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Mistry H, Naghdi S, Brown A, Rees S, Madan J, Grove A, Khanal S, Duncan C, Matharu M, Cooklin A, Aksentyte A, Davies N, Underwood M. Preventive drug treatments for adults with chronic migraine: a systematic review with economic modelling. Health Technol Assess 2024; 28:1-329. [PMID: 39365169 DOI: 10.3310/aywa5297] [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] [Indexed: 10/05/2024] Open
Abstract
Background Chronic migraine is a disabling condition, affecting 2-4% of adults globally. With the introduction of expensive calcitonin gene-related peptide monoclonal antibodies, it is timely to compare the clinical effectiveness and cost-effectiveness of preventive drugs for chronic migraine. Objective To assess the clinical effectiveness and cost-effectiveness of medications used for chronic migraine through systematic reviews and economic modelling. Eligibility criteria Randomised controlled trials of drug treatments for efficacy with > 100 participants with chronic migraine per arm; for adverse events > 100 participants with episodic or chronic migraine per arm. Previous economic analyses of preventive drugs for chronic migraine. Data sources Eight databases. Reviews methods Systematic reviews, network meta-analysis and economic modelling. Outcomes Monthly headache days, monthly migraine days, headache-related quality of life, cost-effectiveness. Results We found 51 individual articles, reporting 11 randomised controlled trials, testing 6 drugs (topiramate, Botox, eptinezumab, erenumab, fremanezumab, galcanezumab), versus placebo, on 7352 adults with chronic migraine. Calcitonin gene-related peptide monoclonal antibodies, Botox and topiramate reduced headache/migraine days by 2.0-2.5, just under two, or by less than 1.5 days per month, respectively. In the network meta-analysis, eptinezumab 300 mg and fremanezumab monthly ranked in first place in both monthly headache day and monthly migraine day analyses. The calcitonin gene-related peptide monoclonal antibodies were consistently the best choices for headache/migraine days and headache-related quality of life. Topiramate was very unlikely to be the best choice for headache/migraine days and headache-related quality of life when compared to calcitonin gene-related peptide monoclonal antibodies or Botox. We found no trials of the commonly used drugs, such as propranolol or amitriptyline, to include in the analysis. The adverse events review included 40 randomised controlled trials with 25,891 participants; 3 additional drugs, amitriptyline, atogepant and rimegepant, were included. There were very few serious adverse events - none of which were linked to the use of these medications. Adverse events were common. Most people using some calcitonin gene-related peptide monoclonal antibodies reported injection site issues; and people using topiramate or amitriptyline had nervous system or gastrointestinal issues. The cost-effectiveness review identified 16 studies evaluating chronic migraine medications in adults. The newer, injected drugs are more costly than the oral preventatives, but they were cost-effective. Our economic model showed that topiramate was the least costly option and had the fewest quality-adjusted life-year gains, whereas eptinezumab 300 mg was more costly but generated the most quality-adjusted life-year gains. The cost-effectiveness acceptability frontier showed that topiramate was the most cost-effective medication if the decision maker is willing to pay up to £50,000 per quality-adjusted life-year. Our consensus workshop brought together people with chronic migraine and headache experts. Consensus was reached on the top three recommendations for future research on medications to prevent chronic migraine: (1) calcitonin gene-related peptide monoclonal antibodies and Botox versus calcitonin gene-related peptide monoclonal antibodies, (2) candesartan versus placebo and (3) flunarizine versus placebo. Limitations Topiramate was the only oral drug for which we were able to include data. We did not find sufficient quality evidence to support the use of other oral drugs. Conclusions We did not find evidence that the calcitonin gene-related peptide monoclonal antibodies are more clinically and cost-effective when compared to topiramate or Botox. We identified directions for future research these drugs might take. Study registration This study is registered as PROSPERO CRD42021265990, CRD42021265993 and CRD42021265995. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR132803) and is published in full in Health Technology Assessment; Vol. 28, No. 63. See the NIHR Funding and Awards website for further award information.
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MESH Headings
- Humans
- Migraine Disorders/drug therapy
- Migraine Disorders/prevention & control
- Cost-Benefit Analysis
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal/economics
- Topiramate/therapeutic use
- Chronic Disease
- Quality of Life
- Randomized Controlled Trials as Topic
- Models, Economic
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Antibodies, Monoclonal, Humanized/adverse effects
- Quality-Adjusted Life Years
- Adult
- Botulinum Toxins, Type A/therapeutic use
- Botulinum Toxins, Type A/economics
- Fructose/analogs & derivatives
- Fructose/therapeutic use
- Calcitonin Gene-Related Peptide/antagonists & inhibitors
- Network Meta-Analysis
- Technology Assessment, Biomedical
- Calcitonin Gene-Related Peptide Receptor Antagonists/therapeutic use
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Affiliation(s)
- Hema Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Seyran Naghdi
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anna Brown
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Bristol Clinical Trials Unit, University of Bristol, Bristol, UK
| | - Jason Madan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Grove
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Saval Khanal
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Callum Duncan
- Department of Neurology, NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Manjit Matharu
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Andrew Cooklin
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Aiva Aksentyte
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Natasha Davies
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Para D, Camponovo C, Riccitelli GC, Mallucci G, Maino P, Mondini Trissino da Lodi C, Saudina D, Trimboli P, Gobbi C, Zecca C. Assessment of Bone Mineral Density Over 1 Year in a Cross-Sectional Cohort of Migraine Patients Receiving Anti-CGRP Monoclonal Antibodies. CNS Drugs 2024; 38:819-825. [PMID: 39174745 PMCID: PMC11377451 DOI: 10.1007/s40263-024-01104-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Calcitonin gene-related peptide (CGRP), implicated in migraine pain, also possesses bone anabolic properties, which leads to the possibility that monoclonal antibodies targeting CGRP (anti-CGRPs) might increase the risk of bone density abnormalities. OBJECTIVE The objective of this study was to explore bone mineral density abnormalities in a cohort of migraine patients treated with anti-CGRPs. METHODS This was a single-center, cross-sectional, cohort study including migraine patients who underwent a densitometry assessment during anti-CGRP treatment. We assessed the frequency of osteopenia or osteoporosis (OSTEO+ status), defined as a bone mineral density T-score of -1 to -2.5, and <-2.5 standard deviations from the young female adult mean, respectively. Additionally, the association of OSTEO+ status with anti-CGRP treatment duration and primary osteoporosis' risk factors was investigated using logistic regression models. RESULTS Data from 51 patients (43 female, mean age 46 ± 13.9 years) were evaluated. The mean duration of anti-CGRP treatment was 15.7 (±11.8) months. Twenty-seven patients (53%) were OSTEO+ (n = 22 osteopenia; n = 5 osteoporosis). In the final model, menopause [odds ratio 11.641 (95% confidence interval 1.486-91.197), p = 0.019] and anti-seizure drug use [odds ratio 12.825 (95% confidence interval 1.162-141.569), p = 0.037] were associated with OSTEO+ status. CONCLUSIONS In our cohort of migraine patients, no evidence of an association between anti-CGRP treatment duration and an increasing risk of bone mineral density abnormalities was found. However, these findings are preliminary and necessitate further longitudinal research with larger cohorts and extended follow-up to be validated.
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Affiliation(s)
- Davide Para
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Neurology, Neurocenter of Southern Switzerland, 6900, Lugano, Switzerland
| | - Chiara Camponovo
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Clinic for Endocrinology and Diabetology, Lugano, Switzerland
| | - Gianna Carla Riccitelli
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Neurology, Neurocenter of Southern Switzerland, 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Giulia Mallucci
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Neurology, Neurocenter of Southern Switzerland, 6900, Lugano, Switzerland
| | - Paolo Maino
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Anesthesiology, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Camilla Mondini Trissino da Lodi
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Neurology, Neurocenter of Southern Switzerland, 6900, Lugano, Switzerland
| | - Demurtas Saudina
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Neurology, Neurocenter of Southern Switzerland, 6900, Lugano, Switzerland
| | - Pierpaolo Trimboli
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Clinic for Endocrinology and Diabetology, Lugano, Switzerland
| | - Claudio Gobbi
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Neurology, Neurocenter of Southern Switzerland, 6900, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Chiara Zecca
- Ente Ospedaliero Cantonale, Regional Hospital of Lugano, Department of Neurology, Neurocenter of Southern Switzerland, 6900, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
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González-Hernández A, Villalón CM. The influence of pharmacodynamics and pharmacokinetics on the antimigraine efficacy and safety of novel anti-CGRPergic pharmacotherapies: a narrative review. Expert Opin Drug Metab Toxicol 2024:1-12. [PMID: 39319681 DOI: 10.1080/17425255.2024.2409253] [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: 05/25/2024] [Revised: 09/11/2024] [Accepted: 09/23/2024] [Indexed: 09/26/2024]
Abstract
INTRODUCTION Migraine is a complex disorder, and its etiology is not yet fully understood. In the last 40 years, calcitonin gene-related peptide (CGRP) has been central to the understanding of migraine pathophysiology, leading to the development of new molecules targeting the CGRPergic system. These new molecules, such as gepants and monoclonal antibodies, are effective, well-tolerated, and safe, and are approved for clinical use. AREAS COVERED By searching multiple electronic scientific databases, this narrative review examined: (i) the role of CGRP in migraine; and (ii) the current knowledge on the effects of CGRPergic antimigraine pharmacotherapies, including a brief analysis of their pharmacodynamic and pharmacokinetic characteristics. EXPERT OPINION Current anti-CGRPergic medications, although effective, have limitations, such as side effects and lack of antimigraine efficacy in some patients. The existence of patients with medication-resistant migraine may be due to the: (i) complex migraine pathophysiology, in which several systems appear to be deregulated before, during, and after a migraine attack; and (ii) pharmacodynamic and pharmacokinetic properties of antimigraine medications. As envisioned here, although seminal studies support the notion that CGRP plays a key role in migraine headache, the dysfunction of CGRPergic transmission does not seem to be relevant in all cases.
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Affiliation(s)
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Ciudad de México, México
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Sirilertmekasakul C, Panto A, Lekhalawan P, Panyarachun P, Jindasakchai P, Rattanawong W. The transition of medication overuse status by acute medication categories in episodic or chronic migraine patients to non-overuse status after receiving anti-CGRP monoclonal antibodies: a systematic review and meta-analysis of phase 3 randomized control trial. Neurol Sci 2024; 45:4451-4462. [PMID: 38564060 DOI: 10.1007/s10072-024-07496-7] [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: 02/06/2024] [Accepted: 03/23/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE The objective of this systematic review and meta-analysis was to determine whether patients with episodic (EM) or chronic migraine (CM), who were treated with anti-CGRP antibodies, showed a reversal from medication overuse (MO) or medication overuse headache (MOH) status at their baseline to non-overuse status. Furthermore, this study aimed to establish which acute headache medication (AHM) categories responded more effectively to anti-CGRP antibodies. METHODS A systematic search was conducted in the PubMed database for relevant studies from January 2013 to September 2023. We included phase three randomized controlled trials to examine the role of anti-CGRP antibodies in patients with EM or CM and their MO status. A meta-analysis was conducted to find the association between anti-CGRP antibodies and the number of EM and CM patients with MO or MOH at baseline that reverted to non-MO status or below the MOH threshold. RESULTS The initial search yielded a total of 345 studies. After removing duplicates and screening with inclusion criteria, 5 studies fulfilled our conditions. Each study reviewed the response to changes in the MO status of patients after receiving anti-CGRP antibodies, including eptinezumab, fremanezumab, galcanezumab, and erenumab, compared to placebo. Our study analyzed three AHM categories: triptans, simple analgesics, and multiple drugs. The overall relative risk (RR) was 1.44 (95% CI, 1.31 to 1.59; p < 0.001). The RRs for triptans, simple analgesics, and multi-drug groups were 1.71 (95% CI, 1.53 to 1.91; p < 0.001), 1.10 (95% CI, 0.83 to 1.47; p = 0.5), and 1.29 (95%CI 1.14 to 1.46; p < 0.001) respectively. CONCLUSION The meta-analysis has shown that anti-CGRP antibodies were statistically significant in transitioning from MO or MOH status to non-MO status or below the MOH threshold (RR = 1.44) for all included studies and all AHM categories except for simple analgesics. Patients from the triptan group had the highest RR of 1.71 with a p-value < 0.001, while the simple analgesics group had an RR of 1.10, however, with a p-value > 0.05. Interestingly, this analysis can be interpreted as that anti-CGRP antibodies might not be effective in reducing simple analgesics use in EM or CM patients. Further studies are needed to investigate these matters.
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Affiliation(s)
| | - Akkanat Panto
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, 10520, Thailand
| | - Pattanan Lekhalawan
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, 10520, Thailand
| | - Pariyada Panyarachun
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, 10520, Thailand
| | - Porpim Jindasakchai
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, 10520, Thailand
| | - Wanakorn Rattanawong
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, 10520, Thailand.
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Areberg J, Rosen M, Lindsten A, Dragheim M, Ryding J. Population pharmacokinetics of eptinezumab in paediatric patients with migraine and dose selection for phase 3 paediatric migraine studies. Basic Clin Pharmacol Toxicol 2024. [PMID: 39206528 DOI: 10.1111/bcpt.14076] [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: 04/23/2024] [Revised: 08/15/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024]
Abstract
This population pharmacokinetics (PopPK) analysis of eptinezumab used data from a paediatric study and a prior adult PopPK model to compare eptinezumab pharmacokinetics between adult and paediatric populations to determine dose recommendations for the phase 3 paediatric studies in migraine. The data consisted of 16 adolescents and 12 children with migraine, with corresponding demographics and 278 plasma concentrations in total. PopPK analysis was performed through nonlinear mixed effect modelling and with prior knowledge taken from a previous PopPK model in adults. A two-compartment model-adjusted for body weight impact on clearances and volumes of distributions and scaled to the power of 0.75 and 1.0, respectively-was found to adequately describe the paediatric pharmacokinetic data. The simulated population showed overlap in area under the plasma concentration-time curve and maximum plasma concentration between the paediatric and adult populations, with paediatric exposures within 10%-15% above adult levels on average. To provide comparable exposure to the approved adult doses, weight-based dosing adjustments are recommended for paediatric patients weighing ≤40 kg, while no adjustments are needed for patients weighing >40 kg. These results support the dosing strategy being used in the ongoing efficacy and safety studies with eptinezumab in children and adolescents with migraine.
