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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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Kastberger B, Winter S, Brandstätter H, Biller J, Wagner W, Plesnila N. Treatment with Cerebrolysin Prolongs Lifespan in a Mouse Model of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy. Adv Biol (Weinh) 2024; 8:e2300439. [PMID: 38062874 DOI: 10.1002/adbi.202300439] [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: 08/22/2023] [Indexed: 02/15/2024]
Abstract
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a rare familial neurological disorder caused by mutations in the NOTCH3 gene and characterized by migraine attacks, depressive episodes, lacunar strokes, dementia, and premature death. Since there is no therapy for CADASIL the authors investigate whether the multi-modal neuropeptide drug Cerebrolysin may improve outcome in a murine CADASIL model. Twelve-month-old NOTCH3R169C mutant mice (n=176) are treated for nine weeks with Cerebrolysin or Vehicle and histopathological and functional outcomes are evaluated within the subsequent ten months. Cerebrolysin treatment improves spatial memory and overall health, reduces epigenetic aging, and prolongs lifespan, however, CADASIL-specific white matter vacuolization is not affected. On the molecular level Cerebrolysin treatment increases expression of Calcitonin Gene-Related Peptide (CGRP) and Silent Information Regulator Two (Sir2)-like protein 6 (SIRT6), decreases expression of Insulin-like Growth Factor 1 (IGF-1), and normalizes the expression of neurovascular laminin. In summary, Cerebrolysin fosters longevity and healthy aging without specifically affecting CADASIL pathology. Hence, Cerebrolysin may serve a therapeutic option for CADASIL and other disorders characterized by accelerated aging.
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Affiliation(s)
| | - Stefan Winter
- Ever Pharma, Oberburgau 3, Unterach am Attersee, 4866, Austria
| | | | - Janina Biller
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, 81377, Munich, Germany
| | - Wolfgang Wagner
- Institute for Stem Cell Biology, RWTH Aachen University Medical School, 52074, Aachen, Germany
- Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, 52074, Aachen, Germany
- Cygenia GmbH, 52078, Aachen, Germany
| | - Nikolaus Plesnila
- Cluster of Systems Neurology (Synergy), 81377, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, 81377, Munich, Germany
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Wang Q, Liu J, Sun H, Dong Y, Tan W, Tang Z, Jiang Y. Adverse event profile of CGRP monoclonal antibodies: findings from the FDA adverse event reporting database. Expert Opin Drug Saf 2024; 23:107-117. [PMID: 37720989 DOI: 10.1080/14740338.2023.2250720] [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: 05/21/2023] [Accepted: 07/10/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Four CGRP Monoclonal Antibodies (mAbs) have been approved for migraine prophylaxis by the Food and Drug Administration (FDA) since 2018. However, there are concerns about the safety of these four drugs for real-world use. OBJECTIVE To compare the adverse event profiles of four CGRP-mAbs with FAERS data. METHODS The study was based on records from the FAERS database. Only reports containing one of the active ingredients with CGRP-mAbs were included in this study. Disproportionality analyses including but not limited to reporting odds ratio (ROR) and information components (IC) were conducted to identify drug-AE associations. RESULTS In total, 58110 reports were identified for CGRP-mAbs. 80 overlapping signals were disproportionately reported. They affected a range of organs and systems, including the gastrointestinal and cardiovascular systems, skin, and hair. Additionally, the rare cardiovascular adverse events were significantly different among the four CGRP-mAbs. CONCLUSION We identified numerous shared underlying signals (overlapping signals) for CGRP-mAbs as suspected drugs in multiple systems and organs. The unlabeled common signals may indicate potential safety issues. In addition, the underlying safety signals varied among the four CGRP-mAbs, particularly in the cardiovascular system, and further studies are needed to confirm these associations and the potential clinical implications.
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Affiliation(s)
- Qi Wang
- Department of Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Jingfang Liu
- Department of obstetrics and gynecology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hao Sun
- Department of Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - YongFei Dong
- Department of Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - WeiLiang Tan
- Department of Chronic Disease, Suzhou Municipal Health Commission, Suzhou, China
| | - Zaixiang Tang
- Department of Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - YiGuo Jiang
- Department of pharmacy, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou, China
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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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Xiong J, Wang Z, Bai J, Cheng K, Liu Q, Ni J. Calcitonin gene-related peptide: a potential protective agent in cerebral ischemia-reperfusion injury. Front Neurosci 2023; 17:1184766. [PMID: 37529236 PMCID: PMC10387546 DOI: 10.3389/fnins.2023.1184766] [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: 03/12/2023] [Accepted: 06/29/2023] [Indexed: 08/03/2023] Open
Abstract
Ischemic stroke is the most common type of cerebrovascular disease with high disability and mortality rates, which severely burdens patients, their families, and society. At present, thrombolytic therapy is mainly used for the treatment of ischemic strokes. Even though it can achieve a good effect, thrombolytic recanalization can cause reperfusion injury. Calcitonin gene-related peptide (CGRP) is a neuropeptide that plays a neuroprotective role in the process of ischemia-reperfusion injury. By combining with its specific receptors, CGRP can induce vasodilation of local cerebral ischemia by directly activating the cAMP-PKA pathway in vascular smooth muscle cells and by indirectly activating the NO-cGMP pathway in an endothelial cell-dependent manner,thus rapidly increasing ischemic local blood flow together with reperfusion. CGRP, as a key effector molecule of neurogenic inflammation, can reduce the activation of microglia, downregulates Th1 classical inflammation, and reduce the production of TNF-α, IL-2, and IFN-γ and the innate immune response of macrophages, leading to the reduction of inflammatory factors. CGRP can reduce the overexpression of the aquaporin-4 (AQP-4) protein and its mRNA in the cerebral ischemic junction, and play a role in reducing cerebral edema. CGRP can protect endothelial cells from angiotensin II by reducing the production of oxidants and protecting antioxidant defense. Furthermore, CGRP-upregulated eNOS can further induce VEGF expression, which then promotes the survival and angiogenesis of vascular endothelial cells. CGRP can also reduce apoptosis by promoting the expression of Bcl-2 and inhibiting the expression of caspase-3. These effects suggest that CGRP can reduce brain injury and repair damaged nerve function. In this review, we focused on the role of CGRP in cerebral ischemia-reperfusion injury.
