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Patlin B, Schwerdtfeger L, Tobet S. Neuropeptide stimulation of physiological and immunological responses in precision-cut lung slices. Physiol Rep 2023; 11:e15873. [PMID: 37994278 PMCID: PMC10665790 DOI: 10.14814/phy2.15873] [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: 06/14/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/24/2023] Open
Abstract
Organotypic lung slices, sometimes known as precision-cut lung slices (PCLS), provide an environment in which numerous cell types and interactions can be maintained outside the body (ex vivo). PCLS were maintained ex vivo for up to a week and demonstrated health via the presence of neurons, maintenance of tissue morphology, synthesis of mucopolysaccharides, and minimal cell death. Multiple phenotypes of neuronal fibers were present in lung slices with varied size, caliber, and neurotransmitter immunoreactivity. Of the neuropeptides present in fibers, calcitonin gene-related peptide (CGRP) was the most prevalent. Exposing PCLS to recombinant CGRP resulted in the proliferation and dispersion of CD19+ B cells in slices taken selectively from females. The number of granules containing immunoreactive (ir) surfactant protein C (SPC), which are representative of alveolar type 2 cells, increased in slices from females within 24 h of exposure to CGRP. Additionally, ir-SPC granule size increased in slices from males and females across 48 h of exposure to CGRP. Exposure of PCLS to exogenous CGRP did not alter the number of solitary pulmonary neuroendocrine cells (PNEC) but did result in neuroendocrine bodies that had significantly more cells. Neuronal fiber numbers were unchanged based on ir-peripherin; however, ir-CGRP became non-detectable in fibers while unchanged in PNECs. The effects of exogenous CGRP provide insight into innate immune and neuroendocrine responses in the lungs that may be partially regulated by neural fibers. The sex-dependent nature of these changes may point to the basis for sex-selective outcomes among respiratory diseases.
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Affiliation(s)
- B. Patlin
- Department of Biochemistry and Molecular BiologyColorado State UniversityFort CollinsColoradoUSA
| | - L. Schwerdtfeger
- Department of NeurologyHarvard Medical School and Ann Romney Center for Neurologic Diseases, Brigham and Women's HospitalBostonMassachusettsUSA
| | - S. Tobet
- School of Biomedical Engineering and Department of Biomedical SciencesColorado State UniversityFort CollinsColoradoUSA
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Berger AA, Keefe J, Stark CW, Moore M, Ramírez GF, Cucarola JR, Han AH, Kaye AD, Ganti L. Eptinezumab-jjmr, a humanized monoclonal specific to Calcitonin Gene Related Peptide, for the preventive treatment of migraine in adults. Health Psychol Res 2022; 10:38439. [DOI: 10.52965/001c.38439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose of Review Migraines are prevalent and cause significant morbidity, decline in quality of life and healthcare costs universally. Treatment options are varied, but efficacy is limited. This review centers on Eptinezumab-jjmr, a humanized monoclonal specific to CGRP for the prevention of migraines in adults. Herein presented are the science and mechanism of action, indication and clinical evidence for use. Recent Findings Migraines are severe, recurrent headaches, which are either episodic or chronic in nature. The pain is severe, often accompanied by co-morbid symptoms, such as photophobia, phonophobia, nausea and emesis, and is limiting in nature. It is a prevalent disorder that causes significant, worldwide disability, morbidity, suffering, and costs. The pathophysiology of migraines is actively studied, though recent research points to an initiating event causing migraine generation, that is then propagated by other brain regions, a significant one being the trigeminocervical complex. This is driven by biochemical transmitters, chiefly CGRP. This discovery led to the development of CGRP-targeting drugs, including gepants (small molecular antagonists) and anti-CGRP antibodies, such as Eptinezumab-jjmr. Traditional therapy includes preventative and abortive treatment; however, adherence with preventative treatment has been historically poor, and certain types of abortive therapy carry risks and side effects that preclude them from a large patient population. Moreover, traditional therapy often falls short in migraine therapy. CGRP antagonist, including Eptinezumab, aims to cover the gaps in migraine therapy. We present here evidence to support the safe and effective use of Eptinezumab for the prevention of migraines. Summary Migraines are a prevalent primary headache disorder causing significant morbidity worldwide. Traditional abortive and preventative treatments fall short for many patients. Eptinezumab is part of new generation of CGRP-targeting medications and has shown significant evidence to support its use for the prevention of migraines. Further research is required to properly compare eptinezumab with existing pharmacotherapy and update guidelines on the appropriate combinations of therapies that are not available and the correct patient selection for each.
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Affiliation(s)
| | | | | | - Matthew Moore
- Louisiana State University Shreveport School of Medicine
| | | | | | | | | | - Latha Ganti
- University of Central Florida School of Medicine
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3
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Berger AA, Winnick A, Carroll AH, Welschmeyer A, Li N, Colon M, Paladini A, Ramírez GF, Hasoon J, Cornett EM, Song J, Varrassi G, Kaye AM, Kaye AD, Ganti L. Rimegepant for the treatment of migraine. Health Psychol Res 2022; 10:38534. [PMID: 36262478 PMCID: PMC9560892 DOI: 10.52965/001c.38534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Migraine is a common form of primary headache, affecting up to 1 in every 6 Americans. The pathophysiology is an intricate interplay of genetic factors and environmental influence and is still being elucidated in ongoing studies. The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as CGRP and substance P. Traditional treatment of migraine is usually divided into acute and preventive treatment. Acute therapy includes non-specific therapy, such as NSAIDs and other analgesics, which may provide relief in mild to moderate migraines. 5-HT1 agonists may provide relief in severe migraine, but are not universally effective and carry a significant side-effect profile with frequent redosing requirement. Prophylactic therapy may reduce the occurrence of acute migraine attacks in selected patients, but does not completely eliminate it. More recently, CGRP antagonism has been studied and shown to be effective in both abortion and prevention of migraine. Novel medications, targeting CGRP, divide into CGRP antibodies and receptor antagonists (gepants). Rimegepant, a second-generation gepant, has shown efficacy in several clinical trials in treating acute migraine. Ongoing trials are also evaluating its role in migraine prophylaxis, and results are promising. It is also generally safer for use than existing options, does not appear to increase the chance of developing chronic migraines, and carries a very tolerable side effects profile. It is a part of a growing arsenal in migraine treatment, and may present the silver bullet for treatment of this disease.
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Affiliation(s)
- Amnon A Berger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School
| | - Ariel Winnick
- Soroka University Medical Center and Faculty of Health Sciences, Ben Gurion University of the Negev, University of California School of Optometry
| | | | | | | | - Marc Colon
- Department of Psychiatry, and Behavioral Medicine, Louisiana State University Health Science Center Shreveport
| | | | | | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center
| | | | | | | | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport
| | - Latha Ganti
- University of Central Florida College of Medicine
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Johnson B, Freitag FG. New Approaches to Shifting the Migraine Treatment Paradigm. FRONTIERS IN PAIN RESEARCH 2022; 3:873179. [PMID: 36147034 PMCID: PMC9488522 DOI: 10.3389/fpain.2022.873179] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
The standard of care paradigm for migraine treatment has been based almost exclusively on approaches that grew out of the happenstance use of market pharmaceuticals. Only methysergide, which has long since been removed from use for safety concerns, the ergotamine family of drugs, and the triptans were explicitly developed with migraine and other vascular headaches in mind. While the forward and innovative thinking to utilize the broad array of agents to treat migraine served millions well, their therapeutic efficacy was often low, and adverse event profiles were troublesome in the least. Advances in biochemical and molecular biology and the application of advanced "designing drugs" methods have brought about a potentially significant shift in treatment. The gepants have efficacies similar to the triptans but without vascular safety or medication overuse concerns. Preventative gepants offer innovative approaches to prevention and efficacy that exceed even the CGRP monoclonal antibodies. Those monoclonal antibodies brought rapid and highly effective outcomes across the spectrum of migraine. They outpaced older oral medication efficacy and eliminated most adverse events while potentially improving compliance with monthly or quarterly dosing. Other serotonin receptors beyond the 5HT1B and1D receptors have been targeted for decades. They now lead us to better formulations of dihydroergotamine for efficacy, convenience, and tolerability, and a 5HT1F-specific acute treatment like the gepants opens new options for acute management. Neuromodulation goes back to the mid-1800's. Our improved understanding of applied biomedical engineering has brought forward several tantalizing devices, including the application of currents distant from the target and patient regulated. Whether these advances change the paradigm of migraine treatment and standards of care remains to be seen, and issues such as cost and patient acceptance will help mold it.
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Affiliation(s)
| | - Frederick G. Freitag
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
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La Fountaine MF, Hohn AN, Leahy CL, Weir JP, Testa AJ. Observations from a prospective small cohort study suggest that CGRP genes contribute to acute posttraumatic headache burden after concussion. Front Neurol 2022; 13:947524. [PMID: 35989941 PMCID: PMC9389220 DOI: 10.3389/fneur.2022.947524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionPost-traumatic headache (PTH) is commonly reported after concussion. Calcitonin gene-related peptide (CGRP) is implicated in the pathogenesis of migraine. We explored how single nucleotide polymorphisms (SNPs) from CGRP-alpha (CALCA) and the receptor activity modifying protein-1 (RAMP1) related to headache burden during the first week after concussion.MethodsA prospective study was performed in 34 collegiate athletes who sustained a concussion. Participants completed the symptom evaluation checklist from the SCAT3 within 48 h of injury (V1), and again 4 (V2) and 7 (V3) days after injury. For each visit, the self-reported score (0–6) for headache, pressure in head, blurred vision, and sensitivity to light/noise were reported and summed to calculate the headache burden. A saliva sample was obtained and genotyped for CALCA (rs3781719) and RAMP1 (rs10185142). RAMP1 (TT, TC, CC) and CALCA (AA, AG, GG) were dichotomized (A+, A- and T+, T-, respectively), and concatenated (T+A+, T+A-, T-A+, T-A-) for analyses.ResultsHeadache Burden at Visit 1 was greatest in T+A+ compared to T-A+, and trended toward a significant difference with T+A-. Repeated-measures ANOVA revealed the presence of significant visit main effects (p < 0.001, η2 = 0.404), but the group (p = 0.055) and interaction effects only trended (p = 0.094). Pearson's χ2-tests revealed that 88% of those with return-to play (RTP) exclusions ≥15 days had PTH with multi-sensory symptoms (PTH+SENS) as compared to 35% in those with RTP < 14 day.ConclusionKnowledge of RAMP1 and CALCA genotypes appear to improve an understanding the presenting features and magnitude of headache burden after concussion injury.