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Greene KA, Gelfand AA, Larry Charleston. Evidence-based review and frontiers of migraine therapy. Neurogastroenterol Motil 2024:e14899. [PMID: 39133210 DOI: 10.1111/nmo.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 07/25/2024] [Accepted: 07/31/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Cyclic vomiting syndrome (CVS) is identified as one of the "episodic syndromes that may be associated with migraine," along with benign paroxysmal torticollis, benign paroxysmal vertigo, and abdominal migraine. It has been proposed that CVS and migraine may share pathophysiologic mechanisms of hypothalamic activation and altered dopaminergic signaling, and impaired sensorimotor intrinsic connectivity. The past decade has brought groundbreaking advances in the treatment of migraine and other headache disorders. While many of these therapies have yet to be studied in episodic syndromes associated with migraine including CVS and abdominal migraine, the potential shared pathophysiology among these conditions suggests that use of migraine-specific treatments may have a beneficial role even in those for whom headache is not the primary symptom. PURPOSE This manuscript highlights newer therapies in migraine. Calcitonin gene-related peptide (CGRP) and its relation to migraine pathophysiology and the therapies that target the CGRP pathway, as well as a 5HT1F receptor agonist and neuromodulation devices used to treat migraine are briefly discussed as they may potentially prove to be useful in the future treatment of CVS.
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Affiliation(s)
- Kaitlin A Greene
- Division of Pediatric Neurology, Oregon Health and Science University, Portland, Oregon, USA
| | - Amy A Gelfand
- Child and Adolescent Headache Program, University of California, San Francisco, California, USA
| | - Larry Charleston
- Department of Neurology and Ophthalmology, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
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Moore L, Pakalnis A. Calcitonin Gene-Related Peptide Inhibitors in the Treatment of Migraine in the Pediatric and Adolescent Populations: A Review. Pediatr Neurol 2024; 157:87-95. [PMID: 38905744 DOI: 10.1016/j.pediatrneurol.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/07/2024] [Accepted: 05/20/2024] [Indexed: 06/23/2024]
Abstract
There are limited well-studied treatments for migraine in the pediatric population. Calcitonin gene-related peptide (CGRP) inhibitors are an established safe and effective treatment in adults, and use may be appropriate for pediatric patients in certain clinical situations. We describe migraine pathophysiology as it relates to CGRP, provide an overview of available medications, and discuss clinical usage in this population.
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Affiliation(s)
- Lisa Moore
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Ann Pakalnis
- Department of Neurology, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurology, Ohio State University Wexner Medical Center, Columbus, Ohio
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Triller P, Raffaelli B. [Anti-CGRP-based Migraine Medications: A Comprehensive Overview]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024; 92:277-282. [PMID: 38547904 DOI: 10.1055/a-2276-2239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
In the early 1990s, the neuropeptide calcitonin gene-related peptide (CGRP) was identified as a key messenger in the pathophysiology of migraine and emerged as a treatment target, fundamentally transforming our approach to migraine therapy. While previous prophylactic drugs were non-specific and often caused intolerable side effects, the discovery of CGRP marked the advent of a new era in migraine treatment. The two main classes of CGRP-specific migraine treatments are monoclonal antibodies that bind to CGRP or the CGRP receptor, and CGRP receptor antagonists, the so-called gepants. Extensive clinical trials have conclusively demonstrated the safety, tolerability, and efficacy of monoclonal CGRP(-receptor) antibodies in the prophylactic treatment of both episodic and chronic migraine. The same positive results apply to the use of various gepants. They have proven to be not only an effective alternative to triptans in acute migraine therapy but also promising options for continuous use as prophylactic treatments. In this review, we aim to present the current state of research on CGRP-specific migraine therapy and insights in real-world data from the first years after their launch in clinical practice.
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Affiliation(s)
- Paul Triller
- Klinik für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bianca Raffaelli
- Klinik für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité, Berlin, Germany
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Blumenfeld A, Kudrow D, McAllister P, Boserup LP, Hirman J, Cady R. Long-term effectiveness of eptinezumab in the treatment of patients with chronic migraine and medication-overuse headache. Headache 2024; 64:738-749. [PMID: 38924044 DOI: 10.1111/head.14767] [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: 10/10/2023] [Revised: 03/08/2024] [Accepted: 04/17/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE This post hoc analysis of the PREVAIL study explored the effectiveness of eptinezumab for up to 2 years of open-label treatment in the subgroup of patients with chronic migraine who had a confirmed diagnosis of medication-overuse headache (MOH) at screening. BACKGROUND MOH is a disabling and costly secondary headache disorder characterized by increased headache frequency and/or severity with increased acute headache medication use. Eptinezumab, an anti-calcitonin gene-related peptide monoclonal antibody, reduces headache frequency, severity, and associated disability and improves functioning and health-related quality of life as a preventive migraine therapy; short-term benefits in patients with concurrent MOH have also been reported. METHODS Participants received up to eight quarterly intravenous infusions of eptinezumab 300 mg in the phase 3, single-arm, open-label PREVAIL study. Safety and patient-reported outcome measures (Migraine Disability Assessment [MIDAS], 6-item Headache Impact Test [HIT-6], patient-identified most bothersome symptom [PI-MBS], Patient Global Impression of Change [PGIC], and 36-item Short-Form Health Survey [SF-36]) were conducted at predefined intervals. Patients were observed up to 20 weeks after their last infusion (Week 104). RESULTS A total of 49/128 (38.3%) patients enrolled in PREVAIL had an MOH diagnosis at screening. In the MOH subgroup, long-term eptinezumab treatment was associated with reductions in headache frequency (43/49 [87.8%] patients reported ≥50% reduction in MIDAS-derived headache days at ≥1 visit), severity (2.2-point reduction [on a 10-point scale]), disability (mean MIDAS total score reduction of 51.9 points), and impact (mean HIT-6 total score reduction of 9.7 points) at Week 104. Most patients described a "much improved" or "very much improved" status by Week 48 (PI-MBS, 31/46 [67.4%]) and Week 104 (PGIC, 31/36 [86.1%]). Health-related quality of life improvements in the SF-36 were also observed. CONCLUSION Eptinezumab preventive therapy in patients with chronic migraine showed benefits that extended to the subset of patients with concomitant MOH.
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Affiliation(s)
| | - David Kudrow
- The Los Angeles Headache Center, Los Angeles, California, USA
| | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, Connecticut, USA
| | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Woodinville, Washington, USA
| | - Roger Cady
- RK Consults, Ozark, Missouri, USA
- Missouri State University, Springfield, Missouri, USA
- Axon Therapeutics, San Diego, California, USA
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Zhao YJ, Ong JJY, Sonu SK, Dang J, Ng CC, Herr KJ, Bose R, Jion YI. A real-world prospective observational study of eptinezumab in Asian patients with migraine. Headache 2024; 64:810-824. [PMID: 38785386 DOI: 10.1111/head.14737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To evaluate the real-world effectiveness of eptinezumab for migraine prevention in Asian patients. BACKGROUND Eptinezumab is a monoclonal antibody that targets calcitonin gene-related peptide (CGRP), a potent vasodilator with an important role in migraine pathophysiology. Although there is robust clinical evidence from pivotal Phase 3 placebo-controlled trials of the efficacy of eptinezumab for migraine prevention, there are limited data on the real-world effectiveness of eptinezumab in Asian patient cohorts. METHODS This was a non-interventional, prospective, multisite cohort study of adults with migraine (International Classification of Headache Disorders, 3rd edition criteria) in Singapore who were prescribed eptinezumab (100 mg at baseline and Month 3, administered intravenously) and were followed until Month 6. The primary endpoint was change from baseline in monthly migraine days (MMDs) at Month 3 and Month 6. Secondary endpoints were ≥30% and ≥50% responder rates, and change from baseline in the Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), Migraine-Specific Quality of Life (MSQ), patient-identified most bothersome symptom (PI-MBS), acute medication use at Month 3 and Month 6, and safety. RESULTS Enrolled patients (completed = 29/30) had on average 3.4 (SD 2.9) previous preventive treatments; 29/30 of the patients had trialed at least one previous preventive treatment without benefit. Most had previously trialed oral preventives (87%, 26/30) and anti-CGRP (70%, 21/30). Relative to baseline, mean MMDs decreased by 4.3 days (95% CI 2.1-6.4; p < 0.001) at Month 3 and 4.9 days (95% CI 2.1-7.7; p < 0.001) at Month 6. At Month 3 and Month 6, 14/30 (47%) and 15/29 (52%) of the patients were ≥30% responders, and 6/30 (20%) and 8/29 (28%) patients were ≥50% responders, respectively. The number of patients with severe life impairment based on the HIT-6 score (total score 60-78) decreased from 24/30 (80%) at baseline to 19/30 (63%) at Month 3 and 19/29 (66%) at Month 6. The mean MIDAS score decreased by 24.6 points (95% CI 2.82-46.38; p = 0.028) at Month 6, and the mean MSQ score increased by 12.2 points (95% CI 5.18-19.20; p = 0.001) at Month 3 and 13.6 points (95% CI 4.58-22.66; p = 0.004) at Month 6. Most patients reported improvement in the PI-MBS at Month 3 (73%, 22/30) and Month 6 (55%, 16/29). Acute medication use for headache relief decreased by 3.3 days/month (95% CI 1.0-5.6; p = 0.007) at Month 3 and 4.7 days/month (95% CI 1.7-7.7; p = 0.003) at Month 6. Treatment-emergent adverse events (TEAEs) were reported in 16/30 (54%) patients, mostly mild/moderate in severity. No serious TEAEs led to treatment discontinuation. CONCLUSION Quarterly eptinezumab administration was effective and well-tolerated in Asian patients with chronic migraine.
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Affiliation(s)
- Yi Jing Zhao
- Mount Elizabeth Medical Centre, Singapore, Singapore
| | - Jonathan Jia Yuan Ong
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- YLL School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sumit Kumar Sonu
- Department of Neurology, Singapore General Hospital, Singapore, Singapore
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Jiaojiao Dang
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Chai Ching Ng
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | | | - Rohini Bose
- Lundbeck Singapore Pte. Ltd., Singapore, Singapore
| | - Yasmin Idu Jion
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
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Barbanti P, Orlando B, Egeo G, d’Onofrio F, Doretti A, Messina S, Autunno M, Messina R, Filippi M, Fiorentini G, Rotondi C, Bonassi S, Aurilia C. Evaluating the Effectiveness, Tolerability, and Safety of Eptinezumab in High-Frequency and Chronic Migraine in Real World: EMBRACE-The First Italian Multicenter, Prospective, Real-Life Study. Brain Sci 2024; 14:672. [PMID: 39061413 PMCID: PMC11275165 DOI: 10.3390/brainsci14070672] [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: 06/06/2024] [Revised: 06/25/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024] Open
Abstract
We conducted a multicenter, prospective study (EMBRACE) evaluating the real-life effectiveness, safety, and tolerability of eptinezumab (100 mg/300 mg)-a monoclonal antibody targeting the calcitonin-gene-related peptide (anti-CGRP mAb)-in high-frequency episodic migraine (HFEM) or chronic migraine (CM). The primary endpoint was the change in monthly migraine days (MMD) for HFEM or monthly headache days (MHD) for CM at weeks 9-12 compared to baseline. The secondary endpoints included changes in monthly analgesic intake (MAI), Numerical Rating Scale (NRS), Headache Impact Test (HIT-6), Migraine Disability Assessment Scale (MIDAS), Migraine Interictal Burden Scale (MIBS-4), and responder rates. The safety analysis involved 44 subjects; the effectiveness analysis included 26 individuals. Eptinezumab was well-tolerated. In CM patients, eptinezumab significantly reduced MHD (-16.1 ± 9.9, p < 0.001), MAI, NRS, HIT-6, MIDAS, and MIBS-4. In HFEM patients, it significantly reduced NRS, HIT-6, MIDAS, and MIBS-4, though reductions in MMD (-3.3 ± 4.5) and MAI were not statistically significant. Overall, ≥50% and ≥75% response rates were 61.5% and 30.8%, respectively (60% and 30% in non-responders to subcutaneous anti-CGRP mAbs). The clinical change was rated as much or very much improved by 61.0% of the patients. Eptinezumab demonstrated high effectiveness, safety, and tolerability in real-life among hard-to-treat migraine patients with multiple treatment failures, including anti-CGRP mAbs.
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Affiliation(s)
- Piero Barbanti
- Headache and Pain Unit, IRCCS San Raffaele, Via della Pisana 235, 00163 Rome, Italy (G.E.)
- San Raffaele University, 00166 Rome, Italy
| | - Bianca Orlando
- Headache and Pain Unit, IRCCS San Raffaele, Via della Pisana 235, 00163 Rome, Italy (G.E.)
| | - Gabriella Egeo
- Headache and Pain Unit, IRCCS San Raffaele, Via della Pisana 235, 00163 Rome, Italy (G.E.)
| | - Florindo d’Onofrio
- Headache Center Neurology Unit, San Giuseppe Moscati Hospital, 83100 Avellino, Italy
| | - Alberto Doretti
- Laboratory of Neurosciences, Department of Neurology-Stroke Unit, Istituto Auxologico Italiano, IRCCS, 20145 Milan, Italy
| | - Stefano Messina
- Laboratory of Neurosciences, Department of Neurology-Stroke Unit, Istituto Auxologico Italiano, IRCCS, 20145 Milan, Italy
| | - Massimo Autunno
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Roberta Messina
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giulia Fiorentini
- Headache and Pain Unit, IRCCS San Raffaele, Via della Pisana 235, 00163 Rome, Italy (G.E.)
- San Raffaele University, 00166 Rome, Italy
| | - Cristina Rotondi
- Clinical and Molecular Epidemiology, IRCCS San Raffaele, 00166 Rome, Italy
| | - Stefano Bonassi
- San Raffaele University, 00166 Rome, Italy
- Clinical and Molecular Epidemiology, IRCCS San Raffaele, 00166 Rome, Italy
| | - Cinzia Aurilia
- Headache and Pain Unit, IRCCS San Raffaele, Via della Pisana 235, 00163 Rome, Italy (G.E.)
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12
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Yuan W, Shi X, Lee LTO. RNA therapeutics in targeting G protein-coupled receptors: Recent advances and challenges. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102195. [PMID: 38741614 PMCID: PMC11089380 DOI: 10.1016/j.omtn.2024.102195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
G protein-coupled receptors (GPCRs) are the major targets of existing drugs for a plethora of human diseases and dominate the pharmaceutical market. However, over 50% of the GPCRs remain undruggable. To pursue a breakthrough and overcome this situation, there is significant clinical research for developing RNA-based drugs specifically targeting GPCRs, but none has been approved so far. RNA therapeutics represent a unique and promising approach to selectively targeting previously undruggable targets, including undruggable GPCRs. However, the development of RNA therapeutics faces significant challenges in areas of RNA stability and efficient in vivo delivery. This review presents an overview of the advances in RNA therapeutics and the diverse types of nanoparticle RNA delivery systems. It also describes the potential applications of GPCR-targeted RNA drugs for various human diseases.
