.7 days/month, p < 0.001) and a higher ≥50% responder rate (RR) (74.7% vs. 50.7%, p < 0.001) compared with onabotulinumtoxinA injections. The findings were consistent in DTT patients (-13.0 vs. -9.1 MMDs, p < 0.001; ≥50% RR: 73.9% vs. 50.3%, p < 0.001) or those with medication-overuse headache (MOH) (-13.3 vs. -9.0 MMDs, p < 0.001; ≥50% RR: 79.0% vs. 51.6%, p < 0.001). Besides, patients receiving CGRP mAbs had greater improvement (-42.2 vs. -11.8, p < 0.001) and a higher ≥50% RR (62.0% vs. 40.0%, p = 0.001) in MIDAS scores and a lower rate of adverse events (AEs) (6.0% vs. 21.0%, p < 0.001). However, none of the patients discontinued treatment due to AEs. CONCLUSIONS In this multicenter, real-world study, CGRP mAbs were more effective than onabotulinumtoxinA in CM patients, even in DTT or MOH patients. All of these injectables were well tolerated. Further prospective studies are needed to verify these findings.
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Affiliation(s)
- Yen‐Feng Wang
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Brain Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Fu‐Chi Yang
- Department of Neurology, Tri‐Service General HospitalNational Defense Medical CenterTaipeiTaiwan
- Graduate Institute of Medical SciencesNational Defense Medical CenterTaipeiTaiwan
| | - Lu‐An Chen
- Department of NeurologyMacKay Memorial HospitalTaipeiTaiwan
| | - Ting‐Yu Chang
- Stroke Center and Department of Neurology, Chang Gung Memorial HospitalLinkou Medical CenterTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
| | - Hui‐Chen Su
- Department of NeurologyNational Cheng Kung University HospitalTainanTaiwan
- College of MedicineNational Cheng Kung UniversityTainanTaiwan
| | - Chun‐Pai Yang
- Department of NeurologyKuang Tien General HospitalTaichungTaiwan
- Ph.D. Program in Translational MedicineNational Chung Hsing UniversityTaichungTaiwan
| | - Yi‐Hsien Tu
- Department of NeurologyAn Nan Hospital, China Medical UniversityTainanTaiwan
| | - Yi‐Shiang Tzeng
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
| | - Shih‐Pin Chen
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Brain Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Translational Research, Department of Medical ResearchTaipei Veterans General HospitalTaipeiTaiwan
| | - Jong‐Ling Fuh
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Brain Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Kuan‐Lin Lai
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Brain Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Yu‐Hsiang Ling
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Wei‐Ta Chen
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Brain Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Neurology, Keelung HospitalMinistry of Health and WelfareKeelungTaiwan
| | - Shuu‐Jiun Wang
- Department of NeurologyNeurological Institute, Taipei Veterans General HospitalTaipeiTaiwan
- School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Brain Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Taipei Municipal Gan‐Dau HospitalTaipeiTaiwan
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Koelsche T, Nikolov P, Koska V, Ingwersen J, Jansen R, Arat E, Meuth SG, Albrecht P, Lee JI. Additional effect of erenumab for patients with chronic migraine treated with onabotulinumtoxin A-real-world data from a preliminary cohort study. Front Neurol 2024; 15:1370503. [PMID: 38988600 PMCID: PMC11234259 DOI: 10.3389/fneur.2024.1370503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 06/12/2024] [Indexed: 07/12/2024] Open
Abstract
Background This preliminary retrospective cohort study investigates the potential additive prophylactic effect of erenumab, a fully human monoclonal antibody that blocks the calcitonin gene-related peptide receptor, in combination with ongoing onabotulinumtoxin A (onaBoNT-A) treatment in patients suffering from chronic migraine. Methods The study included 218 patients and investigated the effects of adding erenumab to the existing treatment regimen. The primary outcome was the MIDAS (Migraine Disability Assessment) score assessed 3 months after the introduction of erenumab. Results The results indicated a significant improvement of the MIDAS score, suggesting a reduction in migraine-related disability following the addition of erenumab to onaBoNT-A. In the inter group comparison, dual therapy showed a significantly greater reduction of the MIDAS when compared to a switch from onaBoNT-A to erenumab monotherapy, but not compared to initiation of onaBoNT-A monotherapy. It is hypothesized that the observed additive effects are due to the independent modes of action of erenumab and onabotulinumtoxin A. Conclusion This study suggests that the combination of erenumab with onaBoNT-A may offer an improved approach for the treatment of chronic migraine in selected patients. However, the results highlight the need for prospective, controlled studies to validate these findings and determine the optimal combination of treatments tailored to the individual patient.
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Affiliation(s)
- Tristan Koelsche
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Petyo Nikolov
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Valeria Koska
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jens Ingwersen
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Robin Jansen
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ercan Arat
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Neurology, Maria Hilf Clinics, Mönchengladbach, Germany
| | - John-Ih Lee
- Department of Neurology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Salim A, Hennessy E, Sonneborn C, Hogue O, Biswas S, Mays M, Suneja A, Ahmed Z, Mata IF. Synergism of Anti-CGRP Monoclonal Antibodies and OnabotulinumtoxinA in the Treatment of Chronic Migraine: A Real-World Retrospective Chart Review. CNS Drugs 2024; 38:481-491. [PMID: 38583127 PMCID: PMC11098928 DOI: 10.1007/s40263-024-01086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Many patients with chronic migraine do not achieve clinically meaningful improvement in their headache frequency with monotherapy. The burden associated with chronic migraine calls for a multifaceted treatment approach targeting multiple aspects of migraine pathophysiology. OBJECTIVE The aim of this study was to evaluate the effect of concurrent anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) and onabotulinumtoxinA (onabot) treatment on median monthly migraine days (MMD) in patients with chronic migraine, through a retrospective study. METHODS The electronic medical records of Cleveland Clinic patients either concurrently (dual therapy) or consecutively (monotherapy) treated with anti-CGRP mAbs and onabot between June 2018 and November 2021 were extracted. Only adult patients (≥ 18 years of age) were included in this study. MMDs for 194 concurrently treated (86.6% female and a median [interquartile range] age of 51 [41-61] years) and 229 consecutively treated (88.2% female and median age of 47 [IQR 39-57] years) patients were examined at baseline, after first therapy of either anti-CGRP mAb or onabot, and following dual therapy for 3 consecutive months. The reduction of MMDs for each treatment group were compared. The same approach was utilized to compare consecutive monotherapy at separate times (n = 229) and dual-therapy groups. RESULTS The initial treatment of the dual-therapy group reduced the median (IQR) MMDs from 30 (30-30) to 15 (12-30) [p < 0.0001]. After initiation of dual therapy, the median MMDs was further decreased from 15 (12-30) to 8 (3-22) [p < 0.0001]. A majority [132/194 (68.0%)] of the dual-therapy patients reported a ≥ 50% reduction in MMD and 90/194 (46.4%) reported a ≥ 75% reduction. For the consecutive monotherapy group, median MMDs changed from a baseline of 30 (25-30) to 15 (8-25) from onabot monotherapy and decreased from 25 (15-30) to 12 (4-25) after anti-CGRP mAb monotherapy. Almost half (113/229 [49.3%] from onabot, and 104/229 [45.4%] from anti-CGRP mAb) of these patients achieved a ≥ 50% reduction in MMDs and a minority (38/229 [16.6%] from onabot, and 45/229 [19.7%] from anti-CGRP mAb) achieved a reduction of ≥ 75%. Additionally, dual therapy showed significant improvement in MMDs compared with monotherapy of either treatment (p < 0.0001). CONCLUSION Dual therapy of anti-CGRP mAbs and onabot may be more efficacious than monotherapy, possibly due to their synergistic mechanisms of action.
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Affiliation(s)
- Amira Salim
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elise Hennessy
- Neuroscience Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Claire Sonneborn
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olivia Hogue
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sudipa Biswas
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - MaryAnn Mays
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aarushi Suneja
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zubair Ahmed
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ignacio F Mata
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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Janković SM, Janković SV. Anti-Calcitonin Gene-Related Peptide Monoclonal Antibodies in Migraine: Focus on Drug Interactions. Eur J Drug Metab Pharmacokinet 2024; 49:263-275. [PMID: 38457093 DOI: 10.1007/s13318-024-00887-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
Calcitonin gene-related peptide neurotransmission was the target for recent development of monoclonal antibodies that effectively prevent attacks of both episodic and chronic migraine. The aim of this narrative review was to offer deeper insight into drug-drug, drug-food and drug-disease interactions of monoclonal antibodies approved for prevention of migraine attacks. For this narrative review, relevant literature was searched for in MEDLINE and Google Scholar databases, covering the 1966-2023 and 2006-2023 periods, respectively. The ClinicalTrials.gov database was also searched for relevant clinical studies whose results had not been published previously in medical journals, covering 2000-2023. Monoclonal antibodies (erenumab, fremanezumab, galcanezumab and eptinezumab) augment prophylactic action of gepants and onabotulinumtoxin A and somewhat increase efficacy of triptans used to abort migraine attacks; however, their adverse reactions may also be augmented. Pharmacokinetic interactions and interactions in general with drugs used for other indications except migraine are negligible, as are drug-food interactions. However, monoclonal antibodies may worsen diseases with already weakened CGRP neurotransmission, Raynaud phenomenon and constipation. Monoclonal antibodies used for prevention of migraine do not engage in significant pharmacokinetic interactions with other drugs; however, they do engage in pharmacodynamic interactions with other anti-migraine drugs, additively augmenting their prophylactic action, but also increasing frequency and severity of adverse reactions, which are a consequence of the CGRP neurotransmission interruption.
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Affiliation(s)
- Slobodan M Janković
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića Street, 69, 34000, Kragujevac, Serbia.
| | - Snežana V Janković
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića Street, 69, 34000, Kragujevac, Serbia
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Oliveira R, Gil-Gouveia R, Puledda F. CGRP-targeted medication in chronic migraine - systematic review. J Headache Pain 2024; 25:51. [PMID: 38575868 PMCID: PMC10996229 DOI: 10.1186/s10194-024-01753-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Chronic migraine is a highly debilitating condition that is often difficult to manage, particularly in the presence of medication overuse headache. Drugs targeting the calcitonin gene-related peptide (CGRP), or its receptor have shown promising results in treating this disorder. METHODS We searched Pubmed and Embase to identify randomized clinical trials and real-world studies reporting on the use of medication targeting the calcitonin gene-related peptide in patients with chronic migraine. RESULTS A total of 270 records were identified. Nineteen studies qualified for the qualitative analysis. Most studies reported on monoclonal antibodies targeting CGRP (anti-CGRP mAbs), that overall prove to be effective in decreasing monthly migraine days by half in about 27.6-61.4% of the patients. Conversion from chronic to episodic migraine was seen in 40.88% of the cases, and 29-88% of the patients stopped medication overuse. Obesity seems to be the main negative predictor of response to anti-CGRP mAbs. There is no evidence to suggest the superiority of one anti-CGRP mAb. Despite the lack of strong evidence, the combination of anti-CGRP medication with onabotulinumtoxinA in chronic migraine is likely to bring benefits for resistant cases. Atogepant is the first gepant to demonstrate a significant decrease in monthly migraine days compared to placebo in a recent trial. Further, anti-CGRP mAb and gepants have a good safety profile. CONCLUSION There is strong evidence from randomized trials and real-world data to suggest that drugs targeting CGRP are a safe and effective treatment for chronic migraine.
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Affiliation(s)
- Renato Oliveira
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK
- Neurology Department, Barking, Havering and Redbridge University Hospitals NHS Foundation Trust, London, UK
| | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz Lisboa, Lisbon, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisbon, Portugal
| | - Francesca Puledda
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9PJ, UK.
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Grazzi L, Giossi R, Montisano DA, Canella M, Marcosano M, Altamura C, Vernieri F. Real-world effectiveness of Anti-CGRP monoclonal antibodies compared to OnabotulinumtoxinA (RAMO) in chronic migraine: a retrospective, observational, multicenter, cohort study. J Headache Pain 2024; 25:14. [PMID: 38308209 PMCID: PMC10836018 DOI: 10.1186/s10194-024-01721-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/17/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Chronic migraine (CM) is a disabling condition with high prevalence in the general population. Until the recent approval of monoclonal antibodies targeting the calcitonin gene-related peptide (Anti-CGRP mAbs), OnabotulinumtoxinA (BoNT-A) was the only treatment specifically approved for CM prophylaxis. Direct comparisons between the two treatments are not available so far. METHODS We performed an observational, retrospective, multicenter study in Italy to compare the real-world effectiveness of Anti-CGRP mAbs and BoNT-A. Patients with CM who had received either treatment according to Italian prescribing regulations were extracted from available clinical databases. Efficacy outcomes included the change from baseline in monthly headache days (MHD), MIgraine Disability ASsessment test (MIDAS), and monthly acute medications (MAM) evaluated at 6 and 12 months of follow-up. The primary outcome was MHD change from baseline at 12 months. Safety outcomes included serious adverse events (SAE) and treatment discontinuation. Unadjusted and adjusted models were used for the analyses. RESULTS Two hundred sixteen potentially eligible patients were screened; 183 (86 Anti-CGRP mAbs; 97 BoNT-A) were included. One hundred seventy-one (80 Anti-CGRP mAbs; 91 BoNT-A) and 154 (69 Anti-CGRP mAbs; 85 BoNT-A) patients were included in the efficacy analysis at 6 and 12 months of follow-up, respectively. Anti-CGRP mAbs and BoNT-A both resulted in a mean MHD reduction at 6 (-11.5 and -7.2 days, respectively; unadjusted mean difference -4.3; 95%CI -6.6 to -2.0; p = 0.0003) and 12 months (-11.9 and -7.6, respectively; unadjusted mean difference -4.4; 95%CI -6.8 to -2.0; p = 0.0002) of follow-up. Similar results were observed after adjusting for baseline confounders. Anti-CGRP mAbs showed a significant MIDAS (-31.7 and -19.2 points, p = 0.0001 and p = 0.0296, respectively) and MAM reduction (-5.1 and -3.1 administrations, p = 0.0023 and p = 0.0574, respectively) compared to BoNT-A at 6 and 12 months. No SAEs were reported. One patient receiving fremanezumab discontinued treatment due to arthralgia. Treatment discontinuations, mainly for inefficacy, were comparable. CONCLUSION Both Anti-CGRP mAbs and BoNT-A were effective in CM patients with Anti-CGRP mAbs presenting higher effect magnitude, with comparable safety. Still, BoNT-A remains a valuable option for CM patients with contraindications to Anti-CGRP mAbs or for frail categories who are candidates to local therapy with limited risk of systemic administration.
