1
|
Dafer RM, Tietjen GE, Rothrock JF, Vann RE, Shrewsbury SB, Aurora SK. Cardiovascular safety of dihydroergotamine mesylate delivered by precision olfactory delivery (INP104) for the acute treatment of migraine. Headache 2024; 64:983-994. [PMID: 38800847 DOI: 10.1111/head.14669] [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: 05/19/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To report the cardiovascular (CV) safety of dihydroergotamine mesylate (DHE) administered by precision olfactory delivery (INP104) from two clinical trials. BACKGROUND Although the absolute risk is low, migraine is associated with an increased risk of CV events. DHE is a highly effective acute treatment for migraine, but due to its theoretical risk of promoting arterial vasoconstriction, DHE is contraindicated in patients with CV disease or an unfavorable risk factor profile. The INP104 is a novel drug-device combination product approved for acute treatment of migraine that delivers DHE to the upper nasal space using precision olfactory delivery (POD®). METHODS The STOP 101 was a Phase 1 open-label study that assessed the safety, tolerability, and bioavailability of INP104 1.45 mg, intravenous DHE 1.0 mg, and MIGRANAL (nasal DHE) 2.0 mg in healthy participants. The STOP 301 was a pivotal Phase 3, open-label study that assessed the safety, tolerability, and exploratory efficacy of INP104 1.45 mg over 24 and 52 weeks in patients with migraine. In both studies, active or a history of CV disease, as well as significant CV risk factors, were exclusion criteria. RESULTS In STOP 101, 36 participants received one or more doses of investigational product. Treatment with intravenous DHE, but not INP104 or nasal DHE, resulted in clinically relevant changes from baseline in systolic blood pressure (BP; 11.4 mmHg, 95% confidence interval [CI] 7.9-15.0) and diastolic BP (13.3 mmHg, 95% CI 9.4-17.1) at 5 min post-dose, persisting up to 30 min post-dose for systolic BP (6.3 mmHg; 95% CI 3.0-9.5) and diastolic BP (7.9 mmHg, 95% CI 3.9-11.9). None of the treatments produced any clinically meaningful electrocardiogram (ECG) changes. In STOP 301, 354 patients received one or more doses of INP104. Over 24 weeks, five patients (1.4%) experienced a non-serious, vascular treatment-emergent adverse event (TEAE). Minimal changes were observed for BP and ECG parameters over 24 or 52 weeks. Off-protocol concomitant use of triptans and other ergot derivatives did not result in any TEAEs. CONCLUSION In two separate studies, INP104 demonstrated a favorable CV safety profile when used in a study population without CV-related contraindications.
Collapse
Affiliation(s)
- Rima M Dafer
- Rush University Medical Center, Chicago, Illinois, USA
| | | | - John F Rothrock
- Inova Health, Fairfax, Virginia, USA
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Robert E Vann
- Formerly of Impel Pharmaceuticals, Seattle, Washington, USA
| | | | | |
Collapse
|
2
|
Silvestro M, Orologio I, Tessitore A, Trojsi F, Tedeschi G, Russo A. Dihydroergotamine mesylate nasal spray: an acute treatment option for migraine in adults. Expert Rev Neurother 2024; 24:555-564. [PMID: 38655598 DOI: 10.1080/14737175.2024.2342446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Although the landscape of migraine symptomatic treatment has been enriched by novel effective drugs, it is mandatory to critically reappraise older molecules to ascertain whether they could still represent reliable alternatives in specific endophenotypes of patients or migraine attacks. Among these, dihydroergotamine (DHE) nasal spray has been shown to be effective and is characterized by greater tolerability and manageability than the parenteral DHE formulation. AREAS COVERED In this narrative review, the authors describe the pharmacodynamic and pharmacokinetic properties of DHE nasal spray and explore the results of the trials which explored its efficacy, safety and tolerability as migraine symptomatic treatment. They also discuss the limitations of the classically used device and the attempts that several companies are carrying out to generate devices warranting a more reproducible drug absorption. EXPERT OPINION DHE nasal spray could be considered as rescue treatment in patients who have failed other symptomatic therapeutic strategies. Nevertheless, in the perspective of tailored therapy, the intranasal route of administration and the consequent rapid onset of action may represent benefits putatively making DHE a treatment of choice for challenging migraine attacks such as those with nocturnal onset or quickly reaching the climax of both headache and neurovegetative associated symptoms.