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Affiliation(s)
- Wanjun Yuan
- Cancer Centre, Faculty of Health Sciences, University of Macau, Taipa 999078, Macau, China
| | - Xiangyang Shi
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai 201620, People’s Republic of China
| | - Leo Tsz On Lee
- Cancer Centre, Faculty of Health Sciences, University of Macau, Taipa 999078, Macau, China
- Ministry of Education Frontiers Science Center for Precision Oncology, University of Macau, Taipa 999078, Macau, China
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Salim A, Hennessy E, Sonneborn C, Hogue O, Biswas S, Mays M, Suneja A, Ahmed Z, Mata IF. Synergism of Anti-CGRP Monoclonal Antibodies and OnabotulinumtoxinA in the Treatment of Chronic Migraine: A Real-World Retrospective Chart Review. CNS Drugs 2024; 38:481-491. [PMID: 38583127 PMCID: PMC11098928 DOI: 10.1007/s40263-024-01086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Many patients with chronic migraine do not achieve clinically meaningful improvement in their headache frequency with monotherapy. The burden associated with chronic migraine calls for a multifaceted treatment approach targeting multiple aspects of migraine pathophysiology. OBJECTIVE The aim of this study was to evaluate the effect of concurrent anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) and onabotulinumtoxinA (onabot) treatment on median monthly migraine days (MMD) in patients with chronic migraine, through a retrospective study. METHODS The electronic medical records of Cleveland Clinic patients either concurrently (dual therapy) or consecutively (monotherapy) treated with anti-CGRP mAbs and onabot between June 2018 and November 2021 were extracted. Only adult patients (≥ 18 years of age) were included in this study. MMDs for 194 concurrently treated (86.6% female and a median [interquartile range] age of 51 [41-61] years) and 229 consecutively treated (88.2% female and median age of 47 [IQR 39-57] years) patients were examined at baseline, after first therapy of either anti-CGRP mAb or onabot, and following dual therapy for 3 consecutive months. The reduction of MMDs for each treatment group were compared. The same approach was utilized to compare consecutive monotherapy at separate times (n = 229) and dual-therapy groups. RESULTS The initial treatment of the dual-therapy group reduced the median (IQR) MMDs from 30 (30-30) to 15 (12-30) [p < 0.0001]. After initiation of dual therapy, the median MMDs was further decreased from 15 (12-30) to 8 (3-22) [p < 0.0001]. A majority [132/194 (68.0%)] of the dual-therapy patients reported a ≥ 50% reduction in MMD and 90/194 (46.4%) reported a ≥ 75% reduction. For the consecutive monotherapy group, median MMDs changed from a baseline of 30 (25-30) to 15 (8-25) from onabot monotherapy and decreased from 25 (15-30) to 12 (4-25) after anti-CGRP mAb monotherapy. Almost half (113/229 [49.3%] from onabot, and 104/229 [45.4%] from anti-CGRP mAb) of these patients achieved a ≥ 50% reduction in MMDs and a minority (38/229 [16.6%] from onabot, and 45/229 [19.7%] from anti-CGRP mAb) achieved a reduction of ≥ 75%. Additionally, dual therapy showed significant improvement in MMDs compared with monotherapy of either treatment (p < 0.0001). CONCLUSION Dual therapy of anti-CGRP mAbs and onabot may be more efficacious than monotherapy, possibly due to their synergistic mechanisms of action.
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Affiliation(s)
- Amira Salim
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elise Hennessy
- Neuroscience Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Claire Sonneborn
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olivia Hogue
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sudipa Biswas
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - MaryAnn Mays
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aarushi Suneja
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zubair Ahmed
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ignacio F Mata
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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Rushendran R, Singh A, Ankul Singh S, Chitra V, Ilango K. A role of NLRP3 and MMP9 in migraine progression: a systematic review of translational study. Front Neurol 2024; 15:1307319. [PMID: 38836002 PMCID: PMC11148868 DOI: 10.3389/fneur.2024.1307319] [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: 10/04/2023] [Accepted: 04/24/2024] [Indexed: 06/06/2024] Open
Abstract
Background Migraines affect one billion individuals globally, with a higher occurrence among young adults and women. A significant survey in the United States indicated that 17.1% of women and 5.6% of men suffer from migraines. This study seeks to investigate the potential connection between NLRP3 and MMP9 in migraine pathology. Methods The research involved searching databases such as PubMed, Scopus, Science Direct, Google Scholar, and Proquest, with the search concluding on March 31, 2024. Following PRISMA guidelines, PICO data were collected, focusing exclusively on animal models induced by Nitroglycerine (10 mg/kg), while excluding clinical studies. Results The study, originally registered in Prospero Reg. No. CRD42022355893, conducted bias analysis using SYRCLE's RoB tool and evaluated author consensus using GraphPad v9.5.1. Out of 7,359 search results, 22 papers met the inclusion criteria. Inter-rater reliability among reviewers was assessed using Cohen's kappa statistics. Conclusion This review summarizes 22 preclinical studies on Nitroglycerin (NTG), NLRP3, MMP9, and related biomarkers in migraine. They reveal that NTG, especially at 10 mg/kg, consistently induces migraine-like symptoms in rodents by activating NLRP3 inflammasome and stimulating proinflammatory molecule production. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, CRD42022355893.
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Affiliation(s)
- Rapuru Rushendran
- Department of Pharmacology, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Chengalpattu, Chennai, India
| | - Anuragh Singh
- Department of Pharmacology, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Chengalpattu, Chennai, India
| | - S Ankul Singh
- Department of Pharmacology, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Chengalpattu, Chennai, India
| | - Vellapandian Chitra
- Department of Pharmacology, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Chengalpattu, Chennai, India
| | - Kaliappan Ilango
- Department of Pharmaceutical Chemistry, Tagore College of Pharmacy, Chennai, India
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15
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Scheffler A, Wenzel P, Bendig M, Gendolla A, Basten J, Kleinschnitz C, Nsaka M, Lindner D, Naegel S, Burow P, Fleischmann R, Holle D. Effectiveness and tolerability of eptinezumab in treating patients with migraine resistant to conventional preventive medications and CGRP (receptor) antibodies: a multicentre retrospective real-world analysis from Germany. J Headache Pain 2024; 25:79. [PMID: 38755541 PMCID: PMC11097519 DOI: 10.1186/s10194-024-01788-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Eptinezumab is a monoclonal antibody that targets calcitonin gene-related peptide (CGRP mAb) and is used for migraine prophylaxis. Efficacy data are mainly from clinical trials, real-world data are hardly available yet. Reimbursement policy in Germany leads to eptinezumab mainly being used in patients having failed pre-treatment with other CGRP mAb. To date, it is unclear whether eptinezumab is efficacious and well tolerated in this population and how the treatment response differs from patients who are naive to CGRP mAbs. METHODS We analysed clinical routine data of 79 patients (episodic migraine (EM): n = 19; chronic migraine (CM): n = 60) from four different centres in Germany. All patients were treated with eptinezumab (100mg). Differences in monthly headache (MHD), migraine (MMD) and acute medication days (AMD) after three months were analysed. The correlation of response with the number of CGRP mAb failures was evaluated. Significance level has been corrected (alpha = 0.017). RESULTS After three months MHD, MMD and AMD were significantly reduced. In EM, the median reduction for MHD was 4.0 days (IQR: -6.5 to -1.0; p = 0.001), for MMD 3.0 days (IQR: -5.5 to -1.5; p < 0.001) and for AMD 2.0 days (IQR: -5.0 to -0.5; p = 0.006). In CM, median reduction of MHD was 4 days (IQR: -8.0 to 0.0; p < 0.001), 3.0 days (IQR: -6.0 to-1.0; p < 0.001) for MMD and 1.0 day (IQR: -5.0 to 0.0; p < 0.001) for AMD. All patients were resistant to conventional preventive therapies and most to CGRP mAbs. Fourteen patients had never received a CGRP mAb and 65 patients had received at least one mAb without sufficient effectiveness and/or intolerability (one: n = 20, two: n = 28, three: n = 17). There was a significant association between the number of prior therapies and the 30% MHD responder rate (none: 78.6%, one: 45.0%, two: 32.1%, three: 23.5%, p = 0.010). Regarding tolerability, 10.4% (8/77) reported mild side effects. CONCLUSIONS The effectiveness of eptinezumab is significantly reduced in patients who have not previously responded to other CGRP mAbs. However, limitations such as the retrospective nature of the analysis, the small sample size and the short treatment period with only the lower dose of eptinezumab must be considered when interpreting the results.
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Affiliation(s)
- Armin Scheffler
- Department of Neurology and Centre for Translational Neuro- and Behavioral Sciences (C-TNBS), West German Headache Centre, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany.
| | - Pauline Wenzel
- Department of Neurology and Centre for Translational Neuro- and Behavioral Sciences (C-TNBS), West German Headache Centre, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany
| | - Merle Bendig
- Department of Neurology, University of Greifswald, Greifswald, Germany
| | | | - Jale Basten
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Centre for Translational Neuro- and Behavioral Sciences (C-TNBS), West German Headache Centre, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany
| | - Michael Nsaka
- Department of Neurology and Centre for Translational Neuro- and Behavioral Sciences (C-TNBS), West German Headache Centre, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany
| | - Diana Lindner
- Department of Neurology and Centre for Translational Neuro- and Behavioral Sciences (C-TNBS), West German Headache Centre, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany
| | - Steffen Naegel
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, University Hospital Halle, Halle (Saale), Germany
- Department of Neurology, Alfried-Krupp Krankenhaus, Essen, Germany
| | - Philipp Burow
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, University Hospital Halle, Halle (Saale), Germany
| | | | - Dagny Holle
- Department of Neurology and Centre for Translational Neuro- and Behavioral Sciences (C-TNBS), West German Headache Centre, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, Essen, 45147, Germany
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Robblee J, Hakim SM, Reynolds JM, Monteith TS, Zhang N, Barad M. Nonspecific oral medications versus anti-calcitonin gene-related peptide monoclonal antibodies for migraine: A systematic review and meta-analysis of randomized controlled trials. Headache 2024; 64:547-572. [PMID: 38634515 DOI: 10.1111/head.14693] [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: 05/03/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To compare calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) versus nonspecific oral migraine preventives (NOEPs). BACKGROUND Insurers mandate step therapy with NOEPs before approving CGRP mAbs. METHODS Databases were searched for class I or II randomized controlled trials (RCTs) comparing CGRP mAbs or NOEPs versus placebo for migraine prevention in adults. The primary outcome measure was monthly migraine days (MMD) or moderate to severe headache days. RESULTS Twelve RCTs for CGRP mAbs, 5 RCTs for topiramate, and 3 RCTs for divalproex were included in the meta-analysis. There was high certainty that CGRP mAbs are more effective than placebo, with weighted mean difference (WMD; 95% confidence interval) of -1.64 (-1.99 to -1.28) MMD, which is compatible with small effect size (Cohen's d -0.25 [-0.34 to -0.16]). Certainty of evidence that topiramate or divalproex is more effective than placebo was very low and low, respectively (WMD -1.45 [-1.52 to -1.38] and -1.65 [-2.30 to -1.00], respectively; Cohen's d -1.25 [-2.47 to -0.03] and -0.48 [-0.67 to -0.29], respectively). Trial sequential analysis showed that information size was adequate and that CGRP mAbs had clear benefit versus placebo. Network meta-analysis showed no statistically significant difference between CGRP mAbs and topiramate (WMD -0.19 [-0.56 to 0.17]) or divalproex (0.01 [-0.73 to 0.75]). No significant difference was seen between topiramate or divalproex (0.21 [-0.45 to 0.86]). CONCLUSIONS There is high certainty that CGRP mAbs are more effective than placebo, but the effect size is small. When feasible, CGRP mAbs may be prescribed as first-line preventives; topiramate or divalproex could be as effective but are less well tolerated. The findings of this study support the recently published 2024 position of the American Headache Society on the use of CGRP mAbs as the first-line treatment.
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Affiliation(s)
- Jennifer Robblee
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sameh M Hakim
- Department of Anesthesiology, Intensive Care, and Pain Management, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - John M Reynolds
- The Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Teshamae S Monteith
- Division of Headache, Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Niushen Zhang
- Department of Neurology & Neurological Sciences, Stanford Health Care, Stanford, California, USA
| | - Meredith Barad
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Health Care, Stanford, California, USA
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Alabbad S, Figueredo N, Yuan H, Silberstein S. Developments in targeting calcitonin gene-related peptide. Expert Rev Neurother 2024; 24:477-485. [PMID: 38557226 DOI: 10.1080/14737175.2024.2332754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Calcitonin Gene-Related Peptide (CGRP)-targeted therapy has revolutionized migraine treatment since its first approval in 2018. CGRP-targeted therapy includes monoclonal antibodies (mAbs) and gepants, which modulate trigeminal nociceptive and inflammatory responses, alleviating pain sensitization involved in migraine pathogenesis. CGRP-targeted therapy is effective not only for migraine but also for other chronic headache disorders that share the CGRP pathway. AREAS COVERED The authors review the latest developments and evidence for CGRP-targeted therapy for episodic migraine and chronic migraine. In addition, the authors discuss the emerging evidence on response prediction, menstrual migraine, vestibular migraine, idiopathic intracranial hypertension, post-traumatic headache, and the relationship between selected migraine comorbidities and CGRP. EXPERT OPINION Since the launch of CGRP-targeted therapy, many practical issues have been raised. Generally, it's safe to combine CGRP-targeted mAbs and gepants; this is an excellent option for patients with partial response. When considering stopping CGRP-targeted therapy, although a disease-modifying effect is likely, the optimal time for discontinuation remains unknown. Finally, beyond migraine, CGRP-targeted therapy may be used for other chronic pain disorders and psychological comorbidities.
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Affiliation(s)
- Sawsan Alabbad
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathalia Figueredo
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stephen Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
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Chen H, Luo W. Efficacy and safety of eptinezumab 300mg versus 100mg for migraine patients: a meta-analysis of randomized controlled studies. Int J Neurosci 2024; 134:462-467. [PMID: 35993143 DOI: 10.1080/00207454.2022.2115906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 10/15/2022]
Abstract
Introduction: Eptinezumab holds important promise in treating migraine patients, but its ideal dose is unknown. This meta-analysis aims to compare the efficacy and safety of eptinezumab 300 mg versus 100 mg for migraine patients.Methods: Several databases including PubMed, Web of science, EBSCO, EMbase and Cochrane library databases have been systematically searched and we included the randomized controlled trials (RCTs) assessing the effect of eptinezumab 300 mg versus 100 mg for migraine patients. This meta-analysis was conducted using the random-effect model.Results: Five RCTs and 1989 patients were included in the meta-analysis. Compared with eptinezumab 100 mg in migraine patients, eptinezumab 300 mg was associated with substantially reduced monthly migraine days (MD=-0.50; 95% CI=-0.56 to -0.44; p < 0.00001), increased 75% responder rate (OR = 1.32; 95% CI = 1.07 to 1.62; p = 0.008) and 50% responder rate (OR = 1.24; 95% CI = 1.04 to 1.48; p = 0.02), but unraveled no remarkable influence on migraine 1 day after dosing (OR = 0.92; 95% CI = 0.72 to 1.18; p = 0.52), adverse events (OR = 1.07; 95% CI = 0.81 to 1.42; p = 0.62) or serious adverse events (OR = 1.60; 95% CI = 0.68 to 3.74; p = 0.40).Conclusions: Eptinezumab 300 mg was superior to eptinezumab 100 mg for the treatment of migraine patients.