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Affiliation(s)
- Licia Grazzi
- Headache Center, Neuroalgology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, Milan, 20133, Italy
| | - Riccardo Giossi
- Poison Control Center and Clinical Pharmacology Unit, Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, Milan, 20162, Italy.
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, Milan, 20133, Italy.
| | - Danilo Antonio Montisano
- Headache Center, Neuroalgology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria, 11, Milan, 20133, Italy
| | - Mattia Canella
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Via Vanvitelli, 32, Milan, 20129, Italy
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, Milan, 20133, Italy
| | - Marilena Marcosano
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
| | - Claudia Altamura
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
| | - Fabrizio Vernieri
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, Roma, 00128, Italy
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, Roma, 00128, Italy
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Zovi A, Langella R, Aloisi AC, De Giorgio C, Del Vecchio M, Dondi C, Handschin G, Lauria C, Marchetti C, Martinazzoli O, Nozza R, Scalzi V, Tratta E, Jemos C, Lasala R. Real-World Effectiveness of Calcitonin Gene-Related Peptide-Binding Monoclonal Antibodies for Migraine Prevention: A Systematic Review. Can J Hosp Pharm 2024; 77:e3382. [PMID: 38204506 PMCID: PMC10754415 DOI: 10.4212/cjhp.3382] [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: 08/16/2022] [Accepted: 04/04/2023] [Indexed: 01/12/2024]
Abstract
Background Migraine is a neurological disease with a high incidence. The new anti-calcitonin gene-related peptide monoclonal antibodies (anti-CGRP mAbs) have demonstrated effectiveness in preventing episodic and chronic migraine. Objective To collect evidence of the real-world effectiveness of anti-CGRP mAbs by assessing outcomes such as reduction in monthly migraine days (MMDs), reduction in monthly headache days (MHDs), and percentage of patients having a 50% reduction in MMDs. Data Sources The PubMed database was searched for the period from inception to October 20, 2021. Study Selection and Data Extraction Of interest for this review were studies that evaluated the real-world effectiveness of anti-CGRP mAbs in terms of MMDs and reduction in MHDs. The search terms included "migraine", "monthly migraine days", and various drug names. The data are reported in terms of patients' baseline characteristics and treatment effectiveness. Data Synthesis A total of 46 studies were evaluated, of which 30 (enrolling a total of 4273 patients across 10 countries) were included in the systematic review. The greatest absolute reduction in MMD was from 20.4 at baseline to 10.7 after 3 months of treatment. After 6 months, the greatest absolute difference was 10, relative to baseline. The largest absolute reduction in MHD at 3 months was from 22 to 8, whereas at 6 months, the greatest absolute reduction in MHD was 13. The treatment could be considered clinically effective (≥ 50% reduction in MMDs) for 41% of patients at 3 months and about 44% of patients at 6 months. Conclusions Despite substantial variability in baseline values, this review confirmed the effectiveness of anti-CGRP mAbs, which yielded important clinical reductions in both MMDs and MHDs.
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Affiliation(s)
- Andrea Zovi
- , PharmD, is with the Hospital Pharmacy, ASST Santi Paolo e Carlo, Milan, Italy
| | - Roberto Langella
- , PharmD, is with the Lombardy Regional Section of SIFO (Società Italiana de Farmacia Ospedaliera e dei Servizi Farmaceutici delle Aziende Sanitarie), Milan, Italy
| | - Anna Chiara Aloisi
- , PharmD, is with the Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Cosimo De Giorgio
- , PharmD, is with the Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Marta Del Vecchio
- , PharmD, is with the Hospital Pharmacy, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Chiara Dondi
- , PharmD, is with the Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Giulia Handschin
- , PharmD, is with the Hospital Pharmacy, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Claudia Lauria
- , PharmD, is with the Hospital Pharmacy, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Carlotta Marchetti
- , PharmD, is with the Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Oscar Martinazzoli
- , PharmD, is with the Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Renata Nozza
- , PharmD, is with the Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Valentina Scalzi
- , PharmD, is with the Hospital Pharmacy, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Tratta
- , PharmD, is with the Hospital Pharmacy, ASST Spedali Civili di Brescia, Milan, Italy
| | - Costantino Jemos
- , PharmD, is with the Hospital Pharmacy, IRCCS Istituto Europeo di Oncologia, Milan, Italy
| | - Ruggero Lasala
- , PharmD, is with the Hospital Pharmacy of Corato, Local Health Unit of Bari, Bari, Italy
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Corasaniti MT, Lawrence GW, Bagetta G, Iannacchero R, Tarsitano A, Monteleone A, Pagliaro M, Tonin P, Sandrini G, Nicotera P, Scuteri D. Combination of anti-CGRP/CGRP-R mAbs with onabotulinumtoxin A as a novel therapeutic approach for refractory chronic migraine: a retrospective study of real-world clinical evidence and a protocol for a double-blind, randomized clinical trial to establish the efficacy and safety. Front Pharmacol 2023; 14:1296577. [PMID: 38152694 PMCID: PMC10751376 DOI: 10.3389/fphar.2023.1296577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023] Open
Abstract
Chronic migraine is a disabling neurovascular disorder that ranks amongst the top causes of years lived with disability worldwide. The duration and the frequency of migraine affect cognitive and affective domains, inducing worsening of memory, executive functions, orientation and causing anxiety. Population-based studies report a worrying level of resistance to treatments. Therefore, this study aims: 1) to assess efficacy of monoclonal antibodies (mAbs) directed towards the calcitonin gene-related peptide (CGRP) or its receptor (CGRP-R) for chronic migraine resistant to current preventatives; 2) to design a clinical trial protocol to evaluate the efficacy and safety of combination therapy utilizing anti-CGRP/CGRP-R together with onabotulinumtoxin A in patients suffering from resistant chronic migraine; 3) to provide a molecular rationale for combination therapy. A controlled trial is warranted as pooled analysis of real-world data from our group highlighted that combined treatment provides ≥50% reduction vs. baseline (onabotulinumtoxin A) of monthly headache days (MHDs) in up to 58.8% of patients, but there has been only sparse application of this combined therapy to date. The mAbs chosen are: erenumab, because its combination effect with onabotulinumtoxin A improved symptoms in 65% of patients; eptinezumab, due to its faster action. The results highlight that early diagnosis of migraine improves therapeutic outcomes with mAbs alone, confirming their effectiveness and the need for an adequately powered clinical trial evaluating the safety and potential superior effectiveness of eptinezumab/erenumab and onabotulinumtoxin A together.
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Affiliation(s)
- M. T. Corasaniti
- Department of Health Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - G. W. Lawrence
- Department of Biotechnology, Dublin City University, Dublin, Ireland
| | - G. Bagetta
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - R. Iannacchero
- Department of Neurology, Headache Center, Regional Hospital “Pugliese-Ciaccio”, Catanzaro, Italy
| | - A. Tarsitano
- Pain Therapy Center, Provincial Health Authority (ASP), Cosenza, Italy
| | - A. Monteleone
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - M. Pagliaro
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - P. Tonin
- Regional Center for Serious Brain Injuries, S. Anna Institute, Crotone, Italy
| | - G. Sandrini
- Department of Brain and Behavioral Sciences, IRCCS C. Mondino Foundation Neurologic Institute, University of Pavia, Pavia, Italy
| | - P. Nicotera
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - D. Scuteri
- Pharmacotechnology Documentation and Transfer Unit, Preclinical and Translational Pharmacology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
- Regional Center for Serious Brain Injuries, S. Anna Institute, Crotone, Italy
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9
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Ceccardi G, Schiano di Cola F, Caratozzolo S, Di Pasquale M, Bolchini M, Padovani A, Rao R. Onabotulinumtoxin-A: Previous Prophylactic Treatment Might Improve Subsequent Anti-CGRP Monoclonal Antibodies Response in Patients with Chronic Migraine. Toxins (Basel) 2023; 15:677. [PMID: 38133181 PMCID: PMC10747467 DOI: 10.3390/toxins15120677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
The aim of the present study was to evaluate whether previous preventive treatment with onabotulinumtoxin-A might influence subsequent clinical response following a switch to anti-CGRP monoclonal antibodies (mAbs). The present retrospective study was conducted at the Headache Centre-Neurology Clinic at the Spedali Civili Hospital of Brescia between November 2018 and May 2023. The primary objective was to assess clinical outcome (monthly headache days (MHDs), monthly migraine days (MMDs), mean analgesics consumption, and clinical disability according to Migraine Disability Assessment (MIDAS)) following three months (T3) of preventive treatment with anti-CGRP mAbs comparing patients who did and those who did not previously receive treatment with Onabotulinumtoxin-A. Moreover, we aimed to evaluate whether the clinical response to anti-CGRP mAbs was affected by the number of previous Onabotulinumtoxin-A administrations. At T3, compared to Onabotulinumtoxin-A naïve patients, patients who previously received Onabotulinumtoxin-A documented fewer MMDs (3.3 ± 3.7 versus 5.2 ± 5.0; p = 0.017) and a lower MIDAS score (23.2 ± 20.9 versus 37.4 ± 39.6; p = 0.013). Patients who received at least 3 onabotulinumtoxin-A administrations documented, at T3, lower MMDs compared to those who received fewer cycles (respectively, 2.1 ± 2.7 vs. 6.5 ± 4.4; p = 0.024). In conclusion, according to our data, previous treatment with onabotulinumtoxin-A might improve subsequent response to anti-CGRP mAbs preventive treatment.
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Affiliation(s)
| | - Francesca Schiano di Cola
- Department of Care Continuity and Frialty, Neurology Unit, University of Brescia, 25128 Brescia, Italy; (G.C.); (A.P.); (R.R.)
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10
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Vernieri F, Brunelli N, Guerzoni S, Iannone LF, Baraldi C, Rao R, Schiano di Cola F, Ornello R, Cevoli S, Lovati C, Albanese M, Perrotta A, Cetta I, Rossi SS, Taranta V, Filippi M, Geppetti P, Sacco S, Altamura C. Retreating migraine patients in the second year with monoclonal antibodies anti-CGRP pathway: the multicenter prospective cohort RE-DO study. J Neurol 2023; 270:5436-5448. [PMID: 37468621 DOI: 10.1007/s00415-023-11872-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The outcome of migraine patients retreated with monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (anti-CGRP) or its receptor (anti-CGRPr) is not completely known. METHODS This multicentric prospective observational cohort study assessed monthly migraine days (MMDs), migraine acute medication intake (MAMI), and HIT-6 at baseline, after 90-112 days (Rev-1), after 84-90 days since Rev-1 (Rev-2) and 30 days after the last injection of anti-CGRP/CGRPr mAbs (Year-end), in the first and the second year after a discontinuation period. RESULTS We enrolled 226 patients (79.6% with chronic migraine; 55.3% on erenumab and 44.7% on galcanezumab or fremanezumab). MMDs, MAMI, and HIT-6-did not differ at the respective first and second-year evaluations in the entire cohort, and comparing anti-CGRP with anti-CGRPr Abs. MMDs (18.1 ± 7.8 vs. 3.4 ± 7.8), MAMI (26.7 ± 28.3 vs.17.7 ± 17.2), and HIT-6 scores (63.1 ± 5.9 vs. 67.1 ± 10.3) were lower in the second year than in the pre-treatment baseline (consistently, p < 0.0001). Second-year baseline MMDs were lower in patients on anti-CGRP mAbs (p = 0.001) and with lower pre-treatment baseline MMDs (p ≤ 0.001). CONCLUSION Anti-CGRP/CGRPr mAbs are effective in the second as in the first year. The use of anti-CGRP or CGRPr mAbs influenced the second-year baseline MMDs, but their effectiveness did not differ during the two treatment years.
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Affiliation(s)
- Fabrizio Vernieri
- Unità Cefalee e Neurosonologia, Fondazione Policlinico Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
- Neurologia, Dipartimento di Medicina e Chirurgia, Università Campus Bio-Medico di Roma, Rome, Italy.
| | - Nicoletta Brunelli
- Unità Cefalee e Neurosonologia, Fondazione Policlinico Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Simona Guerzoni
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology, Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy
| | - Luigi Francesco Iannone
- Headache Center, Section of Clinical Pharmacology and Oncology, Department of Health Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Carlo Baraldi
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology, Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico di Modena, Modena, Italy
| | - Renata Rao
- Headache Center, ASST Spedali Civili of Brescia, Department Continuity of Care and Fragility, Department of Clinical and Experimental Sciences, Neurological Clinic, University of Brescia, Brescia, Italy
| | - Francesca Schiano di Cola
- Headache Center, ASST Spedali Civili of Brescia, Department Continuity of Care and Fragility, Department of Clinical and Experimental Sciences, Neurological Clinic, University of Brescia, Brescia, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Carlo Lovati
- Headache Center, Neurology Unit, L. Sacco University Hospital, Milan, Italy
| | - Maria Albanese
- Neurology Unit, Headache Center, Tor Vergata University Hospital, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | | | - Ilaria Cetta
- Neuroimaging Research Unit, Division of Neuroscience; Neurology Unit and Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Sergio Soeren Rossi
- Neurologia, Dipartimento di Medicina e Chirurgia, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Valentina Taranta
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience; Neurology Unit and Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Pierangelo Geppetti
- Headache Center, Section of Clinical Pharmacology and Oncology, Department of Health Sciences, Careggi University Hospital, University of Florence, Florence, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudia Altamura
- Unità Cefalee e Neurosonologia, Fondazione Policlinico Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
- Neurologia, Dipartimento di Medicina e Chirurgia, Università Campus Bio-Medico di Roma, Rome, Italy
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11
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Pellesi L. Combining onabotulinumtoxin A with a CGRP antagonist for chronic migraine prophylaxis: where do we stand? FRONTIERS IN PAIN RESEARCH 2023; 4:1292994. [PMID: 37965209 PMCID: PMC10641512 DOI: 10.3389/fpain.2023.1292994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/17/2023] [Indexed: 11/16/2023] Open
Affiliation(s)
- Lanfranco Pellesi
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
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12
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Blumenfeld AM, Lipton RB, Silberstein S, Tepper SJ, Charleston L, Landy S, Kuruvilla DE, Manack Adams A. Multimodal Migraine Management and the Pursuit of Migraine Freedom: A Narrative Review. Neurol Ther 2023; 12:1533-1551. [PMID: 37542624 PMCID: PMC10444724 DOI: 10.1007/s40120-023-00529-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/21/2023] [Indexed: 08/07/2023] Open
Abstract
Migraine is a neurologic disease with a complex pathophysiology that can be controlled with current treatment options but not cured. Therefore, treatment expectations are highly variable. The concept of migraine freedom was recently introduced and can mean different things, with some, for example, expecting complete freedom from headache and associated symptoms and others accepting the occasional migraine attack if it does not impact functioning. Therefore, migraine management should be optimized so that patients can have the best opportunity to achieve their optimal treatment goals. With migraine freedom as a goal and, given the complex pathophysiology of migraine and the high incidence of comorbidities among individuals with migraine, treatment with a single modality may be insufficient, as it may not achieve migraine freedom in those with more frequent or disabling attacks. In this clinical perspective article, we have identified four key, partially overlapping principles of multimodal migraine treatment: (1) manage common comorbidities; (2) control modifiable risk factors for progression by addressing medication and caffeine overuse; (3) diagnose and treat secondary causes of headache, if present; and (4) individualize acute and preventive treatments to minimize pain, functional disability, and allodynia. There are many barriers to pursuing migraine freedom, and strategies to overcome them should be optimized. Migraine freedom should be an aspirational goal both at the individual attack level and for the disease overall. We believe that a comprehensive and multimodal approach that addresses all barriers people with migraine face could move patients closer to migraine freedom.