Collapse
Affiliation(s)
- Marcello Silvestro
- Headache Centre, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ilaria Orologio
- Headache Centre, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandro Tessitore
- Headache Centre, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesca Trojsi
- Headache Centre, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Gioacchino Tedeschi
- Headache Centre, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Russo
- Headache Centre, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
3
|
Wang VS, Kosman J, Yuan H, Lauritsen C, Shrewsbury S, Aurora SK, Hopkins M, Silberstein S. Safety, tolerability, and effectiveness of repetitive intravenous dihydroergotamine for refractory chronic migraine with cardiovascular risk factors: A retrospective study. Headache 2023; 63:1251-1258. [PMID: 37740562 DOI: 10.1111/head.14636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Dihydroergotamine (DHE), like triptans, is contraindicated in patients with ischemic heart disease or coronary vasospasm. Its true safety, tolerability, and efficacy in patients with cardiovascular risk without ischemic heart disease or coronary vasospasm remain unclear. OBJECTIVES To assess the safety, tolerability, and effectiveness of repetitive intravenous DHE in patients with cardiovascular risk factors. METHODS A single-center, retrospective cohort study was conducted at the Jefferson Headache Center inpatient unit for refractory chronic migraine patients treated with our intravenous DHE protocol between January 1, 2019, and October 15, 2019. We evaluated tolerability and effectiveness outcomes based on atherosclerotic cardiovascular disease 10-year calculated risk scores, stratified into low (<5.0%) and elevated (≥5.0%) risk. Data were presented in mean ± standard deviation or median (25th percentile, 75th percentile) if non-normally distributed. RESULTS Among 347 patients (median age of 46 [36, 57], female n = 278 [80.1%]), who received inpatient intravenous DHE, 227 patients (age 53 [45, 60], female 81.1%) had calculable risk scores, 64 (28.2%) had elevated risk, and 38 (16.7%) had cardiology consultations. There were no clinically significant electrocardiogram abnormalities or cardiovascular adverse events. The median hospital length of stay was 6 (5, 7) days. Compared to the low-risk group, those with elevated risk had higher nausea (31.3% vs. 14.1%, p = 0.008), but similar initial DHE dose (0.5 [0.25, 0.5] vs. 0.5 [0.25, 0.5], p = 0.009), lower final DHE dose (0.75 [0.5, 1] vs. 1 [0.75, 1] p < 0.001), and lower pain reduction after admission (-3.8 [2.1, 6] vs. -5 [3, 7] p = 0.037). CONCLUSION Patients receiving intravenous DHE by the Jefferson Headache Center inpatient headache protocol had significantly reduced pain severity at discharge. No clinically significant cardiac or electrocardiogram abnormalities were detected in patients with elevated (or low) atherosclerotic cardiovascular disease risk. Repetitive intravenous DHE used by our protocol was safe in refractory chronic migraine patients.
Collapse
Affiliation(s)
- Victor S Wang
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Justin Kosman
- Thomas Jefferson University College of Population Health, Philadelphia, Pennsylvania, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Clinton Lauritsen
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Mary Hopkins
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Robblee J, Harvey LK. Cardiovascular Disease and Migraine: Are the New Treatments Safe? Curr Pain Headache Rep 2022; 26:647-655. [PMID: 35751798 DOI: 10.1007/s11916-022-01064-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The authors present data on cardiovascular safety for the new acute and preventive migraine treatments including ditans, gepants, and calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) alongside older medications like triptans and ergotamines. RECENT FINDINGS The authors conclude that there are no cardiovascular safety concerns for lasmiditan, and that it could be used in those with cardiovascular disease. In fact, the literature even suggests that triptans are safer in cardiovascular disease than their contraindications may suggest. At this time, there is insufficient evidence that gepants and CGRP mAbs should be contraindicated in those with cardiovascular disease including stroke or myocardial infarction, though erenumab has now been associated with hypertension. Vasodilation may be an important CGRP-mediated mechanism mid-ischemia especially in patients with small vessel disease; hence, CGRP antagonists should be use with caution in this context. Long-term data is still needed, and prescribers should ensure patients are aware of the limitations of our knowledge at this time, while still offering these effective and well-tolerated treatment options.