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Affiliation(s)
- Hongsheng Chen
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenqing Luo
- Department of Neurosurgery, People's Hospital of Changshou Chongqing, Chongqing, China
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Pozo-Rosich P, Dolezil D, Paemeleire K, Stepien A, Stude P, Snellman J, Arkuszewski M, Stites T, Ritter S, Lopez Lopez C, Maca J, Ferraris M, Gil-Gouveia R. Early Use of Erenumab vs Nonspecific Oral Migraine Preventives: The APPRAISE Randomized Clinical Trial. JAMA Neurol 2024; 81:461-470. [PMID: 38526461 PMCID: PMC10964163 DOI: 10.1001/jamaneurol.2024.0368] [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: 09/29/2023] [Accepted: 12/13/2023] [Indexed: 03/26/2024]
Abstract
Importance Patients with migraine often cycle through multiple nonspecific preventive medications due to poor tolerability and/or inadequate efficacy leading to low adherence and increased disease burden. Objective To compare the efficacy, tolerability, patient adherence, and patient satisfaction between erenumab and nonspecific oral migraine preventive medications (OMPMs) in patients with episodic migraine (EM) who had previously failed 1 or 2 preventive treatments. Design, Setting, and Participants The 12-month prospective, interventional, global, multicenter, active-controlled, randomized clinical trial comparing sustained benefit of 2 treatment paradigms (erenumab qm vs oral prophylactics) in adult episodic migraine patients (APPRAISE) trial was a 12-month open-label, multicenter, active-controlled, phase 4 randomized clinical trial conducted from May 15, 2019, to October 1, 2021. This pragmatic trial was conducted at 84 centers across 17 countries. Overall, participants 18 years or older with a 12-month or longer history of migraine, and 4 or more but fewer than 15 monthly migraine days (MMDs) were included. Interventions Patients were randomized (2:1) to receive erenumab or OMPMs. Dose adjustment was permitted (label dependent). Main Outcomes and Measures The primary end point was the proportion of patients completing 1 year of the initially assigned treatment and achieving a reduction of 50% or greater from baseline in MMDs at month 12. Secondary end points included the cumulative mean change from baseline in MMDs during the treatment period and the proportion of responders according to the Patients' Global Impression of Change (PGIC) scale at month 12 for patients taking the initially assigned treatment. Results A total of 866 patients were screened, of whom 245 failed the screening and 621 completed the screening and baseline period. Of the 621 randomized patients (mean [SD] age, 41.3 [11.2] years; 545 female [87.8%]; 413 [66.5%] in the erenumab group; 208 [33.5%] in the OMPM group), 523 (84.2%) completed the treatment phase, and 98 (15.8%) discontinued the study. At month 12, significantly more patients assigned to erenumab vs OMPM achieved the primary end point (232 of 413 [56.2%] vs 35 of 208 [16.8%]; odds ratio [OR], 6.48; 95% CI, 4.28-9.82; P <.001). Compared with OMPMs, treatment with erenumab showed higher responder rate (314 of 413 [76.0%] vs 39 of 208 [18.8%]; OR, 13.75; 95% CI, 9.08-20.83; P <.001) on the PGIC scale (≥5 at month 12). Significant reduction in cumulative average MMDs was reported with erenumab treatment vs OMPM treatment (-4.32 vs -2.65; treatment difference [SE]: -1.67 [0.35] days; P < .001). Substantially fewer patients in the erenumab arm compared with the OMPM arm switched medication (9 of 413 [2.2%] vs 72 of 208 [34.6%]) and discontinued treatment due to adverse events (12 of 408 [2.9%] vs 48 of 206 [23.3%]). No new safety signals were identified. Conclusions and Relevance Results of this randomized clinical trial demonstrated that earlier use of erenumab in patients with EM who failed 1 or 2 previous preventive treatments provided greater and sustained efficacy, safety, and adherence than continuous OMPM. Trial Registration ClinicalTrials.gov Identifier: NCT03927144.
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Affiliation(s)
- Patricia Pozo-Rosich
- Headache and Neurological Pain Research Group, Vall d’Hebron Institute of Research (VHIR), Department of Medicine, Universitat Autònoma de Barcelona, Spain
- Headache Unit, Neurology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - David Dolezil
- Headache Center, Dado Medical sro, Prague, Czech Republic
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | - Adam Stepien
- Department of Neurology, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | | | | | | | - Tracy Stites
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Shannon Ritter
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Jeff Maca
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Raquel Gil-Gouveia
- Hospital da Luz Headache Center, Neurology Department, Hospital da Luz, Lisboa, Portugal
- Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisboa, Portugal
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Argoff C, Herzog SP, Smith RM, Kotak SV, Sopina L, Saltarska Y, Soni-Brahmbhatt S, Khan FA. Real-world effectiveness and satisfaction with intravenous eptinezumab treatment in patients with chronic migraine: REVIEW, an observational, multi-site, US-based study. J Headache Pain 2024; 25:65. [PMID: 38664605 PMCID: PMC11044317 DOI: 10.1186/s10194-024-01764-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Despite recent advancements in migraine treatment, some patients continue to endure significant disease burden. Due to the controlled nature of randomized trials in migraine prevention, many real-world patients with comorbidities or prior exposure to certain therapies are excluded. Capturing evidence of the effectiveness of treatment in real-world clinical settings can further shape treatment paradigms. The objective of this study was to develop a comprehensive understanding of both patients' and physicians' real-world experiences with eptinezumab for chronic migraine (CM). METHODS REVIEW (Real-world EVidence and Insights into Experiences With eptinezumab) is an observational, multi-site (n = 4), US-based study designed to evaluate real-world experiences of patients treated with eptinezumab and their treating physicians. Patients were ≥ 18 years of age, with a diagnosis of CM, who had completed ≥ 2 consecutive eptinezumab infusion cycles (≥ 6 months of exposure). The study included a retrospective chart review, a patient survey, and a semi-structured physician interview that assessed patient and/or physician satisfaction with elements of daily living / well-being, migraine symptomology, and perspectives of the eptinezumab infusion experience. RESULTS Of the 94 patients enrolled, 83% (78/94) were female, the mean age was 49.2 years, and the mean time since migraine diagnosis was 15.4 years. Before eptinezumab treatment, patients experienced a mean of 8 self-reported "good" days/month, which increased to 18 after treatment. Most patients took, on average, ≥ 10 days/month of prescription and/or over-the-counter medication (81% [75/93] and 66% [61/93], respectively) to treat migraine attacks before eptinezumab treatment, which dropped to 26% (24/93) and 23% (21/93) following eptinezumab treatment. Prior to receiving eptinezumab, 62% (58/93) of patients indicated being at least slightly concerned about infusions; after eptinezumab infusion, this dropped to 14% (13/93). These patient survey findings were consistent with physician responses. CONCLUSION This real-world evidence study demonstrated high overall satisfaction with the effectiveness of eptinezumab treatment for CM among most patients and their physicians.
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Affiliation(s)
- Charles Argoff
- Albany Medical Center, 47 New Scotland Ave, 12208, Albany, NY, USA.
| | | | | | | | | | | | | | - Fawad A Khan
- The McCasland Family Comprehensive Headache Center, Ochsner Neurosciences Institute, New Orleans, LA, USA
- University of Queensland-Ochsner Clinical School, New Orleans, LA, USA
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21
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Naghdi S, Underwood M, Brown A, Matharu M, Duncan C, Davies N, Aksentyte A, Mistry H. Adverse and serious adverse events incidence of pharmacological interventions for managing chronic and episodic migraine in adults: a systematic review. BMJ Neurol Open 2024; 6:e000616. [PMID: 38646505 PMCID: PMC11029425 DOI: 10.1136/bmjno-2023-000616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/01/2024] [Indexed: 04/23/2024] Open
Abstract
Background Migraine is the second most common prevalent disorder worldwide and is a top cause of disability with a substantial economic burden. Many preventive migraine medications have notable side effects that affect different body organs. Method We systematically searched for published randomised controlled trials (RCTs) using terms for migraine/headache and preventive medications. Using eligibility criteria, two reviewers independently assessed the articles. Cochrane risk-of-bias tool was applied to assess the quality of the studies. Data were classified by system organ class (SOC). Results Thirty-two RCTs with 21 780 participants met the eligibility criteria for the incidence of adverse events (AEs). Additionally, 33 RCTs with 22 615 participants were included to synthesise the incidence of serious AEs (SAEs). The percentage of attributed AEs and SAEs to each SOC for 10 preventive drugs with different dosing regimens was calculated. Amitriptyline and topiramate had a higher incidence of nervous system disorders; Topiramate was also associated with a higher incidence of psychiatric disorders. All drugs showed a certain incidence of infections and infestations, with Onabotulinumtoxin A (BTA) having the lowest rate. BTA had a higher incidence of musculoskeletal disorders than the other drugs. Calcitonin gene-related peptide (CGRP) monoclonal antibodies (MAbs) such as fremanezumab and galcanezumab were linked to more general disorders and administration site conditions than other drugs. Conclusion Notably, the observed harm to SOCs varies among these preventive drugs. We suggest conducting head-to-head RCTs to evaluate the safety profile of oral medications, BTA, and CGRP MAbs in episodic and/or chronic migraine populations. PROSPERO registration number CRD42021265993.
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Affiliation(s)
- Seyran Naghdi
- Warwick Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Coventry, UK
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Manjit Matharu
- Headache Group, UCL Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Callum Duncan
- Department of Neurology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Natasha Davies
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aiva Aksentyte
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Warwick Clinical Trials Unit, University of Warwick, Warwick Medical School, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Coventry, UK
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Omaer A, Albilali A, Bamogaddam R, Almutairi F, Alsaif R, Almohammadi O, Alhifany AA. Improvement of comorbid anxiety and depression in patients with migraine treated with injectable preventive calcitonin gene-related peptide antagonists: Review of clinical evidence. Saudi Pharm J 2024; 32:101989. [PMID: 38405041 PMCID: PMC10882171 DOI: 10.1016/j.jsps.2024.101989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/07/2024] [Indexed: 02/27/2024] Open
Abstract
Background Migraine is often associated with depression and anxiety, leading to a diminished quality of life. Calcitonin gene-related peptide (CGRP) antagonists have shown promise in treating migraines, but their effects on concurrent depression and anxiety have not been clarified. Methods A literature review was conducted on ClinicalTrials.gov, PubMed, Ovid Medline, and EMBASE focusing on phase 3 clinical trials, post-hoc analysis studies, and real-world evidence (RWE) published in the past 5 years. The review primarily utilized patient-reported outcome tools, such as the Patient Health Questionnaire-9, Hamilton Depression Rating Scale, Beck Depression Inventory-II, generalized anxiety disorder (GAD)-7, and Hamilton Anxiety Rating Scale (HARS), to assess anxiety and depression in relation to CGRP-targeted monoclonal antibodies. Results Out of 260 studies, 17 met the inclusion criteria. Eptinezumab lacked sufficient evidence regarding its impact on depression and anxiety. While sufficient evidence on its effect on comorbid anxiety was not available, fremanezumab was shown to significantly improve comorbid depression in one study while not achieving statistical significance in another. Erenumab and galcanezumab showed significant improvement in comorbid depression, implying possible benefits in patients with migraine. Galcanezumab showed faster relief from depressive symptoms than other injectable CGRP antagonists. Galcanezumab also exhibited improvements in GAD-7 scores for anxiety, although not statistically significant, whereas RWE showed promising HARS scores for both galcanezumab and erenumab. Conclusions Galcanezumab and erenumab appear to be more effective in improving concurrent depressive and anxiety symptoms in migraine patients than fremanezumab. Notably, these psychometric questionnaires were not the primary outcome measures of the trials and were not specifically designed to investigate the effects of these medications on depression or anxiety. Further research is needed to fully understand the impact of CGRP antagonists on mental health disorders associated with migraines. These findings have implications for enhancing the overall well-being and quality of life in individuals with migraines and comorbid psychiatric conditions.
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Affiliation(s)
- Abubker Omaer
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Abdulrazaq Albilali
- Neurology Unit, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reem Bamogaddam
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Fares Almutairi
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Raghad Alsaif
- Clinical Pharmacy Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Osama Almohammadi
- Pharmacy Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Abdullah A Alhifany
- Pharmacy Practices Department, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
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Rattanawong W, Rapoport A, Srikiatkhachorn A. Medication "underuse" headache. Cephalalgia 2024; 44:3331024241245658. [PMID: 38613233 DOI: 10.1177/03331024241245658] [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] [Indexed: 04/14/2024]
Abstract
BACKGROUND Many risk factors have been associated with migraine progression, including insufficient and ineffective utilization of migraine medications; however, they have been inadequately explored. This has resulted in suboptimal usage of medications without effective altering of prescribing recommendations for patients, posing a risk for migraine chronification. METHODS Our aim is to conduct a comprehensive review of the available evidence regarding the underuse of migraine medications, both acute and preventive. The term "underuse" includes, but is not limited to: (1) ineffective use of appropriate and inappropriate medication; (2) underutilization; (3) inappropriate timing of usage; and (4) patient dissatisfaction with medication. RESULTS The underuse of both acute and preventive medications has been shown to contribute to the progression of migraine. In terms of acute medication, chronification occurs as a result of insufficient drug use, including failure of the prescriber to select the appropriate type based on pain intensity and disability, patients taking medication too late (more than 60 minutes after the onset or after central sensitization has occurred as evidenced by allodynia), and discontinuation because of lack of effect or intolerable side effects. The underlying cause of inadequate effectiveness of acute medication lies in its inability to halt the propagation of peripheral activation to central sensitization in a timely manner. For oral and injectable preventive migraine medications, insufficient efficacy and intolerable side effects have led to poor adherence and discontinuation with subsequent progression of migraine. The underlying pathophysiology here is rooted in the repetitive stimulation of afferent sensory pain fibers, followed by ascending brainstem pain pathways plus dysfunction of the endogenous descending brainstem pain inhibitory pathway. Although anti-calcitonin gene-related peptide (CGRP) medications partially address pain caused by the above factors, including decreased efficacy and tolerability from conventional therapy, some patients do not respond well to this treatment. Research suggests that initiating preventive anti-CGRP treatment at an early stage (during low frequency episodic migraine attacks) is more beneficial than commencing it during high frequency episodic attacks or when chronic migraine has begun. CONCLUSIONS The term "medication underuse" is underrecognized, but it holds significant importance. Optimal usage of acute care and preventive migraine medications could potentially prevent migraine chronification and improve the treatment of migraine attacks.