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Affiliation(s)
| | | | | | - Stewart J Tepper
- New England Institute for Neurology and Headache, Stamford, CT, USA
| | - Larry Charleston
- Department of Neurology and Ophthalmology, Michigan State University College of Human Medicine, East Lansing, MI, USA
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13
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Juhasz G, Gecse K, Baksa D. Towards precision medicine in migraine: Recent therapeutic advances and potential biomarkers to understand heterogeneity and treatment response. Pharmacol Ther 2023; 250:108523. [PMID: 37657674 DOI: 10.1016/j.pharmthera.2023.108523] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 09/03/2023]
Abstract
After 35 years since the introduction of the International Classification of Headache Disorders (ICHD), we are living in the era of the second great revolution in migraine therapies. First, discoveries of triptans provided a breakthrough in acute migraine treatment utilizing bench-to-bedside research results on the role of serotonin in migraine. Next, the discovery of the role of neuropeptides, more specifically calcitonin gene-related peptide (CGRP) in migraine attack led to the development of anti-CGRP therapies that are effective both in acute and preventive treatment, and are also able to reduce migraine-related burden. Here, we reviewed the most recent clinical studies and real-world data on available migraine-specific medications, including triptans, ditants, gepants and anti-CGRP monoclonal antibodies. Novel drug targets, such as PACAP and amylins were also discussed. To address the main challenges of migraine therapy, the high heterogeneity of people with migraine, the prevalent presence of various comorbid disorders, and the insufficient medical care of migraine patients were covered. Promising novel approaches from the fields of omics, blood and saliva biomarker, imaging and provocation studies might bring solutions for these challenges with the potential to identify further drug targets, distinguish more homogeneous patient subgroups, contribute to more optimal drug selection strategies, and detect biomarkers in association with headache features or predicting treatment efficacy. In the future, the combined analysis of data of different biomarker modalities with machine learning algorithms may serve precision medicine in migraine treatment.
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Affiliation(s)
- Gabriella Juhasz
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary.
| | - Kinga Gecse
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary
| | - Daniel Baksa
- Department of Pharmacodynamics, Faculty of Pharmaceutical Sciences, Semmelweis University, Budapest, Hungary; NAP3.0 Neuropsychopharmacology Research Group, Hungarian Brain Research Program, Semmelweis University, Budapest, Hungary; Department of Personality and Clinical Psychology, Institute of Psychology, Faculty of Humanities and Social Sciences, Pazmany Peter Catholic University, Budapest, Hungary
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14
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Lambru G, Caponnetto V, Hill B, Ratti S, Sacco S, Murphy M, Briscoe J, Andreou AP. Long-Term Effect of Switching From an Anti-CGRP Receptor to an Anti-CGRP Ligand Antibody in Treatment-Refractory Chronic Migraine: A Prospective Real-World Analysis. Neurotherapeutics 2023; 20:1284-1293. [PMID: 37430146 PMCID: PMC10480365 DOI: 10.1007/s13311-023-01394-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 07/12/2023] Open
Abstract
In migraine patients with a poor response to a calcitonin gene-related peptide monoclonal antibody against the receptor, switching to a calcitonin gene-related peptide monoclonal antibodies against the ligand may be beneficial. This was a long-term real-world prospective analysis conducted in treatment-refractory chronic migraine patients coming from two large tertiary referral headache centres, who did not achieve a meaningful response to erenumab and were switched to fremanezumab. Responders to fremanezumab were considered those who achieved at least 30% reduction in monthly migraine days by month 3, compared to the post-erenumab baseline. Secondary efficacy and disability outcomes were analysed. Thirty-nine patients (female n = 32, 82.1%; median age: 49 years old, IQR = 29.0-56.0) were included. After three months of treatment with fremanezumab, ten out of 39 patients (25.6%) were considered responders. Four of the 11 patients who continued fremanezumab became responders at month 6, increasing the number of responders to 14 patients (35.9%). Responders received a median of 12 injections (IQR = 9.0-18.0) at the time of the analysis. After the last treatment, 13 patients (33.3%) remained responders. The number of mean monthly migraine days significantly decreased from 21.4 at baseline (IQR = 10.7-30.0) to 8.6 (IQR = 3.8-13.9) at the last follow-up. Painkillers intake and HIT-6 score were significantly reduced at the last follow-up. About 1/3 of patients with treatment refractory chronic migraine who have a disappointing response to erenumab and switch to fremanezumab, obtained a meaningful and sustained improvement of their migraine load over time, supporting the appropriateness of this therapeutic approach in clinical practice.
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Affiliation(s)
- Giorgio Lambru
- The Headache and Facial Pain Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.
- Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom, London, UK.
| | - Valeria Caponnetto
- The Headache and Facial Pain Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Bethany Hill
- The Headache and Facial Pain Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Susanna Ratti
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Madeleine Murphy
- The Headache and Facial Pain Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jessica Briscoe
- The Headache and Facial Pain Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anna P Andreou
- The Headache and Facial Pain Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Headache Research‑Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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15
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Manack Adams A, Hutchinson S, Engstrom E, Ayasse ND, Serrano D, Davis L, Sommer K, Contreras-De Lama J, Lipton RB. Real-world effectiveness, satisfaction, and optimization of ubrogepant for the acute treatment of migraine in combination with onabotulinumtoxinA: results from the COURAGE Study. J Headache Pain 2023; 24:102. [PMID: 37537578 PMCID: PMC10399003 DOI: 10.1186/s10194-023-01622-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Individuals using onabotulinumtoxinA as a preventive migraine treatment often use acute treatments for breakthrough attacks. Data on real-world effectiveness of the small-molecule calcitonin gene-related peptide (CGRP) receptor antagonist ubrogepant in combination with onabotulinumtoxinA are limited. METHODS COURAGE, a prospective, multiple attack, observational study, evaluated the real-world effectiveness of ubrogepant (50 or 100 mg) for acute treatment of migraine in people receiving onabotulinumtoxinA, an anti-CGRP monoclonal antibody (mAb), or both. This analysis focused only on onabotulinumtoxinA users. The Migraine Buddy app was used to identify eligible participants and track response to treated attacks. For each ubrogepant-treated attack, meaningful pain relief (MPR) and return to normal function (RNF) at 2 and 4 h post-dose over 30 days was assessed. MPR was defined as a level of relief that is meaningful to the participant, usually occurring before the pain is all gone. After 30 days, satisfaction was reported on a 7-point scale and overall acute treatment optimization was evaluated using the migraine Treatment Optimization Questionnaire-4 (mTOQ-4). RESULTS This analysis included 122 participants who received ubrogepant and onabotulinumtoxinA and reported on 599 ubrogepant-treated attacks. Following the first ubrogepant-treated attack, MPR was achieved in 53.3% of participants 2 h post-dose and in 76.2% of participants 4 h post-dose. RNF was achieved in 25.4% of participants 2 h post-dose and in 45.9% of participants 4 h post-dose. MPR and RNF results were similar across up to 10 ubrogepant-treated attacks. After 30 days, satisfaction with ubrogepant in combination with onabotulinumtoxinA was reported by 69.8% of participants and acute treatment optimization (defined as mTOQ-4 score ≥ 4) was achieved in 77.6%. CONCLUSIONS In this prospective real-world effectiveness study, ubrogepant treatment in onabotulinumtoxinA users with self-identified migraine was associated with high rates of MPR and RNF at 2 and 4 h as well as satisfaction and acute treatment optimization. Although the lack of a contemporaneous control group limits causal inference, these findings demonstrate the feasibility of using a novel, app-based design to evaluate the real-world effectiveness and satisfaction of treatments.
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Affiliation(s)
| | | | | | | | | | - Linda Davis
- Kolvita Family Medical Group, Mission Viejo, CA, USA
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16
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Schoenen J, Van Dycke A, Versijpt J, Paemeleire K. Ten open questions in migraine prophylaxis with monoclonal antibodies blocking the calcitonin-gene related peptide pathway: a narrative review. J Headache Pain 2023; 24:99. [PMID: 37528353 PMCID: PMC10391994 DOI: 10.1186/s10194-023-01637-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023] Open
Abstract
The monoclonal antibodies (mAbs) blocking the calcitonin-gene related peptide (CGRP) pathway, collectively called here "anti-CGRP/rec mAbs", have dramatically improved preventive migraine treatment. Although their efficacy and tolerability were proven in a number of randomized controlled trials (RCTs) and, maybe even more convincingly, in real world settings, a number of open questions remain. In this narrative review, we will analyze published data allowing insight in some of the uncertainties related to the use of anti-CGRP/rec mAbs in clinical practice: their differential efficacy in migraine subtypes, outcome predictors, switching between molecules, use in children and adolescents, long-term treatment adherence and persistence, effect persistence after discontinuation, combined treatment with botulinum toxin or gepants, added-value and cost effectiveness, effectiveness in other headache types, and potential contraindications based on known physiological effects of CGRP. While recent studies have already provided hints for some of these questions, many of them will not find reliable and definitive answers before larger studies, registries or dedicated RCTs are available.
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Affiliation(s)
- Jean Schoenen
- Headache Research Unit, Department of Neurology‑Citadelle Hospital, University of Liège, Boulevard du 12 ème de Ligne 1, Liège, 4000, Belgium.
| | - Annelies Van Dycke
- Department of Neurology, General Hospital Sint-Jan Bruges, Ruddershove 10, Bruges, 8000, Belgium
| | - Jan Versijpt
- Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, 9000, Belgium
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17
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Briceño-Casado MDP, Gil-Sierra MD, De-La-Calle-Riaguas B. Switching of monoclonal antibodies against calcitonin gene-related peptide in chronic migraine in clinical practice: a case series. Eur J Hosp Pharm 2023; 30:e19. [PMID: 34521726 PMCID: PMC10359803 DOI: 10.1136/ejhpharm-2021-002946] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/31/2021] [Indexed: 12/28/2022] Open
Abstract
A multicentre case series of patients with chronic migraine (CM) treated with monoclonal antibodies directed against calcitonin gene-related peptide (CGRP-mAbs) switching were developed. The effectiveness and safety of CGRP-mAbs switching as a preventive treatment for CM in clinical practice were recorded. Effectiveness was measured by ≥50% reduction of monthly migraine days in respect to baseline and reduction in pain intensity. Safety was analysed through adverse events (AEs) and treatment discontinuations. Seven patients were included. The reason for switching was non-response in all cases. Two patients presented a response to the first CGRP-mAb, but the effect was lost after 3 months. The remaining five patients were non-responders. Response to the second CGRP-mAb was observed in three patients, one of them for >3 months. Less than half of the patients previously treated with a CGRP-mAb responded to switching with a second CGRP-mAb. AEs were rare, with no treatment discontinuations.
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Affiliation(s)
| | - Manuel David Gil-Sierra
- Department of Pharmacology, Universidad de Sevilla, Sevilla, Spain
- Pharmacy, Hospital Doctor José Molina Orosa, Lanzarote, Las Palmas, Spain
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18
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Overeem LH, Ornello R, Pocora MM, Reuter U, Sacco S, Tassorelli C, Dueland AN, Raffaelli B, Martinelli D. A Retrospective Real-Life Multicenter Study on Concurrent Oral Preventive Treatments in Patients with Chronic Migraine Treated with OnabotulinumtoxinA. CNS Drugs 2023; 37:453-465. [PMID: 37212943 DOI: 10.1007/s40263-023-01001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND AND OBJECTIVE OnabotulinumtoxinA (BoNTA) is a relatively safe and effective treatment for chronic migraine. The local mode of action of BoNTA favors the combination of oral treatments with systemic action. However, little is known about the possible interactions with other preventive treatments. The objective of the study was to describe the use of oral preventive treatments in patients with chronic migraine treated with BoNTA in routine clinical care and discuss the tolerability and efficacy according to the presence or absence of concomitant oral treatments. METHODS In this multicenter, observational, retrospective, cohort study, we collected data from patients with chronic migraine receiving prophylactic treatment with BoNTA. Patients were eligible if aged ≥18 years, diagnosed with chronic migraine according to the International Classification of Headache Disorders, Third Edition criteria, and treated with BoNTA according to the PREEMPT paradigm. We documented the proportion of patients with at least one concomitant treatment prescribed specifically for migraine (CT+M) and their side effects during four BoNTA treatment cycles. Additionally, we collected monthly headache days and monthly acute medication days from the patients' headache diaries. Patients with CT+M were compared to those without concomitant treatment (CT-) using a nonparametric approach. RESULTS Our cohort included 181 patients taking BoNTA, of whom 77 (42.5%) received a CT+M. The most frequently prescribed concomitant treatments were antidepressants and antihypertensive drugs. Side effects in the CT+M group occurred in 14 patients (18.2%). Only in three of them (3.9%), the side effects had a significant interference with the patient's functioning (all in topiramate 200-mg/day users). Both CT+M and CT- groups had a significant reduction in monthly headache days of respectively - 6 (95% confidence interval - 9, - 3; p < 0.001; w = 0.200) during cycle 4 compared with baseline versus - 9 (95% confidence interval - 13, -6; p < 0.001; w = 0.469). However, the reduction in monthly headache days was significantly smaller in patients with CT+M after the fourth treatment cycle compared with patients with CT- (p = 0.004). CONCLUSIONS Prescription of oral concomitant preventive treatment is common in patients with chronic migraine receiving BoNTA. We did not identify any unexpected safety or tolerability issues in patients receiving BoNTA and a CT+M. However, patients with a CT+M experienced a smaller reduction in monthly headache days when compared with those with CT-, which might be associated with a higher resistance to treatment in that subgroup of patients.