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Affiliation(s)
- Michael F. La Fountaine
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, United States
- Departments of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Nutley, NJ, United States
- *Correspondence: Michael F. La Fountaine
| | - Asante N. Hohn
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, United States
| | - Caroline L. Leahy
- Department of Physical Therapy, School of Health and Medical Sciences, Seton Hall University, Nutley, NJ, United States
| | - Joseph P. Weir
- Department of Health, Sport and Exercise Sciences, University of Kansas, Lawrence, KS, United States
- Osness Human Performance Laboratories, University of Kansas, Lawrence, KS, United States
| | - Anthony J. Testa
- Center for Sports Medicine, Seton Hall University, South Orange, NJ, United States
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Cocores AN, Monteith TS. Headache as a Neurologic Manifestation of Systemic Disease. Curr Treat Options Neurol 2022; 24:17-40. [PMID: 35317303 PMCID: PMC8931180 DOI: 10.1007/s11940-022-00704-9] [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] [Accepted: 12/15/2021] [Indexed: 11/26/2022]
Abstract
Purpose of Review Recent Findings Summary
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Affiliation(s)
- Alexandra N. Cocores
- Division of Headache, Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14 Street, Florida, Miami 33132 USA
| | - Teshamae S. Monteith
- Division of Headache, Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14 Street, Florida, Miami 33132 USA
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Argunhan F, Brain SD. The Vascular-Dependent and -Independent Actions of Calcitonin Gene-Related Peptide in Cardiovascular Disease. Front Physiol 2022; 13:833645. [PMID: 35283798 PMCID: PMC8914086 DOI: 10.3389/fphys.2022.833645] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/21/2022] [Indexed: 12/21/2022] Open
Abstract
The treatment of hypertension and heart failure remains a major challenge to healthcare providers. Despite therapeutic advances, heart failure affects more than 26 million people worldwide and is increasing in prevalence due to an ageing population. Similarly, despite an improvement in blood pressure management, largely due to pharmacological interventions, hypertension remains a silent killer. This is in part due to its ability to contribute to heart failure. Development of novel therapies will likely be at the forefront of future cardiovascular studies to address these unmet needs. Calcitonin gene-related peptide (CGRP) is a 37 amino acid potent vasodilator with positive-ionotropic and -chronotropic effects. It has been reported to have beneficial effects in hypertensive and heart failure patients. Interestingly, changes in plasma CGRP concentration in patients after myocardial infarction, heart failure, and in some forms of hypertension, also support a role for CGRP on hemodynamic functions. Rodent studies have played an important role thus far in delineating mechanisms involved in CGRP-induced cardioprotection. However, due to the short plasma half-life of CGRP, these well documented beneficial effects have often proven to be acute and transient. Recent development of longer lasting CGRP agonists may therefore offer a practical solution to investigating CGRP further in cardiovascular disease in vivo. Furthermore, pre-clinical murine studies have hinted at the prospect of cardioprotective mechanisms of CGRP which is independent of its hypotensive effect. Here, we discuss past and present evidence of vascular-dependent and -independent processes by which CGRP could protect the vasculature and myocardium against cardiovascular dysfunction.
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Pak K, Kim J, Lee GH, Cho JW, Kim HW. Effectiveness of Calcitonin Gene-Related Peptide Receptor Antagonists for Migraine Treatment: A Meta-Analysis. Eur Neurol 2022; 85:195-201. [PMID: 35100579 DOI: 10.1159/000521697] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The pathophysiology of migraine has been researched incessantly, and it has been suggested that calcitonin gene-related peptide (CGRP) is associated with migraine attacks. CGRP receptor blockers are attracting attention as potential agents for migraine prevention and treatment of acute episodes. This meta-analysis aimed to assess the effects of available CGRP receptor antagonists, focusing on their therapeutic doses for acute migraine treatment. METHODS We systematically searched MEDLINE and Embase from inception to March 27, 2021, for English-language publications using the keywords "migraine" and "calcitonin gene-related peptide"; the searches were limited to human studies. RESULTS Five studies that focused on examining the effects of CGRP receptor antagonists on acute migraine treatment met the eligibility criteria for this meta-analysis. A pooled analysis demonstrated that CGRP receptor antagonists significantly increased freedom from pain (odds ratio [OR] = 2.066, 95% confidence interval [CI] 1.766-2.418, I2 = 0%) and from bothersome symptoms in general (OR = 1.606, 95% CI = 1.408-1.830, I2 = 0%); reduced the intensity of pain (OR = 1.791, 95% CI = 1.598-2.008, I2 = 0%); and increased freedom from nausea (OR = 1.361, 95% CI = 1.196-1.548, I2 = 0%) compared to a placebo. CONCLUSIONS CGRP receptor antagonists are effective for acute migraine treatment and are expected to be used clinically as emerging therapeutic agents.
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Affiliation(s)
- Kyoungjune Pak
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jiyoung Kim
- Department of Neurology and BioMedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Gha-Hyun Lee
- Department of Neurology and BioMedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jae Wook Cho
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyun-Woo Kim
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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Soni P, Chawla E. Quality of Life Related to Functional Disability in Migraine Patients: A Systematic Review and Network Meta-analysis. Clin J Pain 2021; 37:845-851. [PMID: 34419975 DOI: 10.1097/ajp.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 07/27/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to conduct a systematic review and network meta-analysis of all randomized trials investigating effect of anti-calcitonin gene-related peptide monoclonal antibodies on disability related to migraine in adult patients. MATERIALS AND METHODS Medline, Embase, and Cochrane Central Register of Controlled Trials searched from inception to July 2020 with an additional review of clinical trial registries. Disability evaluated using change in patient reported Migraine Disability Assessment scores from baseline were considered for the final analysis. The network meta-analysis was conducted in Bayesian framework using OpenBUGS and R, with the random effects model selected to allow for apparent heterogeneity between studies in the treatment comparison effects. RESULTS Overall 41 studies (7095 migraineurs in 9 randomized trials) were included with treatment course of at least 12 weeks. Subcutaneous injections of fremanezumab 675+225+225 mg QM and 225+225+225 mg QM were more effective in reducing disability in chronic and episodic migraine patients, respectively, with higher median difference in Migraine Disability Assessment score from baseline compared with other treatments including erenumab (70 mg QM; 140 mg QM), galcanezumab (120 mg QM; 240 mg QM), and low doses of fremanezumab (225 mg single dose; 675 mg single dose). DISCUSSION For short-term prevention of migraine, fremanezumab demonstrated slightly better improvement in disability compared with other anti-calcitonin gene-related peptide monoclonal antibodies in adult patients with migraine.
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Affiliation(s)
- Prashant Soni
- Real-World Solutions, Scientific Services, Health Economics and Outcomes Research, IQVIA, Delhi, India
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González-Hernández A, Marichal-Cancino BA, Villalón CM. The impact of CGRPergic monoclonal antibodies on prophylactic antimigraine therapy and potential adverse events. Expert Opin Drug Metab Toxicol 2021; 17:1223-1235. [PMID: 34535065 DOI: 10.1080/17425255.2021.1982892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Migraine is a prevalent medical condition and the second most disabling neurological disorder. Regarding its pathophysiology, calcitonin gene-related peptide (CGRP) plays a key role, and, consequently, specific antimigraine pharmacotherapy has been designed to target this system. Hence, apart from the gepants, the recently developed monoclonal antibodies (mAbs) are a novel approach to treat this disorder. In this review we consider the current knowledge on the mechanisms of action, specificity, safety, and efficacy of the above mAbs as prophylactic antimigraine agents, and examine the possible adverse events that these agents may trigger. Antimigraine mAbs act as direct scavengers of CGRP (galcanezumab, fremanezumab, and eptinezumab) or against the CGRP receptor (erenumab). Due to their long half-lives, these molecules have revolutionized the prophylactic treatment of this neurovascular disorder. Moreover, because of their physicochemical properties, these agents are hepato-friendly and do not cross the blood-brain barrier (highlighting the relevance of peripheral mechanisms in migraine). Nevertheless, apart from potential cardiovascular side effects, the interaction with AMY1 receptors and immunogenicity induced by autoantibodies against mAbs could be a concern for the safety of long-term treatment with these molecules.
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Affiliation(s)
- Abimael González-Hernández
- Departamento de Neurobiología del Desarrollo y Neurofisiología, Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México
| | - Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Universidad Autónoma de Aguascalientes, Ciudad Universitaria, Aguascalientes, México
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav‑Coapa, Ciudad de México, México
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Efficacy and safety of anti-calcitonin gene-related peptide monoclonal antibodies for treatment of chronic migraine: A systematic review and network meta-analysis. Clin Neurol Neurosurg 2021; 209:106893. [PMID: 34464833 DOI: 10.1016/j.clineuro.2021.106893] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/16/2021] [Accepted: 08/08/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND & OBJECTIVE To conduct a systematic review and network meta-analysis of all randomized trials investigating effects of anti-calcitonin gene related peptide monoclonal antibodies (anti-CGRP mAbs) on adult patients with chronic migraine. METHODS MEDLINE, Embase and Cochrane Central Register of Controlled Trials searched from inception to July 2020; and clinical trial registries. The network meta-analysis was conducted in Bayesian framework using OpenBUGS and R, with the random effects model selected to allow for apparent heterogeneity between studies in the treatment comparison effects. RESULTS Overall 38 studies (5164 chronic migraineurs in seven randomized trials) were included with treatment course of at least 12 weeks. Fremanezumab 675 + 225 + 225 mg QM (SC) injections were numerically more effective in lowering migraine days with lower MDs compared to eptinezumab 10 mg (IV) (MD: -1.52, 95% CrIs: -4.24, 0.99), eptinezumab 30 mg (IV) (MD: -0.33, 95% CrIs: -3.02, 2.16), eptinezumab 100 mg (IV) (MD: -0.59, 95% CrIs: -2.80, 1.42), eptinezumab 300 mg (IV) (MD: -0.02, 95% CrIs: -2.29, 1.98), erenumab 70 mg QM (SC) (MD: -0.17, 95% CrIs: -2.84, 2.25), erenumab 140 mg QM (SC) (MD: -0.18, 95% CrIs: -2.87, 2.26), fremanezumab 675 mg (SC) (MD: -0.30, 95% CrIs: -1.81, 1.14), galcanezumab 120 mg QM (SC) (MD: -0.71, 95% CrIs: -3.44, 1.55) and galcanezumab 240 mg QM (SC) (MD: -0.58, 95% CrIs: -3.09, 1.89), however the results were non-significant. Similarly, the anti-CGRP mAbs were also observed to have comparable safety and immunogenicity with no significant differences. CONCLUSIONS Although all doses of anti-CGRP mAbs have comparable efficacy, safety and tolerability based on uncertainties in indirect comparisons for all outcomes, the calculated effect estimates numerically favored high doses of subcutaneous fremanezumab and intravenous eptinezumab as the effective therapy with acceptable safety and tolerability for short term prevention of chronic migraine.
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12
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Mungoven TJ, Henderson LA, Meylakh N. Chronic Migraine Pathophysiology and Treatment: A Review of Current Perspectives. FRONTIERS IN PAIN RESEARCH 2021; 2:705276. [PMID: 35295486 PMCID: PMC8915760 DOI: 10.3389/fpain.2021.705276] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
Chronic migraine is a disabling neurological disorder that imposes a considerable burden on individual and socioeconomic outcomes. Chronic migraine is defined as headaches occurring on at least 15 days per month with at least eight of these fulfilling the criteria for migraine. Chronic migraine typically evolves from episodic migraine as a result of increasing attack frequency and/or several other risk factors that have been implicated with migraine chronification. Despite this evolution, chronic migraine likely develops into its own distinct clinical entity, with unique features and pathophysiology separating it from episodic migraine. Furthermore, chronic migraine is characterized with higher disability and incidence of comorbidities in comparison to episodic migraine. While existing migraine studies primarily focus on episodic migraine, less is known about chronic migraine pathophysiology. Mounting evidence on aberrant alterations suggest that pronounced functional and structural brain changes, central sensitization and neuroinflammation may underlie chronic migraine mechanisms. Current treatment options for chronic migraine include risk factor modification, acute and prophylactic therapies, evidence-based treatments such as onabotulinumtoxinA, topiramate and newly approved calcitonin gene-related peptide or receptor targeted monoclonal antibodies. Unfortunately, treatments are still predominantly ineffective in aborting migraine attacks and decreasing intensity and frequency, and poor adherence and compliance with preventative medications remains a significant challenge. Novel emerging chronic migraine treatments such as neuromodulation offer promising therapeutic approaches that warrant further investigation. The aim of this narrative review is to provide an update of current knowledge and perspectives regarding chronic migraine background, pathophysiology, current and emerging treatment options with the intention of facilitating future research into this debilitating and largely indeterminant disorder.