Collapse
Affiliation(s)
- Jennifer Robblee
- Lewis Headache Center, Department of Neurology, Barrow Neurological Institute
- St Joseph Health Center, 350 W. Thomas Rd, AZ, 85013, Phoenix, USA.
| | - Lauren K Harvey
- Lewis Headache Center, Department of Neurology, Barrow Neurological Institute
- St Joseph Health Center, 350 W. Thomas Rd, AZ, 85013, Phoenix, USA
| |
Collapse
|
5
|
Shafqat R, Flores-Montanez Y, Delbono V, Nahas SJ. Updated Evaluation of IV Dihydroergotamine (DHE) for Refractory Migraine: Patient Selection and Special Considerations. J Pain Res 2020; 13:859-864. [PMID: 32431533 PMCID: PMC7200221 DOI: 10.2147/jpr.s203650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/17/2020] [Indexed: 12/14/2022] Open
Abstract
Dihydroergotamine (DHE) is an ergot alkaloid derivative of substances produced by rye fungus. Ergotamine was first used in the field of gynecology and obstetrics, then used for migraine treatment a few years later. DHE was developed as a derivative of ergotamine. DHE, when compared to ergotamine, demonstrates greater alpha-adrenergic antagonist activity, lower arterial vasoconstriction, less dopaminergic agonism, and lower emetic potential. DHE can be delivered via several routes including intravenous (IV), intramuscular (IM), subcutaneous (SC), intranasal (IN), oral, and orally inhaled (although the latter two are not available in the USA and the last remains experimental only). DHE can be used in an outpatient basis in infusion centers, emergency departments, and urgent care centers, as well as inpatient treatment for admitted patients. There are protocols for adults as well as pediatric migraine treatment. DHE and other ergot alkaloids are considered contraindicated in pregnant women as they decrease uterine blood flow and increase uterine muscle contractility predisposing to spontaneous abortion. DHE during lactation is also not recommended as it can lead to gastrointestinal distress and weakness in infants; it can also suppress milk production. Caution should be taken before administering DHE in patients with cardiovascular risk factors. DHE is an older drug with an interesting history, yet it is still clinically useful today for patients with migraine attacks not responsive to triptans, who have a greater burden from migraine, and in refractory migraine.
Collapse
Affiliation(s)
- Rafia Shafqat
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Victoria Delbono
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephanie J Nahas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
6
|
Rubio‐Beltrán E, Labastida‐Ramírez A, Haanes KA, van den Bogaerdt A, Bogers AJ, Zanelli E, Meeus L, Danser AJ, Gralinski MR, Senese PB, Johnson KW, Kovalchin J, Villalón CM, MaassenVanDenBrink A. Characterization of binding, functional activity, and contractile responses of the selective 5-HT 1F receptor agonist lasmiditan. Br J Pharmacol 2019; 176:4681-4695. [PMID: 31418454 PMCID: PMC6965684 DOI: 10.1111/bph.14832] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Triptans are 5-HT1B/1D receptor agonists (that also display 5-HT1F receptor affinity) with antimigraine action, contraindicated in patients with coronary artery disease due to their vasoconstrictor properties. Conversely, lasmiditan was developed as an antimigraine 5-HT1F receptor agonist. To assess the selectivity and cardiovascular effects of lasmiditan, we investigated the binding, functional activity, and in vitro/in vivo vascular effects of lasmiditan and compared it to sumatriptan. EXPERIMENTAL APPROACH Binding and second messenger activity assays of lasmiditan and other serotoninergic agonists were performed for human 5-HT1A , 5-HT1B , 5-HT1D , 5-ht1E , 5-HT1F , 5-HT2A , 5-HT2B , and 5-HT7 receptors, and the results were correlated with their potency to constrict isolated human coronary arteries (HCAs). Furthermore, concentration-response curves to lasmiditan and sumatriptan were performed in proximal and distal HCA, internal mammary, and middle meningeal arteries. Finally, anaesthetized female beagle dogs received i.v. infusions of lasmiditan or sumatriptan in escalating cumulative doses, and carotid and coronary artery diameters were measured. KEY RESULTS Lasmiditan showed high selectivity for 5-HT1F receptors. Moreover, the functional potency of the analysed compounds to inhibit cAMP increase through 5-HT1B receptor activation positively correlated with their potency to contract HCA. In isolated human arteries, sumatriptan, but not lasmiditan, induced contractions. Likewise, in vivo, sumatriptan decreased coronary and carotid artery diameters at clinically relevant doses, while lasmiditan was devoid of vasoconstrictor activity at all doses tested. CONCLUSIONS AND IMPLICATIONS Lasmiditan is a selective 5-HT1F receptor agonist devoid of vasoconstrictor activity. This may represent a cardiovascular safety advantage when compared to the triptans.