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Affiliation(s)
- Lucas Hendrik Overeem
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- International Graduate Program Medical Neurosciences, Humboldt Graduate School, Berlin, Germany.
| | - Raffaele Ornello
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Maria Magdalena Pocora
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Rehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Uwe Reuter
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Universitätsmedizin Greifswald, Greifswald, Germany
| | - Simona Sacco
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Rehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Aud Nome Dueland
- Sandvika Nevrosenter, Sandvika, Norway
- Department of Neurology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Bianca Raffaelli
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health at Charité (BIH), Berlin, Germany
| | - Daniele Martinelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science and Rehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
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Altamura C, Brunelli N, Viticchi G, Salvemini S, Cecchi G, Marcosano M, Fofi L, Silvestrini M, Vernieri F. Quantitative and Qualitative Pain Evaluation in Response to OnabotulinumtoxinA for Chronic Migraine: An Observational Real-Life Study. Toxins (Basel) 2023; 15:toxins15040284. [PMID: 37104222 PMCID: PMC10145239 DOI: 10.3390/toxins15040284] [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: 03/14/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023] Open
Abstract
(1) Background: Randomized controlled trials and real-life studies demonstrated the efficacy of OnabotulinumtoxinA (OBT-A) for CM prevention. However, no studies specifically addressed its effect on pain's quantitative intensity and qualitative characteristics. (2) Methods: This is an ambispective study: a post-hoc retrospective analysis of real-life prospectively collected data from two Italian headache centers on CM patients treated with OBT-A over one year (i.e., Cy1-4). The primary endpoint was the changes in pain intensity (Numeric Rating Scale, NRS; the Present Pain Intensity (PPI) scale, the 6-point Behavioral Rating Scale (BRS-6)) and quality scale (the short-form McGill Pain Questionnaire (SF-MPQ)) scores. We also assessed the relationship between changes in intensity and quality of pain and disability scale (MIDAS; HIT-6) scores, monthly headache days (MHDs), and monthly acute medication intake (MAMI) (3) Results: We retrieved 152 cases (51.5 years SD 11.3, 80.3% females). From baseline to Cy-4, MHDs, MAMI, NRS, PPI, and BRS-6 scores decreased (consistently p < 0.001). Only the throbbing (p = 0.004), splitting (p = 0.018), and sickening (p = 0.017) qualities of pain collected in the SF-MPQ were reduced. Score variations in MIDAS related to those in PPI scales (p = 0.035), in the BRS-6 (p = 0.001), and in the NRS (p = 0.003). Similarly, HIT-6 score changes related to PPI score modifications (p = 0.027), in BRS-6 (p = 0.001) and NRS (p = 0.006). Conversely, MAMI variation was not associated with qualitative or quantitative pain score modifications except BRS-6 (p = 0.018). (4) Conclusions: Our study shows that OBT-A alleviates migraine by reducing its impact on multiple aspects, such as frequency, disability, and pain intensity. The beneficial effect on pain intensity seems specific to pain characteristics related to C-fiber transmission and is associated with a reduction in migraine-related disability.
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Affiliation(s)
- Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Nicoletta Brunelli
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Giovanna Viticchi
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020 Ancona, Italy
| | - Sergio Salvemini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020 Ancona, Italy
| | - Gianluca Cecchi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Marilena Marcosano
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Luisa Fofi
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Marche Polytechnic University, Via Conca 1, 60020 Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
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20
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Russo AF, Hay DL. CGRP physiology, pharmacology, and therapeutic targets: migraine and beyond. Physiol Rev 2023; 103:1565-1644. [PMID: 36454715 PMCID: PMC9988538 DOI: 10.1152/physrev.00059.2021] [Citation(s) in RCA: 63] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 11/23/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) is a neuropeptide with diverse physiological functions. Its two isoforms (α and β) are widely expressed throughout the body in sensory neurons as well as in other cell types, such as motor neurons and neuroendocrine cells. CGRP acts via at least two G protein-coupled receptors that form unusual complexes with receptor activity-modifying proteins. These are the CGRP receptor and the AMY1 receptor; in rodents, additional receptors come into play. Although CGRP is known to produce many effects, the precise molecular identity of the receptor(s) that mediates CGRP effects is seldom clear. Despite the many enigmas still in CGRP biology, therapeutics that target the CGRP axis to treat or prevent migraine are a bench-to-bedside success story. This review provides a contextual background on the regulation and sites of CGRP expression and CGRP receptor pharmacology. The physiological actions of CGRP in the nervous system are discussed, along with updates on CGRP actions in the cardiovascular, pulmonary, gastrointestinal, immune, hematopoietic, and reproductive systems and metabolic effects of CGRP in muscle and adipose tissues. We cover how CGRP in these systems is associated with disease states, most notably migraine. In this context, we discuss how CGRP actions in both the peripheral and central nervous systems provide a basis for therapeutic targeting of CGRP in migraine. Finally, we highlight potentially fertile ground for the development of additional therapeutics and combinatorial strategies that could be designed to modulate CGRP signaling for migraine and other diseases.
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Affiliation(s)
- Andrew F Russo
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa
- Department of Neurology, University of Iowa, Iowa City, Iowa
- Center for the Prevention and Treatment of Visual Loss, Department of Veterans Affairs Health Center, Iowa City, Iowa
| | - Debbie L Hay
- Department of Pharmacology and Toxicology, University of Otago, Dunedin, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, School of Biological Sciences, The University of Auckland, Auckland, New Zealand
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21
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Papetti L, Frattale I, Ursitti F, Sforza G, Monte G, Ferilli MAN, Tarantino S, Proietti Checchi M, Valeriani M. Real Life Data on OnabotulinumtoxinA for Treatment of Chronic Migraine in Pediatric Age. J Clin Med 2023; 12:jcm12051802. [PMID: 36902596 PMCID: PMC10003637 DOI: 10.3390/jcm12051802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND The use of OnabotulinumtoxinA (OBT-A) for the treatment of chronic migraine (CM) in adults represents a therapy with the greatest efficacy and safety data. However, we have little evidence on the use of OBT-A in children or adolescents. The present study aims to describe the experience with OBT-A in the treatment of CM in adolescents in an Italian third-level headache center. METHODS The analysis included all patients under the age of 18 treated with OBT-A for CM at the Bambino Gesù Children's Hospital. All patients received OBT-A following the PREEMPT protocol. Subjects were classified as good responders if a greater than 50% reduction in the monthly frequency of attacks was observed, partial responders if the reduction was between 30 and 50%, and non-responders if it was <30%. RESULTS The treated population consisted of 37 females and 9 males with a mean age of 14.7 years. Before starting OBT-A, 58.7% of the subjects had attempted prophylactic therapy with other drugs. From OBT-A initiation to the last clinical observation, the mean duration of follow-up was 17.6 ± 13.7 SD (range: 1-48) months. The number of OBT-A injections were 3.4 ± 3 SD. Sixty eight percent of the subjects responded to treatment within the first three administrations of OBT-A. Proceeding with the number of administrations, a progressive improvement in frequency was further observed. CONCLUSIONS The use of OBT-A in pediatric age can have benefits in terms of reduction in the frequency and intensity of headache episodes. Furthermore, treatment with OBT-A has an excellent safety profile. These data support the use of OBT-A in the treatment of childhood migraine.
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Affiliation(s)
- Laura Papetti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-06-6859-2865
| | - Ilaria Frattale
- Child Neurology and Psychiatry Unit, Tor Vergata University of Rome, 00165 Rome, Italy
| | - Fabiana Ursitti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Giorgia Sforza
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Gabriele Monte
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | | | - Samuela Tarantino
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | | | - Massimiliano Valeriani
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
- Center for Sensory-Motor Interaction, Aalborg University, Fredrik Bajers Vej 7 D3, DK-9220 Aalborg, Denmark
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22
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Affiliation(s)
- Velina Tzankova
- Division of Neurology, Department of Medicine (Tzankova), University of Toronto, Toronto, Ont.; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Becker), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Clinical Neurological Sciences (Chan), Western University, London, Ont
| | - Werner J Becker
- Division of Neurology, Department of Medicine (Tzankova), University of Toronto, Toronto, Ont.; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Becker), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Clinical Neurological Sciences (Chan), Western University, London, Ont
| | - Tommy L H Chan
- Division of Neurology, Department of Medicine (Tzankova), University of Toronto, Toronto, Ont.; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Becker), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Clinical Neurological Sciences (Chan), Western University, London, Ont.
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23
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Iannone LF, Fattori D, Marangoni M, Benemei S, Chiarugi A, Geppetti P, De Cesaris F. Switching OnabotulinumtoxinA to Monoclonal Anti-CGRP Antibodies in Drug-Resistant Chronic Migraine. CNS Drugs 2023; 37:189-202. [PMID: 36656298 DOI: 10.1007/s40263-022-00983-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND OnabotulinumtoxinA (BTX-A) and anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (anti-CGRP mAbs) are approved drugs for chronic migraine (CM), a difficult-to-treat condition. Optimization of CM patient management by choosing the best options and determining appropriate time for switching or adding concomitant treatments are highly needed. OBJECTIVE Evaluate clinical response to anti-CGRP mAbs in patients who switched from BTX-A due to ineffectiveness defined by different cut-offs and assess the retention rate, effectiveness, and safety of both drugs within the first 9 months of treatment. METHODS A monocentric, cohort study, enrolling patients with CM, resistant to several preventive treatments, first treated with BTX-A and then with anti-CGRP mAbs with two observational phases of 9 months preceded by respective baseline. First, the retention rate and effectiveness of both treatments were measured in all patients. A second analysis assessed effectiveness in patients stratified according to <50 or <30% response rate to BTX-A. The absolute change from baseline in monthly headache days (MHDs), response rate, analgesic use, and persistence in medication overuse (MO) at 3, 6, and 9 months of treatment were recorded. Last observation carried forward (LOCF) analyses, including all patients and assuming no further changes after discontinuation, were performed for all outcomes. RESULTS Of the 78 enrolled patients (80.8% female, and 89.7% with MO at baseline), 32 (41.0%) received erenumab, 32 (41.0%) galcanezumab, and 14 (18.0%) fremanezumab. Retention rate was 62.2 and 91.0% for BTX-A and 76.9 and 96.2%, for anti-CGRP mAbs at 3 and 9 months of treatment, respectively. At 9 months of treatment, 22.4% of BTX-A patients and 65.0% of anti-CGRP mAbs patients achieved a ≥50% response rate. Anti-CGRP mAbs reduced MHDs, AMN, and AMDs, and decreased the number of MO patients at 9 months. In patients stratified according to <50 or <30% response rate to BTX-A, response rate (≥50% response at 9 months) to anti-CGRP was 62.9 and 57.9%, respectively. LOCF analyses confirmed these findings. No serious adverse events (AEs) were recorded and only two patients discontinued treatment due to AEs. CONCLUSIONS Difficult-to-treat CM patients who discontinued BTX-A and received anti-CGRP mAbs showed a substantial clinical improvement in migraine-related outcomes. Switching to an anti-CGRP mAb appears to be a viable option in patients with insufficient response after the first 2 cycles with BTX-A. The appropriate variables, cut-offs, and timing to define ineffectiveness and the best time to switch or combine therapies for difficult-to-treat CM need to be investigated further.
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Affiliation(s)
- Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Davide Fattori
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
| | - Martina Marangoni
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
| | - Silvia Benemei
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Chiarugi
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy.
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy.
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
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24
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Vernieri F, Brunelli N, Marcosano M, Aurilia C, Egeo G, Lovati C, Favoni V, Perrotta A, Maestrini I, Rao R, d'Onofrio L, Finocchi C, Aguggia M, Bono F, Ranieri A, Albanese M, Di Piero V, Cevoli S, Altamura C, Barbanti P. Maintenance of response and predictive factors of 1-year GalcanezumAb treatment in real-life migraine patients in Italy: The multicenter prospective cohort GARLIT study. Eur J Neurol 2023; 30:224-234. [PMID: 36097739 PMCID: PMC10086852 DOI: 10.1111/ene.15563] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate the 1-year effectiveness and tolerability of galcanezumab in real life and the prognostic indicators of persistent response. METHODS High-frequency episodic migraine (HFEM) and chronic migraine (CM) patients treated with galcanezumab who completed a 1-year observation were enrolled. The primary outcomes assessed during the 12 months (V1-V12) were the change in monthly migraine days (MMDs) from baseline and the response rates ≥50% in MMDs (MMD ≥50% RR). The secondary outcomes were changes in pain intensity (numerical rating scale [NRS]) and in monthly acute medication intake (MAMI). RESULTS We enrolled 191 patients (77.5% CM). Twenty-three patients (12%) dropped out, two for nonserious adverse events. At least 40% of patients took add-on standard preventives from baseline to V12. At V12, MMDs were reduced by 6.0 days in HFEM and by 11.9 days in CM patients (both p < 0.00001); NRS and MAMI were also decreased in both groups (p < 0.00001). One-hundred eight (56.5%) patients presented MMD ≥50% RR for 9 cumulative months (interquartile range=8): we defined this value as the cutoff for a persistent response. Persistent responders were less likely to have a higher body mass index (BMI) (p = 0.007) but more frequently had a good response to triptans (p = 0.005) and MMD ≥50% RR at V1 (p < 0.0000001). Patients without a persistent response were on add-on therapy for longer periods of time (p < 0.001). CONCLUSIONS Galcanezumab was effective and well-tolerated in the 1-year term, with most patients presenting MMD ≥50% RR for at least 9 months. Triptan response, lower BMI, and MMD ≥50% RR in the first month emerged as predictive factors for a persistent response.