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Affiliation(s)
- Jie Xiong
- Department of Rehabilitation, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Zhiyong Wang
- Department of Rehabilitation, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Junhui Bai
- Department of Rehabilitation, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Keling Cheng
- Department of Rehabilitation, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Qicai Liu
- Department of Reproductive Medicine Centre, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jun Ni
- Department of Rehabilitation, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
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van Welie FC, Kreft LA, Huisman JMA, Terwindt GM. Sex-specific metabolic profiling to explain the increased CVD risk in women with migraine: a narrative review. J Headache Pain 2023; 24:64. [PMID: 37277733 DOI: 10.1186/s10194-023-01601-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/23/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Migraine is a disabling neurological disorder whose diagnosis is based on clinical criteria. A shortcoming of these criteria is that they do not fully capture the underlying neurobiological factors and sex-specific complications in migraine such as cardio- and cerebrovascular disease. Biomarker research can help to improve disease characterization and identify pathophysiological mechanism underlying these comorbidities. OBJECTIVE In this narrative review we searched for sex-specific metabolomics research to identify markers that may explain the migraine-cardiovascular disease (CVD) relationship. DISCUSSION Large-scale plasma metabolome analyses revealed alterations in migraine. Sex-specific findings showed a less CVD-protective HDL metabolism as well as the ApoA1 lipoprotein, especially for women with migraine. To explore other possible pathophysiological pathways, we expanded our review to include inflammatory markers, endothelial and vascular markers and sex hormones. Biological sex differences may affect the pathophysiology of migraine and its complications. CONCLUSIONS There is no general large dyslipidemia profile in migraine patients, in line with findings that the increased risk of CVD in migraine patients seems not to be due to (large artery) atherosclerosis. Sex-specific associations are indicative towards a less CVD-protective lipoprotein profile in women with migraine. Future studies into the pathophysiology of CVD and migraine need to take sex specific factors into account. By establishing the overlapping pathophysiological mechanism of migraine and CVD, and unraveling the associated effects these diseases exert on each other, better preventative measures can be identified.
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Affiliation(s)
- F C van Welie
- Department of Neurology, Leiden University Medical Center, P.O. 9600, 2300 WB, Leiden, The Netherlands
| | - L A Kreft
- Department of Neurology, Leiden University Medical Center, P.O. 9600, 2300 WB, Leiden, The Netherlands
| | - J M A Huisman
- Department of Neurology, Leiden University Medical Center, P.O. 9600, 2300 WB, Leiden, The Netherlands
| | - G M Terwindt
- Department of Neurology, Leiden University Medical Center, P.O. 9600, 2300 WB, Leiden, The Netherlands.
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Pelzer N, de Boer I, van den Maagdenberg AMJM, Terwindt GM. Neurological and psychiatric comorbidities of migraine: Concepts and future perspectives. Cephalalgia 2023; 43:3331024231180564. [PMID: 37293935 DOI: 10.1177/03331024231180564] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND This narrative review aims to discuss several common neurological and psychiatric disorders that show comorbidity with migraine. Not only can we gain pathophysiological insights by studying these disorders, comorbidities also have important implications for treating migraine patients in clinical practice. METHODS A literature search on PubMed and Embase was conducted with the keywords "comorbidity", "migraine disorders", "migraine with aura", "migraine without aura", "depression", "depressive disorders", "epilepsy", "stroke", "patent foramen ovale", "sleep wake disorders", "restless legs syndrome", "genetics", "therapeutics". RESULTS Several common neurological and psychiatric disorders show comorbidity with migraine. Major depression and migraine show bidirectional causality and have shared genetic factors. Dysregulation of both hypothalamic and thalamic pathways have been implicated as a possibly cause. The increased risk of ischaemic stroke in migraine likely involves spreading depolarizations. Epilepsy is not only bidirectionally related to migraine, but is also co-occurring in monogenic migraine syndromes. Neuronal hyperexcitability is an important overlapping mechanism between these conditions. Hypothalamic dysfunction is suggested as the underlying mechanism for comorbidity between sleep disorders and migraine and might explain altered circadian timing in migraine. CONCLUSION These comorbid conditions in migraine with distinct pathophysiological mechanisms have important implications for best treatment choices and may provide clues for future approaches.
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Affiliation(s)
- Nadine Pelzer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arn M J M van den Maagdenberg
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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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: 66] [Impact Index Per Article: 66.0] [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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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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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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Woldeamanuel YW, Shrivastava S, Vila-Pueyo M. Editorial: Lifestyle modifications to manage migraine. Front Neurol 2022; 13:966424. [PMID: 36105771 PMCID: PMC9465452 DOI: 10.3389/fneur.2022.966424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yohannes W. Woldeamanuel
- Division of Headache & Facial Pain, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
- *Correspondence: Yohannes W. Woldeamanuel
| | | | - Marta Vila-Pueyo
- Headache and Neurological Pain Research Group, Department of Medicine, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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12
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Basedau H, Oppermann T, Gundelwein Silva E, Peng KP, May A. Galcanezumab modulates Capsaicin-induced C-fiber reactivity. Cephalalgia 2022; 42:1331-1338. [PMID: 35796521 PMCID: PMC9638712 DOI: 10.1177/03331024221112906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The vasodilatory calcitonin-gene related peptide (CGRP) is understood as
pivotal mediator in migraine pathophysiology. Blocking CGRP with small
molecules or monoclonal antibodies (CGRP-mAb) reduces migraine frequency.
However, prescription of CGRP-mAbs is still regulated and possible
predictive measures of therapeutic success would be useful. Methods Using standardized capsaicin-induced dermal blood flow model, 29 migraine
patients underwent a laser speckle imaging measurement before and after
administration of galcanezumab. At both sessions dermal blood flow before
and after capsaicin stimulation as well as flare size were analyzed over all
three trigeminal branches and the volar forearm for extracranial control.