Collapse
Affiliation(s)
- Eloísa Rubio‐Beltrán
- Division of Pharmacology, Department of Internal MedicineErasmus University Medical CentreRotterdamThe Netherlands
| | - Alejandro Labastida‐Ramírez
- Division of Pharmacology, Department of Internal MedicineErasmus University Medical CentreRotterdamThe Netherlands
| | - Kristian A. Haanes
- Division of Pharmacology, Department of Internal MedicineErasmus University Medical CentreRotterdamThe Netherlands
| | - Antoon van den Bogaerdt
- Department of Cardiothoracic SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | - Ad J.J.C. Bogers
- Department of Cardiothoracic SurgeryErasmus University Medical CentreRotterdamThe Netherlands
| | - Eric Zanelli
- Research and DevelopmentDéclion Pharmaceuticals, Inc.MarbleheadMassachusetts
| | - Laurent Meeus
- Euroscreen Fast Services UnitEpics Therapeutics SAGosseliesBelgium
| | - A.H. Jan Danser
- Division of Pharmacology, Department of Internal MedicineErasmus University Medical CentreRotterdamThe Netherlands
| | | | | | - Kirk W. Johnson
- Lilly Corporate CenterEli Lilly and CompanyIndianapolisIndiana
| | - Joseph Kovalchin
- Research and DevelopmentCoLucid Pharmaceuticals, Inc.CambridgeMassachusetts
| | | | | |
Collapse
|
7
|
Leroux E, Rothrock J. Triptans for Migraine Patients With Vascular Risks: New Insights, New Options. Headache 2019; 59:1589-1596. [DOI: 10.1111/head.13656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2019] [Indexed: 01/12/2023]
Affiliation(s)
- Elizabeth Leroux
- Department of Clinical Neurosciences University of Calgary Calgary Canada
| | - John Rothrock
- The George Washington University School of Medicine & Health Sciences Washington DC USA
| |
Collapse
|
8
|
Labastida-Ramírez A, Rubio-Beltrán E, Haanes KA, de Vries R, Dammers R, Bogers AJJC, van den Bogaerdt A, Daugherty BL, Danser AHJ, Villalón CM, MaassenVanDenBrink A. Effects of two isometheptene enantiomers in isolated human blood vessels and rat middle meningeal artery - potential antimigraine efficacy. J Headache Pain 2019; 20:47. [PMID: 31053059 PMCID: PMC6734216 DOI: 10.1186/s10194-019-1003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 04/22/2019] [Indexed: 11/17/2022] Open
Abstract
Background Racemic isometheptene [(RS)-isometheptene] is an antimigraine drug that due to its cardiovascular side-effects was separated into its enantiomers, (R)- and (S)-isometheptene. This study set out to characterize the contribution of each enantiomer to its vasoactive profile. Moreover, rat neurogenic dural vasodilatation was used to explore their antimigraine mechanism of action. Methods Human blood vessel segments (middle meningeal artery, proximal and distal coronary arteries, and saphenous vein) were mounted in organ baths and concentration response curves to isometheptene were constructed. Calcitonin gene-related peptide (CGRP)-induced neurogenic dural vasodilation was elicited in the presence of the enantiomers using a rat closed cranial window model. Results The isometheptene enantiomers did not induce any significant contraction in human blood vessels, except in the middle meningeal artery, when they were administered at the highest concentration (100 μM). Interestingly in rats, (S)-isometheptene induced more pronounced vasopressor responses than (R)-isometheptene. However, none of these compounds affected the CGRP-induced vasodilator responses. Conclusion The isometheptene enantiomers displayed a relatively safe peripheral vascular profile, as they failed to constrict the human coronary artery. These compounds do not appear to modulate neurogenic dural CGRP release, therefore, their antimigraine site of action remains to be determined.