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Affiliation(s)
| | | | - Noemi Meylakh
- Department of Anatomy and Histology, Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
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Real-Life Response to Erenumab in a Therapy-Resistant Case Series of Migraine Patients From the Province of Québec, Eastern Canada. Clin Drug Investig 2021; 41:733-739. [PMID: 34287786 DOI: 10.1007/s40261-021-01059-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Erenumab is the first migraine-specific preventive therapy approved by Health Canada since the approval of onabotulinumtoxinA 10 years ago. It is one of four calcitonin gene-related peptide antagonist monoclonal antibodies that have been commercialized worldwide for use in the headache pipeline. The objective of our study was to determine real-life efficacy of monthly erenumab for the prevention of migraine in a small case series of difficult-to-treat patients followed at a tertiary headache clinic from the Canadian province of Québec. METHODS We performed a retrospective chart audit of patients having failed four or more conventional migraine oral preventive therapies and who were treated with monthly self-administered subcutaneous erenumab (70 or 140 mg/mL dose) over a 1-year period. We assessed the patients' baseline characteristics, response to treatment, and tolerability. RESULTS A total of 18 patients with a diagnosis of high-frequency episodic migraines or chronic migraine met criteria (83.3% female; mean age: 48.7 years; mean duration of migraine condition: 32.9 years). Patients self-administered erenumab using a prefilled disposable autoinjector on a monthly basis; 16 patients received a 140 mg/mL dosage, two patients received a 70 mg/mL dosage. At 1 year follow-up, 50% of patients reported ≥ 50% reduction in migraine frequency and were deemed responders. Patients attempted six doses of erenumab therapy prior to discontinuation for non-response, except for two patients with other concomitant chronic pain conditions, who required ten doses to reach a 50% response. For the overall cohort, there was a decrease of 5.2 monthly migraine days; 9 days for responders and 1.3 days for non-responders (t-test (df = 16) = - 2.77, p = 0.014). There was an additional decrease of 7 monthly non-migraine days amongst patients with unremitting daily headaches; 8 days for responders and 5 days for non-responders (p > 0.05). There was a decrease of 5.4 monthly days using acute analgesics; 8.9 days for responders and 2 days for non-responders (T(16) = - 2.33, p = 0.033). The overall mean reduction in disability using the Headache Impact Test (HIT-6) score was 5.6 points; only responders showed a reduction in HIT-6 severity category (p > 0.05). The most commonly reported adverse event was constipation (16.7%), which did not lead to treatment discontinuation and was successfully managed in all patients with early counselling and intervention. CONCLUSION This study supports the efficacy of erenumab in a case series of therapy-resistant migraine patients from the region of Québec. A high rate of previously failed preventive oral agents and medication overuse did not predict response in our patient cohort. In the presence of real-world complexity factors, such as psychological distress, regular opioid consumption and concomitant chronic pain conditions, a longer therapy trial may be warranted in obtaining optimal response.
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Cluster headache pathophysiology - insights from current and emerging treatments. Nat Rev Neurol 2021; 17:308-324. [PMID: 33782592 DOI: 10.1038/s41582-021-00477-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 02/01/2023]
Abstract
Cluster headache is a debilitating primary headache disorder that affects approximately 0.1% of the population worldwide. Cluster headache attacks involve severe unilateral pain in the trigeminal distribution together with ipsilateral cranial autonomic features and a sense of agitation. Acute treatments are available and are effective in just over half of the patients. Until recently, preventive medications were borrowed from non-headache indications, so management of cluster headache is challenging. However, as our understanding of cluster headache pathophysiology has evolved on the basis of key bench and neuroimaging studies, crucial neuropeptides and brain structures have been identified as emerging treatment targets. In this Review, we provide an overview of what is known about the pathophysiology of cluster headache and discuss the existing treatment options and their mechanisms of action. Existing acute treatments include triptans and high-flow oxygen, interim treatment options include corticosteroids in oral form or for greater occipital nerve block, and preventive treatments include verapamil, lithium, melatonin and topiramate. We also consider emerging treatment options, including calcitonin gene-related peptide antibodies, non-invasive vagus nerve stimulation, sphenopalatine ganglion stimulation and somatostatin receptor agonists, discuss how evidence from trials of these emerging treatments provides insights into the pathophysiology of cluster headache and highlight areas for future research.
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15
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Fiedler-Kelly J, Raddad E, de Hoon J, Ludwig EA, Passarell J, Kielbasa W, Collins EC. Relationship of the Calcitonin Gene-Related Peptide Monoclonal Antibody Galcanezumab Pharmacokinetics and Capsaicin-Induced Dermal Blood Flow in Healthy Subjects. Clin Pharmacol Drug Dev 2021; 10:440-452. [PMID: 33740315 DOI: 10.1002/cpdd.929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/02/2021] [Indexed: 11/05/2022]
Abstract
Galcanezumab, a humanized monoclonal antibody targeting calcitonin gene-related peptide, was recently approved for migraine prophylaxis. The pharmacokinetic/pharmacodynamic (PK/PD) relationship between galcanezumab concentration and inhibition of capsaicin-induced dermal blood flow (CIDBF) was evaluated using first-in-human data following 6 single subcutaneous doses (1 to 600 mg) or multiple (4) 150-mg doses every 2 weeks in 7 cohorts (7 actively treated subjects and 2 placebo-treated healthy subjects). Galcanezumab pharmacokinetics were best described by a 1-compartment model with delayed first-order absorption/linear elimination. Apparent estimates (between-subject variability) of clearance, volume of distribution, absorption rate constant, and lag time were 0.0106 L/h (27%CV), 11.2 L (21%CV), 0.0192 h-1 (89%CV), and 0.202 hours, respectively. Estimated elimination half-life was about 30 days. An effect compartment link model described the concentration-effect relationship; estimated maximum inhibitory effect was 70.5%, and 50% maximum inhibitory effect concentration (IC50 ) was 1060 ng/mL. Galcanezumab showed dose- and concentration-dependent potent and durable inhibition of CIDBF. Simulated effect compartment concentrations were maintained above IC50 after 12 weeks of dosing. Near-maximal CIDBF inhibition occurred with 150 mg biweekly for 12 weeks lasting ≥24 weeks or with ≥30 mg every 2 weeks or 195 mg every 13 weeks. Quantitative modeling of galcanezumab PK/PD supported dose selection for the phase 2 proof-of-concept study.
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Affiliation(s)
- Jill Fiedler-Kelly
- Cognigen Corporation, a Simulations Plus company, Buffalo, New York, USA
| | - Eyas Raddad
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Jan de Hoon
- Center for Clinical Pharmacology, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Elizabeth A Ludwig
- Cognigen Corporation, a Simulations Plus company, Buffalo, New York, USA
| | - Julie Passarell
- Cognigen Corporation, a Simulations Plus company, Buffalo, New York, USA
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16
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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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17
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The Role of the Kynurenine Signaling Pathway in Different Chronic Pain Conditions and Potential Use of Therapeutic Agents. Int J Mol Sci 2020; 21:ijms21176045. [PMID: 32842609 PMCID: PMC7503462 DOI: 10.3390/ijms21176045] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/11/2020] [Accepted: 08/19/2020] [Indexed: 12/11/2022] Open
Abstract
Tryptophan (TRP) is an essential, aromatic amino acid catabolized by indoleamine 2,3-dioxygenase (IDO) and tryptophan 2,3-dioxygenase (TDO) enzymes into kynurenine. The IDO enzyme is expressed in peripheral tissues and the central nervous system. Another enzyme of interest in the kynurenine signaling pathway is kynurenine 3-monooxygenase (KMO). The purpose of this review is to discuss the role of TRP and the kynurenine signaling pathway in different chronic pain patients. The IDO-1, IDO-2, and KMO enzymes and the kynurenine metabolite have been shown to be involved in the pathogenesis of neuropathic pain and other painful conditions (migraine, cluster headache, etc.) as well as depressive behavior. We highlighted the analgesic potential of novel agents targeting the enzymes of the kynurenine signaling pathway to explore their efficacy in both future basic science and transitional studies. Upcoming studies conducted on animal models will need to take into consideration the differences in TRP metabolism between human and non-human species. Since chronic painful conditions and depression have common pathophysiological patterns, and the kynurenine signaling pathway is involved in both of them, future clinical studies should aim to have outcomes targeting not only pain, but also functionality, mood changes, and quality of life.
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18
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Urits I, Clark G, An D, Wesp B, Zhou R, Amgalan A, Berger AA, Kassem H, Ngo AL, Kaye AD, Kaye RJ, Cornett EM, Viswanath O. An Evidence-Based Review of Fremanezumab for the Treatment of Migraine. Pain Ther 2020; 9:195-215. [PMID: 32222952 PMCID: PMC7203396 DOI: 10.1007/s40122-020-00159-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Indexed: 11/27/2022] Open
Abstract
Migraine headache is a common, chronic, debilitating disease with a complex etiology. Current therapy for migraine headache comprises either treatments targeting acute migraine pain or prophylactic therapy aimed at increasing the length of time between migraine episodes. Recent evidence suggests that calcium gene-related peptide (CGRP) is a critical component in the pathogenesis of migraines. Fremanezumab, a monoclonal antibody against CGRP, was recently approved by the Food and Drug Administration (FDA) after multiple studies showed that it was well-tolerated, safe, and effective in the treatment of migraines. Further research is needed to elucidate the long-term effects of fremanezumab and CGRP-antagonists in general, and additional data is required in less healthy patients to estimate its effects in these populations and potentially increase the eligible group of recipients. This is a comprehensive review of the current literature on the efficacy and safety of fremanezumab for the treatment of chronic migraine. In this review we provide an update on the epidemiology, pathogenesis, diagnosis, and current treatment of migraine, and summarize the evidence for fremanezumab as a treatment for migraine.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Gavin Clark
- Georgetown University School of Medicine, Washington, DC, USA
| | - Daniel An
- Georgetown University School of Medicine, Washington, DC, USA
| | - Bredan Wesp
- Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Zhou
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Amnon A Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Hisham Kassem
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Anh L Ngo
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Pain Medicine, Pain Specialty Group, Newington, NH, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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19
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Cseh EK, Veres G, Körtési T, Polyák H, Nánási N, Tajti J, Párdutz Á, Klivényi P, Vécsei L, Zádori D. Neurotransmitter and tryptophan metabolite concentration changes in the complete Freund's adjuvant model of orofacial pain. J Headache Pain 2020; 21:35. [PMID: 32316909 PMCID: PMC7175490 DOI: 10.1186/s10194-020-01105-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/08/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The neurochemical background of the evolution of headache disorders, still remains partially undiscovered. Accordingly, our aim was to further explore the neurochemical profile of Complete Freund's adjuvant (CFA)-induced orofacial pain, involving finding the shift point regarding small molecule neurotransmitter concentrations changes vs. that of the previously characterized headache-related neuropeptides. The investigated neurotransmitters consisted of glutamate, γ-aminobutyric acid, noradrenalin and serotonin. Furthermore, in light of its influence on glutamatergic neurotransmission, we measured the level of kynurenic acid (KYNA) and its precursors in the kynurenine (KYN) pathway (KP) of tryptophan metabolism. METHODS The effect of CFA was evaluated in male Sprague Dawley rats. Animals were injected with CFA (1 mg/ml, 50 μl/animal) into the right whisker pad. We applied high-performance liquid chromatography to determine the concentrations of the above-mentioned compounds from the trigeminal nucleus caudalis (TNC) and somatosensory cortex (ssCX) of rats. Furthermore, we measured some of these metabolites from the cerebrospinal fluid and plasma as well. Afterwards, we carried out permutation t-tests as post hoc analysis for pairwise comparison. RESULTS Our results demonstrated that 24 h after CFA treatment, the level of glutamate, KYNA and that of its precursor, KYN was still elevated in the TNC, all diminishing by 48 h. In the ssCX, significant concentration increases of KYNA and serotonin were found. CONCLUSION This is the first study assessing neurotransmitter changes in the TNC and ssCX following CFA treatment, confirming the dominant role of glutamate in early pain processing and a compensatory elevation of KYNA with anti-glutamatergic properties. Furthermore, the current findings draw attention to the limited time interval where medications can target the glutamatergic pathways.