Long-term measures were repeated in 14 patients after continuous treatment
ranging from 6 to 12 months. Results Resting dermal blood flow remained unchanged after administration of
galcanezumab. Capsaicin-induced dermal blood flow decreased significantly
after CGRP-mAb in all tested areas compared to baseline and this was
consistent even after 12 months of treatment. However, following
galcanezumab administration, the flare size decreased only in the three
trigeminal dermatomes, not the arm and was therefore specific for the
trigemino-vascular system. None of these two markers distinguished between
responders and non-responders. Conclusion CGRP-mAb changed blood flow response to capsaicin stimulation profoundly and
this effect did not change over a 12-month application. Neither
capsaicin-induced flare nor dermal blood flow can be used as a predictor for
treatment efficacy. These data suggest that the mechanism of headache
development in migraine is not entirely CGRP-mediated.
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Affiliation(s)
- Hauke Basedau
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thalea Oppermann
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elisa Gundelwein Silva
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Perino J, Corand V, Laurent E, Théophile H, Miremont-Salamé G, Pariente A, Colas JL, Couffinhal T, Salvo F. Myocardial infarction associated with erenumab: A case report. Pharmacotherapy 2022; 42:585-589. [PMID: 35620946 PMCID: PMC9541222 DOI: 10.1002/phar.2706] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 12/28/2022]
Abstract
Background Monoclonal antibodies acting on the calcitonin gene‐related peptide or its receptor (CGRP‐mabs) are novel drugs for resistant migraine prophylaxis. As CGRP‐mabs cause inhibition of vasodilatation, their use is reserved to patients with no recent history of cardiovascular diseases. We report a case of myocardial infarction associated with erenumab. Case A 57‐year‐old woman with a familial history of coronaropathy was first treated with erenumab 70 mg for 6 months and then increased to 140 mg. Almost 5 months after, the patient presented chest pain, increased troponin, and abnormal electrocardiogram. A myocardial infarction without coronarography abnormality was diagnosed through MRI. Conclusion Further evidence is needed to assess the risk of myocardial infarction in patients treated with a CGRP‐mab. In patients over 40 years of age, the risk of coronary or cardiovascular events should be assessed using risk tables or algorithms to take into account cardiovascular risk factors. This may be complemented by appropriate examinations to measure the burden of coronary atherosclerosis, if necessary.
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Affiliation(s)
- Justine Perino
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM, BPH, U1219, Bordeaux, France
| | - Virginie Corand
- Pain Center of Bordeaux, Department of Clinical Neurosciences, University Hospital of Bordeaux, Bordeaux, France
| | - Elise Laurent
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France
| | - Hélène Théophile
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France
| | - Ghada Miremont-Salamé
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France
| | - Antoine Pariente
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM, BPH, U1219, Bordeaux, France
| | - Jean-Laurent Colas
- Department of Cardiology, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - Thierry Couffinhal
- Univ. Bordeaux, INSERM, Biology of Cardiovascular Diseases, U1034, CHU de Bordeaux, Bordeaux, France
| | - Francesco Salvo
- Pharmacovigilance Center of Bordeaux, Department of Medical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM, BPH, U1219, Bordeaux, France
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14
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Chua AL, Mehla S, Orlova YY. Drug Safety in Episodic Migraine Management in Adults. Part 2: Preventive Treatments. Curr Pain Headache Rep 2022; 26:493-504. [PMID: 35587859 DOI: 10.1007/s11916-022-01051-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to aid in decision-making when choosing safe and effective options for preventive migraine medications. RECENT FINDINGS In Part 2, we have compiled clinically relevant safety considerations for commonly used migraine prophylactic treatments. Preventive treatment of episodic migraine includes nonspecific and migraine-specific drugs. While medications from several pharmacological classes-such as anticonvulsants, beta-blockers, and antidepressants-have an established efficacy in migraine prevention, they are associated with a number of side effects. The safety of migraine-specific treatments such as anti-CGRP monoclonal antibodies and gepants are also discussed. This review highlights safety concerns of commonly used migraine prophylactic agents and offers suggestions on how to mitigate those risks.
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Affiliation(s)
- Abigail L Chua
- Geisinger Health Systems, Neurology, 1000 E. Mountain Boulevard, Wilkes-Barre, PA, 18711, USA.
| | - Sandhya Mehla
- Ayer Neurosciences Institute, Hartford HealthCare Medical Group, University of Connecticut School of Medicine, Norwich, CT, USA
| | - Yulia Y Orlova
- Neurology Department, University of Florida, Gainesville, USA
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15
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Ouerdane Y, Khlidj Y, Attia MS, Korissi R. Calcitonin gene-related peptide: A biomarker for stroke in SARS-CoV-2 infection? Med Hypotheses 2022; 162:110807. [PMID: 35228771 PMCID: PMC8864889 DOI: 10.1016/j.mehy.2022.110807] [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: 11/29/2021] [Revised: 01/11/2022] [Accepted: 02/10/2022] [Indexed: 11/03/2022]
Abstract
COVID-19 infection was mainly associated with respiratory symptoms, but lately, ischemic stroke (IS) has been reported in several cases. The incidence of IS in SARS-CoV-2 infection is increasing, and its mechanism is still not fully understood. Calcitonin gene-related peptide (CGRP) -the abundantly expressed protein in the peripheral and central nervous system- showed low expression in SARS-CoV-2 patients. This peptide is strongly implicated in regulating cerebral blood flow (CBF) and improving neurological deficits after cerebral arterial occlusion. We assume that a possible interplay between the low circulating levels of CGRP may affect CBF, thus worsening the symptoms of IS in SARS-CoV-2 patients.