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Affiliation(s)
- Wanakorn Rattanawong
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Alan Rapoport
- Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anan Srikiatkhachorn
- Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
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24
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Lipton RB. Preventive Treatment of Migraine. Continuum (Minneap Minn) 2024; 30:364-378. [PMID: 38568488 DOI: 10.1212/con.0000000000001418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE This article describes strategies for the preventive treatment of migraine including the emerging role of calcitonin gene-related peptide (CGRP)-targeted therapies and introduces novel paradigms for the preventive treatment of migraine. LATEST DEVELOPMENTS Multiple migraine medications targeting CGRP have been introduced since 2018, including injectable monoclonal antibodies (ie, eptinezumab, erenumab, fremanezumab, and galcanezumab) and oral small-molecule CGRP receptor antagonists (ie, ubrogepant, rimegepant, atogepant, and zavegepant). With the exceptions of ubrogepant and zavegepant, which are approved only as acute treatments, all of these agents have demonstrated efficacy in the preventive treatment of migraine; the monoclonal antibodies and atogepant have evidence of effectiveness in adults with either episodic or chronic migraine. The safety and tolerability profiles of CGRP-targeted therapies in migraine are favorable. ESSENTIAL POINTS The goals of preventive migraine therapy include reducing the frequency, severity, duration, and disability associated with attacks, reducing the need for acute treatment and the risk of medication overuse, enhancing self-efficacy and health-related quality of life, and reducing headache-related distress and interictal burden. Six drugs targeting CGRP (four monoclonal antibodies and two gepants) are now available for the preventive treatment of episodic migraine in adults. The efficacy of CGRP-targeted medications in the acute and preventive treatment of migraine, together with good safety and tolerability, has led to the emergence of new approaches to preventive treatment.
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Pozo-Rosich P, Ashina M, Tepper SJ, Jensen S, Boserup LP, Josiassen MK, Sperling B. Eptinezumab Demonstrated Efficacy Regardless of Prior Preventive Migraine Treatment Failure Type: Post Hoc Analyses of the DELIVER Study. Neurol Ther 2024; 13:339-353. [PMID: 38236314 PMCID: PMC10951156 DOI: 10.1007/s40120-023-00575-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION In the DELIVER study, eptinezumab reduced monthly migraine days (MMDs) more than placebo in patients with 2-4 prior preventive migraine treatment failures. This post hoc analysis evaluated the efficacy of eptinezumab across the 24-week placebo-controlled period of the DELIVER study in subgroups defined by prior treatment failure type. METHODS DELIVER (NCT04418765) randomized adults with migraine to eptinezumab 100 mg, 300 mg, or placebo, administered intravenously every 12 weeks. Changes from baseline in MMDs and percentages of patients with ≥ 50% reduction from baseline in MMDs (≥ 50% migraine responder rates [MRRs]) were summarized in subgroups of patients defined by prior treatment failure type. Subgroups were not mutually exclusive and included patients for whom topiramate, beta blockers (metoprolol, propranolol), amitriptyline, and/or flunarizine had failed. RESULTS Across Weeks 1-12 in all subgroups, patients treated with eptinezumab experienced greater reductions from baseline in MMDs than those receiving placebo (reductions ranged from 4.5-5.5 vs 1.6-2.4, respectively), with larger reductions over Weeks 13-24. Similarly, ≥ 50% MRRs were consistently higher with eptinezumab than placebo and increased following a second infusion. CONCLUSION In all subgroups, regardless of prior preventive treatment failure type, eptinezumab demonstrated greater reductions in MMDs and higher MRRs compared with placebo. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT04418765).
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Affiliation(s)
- Patricia Pozo-Rosich
- Neurology Department, Headache Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
- Headache Research Group, Department of Medicine, Vall d'Hebron Institute of Research, Universitat Autonoma de Barcelona, Barcelona, Spain.
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Stewart J Tepper
- New England Institute for Neurology and Headache, Stamford, CT, USA
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Rikos D, Vikelis M, Dermitzakis EV, Soldatos P, Rallis D, Rudolf J, Andreou AP, Argyriou AA. Reporting Quality and Risk of Bias Analysis of Published RCTs Assessing Anti-CGRP Monoclonal Antibodies in Migraine Prophylaxis: A Systematic Review. J Clin Med 2024; 13:1964. [PMID: 38610729 PMCID: PMC11012539 DOI: 10.3390/jcm13071964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Objective: Phase II/III randomized clinical trials (RCTs) are vulnerable to many types of bias beyond randomization. Insights into the reporting quality of RCTs involving migraine patients treated with monoclonal antibodies targeting the calcitonin gene-related peptide system (anti-CGRP MAbs) are currently lacking. Our aim was to analyze the reporting quality of phase II/III RCTs involving migraine patients treated with anti-CGRP MAbs. Methods: A systematic search was performed on the PubMed and EMBASE databases, according to PRISMA guidelines, for relevant RCTs in either episodic or chronic migraine prevention. Additionally, an adapted version of the 2010 CONSORT statement checklist was utilized. The ROBvis online tool was used to document the risk of bias. Results: From the initially identified 179 articles, we finally found 31 RCTs that were eligible for evaluation. The average CONSORT compliance was 88.7% (69.7-100%), while 93.5% (N = 29) of the articles had a compliance greater than 75%. Twenty-eight CONSORT items were reported in more than 75% of the articles. The average compliance of the analyzed RCTs was 93.9% for Galcanezumab, 91.3% for Fremanezumab, followed by 85.4% for Erenumab and Eptinezumab studies. Implementation of the ROB2 tool showed some concerning "missing information" arising from the inadequate reporting. Specifically, 50% of the studies (N = 16) were categorized as having inadequate information regarding the randomization process. Conclusions: Adequate reporting quality was disclosed in the evaluated RCTs with anti-CGRP MAbs in migraine prevention. However, some methodological issues need to be highlighted to be addressed in future studies assessing the efficacy of new molecules targeting CGRP or other candidate pathways implicated in migraine pathophysiology.
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Affiliation(s)
| | - Michail Vikelis
- Headache Clinic, Mediterraneo Hospital, 16675 Athens, Greece;
| | | | | | - Dimitrios Rallis
- Department of Neurology, Tzaneio General Hospital of Piraeus, 18536 Athens, Greece;
| | - Jobst Rudolf
- Department of Neurology, Papageorgiou General Hospital of Thessaloniki, 54645 Thessaloniki, Greece;
| | - Anna P. Andreou
- Headache Centre, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK;
- Headache Research-Wolfson Sensory, Pain and Regeneration Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE1 1LU, UK
| | - Andreas A. Argyriou
- Headache Outpatient Clinic, Department of Neurology, Agios Andreas General Hospital of Patras, 26335 Patras, Greece;
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Ciciarelli MC, Simioni CVDMG, Londero RG. Headaches in adults in supplementary health: management. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e023D701. [PMID: 38511747 PMCID: PMC10941913 DOI: 10.1590/1806-9282.023d701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 03/22/2024]
Affiliation(s)
| | | | - Renata Gomes Londero
- Brazilian Academy of Neurology, Porto Alegre Clinical Hospital – Porto Alegre (RS), Brazil
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Irimia P, Santos-Lasaosa S, Pozo-Rosich P, Leira R, Pascual J, Láinez JM. Eptinezumab for the preventive treatment of episodic and chronic migraine: a narrative review. Front Neurol 2024; 15:1355877. [PMID: 38523607 PMCID: PMC10959239 DOI: 10.3389/fneur.2024.1355877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/19/2024] [Indexed: 03/26/2024] Open
Abstract
Eptinezumab, a monoclonal antibody that targets calcitonin gene-related peptide (CGRP), was recently approved in Europe for the prophylactic treatment of migraine in adults who have at least four migraine days a month. Eptinezumab is administered by intravenous infusion every 12 weeks. During recent months, a considerable amount of evidence from eptinezumab trials has been published. The aim of this review is to describe the existing evidence on the tolerability, safety and efficacy of eptinezumab in patients with migraine. Data from randomized (PROMISE-1, PROMISE-2, RELIEF and DELIVER) and open-label (PREVAIL) phase 3 clinical trials have demonstrated the favorable effect of eptinezumab in migraine symptoms from first day of treatment. These studies showed that eptinezumab results in an overall reduction in mean monthly migraine days (MMDs), increases in the ≥50% and ≥ 75% migraine responder rates (MRRs) and improvements in patient-reported outcome measures in both patients with episodic migraine (EM) and with chronic migraine (CM), including patients who failed previous preventive treatments. The RELIEF trial also showed that eptinezumab, within 2 h of administration, reduced headache pain, migraine-associated symptoms and acute medication use when administered during a migraine attack. Eptinezumab benefits manifested as early as day 1 after dosing and with the subsequent doses lasted up to at least 2 years. Treatment-emergent adverse events reported by ≥2% of patients included upper respiratory tract infection and fatigue. Current evidence demonstrates that eptinezumab has a potent, fast-acting, sustained migraine preventive effect in patients with EM and CM. Eptinezumab has also shown to be well tolerated, supporting its use in the treatment of patients with migraine and inclusion in the current migraine therapeutic options.
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Affiliation(s)
| | - Sonia Santos-Lasaosa
- Aragon Institute for Health Research (IIS Aragon), Hospital Clínico Universitario Lozano Blesa, University of Zaragoza, Zaragoza, Spain
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, VHIR, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Rogelio Leira
- Department of Neurology, Headache Unit, Hospital Clínico Universitario, Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Julio Pascual
- Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria and IDIVAL, Santander, Spain
| | - José Miguel Láinez
- Department of Neurology, Hospital Clínico Universitario, Universidad Católica de Valencia, Valencia, Spain
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Haridas MP, Tripathy A, Maiti R, Srinivasan A. Efficacy and Safety of Anti-CGRP Monoclonal Antibodies in Prevention of Chronic Migraine: A Bayesian Network Meta-analysis. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2024; 22:23-32. [PMID: 38247409 PMCID: PMC10811399 DOI: 10.9758/cpn.23.1109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 01/23/2024]
Abstract
Due to the unmet needs in the management of migraine, a primary headache, and disabling disorder, the past decade has focused on developing monoclonal antibodies (mAbs) against the calcitonin-gene-related peptide (CGRP) as migraine prophylactic agents. The objective of the study was to evaluate the efficacy and safety of various anti-CGRP mAbs in the prevention of chronic migraine. Network meta-analysis (NMA) was performed using the Bayesian framework to estimate the efficacy and safety of mAbs after performing a literature search in PubMed, MEDLINE, Cochrane database, and International Clinical Trial Registry Platform (ICTRP). The outcomes calculated were in terms of mean difference (MD) or odds ratio (OR) with a 95% credible interval (95%CrI). Network graphs were constructed and node-split analysis was done to analyze the inconsistency. The NMA included a total of 10 clinical trials. Galacanezumab (120 mg) (MD: -2.7; 95%CrI: -4.8 to -0.83) was found to be better than other mAbs in terms of the difference in mean migraine days (MMD). Fremanezumab quarterly dose administration showed the best response (OR: 2.9; 95%CrI: 1.9 to 4.6) in terms of responder rate. Eptinezumab was found to be safer (OR: 0.88; 95%CrI: 0.61-1.3) as compared to other mAbs in terms of the rate of adverse events. Fremanezumab (quarterly) ranked better in terms of response rate, and eptinezumab was found to be the safest in the prophylactic management of migraine. Galacenequmab was better at reducing MMD. Further studies are needed to evaluate the long-term safety, efficacy, and use of mAbs in migraine patients.
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Affiliation(s)
| | - Amruta Tripathy
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Rituparna Maiti
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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Mainland RL, Skinner CR, Saary J. Aeromedical Risk of Migraine. Aerosp Med Hum Perform 2024; 95:101-112. [PMID: 38263111 DOI: 10.3357/amhp.6291.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
INTRODUCTION: Migraine is a common condition that can carry considerable risk to aeromedical duties. Because randomized controlled trials are not an appropriate method to evaluate flight safety risk for medical conditions that may cause subtle or sudden incapacitation, the determination of fitness-to-fly must be based on risk assessments informed by extrapolated evidence. Therefore, we conducted a review of current literature to provide background information to inform the aeromedical risk assessment of migraine using a risk matrix approach.METHODS: We identified studies on topics pertinent to conducting an aeromedical risk assessment of migraine. We generated an overview of the literature synthesizing the findings of articles retrieved from searches of Scopus, Ovid, PubMed, and the Cochrane Library published in English from all years, in both general and aircrew populations. International headache and neurology guidelines, as well as headache policies from the U.S. Air Force, were also reviewed.RESULTS: This review includes information on the following topics relevant to conducting an evidence-based risk assessment of migraine: diagnosis, prevalence, incidence, natural course, clinical presentation, triggers, comorbidities, neuroimaging, implications of family history, and efficacy of pharmacological and nonpharmacological therapies.DISCUSSION: This review summarizes current literature on migraine for use in a risk matrix approach to the aeromedical assessment of migraine in prospective and current aircrew. Awareness of the most current epidemiological data related to a variety of migraine parameters facilitates an evidence-based risk assessment of migraine in aircrew and requires iterative updates as new information becomes available.Mainland RL, Skinner CR, Saary J. Aeromedical risk of migraine. Aerosp Med Hum Perform. 2024; 95(2):101-112.