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Affiliation(s)
- Edina K Cseh
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary
| | - Gábor Veres
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary.,MTA-SZTE Neuroscience Research Group, Szeged, Hungary
| | - Tamás Körtési
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary
| | - Helga Polyák
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary
| | - Nikolett Nánási
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary
| | - János Tajti
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary
| | - Árpád Párdutz
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary
| | - Péter Klivényi
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary
| | - László Vécsei
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary.,MTA-SZTE Neuroscience Research Group, Szeged, Hungary
| | - Dénes Zádori
- Department of Neurology, Interdisciplinary Excellence Center, Faculty of Medicine, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweis u. 6, Szeged, H-6725, Hungary.
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20
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Edvinsson L. The CGRP Pathway in Migraine as a Viable Target for Therapies. Headache 2019; 58 Suppl 1:33-47. [PMID: 29697153 DOI: 10.1111/head.13305] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 12/22/2022]
Abstract
The neuropeptide calcitonin gene-related peptide is well established as a key player in the pathogenesis of migraine. Clinical studies show calcitonin gene-related peptide levels correlate with migraine attacks, and decreases in this neuropeptide can indicate antimigraine therapy effectiveness. Research has revealed a wide distribution of expression sites for calcitonin gene-related peptide in the central and peripheral nervous system. Of these, the calcitonin gene-related peptide receptor, which binds calcitonin gene-related peptide with high affinity, has attracted growing interest as a viable target for antimigraine therapies. An incentive to pursue such research is the continuing unmet medical need of patients. Triptans have offered some clinical benefit, but many patients do not respond and these drugs have important safety considerations. Initial calcitonin gene-related peptide-focused research led to development of the "gepant" small-molecule calcitonin gene-related peptide receptor blockers. Positive efficacy reports concerning the gepants have been tempered by safety findings which led to the discontinuation of some of these agents. Currently, there is considerable excitement regarding monoclonal antibodies against calcitonin gene-related peptide (eptinezumab, galcanezumab, fremanezumab) and the calcitonin gene-related peptide receptor (erenumab). To date, these monoclonal antibodies have shown promising efficacy in clinical trials, with no major safety concerns. If ongoing long-term studies show that their efficacy can be maintained, this may herald a new era for effective antimigraine therapies.
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Affiliation(s)
- Lars Edvinsson
- Institute of Clinical Sciences, Lund University, Lund, Sweden
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21
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Skljarevski V, Oakes TM, Zhang Q, Ferguson MB, Martinez J, Camporeale A, Johnson KW, Shan Q, Carter J, Schacht A, Goadsby PJ, Dodick DW. Effect of Different Doses of Galcanezumab vs Placebo for Episodic Migraine Prevention: A Randomized Clinical Trial. JAMA Neurol 2019; 75:187-193. [PMID: 29255900 DOI: 10.1001/jamaneurol.2017.3859] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Galcanezumab (LY2951742), a monoclonal antibody against calcitonin gene-related peptide (CGRP), is one of a novel class of new medicines for migraine prevention. Objective To assess whether at least 1 dose of galcanezumab was superior to placebo for episodic migraine prevention. Design, Setting, and Participants A randomized clinical trial was conducted in the United States (July 7, 2014, to August 19, 2015) in clinics of 37 licensed physicians with a specialty including, but not limited to, psychiatry, neurology, internal medicine, and primary care. Subcutaneous injections of galcanezumab, 5, 50, 120, or 300 mg, or placebo were given monthly during the 3-month treatment period. A total of 936 patients were assessed; 526 did not meet study entry or baseline criteria and 410 patients were randomly assigned to receive placebo or galcanezumab. Analyses were conducted on an intent-to-treat population, which included all patients who were randomized and received at least 1 dose of study drug. Interventions Short-term migraine treatments were allowed as needed except for opioids or barbiturates. Main Outcomes and Measures To determine if at least 1 of the 4 doses of galcanezumab tested was superior to placebo for migraine prevention measured by the mean change from baseline in the number of migraine headache days 9 weeks to 12 weeks after randomization. Results Of the 936 patients assessed, 410 met entry criteria (aged 18-65 years with 4-14 migraine headache days per month and migraine onset prior to age 50 years) and were randomized to receive placebo or galcanezumab. For the primary end point, galcanezumab, 120 mg, significantly reduced migraine headache days compared with placebo (99.6% posterior probability -4.8 days; 90% BCI, -5.4 to -4.2 days vs 95% superiority threshold [Bayesian analysis] -3.7 days; 90% BCI, -4.1 to -3.2 days). Adverse events reported by 5% or more of patients in at least 1 galcanezumab dose group and more frequently than placebo included injection-site pain, upper respiratory tract infection, nasopharyngitis, dysmenorrhea, and nausea. Conclusions and Relevance Monthly subcutaneous injections of galcanezumab, both 120 mg and 300 mg, demonstrated efficacy (repeated-measures analysis) for the preventive treatment of migraine and support further development in larger phase 3 studies. All dosages were safe and well tolerated for the preventive treatment of episodic migraine. Trial Registration clinicaltrials.gov Identifier: NCT02163993.
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Affiliation(s)
| | | | - Qi Zhang
- Eli Lilly and Company, Indianapolis, Indiana
| | | | | | | | | | | | | | | | - Peter J Goadsby
- National Institute for Health Research-Wellcome Trust King's Clinical Research Facility, King's College London, London, UK.,Department of Neurology, University of California, San Francisco
| | - David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona
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22
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Agostoni EC, Barbanti P, Calabresi P, Colombo B, Cortelli P, Frediani F, Geppetti P, Grazzi L, Leone M, Martelletti P, Pini LA, Prudenzano MP, Sarchielli P, Tedeschi G, Russo A. Current and emerging evidence-based treatment options in chronic migraine: a narrative review. J Headache Pain 2019; 20:92. [PMID: 31470791 PMCID: PMC6734211 DOI: 10.1186/s10194-019-1038-4] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/01/2019] [Indexed: 12/29/2022] Open
Abstract
Background Chronic migraine is a disabling condition that is currently underdiagnosed and undertreated. In this narrative review, we discuss the future of chronic migraine management in relation to recent progress in evidence-based pharmacological treatment. Findings Patients with chronic migraine require prophylactic therapy to reduce the frequency of migraine attacks, but the only currently available evidence-based prophylactic treatment options for chronic migraine are topiramate and onabotulinumtoxinA. Improved prophylactic therapy is needed to reduce the high burden of chronic migraine in Italy. Monoclonal antibodies that target the calcitonin gene-related peptide (CGRP) pathway of migraine pathogenesis have been specifically developed for the prophylactic treatment of chronic migraine. These anti-CGRP/R monoclonal antibodies have demonstrated good efficacy and excellent tolerability in phase II and III clinical trials, and offer new hope to patients who are currently not taking any prophylactic therapy or not benefitting from their current treatment. Conclusions Treatment of chronic migraine is a dynamic and rapidly advancing area of research. New developments in this field have the potential to improve the diagnosis and provide more individualised treatments for this condition. Establishing a culture of prevention is essential for reducing the personal, social and economic burden of chronic migraine.
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Affiliation(s)
| | - Piero Barbanti
- Headache and Pain Unit, Department of Neurological, Motor and Sensorial Sciences, IRCCS San Raffaele Pisana, Rome, Italy. .,San Raffaele University, Rome, Italy.
| | - Paolo Calabresi
- Neurologic Clinic, Ospedale Santa Maria della, Perugia, Italy
| | - Bruno Colombo
- Dipartimento di Neurologia, Università Vita-Salute, Ospedale San Raffaele, Milan, Italy
| | - Pietro Cortelli
- IRCCS- Istituto di Scienze Neurologiche di Bologna, Bologna, Italy.,DIBINEM- University of Bologna, Bologna, Italy
| | - Fabio Frediani
- Headache Centre, UOC Neurologia e Stroke Unit, P.O. San Carlo Borromeo, ASST Santi Paolo e Carlo, Milan, Italy
| | - Pietrangelo Geppetti
- Department of Health Sciences, Section of Clinical Pharmacology and Headache Center, University of Florence, Florence, Italy
| | - Licia Grazzi
- Fondazione IRCCS Istituto Neurologico "C.Besta", Milan, Italy
| | - Massimo Leone
- Fondazione IRCCS Istituto Neurologico "C.Besta", Milan, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Luigi Alberto Pini
- Headache Center, Department of Biomedical, Metabolic and Neuro Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Pia Prudenzano
- Headache Center, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Paola Sarchielli
- Headache Center, Neurologic Clinic, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Gioacchino Tedeschi
- Headache Center Department of Medical, Surgical, Neurological, Metabolic, and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Russo
- Headache Center Department of Medical, Surgical, Neurological, Metabolic, and Aging Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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Silberstein SD, Cohen JM, Yeung PP. Fremanezumab for the preventive treatment of migraine. Expert Opin Biol Ther 2019; 19:763-771. [PMID: 31177856 DOI: 10.1080/14712598.2019.1627323] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction: The recent approval of monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway introduced the first preventive treatments for migraine that were specifically designed to target the underlying pathophysiology of the disease. Fremanezumab, a fully humanized monoclonal antibody (IgG2Δa) administered via subcutaneous injection, is the first approved monoclonal antibody that targets the CGRP ligand and offers both quarterly (once every 3 months) and monthly dosing. Areas covered: An introduction to migraine, overview of the migraine preventive treatments that target CGRP or its receptor, background on CGRP, and details on the fremanezumab clinical development program in both chronic and episodic migraine. Focus is on the Phase 2b and Phase 3 studies, as well as the recently completed long-term Phase 3 study. Expert opinion: The approval of the first disease-specific preventive treatments for migraine heralds a new era in the treatment of migraine. Fremanezumab has a favorable efficacy and safety profile, which is maintained over the long term. Data from patient subgroups with more-complex disease are promising, and an ongoing study in treatment-refractory patients is evaluating the efficacy of fremanezumab in patients who have failed on multiple prior therapies.