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16
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Myocardial infarction in a patient with migraine and triptan overuse treated with anti-CGRP receptor monoclonal antibody: a case report. J Neurol 2022; 269:5170-5172. [PMID: 35420352 DOI: 10.1007/s00415-022-11128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
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17
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De Matteis E, Sacco S, Ornello R. Migraine Prevention with Erenumab: Focus on Patient Selection, Perspectives and Outcomes. Ther Clin Risk Manag 2022; 18:359-378. [PMID: 35411146 PMCID: PMC8994624 DOI: 10.2147/tcrm.s263825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/14/2022] [Indexed: 01/13/2023] Open
Abstract
Erenumab is a monoclonal antibody targeting the calcitonin gene-related peptide (CGRP) receptor suitable for episodic and chronic migraine prevention. Randomized clinical trials proved the superiority of erenumab to placebo in a strictly selected population, while real-world studies confirmed treatment efficacy in more severe forms of disease – most patients suffered from chronic migraine with medication overuse headache, had prior treatment failures, and long disease duration. According to guidelines, anti-CGRP pathway monoclonal antibodies should be reserved to patients who failed or have contraindication to several classes of preventive treatments. However, their ease of use, tolerability and efficacy make these monoclonal antibodies ideally suitable for most patients with migraine; cost-effectiveness needs to be considered when looking at expanding current prescription criteria. Also, data from open label extensions of randomized control trials confirmed sustained benefits of prolonged treatment up to 5 consecutive years without significant risk of adverse events. Further studies will provide insights on optimal treatment duration to achieve migraine remission and predictors of treatment response. In the present work, we aimed at reviewing design and results of the main studies on erenumab and discussing treatment use in the current migraine prevention scenario; we also summarized the main ongoing research projects and provided clinical perspectives for the future.
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Affiliation(s)
- Eleonora De Matteis
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
- Correspondence: Simona Sacco, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio, L’Aquila, 67100, Italy, Tel +39 0862433561; +39 0863499734, Email
| | - Raffaele Ornello
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
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18
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Skaria T, Vogel J. The Neuropeptide α-Calcitonin Gene-Related Peptide as the Mediator of Beneficial Effects of Exercise in the Cardiovascular System. Front Physiol 2022; 13:825992. [PMID: 35431990 PMCID: PMC9008446 DOI: 10.3389/fphys.2022.825992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
Regular physical activity exerts cardiovascular protective effects in healthy individuals and those with chronic cardiovascular diseases. Exercise is accompanied by an increased plasma concentration of α-calcitonin gene-related peptide (αCGRP), a 37-amino acid peptide with vasodilatory effects and causative roles in migraine. Moreover, mouse models revealed that loss of αCGRP disrupts physiological adaptation of the cardiovascular system to exercise in normotension and aggravates cardiovascular impairment in primary chronic hypertension, both can be reversed by αCGRP administration. This suggests that αCGRP agonists could be a therapeutic option to mediate the cardiovascular protective effects of exercise in clinical setting where exercise is not possible or contraindicated. Of note, FDA has recently approved αCGRP antagonists for migraine prophylaxis therapy, however, the cardiovascular safety of long-term anti-CGRP therapy in individuals with cardiovascular diseases has yet to be established. Current evidence from preclinical models suggests that chronic αCGRP antagonism may abolish the cardiovascular protective effects of exercise in both normotension and chronic hypertension.
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Affiliation(s)
- Tom Skaria
- School of Biotechnology, National Institute of Technology Calicut, Kerala, India
| | - Johannes Vogel
- Zürich Center for Integrative Human Physiology, Institute of Veterinary Physiology, University of Zurich, Zurich, Switzerland
- *Correspondence: Johannes Vogel,
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19
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Ray JC, Kapoor M, Stark RJ, Wang SJ, Bendtsen L, Matharu M, Hutton EJ. Calcitonin gene related peptide in migraine: current therapeutics, future implications and potential off-target effects. J Neurol Neurosurg Psychiatry 2021; 92:1325-1334. [PMID: 33495299 DOI: 10.1136/jnnp-2020-324674] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/17/2020] [Accepted: 12/16/2020] [Indexed: 12/21/2022]
Abstract
Migraine is the second largest cause of years lost to disability globally among all diseases, with a worldwide prevalence over 1 billion. Despite the global burden of migraine, few classes of therapeutics have been specifically developed to combat migraine. After 30 years of translational research, calcitonin gene-related peptide (CGRP) inhibitors have emerged as a promising new tool in the prevention of migraine. Like all new therapeutics; however, we have limited real-world experience and CGRP has several known systemic actions that warrant consideration. This article provides a narrative review of the evidence for CGRP antagonists and summarises the known and potential side effects that should be considered.
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Affiliation(s)
- Jason Charles Ray
- Neurology, Alfred Health, Melbourne, Victoria, Australia .,Department of Neuroscience, Monash University, Clayton, Victoria, Australia
| | - Mahima Kapoor
- Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University, Clayton, Victoria, Australia
| | - Richard J Stark
- Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University, Clayton, Victoria, Australia
| | - Shuu-Jiun Wang
- The Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark.,University of Copenhagen, Kobenhavn, Denmark
| | - Manjit Matharu
- Headache Group, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Elspeth Jane Hutton
- Neurology, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Monash University, Clayton, Victoria, Australia
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20
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Shi M, Guo J, Li Z, Sun H, Yang X, Yang D, Zhao H. Network meta-analysis on efficacy and safety of different anti-CGRP monoclonal antibody regimens for prophylaxis and treatment of episodic migraine. Neurol Res 2021; 43:932-949. [PMID: 34281473 DOI: 10.1080/01616412.2021.1940672] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Currently, studies have shown that anti-CGRP monoclonal antibodies are effective drugs for the prophylaxis and treatment of episodic migraine. Therefore, for the first time, we classified and concluded 10 treatment regimens according to the different doses, drugs, routes of administration, and courses of treatment, so as to provide a reference for further clinical studies. METHODS We studied relevant randomized controlled trials (RCTs) published before August 2020 on PubMed, Embase, Ovid MEDLINE, Web of Science, and the Cochrane Central Register of Controlled Trials. RESULTS Eleven RCTs involving 6397 patients were included in our analysis. Network meta-analysis results suggested that in the comparison of the average migraine days per month, Erenumab (140 mg), Galcanezumab (120 mg, 240 mg), Fremanezumab (225 mg, 675 mg) were superior to placebo, Erenumab(7 mg), and the difference was statistically significant; Fremanezumab (225 mg, 675 mg) was superior to Erenumab (21 mg, 70 mg), and the difference was statistically significant; in the comparison of average medication days of acute migraine-specific drug per month, Erenumab (70 mg, 140 mg), Galcanezumab (120 mg, 240 mg), Fremanezumab (225 mg, 675 mg) was superior to placebo, and Erenumab (140 mg) and Galcanezumab (120 mg, 240 mg) were superior to Erenumab (70 mg), and the difference was statistically significant; there was no statistically significant difference in the average migraine days in the last month or in the medication days of acute migraine-specific drug. CONCLUSION Fremanezumab (225 mg) and Galcanezumab (120 mg) may be the best clinical protocol after a comprehensive assessment.