Collapse
Affiliation(s)
- Alejandro Labastida-Ramírez
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - Eloísa Rubio-Beltrán
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - Kristian A Haanes
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - René de Vries
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - A J J C Bogers
- Department of Thoracic surgery, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | | | - Bruce L Daugherty
- Tonix Pharmaceuticals, Inc, 509 Madison Avenue, Suite 306, New York, NY, 10022, USA
| | - Alexander H J Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Czda de los Tenorios 235, Col. Granjas-Coapa, Deleg. Tlalpan, C.P, 14330, Ciudad de México, Mexico
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, Dr Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands.
| |
Collapse
|
9
|
Khalife J, Lauritsen CG, Liang J, Shah SO. DHE-Induced Peripheral Arterial Vasospasm in Primary Raynaud Phenomenon: Case Report. Neurohospitalist 2018; 9:113-115. [PMID: 30915191 DOI: 10.1177/1941874418797764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Dihydroergotamine (DHE) is primarily a serotonin 5HT1B and 5HT1D receptor agonist used for acute migraine treatment. It is associated with acute vasoconstriction mediated through the 5HT1B receptor and is contraindicated in patients with history of cardiac disease and peripheral vascular disease. We present a case of acute peripheral arterial vasospasm in a patient with primary Raynaud phenomenon while receiving inpatient treatment for status migrainosus with intravenous (IV) DHE. The patient is a 35-year-old female with a history of chronic migraine and primary Raynaud phenomenon. After 15 doses of IV DHE, the patient reported paresthesias of the right hand and was noted to have absent right radial and ulnar pulses to palpation. Portable arterial Doppler study demonstrated abnormal flat line pulse volume recordings (PVRs) in the right second, third, and fourth digits, with markedly dampened PVR in the right thumb and fifth finger along with no ulnar PVR detectable at the wrist. Duplex revealed bilateral severely diminished flow in the right ulnar and radial arteries without acute occlusions. Computed tomography angiogram of right upper extremity visualized arteries through the mid-forearm but not distally. Dihydroergotamine was discontinued, and the patient was started on oral amlodipine and aspirin. Repeat Doppler ultrasound 3 days later revealed normal arm and digital waveforms bilaterally consistent with resolution of vasospasm. This case highlights a potential complication of IV DHE therapy. Risk may be increased in patients with primary Raynaud phenomenon. We suggest cautious use of IV DHE in this population.
Collapse
Affiliation(s)
- Jane Khalife
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - John Liang
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Syed O Shah
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
10
|
González-Hernández A, Marichal-Cancino BA, MaassenVanDenBrink A, Villalón CM. Side effects associated with current and prospective antimigraine pharmacotherapies. Expert Opin Drug Metab Toxicol 2018; 14:25-41. [PMID: 29226741 DOI: 10.1080/17425255.2018.1416097] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Migraine is a neurovascular disorder. Current acute specific antimigraine pharmacotherapies target trigeminovascular 5-HT1B/1D, 5-HT1F and CGRP receptors but, unfortunately, they induce some cardiovascular and central side effects that lead to poor treatment adherence/compliance. Therefore, new antimigraine drugs are being explored. Areas covered: This review considers the adverse (or potential) side effects produced by current and prospective antimigraine drugs, including medication overuse headache (MOH) produced by ergots and triptans, the side effects observed in clinical trials for the new gepants and CGRP antibodies, and a section discussing the potential effects resulting from disruption of the cardiovascular CGRPergic neurotransmission. Expert opinion: The last decades have witnessed remarkable developments in antimigraine therapy, which includes acute (e.g. triptans) and prophylactic (e.g. β-adrenoceptor blockers) antimigraine drugs. Indeed, the triptans represent a considerable advance, but their side effects (including nausea, dizziness and coronary vasoconstriction) preclude some patients from using triptans. This has led to the development of the ditans (5-HT1F receptor agonists), the gepants (CGRP receptor antagonists) and the monoclonal antibodies against CGRP or its receptor. The latter drugs represent a new hope in the antimigraine armamentarium, but as CGRP plays a role in cardiovascular homeostasis, the potential for adverse cardiovascular side effects remains latent.