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Affiliation(s)
| | - Joshua M Cohen
- b Teva Pharmaceutical Industries Ltd. , Frazer , PA , USA
| | - Paul P Yeung
- b Teva Pharmaceutical Industries Ltd. , Frazer , PA , USA
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Chang CL, Hsu SYT. Development of chimeric and bifunctional antagonists for CLR/RAMP receptors. PLoS One 2019; 14:e0216996. [PMID: 31150417 PMCID: PMC6544337 DOI: 10.1371/journal.pone.0216996] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 05/02/2019] [Indexed: 11/26/2022] Open
Abstract
CGRP, adrenomedullin (ADM), and adrenomedullin 2 (ADM2) family peptides are
important neuropeptides and hormones for the regulation of neurotransmission,
vasotone, cardiovascular morphogenesis, vascular integrity, and feto‒placental
development. These peptides signal through CLR/RAMP1, 2 and 3 receptor
complexes. CLR/RAMP1, or CGRP receptor, antagonists have been developed for the
treatment of migraine headache and osteoarthritis pain; whereas CLR/RAMP2, or
ADM receptor, antagonists are being developed for the treatment of tumor
growth/metastasis. Based on the finding that an acylated chimeric ADM/ADM2
analog potently stimulates CLR/RAMP1 and 2 signaling, we hypothesized that the
binding domain of this analog could have potent inhibitory activity on CLR/RAMP
receptors. Consistent with this hypothesis, we showed that acylated truncated
ADM/ADM2 analogs of 27–31 residues exhibit potent antagonistic activity toward
CLR/RAMP1 and 2. On the other hand, nonacylated analogs have minimal activity.
Further truncation at the junctional region of these chimeric analogs led to the
generation of CLR/RAMP1-selective antagonists. A 17-amino-acid analog
(Antagonist 2–4) showed 100-fold selectivity for CLR/RAMP1 and was >100-fold
more potent than the classic CGRP receptor antagonist CGRP8-37. In addition, we
showed (1) a lysine residue in the Antagonist 2–4 is important for enhancing the
antagonistic activity, (2) an analog consisted of an ADM sequence motif and a
12-amino-acid binding domain of CGRP exhibits potent CLR/RAMP1-inhibitory
activity, and (3) a chimeric analog consisted of a somatostatin analog and an
ADM antagonist exhibits dual activities on somatostatin and CLR/RAMP receptors.
Because the blockage of CLR/RAMP signaling prevents migraine pain and suppresses
tumor growth/metastasis, further studies of these analogs, which presumably have
better access to the tumor microenvironment and nerve endings at the trigeminal
ganglion and synovial joints as compared to antibody-based therapies, may lead
to the development of better anti-CGRP therapy and alternative antiangiogenesis
therapy. Likewise, the use of bifunctional somatostatin-ADM antagonist analogs
could be a promising strategy for the treatment of high-grade neuroendocrine
tumors by targeting an antiangiogenesis agent to the neuroendocrine tumor
microenvironment.
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Affiliation(s)
- Chia Lin Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital
Linkou Medical Center, Chang Gung University, Kweishan, Taoyuan,
Taiwan
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Bigal ME, Walter S, Rapoport AM. Fremanezumab as a preventive treatment for episodic and chronic migraine. Expert Rev Neurother 2019; 19:719-728. [PMID: 31043094 DOI: 10.1080/14737175.2019.1614742] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: The importance of calcitonin gene-related peptide (CGRP) in migraine pathogenesis is well established. Fremanezumab is a humanized IgG2a monoclonal antibody that binds to CGRP. Areas covered: In this paper, we review the development of fremanezumab, from early development into approval. The authors focus on the efficacy and safety of fremanezumab in both migraine stages. The authors highlight studies conducted in special populations and focus on unique aspects of its development, as well as on clinical pearls supported by the data. Expert opinion: Fremanezumab was shown to be effective in episodic and chronic migraine, with a monthly and quarterly dose of administration, as monotherapy and add-on therapy. As with other monoclonal antibodies, the anti-CGRP onset of action was remarkably quick, and the effect seems to be maintained over time. No overt safety concerns emerged from the clinical studies, although long-term surveillance is necessary.
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Affiliation(s)
| | | | - Alan M Rapoport
- c Department of Neurology , The David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
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Pijpers JA, Kies DA, Louter MA, van Zwet EW, Ferrari MD, Terwindt GM. Acute withdrawal and botulinum toxin A in chronic migraine with medication overuse: a double-blind randomized controlled trial. Brain 2019; 142:1203-1214. [PMID: 30982843 PMCID: PMC6511115 DOI: 10.1093/brain/awz052] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/15/2018] [Accepted: 01/18/2019] [Indexed: 01/03/2023] Open
Abstract
Botulinum toxin A (BTA) is widely used as treatment of chronic migraine. Efficacy in studies, however, was only modest and likely influenced by unblinding due to BTA-induced removal of forehead wrinkles. Moreover, most study participants were overusing acute headache medications and might have benefitted from withdrawal. We assessed in a double blind, placebo-controlled, randomized clinical trial whether add-on therapy with BTA enhances efficacy of acute withdrawal. Participants were enrolled between December 2012 and February 2015, with follow-up to January 2016, in a single academic hospital in the Netherlands. A total of 179 participants, male and female, aged 18-65, diagnosed with chronic migraine and overuse of acute headache medication were included. All participants were instructed to withdraw acutely from all medication for a 12-week period, in an outpatient setting. In addition, they were randomly assigned (1:1) to 31 injections with BTA (155 units) or placebo (saline); to prevent unblinding, placebo-treated participants received low doses of BTA (17.5 units in total) in the forehead, along with saline injections outside the forehead region. Primary endpoint was percentage change in monthly headache days from baseline to the last 4 weeks of double-blind treatment (Weeks 9-12). Among 179 randomized patients, 90 received BTA and 89 received placebo, and 175 (98%) completed the double-blind phase. All 179 patients were included in the intention-to-treat analyses. BTA did not reduce monthly headache days versus placebo (-26.9% versus -20.5%; difference -6.4%; 95% confidence interval: -15.2 to 2.4; P = 0.15). Absolute changes in migraine days at 12 weeks for BTA versus placebo were -6.2 versus -7.0 (difference: 0.8; 95% confidence interval: -1.0 to 2.7; P = 0.38). Other secondary endpoints, including measures for disability and quality of life, did also not differ. Withdrawal was well tolerated and blinding was successful. Thus, in patients with chronic migraine and medication overuse, BTA does not afford any additional benefit over acute withdrawal alone. Acute withdrawal should be tried first before initiating more expensive treatment with BTA.
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Affiliation(s)
- Judith A Pijpers
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Dennis A Kies
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
- Department of Radiology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Mark A Louter
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
- Department of Psychiatry, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
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27
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Johnson KW, Morin SM, Wroblewski VJ, Johnson MP. Peripheral and central nervous system distribution of the CGRP neutralizing antibody [125I] galcanezumab in male rats. Cephalalgia 2019; 39:1241-1248. [DOI: 10.1177/0333102419844711] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objective The objective of this investigation was to examine the distribution of galcanezumab and a control immunoglobulin 4 antibody containing the same constant regions as galcanezumab, into peripheral and central tissues. Methods Galcanezumab and a control immunoglobulin 4 antibody were radioiodinated with Iodine-125 to specific activities of 0.11 mCi/mg and 0.16 mCi/mg, respectively. At 24, 72, and 168 hours following subcutaneous injection of either antibody (4 mg/kg), cerebrospinal fluid and plasma were obtained followed by saline perfusion to remove residual blood and collection of selected tissues for determination of Iodine-125 content by gamma counting. Results The peak plasma levels of Iodine-125 galcanezumab and Iodine-125 control immunoglobulin 4 were observed at 72 hours and remained high at 168 hours post-dose. The rank order of tissue levels was dura mater = spleen > trigeminal ganglia ≫hypothalamus = spinal cord = prefrontal cortex = cerebellum. Iodine-125 galcanezumab levels in peripheral tissue (dura mater, spleen, and trigeminal ganglia) averaged 5% to 11% of plasma, whereas all of the central nervous system (CNS) tissue levels and the cerebrospinal fluid levels were < 0.4% of plasma. Distribution of the antibodies into the dura mater and the trigeminal ganglia was similar to that observed in the spleen and significantly greater than exposure in the brain or spinal cord. Conclusions The central levels of galcanezumab were relatively low, which would favor the dura mater and trigeminal ganglia as sites of action for its observed clinical efficacy. However, a central site of action cannot be excluded.
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Affiliation(s)
- Kirk W Johnson
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - S Michelle Morin
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Victor J Wroblewski
- Indiana Biosciences Research Institute – Pharmaceutical Biotechnology Center, Indianapolis, IN, USA
| | - Michael P Johnson
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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Maasumi K, Michael RL, Rapoport AM. CGRP and Migraine: The Role of Blocking Calcitonin Gene-Related Peptide Ligand and Receptor in the Management of Migraine. Drugs 2019; 78:913-928. [PMID: 29869205 DOI: 10.1007/s40265-018-0923-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Migraine is a highly prevalent, complex neurological disorder. The burden of disease and the direct/indirect annual costs are enormous. Thus far, treatment options have been inadequate and mostly based on trial and error, leaving a significant unmet need for effective therapies. While the underlying pathophysiology of migraine is incompletely understood, blocking the calcitonin gene-related peptide (CGRP) using monoclonal antibodies targeting CGRP or its receptor and small molecule CGRP receptor antagonists (gepants) have emerged as a promising therapeutic opportunity for the management of migraine. In this review, we discuss new concepts in the pathophysiology of migraine and the role of CGRP, the current guidelines for treating migraine preventively, the medications that are being used, and their limitations. We then discuss small molecule CGRP receptor antagonists, monoclonal antibodies to CGRP ligand and receptor, as well as the detailed results of Phase II and III trials involving these novel treatments. We conclude with a discussion of the implications of blocking CGRP and its receptor.
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Affiliation(s)
- Kasra Maasumi
- Department of Neurology, University of California, San Francisco, USA.
| | - Rebecca L Michael
- Department of Neurology, University of California, San Francisco, USA
| | - Alan M Rapoport
- Department of Neurology, University of California, Los Angeles, USA
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29
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Dodick DW. CGRP ligand and receptor monoclonal antibodies for migraine prevention: Evidence review and clinical implications. Cephalalgia 2019; 39:445-458. [DOI: 10.1177/0333102418821662] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Monoclonal antibodies that target calcitonin gene-related peptide or the canonical calcitonin gene-related peptide receptor have emerged as effective and well tolerated for the preventive treatment of migraine. These large molecules appear ideally suited for migraine prevention. They have an extended biological half-life, are administered either monthly or quarterly either by subcutaneous injection or intravenous infusion, require minimal or no dose-titration and have the potential for a rapid onset of effect compared to conventional oral preventive drugs. There is high selectivity and they target an important mediator in the pathogenesis of migraine. Investigation: Phase II and pivotal phase III studies have all yielded positive results with a favorable adverse event profile. No serious treatment-related adverse outcomes have thus far been reported in controlled or long-term open-label extension studies. This tolerability profile promises to improve adherence and, possibly, long-term outcomes. Conclusions: Calcitonin gene-related peptide monoclonal antibodies are effective and well tolerated for the preventive treatment of migraine. They have distinct advantages over currently available oral preventive drugs. While treatment-related serious adverse events have not been observed in open-label extension studies, long-term outcomes and safety will require broad exposure in heterogeneous patient populations in clinical practice. In addition, their safety in women, especially during pregnancy, will require longitudinal surveillance. Given the overlapping mechanism(s), the effectiveness of existing (triptans) and emerging (calcitonin gene-related peptide receptor antagonists) acute therapies in those using a calcitonin gene-related peptide mAb will require further study.