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Affiliation(s)
- Min Shi
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, PR China
| | - Jun Guo
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, PR China
| | - Zhaoying Li
- Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, PR China
| | - Honghui Sun
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, PR China
| | - Xuhong Yang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, PR China
| | - Dongdong Yang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, PR China
| | - Huan Zhao
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, PR China
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21
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1236] [Impact Index Per Article: 412.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Drug interactions and risks associated with the use of triptans, ditans and monoclonal antibodies in migraine. Curr Opin Neurol 2021; 34:330-338. [PMID: 33852525 DOI: 10.1097/wco.0000000000000932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to review current evidence concerning potential risks and interactions associated with concomitant use of drugs indicated for the abortive treatment of migraine, namely triptans and ditans, and more recently developed drugs used for the preventive treatment. The latter drug class encompasses monoclonal antibodies (mAbs), which target either calcitonin gene-related peptide (CGRP) or its receptor. RECENT FINDINGS To date, no pharmacokinetic interactions between these drug classes have been reported. However, patients who suffer from triptan- (or ditan-) induced medication overuse headache or those who are nonresponders to triptans might respond less effectively to mAbs. Caution is warranted when coadministrating these drugs in migraine patients with comorbid cardiovascular disease or with an increased cardiovascular risk profile. SUMMARY In this review, the main mechanisms of action of triptans, ditans and mAbs targeting CGRP or its receptor are summarized as well as the current evidence on their individual risks. Studies on risks and interactions in case of concomitant use of triptans, ditans and mAbs in migraine patients are relatively scarce. Therefore, these aspects have been considered from a theoretical and hypothetical point of view by taking both their overlapping target, CGRP, and contraindications into account.
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23
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Gklinos P, Mitsikostas DD. The Role of Galcanezumab in Migraine Prevention: Existing Data and Future Directions. Pharmaceuticals (Basel) 2021; 14:245. [PMID: 33803190 PMCID: PMC7998387 DOI: 10.3390/ph14030245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 11/16/2022] Open
Abstract
Galcanezumab is a humanized monoclonal antibody blocking the calcitonin gene-related peptide (CGRP) pathway by targeting the CGRP. Data from four phase-3 randomized placebo-controlled clinical trials showed that galcanezumab is superior to placebo in reducing migraine headaches, migraine-specific quality of life, and headache-related disability. Most of the adverse events (AEs) were mild to moderate and did not affect trial completion rates significantly. Along with erenumab, fremanezumab, and eptinezumab, galcanezumab forms a novel class of anti-migraine preventative treatments that is disease-specific and mechanism-based, unlike the standard ones. In addition, galcanezumab has also been shown to be effective in cluster headache, though more clinical trials are required. Overall, galcanezumab is a promising emerging treatment in migraine prophylaxis. However, it needs to be tested in larger clinical trials focused on treatment-resistant migraine. Furthermore, its safety profile, especially its potential association with an increased cardiovascular risk, needs to be established through long-term, real-world data. This review aims to give an overview of its pharmacological properties as well as to report and discuss data from clinical trials and its potential place in headache therapeutics.
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Affiliation(s)
- Panagiotis Gklinos
- Department of Neurology, KAT General Hospital of Attica, 14561 Athens, Greece
| | - Dimos D. Mitsikostas
- 1st Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, 11521 Athens, Greece;
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24
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Chiang CC, Arca KN, Dunn RB, Girardo ME, Quillen JK, Dodick DW, Starling AJ. Real-world efficacy, tolerability, and safety of ubrogepant. Headache 2021; 61:620-627. [PMID: 33547676 DOI: 10.1111/head.14062] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the real-world efficacy, tolerability, and safety of ubrogepant in a tertiary headache center. BACKGROUND The efficacy and safety of ubrogepant for the acute treatment of migraine were established in phase 3 randomized controlled trials. However, there is no real-world data of patient experience with ubrogepant in a population in which the majority of patients have chronic migraine, multiple prior unsuccessful treatments, complex medical comorbidities, and concurrent use of other migraine-specific medications. METHOD This was a post-market cohort study conducted at Mayo Clinic Arizona. All patients prescribed ubrogepant were tracked and contacted 1-3 months after the prescription to answer a list of standardized questions. Demographic information and additional headache history were obtained from chart review. RESULTS We obtained eligible questionnaire responses from 106 patients. Chronic migraine accounted for 92/106 (86.8%) of the population. Complete headache freedom (from mild/moderate/severe to no pain) and headache relief (from moderate/severe to mild/no pain or mild to no pain) for ≥75% of all treated attacks at 2 hours after taking ubrogepant were achieved in 20/105 (19.0%) and 50/105 (47.6%) patients, respectively. A total of 33/106 (31.1%) patients reported being "very satisfied" with ubrogepant. Adverse events were reported in 42/106 (39.6%) patients, including fatigue in 29/106 (27.4%), dry mouth in 8/106 (7.5%), nausea/vomiting in 7/106 (6.6%), constipation in 5/106 (4.7%), dizziness in 3/106 (2.8%), and other adverse events in 7/106 (6.6%). Predictive factors for being a "good responder" to ubrogepant, defined as headache relief for ≥75% of all treated attacks at 2 hours after taking ubrogepant, included migraine with aura, episodic migraine, <5 prior unsuccessful preventive or acute treatment trials. Additionally, prior treatment responses to a CGRP monoclonal antibody and onabotulinumtoxinA injections are predictive of treatment responses and patient satisfaction to ubrogepant. For the 62/106 (58.5%) patients concurrently using a CGRP monoclonal antibody, there was no difference in the "good responder" rate or adverse event rate compared to those who were not on a CGRP monoclonal antibody, though the rate of moderate, as opposed to mild adverse events was higher, 11/62 (47.8%) versus 3/44 (17.6%), p = 0.048. Additionally, 16 patients had a history of significant cardiovascular or cerebrovascular diseases. No severe adverse events were reported in any patient. CONCLUSION Our study confirms and extends the efficacy profile and tolerability of ubrogepant in a real-world tertiary headache clinic and identifies factors that may predict efficacy. Adverse event rates were higher than reported in clinical trials. Further studies are needed to confirm these findings and to evaluate the long-term efficacy and safety of ubrogepant.