Collapse
Affiliation(s)
| | - Bruno A Marichal-Cancino
- b Departamento de Fisiología y Farmacología, Universidad Autónoma de Aguascalientes , Ciudad Universitaria , Aguascalientes , México
| | - Antoinette MaassenVanDenBrink
- c Division of Vascular Medicine and Pharmacology, Department of Internal Medicine , Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Carlos M Villalón
- d Departamento de Farmacobiología , Cinvestav-Coapa , Ciudad de México , México
| |
Collapse
|
11
|
Lima Neto JX, Soares-Rachetti VP, Albuquerque EL, Manzoni V, Fulco UL. Outlining migrainous through dihydroergotamine–serotonin receptor interactions using quantum biochemistry. NEW J CHEM 2018. [DOI: 10.1039/c7nj03645k] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We present the electronic structure of the complex dihydroergotamine–serotonin receptor to unveil new medications to treat migraine and related diseases.
Collapse
Affiliation(s)
- José X. Lima Neto
- Departamento de Biofísica e Farmacologia
- Universidade Federal do Rio Grande do Norte
- Natal-RN
- Brazil
| | | | | | - Vinicius Manzoni
- Instituto de Física
- Universidade Federal de Alagoas
- Maceio-AL
- Brazil
| | - Umberto L. Fulco
- Departamento de Biofísica e Farmacologia
- Universidade Federal do Rio Grande do Norte
- Natal-RN
- Brazil
| |
Collapse
|
12
|
Tso AR, Patniyot IR, Gelfand AA, Goadsby PJ. Increased rate of venous thrombosis may be associated with inpatient dihydroergotamine treatment. Neurology 2017; 89:279-283. [PMID: 28615428 DOI: 10.1212/wnl.0000000000004108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/24/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review whether the incidence of catheter-associated venous thromboses was higher in patients receiving IV dihydroergotamine compared to lidocaine. METHODS We retrospectively reviewed all admissions at the University of California, San Francisco Headache Center from February 25, 2008, through October 31, 2014, for age, sex, diagnosis, aura, treatment dose, type of IV line used, days with line, superficial (SVT) or deep venous thrombosis (DVT), and pulmonary embolism (PE). RESULTS A peripherally inserted central catheter (PICC) or midline catheter was placed in 315 of 589 (53%) admissions. Mean age was 38 years with a range of 6 to 79 years; 121 patients (21%) were ≤18 years old. Seventy-four percent (433 of 589) of patients were female. Of 263 dihydroergotamine admissions using a PICC or midline catheter, 19 (7.2%) had either an SVT or DVT or a PE; 2 patients were diagnosed with both DVT and PE. Of 52 lidocaine admissions using a PICC or midline catheter, none had a thrombotic event (p = 0.05, Fisher exact test). Age, sex, aura, total dihydroergotamine dose, and number of days with line were not significant predictors of venous thrombosis. CONCLUSIONS IV dihydroergotamine treatment may be associated with an increased risk of catheter-associated venous thrombosis. A low threshold for diagnostic ultrasound investigation is appropriate because anticoagulation therapy was frequently required.