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Affiliation(s)
- David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
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30
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Taylor FR. CGRP, Amylin, Immunology, and Headache Medicine. Headache 2018; 59:131-150. [DOI: 10.1111/head.13432] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2018] [Indexed: 12/19/2022]
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Abstract
Calcitonin gene-related peptide (CGRP) is a neuropeptide of importance in migraine pathogenesis. Its central role in migraine was proven pharmacologically by the development of CGRP receptor antagonists. Monoclonal antibodies targeting CGRP or its receptor are effective in the preventive treatment of episodic and chronic migraine and are considered potential breakthroughs in their treatment. Fremanezumab (previously known as TEV-48125, LBR-101, or RN-307) is a humanized IgG2a monoclonal antibody that binds to CGRP. The development of this antibody validated the role of CGRP in chronic migraine and the drug has been recently approved in the US by the FDA, while it continues to be reviewed by other regulatory agencies. Herein we provide an in-depth review of its development. We start by summarizing its in vitro and in vivo pharmacology, and the phase I studies. We then review the late-stage clinical development, with a focus on its efficacy, safety, similarities, and uniqueness relative to other CGRP antibodies. We close by discussing lessons learned on the mechanisms of migraine and areas for future development and exploration.
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32
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Taylor FR. Antigens and Antibodies in Disease With Specifics About CGRP Immunology. Headache 2018; 58 Suppl 3:230-237. [PMID: 30187471 DOI: 10.1111/head.13409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 11/28/2022]
Abstract
Growth in knowledge about calcitonin gene-related peptide (CGRP) in the pathophysiology of migraine brought CGRP antagonism to headache medicine. Failures in development of small molecule CGRP receptor antagonists and increasing knowledge and use of monoclonal antibodies (mAbs) in medicine led to the breakthrough development of large molecule anti-CGRP mAbs: eptinezumab, erenumab, fremanezumab, and galcanezumab. This specifics about CGRP immunology aims to outline: (1) knowledge needed for CGRP antagonism and (2) developmental issues of specific CGRP antagonists for provider use. This clinically oriented review documents IgG structure and function; state of the art of monoclonal IgG production and ligand-antigen-antibodies in migraine therapeutics contributing to immunogenic risks and off-target toxicities. Specifics to CGRP ligand, receptor, antagonism, and molecules, small and large, complete this review. Completion will facilitate assessment of the similarities, differences, and application of the forthcoming anti-CGRP receptor and ligand antagonists for patients.
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Affiliation(s)
- Frederick R Taylor
- Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA
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The α6 subunit-containing GABA A receptor: A novel drug target for inhibition of trigeminal activation. Neuropharmacology 2018; 140:1-13. [PMID: 30016665 DOI: 10.1016/j.neuropharm.2018.07.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/29/2018] [Accepted: 07/12/2018] [Indexed: 01/21/2023]
Abstract
Novel treatments against migraine are an urgent medical requirement. The α6 subunit-containing GABAA receptors (α6GABAARs) are expressed in trigeminal ganglia (TG), the hub of the trigeminal vascular system (TGVS) that is involved in the pathogenesis of migraine. Here we reveal an unprecedented role of α6GABAARs in ameliorating TGVS activation using several pharmacological approaches in an animal model mimicking pathological changes in migraine. TGVS activation was induced by intra-cisternal (i.c.) instillation of capsaicin in Wistar rats. Centrally, i.c. capsaicin activated the trigeminal cervical complex (TCC) measured by the increased number of c-Fos-immunoreactive (c-Fos-ir) TCC neurons. Peripherally, it elevated calcitonin gene-related peptide immunoreactivity (CGRP-ir) in TG and depleted CGRP-ir in the dura mater. Pharmacological approaches included a recently identified α6GABAAR-selective positive allosteric modulator (PAM), the pyrazoloquinolinone Compound 6, two α6GABAAR-active PAMs (Ro15-4513 and loreclezole), an α6GABAAR-inactive benzodiazepine (diazepam), an α6GABAAR-selective antagonist (furosemide), and a clinically effective antimigraine agent (topiramate). We examined effects of these compounds on both central and peripheral TGVS responses induced by i.c. capsaicin. Compound 6 (3-10 mg/kg, i.p.) significantly attenuated the TCC neuronal activation and TG CGRP-ir elevation, and dural CGRP depletion induced by capsaicin. All these effects of Compound 6 were mimicked by topiramate, Ro15-4513 and loreclezole, but not by diazepam. The brain-impermeable furosemide antagonized the peripheral, but not central, effects of Compound 6. These results suggest that the α6GABAAR in TG is a novel drug target for TGVS activation and that α6GABAAR-selective PAMs have the potential to be developed as a novel pharmacotherapy for migraine.
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Reuter U. A Review of Monoclonal Antibody Therapies and Other Preventative Treatments in Migraine. Headache 2018; 58 Suppl 1:48-59. [DOI: 10.1111/head.13302] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/16/2018] [Accepted: 03/18/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Uwe Reuter
- Charité - Universitätsmedizin Berlin, Charitéplatz 1; 10117 Berlin Germany
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35
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CGRP as the target of new migraine therapies — successful translation from bench to clinic. Nat Rev Neurol 2018; 14:338-350. [DOI: 10.1038/s41582-018-0003-1] [Citation(s) in RCA: 434] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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36
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Interictal levels of calcitonin gene related peptide in gingival crevicular fluid of chronic migraine patients. Neurol Sci 2018; 39:1217-1223. [DOI: 10.1007/s10072-018-3340-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
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Raffaelli B, Reuter U. The Biology of Monoclonal Antibodies: Focus on Calcitonin Gene-Related Peptide for Prophylactic Migraine Therapy. Neurotherapeutics 2018; 15:324-335. [PMID: 29616494 PMCID: PMC5935651 DOI: 10.1007/s13311-018-0622-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Calcitonin gene-related peptide (CGRP) is 37-amino-acid neuropeptide, crucially involved in migraine pathophysiology. Four monoclonal antibodies (mAbs) targeting the CGRP pathway are currently under evaluation for the prevention of episodic and chronic migraine: eptinezumab (ALD403), fremanezumab (TEV-48125), galcanezumab (LY2951742), and erenumab (AMG334). As reviewed in this article, all 4 antibodies have been proven effective, tolerable, and safe as migraine prophylactic treatments in phase II clinical trials. The mean decrease in migraine days per month was between 3.4 and 6.3 days/month after 8 to 12 weeks of treatment, and the placebo subtracted benefit ranged from 1 to 2.18 days. Notably, up to 32% of subjects experienced total migraine freedom after drug administration. Substance class-specific adverse events and treatment-related serious adverse event did not occur. Further long-term and large-scale trials are currently under way to verify the safety and efficacy profile of mAbs. In particular, the potential risk of vascular adverse events and the role of anti-drug antibodies deserve special attention. Anti-CGRP peptide and anti-CGRP receptor antibodies are the first effective treatments, which were specifically developed for the prevention of migraine. Their site of action in migraine prevention is most likely peripheral due to large molecule size, which prevents the penetration through the blood-brain barrier and thereby shows that peripheral components play a pivotal role in the pathophysiology of a CNS disease.
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Affiliation(s)
- Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Oakes TMM, Skljarevski V, Zhang Q, Kielbasa W, Hodsdon ME, Detke HC, Camporeale A, Saper JR. Safety of galcanezumab in patients with episodic migraine: A randomized placebo-controlled dose-ranging Phase 2b study. Cephalalgia 2018; 38:1015-1025. [PMID: 29310444 DOI: 10.1177/0333102417747230] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Safety findings from a Phase 2b study of galcanezumab, a humanized monoclonal antibody against calcitonin gene-related peptide, for prevention of migraine (NCT02163993) are reported here. Methods Patients aged 18-65 years with episodic migraine were evaluated in this multicenter, double-blind, randomized study. After randomization, 410 patients were administered 5, 50, 120 or 300 mg of galcanezumab or placebo subcutaneously once every 4 weeks for 12 weeks, followed by a post-treatment off-drug period lasting 12 weeks. Results Treatment-emergent adverse events (TEAEs) were primarily rated as mild to moderate. Serious adverse events reported in galcanezumab dose groups were appendicitis, Crohn's disease, suicidal ideation, and congenital ankyloglossia in an infant of a paternal pregnancy; each of these were reported by one patient. Adverse events leading to discontinuation with galcanezumab treatment were abdominal pain, visual impairment, and upper limb fracture, each reported by one patient. Treatment-emergent injection-site reactions were reported significantly more frequently ( p = 0.013) with galcanezumab (13.9%) than with placebo (5.8%). Injection-site pain was the most common injection-site reaction (galcanezumab 11.4%; placebo 2.9%, p = 0.004). Upper respiratory tract infection (galcanezumab 10.0%; placebo 8.8%) and nasopharyngitis (galcanezumab 7.0%; placebo 2.2%) also occurred more frequently with galcanezumab treatment. Potential hypersensitivity events were reported at similar frequencies in galcanezumab (3.3%) and placebo (5.1%) groups. Incidence of treatment-emergent anti-drug antibodies in galcanezumab dose groups (4.6% of patients during treatment period) did not appear to have any meaningful effects on safety, the pharmacokinetics of galcanezumab, or its ability to bind to the target ligand. Conclusion The results from this 3-month Phase 2b study support the initiation of larger Phase 3 trials of longer duration.
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Affiliation(s)
| | | | - Qi Zhang
- 1 Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | | | | | - Joel R Saper
- 3 Michigan Headache & Neurological Institute, Ann Arbor, MI, USA
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40
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Giamberardino MA, Affaitati G, Costantini R, Cipollone F, Martelletti P. Calcitonin gene-related peptide receptor as a novel target for the management of people with episodic migraine: current evidence and safety profile of erenumab. J Pain Res 2017; 10:2751-2760. [PMID: 29263689 PMCID: PMC5727105 DOI: 10.2147/jpr.s128143] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Migraine is a highly disabling neurological condition, and preventative treatment still remains problematic, due to aspecificity of the majority of the currently available prophylactic drugs. Calcitonin-gene-related peptide (CGRP) plays a crucial role in migraine pathophysiology; agents aimed at blocking its activity have, therefore, been developed in recent years, among which are monoclonal antibodies (mAbs) against CGRP, to prevent migraine. Erenumab is the only mAb that targets the CGRP receptor instead of the ligand, with high specificity and affinity of binding. This review will report on the most recent data on erenumab characteristics and on the results of clinical trials on its employment in the prevention of episodic migraine (4–14 monthly migraine days): one Phase II and two Phase III trials (completed) and one Phase III trial (ongoing). Monthly subcutaneous administration (70 mg or 140 mg) of erenumab vs placebo for 3–6 months showed significantly higher efficacy in reducing the mean monthly number of migraine days and the use of migraine-specific medication, and in decreasing physical impairment and impact of migraine on everyday activities (P<0.001). A favorable safety profile was demonstrated by the lack of significant differences in the occurrence of adverse events in erenumab-treated vs placebo-treated patients. Global results so far obtained point to erenumab as a new promising candidate for the preventative treatment of episodic migraine. Licence applications for erenumab were recently submitted to the Food and Drug Administration in the USA and European Medicines Agency in Europe (May/June 2017).