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Affiliation(s)
| | - Karissa N Arca
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Rachel B Dunn
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Marlene E Girardo
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Jaxon K Quillen
- Department of Biostatistics, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - David W Dodick
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Amaal J Starling
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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25
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Indirect Comparison of Topiramate and Monoclonal Antibodies Against CGRP or Its Receptor for the Prophylaxis of Episodic Migraine: A Systematic Review with Meta-Analysis. CNS Drugs 2021; 35:805-820. [PMID: 34272688 PMCID: PMC8354912 DOI: 10.1007/s40263-021-00834-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Head-to-head comparator trials between first-line oral migraine preventatives and the new monoclonal antibodies (mAbs) blocking the calcitonin gene-related peptide (CGRP) pathway have not been published to date. OBJECTIVES This study aimed to indirectly compare the clinical efficacy and safety of mAbs against CGRP or its receptor (CGRPR) and topiramate in episodic migraine prophylaxis using meta-analysis. METHODS We included controlled trials testing efficacy and safety of erenumab, galcanezumab, fremanezumab, eptinezumab, and topiramate in adults diagnosed with episodic migraine. We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from January 2000 to November 2020. We used the Risk of Bias 2 (RoB2) tool to assess the risk of bias and report pooled mean effects (mean difference and risk ratio) as estimated in a random effect model. For efficacy analysis, we determined the reduction of monthly migraine days (MMDs), reduction of days with acute medication (AMDs), and 50% responder rates (50% RR). For safety, we determined adverse events (AEs) occurring in ≥ 2% of study participants and the number of patients who discontinue treatment due to AEs (DAEs). The number needed to treat (NNT) and to harm (NNH) were estimated as well as the likelihood to help or harm (LLH). RESULTS We included 13 trials involving 7557 patients: three trials with erenumab, two trials with galcanezumab, two trials with fremanezumab, one trial with eptinezumab, and five trials with topiramate, for the prophylaxis of episodic migraine in adults. The placebo-subtracted reduction (pooled mean difference) of MMDs were - 1.55 (95% CI - 1.86 to - 1.24; active drug n = 3326 vs placebo n = 2219, 8 studies) for the CGRP(R) mAb and - 1.11 (95% CI - 1.62 to - 0.59; active drug n = 1032 vs placebo n = 543, 4 studies) for topiramate (p for subgroup difference = 0.15). 'Cognitive' and 'sensory & pain'-related adverse events occurred more often in patients treated with topiramate compared with those treated with a CGRP(R) mAb (p for subgroup difference 0.03 and < 0.001, respectively). Based on the 50% RR and DAE, the NNT, NNH, and LHH for the CGRP(R) mAbs were 6, 130, and 24.3:1, respectively. For topiramate, these values were 7, 9, and 1.8:1, respectively. CONCLUSION The efficacy of CGRP(R) mAbs to reduce migraine days does not differ from topiramate. However, the safety profile is in favor of the CGRP(R) mAbs, with a higher likelihood to help than to harm compared with topiramate. The diversity of endpoint determination and the heterogeneity between studies for some endpoints cause some limitations for this study.
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26
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Altamura C, Viticchi G, Fallacara A, Costa CM, Brunelli N, Fiori C, Silvestrini M, Vernieri F. Erenumab does not alter cerebral hemodynamics and endothelial function in migraine without aura. Cephalalgia 2020; 41:90-98. [PMID: 32867533 DOI: 10.1177/0333102420956692] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To assess whether erenumab influences cerebral vasomotor reactivity and flow-mediated dilation in migraine patients. METHODS Consecutive migraineurs prescribed erenumab at our Headache Centre and age and sex-matching controls were invited to participate in this observational longitudinal study. Patients were evaluated for cerebral vasomotor reactivity to hypercapnia (breath-holding index) in middle and posterior cerebral arteries and for brachial corrected flow mediated dilation at baseline (T0), after 2 weeks from the first erenumab injection (T2) and after 2 weeks from the fourth Erenumab injection (T18). Patients displaying a reduction of at least 50% in monthly migraine days after completing the fourth month of therapy were classified as responders. RESULTS Sixty patients and 25 controls agreed to participate. Middle and posterior cerebral artery mean flow velocities, breath-holding index and flow-mediated dilation did not differ at T0 and from T0 to T2 in patients and controls. In patients, we neither observed a variation of the explored variables from T0 to T18 nor an interaction between evaluation times (T0-T2 or T0-T18) and chronic condition at T0, responder state or erenumab fourth dose. CONCLUSIONS Our findings demonstrate that erenumab preserves cerebral vasomotor reactivity and flow-mediated dilation in migraineurs without aura.