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Schwedt TJ, Myers Oakes TM, Martinez JM, Vargas BB, Pandey H, Pearlman EM, Richardson DR, Varnado OJ, Cobas Meyer M, Goadsby PJ. Comparing the Efficacy and Safety of Galcanezumab Versus Rimegepant for Prevention of Episodic Migraine: Results from a Randomized, Controlled Clinical Trial. Neurol Ther 2024; 13:85-105. [PMID: 37948006 PMCID: PMC10787669 DOI: 10.1007/s40120-023-00562-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION There have been no prior trials directly comparing the efficacy of different calcitonin gene-related peptide (CGRP) antagonists for migraine prevention. Reported are the results from the first head-to-head study of two CGRP antagonists, galcanezumab (monoclonal antibody) versus rimegepant (gepant), for the prevention of episodic migraine. METHODS In this 3-month, double-blind, double-dummy study, participants were randomized (1:1) to subcutaneous (SC) galcanezumab 120 mg per month (after a 240 mg loading dose) and a placebo oral disintegrating tablet (ODT) every other day (q.o.d.) or to rimegepant 75 mg ODT q.o.d. and a monthly SC placebo. The primary endpoint was the proportion of participants with a ≥ 50% reduction in migraine headache days per month from baseline across the 3-month double-blind treatment period. Key secondary endpoints were overall mean change from baseline in: migraine headache days per month across 3 months and at month 3, 2, and 1; migraine headache days per month with acute migraine medication use; Migraine-Specific Quality of Life Questionnaire Role Function-Restrictive domain score at month 3; and a ≥ 75% and 100% reduction from baseline in migraine headache days per month across 3 months. RESULTS Of 580 randomized participants (galcanezumab: 287, rimegepant: 293; mean age: 42 years), 83% were female and 81% Caucasian. Galcanezumab was not superior to rimegepant in achieving a ≥ 50% reduction from baseline in migraine headache days per month (62% versus 61% respectively; P = 0.70). Given the pre-specified multiple testing procedure, key secondary endpoints cannot be considered statistically significant. Overall, treatment-emergent adverse events were reported by 21% of participants, with no significant differences between study intervention groups. CONCLUSIONS Galcanezumab was not superior to rimegepant for the primary endpoint; however, both interventions demonstrated efficacy as preventive treatments in participants with episodic migraine. The efficacy and safety profiles observed in galcanezumab-treated participants were consistent with previous studies. TRIAL REGISTRATION ClinTrials.gov-NCT05127486 (I5Q-MC-CGBD).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Peter J Goadsby
- NIHR King's Clinical Research Facility and Headache Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Wolfson SPRRC, London, UK
- Department of Neurology, University of California, Los Angeles, CA, USA
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Ashina M, Lipton RB, Ailani J, Versijpt J, Sacco S, Mitsikostas DD, Christoffersen CL, Sperling B, Ettrup A. Responder rates with eptinezumab over 24 weeks in patients with prior preventive migraine treatment failures: post hoc analysis of the DELIVER randomized clinical trial. Eur J Neurol 2024; 31:e16131. [PMID: 37955557 PMCID: PMC11235785 DOI: 10.1111/ene.16131] [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: 07/21/2023] [Accepted: 10/19/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND AND PURPOSE Eptinezumab reduced monthly migraine days more than placebo in the DELIVER study, a clinical trial with patients with difficult-to-treat migraine and prior preventive treatment failures. This post hoc analysis assesses the sustained response to eptinezumab at the population and patient level and evaluates the potential for response in initial non-responders. METHODS Adults with chronic or episodic migraine and two to four prior preventive treatment failures were randomized to eptinezumab 100 mg, 300 mg or placebo every 12 weeks. Primary outcomes in this post hoc analysis are the proportion of patients with ≥30%, ≥50% or ≥75% reduction in monthly migraine days (i.e., migraine responder rates [MRRs]) during weeks 1-12 and weeks 13-24 and across 4-week intervals. Secondary outcomes are maintenance and shifts in MRRs from weeks 1-12 to weeks 13-24. RESULTS Between weeks 1-12 and 13-24, ≥30% MRRs increased from 65.9% to 70.4% (100 mg) and from 71.0% to 74.5% (300 mg), versus 36.9% to 43.1% (placebo). The ≥50% and ≥75% MRRs were sustained or increased over the 24-week period. The largest increase in ≥30% MRRs occurred after the second infusion with eptinezumab. The percentage of initial non-responders (<30% MRRs during weeks 1-12) who experienced response (≥30% MRRs during weeks 13-24) to the second dose was 34.7% (100 mg) and 30.4% (300 mg) with eptinezumab versus 21.1% with placebo. CONCLUSION Across MRR thresholds, most patients who responded to eptinezumab during weeks 1-12 maintained or improved response during weeks 13-24. More than one-third of initial non-responders became responders after their second infusion.
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Affiliation(s)
- Messoud Ashina
- Danish Headache Center, Rigshospitalet GlostrupUniversity of CopenhagenCopenhagenDenmark
| | - Richard B. Lipton
- Department of NeurologyAlbert Einstein College of MedicineBronxNYUSA
| | - Jessica Ailani
- Department of NeurologyGeorgetown University HospitalWashingtonDCUSA
| | - Jan Versijpt
- Department of NeurologyVrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel)BrusselsBelgium
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'AquilaL'AquilaItaly
| | - Dimos D. Mitsikostas
- First Neurology Department, Aeginition Hospital, Medical SchoolNational and Kapodistrian University of AthensAthensGreece
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Shibata M, Fujita K, Hoshino E, Minami K, Koizumi K, Okada S, Sakai F. Real-world experience with calcitonin gene-related peptide-targeted antibodies for migraine prevention: a retrospective observational cohort study at two Japanese headache centers. BMC Neurol 2024; 24:32. [PMID: 38238659 PMCID: PMC10795407 DOI: 10.1186/s12883-023-03521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/22/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Although randomized controlled trials (RCTs) have shown that calcitonin gene-related peptide (CGRP)-targeted monoclonal antibodies (CGRP mAbs) are an efficacious and safe therapeutic modality for migraine prevention, their clinical benefits have not been well validated in Japanese patients in the real-world setting. The present study aimed to evaluate the real-world efficacy and safety of galcanezumab, fremanezumab, and erenumab in Japanese patients with migraine. METHODS This observational retrospective cohort study was conducted at two headache centers in Japan. Patients with migraine who had experienced treatment failure with at least one traditional oral migraine preventive agent were treated with a CGRP mAb de novo. The primary efficacy endpoints were the changes from baseline in monthly migraine days (MMDs) and Headache Impact Test-6 (HIT-6) score after 3 dosing intervals (V3). We explored whether demographic and clinical characteristics predicted therapeutic outcomes at V3. RESULTS Sixty-eight patients who completed three doses of a CGRP mAb (85.3% female [58/68], mean age: 46.2 ± 13.1 years) were included in the analysis. There were 19 patients with chronic migraine. The baseline MMDs were 13.4 ± 6.0. After 3 doses, the MMDs significantly decreased to 7.4 ± 5.5 (p < 0.0001), and the 50% response rate was 50.0%. HIT-6 score was significantly reduced from 66.7 ± 5.4 to 56.2 ± 8.7 after 3 doses (P = 0.0001). There was a positive correlation between the changes in MMDs and HIT-6 score from baseline after 2 doses (p = 0.0189). Those who achieved a ≥ 50% therapeutic response after the first and second doses were significantly more likely to do so at V3 (crude odds ratio: 3.474 [95% CI: 1.037 to 10.4], p = 0.0467). The most frequent adverse event was constipation (7.4%). None of the adverse events were serious, and there was no need for treatment discontinuation. CONCLUSIONS This real-world study demonstrated that CGRP mAbs conferred Japanese patients with efficacious and safe migraine prevention, and an initial positive therapeutic response was predictive of subsequent favorable outcomes. Concomitant measurement of MMDs and HIT-6 score was useful in evaluating the efficacy of CGRP mAbs in migraine prevention.
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Affiliation(s)
- Mamoru Shibata
- Department of Neurology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, 272-8513, Japan.
| | - Kazuki Fujita
- Saitama International Headache Center, Saitama Neuropsychiatric Institute, Saitama, Japan
| | - Eri Hoshino
- Saitama International Headache Center, Saitama Neuropsychiatric Institute, Saitama, Japan
| | - Kazushi Minami
- Department of Neurology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, 272-8513, Japan
| | - Kenzo Koizumi
- Department of Neurology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, 272-8513, Japan
| | - Satoshi Okada
- Department of Neurology, Tokyo Dental College Ichikawa General Hospital, 5-11-13 Sugano, Ichikawa, Chiba, 272-8513, Japan
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Mínguez-Olaondo A, López-Bravo A, Quintas S, Nieves-Castellanos C, Layos-Romero A, Belvís R, Irimia P, Díaz-Insa S. [New therapeutic era for migraine attacks with recently approved monoclonal antibodies, ditans and gepants]. Rev Neurol 2024; 78:47-57. [PMID: 38223948 PMCID: PMC11064959 DOI: 10.33588/rn.7802.2023176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Treatment of migraine attacks is advised in all patients, using non-steroidal anti-inflammatory drugs when the pain is mild and triptans when the pain intensity is moderate-severe. However, the effectiveness of these drugs is moderate, a high percentage of patients have side effects, and triptans are contraindicated in people with a history of stroke, ischaemic heart disease or poorly controlled hypertension. Hence, there is an urgent need for new therapeutic alternatives. In recent years, new drugs for migraine attacks have become available, most notably ditans (lasmiditan) and gepants (ubrogepant and rimegepant). Furthermore, eptinezumab, which has been approved for the preventive treatment of migraine in adults, has also been used for migraine attacks. This manuscript reviews the efficacy and safety results of the new drugs for migraines that will soon be on the market.
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Affiliation(s)
- A Mínguez-Olaondo
- Instituto de Investigación Sanitaria Biogipuzkoa, Donostia-San Sebastián, España
- Athenea Neuroclinics, Donostia-San Sebastián, España
- Hospital Universitario Donostia-Osakidetza, Donostia-San Sebastián, España
- Universidad de Deusto, Donostia-San Sebastián, España
| | - A López-Bravo
- Hospital Reina Sofía, Tudela, España
- Instituto de Investigación Sanitaria Aragón, Zaragoza, España
| | - S Quintas
- Hospital Universitario de La Princesa, Madrid, España
| | - C Nieves-Castellanos
- Hospital Universitario y Politécnico La Fe, Valencia, España
- Instituto de Investigación Sanitaria La Fe, Valencia, España
| | | | - R Belvís
- Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, España
| | - P Irimia
- Universidad de Navarra, Pamplona, España
| | - S Díaz-Insa
- Hospital Universitario y Politécnico La Fe, Valencia, España
- Instituto de Investigación Sanitaria La Fe, Valencia, España
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Deligianni CI, Martelletti P, Mitsikostas DD. Placebo responses vary by route of administration in migraine prevention trials. What does this mean? J Med Econ 2024; 27:442-444. [PMID: 38425286 DOI: 10.1080/13696998.2024.2323900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/23/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Christina I Deligianni
- Neurology Department, Athens Naval Hospital, Athens, Greece
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian Universtiy of Athens, Athens, Greece
| | - Paolo Martelletti
- School of Health Sciences, Unitelma Sapienza University of Rome, Rome, Italy
| | - Dimos D Mitsikostas
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian Universtiy of Athens, Athens, Greece
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Ihara K, Takizawa T, Watanabe N, Nakahara J, Martelletti P. Potential benefits and possible risks of CGRP-targeted multitherapy in migraine. Expert Opin Drug Metab Toxicol 2024; 20:1-4. [PMID: 38323326 DOI: 10.1080/17425255.2024.2316131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 02/08/2024]
Affiliation(s)
- Keiko Ihara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
- Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Narumi Watanabe
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Paolo Martelletti
- School of Health Sciences, Unitelma Sapienza University of Rome, Rome, Italy
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Chase BA, Semenov I, Rubin S, Meyers S, Mark A, Makhlouf T, Chirayil TT, Maraganore D, Wei J, Zheng SL, Xu J, Epshteyn A, Pham A, Frigerio R, Markopoulou K. Characteristics associated with response to subcutaneously administered anti-CGRP monoclonal antibody medications in a real-world community cohort of persons living with migraine: A retrospective clinical and genetic study. Headache 2024; 64:68-92. [PMID: 38071464 DOI: 10.1111/head.14655] [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: 06/20/2023] [Revised: 10/12/2023] [Accepted: 10/20/2023] [Indexed: 01/23/2024]
Abstract
OBJECTIVE To evaluate response to anti-calcitonin gene-related peptide (CGRP) migraine preventives in a real-world community cohort of persons living with migraine and to identify clinical and genetic characteristics associated with efficacious response. BACKGROUND Erenumab-aooeb, fremanezumab-vrfm, and galcanezumab-gnlm target CGRP or its receptor; however, many patients are non-responsive. METHODS In this retrospective clinical and genetic study, we identified 1077 adult patients who satisfied the International Classification of Headache Disorders, 3rd edition, criteria for migraine without aura, migraine with aura, or chronic migraine and who were prescribed an anti-CGRP migraine preventive between May 2018 and May 2021. Screening of 558 patients identified 289 with data at baseline and first follow-up visits; data were available for 161 patients at a second follow-up visit. The primary outcome was migraine days per month (MDM). In 198 genotyped patients, we evaluated associations between responders (i.e., patients with ≥50% reduction in MDM at follow-up) and genes involved in CGRP signaling or pharmacological response, and genetic and polygenic risk scores. RESULTS The median time to first follow-up was 4.4 (0.9-22) months after preventive start. At the second follow-up, 5.7 (0.9-13) months later, 145 patients had continued on the same preventive. Preventives had strong, persistent effects in reducing MDM in responders (follow-up 1: η2 = 0.26, follow-up 2: η2 = 0.22). At the first but not second follow-up: galcanezumab had a larger effect than erenumab, while no difference was seen at either follow-up between galcanezumab and fremanezumab or fremanezumab and erenumab. The decrease in MDM at follow-up was generally proportional to baseline MDM, larger in females, and increased with months on medication. At the first follow-up only, patients with prior hospitalization for migraine or who had not responded to more preventive regimens had a smaller decrease in MDM. Reasons for stopping or switching a preventive varied between medications and were often related to cost and insurance coverage. At both follow-ups, patient tolerance (1: 92.2% [262/284]; 2: 95.2% [141/145]) and continued use (1: 77.5% [224/289]; 2: 80.6% [116/145]) were high and similar across preventives. Response consistency (always non-responders: 31.7% [46/145]; always responders: 56.5% [82/145], and one-time only responders: 11.7% [17/145]) was also similar across preventives. Non-responder status had nominally significant associations with rs12615320-G in RAMP1 (odds ratio [95% confidence interval]: 4.7 [1.5, 14.7]), and rs4680-A in COMT (0.6[0.4, 0.9]). Non-responders had a lower mean genetic risk score than responders (1.0 vs. 1.1; t(df) = -1.75(174.84), p = 0.041), and the fraction of responders increased with genetic and polygenic risk score percentile. CONCLUSIONS In this real-world setting, anti-CGRP preventives reduced MDM persistently and had similar and large effect sizes on MDM reduction; however, clinical and genetic factors influenced response.