Collapse
Affiliation(s)
- Amy R Tso
- From the Headache Group (A.R.T., I.R.P., A.A.G., P.J.G.), Department of Neurology, University of California, San Francisco; Headache Group (A.R.T., P.J.G.), Basic and Clinical Neuroscience, King's College London; and NIHR, Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK (A.R.T., P.J.G.).
| | - Irene R Patniyot
- From the Headache Group (A.R.T., I.R.P., A.A.G., P.J.G.), Department of Neurology, University of California, San Francisco; Headache Group (A.R.T., P.J.G.), Basic and Clinical Neuroscience, King's College London; and NIHR, Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK (A.R.T., P.J.G.)
| | - Amy A Gelfand
- From the Headache Group (A.R.T., I.R.P., A.A.G., P.J.G.), Department of Neurology, University of California, San Francisco; Headache Group (A.R.T., P.J.G.), Basic and Clinical Neuroscience, King's College London; and NIHR, Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK (A.R.T., P.J.G.)
| | - Peter J Goadsby
- From the Headache Group (A.R.T., I.R.P., A.A.G., P.J.G.), Department of Neurology, University of California, San Francisco; Headache Group (A.R.T., P.J.G.), Basic and Clinical Neuroscience, King's College London; and NIHR, Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK (A.R.T., P.J.G.)
| |
Collapse
|
13
|
Labastida-Ramírez A, Rubio-Beltrán E, Hernández-Abreu O, Daugherty BL, MaassenVanDenBrink A, Villalón CM. Pharmacological analysis of the increases in heart rate and diastolic blood pressure produced by (S)-isometheptene and (R)-isometheptene in pithed rats. J Headache Pain 2017; 18:52. [PMID: 28474252 PMCID: PMC5418177 DOI: 10.1186/s10194-017-0761-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/22/2017] [Indexed: 11/27/2022] Open
Abstract
Background Isometheptene is a sympathomimetic drug effective in acute migraine treatment. It is composed of two enantiomers with diverse pharmacological properties. This study investigated in pithed rats the cardiovascular effects of (S)- isometheptene and (R)-isometheptene, and the pharmacological profile of the more potent enantiomer. Methods The effects of i.v. bolus injections (0.03, 0.1, 0.3, 1 and 3 mg/kg) of isometheptene racemate, (S)-isometheptene or (R)-isometheptene on heart rate and blood pressure were analyzed in control experiments. The enantiomer producing more pronounced tachycardic and/or vasopressor responses was further analyzed in rats receiving i.v. injections of prazosin (0.1 mg/kg), rauwolscine (0.3 mg/kg), propranolol (1 mg/kg) or intraperitoneal reserpine (5 mg/kg, -24 h). Results Compared to (R)-isometheptene, (S)-isometheptene produced greater vasopressor responses, whilst both compounds equipotently increased heart rate. The tachycardic responses to (S)-isometheptene were abolished after propranolol, but remained unaffected by the other antagonists. In contrast, the vasopressor responses to (S)-isometheptene were practically abolished after prazosin. Interestingly, after reserpine, the tachycardic responses to (S)-isometheptene were abolished, whereas its vasopressor responses were attenuated and subsequently abolished by prazosin. Conclusions The different cardiovascular effects of the isometheptene enantiomers are probably due to differences in their mechanism of action, namely: (i) a mixed sympathomimetic action for (S)-isometheptene (a tyramine-like action and a direct stimulation of α1-adrenoceptors); and (ii) exclusively a tyramine like action for (R)-isometheptene. Thus, (R)-isometheptene may represent a superior therapeutic benefit as an antimigraine agent.
Collapse
Affiliation(s)
- Alejandro Labastida-Ramírez
- Department of Pharmacobiology, Cinvestav-Coapa, Czda. Tenorios 235, Col. Granjas-Coapa, Deleg. Tlalpan, 14330, Mexico City, Mexico
| | - Eloísa Rubio-Beltrán
- Department of Pharmacobiology, Cinvestav-Coapa, Czda. Tenorios 235, Col. Granjas-Coapa, Deleg. Tlalpan, 14330, Mexico City, Mexico
| | - Oswaldo Hernández-Abreu
- Department of Pharmacobiology, Cinvestav-Coapa, Czda. Tenorios 235, Col. Granjas-Coapa, Deleg. Tlalpan, 14330, Mexico City, Mexico
| | - Bruce L Daugherty
- Tonix Pharmaceuticals, Inc. 509 Madison Avenue, Suite 306, New York, NY, 10022, USA
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Carlos M Villalón
- Department of Pharmacobiology, Cinvestav-Coapa, Czda. Tenorios 235, Col. Granjas-Coapa, Deleg. Tlalpan, 14330, Mexico City, Mexico.
| |
Collapse
|