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Affiliation(s)
- Claudia Altamura
- Headache and Neurosonology Unit, Neurology, Campus Bio-Medico University Hospital, Rome, Italy
| | | | - Adriana Fallacara
- Headache and Neurosonology Unit, Neurology, Campus Bio-Medico University Hospital, Rome, Italy
| | - Carmelina Maria Costa
- Headache and Neurosonology Unit, Neurology, Campus Bio-Medico University Hospital, Rome, Italy
| | - Nicoletta Brunelli
- Headache and Neurosonology Unit, Neurology, Campus Bio-Medico University Hospital, Rome, Italy
| | - Chiara Fiori
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | | | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Neurology, Campus Bio-Medico University Hospital, Rome, Italy
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Mulder IA, Li M, de Vries T, Qin T, Yanagisawa T, Sugimoto K, van den Bogaerdt A, Danser AHJ, Wermer MJH, van den Maagdenberg AMJM, MaassenVanDenBrink A, Ferrari MD, Ayata C. Anti-migraine Calcitonin Gene-Related Peptide Receptor Antagonists Worsen Cerebral Ischemic Outcome in Mice. Ann Neurol 2020; 88:771-784. [PMID: 32583883 PMCID: PMC7540520 DOI: 10.1002/ana.25831] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 06/11/2020] [Accepted: 06/21/2020] [Indexed: 12/31/2022]
Abstract
Objective Calcitonin gene–related peptide (CGRP) pathway inhibitors are emerging treatments for migraine. CGRP‐mediated vasodilation is, however, a critical rescue mechanism in ischemia. We, therefore, investigated whether gepants, small molecule CGRP receptor antagonists, worsen cerebral ischemia. Methods Middle cerebral artery was occluded for 12 to 60 minutes in mice. We compared infarct risk and volumes, collateral flow, and neurological deficits after pretreatment with olcegepant (single or 10 daily doses of 0.1–1mg/kg) or rimegepant (single doses of 10–100mg/kg) versus vehicle. We also determined their potency on CGRP‐induced relaxations in mouse and human vessels, in vitro. Results Olcegepant (1mg/kg, single dose) increased infarct risk after 12‐ to 20‐minute occlusions mimicking transient ischemic attacks (14/19 vs 6/18 with vehicle, relative risk = 2.21, p < 0.022), and doubled infarct volumes (p < 0.001) and worsened neurological deficits (median score = 9 vs 5 with vehicle, p = 0.008) after 60‐minute occlusion. Ten daily doses of 0.1 to 1mg/kg olcegepant yielded similar results. Rimegepant 10mg/kg increased infarct volumes by 60% after 20‐minute ischemia (p = 0.03); 100mg/kg caused 75% mortality after 60‐minute occlusion. In familial hemiplegic migraine type 1 mice, olcegepant 1mg/kg increased infarct size after 30‐minute occlusion (1.6‐fold, p = 0.017). Both gepants consistently diminished collateral flow and reduced reperfusion success. Olcegepant was 10‐fold more potent than rimegepant on CGRP‐induced relaxations in mouse aorta. Interpretation Gepants worsened ischemic stroke in mice via collateral dysfunction. CGRP pathway blockers might thus aggravate coincidental cerebral ischemic events. The cerebrovascular safety of these agents must therefore be better delineated, especially in patients at increased risk of ischemic events or on prophylactic CGRP inhibition. ANN NEUROL 2020;88:771–784
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Affiliation(s)
- Inge A Mulder
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mei Li
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tessa de Vries
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tao Qin
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takeshi Yanagisawa
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kazutaka Sugimoto
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arn M J M van den Maagdenberg
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Cenk Ayata
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Calcitonin gene-related peptide (CGRP)-targeted therapies as preventive and acute treatments for migraine-The monoclonal antibodies and gepants. PROGRESS IN BRAIN RESEARCH 2020; 255:143-170. [PMID: 33008505 DOI: 10.1016/bs.pbr.2020.06.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/22/2022]
Abstract
Calcitonin Gene-Related Peptide (CGRP) plays a pivotal role in migraine pathophysiology. Two types of CGRP function-blocking modalities, monoclonal antibodies, and small molecules (gepants), have been developed to target the CGRP ligands and CGRP receptors. Four CGRP monoclonal antibodies have received FDA approval for the prevention of migraine: erenumab, fremanezumab, galcanezumab, and eptinezumab. Two gepants have been approved by the FDA for the acute treatment of migraine: ubrogepant and rimegepant. Multiple clinical trials of the CGRP monoclonal antibodies and gepants, and now some open-label long-term extension data, established their efficacy, safety, and tolerability. In this chapter, we summarize the major clinical trials, pharmacokinetic insights, safety and tolerability profiles, and real-world data (if available) of the CGRP monoclonal antibodies and gepants.
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de Boer I, MaassenVanDenBrink A, Terwindt GM. The potential danger of blocking CGRP for treating migraine in CADASIL patients. Cephalalgia 2020; 40:1676-1678. [PMID: 32660269 PMCID: PMC7691636 DOI: 10.1177/0333102420941814] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Cerebral autosomal dominant arteriopathy with subcortical infarcts and
leukoencephalopathy (CADASIL) is an inherited small vessel disease characterised by
recurrent ischemic stroke, cognitive decline progressing to dementia, psychiatric
disturbances and apathy. More than half of mutation carriers suffer from migraine, most
often migraine with aura. Recently, a CADASIL patient was treated with a monoclonal
antibody targeting the calcitonin gene-related peptide (CGRP) receptor. Monoclonal
antibodies targeting the CGRP system have been demonstrated to be safe, well tolerated,
and effective in reducing migraine attacks. There is, however, abundant evidence that CGRP
is important in maintaining cardiovascular homeostasis under (patho)physiological
conditions. CGRP may act as a vasodilatory safeguard during cerebral and cardiac ischemia
and blockage of the system could, therefore, potentially worsen ischemic events.
Therefore, we caution against treating patients with small vessel diseases, such as the
monogenic disorder CADASIL, with these drugs until relevant safety data and long term
follow up results are available. Alternative preventive migraine treatments in CADASIL may
be acetazolamide, sodium valproate, lamotrigine, topiramate, verapamil, or
flunarizine.
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Affiliation(s)
- Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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30
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de Vries T, Villalón CM, MaassenVanDenBrink A. Pharmacological treatment of migraine: CGRP and 5-HT beyond the triptans. Pharmacol Ther 2020; 211:107528. [PMID: 32173558 DOI: 10.1016/j.pharmthera.2020.107528] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/08/2020] [Indexed: 01/08/2023]
Abstract
Migraine is a highly disabling neurovascular disorder characterized by a severe headache (associated with nausea, photophobia and/or phonophobia), and trigeminovascular system activation involving the release of calcitonin-gene related peptide (CGRP). Novel anti-migraine drugs target CGRP signaling through either stimulation of 5-HT1F receptors on trigeminovascular nerves (resulting in inhibition of CGRP release) or direct blockade of CGRP or its receptor. Lasmiditan is a highly selective 5-HT1F receptor agonist and, unlike the triptans, is devoid of vasoconstrictive properties, allowing its use in patients with cardiovascular risk. Since lasmiditan can actively penetrate the blood-brain barrier, central therapeutic as well as side effects mediated by 5-HT1F receptor activation should be further investigated. Other novel anti-migraine drugs target CGRP signaling directly. This neuropeptide can be targeted by the monoclonal antibodies eptinezumab, fremanezumab and galcanezumab, or by CGRP-neutralizing L-aptamers called Spiegelmers. The CGRP receptor can be targeted by the monoclonal antibody erenumab, or by small-molecule antagonists called gepants. Currently, rimegepant and ubrogepant have been developed for acute migraine treatment, while atogepant is studied for migraine prophylaxis. Of these drugs targeting CGRP signaling directly, eptinezumab, erenumab, fremanezumab, galcanezumab, rimegepant and ubrogepant have been approved for clinical use, while atogepant is in the last stage before approval. Although all of these drugs seem highly promising for migraine treatment, their safety should be investigated in the long-term. Moreover, the exact mechanism(s) of action of these drugs need to be elucidated further, to increase both safety and efficacy and to increase the number of responders to the different treatments, so that all migraine patients can satisfactorily be treated.