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Affiliation(s)
- Fabrizio Vernieri
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
| | - Nicoletta Brunelli
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
| | - Marilena Marcosano
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy
| | - Carlo Lovati
- Neurology Unit, Headache Center, University Hospital L. Sacco, Milan, Italy
| | - Valentina Favoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | | | - Ilaria Maestrini
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Renata Rao
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luigi d'Onofrio
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
| | | | - Marco Aguggia
- Neurology and Stroke Unit, Asti Hospital, Asti, Italy
| | - Francesco Bono
- Neurology Unit, Center for Headache and Intracranial Pressure Disorders, A.O.U. Mater Domini, Catanzaro, Italy
| | - Angelo Ranieri
- Neurology and Stroke Unit, AORN A. Cardarelli, Naples, Italy
| | - Maria Albanese
- Neurology Unit, Headache Center, Tor Vergata University Hospital, Rome, Italy.,Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Vittorio Di Piero
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Claudia Altamura
- Headache and Neurosonology Unit, Neurology, Fondazione Policlinico Campus Bio-Medico, Rome, Italy
| | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele Pisana, Rome, Italy.,San Raffaele University, Rome, Italy
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25
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Mahon R, Vo P, Pannagl K, Tiwari S, Heemstra H, Ferraris M, Zhao J, Betts KA, Proot P. Assessment of the relative effectiveness of erenumab compared with onabotulinumtoxinA for the prevention of chronic migraine. Curr Med Res Opin 2023; 39:105-112. [PMID: 36189948 DOI: 10.1080/03007995.2022.2131299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To assess the available clinical and economic evidence of erenumab vs onabotulinumtoxinA for chronic migraine (CM) and present de-novo indirect treatment comparisons (ITCs) based on available clinical trial data. METHODS We conducted ITCs based on results from the pivotal 295 trial (NCT02066415) of erenumab vs placebo and published aggregate data from the PREEMPT 1 (NCT00156910) and PREEMPT 2 (NCT00168428) trials of onabotulinumtoxinA vs placebo. ITCs were conducted for CM patients with and without prior administration of onabotulinumtoxinA and among CM patients with ≥3 prior preventive treatment failures. Efficacy was assessed based on responder rates of ≥50% reductions in monthly headache days (MHDs) and monthly migraine days (MMDs) as well as change from baseline in both MHDs and MMDs. RESULTS Among patients with CM, 140 mg erenumab was associated with a reduction of 1.2 MHD (p = .092) and a reduction of 1.0 MMD (p = .174) compared to onabotulinumtoxinA at Week 12. Among onabotulinumtoxinA-naïve patients, erenumab was associated with a reduction of 1.8 MHD (p = .026) and 1.4 MMD (p = .080) at Week 12. Among patients that had received ≥3 prior preventive treatments, the odds ratios comparing erenumab vs onabotulinumtoxinA were 1.7 for ≥50% responder rates based on reductions in MHD (p = .155) and 1.7 for ≥50% responder rates based on reductions in MMD (p = .140). CONCLUSION These findings suggest directional benefits (although not reaching the threshold of statistical significance) associated with erenumab vs onabotulinumtoxinA for the preventive treatment of CM. Evidence from this study may inform healthcare stakeholders in treatment selection and optimization for patients with CM.
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Affiliation(s)
| | - Pamela Vo
- Novartis Pharma AG, Basel, Switzerland
| | | | | | | | | | - Jing Zhao
- Analysis Group, Inc, Los Angeles, CA, USA
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26
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Root S, Ahn K, Kirsch J, Hoskin JL. Review of Tolerability of Fremanezumab for Episodic and Chronic Migraine. Neuropsychiatr Dis Treat 2023; 19:391-401. [PMID: 36846598 PMCID: PMC9951598 DOI: 10.2147/ndt.s371686] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/10/2023] [Indexed: 02/22/2023] Open
Abstract
Calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) were the first class of medication specifically developed for the prevention of migraine. Fremanezumab is one of four CGRP mAbs currently available and is approved by the US Food and Drug Administration (FDA) for the preventative treatment of episodic and chronic migraines. This narrative review summarizes the history of fremanezumab development, the trials that led to its approval, and the later studies published evaluating its tolerability and efficacy. Evidence of fremanezumab for clinically significant efficacy and tolerability in patients with chronic migraine is especially important when considering the high level of disability, lower quality of life scores, and higher levels of health-care utilization associated with this condition. Multiple clinical trials demonstrated superiority of fremanezumab over placebo in terms of efficacy while demonstrating good tolerability. Treatment-related adverse reactions did not differ significantly compared to placebo and dropout rates were minimal. The most commonly observed treatment-related adverse reaction was mild-to-moderate injection site reaction, described as erythema, pain, induration, or swelling at the injection site.
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Affiliation(s)
- Shane Root
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA.,University of Arizona School of Medicine, Phoenix, AZ, USA.,Creighton University School of Medicine, Omaha, NE, USA
| | - Kevin Ahn
- Creighton University School of Medicine, Omaha, NE, USA
| | - Jack Kirsch
- Creighton University School of Medicine, Omaha, NE, USA
| | - Justin L Hoskin
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA.,University of Arizona School of Medicine, Phoenix, AZ, USA.,Creighton University School of Medicine, Omaha, NE, USA
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Pavelic AR, Wöber C, Riederer F, Zebenholzer K. Monoclonal Antibodies against Calcitonin Gene-Related Peptide for Migraine Prophylaxis: A Systematic Review of Real-World Data. Cells 2022; 12:cells12010143. [PMID: 36611935 PMCID: PMC9819019 DOI: 10.3390/cells12010143] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To perform a systematic review of real-world outcomes for anti-CGRP-mAbs. METHODS Following the PRISMA guidelines, we searched PubMed for real-world data of erenumab, galcanezumab, fremanezumab, or eptinezumab in patients with migraines. RESULTS We identified 134 publications (89 retrospective), comprising 10 pharmaco-epidemiologic and 83 clinic-based studies, 38 case reports, and 3 other articles. None of the clinic-based studies provided follow-up data over more than one year in more than 200 patients. Findings suggest that there are reductions in health insurance claims and days with sick-leave as well as better treatment adherence with anti-CGRP-mAbs. Effectiveness, reported in 77 clinic-based studies, was comparable to randomized controlled trials. A treatment pause was associated with an increase in migraine frequency, and switching to another antibody resulted in a better response in some of the patients. Adverse events and safety issues were addressed in 86 papers, including 24 single case reports. CONCLUSION Real-world data on anti-CGRP-mAbs are limited by retrospective data collection, small patient numbers, and short follow-up periods. The majority of papers seem to support good effectiveness and tolerability of anti-CGRP-mAbs in the real-world setting. There is an unmet need for large prospective real-world studies providing long-term follow-ups of patients treated with anti-CGRP-mAbs.
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Affiliation(s)
- Antun R. Pavelic
- Department of Neurology, Hietzing Hospital, 1130 Vienna, Austria
| | - Christian Wöber
- Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence:
| | - Franz Riederer
- Department of Neurology, Hietzing Hospital, 1130 Vienna, Austria
- Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
| | - Karin Zebenholzer
- Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, 1090 Vienna, Austria
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Argyriou AA, Dermitzakis EV, Xiromerisiou G, Vikelis M. OnabotulinumtoxinA Add-On to Monoclonal Anti-CGRP Antibodies in Treatment-Refractory Chronic Migraine. Toxins (Basel) 2022; 14:toxins14120847. [PMID: 36548744 PMCID: PMC9785576 DOI: 10.3390/toxins14120847] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/23/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
We sought to assess the effectiveness of combining dual therapy with onabotulinumtoxinA (BTX) add-on to anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (anti-CGRP MAbs) in treatment-refractory patients with chronic migraine (CM). We retrospectively reviewed the medical files of 19 treatment-refractory patients with CM who had failed to two oral migraine preventatives, at least three consecutive BTX cycles (less than 30% response rate), at least three consecutive sessions with either fremanezumab or erenumab (less than 30% response rate), and were eventually switched to dual therapy with BTX add-on to any of the already-given anti-CGRP MAbs. We then assessed from baseline to each monotherapy or dual intervention predefined efficacy follow-up the changes in the following efficacy outcomes: (i) monthly headache days (MHD), (ii) monthly days with moderate/severe peak headache intensity, and (iii) monthly days with intake of any acute headache medication. Response (50% reduction in MHD) rates, safety, and tolerability were also determined. In the majority of cases (n = 14), dual targeting proved effective and was associated with clinically meaningful improvement in all efficacy variables; 50% response rates (also disability and QOL outcomes) coupled with favorable safety/tolerability. Our results advocate in favor of the view that dual therapy is effective and should be considered in difficult-to-treat CM patients who have failed all available monotherapies.
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Affiliation(s)
- Andreas A. Argyriou
- Headache Outpatient Clinic, Neurology Department, Agios Andreas State General Hospital of Patras, 26352 Patras, Greece
- Correspondence:
| | | | - Georgia Xiromerisiou
- Department of Neurology, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, 41110 Larissa, Greece
| | - Michail Vikelis
- Headache Clinic, Mediterraneo Hospital, 16675 Glyfada, Greece
- Glyfada Headache Clinic, 16675 Glyfada, Greece
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Andreou AP, Fuccaro M, Hill B, Murphy M, Caponnetto V, Kilner R, Lambru G. Two-year effectiveness of erenumab in resistant chronic migraine: a prospective real-world analysis. J Headache Pain 2022; 23:139. [PMID: 36333710 PMCID: PMC9635079 DOI: 10.1186/s10194-022-01507-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background Controlled and real-world evidence have demonstrated the efficacy of calcitonin gene related peptide (CGRP) monoclonal antibodies (MABs) in migraine. However, data on the over-one-year sustained effectiveness of CGRP MABs in resistant chronic migraine (CM) is sparse. Methods This is a two-year real-world prospective analysis of an ongoing single centre audit conducted in patients with resistant CM. Patients received monthly erenumab for six months before assessing its effectiveness. Responders were considered those who achieved at least 30% reduction in monthly migraine days (MMD) by month 6, compared to baseline. Secondary outcomes were also analysed, including changes of the Headache Impact Test version 6 (HIT-6). Results One hundred sixty-four patients [135 (82.3%) females; mean age 46 SD 14) years] were included in the audit and 160 patients analysed. Patients had failed a mean of 8.4 preventive treatments at baseline. At month 6, 76 patients (48%) were 30% responders to erenumab, 50 patients (31%) were 50% responders and 25 (15%) were 75% responders. The mean reduction in MMD at month 6 was 7.5 days compared to baseline (P < 0.001). At month 12 and month 18, 61 patients (38%) and 52 patients (33%) remained 30% responders respectively. At month 24, 36 patients (23%) remained 30% responders, 25 patients (16%) and 13 patients (8%) were respectively 50% and 75% responders. Compared to 95% of patients at baseline, at months 6, 12 and 24, 46%, 29% and 16% of responders respectively had severe disability. At least one adverse event at month 6, 12, 18 and 24 was reported by 49%, 19%, 11% and 3% of patients. By month 6, 13% of patients discontinued the treatment because of side effects, often constipation. Conclusions Long-term sustained effectiveness of erenumab was reported only by a minority of resistant CM patients. Although more research in resistant migraine is needed, Erenumab can provide long-term meaningful reduction in migraine load and migraine-related disability in some patients.
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Affiliation(s)
- Anna P. Andreou
- grid.13097.3c0000 0001 2322 6764Institute of Psychiatry, Psychology and Neuroscience, Headache Research-Wolfson CARD, King’s College London, London, UK
| | - Matteo Fuccaro
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Bethany Hill
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Madeleine Murphy
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Valeria Caponnetto
- grid.158820.60000 0004 1757 2611Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Rachael Kilner
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Giorgio Lambru
- grid.420545.20000 0004 0489 3985Headache and Facial Pain Service, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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30
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Kung D, Rodriguez G, Evans R. Chronic Migraine. Neurol Clin 2022; 41:141-159. [DOI: 10.1016/j.ncl.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Holdridge A, Buczyner J, Aymat CC, Le A. Prevention of Migraine. Semin Neurol 2022; 42:558-570. [PMID: 36513096 DOI: 10.1055/s-0042-1758781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Migraine, a primary headache disorder is a chronic and complex neurological disease that affects millions of people worldwide, impacting their quality of life. It is one of the most common reasons why individuals seek the advice of their physician, and is one of the most common referrals seen in the offices of general neurologists and headache specialists. In the past decade, there has been robust research on not only the pathophysiology of migraine but in the efforts to treat and, importantly, prevent. The introduction of calcitonin gene related peptide antagonists (CGRP-A) have opened new doors for preventive treatment options. OnabotulinumtoxinA (BoNTA) has remained a staple in the treatment of chronic migraine with data emerging with combination therapy. Neurostimulation has offered additional nonpharmacologic approaches to migraine treatment. In addition to lifestyle and behavioral modifications, these have changed the landscape of migraine prevention.