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Affiliation(s)
- Bruce A Chase
- Health Information Technology, NorthShore University HealthSystem, Skokie, Illinois, USA
- Pritzker School of Medicine, Chicago, Illinois, USA
| | - Irene Semenov
- Pritzker School of Medicine, Chicago, Illinois, USA
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Susan Rubin
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Steven Meyers
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Angela Mark
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Thomas Makhlouf
- Pritzker School of Medicine, Chicago, Illinois, USA
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Tanya T Chirayil
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Jun Wei
- Center for Individualized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Siqun L Zheng
- Center for Individualized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jianfeng Xu
- Center for Individualized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Alexander Epshteyn
- Health Information Technology, NorthShore University HealthSystem, Skokie, Illinois, USA
| | - Anna Pham
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Roberta Frigerio
- Pritzker School of Medicine, Chicago, Illinois, USA
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Katerina Markopoulou
- Department of Neurology, NorthShore University HealthSystem, Evanston, Illinois, USA
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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Yu S, Zhou J, Luo G, Xiao Z, Ettrup A, Jansson G, Florea I, Ranc K, Pozo-Rosich P. Efficacy and safety of eptinezumab in patients with chronic migraine and medication-overuse headache: a randomized, double-blind, placebo-controlled study. BMC Neurol 2023; 23:441. [PMID: 38102535 PMCID: PMC10722704 DOI: 10.1186/s12883-023-03477-z] [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: 06/28/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND For some people with migraine, despite taking greater amounts of acute headache medication (AHM), they develop an increase in monthly headache days. This cycle of increasing headache days, and in turn AHM use, can lead to a secondary headache disorder called medication-overuse headache (MOH). Preventive medications can prevent migraine from occurring and reduce reliance on AHMs, thereby preventing the cycle of MOH. This study was performed to evaluate the efficacy and safety of eptinezumab to prevent migraine/headache in a mainly Asian patient population with a dual diagnosis of chronic migraine and MOH. METHODS SUNLIGHT was a phase 3, multicenter, double-blind, parallel-group, placebo-controlled trial. Patients aged 18-75 years with ≥ 8 migraine days/month and a diagnosis of MOH were randomly allocated (1:1) to one of two treatment groups: eptinezumab 100 mg or placebo. Monthly migraine days (MMDs) were captured using a daily electronic diary; the change from baseline in the number of MMDs over Weeks 1-12 was the primary efficacy endpoint. RESULTS Patients were randomized to eptinezumab 100 mg (n = 93) or placebo (n = 100). Over Weeks 1-12, eptinezumab reduced mean MMDs more than placebo (difference between treatments was -1.2; p = 0.1484). Differences between treatment groups with p-values below 0.05 favoring eptinezumab were observed in 3 out of the 6 key secondary endpoints. CONCLUSION All endpoints numerically favored eptinezumab treatment when compared to placebo; however, this study did not meet its primary endpoint and is therefore negative. No new safety signals were identified in this study, like previous reports that confirmed the safety and tolerability of eptinezumab treatment. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04772742 (26/02/2021).
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Affiliation(s)
- Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing, China.
| | - Jiying Zhou
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guogang Luo
- Neurology Department, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zheman Xiao
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | | | | | | | | | - Patricia Pozo-Rosich
- Neurology Department, Headache Unit, Vall d'Hebron University Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, Vall d'Hebron Research Institute, Department de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
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Kowacs PA, Sampaio Rocha-Filho PA, Peres MFP, Edvinsson L. The history and rationale of the development of new drugs for migraine treatment. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1084-1097. [PMID: 38157876 PMCID: PMC10756794 DOI: 10.1055/s-0043-1777723] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
Migraine is one of the most prevalent and disabling diseases in the world. Migraine attack treatments and prophylactic treatments of this disease are essential to lessen its individual, social, and economic impact. This is a narrative review of the main drugs used for treating migraine, as well as the experimental models and the theoretical frameworks that led to their development. Ergot derivatives, triptans, non-steroid anti-inflammatory drugs, tricyclic antidepressants, beta-blockers,: flunarizine,: valproic acid,: topiramate, onabotulinumtoxin A, ditans, monoclonal antibodies against CGRP and its receptor, and gepants are discussed. Possible therapeutic targets for the development of new drugs that are under development are also addressed. Many of the drugs currently in use for treating migraine were developed for the treatment of other diseases, but have proven effective for the treatment of migraine, expanding knowledge about the disease. With a better understanding of the pathophysiology of migraine, new drugs have been and continue to be developed specifically for the treatment of this disease.
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Affiliation(s)
- Pedro André Kowacs
- Instituto de Neurologia de Curitiba, Serviço de Neurologia, Curitiba PR, Brazil.
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Unidade do Sistema Nervoso, Curitiba PR, Brazil.
| | - Pedro Augusto Sampaio Rocha-Filho
- Universidade Federal de Pernambuco, Centro de Ciências Médicas, Divisão de Neuropsiquiatria, Recife PE, Brazil.
- Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Clínica de Cefaleia, Recife PE, Brazil.
| | | | - Lars Edvinsson
- Lund University, Institute of Clinical Sciences, 22185 Lund, Sweden.
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Tana C, Cipollone F, Giamberardino MA, Martelletti P. New drugs targeting calcitonin gene-related peptide for the management of migraines. Expert Opin Emerg Drugs 2023; 28:233-240. [PMID: 37996401 DOI: 10.1080/14728214.2023.2288334] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Significant advances in migraine research have contributed to the development of new drugs for the treatment of migraine. Monoclonal antibodies (mAbs) against Calcitonin Gene-Related Peptide (CGRP) or its receptor and CGRP receptor antagonists (gepants) have been associated with a good safety profile and resulted in an overall efficacy in reducing the number of monthly migraine days both in episodic and chronic forms of migraine. AREAS COVERED The results from main investigation studies (phase 2 or 3) of CGRP-targeting drugs (both anti-CGRP mAbs and gepants) are reported in this expert-opinion review. EXPERT OPINION The introduction of new drugs targeting CGRP is a significant breakthrough in the migraine field, and represents a new generation of therapeutic agents that are available to manage migraine. The evaluation of efficacy and safety in the long-term follow-up and the development of trials comparing the available drugs could improve the current knowledge. The economic sustainability of these drugs remains to be clarified, and a cost-cutting campaign should be promoted based on the high burden of migraine.
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Affiliation(s)
- Claudio Tana
- Headache Center, Geriatrics Clinic, SS Annunziata Hospital of Chieti, Chieti, Italy
| | - Francesco Cipollone
- Department of Medicine and Science of Aging, Medical Clinic, SS. Annunziata Hospital of Chieti, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Maria Adele Giamberardino
- Headache Center, Geriatrics Clinic, SS Annunziata Hospital of Chieti, Chieti, Italy
- Department of Medicine and Science of Aging and CAST, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Paolo Martelletti
- School of Health Sciences, Unitelma Sapienza University of Rome, Rome, Italy
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Takizawa T, Ihara K, Uno S, Ohtani S, Watanabe N, Imai N, Nakahara J, Hori S, Garcia-Azorin D, Martelletti P. Metabolic and toxicological considerations regarding CGRP mAbs and CGRP antagonists to treat migraine in COVID-19 patients: a narrative review. Expert Opin Drug Metab Toxicol 2023; 19:951-967. [PMID: 37925645 DOI: 10.1080/17425255.2023.2280221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Migraine pharmacological therapies targeting calcitonin gene-related peptide (CGRP), including monoclonal antibodies and gepants, have shown clinical effect and optimal tolerability. Interactions between treatments of COVID-19 and CGRP-related drugs have not been reviewed. AREAS COVERED An overview of CGRP, a description of the characteristics of each CGRP-related drug and its response predictors, COVID-19 and its treatment, the interactions between CGRP-related drugs and COVID-19 treatment, COVID-19 and vaccination-induced headache, and the neurological consequences of Covid-19. EXPERT OPINION Clinicians should be careful about using gepants for COVID-19 patients, due to the potential drug interactions with drugs metabolized via CYP3A4 cytochrome. In particular, COVID-19 treatment (especially nirmatrelvir packaged with ritonavir, as Paxlovid) should be considered cautiously. It is advisable to stop or adjust the dose (10 mg atogepant when used for episodic migraine) of gepants when using Paxlovid (except for zavegepant). CGRP moncolconal antibodies (CGRP-mAbs) do not have drug - drug interactions, but a few days' interval between a COVID-19 vaccination and the use of CGRP mAbs is recommended to allow the accurate identification of the possible adverse effects, such as injection site reaction. Covid-19- and vaccination-related headache are known to occur. Whether CGRP-related drugs would be of benefit in these circumstances is not yet known.
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Affiliation(s)
- Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Keiko Ihara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
- Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Shunsuke Uno
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Seiya Ohtani
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Narumi Watanabe
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Noboru Imai
- Department of Neurology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Satoko Hori
- Division of Drug Informatics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - David Garcia-Azorin
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Paolo Martelletti
- School of Health Sciences, Unitelma Sapienza University of Rome, Rome, Italy
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Zhong Y, Wang J, Li H, Yang S, Li X, Gao H, Chen G. Efficacy and safety of eptinezumab for migraine: A systematic review and meta-analysis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2023; 28:82. [PMID: 38292336 PMCID: PMC10826853 DOI: 10.4103/jrms.jrms_306_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/08/2023] [Accepted: 09/22/2023] [Indexed: 02/01/2024]
Abstract
Background Calcitonin gene-related peptides (CGRP) have been considered a new effective means to prevent and treat migraine. Eptinezumab is a new class of CGRP antagonists that has been ratified for clinical treatment. The purpose of this systematic review was to assess and contrast the therapeutic effect and safety of eptinezumab in the management of migraine in comparison with a placebo. Materials and Methods We systematically searched PubMed, Embase, Cochrane Library, and the US National Institutes of Health Clinical Trials Registry from the earliest date to February 16, 2023, for randomized controlled trials (RCTs). The mean difference (MD) and risk ratio (RR) were chosen to assess clinical indicators. Results In total, there were 2, 739 patients in four RCTs, who were ultimately included. Our summarized results showed that eptinezumab had better healing efficacy compared to placebo with respect to monthly migraine days (MD = -1.56, 95% confidence interval [CI]: -2.32, -0.79, P < 0.001), improving ≥75% migraine responder rate (RR = 1.80, 95% CI: 1.40, 2.33, P < 0.001), ≥50% migraine responder rate (RR = 1.46, 95% CI: 1.33, 1.61, P < 0.001), and 100% migraine responder rate (RR = 2.41, 95% CI: 1.08, 5.38, P < 0.001). Furthermore, compared with placebo, there was no significant increase for treatment-related adverse events (RR = 1.01, 95% CI 0.94, 1.10, P = 0.71) and serious AEs (RR = 0.93, 95% CI 0.46, 1.90, P = 0.84). It was found that all dosages except for 10 mg had significant efficacy compared with placebo, especially 300 mg (P < 0.001). Conclusion Eptinezumab has good healing efficacy and insignificant adverse effects in treating migraine, particularly the dosage of 300 mg.
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Affiliation(s)
- Yi Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu, China
| | - Jiahe Wang
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin City, Jiangsu Province, China
| | - Hang Li
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu, China
| | - Siyuan Yang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu, China
| | - Xiang Li
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu, China
| | - Heng Gao
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin City, Jiangsu Province, China
| | - Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu, China
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Altamura C, Brunelli N, Marcosano M, Alesina A, Fofi L, Vernieri F. Eptinezumab for the Prevention of Migraine: Clinical Utility, Patient Preferences and Selection - A Narrative Review. Ther Clin Risk Manag 2023; 19:959-971. [PMID: 38023625 PMCID: PMC10680459 DOI: 10.2147/tcrm.s263824] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/18/2023] [Indexed: 12/01/2023] Open
Abstract
The new Calcitonin Gene-Related Peptide (CGRP)-targeted therapies have proven high efficacy and tolerability in episodic and chronic migraine. Eptinezumab is a humanized monoclonal antibody that selectively binds CGRP with high affinity. Eptinezumab was approved by the Food and Drug Administration on February 21st, 2020, for the preventive treatment of migraine in adults. It is administered intravenously over 30 minutes with a standard dose of 100 mg and has a T-max of 30 minutes-1 hour and a half-life of 27 days. These pharmacological properties allow for a very rapid onset of effect and a quarterly administration. It is the first time that a preventive treatment for migraine can be offered as an intravenous administration. As the range of therapeutic possibilities in migraine is expanding, the treatment process must include common decision-making, where physicians should explain in detail to patients the different characteristics of treatment options beyond efficacy and side effects. Patients can now express a preference on a range of opportunities: pharmacological versus non-pharmacological approaches, route of administration, frequency of administration, efficacy, rapidity, side effects, costs, the possibility of titration or dosing, and durability of effectiveness at suspension. Also, patient preferences can be influenced by age, country, migraine severity, and earlier experience with CGRP-targeted therapies. Besides, adherence may be influenced by several factors, including route and the schedule of administration. This narrative review describes a new perspective from the patient's point of view. Clinicians should ally with patients to select treatments that meet each patient's needs and thus apply a tailored approach, addressing not only headaches. In this way, physicians would care for the patients globally and stand out their preferences on different aspects of treatment. Besides, healthcare professionals shall be aware that patients' beliefs about therapies are subject to change with increasing experience with new therapeutic approaches.
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Affiliation(s)
- Claudia Altamura
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Nicoletta Brunelli
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Marilena Marcosano
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Alessandro Alesina
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Luisa Fofi
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Fabrizio Vernieri
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, 00128, Italy
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
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Ashina M, Tepper SJ, Gendolla A, Sperling B, Ettrup A, Josiassen MK, Starling AJ. Long-term effectiveness of eptinezumab in patients with migraine and prior preventive treatment failures: extension of a randomized controlled trial. J Headache Pain 2023; 24:155. [PMID: 37985968 PMCID: PMC10662788 DOI: 10.1186/s10194-023-01688-w] [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: 10/04/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Eptinezumab demonstrated efficacy in adults with migraine and prior preventive treatment failures in the placebo-controlled phase of the DELIVER clinical trial; its long-term effectiveness in this population has not yet been reported. The objective of this study was to evaluate the long-term effectiveness of eptinezumab in a migraine patient population during the 48-week extension phase of DELIVER. METHODS DELIVER was conducted June 1, 2020 to September 15, 2022. 865 adults with migraine, with documented evidence of 2-4 prior preventive migraine treatment failures and with completion of the 24-week placebo-controlled period of DELIVER received eptinezumab (100 or 300 mg) during the dose-blinded extension, either continuing their randomized dose or, if originally receiving placebo, were randomized 1:1 to an eptinezumab dose (100 or 300 mg). A mixed model for repeated measures was used to evaluate changes from baseline in the number of monthly migraine days (MMDs). RESULTS Of 865 patients entering the extension (eptinezumab 100 mg, n = 433; 300 mg, n = 432), 782 (90.4%) completed and 11 (1.3%) discontinued due to an adverse event. Eptinezumab was associated with early and sustained reductions in migraine frequency. Mean MMDs at baseline were approximately 14 days across groups. Mean (standard error) change from baseline in MMDs over the final dosing interval (weeks 61-72) was -6.4 (0.50) with placebo/eptinezumab 100 mg, -7.3 (0.49) with placebo/eptinezumab 300 mg, -7.1 (0.39) with eptinezumab 100 mg, and -7.0 (0.39) with eptinezumab 300 mg. During weeks 61-72, 63-70% of patients demonstrated ≥ 50% reduction in MMDs, and 36-45% demonstrated ≥ 75% reduction. Headache severity and acute medication use reductions, and patient-reported improvements in most bothersome symptom, disease status, quality of life, and work productivity, were observed. Adverse events were generally mild, transient, and similar in frequency/type to previous eptinezumab trials. CONCLUSIONS The long-term effectiveness and safety/tolerability of eptinezumab in patients with migraine and 2-4 prior preventive treatment failures was demonstrated by high completion rates and migraine-preventive benefits sustained for up to 18 months, implying that eptinezumab is a viable long-term treatment option for patients still seeking successful migraine treatments. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT04418765; URL: https://www. CLINICALTRIALS gov/ct2/show/NCT04418765 ); EudraCT (Identifier: 2019-004497-25; URL: https://www.clinicaltrialsregister.eu/ctr-search/search?query=2019-004497-25 ).