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Affiliation(s)
- Maria Adele Giamberardino
- Department of Medicine and Science of Aging, Headache Center, Geriatrics Clinic and Ce.S.I.-Met, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Giannapia Affaitati
- Department of Medicine and Science of Aging, Headache Center, Geriatrics Clinic and Ce.S.I.-Met, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Raffaele Costantini
- Department of Medical, Oral and Biotechnological Sciences, Institute of Surgical Pathology, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Francesco Cipollone
- Department of Medicine and Science of Aging, Medical Clinic and Ce.S.I.-Met, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Regional Referral Headache Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Hou M, Xing H, Cai Y, Li B, Wang X, Li P, Hu X, Chen J. The effect and safety of monoclonal antibodies to calcitonin gene-related peptide and its receptor on migraine: a systematic review and meta-analysis. J Headache Pain 2017; 18:42. [PMID: 28389966 PMCID: PMC5383797 DOI: 10.1186/s10194-017-0750-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 03/22/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Migraine has been recognized as one of the leading causes of disability in the 2013 Global Burden of Disease Study and seriously affects the quality of patients' life, current treatment options are not ideal. Monoclonal antibodies to calcitonin gene-related peptide and its receptor (CGRP-mAbs) appear more promising for migraine because of considerably better effect and safety profiles. The objective of this study is to systematically assess the clinical efficacy and safety of CGRP-mAbs for migraine therapy. METHODS A systematic literature search in PubMed, Cochrane Library and Baidu Scholar was performed to identify randomized controlled trials (RCTs), which compared the effect and safety of CGRP-mAbs with placebo on migraine. Regarding the efficacy, the reduction of monthly migraine days from baseline to weeks 1-4, 5-8, and 9-12; responder rates were extracted as the outcome measures of the effects of CGRP-mAbs. Regarding the safety, total adverse events, the main adverse events, and other adverse events were evaluated. RESULTS We found significant reduction of monthly migraine days in CGRP-mAbs vs. placebo (weeks 1-4: SMD -0.49, 95% CI -0.61 to -0.36; weeks 5-8: SMD -0.43, 95% CI -0.56 to -0.30; weeks 9-12: SMD -0.37, 95% CI -0.49 to -0.24). 50% and 75% responder rates (OR 2.59, 95% CI 1.99 to 3.37; and OR 2.91, 95% CI 2.06 to 4.10) were significantly increased compared with placebo. There was no significant difference in total adverse events (OR 1.17, 95% CI 0.91 to 1.51), and the main adverse events including upper respiratory tract infection (OR 1.44, 95% CI 0.82 to 2.55), nasopharyngitis (OR 0.59, 95% CI 0.30 to 1.16), nausea (OR 0.61, 95% CI 0.29 to 1.32), injection-site pain (OR 1.73, 95% CI 0.95 to 3.16) and back pain (OR 0.97, 95% CI 0.49 to 1.90) were not obviously changed compared with placebo control, but the results showed significant increase of dizziness in CGRP-mAbs vs. placebo (OR 3.22, 95% CI 1.09 to 9.45). CONCLUSIONS This meta-analysis suggests that CGRP-mAbs are effective in anti-migraine therapy with few adverse reactions, but more and larger sample-size RCTs are required to verify the current findings.
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Affiliation(s)
- Min Hou
- Department of Pharmacy, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Haiyan Xing
- Department of Pharmacy, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Yongqing Cai
- Department of Pharmacy, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Bin Li
- Department of Pharmacy, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Xianfeng Wang
- Department of Pharmacy, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Pan Li
- Department of Pharmacy, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Xiaolin Hu
- China Pharmacy Publishing House, Chongqing, 500000, People's Republic of China
| | - Jianhong Chen
- Department of Pharmacy, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, People's Republic of China.
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Okragly AJ, Morin SM, DeRosa D, Martin AP, Johnson KW, Johnson MP, Benschop RJ. Human mast cells release the migraine-inducing factor pituitary adenylate cyclase-activating polypeptide (PACAP). Cephalalgia 2017; 38:1564-1574. [PMID: 29103295 DOI: 10.1177/0333102417740563] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Many patients with migraines suffer from allergies and vice versa, suggesting a relationship between biological mechanisms of allergy and migraine. It was proposed many years ago that mast cells may be involved in the pathophysiology of migraines. We set out to investigate the relationship between mast cell activation and known neurogenic peptides related to migraine. Methods Cultured human mast cells were assayed for the presence of neuropeptides and their receptors at the RNA and protein level. Immunohistochemistry analyses were performed on tissue resident and cultured mast cells. Mast cell degranulation assays were performed and pituitary adenylate cyclase-activating polypeptide (PACAP) activity was measured with a bioassay. Results We found that cultured and tissue resident human mast cells contain PACAP in cytoplasmic granules. No other neurogenic peptide known to be involved in migraine was detected, nor did mast cells express the receptors for PACAP or other neurogenic peptides. Furthermore, mast cell degranulation through classic IgE-mediated allergic mechanisms led to the release of PACAP. The PACAP released from mast cells was biologically active, as demonstrated using PACAP receptor reporter cell lines. We confirmed existing literature that mast cell degranulation can also be induced by several neurogenic peptides, which also resulted in PACAP release. Conclusion Our data provides a potential biological explanation for the association between allergy and migraine by demonstrating the release of biologically active PACAP from mast cells.
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Affiliation(s)
- Angela J Okragly
- 1 Immunology Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - S Michelle Morin
- 2 Neuroscience Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - David DeRosa
- 1 Immunology Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Andrea P Martin
- 1 Immunology Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Kirk W Johnson
- 2 Neuroscience Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Michael P Johnson
- 2 Neuroscience Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - Robert J Benschop
- 1 Immunology Research, Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
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43
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Jay GW, Barkin RL. Primary Headache Disorders Part I- Migraine and the Trigeminal Autonomic Cephalalgias. Dis Mon 2017; 63:308-338. [DOI: 10.1016/j.disamonth.2017.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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44
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Sundrum T, Walker CS. Pituitary adenylate cyclase-activating polypeptide receptors in the trigeminovascular system: implications for migraine. Br J Pharmacol 2017; 175:4109-4120. [PMID: 28977676 DOI: 10.1111/bph.14053] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/24/2017] [Accepted: 09/11/2017] [Indexed: 12/13/2022] Open
Abstract
The neuropeptide pituitary adenylate cyclase-activating polypeptide (PACAP) has been implicated in a wide range of functions including vasodilatation, neuroprotection, nociception and neurogenic inflammation. PACAP activates three distinct receptors, the PAC1 receptor, which responds to PACAP, and the VPAC1 and VPAC2 receptors, which respond to both PACAP and vasoactive intestinal polypeptide. The trigeminovascular system plays a key role in migraine and contains the trigeminal nerve, which is the major conduit of craniofacial pain. PACAP is expressed throughout the trigeminovascular system and in higher brain regions involved in processing pain. Evidence from human clinical studies suggests that PACAP may act outside the blood-brain barrier in the pathogenesis of migraine. However, the precise mechanisms involved remain unclear. PACAP potentially induces migraine attacks by activating different receptors in different cell types and tissues. This complexity prompted this review of PACAP receptor pharmacology, expression and function in the trigeminovascular system. Current evidence suggests that the PAC1 receptor is the likely pathophysiological target of PACAP in migraine. However, multiple PACAP receptors are expressed in key parts of the trigeminovascular system and further work is required to determine their contribution to PACAP physiology and the pathology of migraine. LINKED ARTICLES This article is part of a themed section on Molecular Pharmacology of GPCRs. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.21/issuetoc.
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Affiliation(s)
- Tahlia Sundrum
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Christopher S Walker
- School of Biological Sciences, University of Auckland, Auckland, New Zealand.,Maurice Wilkins Centre and Centre for Brain Research, University of Auckland, Auckland, New Zealand
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45
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Ben Aissa M, Tipton AF, Bertels Z, Gandhi R, Moye LS, Novack M, Bennett BM, Wang Y, Litosh V, Lee SH, Gaisina IN, Thatcher GR, Pradhan AA. Soluble guanylyl cyclase is a critical regulator of migraine-associated pain. Cephalalgia 2017; 38:1471-1484. [PMID: 29022756 DOI: 10.1177/0333102417737778] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Nitric oxide (NO) has been heavily implicated in migraine. Nitroglycerin is a prototypic NO-donor, and triggers migraine in humans. However, nitroglycerin also induces oxidative/nitrosative stress and is a source of peroxynitrite - factors previously linked with migraine etiology. Soluble guanylyl cyclase (sGC) is the high affinity NO receptor in the body, and the aim of this study was to identify the precise role of sGC in acute and chronic migraine. Methods We developed a novel brain-bioavailable sGC stimulator (VL-102), and tested its hyperalgesic properties in mice. We also determined the effect of VL-102 on c-fos and calcitonin gene related peptide (CGRP) immunoreactivity within the trigeminovascular complex. In addition, we also tested the known sGC inhibitor, ODQ, within the chronic nitroglycerin migraine model. Results VL-102-evoked acute and chronic mechanical cephalic and hind-paw allodynia in a dose-dependent manner, which was blocked by the migraine medications sumatriptan, propranolol, and topiramate. In addition, VL-102 also increased c-fos and CGRP expressing cells within the trigeminovascular complex. Importantly, ODQ completely inhibited acute and chronic hyperalgesia induced by nitroglycerin. ODQ also blocked hyperalgesia already established by chronic nitroglycerin, implicating this pathway in migraine chronicity. Conclusions These results indicate that nitroglycerin causes migraine-related pain through stimulation of the sGC pathway, and that super-activation of this receptor may be an important component for the maintenance of chronic migraine. This work opens the possibility for negative sGC modulators as novel migraine therapies.
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Affiliation(s)
- Manel Ben Aissa
- 1 Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, IL, USA.,2 UICentre for Drug Discovery, University of Illinois at Chicago, Chicago, IL, USA
| | - Alycia F Tipton
- 3 Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Zachariah Bertels
- 3 Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Ronak Gandhi
- 1 Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, IL, USA
| | - Laura S Moye
- 3 Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Madeline Novack
- 3 Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Brian M Bennett
- 4 Department of Biomedical and Molecular Sciences, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Yueting Wang
- 1 Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, IL, USA.,2 UICentre for Drug Discovery, University of Illinois at Chicago, Chicago, IL, USA
| | - Vladislav Litosh
- 1 Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, IL, USA.,2 UICentre for Drug Discovery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sue H Lee
- 1 Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, IL, USA.,2 UICentre for Drug Discovery, University of Illinois at Chicago, Chicago, IL, USA
| | - Irina N Gaisina
- 1 Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, IL, USA.,2 UICentre for Drug Discovery, University of Illinois at Chicago, Chicago, IL, USA
| | - Gregory Rj Thatcher
- 1 Department of Medicinal Chemistry and Pharmacognosy, University of Illinois at Chicago, Chicago, IL, USA.,2 UICentre for Drug Discovery, University of Illinois at Chicago, Chicago, IL, USA
| | - Amynah A Pradhan
- 3 Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
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46
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Deen M, Correnti E, Kamm K, Kelderman T, Papetti L, Rubio-Beltrán E, Vigneri S, Edvinsson L, Maassen Van Den Brink A. Blocking CGRP in migraine patients - a review of pros and cons. J Headache Pain 2017; 18:96. [PMID: 28948500 PMCID: PMC5612904 DOI: 10.1186/s10194-017-0807-1] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/14/2017] [Indexed: 02/02/2023] Open
Abstract
Migraine is the most prevalent neurological disorder worldwide and it has immense socioeconomic impact. Currently, preventative treatment options for migraine include drugs developed for diseases other than migraine such as hypertension, depression and epilepsy. During the last decade, however, blocking calcitonin gene-related peptide (CGRP) has emerged as a possible mechanism for prevention of migraine attacks. CGRP has been shown to be released during migraine attacks and it may play a causative role in induction of migraine attacks. Here, we review the pros and cons of blocking CGRP in migraine patients. To date, two different classes of drugs blocking CGRP have been developed: small molecule CGRP receptor antagonists (gepants), and monoclonal antibodies, targeting either CGRP or the CGRP receptor. Several trials have been conducted to test the efficacy and safety of these drugs. In general, a superior efficacy compared to placebo has been shown, especially with regards to the antibodies. In addition, the efficacy is in line with other currently used prophylactic treatments. The drugs have also been well tolerated, except for some of the gepants, which induced a transient increase in transaminases. Thus, blocking CGRP in migraine patients is seemingly both efficient and well tolerated. However, CGRP and its receptor are abundantly present in both the vasculature, and in the peripheral and central nervous system, and are involved in several physiological processes. Therefore, blocking CGRP may pose a risk in subjects with comorbidities such as cardiovascular diseases. In addition, long-term effects are still unknown. Evidence from animal studies suggests that blocking CGRP may induce constipation, affect the homeostatic functions of the pituitary hormones or attenuate wound healing. However, these effects have so far not been reported in human studies. In conclusion, this review suggests that, based on current knowledge, the pros of blocking CGRP in migraine patients exceed the cons.