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Affiliation(s)
- Ashley Holdridge
- Department of Neurology and Headache, Advocate Aurora HealthCare, Whitefish Bay, Wisconsin
| | - Jennifer Buczyner
- Department of Neurology, First Choice Neurology, Palm Beach Gardens, Florida
| | - Cristina Cabret Aymat
- Department of Neurology and Headache, Ochsner Health Center - Covington, Covington, Louisiana
| | - Ariel Le
- Department of Neurology, First Choice Neurology, Palm Beach Gardens, Florida
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Murray AM, Stern JI, Robertson CE, Chiang CC. Real-World Patient Experience of CGRP-Targeting Therapy for Migraine: a Narrative Review. Curr Pain Headache Rep 2022; 26:783-794. [PMID: 36063264 DOI: 10.1007/s11916-022-01077-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize available calcitonin gene-related peptide (CGRP)-targeting therapies for migraine and discuss their use in real-world populations. BACKGROUND CGRP has long been a topic of interest in migraine pathophysiology, with new therapies targeting CGRP since 2018 for both the preventive and acute treatment of migraine. METHODS We searched PubMed using keywords including "migraine," "CGRP," "real-world," "erenumab," "galcanezumab," "fremanezumab," "eptinezumab," "ubrogepant," "rimegepant," and "atogepant." We reviewed all pertinent studies and summarized main findings. We also compiled detailed patient characteristics (e.g., migraine diagnoses, medication overuse, prior treatment failures) and treatment outcome measures, such as 50% responder rates, reduction in migraine days, and adverse event rates in several tables. Overall, studies reporting real-world patient experiences of CGRP-targeting therapies suggested meaningful effectiveness for migraine treatment with response rates comparable to the numbers reported in clinical trials. Furthermore, studies suggested benefit in patients with multiple prior unsuccessful treatment trials, medication overuse, and complex medical comorbidities. In some studies, adverse event rates have been notably higher than reported in clinical trials. Additional long-term data is needed to further evaluate sustained efficacy, predictors of treatment response, and adverse events.
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Affiliation(s)
- Ann M Murray
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | | | | | - Chia-Chun Chiang
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA.
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Guerzoni S, Baraldi C, Pani L. The association between onabotulinumtoxinA and anti-CGRP monoclonal antibodies: a reliable option for the optimal treatment of chronic migraine. Neurol Sci 2022; 43:5687-5695. [PMID: 35680766 DOI: 10.1007/s10072-022-06195-5] [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: 04/13/2022] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Abstract
Chronic migraine (CM) is a great challenge for physicians dealing with headaches. Despite the introduction of the monoclonal antibodies (mAbs) acting against the calcitonin gene-related peptide (CGRP) that has revolutionized the treatment of CM, some patients still experience an incomplete relief. So, the association of two preventive treatments may be a reliable option for these patients. So, onabotulinumtoxinA (BT-A) and anti-CGRP mAbs may be used together, and some pre-clinical and clinical evidence of an additive action of the 2 drugs is emerging. In particular, since BT-A acts mainly on C-fibers and anti-CGRP mAbs on Aδ ones, their association may prevent the wearing-off phenomenon of BT-A, thus giving an additional benefit in those patients experiencing an incomplete response to BT-A alone. Despite this, the clinical studies available in the literature have a small sample size, often a retrospective design, and are heterogeneous in terms of the outcomes chosen. Considering this, the evidence of a favorable effect of the association between BT-A and anti-CGRP mAbs is still scarce. Furthermore, this association is explicitly forbidden by many National regulatory agencies, due to the high costs of both treatments. Anyway, their association could help in reducing the burden associated with the most severe cases of CM, thus relieving the direct and indirect costs of this condition. More well-designed studies with big samples are needed to unveil the real therapeutic gain of this association. Moreover, pharmacoeconomics studies should be performed, to assess the economic suitability of this association.
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Affiliation(s)
- Simona Guerzoni
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy.
| | - Carlo Baraldi
- PhD School in Neuroscience, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Luca Pani
- Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, Department of Specialist Medicines, AOU Policlinico Di Modena, Modena, Italy.,Pharmacology Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, FL, USA.,VeraSci, Durham, NC, USA
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Pooled Analysis of Real-World Evidence Supports Anti-CGRP mAbs and OnabotulinumtoxinA Combined Trial in Chronic Migraine. Toxins (Basel) 2022; 14:toxins14080529. [PMID: 36006191 PMCID: PMC9413678 DOI: 10.3390/toxins14080529] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/26/2022] [Accepted: 07/30/2022] [Indexed: 01/27/2023] Open
Abstract
OnabotulinumtoxinA, targeting the CGRP machinery, has been approved for the last two decades for chronic migraine prevention. The recently approved monoclonal antibodies (mAbs) directed towards the calcitonin gene-related peptide (CGRP) pathway open a new age for chronic migraine control. However, some 40% patients suffering from chronic migraine is still resistant to treatment. The aim of this work is to answer the following PICOS (participants intervention comparator outcome study design) question: Is there evidence of efficacy and safety of the combined administration of anti-CGRP mAbs and onabotulinumtoxinA in chronic migraine? A systematic review and meta-analysis [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations] was made up to 19 April 2022. The results are encouraging: the combined treatment proved to afford ≥50% monthly headache days (MHDs)/frequency reduction respect to baseline in up to 58.8% of patients; in comparison, anti-CGRP mAbs reduce MHDs of 1.94 days from baseline and botulinum toxin of 1.86 days. Our study demonstrates for the first time that the combination therapy of onabotulinumtoxinA with anti-CGRP mAbs affords a reduction of 2.67 MHDs with respect to onabotulinumtoxinA alone, with moderate certainty of evidence. Adequately powered, good-quality studies are needed to confirm the response to combination therapy in terms of efficacy and safety. PROSPERO registration: CRD42022313640.
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Reducing the Burden of Migraine: Safety and Efficacy of CGRP Pathway-Targeted Preventive Treatments. J Clin Med 2022; 11:jcm11154359. [PMID: 35955976 PMCID: PMC9369309 DOI: 10.3390/jcm11154359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Migraine is a highly disabling and often chronic neurological disease that affects more than one billion people globally. Preventive migraine treatment is recommended for individuals who have frequent and/or disabling attacks; however, many of the medications used for migraine prevention (e.g., antiepileptics, antidepressants, antihypertensives) were not specifically developed for migraine, and often have limited efficacy or poor tolerability. Four monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway, which is believed to play a crucial role in the pathophysiology of migraine, have been approved by the US Food and Drug Administration for the preventive treatment of migraine in adults. All four migraine-specific treatments have demonstrated efficacy based on reductions in monthly days with migraine for patients with both episodic and chronic migraine, including those with comorbidities. They have also demonstrated favorable safety and tolerability profiles. Based on these accounts, CGRP pathway-targeted monoclonal antibodies have the potential to revolutionize preventive treatment for patients with migraine.
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Fitzek M, Raffaelli B, Reuter U. Advances in pharmacotherapy for the prophylactic treatment of resistant and refractory migraine. Expert Opin Pharmacother 2022; 23:1143-1153. [PMID: 35698795 DOI: 10.1080/14656566.2022.2088281] [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 Refractory migraine is associated with low quality of life and great socioeconomic burden. Despite high need for effective, tolerable preventive therapies, there has been little research on potential therapeutic options. Monoclonal antibodies (mAbs) against Calcitonin Gene-Related Peptide (CGRP) are the first preventive therapeutic approach for migraine based on the underlying pathophysiology. AREAS COVERED Following a brief introduction into the term 'refractory migraine,' the authors reviewavailable treatment options, focusing on current phase III trials of substances acting on the CGRP pathway. EXPERT OPINION No uniform definition for refractory migraine is available. The vast majority of proposals recommend treatment failure of 2-4 drug classes as a key diagnostic criterion. Phase III studies on CGRP-(receptor) mAbs demonstrated excellent efficacy and tolerability in patients with chronic and episodic migraine including subjects with multiple unsuccessful conventional therapy attempts. However, more comparator trials showing superiority of mAbs versus oral preventatives, such as the HER-MEs study are needed. In summary, with the CGRP antibodies, a group of drugs has entered the market which will most likely not only significantly improve the quality of life of many individual migraine patients but could also reduce indirect health-care costs associated with migraine by reducing recurrent medical consultations.
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Affiliation(s)
- Mira Fitzek
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Clinician Scientist Programm, Berlin Institute of Health (BIH), Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Universitätsmedizin Greifswald, Greifswald, Germany
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López‐Bravo A, Oliveros‐Cid A, Sevillano‐Orte L. Treatment satisfaction with calcitonin gene-related peptide monoclonal antibodies as a new patient-reported outcome measure: A real-life experience in migraine. Acta Neurol Scand 2022; 145:669-675. [PMID: 35243611 DOI: 10.1111/ane.13599] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate treatment satisfaction with galcanezumab as a patient-reported outcome measure (PROM) in migraine. METHODS Patients with ≥8 headache days/month that had failed at ≥3 medications were included. Demographic and medical history were collected. Patient´s satisfaction (effectiveness, safety, convenience, and global satisfaction [GS]) was assessed by the Treatment Satisfaction Questionnaire for Medication version 1.4 (TSQM-1.4©). RESULTS We included 30 patients with migraine (76.7% chronic migraine). After 12 weeks of galcanezumab treatment, median monthly headache days (MHDs) decreased 11.5 (IQR 14.0) and median monthly migraine days (MMDs) 9.0 (IQR 7.5); at 24 weeks, the change was 15.0 (IQR 12.0) and 8.0 days (IQR 6.0). HIT-6 score decreased from 68.0 (IQR 7.5) to 54.0 (IQR 9.5) at 12 weeks (p < .001) and to 52.0 (IQR12.0) at 24 weeks (p < .001) and MIDAS from 60.0 (IQR 62.7) to 25.5 (IQR 41.2, p = .004) and 7.0 (IQR 18.5, p < .001), respectively. TSQM-1.4© at 12 weeks was higher compared to other preventive therapy in effectiveness (80.6/50.4, p < .001), convenience (83.3/66.7, p = .001), and GS (78.6/50.0, p < .001). These rates of satisfaction were similar at 24 weeks of galcanezumab treatment. Reductions in HIT-6 (r = -.444, p = .014), MIDAS (r = -.423, p = .020), MMDs (r = -.515, p = .004), and MHDs (r = -.477, p = .008) were associated significantly with GS at 12 weeks. This correlation was significantly associated with changes in HIT-6 and MHDs at 24 weeks. CONCLUSIONS The results of this study suggest that migraine patients receiving galcanezumab are significantly more satisfied compared to other preventive therapies, associating treatment GS with meaningful reductions in frequency, impact, and disability caused by migraine.
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Affiliation(s)
- Alba López‐Bravo
- Department of Neurology Hospital Reina Sofia Navarra Spain
- Aragon Institute for Health Research (IIS Aragón) Zaragoza Spain
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Driessen MT, Cohen JM, Thompson SF, Patterson-Lomba O, Seminerio MJ, Carr K, Totev TI, Sun R, Yim E, Mu F, Ayyagari R. Real-world effectiveness after initiating fremanezumab treatment in US patients with episodic and chronic migraine or difficult-to-treat migraine. J Headache Pain 2022; 23:56. [PMID: 35578182 PMCID: PMC9109352 DOI: 10.1186/s10194-022-01415-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background Fremanezumab, a fully humanized monoclonal antibody (mAb; IgG2Δa) that selectively targets calcitonin gene-related peptide (CGRP), is approved for the preventive treatment of migraine in adults. The efficacy and safety of fremanezumab for migraine prevention have been demonstrated in randomized, double-blind, placebo-controlled trials. Real-world effectiveness data are needed to complement clinical trial data. This study assessed the effectiveness of fremanezumab across different subgroups of adult patients with episodic migraine (EM), chronic migraine (CM), or difficult-to-treat (DTT) migraine in real-world clinical settings. Methods This retrospective, panel-based online chart review used electronic case report forms. Patient inclusion criteria were a physician diagnosis of EM or CM; age ≥ 18 years at the time of first fremanezumab initiation; ≥ 1 dose of fremanezumab treatment; ≥ 1 follow-up visit since first initiation; and ≥ 2 measurements of monthly migraine days (MMD; with 1 within a month before or at first initiation and ≥ 1 after first initiation). Changes in MMD and monthly headache days were assessed during the follow-up period. These endpoints were evaluated in subgroups of patients by migraine type (EM/CM) and in subgroups with DTT migraine (diagnosis of medication overuse [MO], major depressive disorder [MDD], generalized anxiety disorder [GAD], or prior exposure to a different CGRP pathway–targeted mAb [CGRP mAb]). Results Data were collected from 421 clinicians and 1003 patients. Mean (percent) reductions from baseline in MMD at Month 6 were − 7.7 (77.0%) in EM patients, − 10.1 (68.7%) in CM patients, − 10.8 (80.6%) in the MO subgroup, − 9.9 (68.3%) in the MDD subgroup, − 9.5 (66.4%) in the GAD subgroup, and − 9.0 (68.7%) in the prior CGRP mAb exposure subgroup. Improvements in MDD or GAD severity were reported by 45.5% and 45.8% of patients with comorbid MDD or GAD, respectively. Conclusions In this real-world study, fremanezumab demonstrated effectiveness for migraine regardless of migraine type or the presence of factors contributing to DTT migraine (MO, GAD, MDD, or prior exposure to a different CGRP mAb). Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01415-x.
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Wang YF, Wang SJ. CGRP Targeting Therapy for Chronic Migraine-Evidence from Clinical Trials and Real-world Studies. Curr Pain Headache Rep 2022; 26:543-554. [PMID: 35567661 DOI: 10.1007/s11916-022-01056-4] [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] [Accepted: 04/18/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Monoclonal antibodies against calcitonin gene-related peptide (CGRP) or its receptor have become part of the standard treatment for migraine in clinical practice. The current review focuses on the clinical evidence of CGRP monoclonal antibodies in patients with chronic migraine (CM), including more challenging cases. RECENT FINDINGS CGRP monoclonal antibodies were more effective than placebo in reducing the number of monthly migraine days (MMDs), and the change relative to placebo in the treatment group was between - 1.2 and - 2.7 days at 3 months. CGRP monoclonal antibodies resulted in ≥ 50% response in 27.5 to 61.4% of patients, and doubled the odds for having ≥ 50% response. The findings were generally consistent in patients with coexisting medication overuse or with treatment failures to multiple preventive medications, including onabotulinumtoxinA. The results from real-world studies (RWS) were similar to those seen in clinical trials, and the changes from baseline in the number of MMDs and the response rates largely fell within the ranges of those reported in the treatment group in pivotal trials. The therapeutic effects typically started within a few days, and remained steady after regular treatment for up to 1 year. These agents were generally well tolerated, and the discontinuation rates due to adverse events in clinical trials and in many RWS were < 4.5%. CGRP monoclonal antibodies are effective and safe in the treatment of patients with CM, including clinical challenging cases. However, the role of CGRP monoclonal antibodies in a number of conditions, such as cardiovascular or cerebrovascular diseases, pregnancy, and overuse of opioids or barbiturates, needs to be further clarified.
