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Aditya S, Rattan A. Advances in CGRP Monoclonal Antibodies as Migraine Therapy: A Narrative Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2023; 11:11-18. [PMID: 36909005 PMCID: PMC9997852 DOI: 10.4103/sjmms.sjmms_95_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 12/01/2022] [Accepted: 12/21/2022] [Indexed: 03/14/2023]
Abstract
Migraine is a potentially disabling disorder, yet it remains underdiagnosed and undertreated. The release of the neuropeptide calcitonin gene-related peptide (CGRP) in the trigemino-cerebrovascular system plays a vital role in the evolution of migraine. It enhances peripheral sensitization by mediating neurogenic inflammation and also influences central sensitization. The majority of the drug classes available for migraine prophylaxis are nonspecific and associated with numerous side effects and drug interactions. Anti-CGRP monoclonal antibodies (mAb) are an innovative therapeutic class that fulfills the need for more efficacious and tolerable preventive therapy. While erenumab is a mAb to the CGRP receptor, eptinezumab, fremanezumab, and galcanezumab bind to the CGRP molecule. They decrease the number of headache days and improve disability. Upper respiratory tract infection, nausea, constipation, pain at the site of injection, and fatigue are the associated side effects. CGRP mAbs are an excellent advancement in translational research and are a promising addition in migraine therapy. This article discusses the recent advances in the development of the CGRP mAbs.
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Affiliation(s)
- Suruchi Aditya
- Department of Pharmacology, Dr. Harvansh Singh Judge Institute of Dental Sciences, Panjab University, Chandigarh, India
| | - Aditya Rattan
- Cardiology Clinic, Heart Line, Panchkula, Haryana, India
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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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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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Kumar A, Williamson M, Hess A, DiPette DJ, Potts JD. Alpha-Calcitonin Gene Related Peptide: New Therapeutic Strategies for the Treatment and Prevention of Cardiovascular Disease and Migraine. Front Physiol 2022; 13:826122. [PMID: 35222088 PMCID: PMC8874280 DOI: 10.3389/fphys.2022.826122] [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: 01/17/2022] [Indexed: 12/13/2022] Open
Abstract
Alpha-calcitonin gene-related peptide (α-CGRP) is a vasodilator neuropeptide of the calcitonin gene family. Pharmacological and gene knock-out studies have established a significant role of α-CGRP in normal and pathophysiological states, particularly in cardiovascular disease and migraines. α-CGRP knock-out mice with transverse aortic constriction (TAC)-induced pressure-overload heart failure have higher mortality rates and exhibit higher levels of cardiac fibrosis, inflammation, oxidative stress, and cell death compared to the wild-type TAC-mice. However, administration of α-CGRP, either in its native- or modified-form, improves cardiac function at the pathophysiological level, and significantly protects the heart from the adverse effects of heart failure and hypertension. Similar cardioprotective effects of the peptide were demonstrated in pressure-overload heart failure mice when α-CGRP was delivered using an alginate microcapsules-based drug delivery system. In contrast to cardiovascular disease, an elevated level of α-CGRP causes migraine-related headaches, thus the use of α-CGRP antagonists that block the interaction of the peptide to its receptor are beneficial in reducing chronic and episodic migraine headaches. Currently, several α-CGRP antagonists are being used as migraine treatments or in clinical trials for migraine pain management. Overall, agonists and antagonists of α-CGRP are clinically relevant to treat and prevent cardiovascular disease and migraine pain, respectively. This review focuses on the pharmacological and therapeutic significance of α-CGRP-agonists and -antagonists in various diseases, particularly in cardiac diseases and migraine pain.
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Affiliation(s)
- Ambrish Kumar
- Department of Cell Biology and Anatomy, School of Medicine, University of South Carolina, Columbia, SC, United States
| | - Maelee Williamson
- Department of Cell Biology and Anatomy, School of Medicine, University of South Carolina, Columbia, SC, United States
| | - Andrew Hess
- Department of Cell Biology and Anatomy, School of Medicine, University of South Carolina, Columbia, SC, United States
| | - Donald J. DiPette
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC, United States
| | - Jay D. Potts
- Department of Cell Biology and Anatomy, School of Medicine, University of South Carolina, Columbia, SC, United States
- *Correspondence: Jay D. Potts,
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Gottschalk C, Basu A, Blumenfeld A, Torphy B, Marmura MJ, Pavlovic JM, Dumas PK, Lalvani N, Buse DC. The importance of an early onset of migraine preventive disease control: A roundtable discussion. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221134593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Newly approved migraine preventive therapies have allowed for rapid control of migraine activity, offering potential to minimize the burden of migraine. This report summarizes a roundtable discussion convened to analyze evidence for early onset of prevention, ascertain its clinical relevance, and provide guidance for healthcare professionals in crafting goals and treatment expectations for patients with migraine initiating preventive therapy. Methods: A virtual roundtable meeting of migraine clinicians, researchers, and patient advocates convened in October 2020. Participants reviewed and discussed data summarizing patient and healthcare professional perceptions of migraine prevention and evidence from the peer-reviewed and gray literature to develop corresponding recommendations. Summary: Evidence from clinical studies of anti-calcitonin gene-related peptide monoclonal antibodies (erenumab, fremanezumab, galcanezumab, and eptinezumab) and the chemodenervation agent onabotulinumtoxinA indicate that patients may experience reduction of migraine activity within 7 days of drug administration and early attainment of disease control is associated with improvements in clinically important outcomes. The roundtable of experts proposes that early onset be defined as demonstration of preventive benefits within 1 week of treatment initiation. We recommend focusing discussion with patients around “disease control” and potential benefits of early onset of prevention, so patients can set realistic preventive therapy goals and expectations.
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Affiliation(s)
| | - Anirban Basu
- The CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Andrew Blumenfeld
- Headache Center of Southern California, The Neurology Center, Carlsbad, CA, USA
| | - Bradley Torphy
- Chicago Headache Center and Research Institute, Chicago, IL, USA
| | - Michael J Marmura
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jelena M Pavlovic
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Nim Lalvani
- American Migraine Foundation, Mount Royal, NJ, USA
| | - Dawn C Buse
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
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