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Affiliation(s)
- Tessa de Vries
- Division of Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Carlos M Villalón
- Deptartment de Farmacobiología, Cinvestav-Coapa, C.P. 14330 Ciudad de México, Mexico
| | - Antoinette MaassenVanDenBrink
- Division of Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, PO Box 2040, 3000, CA, Rotterdam, the Netherlands.
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Andreou AP, Fuccaro M, Lambru G. The role of erenumab in the treatment of migraine. Ther Adv Neurol Disord 2020; 13:1756286420927119. [PMID: 32523630 PMCID: PMC7257830 DOI: 10.1177/1756286420927119] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 01/03/2023] Open
Abstract
Calcitonin gene related peptide (CGRP) monoclonal antibodies (mAbs) have been the
first class of specifically developed preventive treatments for migraine.
Clinical trials data suggest superiority of the CGRP mAbs to placebo in terms of
prevention of migraine symptoms, migraine-specific quality of life and headache
related disability. Treatment-related side effects overall did not differ
significantly from placebo and discontinuation rate due to side effects has been
low across the clinical trials, perhaps in view of their peripheral mode of
action. Along with their route and frequency of administration, these novel
class of drugs may constitute an improvement compared with the established
arsenal of migraine treatments. Erenumab is a fully human antibody and the only
mAb acting on the CGRP pathway by blocking its receptor. It is the first of the
CGRP mAb class approved by the US Food and Drug Administration (May 2018) and
the European Medicines Agency (July 2018). Erenumab exists in two different
doses (70 mg and 140 mg) and it is administered with monthly subcutaneous
injections. This review summarises erenumab pharmacological characteristics,
clinical trials data, focusing on the potential role of this treatment in
clinical practice.
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Affiliation(s)
- Anna P Andreou
- The Headache Service, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Matteo Fuccaro
- Department of Neurology, Treviso Hospital, Treviso, Italy
| | - Giorgio Lambru
- The Headache Service, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
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32
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Dubowchik GM, Conway CM, Xin AW. Blocking the CGRP Pathway for Acute and Preventive Treatment of Migraine: The Evolution of Success. J Med Chem 2020; 63:6600-6623. [PMID: 32058712 DOI: 10.1021/acs.jmedchem.9b01810] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The pivotal role of calcitonin gene-related peptide (CGRP) in migraine pathophysiology was identified over 30 years ago, but the successful clinical development of targeted therapies has only recently been realized. This Perspective traces the decades long evolution of medicinal chemistry required to advance small molecule CGRP receptor antagonists, also called gepants, including the current clinical agents rimegepant, vazegepant, ubrogepant, and atogepant. Providing clinically effective blockade of CGRP signaling required surmounting multiple challenging hurdles, including defeating a sizable ligand with subnanomolar affinity for its receptor, designing antagonists with an extended confirmation and multiple pharmacophores while retaining solubility and oral bioavailability, and achieving circulating free plasma levels that provided near maximal CGRP receptor coverage. The clinical efficacy of oral and intranasal gepants and the injectable CGRP monoclonal antibodies (mAbs) are described, as are recent synthetic developments that have benefited from new structural biology data. The first oral gepant was recently approved and heralds a new era in the treatment of migraine.
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Affiliation(s)
- Gene M Dubowchik
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
| | - Charles M Conway
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
| | - Alison W Xin
- Biohaven Pharmaceuticals Inc., 215 Church Street, New Haven, Connecticut 06510, United States
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Wattiez AS, Sowers LP, Russo AF. Calcitonin gene-related peptide (CGRP): role in migraine pathophysiology and therapeutic targeting. Expert Opin Ther Targets 2020; 24:91-100. [PMID: 32003253 DOI: 10.1080/14728222.2020.1724285] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: The neuropeptide calcitonin gene-related peptide (CGRP) is recognized as a critical player in migraine pathophysiology. Excitement has grown regarding CGRP because of the development and clinical testing of drugs targeting CGRP or its receptor. While these drugs alleviate migraine symptoms in half of the patients, the remaining unresponsive half of this population creates an impetus to address unanswered questions that exist in this field.Areas covered: We describe the role of CGRP in migraine pathophysiology and CGRP-targeted therapeutics currently under development and in use. We also discuss how a second CGRP receptor may provide a new therapeutic target.Expert opinion: CGRP-targeting drugs have shown a remarkable safety profile. We speculate that this may reflect the redundancy of peptides within the CGRP family and a second CGRP receptor that may compensate for reduced CGRP activity. Furthermore, we propose that an inherent safety feature of peptide-blocking antibodies is attributed to the fundamental nature of peptide release, which occurs as a large bolus in short bursts of volume transmission. These facts support the development of more refined CGRP therapeutic drugs, as well as drugs that target other neuropeptides. We believe that the future of migraine research is bright with exciting advances on the horizon.
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Affiliation(s)
- Anne-Sophie Wattiez
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA
| | - Levi P Sowers
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA
| | - Andrew F Russo
- Department of Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,VA Center for the Prevention and Treatment of Visual Loss, VA Medical Center, Iowa City, IA, USA.,Department of Neurology, University of Iowa, Iowa City, IA, USA
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