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Affiliation(s)
- Yen-Feng Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Bei-Tou District, Taipei, 11217, Taiwan. .,College of Medicine National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Bei-Tou District, Taipei, 11217, Taiwan.,College of Medicine National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Blumenfeld A, McVige J, Knievel K. Post-traumatic headache: Pathophysiology and management - A review. JOURNAL OF CONCUSSION 2022. [DOI: 10.1177/20597002221093478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Post-traumatic headache (PTH) is a common secondary headache due to traumatic brain injury. In the past, significant research has been conducted to understand the pathophysiology and treatment options for PTH. However, PTH still lacks evidence-based treatment, and most of the management depends on the primary phenotype observed in the patient. Objective The main objective of this review is to provide a single reference that covers the current understanding of the pathophysiology and the treatment options available for PTH. Methods A detailed literature search on PubMed was performed, and a narrative review was prepared. Results The pathophysiology of PTH is multifactorial. Acute PTH may be attributed to increased peripheral pain sensitization with impaired pain inhibiting pathways. Chronic or persistent PTH may be due to a chronic inflammatory response and peripheral as well as central sensitization. The mechanism responsible for the transition of acute to persistent PTH is unknown. The migraine-like phenotype is reported to be the most prevalent headache type seen in PTH. New targets for preventive treatment have been identified in recent years, such as neuropeptides like calcitonin-gene-related peptide (CGRP), nitric oxide, and glutamate. The preventive pharmacological and non-pharmacological strategies employed for migraine (e.g. anti-CGRP monoclonal antibodies, onabotulinumtoxinA, physical therapy, cognitive and behavioral treatment, and neurostimulation techniques) have shown in preliminary studies that they are potentially efficacious, but large, randomized, double blind, placebo controlled trials are needed to further establish these as treatment options for PTH. Conclusions The lack of evidence-based treatment for PTH has created a need for future large trials to confirm the safety and efficacy of the currently employed treatments.
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Affiliation(s)
- Andrew Blumenfeld
- The Los Angeles Headache Center and The San Diego Headache Center, Los Angeles, CA, USA
| | | | - Kerry Knievel
- Barrow Neurological Institute, Phoenix, Arizona, USA
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Cohen F, Yuan H, Silberstein SD. Calcitonin Gene-Related Peptide (CGRP)-Targeted Monoclonal Antibodies and Antagonists in Migraine: Current Evidence and Rationale. BioDrugs 2022; 36:341-358. [PMID: 35476215 PMCID: PMC9043885 DOI: 10.1007/s40259-022-00530-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/25/2022]
Abstract
Calcitonin gene-related peptide (CGRP), a 37 amino-acid neuropeptide found mostly in peptidergic sensory C-fibers, has been suggested to be implicated in the pathogenesis of migraine, which is one of the most common neurological disorders seen in medical practice, affecting almost 16% of the US population. While previously thought to be a vascular condition, migraine attacks are the result of neurogenic inflammation and peripheral/central sensitization through dysfunctional activation of the trigeminovascular system. To date, two classes of therapeutic agents have been developed to interrupt the function of CGRP: CGRP-targeted monoclonal antibodies (mAbs) and small-molecule antagonists (gepants). There are currently four CGRP-targeted mAbs and three gepants that are US Food and Drug Administration (FDA) approved for the treatment of migraine. Multiple phase II and III studies have established the efficacies and tolerability of these treatments. Previously, we reviewed the fundamental role of CGRP in migraine pathogenesis. Here, we discuss in depth the clinical evidence (randomized controlled trials and real-world studies), safety, and tolerability of CGRP-targeted mAbs and gepants for treating migraine.
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Affiliation(s)
- Fred Cohen
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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Cohen F, Yuan H, DePoy EMG, Silberstein SD. The Arrival of Anti-CGRP Monoclonal Antibodies in Migraine. Neurotherapeutics 2022; 19:922-930. [PMID: 35426060 PMCID: PMC9294119 DOI: 10.1007/s13311-022-01230-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 01/08/2023] Open
Abstract
Remarkable advancements have been made in the field of migraine pathophysiology and pharmacotherapy over the past decade. Understanding the molecular mechanism of calcitonin gene-related peptide (CGRP) has led to the discovery of a novel class of drugs, CGRP functional blocking monoclonal antibodies (mAbs), for migraine prevention. CGRP is a neuropeptide inherently involved in migraine physiology where its receptors are found dispersed throughout the central and peripheral nervous systems. CGRP-targeted mAbs are effective in the preventive treatment of both chronic and episodic migraine. The advantages of mAbs over oral migraine preventives are numerous. Favorable attributes of the mAbs include high affinity and selectivity for CGRP molecular targets, long-circulating plasma half-lives, and limited risk for nonspecific hepatic and renal toxicity. This pharmacological profile leads to fewer off-target (side) effects and drug-drug interactions rendering mAbs an attractive alternative to traditional small molecule therapies, especially for the preventive treatment of migraine. MAbs display minimal drug interaction thus are excellent for patients prescribed with multiple medications. However, the long-term safety of CGRP blockade is incompletely known, and CGRP mAbs use should be avoided during pregnancy. CGRP mAbs represent a radical shift in preventing chronic and episodic migraine.
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Affiliation(s)
- Fred Cohen
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Hsiangkuo Yuan
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - E M G DePoy
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA
| | - Stephen D Silberstein
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 900 Walnut Street, Suite 200, Philadelphia, PA, 19107, USA.
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43
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Ornello R, Baraldi C, Guerzoni S, Lambru G, Andreou AP, Raffaelli B, Gendolla A, Barbanti P, Aurilia C, Egeo G, Cevoli S, Favoni V, Vernieri F, Altamura C, Russo A, Silvestro M, Valle ED, Mancioli A, Ranieri A, Alfieri G, Latysheva N, Filatova E, Talbot J, Cheng S, Holle D, Scheffler A, Nežádal T, Čtrnáctá D, Šípková J, Matoušová Z, Casalena A, Maddestra M, Viola S, Affaitati G, Giamberardino MA, Pistoia F, Reuter U, Sacco S. Comparing the relative and absolute effect of erenumab: is a 50% response enough? Results from the ESTEEMen study. J Headache Pain 2022; 23:38. [PMID: 35305579 PMCID: PMC8933935 DOI: 10.1186/s10194-022-01408-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 12/22/2022] Open
Abstract
Background Monoclonal antibodies acting on the calcitonin gene-related peptide (CGRP) or its receptor have changed migraine preventive treatment. Those treatments have led to reconsidering the outcomes of migraine prevention. Available data mostly considered benefits in terms of relative efficacy (percent or absolute decrease in monthly migraine days [MMDs] or headache days compared with baseline). However, not enough attention has been paid to residual MMDs and/or migraine-related disability in treated patients. In the present study, we aimed at comparing the relative and absolute efficacy of erenumab. Methods ESTEEMen was a collaborative project among 16 European headache centers which already performed real-life data collections on patients treated with erenumab for at least 12 weeks. For the present study, we performed a subgroup analysis on patients with complete data on MMDs at baseline and at weeks 9-12 of treatment. Starting from efficacy thresholds proposed by previous literature, we classified patients into 0-29%, 30-49%, 50-74%, and ≥75% responders according to MMD decrease from baseline to weeks 9-12 of treatment. For each response category, we reported the median MMDs and Headache Impact test-6 (HIT-6) scores at baseline and at weeks 9-12. We categorized the number of residual MMDs at weeks 9-12 as follows: 0-3, 4-7, 8-14, ≥15. We classified HIT-6 score into four categories: ≤49, 50-55, 56-59, and ≥60. To keep in line with the original scope of the ESTEEMen study, calculations were performed in men and women. Results Out of 1215 patients, at weeks 9-12, 381 (31.4%) had a 0-29% response, 186 (15.3%) a 30-49% response, 396 (32.6%) a 50-74% response, and 252 (20.7%) a ≥75% response; 246 patients (20.2%) had 0-3 residual MMDs, 443 (36.5%) had 4-7 MMDs, 299 (24.6%) had 8-14 MMDs, and 227 (18.7%) had ≥15 MMDs. Among patients with 50-74% response, 246 (62.1%) had 4-7 and 94 (23.7%) 8-14 residual MMDs, while among patients with ≥75% response 187 (74.2%) had 0-3 and 65 (25.8%) had 4-7 residual MMDs. Conclusions The present study shows that even patients with good relative response to erenumab may have a clinically non-negligible residual migraine burden. Relative measures of efficacy cannot be enough to thoroughly consider the efficacy of migraine prevention. Supplementary Information The online version contains supplementary material available at 10.1186/s10194-022-01408-w.
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Affiliation(s)
- Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio 1, L'Aquila, Italy
| | - Carlo Baraldi
- PhD school in neurosciences; Department of biomedical, metabolic and neural sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Simona Guerzoni
- Medical toxicology - Headache and Drug Abuse Research Center; Department of biomedical, metabolic and neural sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giorgio Lambru
- The Headache Service, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Anna P Andreou
- The Headache Service, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Bianca Raffaelli
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele, Rome, Italy.,San Raffaele University, Rome, Italy
| | | | | | - Sabina Cevoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Valentina Favoni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Claudia Altamura
- Headache and Neurosonology Unit, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Antonio Russo
- Headache Center, Department of Medical, Surgical, Neurological, Metabolic, and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marcello Silvestro
- Headache Center, Department of Medical, Surgical, Neurological, Metabolic, and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Andrea Mancioli
- Headache Centre, Ospedale S. Antonio Abate, ASST Valle Olona, Gallarate, Italy
| | - Angelo Ranieri
- Headache Centre, Division of Neurology and Stroke Unit, "A. Cardarelli" Hospital, Naples, Italy
| | - Gennaro Alfieri
- Headache Centre, Division of Neurology and Stroke Unit, "A. Cardarelli" Hospital, Naples, Italy
| | - Nina Latysheva
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Elena Filatova
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
| | - Jamie Talbot
- Southwest Neurology Audit and Research group (SoNAR), Department of Neurology, Derriford Hospital, Plymouth, PL6 8DH, UK
| | - Shuli Cheng
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Dagny Holle
- Department of Neurology, West German Headache Center, University hospital Essen, Essen, Germany
| | - Armin Scheffler
- Department of Neurology, West German Headache Center, University hospital Essen, Essen, Germany
| | - Tomáš Nežádal
- Military University Hospital Prague, Department of Neurology, 1st Faculty of Medicine Charles University, Prague, Czech Republic
| | - Dana Čtrnáctá
- Military University Hospital Prague, Department of Neurology, 1st Faculty of Medicine Charles University, Prague, Czech Republic
| | - Jitka Šípková
- Military University Hospital Prague, Department of Neurology, 1st Faculty of Medicine Charles University, Prague, Czech Republic
| | - Zuzana Matoušová
- Motol University Hospital Prague, Department of Neurology, 2nd Faculty of Medicine Charles University, Prague, Czech Republic
| | | | - Maurizio Maddestra
- Department of Neurology, "F. Renzetti" Hospital, Lanciano, Chieti, Italy
| | - Stefano Viola
- Department of Neurology, "S. Pio da Pietrelcina" Hospital, Vasto, Chieti, Italy
| | - Giannapia Affaitati
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Center for Advanced Studies and Technology (CAST), G. D'Annunzio University, Chieti, Italy
| | - Maria Adele Giamberardino
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Center for Advanced Studies and Technology (CAST), G. D'Annunzio University, Chieti, Italy
| | - Francesca Pistoia
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio 1, L'Aquila, Italy
| | - Uwe Reuter
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Universitätsmedizin Greifswald, Greifswald, Germany
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Via Vetoio 1, L'Aquila, Italy.
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Chowdhury D, Mundra A, Datta D, Duggal A, Krishnan A, Koul A. Efficacy and tolerability of combination treatment of topiramate and greater occipital nerve block versus topiramate monotherapy for the preventive treatment of chronic migraine: A randomized controlled trial. Cephalalgia 2022; 42:859-871. [PMID: 35259978 DOI: 10.1177/03331024221082077] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare the efficacy and tolerability of combination treatment of topiramate and greater occipital nerve block to topiramate monotherapy in adult chronic migraine patients. BACKGROUND Options for the preventive treatment of chronic migraine are limited and costly. Combination treatments do not have an evidence base yet. METHODS This was a parallel group, 3 arms with 1:1:1 allocation ratio randomized controlled study in consecutive adult chronic migraine patients attending Headache Clinic in a tertiary care hospital. Patients received either topiramate monotherapy 100 mg/day (group A), or topiramate plus greater occipital nerve block with 40 mg lidocaine (2%) and 80mg (2 ml) methylprednisolone as the first injection followed by monthly injections of lidocaine for the next 2 months (group B) or topiramate plus greater occipital nerve block with 40 mg lidocaine (2%) injections monthly for 3 months (group C). The primary endpoint was the mean change in monthly migraine days at Month 3. Multiple secondary endpoints were assessed that included among others, achievement of ≥50% reduction in mean monthly headache days compared to baseline at Month 3 and assessment for any adverse events. RESULTS One hundred and twenty-five patients were randomized; 41 to group A, 44 to group B, and 40 to group C. Efficacy assessments were done for 121 patients. Patients receiving combination treatment of topiramate and greater occipital nerve block with steroids and lidocaine and greater occipital nerve block with only lidocaine compared to topiramate monotherapy showed greater reductions in monthly migraine days at Month 3 (-9.6 vs -7.3 days; p = 0.003) and (-10.1 vs -7.3 days; p < 0.001) respectively. Greater proportion of patients in both the combination treatment groups (added greater occipital nerve block with and without steroid) achieved ≥50% reduction in mean monthly headache days [71.4% vs 39%; OR (95% CI) 3.9(1.6-9.8); p = 0.004] and [62.4% vs 39%; OR (95% CI) 2.7(1.1-6.7); p = 0.034] respectively, compared to those receiving topiramate monotherapy. Adverse effects between the groups were comparable although patients receiving combination treatment with added greater occipital nerve block reported transient adverse effects like post-injection dizziness, local site swelling, and pain. No serious adverse event was reported. CONCLUSION Combination treatments of topiramate with monthly injections of greater occipital nerve block were more effective in reducing monthly migraine days in chronic migraine than topiramate monotherapy at Month 3. Combination treatments were well tolerated.