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Affiliation(s)
- Marie Deen
- Danish Headache Center, Department of Neurology, Rigshospitalet, Copenhagen, Denmark.
| | - Edvige Correnti
- Department of Child Neuropsychiatry, University of Palermo, Palermo, Italy
| | - Katharina Kamm
- Department of Neurology, University Hospital, LMU, Munich, Germany
| | - Tim Kelderman
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Laura Papetti
- Headache Center, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Eloisa Rubio-Beltrán
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simone Vigneri
- Department of Experimental Biomedicine and Clinical Neurosciences, University of Palermo; Advanced Algology Research and Pain Medicine Unit, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | - Lars Edvinsson
- Department of Internal Medicine, Institute of Clinical Sciences, Lund University, Lund, Sweden
| | - Antoinette Maassen Van Den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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Dux M, Will C, Eberhardt M, Fischer MJM, Messlinger K. Stimulation of rat cranial dura mater with potassium chloride causes CGRP release into the cerebrospinal fluid and increases medullary blood flow. Neuropeptides 2017; 64:61-68. [PMID: 28202186 DOI: 10.1016/j.npep.2017.02.080] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/30/2016] [Accepted: 02/08/2017] [Indexed: 01/28/2023]
Abstract
Primary headaches may be accompanied by increased intracranial blood flow induced by the release of the potent vasodilator calcitonin gene-related peptide (CGRP) from activated meningeal afferents. We aimed to record meningeal and medullary blood flow simultaneously and to localize the sites of CGRP release in rodent preparations in vivo and ex vivo. Blood flow in the exposed rat parietal dura mater and the medulla oblongata was recorded by laser Doppler flowmetry, while the dura was stimulated by topical application of 60mM potassium chloride (KCl). Samples of jugular venous plasma and cerebrospinal fluid (CSF) collected from the cisterna magna were analysed for CGRP concentrations using an enzyme immunoassay. In a hemisected rat skull preparation lined with dura mater the CGRP releasing effect of KCl superfusion was examined. Superfusion of the dura mater with KCl decreased meningeal blood flow unless alpha-adrenoceptors were blocked by phentolamine, whereas the medullary blood flow was increased. The same treatment caused increased CGRP concentrations in jugular plasma and CSF and induced significant CGRP release in the hemisected rat skull preparation. Anaesthesia of the trigeminal ganglion by injection of lidocaine reduced increases in medullary blood flow and CGRP concentration in the CSF upon meningeal KCl application. CGRP release evoked by depolarisation of meningeal afferents is accompanied by increased blood flow in the medulla oblongata but not the dura mater. This discrepancy can be explained by the smooth muscle depolarising effect of KCl and the activation of sympathetic vasoconstrictor mechanisms. The medullary blood flow response is most likely mediated by CGRP released from activated central terminals of trigeminal afferents. Increased blood supply of the medulla oblongata and CGRP release into the CSF may also occur in headaches accompanying vigorous activation of meningeal afferents.
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Affiliation(s)
- Mária Dux
- Department of Physiology, University of Szeged. Dóm tér 10, H-6720 Szeged, Hungary
| | - Christine Will
- Institute of Physiology and Pathophysiology, Friedrich-Alexander University Erlangen-Nürnberg, Universitätsstrasse 17, D-91054 Erlangen, Germany
| | - Mirjam Eberhardt
- Department of Anaesthesia and Critical Care Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Michael J M Fischer
- Institute of Physiology and Pathophysiology, Friedrich-Alexander University Erlangen-Nürnberg, Universitätsstrasse 17, D-91054 Erlangen, Germany
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander University Erlangen-Nürnberg, Universitätsstrasse 17, D-91054 Erlangen, Germany.
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48
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Li X, Xia X, Li X. Plasmid pLXSN-Mediated Adrenomedullin Gene Therapy for Cerebral Vasospasm Following Subarachnoid Hemorrhage in Rats. Med Sci Monit 2017; 23:3293-3302. [PMID: 28684727 PMCID: PMC5513563 DOI: 10.12659/msm.901914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background The aim of this study was to investigate the protective effect of ADM gene mediated by plasmid pVAX1 on cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH). Material/Methods The recombinant plasmid pVAX-ADM was successfully established, and 40 SD rats were randomly divided into normal saline, pVAX1, pVAX1-ADM low-dose, pVAX1-ADM mid-dose, and pVAX1-ADM high-dose groups. The circumference and diameter of basilar artery, diameter of middle cerebral artery and internal carotid artery, and thickness of basilar artery wall were observed. The levels of circulating endothelial cells (CEC) and levels of regional cerebral blood flow (rCBF) of the parietal cortex were detected at different time-points. The expression levels of serum ADM, ET-1, and NOS of each group and the neurological functions were compared. Results The circumference and diameter of basilar artery and the diameter of the middle cerebral artery and internal carotid artery in pVAX1-ADM groups were significantly longer than those in the saline group and pVAX1 group (P<0.05), but the thickness of the basilar artery wall in pVAX1-ADM groups was significantly lower (P<0.05), and the levels of growth or decrease were both dose-dependent (P<0.05). Compared with the saline group and pVAX1 group, the expression levels of serum ADM, NOS, and rCBF in pVAX1-ADM groups were significantly higher (P<0.05), but the levels of serum ET-1 and CEC were significantly lower (P<0.05). The scores of neurobehavioral functions of pVAX1-ADM groups were significantly lower (P<0.05), and the scores were also dose-dependent (P<0.05). Conclusions The recombinant eukaryotic expression plasmid pVAX1-ADM can significantly relieve cerebral vasospasm, increase the expression of serum ADM and NOS, and decrease the expression of serum ET-1 in a rat model of CVS; it is dose-dependent and can also improve nervous system function.
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Affiliation(s)
- Xin Li
- Department of Neurology, The Second Affiliated Hospital of Tianjin Medical University, Tianjin, China (mainland).,1st Department of Neurology, The First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China (mainland)
| | - Xiaoshuang Xia
- Department of Neurology, The Second Affiliated Hospital of Tianjin Medical University, Tianjin, China (mainland)
| | - Xin Li
- Department of Neurology, The Second Affiliated Hospital of Tianjin Medical University, Tianjin, China (mainland)
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Giamberardino MA, Costantini R. Challenging chronic migraine: targeting the CGRP receptor. Lancet Neurol 2017; 16:410-411. [PMID: 28460891 DOI: 10.1016/s1474-4422(17)30126-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Maria Adele Giamberardino
- Headache Center, Department of Medicine and Science of Aging, and Center on Aging Science and Translational Medicine, G D'Annunzio University of Chieti, 66100 Chieti, Italy.
| | - Raffaele Costantini
- Institute of Surgical Pathology, Department of Medical, Oral and Biotechnological Sciences, G D'Annunzio University of Chieti, 66100 Chieti, Italy
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50
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Bohn KJ, Li B, Huang X, Mason BN, Wattiez AS, Kuburas A, Walker CS, Yang P, Yu J, Heinz BA, Johnson KW, Russo AF. CGRP receptor activity in mice with global expression of human receptor activity modifying protein 1. Br J Pharmacol 2017; 174:1826-1840. [PMID: 28317098 DOI: 10.1111/bph.13783] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 01/26/2017] [Accepted: 03/03/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND PURPOSE CGRP is a potent vasodilator and nociceptive neuropeptide linked to migraine. CGRP receptors are heterodimers of receptor activity modifying protein 1 (RAMP1) and either calcitonin receptor-like receptor (CLR; forms canonical CGRP receptor) or calcitonin receptor (CT receptor; forms AMY1 receptor). The goal of this study was to test whether transgenic mice globally expressing human RAMP1 have increased CGRP receptor activity and whether the receptors are sensitive to human selective antagonist telcagepant. EXPERIMENTAL APPROACH cAMP production was measured in primary cultures of aortic smooth muscle and trigeminal ganglia neurons from global hRAMP1 mice and non-transgenic littermates. Functional activity and inhibition were compared with clonal cell lines expressing combinations of CLR or CT receptors with RAMP1. KEY RESULTS Cultured smooth muscle from global hRAMP1 mice had a 10-fold greater CGRP-induced cAMP maximal response (Rmax) than non-transgenic littermates, with similar EC50 s. In contrast, cultured trigeminal ganglia from global hRAMP1 mice had a 40-fold leftward shift of the EC50 , with similar Rmax values as littermates. In both hRAMP1 cultures, telcagepant blocked CGRP-induced cAMP production, but was not effective in non-transgenic cultures. IC50 values were closer to those observed for CT receptor/hRAMP1 than CLR/hRAMP1 in clonal cell lines. CONCLUSIONS AND IMPLICATIONS Overexpression of hRAMP1 increases CGRP signalling by changing the maximal response or ligand sensitivity, depending on tissue type. Furthermore, telcagepant inhibited transgenic hRAMP1 CGRP receptors, but the degree of inhibition suggests that the transgenic mice are only partially humanized or both canonical CGRP and AMY1 receptors are functional in trigeminal ganglia neurons and vascular smooth muscle.
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Affiliation(s)
- Keegan J Bohn
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA
| | - Baolin Li
- Neuroscience Research Division, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Xiaofang Huang
- Neuroscience Research Division, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Bianca N Mason
- Molecular and Cellular Biology Program, University of Iowa, Iowa City, IA, USA
| | - Anne-Sophie Wattiez
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA
| | - Adisa Kuburas
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA
| | - Christopher S Walker
- Maurice Wilkins Centre and Centre for Brain Research, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Peiyi Yang
- Quantitative Biology, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Jianliang Yu
- Quantitative Biology, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Beverly A Heinz
- Quantitative Biology, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Kirk W Johnson
- Neuroscience Research Division, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Andrew F Russo
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA, USA.,Department of Neurology, University of Iowa, Iowa City, IA, USA.,Molecular and Cellular Biology Program, University of Iowa, Iowa City, IA, USA.,Veterans Affairs Medical Center, Iowa City, IA, USA
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