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Affiliation(s)
- Messoud Ashina
- Department of Neurology, Danish Headache Center, Copenhagen University Hospital, Rigshospitalet Glostrup Valdemar Hansen Vej 5, Glostrup, DK-2600, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Stewart J Tepper
- The New England Institute for Neurology and Headache, Stamford, CT, USA
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Chan M, Thaler A. Post-stroke Headache. Curr Pain Headache Rep 2023; 27:673-678. [PMID: 37676411 DOI: 10.1007/s11916-023-01169-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE OF REVIEW Stroke is a major health concern and a leading cause of long-term disability. Persistent post-stroke headache (PPSH) is a common complication of stroke yet little is known about its specific characteristics or optimal management. The purpose of this review is to discuss the epidemiology, presentation, and hypothesized pathophysiology of PPSH. Acute and preventive treatment options, as well as specific concerns regarding triptans and the newer CGRP antagonists, will be discussed in detail as well. RECENT FINDINGS The 2018 International Classification of Headache Disorders, 3rd edition (ICHD-3) was the first headache diagnostic manual to include criteria for PPSH and defines this disorder as an acute headache that develops in close temporal relation to stroke and persists beyond 3 months. Recent literature estimates the prevalence of PPSH to be somewhere between 1 and 23% of patients post-stroke. Presentation is variable, but most often mimics tension-type headache. There are no evidence-based guidelines on the optimal treatment of PPSH. PPSH is a common but poorly understood complication of stroke. Given the significant disability burden that PPSH carries, the epidemiology and pathophysiology of PPSH, as well as the efficacy and safety of potential treatment options, warrant further investigation.
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Affiliation(s)
- Monica Chan
- Division of Headache and Facial Pain, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
- Department of Neurology, Mid-Atlantic Permanente Medical Group, 700 2nd St NE, Washington, DC, 20002, USA.
| | - Alison Thaler
- Division of Headache and Facial Pain, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- , 1468 Madison Avenue Annenberg 2-035, New York, NY, 10029, USA
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Li XN, Xu HR, Cui E, Petersen KB, Ryding J, Ettrup A, Østergaard JB, Larsen F. Pharmacokinetics and Safety of Eptinezumab in Healthy Chinese Participants: A Randomized Clinical Trial. Clin Drug Investig 2023; 43:873-881. [PMID: 37917246 PMCID: PMC10632206 DOI: 10.1007/s40261-023-01315-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Most evidence suggests that the pharmacokinetics of monoclonal antibodies (mAbs) are not meaningfully altered by patient characteristics, including racial/ethnic differences. Nevertheless, the pharmacokinetic profile of eptinezumab has not been evaluated in a Chinese population. This study was designed to confirm the hypothesis that the pharmacokinetic profile of the anti-calcitonin gene-related peptide mAb, eptinezumab, is similar in healthy Chinese individuals to that of healthy non-Asian individuals and non-Asian patients with migraine. METHODS Over a study period of 12 weeks, healthy adult Chinese participants (N = 20) were randomized (1:1) to receive a single intravenous dose of eptinezumab 100 mg (n = 10) or 300 mg (n = 10) in a prospective, single-site, open-label parallel-group trial. Blood samples for the evaluation of plasma eptinezumab concentrations were obtained over 84 days, and standard pharmacokinetic parameters were derived. RESULTS Mean maximum plasma concentrations (Cmax) of eptinezumab occurred 1.0-1.5 h post start of infusion, were similar between the 100 mg and 300 mg dose groups, and slowly declined in a biphasic manner. Cmax and area under the drug concentration-time curve (AUC) increased in a dose-proportional manner. Volume of distribution and clearance were similar between the 100 mg and 300 mg dose groups, and half-life was 22.5-28.1 days. Eptinezumab was generally well tolerated with no new safety signals identified. Only one participant, randomized to the 100 mg dose group, was positive for eptinezumab anti-drug antibodies, but negative for neutralizing antibodies, with no impact on pharmacokinetics. CONCLUSION The pharmacokinetic profile of eptinezumab in healthy Chinese individuals was generally similar to that reported for non-Asian populations with migraine, and eptinezumab was generally well tolerated. Evaluation of immunogenicity showed no evidence of an impact of anti-drug antibodies or neutralizing antibodies on safety profiles. This supports the globally approved doses of 100 mg and 300 mg as being appropriate for Chinese patients with episodic migraine or chronic migraine.
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Affiliation(s)
- Xue-Ning Li
- Department of Clinical Pharmacology, Fudan University, Shanghai, China.
- Department of Clinical Pharmacology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China.
| | - Hong-Rong Xu
- Department of Clinical Pharmacology, Fudan University, Shanghai, China
| | - Ellen Cui
- Lundbeck (Beijing) Pharmaceuticals Consulting Co., Ltd., Beijing, China
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Aleksovska K, Hershey AD, Deen M, Icco RD, Lee MJ, Diener HC. Efficacy and safety of monoclonal antibodies targeting CGRP in migraine prevention. GRADE tables elaborated by the ad hoc working group of the International Headache Society. Cephalalgia 2023; 43:3331024231206162. [PMID: 37879637 DOI: 10.1177/03331024231206162] [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] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Grading of Recommendations, Assessment Development and Evaluation (GRADE) tables were created using a standardized and independent assessment of the efficacy and side effects of treatments with monoclonal antibodies (mAb) against calcitonin gene-related peptide (CGRP) or the CGRP receptor for the prevention of migraine. We hope to provide support for author groups writing national or regional treatment or management guidelines for migraine prevention. METHODS We formulated patient/population, intervention, comparison and outcomes (PICO) questions for the efficacy and safety of mAb against CGRP or the CGRP-receptor for the prevention of migraine attacks. We performed a systematic literature research for randomized studies with eptinezumab, erenumab, fremanezumab and galcanezumab and a pooled analysis was done, using RevMan 5.4 software. For dichotomous outcomes we used risk ratio, and for continuous outcomes we used the mean difference to compare and summarize the evidence between groups. The evidence across studies, for each outcome, except serious adverse events, was assessed using GRADE evidence tables. Additionally, we report the serious adverse effects in the tables of the characteristics of the studies. RESULTS All mAb are superior to placebo for the reduction in monthly migraine days (days in which a headache consistent with migraine occurred) in participants with episodic and chronic migraine. There are no major differences between the mAb. CONCLUSIONS The GRADE evidence summary tables provided will support author groups to write treatment guidelines for the prevention of migraine with mAb.
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Affiliation(s)
- Katina Aleksovska
- Department of Neurology, Ss. Cyril and Methodius University, Skopje, Macedonia
| | - Andrew D Hershey
- Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, USA
| | - Marie Deen
- Department of Neurology, Danish Headache Center, Rigshospitalet - Glostrup, Glostrup, Denmark
| | - Robert de Icco
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Kaniecki RG, Friedman DI, Asher D, Hirman J, Cady R. Improving to Four or Fewer Monthly Headache Days Per Month Provides a Clinically Meaningful Therapeutic Target for Patients with Chronic Migraine. Pain Ther 2023; 12:1179-1194. [PMID: 37378754 PMCID: PMC10444931 DOI: 10.1007/s40122-023-00525-x] [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: 02/23/2023] [Accepted: 05/11/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Treatment target goals for patients receiving preventive migraine treatment are complicated to assess and not achieved by most patients. A headache "number" could establish an understandable treatment target goal for patients with chronic migraine (CM). This study investigates the clinical impact of reduced headache frequency to ≤ 4 monthly headache days (MHDs) as a treatment-related migraine prevention target goal. METHODS All treatment arms were pooled for analysis from the PROMISE-2 trial evaluating eptinezumab for the preventive treatment of CM. Patients (N = 1072) received eptinezumab 100 mg, 300 mg, or placebo. Data for the 6-item Headache Impact Test (HIT-6), Patient Global Impression of Change (PGIC), and acute medication use days were combined for all post-baseline assessments and analyzed by MHD frequency (≤ 4, 5-9, 10-15, > 15) in the 4 weeks preceding assessment. RESULTS Based on pooled data, the percentage of patient-months with ≤ 4 MHDs associated with "very much improved" PGIC was 40.9% (515/1258) versus 22.9% (324/1415), 10.4% (158/1517), and 3.2% (62/1936) of patient-months with 5-9, 10-15, and > 15 MHDs, respectively. Rates of patient-months with ≥ 10 days of acute medication use were 1.9% (21/1111, ≤ 4 MHDs), 4.9% (63/1267, 5-9 MHDs), 49.5% (670/1351, 10-15 MHDs), and 74.1% (1232/1662, > 15 MHDs). Of patient-months with ≤ 4 MHDs, 37.1% (308/830) were associated with "little to none" HIT-6 impairment versus 19.9% (187/940), 10.1% (101/999), and 3.7% (49/1311) of patient-months with 5-9, 10-15, and > 15 MHDs, respectively. CONCLUSION Participants improving to ≤ 4 MHDs reported less acute medication use and improved patient-reported outcomes, suggesting that 4 MHDs may be a useful patient-centric treatment target when treating CM. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT02974153) ( https://clinicaltrials.gov/ct2/show/NCT02974153 ).
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Affiliation(s)
- Robert G Kaniecki
- Department of Neurology, University of Pittsburgh School of Medicine, UPMC Headache Center, 120 Lytton Ave, Suite 300, Pittsburgh, PA, 15213, USA.
| | - Deborah I Friedman
- Departments of Neurology and Ophthalmology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Joe Hirman
- Pacific Northwest Statistical Consulting, Woodinville, WA, USA
| | - Roger Cady
- Lundbeck LLC, Deerfield, IL, USA
- RK Consults, Ozark, MO, USA
- Missouri State University, Springfield, MO, USA
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Sun W, Cheng H, Xia B, Liu X, Li Y, Wang X, Liu C. Comparative Efficacy and Safety of Five Anti-calcitonin Gene-related Peptide Agents for Migraine Prevention: A Network Meta-analysis. Clin J Pain 2023; 39:560-569. [PMID: 37278480 DOI: 10.1097/ajp.0000000000001136] [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: 11/30/2022] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Anti-calcitonin gene-related peptide (CGRP) agents are some of the newest preventive medications for migraine. There is limited literature comparing the efficacy of the most recent CGRP antagonist, atogepant, to CGRP monoclonal antibodies for migraine prevention. In this network meta-analysis, the efficacy and safety of migraine treatments including different doses of atogepant and CGRP monoclonal antibodies were evaluated to provide a reference for future clinical trials. MATERIALS AND METHODS A search using PubMed, Embase, and Cochrane Library identified all randomized controlled trials published through May 2022 and including patients diagnosed with episodic or chronic migraine and treated with erenumab, fremanezumab, eptinezumab, galcanezumab, atogepant, or placebo. The primary outcomes were the reduction of monthly migraine days, 50% response rate, and the number of adverse events (AEs). The Cochrane Collaboration tool was used to assess the risk of bias. RESULTS In this study, 24 articles were considered for analysis. Regarding efficacy, all interventions were superior to placebo with a statistically significant difference. The most effective intervention was monthly fremanezumab 225 mg in change from baseline of migraine days (standard mean difference = -0.49, 95% CI: -0.62, -0.37) and 50% response rate (risk ratio = 2.98, 95% CI: 2.16,4.10), while the optimal choice for reducing acute medication days was monthly erenumab 140 mg (standard mean difference = -0.68, 95% CI: -0.79, -0.58). In terms of AEs, all therapies and placebo did not achieve statistical significance except for monthly galcanezumab 240 mg and quarterly fremanezumab 675 mg. There was no significant difference in discontinuation due to AEs between interventions and placebo. DISCUSSION All anti-CGRP agents were more effective than placebo in migraine prevention. Overall, monthly fremanezumab 225 mg, monthly erenumab 140 mg, and daily atogepant 60 mg were effective interventions with fewer side effects.
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Affiliation(s)
| | | | | | | | | | - Xuemei Wang
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing
| | - Chengjiang Liu
- Department of General, Practice, Anhui Medical University, Hefei, China
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Rastogi RG, Hastriter EV, Evans RL, Bassal F, Hickman C, Karnik KT, Little R, Lewis KS. Advances in the Acute and Preventive Treatment of Pediatric Migraine. Curr Pain Headache Rep 2023; 27:521-529. [PMID: 37561313 DOI: 10.1007/s11916-023-01157-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Headaches are common in children and adolescents. Treatments for debilitating migraine are often not FDA approved or lack evidence of efficacy for children. This narrative review looks at the evidence for acute and preventative pharmacologic and non-pharmacologic treatment of pediatric migraine, as well as reviewing any recent or ongoing clinical trials. RECENT FINDINGS Studies have been published on pharmacological treatments for headache, as well as non-pharmacological treatments. Recent findings in pediatric migraine using onabotulinumtoxinA, calcitonin gene related peptide antagonists, interventional procedures, and devices are reviewed. Pharmacologic as well as non-pharmacologic approaches for the prevention and treatment of migraine show safety and efficacy data that is promising. These treatments should be incorporated in a multi-modal approach to the management of pediatric migraine. Continued studies, prospective and randomized, are needed to further assess these newer treatments for migraine in the pediatric setting.
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Affiliation(s)
- Reena Gogia Rastogi
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA.
| | - Eric Vance Hastriter
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Rachel L Evans
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Frederick Bassal
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Carolyn Hickman
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Kavitha T Karnik
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Robert Little
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
| | - Kara Stuart Lewis
- Department of Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, USA
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