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Affiliation(s)
- Debashish Chowdhury
- GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Ankit Mundra
- GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Debabrata Datta
- GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Ashish Duggal
- GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Anand Krishnan
- All India Institute of Medical sciences, New Delhi, India
| | - Arun Koul
- GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
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45
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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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46
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Hamann T, Rimmele F, Jürgens TP. [CGRP antibodies in migraine prophylaxis : The new standard in migraine treatment?]. Schmerz 2022; 36:59-72. [PMID: 35041064 DOI: 10.1007/s00482-021-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
Migraine is associated with a high individual level of suffering. Therefore, an effective preventive treatment is highly important. The spectrum of classical prophylactic drugs has now been expanded to include monoclonal antibodies against calcitonin gene-related peptide (CGRP) and its receptor. These antibodies have shown reliable efficacy compared to placebo and a rapid onset of action with a low rate of side effects and negligible interactions in pivotal studies. Recently, the efficacy of the antibody was shown in many studies even on drug-refractory migraine and migraine associated with medication overuse. Comprehensive head to head comparisons with previously established drugs and among the antibodies are not yet available; however, initial studies suggest better tolerability and efficacy compared to conventional drugs and other antibodies. The role of antibodies in established treatment cascades still needs to be clarified.
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Affiliation(s)
- Till Hamann
- Klinik und Poliklinik für Neurologie, Kopfschmerzzentrum Nord-Ost, Universitätsmedizin Rostock, Gehlsheimer Straße 20, 18147, Rostock, Deutschland.
| | - Florian Rimmele
- Klinik und Poliklinik für Neurologie, Kopfschmerzzentrum Nord-Ost, Universitätsmedizin Rostock, Gehlsheimer Straße 20, 18147, Rostock, Deutschland
| | - Tim Patrick Jürgens
- Klinik und Poliklinik für Neurologie, Kopfschmerzzentrum Nord-Ost, Universitätsmedizin Rostock, Gehlsheimer Straße 20, 18147, Rostock, Deutschland.,Neurologisches Zentrum, Klinik für Neurologie, KMG Klinikum Güstrow, Güstrow, Deutschland
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47
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Mechtler L, Saikali N, McVige J, Hughes O, Traut A, Adams AM. Real-World Evidence for the Safety and Efficacy of CGRP Monoclonal Antibody Therapy Added to OnabotulinumtoxinA Treatment for Migraine Prevention in Adult Patients With Chronic Migraine. Front Neurol 2022; 12:788159. [PMID: 35069416 PMCID: PMC8770868 DOI: 10.3389/fneur.2021.788159] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022] Open
Abstract
Background: OnabotulinumtoxinA and calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) target different migraine pathways, therefore, combination treatment may provide additional effectiveness for the preventive treatment of chronic migraine (CM) than either treatment alone. The objective of this study was to collect real-world data to improve the understanding of the safety, tolerability, and effectiveness of adding a CGRP mAb to onabotulinumtoxinA treatment for the preventive treatment of CM. Methods: This was a retrospective, longitudinal study conducted using data extracted from a single clinical site's electronic medical records (EMR) of adult patients (≥18 years) with CM treated with ≥2 consecutive cycles of onabotulinumtoxinA before ≥1 month of continuous onabotulinumtoxinA and CGRP mAb (erenumab, fremanezumab, or galcanezumab) combination treatment. Safety was evaluated by the rate of adverse events (AE) and serious adverse events (SAE). The proportion of patients who discontinued either onabotulinumtoxinA, a CGRP mAb, or combination treatment, and the reason for discontinuation, if available, was collected. The effectiveness of combination preventive treatment was assessed by the reduction in monthly headache days (MHD). Outcome data were extracted from EMR at the first CGRP mAb prescription (index) and up to four assessments at ~3, 6, 9, and 12 months post-index. The final analyses were based on measures consistently reported in the EMR. Results: EMR were collected for 192 patients, of which 148 met eligibility criteria and were included for analysis. Erenumab was prescribed to 56.7% of patients, fremanezumab to 42.6%, and galcanezumab to 0.7%. Mean (standard deviation [SD]) MHD were 20.4 (6.6) prior to onabotulinumtoxinA treatment and 14.0 (6.9) prior to the addition of a CGRP mAb (baseline). After real-world addition of a CGRP mAb, there were significant reductions in MHD at the first assessment (~3 months) (mean -2.6 days/month, 95% CI -3.7, -1.4) and at all subsequent visits. After ~12 months of continuous combination treatment, MHD were reduced by 4.6 days/month (95% CI -6.7, -2.5) and 34.9% of patients achieved ≥50% MHD reduction from index. AEs were reported by 18 patients (12.2%), with the most common being constipation (n = 8, 5.4% [onabotulinumtoxinA plus erenumab only]) and injection site reactions (n = 5, 3.4%). No SAEs were reported. Overall, 90 patients (60.8%) discontinued one or both treatments. The most common reason for discontinuing either treatment was lack of insurance coverage (40%); few (~14%) patients discontinued a CGRP mAb and none discontinued onabotulinumtoxinA due to safety/tolerability. Conclusion: In this real-world study, onabotulinumtoxinA was effective at reducing MHD and the addition of a CGRP mAb was safe, well-tolerated and associated with incremental and clinically meaningful reductions in MHD for those who stayed on the combination treatment. No new safety signals were identified. Of those who discontinued, the majority reported lack of insurance coverage as a reason. Prospective real-world and controlled trials are needed to further evaluate the safety and potential benefits of this combination treatment paradigm for people with CM.
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48
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Iannone LF, Fattori D, Benemei S, Chiarugi A, Geppetti P, De Cesaris F. Long-Term Effectiveness of Three Anti-CGRP Monoclonal Antibodies in Resistant Chronic Migraine Patients Based on the MIDAS score. CNS Drugs 2022; 36:191-202. [PMID: 35146696 PMCID: PMC8863684 DOI: 10.1007/s40263-021-00893-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Criteria, including clinical features and effective outcomes, for access and persistence of novel but costly treatments may vary between countries, thus affecting the health of patients. Monoclonal antibodies against the calcitonin gene-related peptide pathway (anti-CGRP mAbs) for migraine treatment are currently prescribed following strict criteria. OBJECTIVE The aim was to assess the effectiveness and safety of three anti-CGRP mAbs (erenumab, galcanezumab, and fremanezumab) in consecutive resistant chronic migraine patients presenting at our Headache Center and the impact of criteria set by the Italian Medicines Agency to start and continue (achieving a ≥ 50% reduction in Migraine Disability Assessment [MIDAS] score) with treatment under the reimbursement program. METHODS A monocentric, prospective, cohort study was conducted, enrolling 203 severe (resistant to three or more preventive treatments) chronic migraine patients (84.7% with medication overuse) treated with erenumab (47.2%), galcanezumab (36.5%), or fremanezumab (16.3%), with up to 12 months follow-up. Patients completed a headache diary that included monthly migraine days (MMDs), number of analgesics and days with analgesic use, and patient-reported outcome questionnaires (MIDAS, Headache Impact Test 6 [HIT-6] questionnaires, and the Patient Global Impression of Change [PGIC] scale). Moreover, percentages of patients showing ≥ 50%, ≥ 75% and 100% reduction in MMDs (responder rates) were calculated at different follow-ups. A subgroup analysis was performed for patients with 12-month follow-up. Potential predictors of response were assessed at different follow-ups. RESULTS In the overall population, all three anti-CGRP mAbs were similarly effective and dropouts were 17.2%. The percentage of patients with ≥ 50% reduction in MMDs (min-max 36.4-56.8%) and in monthly analgesic consumption (51.1-75.7%) was inferior to the percentage of patients who reported a ≥ 50% reduction in MIDAS score (89.5-100%). HIT-6 score was also consistently reduced at all follow-ups. In patients with a 12-month follow-up, MIDAS and HIT-6 scores were also reduced at all follow-ups compared with baseline, with 84.4-100% of patients achieving a ≥ 50% reduction in MIDAS score, and patients with a ≥ 50% response rate ranging from 36.4 to 66.6%. No severe adverse events were recorded. Fewer migraine days at baseline were associated with ≥ 50% response rate at 1 month and fewer MMDs, years of chronic migraine, and monthly analgesic use at 6 months. CONCLUSION In resistant chronic migraine patients, anti-CGRP mAbs are effective and safe. A ≥ 50% reduction in MIDAS score seems to be the most advantageous outcome measure in this setting, which allows most severe migraine patients to persist with treatment.
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Affiliation(s)
- Luigi Francesco Iannone
- grid.8404.80000 0004 1757 2304Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy ,grid.24704.350000 0004 1759 9494Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Davide Fattori
- grid.8404.80000 0004 1757 2304Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Silvia Benemei
- grid.24704.350000 0004 1759 9494Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Chiarugi
- grid.8404.80000 0004 1757 2304Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy ,grid.24704.350000 0004 1759 9494Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy. .,Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy.
| | - Francesco De Cesaris
- grid.24704.350000 0004 1759 9494Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
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Straube A, Stude P, Gaul C, Schuh K, Koch M. Real-world evidence data on the monoclonal antibody erenumab in migraine prevention: perspectives of treating physicians in Germany. J Headache Pain 2021; 22:133. [PMID: 34742252 PMCID: PMC8572451 DOI: 10.1186/s10194-021-01344-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Erenumab, the first-in-class fully human monoclonal antibody targeting the calcitonin gene-related peptide receptor, was shown to be efficacious and safe for the prophylactic treatment of migraine in adults in randomized clinical trials. Large-scale, real-world evidence in multi-centre settings is still needed to confirm these results. Erenumab patient profiles outside clinical trials and physicians' treatment patterns, as well as data from patients treated in Germany, a severely impacted population, are not published yet. METHODS TELESCOPE was a multi-centre survey gathering real-world data from 45 German headache centres between July 2019 and December 2019. The project consisted of two parts. In the first part, treating physicians shared their experiences on current erenumab treatment with regard to patient profiles, treatment patterns and treatment responses. In the second part, a retrospective chart review was conducted of 542 migraine patients treated with erenumab for at least three months. Treatment responses focused on various aspects of patients' quality of life. RESULTS The analysis of 542 patients' charts revealed that three-month treatment with erenumab significantly reduced monthly headaches, migraine and acute medication days. Furthermore, headache intensity and frequency were reduced in over 75 % and accompanying aura in 35 % of patients. The clinical global impression scale revealed a general improvement in 91 % of patients. According to the treating physicians' professional judgement, 83 % of patients responded to erenumab and 80 % were satisfied with the treatment. Physicians evaluated restricted quality of life, the number of monthly migraine days and previous, prophylactic treatments as the main components of the current patient profile for monoclonal antibody recipients. Based on the assessment of physicians, erenumab reduced migraine symptoms in 65 % and increased quality of life in more than 75 % of their patients. CONCLUSIONS TELESCOPE confirms positive treatment responses with erenumab shown in clinical trials in a real-world multi-centre setting. The results show consistently positive experiences of physicians utilizing erenumab in clinical practice and underline that therapy with this monoclonal antibody is effective in migraine patients, particular in those, who have failed several prophylactic therapies.
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Affiliation(s)
- Andreas Straube
- Department of Neurology, University Hospital LMU, Ludwig-Maximillians-University, 81377, Munich, Germany
| | | | - Charly Gaul
- Headache Center Frankfurt, Frankfurt a. Main, Germany
| | - Katrin Schuh
- Clinical Research Neuroscience, Novartis Pharma GmbH, Roonstrasse 25, 90429, Nürnberg, Germany.
| | - Mirja Koch
- Global Medical Affairs Neuroscience, Novartis Pharma AG, Fabrikstrasse 2, 4056, Basel, Switzerland.
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Cheng F, Ahmed F. OnabotulinumtoxinA for the prophylactic treatment of headaches in adult patients with chronic migraine: a safety evaluation. Expert Opin Drug Saf 2021; 20:1275-1289. [PMID: 34187265 DOI: 10.1080/14740338.2021.1948531] [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] [Indexed: 10/21/2022]
Abstract
Introduction: Existing oral prophylaxis for chronic migraine (CM) are often ineffective or poorly tolerated. OnabotulinumtoxinA (onabotA) is approved for headache prophylaxis in CM and ameliorates headaches in patients refractory to multiple preventatives.Areas covered: We appraise evidence regarding action mechanisms, pharmacodynamics, and pharmacokinetics of onabotA in CM prophylaxis. We critically evaluate salient clinical and real-world studies demonstrating its efficacy in improving multiple aspects of CM. We discuss onabotA safety, tolerability, and adverse events (AEs) for CM prophylaxis from clinical trials, post-authorization studies and meta-analyses, including novel pregnancy safety data and comparisons with oral prophylactics. We explore areas of future interest, particularly onabotA safety and efficacy in the context of novel antibody-based prophylaxis.Expert opinion: Clinical and real-world evidence demonstrate onabotA safety, tolerability and efficacy for CM prophylaxis. Most AEs are mild/moderate and self-limiting, with few serious AEs and no treatment-related deaths. Common AEs include neck pain, ptosis, muscle weakness, and stiffness. Modifying existing responder-criteria enables more patients to benefit from onabotA. OnabotA shows superior safety and efficacy to oral preventatives, and appears safe in pregnancy. Future pregnancy-risk register will clarify pregnancy and lactation safety further. Future research comparing onabotA safety and efficacy with newly emergent antibody-based prophylaxis is keenly awaited.
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Affiliation(s)
- Fan Cheng
- Department of Neurosciences, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Fayyaz Ahmed
- Department of Neurosciences, Hull University Teaching Hospitals NHS Trust, Hull, UK
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