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de Vries T, Boucherie DM, Chan KY, Rubio-Beltrán E, Labastida-Ramírez A, Labruijere S, Gupta S, van den Bogaerdt A, Vincent A, Dammers R, Danser AHJ, MaassenVanDenBrink A. Sex differences in CGRP-induced vasodilation of human middle meningeal arteries but not human coronary arteries: implications for migraine. Cephalalgia 2024; 44:3331024241254088. [PMID: 39043230 DOI: 10.1177/03331024241254088] [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: 07/25/2024]
Abstract
BACKGROUND Migraine prevalence and levels of calcitonin gene-related peptide (CGRP), a peptide involved in migraine pathophysiology, differ between men and women, and appear to be affected by changes in sex hormones. The present study investigated the sex-specific responses to CGRP in human isolated arteries. METHODS CGRP-induced relaxation of 62 (28 men and 34 women) human isolated middle meningeal arteries (HMMA) and 139 (69 men and 70 women) human isolated coronary arteries (HCA) was compared between men and women in groups <50 years and ≥50 years of age as a proxy for pre- and postmenopausal status in women, as well as matched-age groups for men. RESULTS In HCA, no differences were observed between male and female tissue, or between the different age groups. However, in HMMA, the maximum response was significantly smaller and CGRP was less potent in females <50 compared with males <50 years of age. No differences were observed between the older age groups. CONCLUSIONS Sex differences were observed for CGRP-induced relaxation of HMMA, but not HCA. These differences could arise from differential receptor expression in the vascular beds combined with the effect of sex hormones on CGRP and subsequent receptor desensitization.
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Affiliation(s)
- Tessa de Vries
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Deirdre M Boucherie
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Kayi Y Chan
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Eloísa Rubio-Beltrán
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Alejandro Labastida-Ramírez
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Sieneke Labruijere
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Saurabh Gupta
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | | | - Arnaud Vincent
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - A H Jan Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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Tanaka M, Tuka B, Vécsei L. Navigating the Neurobiology of Migraine: From Pathways to Potential Therapies. Cells 2024; 13:1098. [PMID: 38994951 PMCID: PMC11240811 DOI: 10.3390/cells13131098] [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] [Received: 06/14/2024] [Accepted: 06/21/2024] [Indexed: 07/13/2024] Open
Abstract
Migraine is a debilitating neurological disorder characterized by recurring episodes of throbbing headaches that are frequently accompanied by sensory disturbances, nausea, and sensitivity to light and sound [...].
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Affiliation(s)
- Masaru Tanaka
- HUN-REN-SZTE Neuroscience Research Group, Danube Neuroscience Research Laboratory, Hungarian Research Network, University of Szeged (HUN-REN-SZTE), Tisza Lajos krt. 113, H-6725 Szeged, Hungary;
| | - Bernadett Tuka
- Department of Radiology, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis u. 6, H-6725 Szeged, Hungary;
| | - László Vécsei
- HUN-REN-SZTE Neuroscience Research Group, Danube Neuroscience Research Laboratory, Hungarian Research Network, University of Szeged (HUN-REN-SZTE), Tisza Lajos krt. 113, H-6725 Szeged, Hungary;
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis u. 6, H-6725 Szeged, Hungary
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Wang J, Liu X, Gou J, Deng J, Li M, Zhu Y, Wu Z. Role of neuropeptides in orofacial pain: A literature review. J Oral Rehabil 2024; 51:898-908. [PMID: 38213060 DOI: 10.1111/joor.13656] [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: 05/17/2023] [Revised: 11/19/2023] [Accepted: 01/05/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Neuropeptides play a critical role in regulating pain and inflammation. Despite accumulating evidence has further uncovered the novel functions and mechanisms of different neuropeptides in orofacial pain sensation and transmission, there is deficient systematic description of neuropeptides' pain modulation in the orofacial region, especially in the trigeminal system. OBJECTIVES The present review aims to summarise several key neuropeptides and gain a better understanding of their major regulatory roles in orofacial inflammation and pain. METHODS We review and summarise current studies related to calcitonin gene-related peptide (CGRP), substance P (SP), opioid peptide (OP), galanin (GAL) and other neuropeptides' functions and mechanisms as well as promising targets for orofacial pain control. RESULTS A number of neuropeptides are clearly expressed in the trigeminal sensory system and have critical functions in the transduction and pathogenesis of orofacial pain. The functions, possible cellular and molecular mechanisms have been introduced and discussed. Neuropeptides and their agonists or antagonists which are widely studied to be potential treatment options of orofacial pain has been evaluated. CONCLUSIONS Various neuropeptides play important but distinct (pro-nociceptive or analgesic) roles in orofacial pain with different mechanisms. In summary, CGRP, SP, NPY, NKA, HK-1, VIP mainly play proinflammatory and pro-nociceptive effects while OP, GAL, OXT, OrxA mainly have inhibitory effects on orofacial pain.
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Affiliation(s)
- Jian Wang
- Department of Pediatric Dentistry, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China
| | - Xiangtao Liu
- Department of Pediatric Dentistry, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China
| | - Junzhuo Gou
- Department of Pediatric Dentistry, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China
| | - Jing Deng
- Department of Pediatric Dentistry, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China
| | - Mujia Li
- Department of Pediatric Dentistry, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China
| | - Yafen Zhu
- Department of Pediatric Dentistry, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China
| | - Zhifang Wu
- Department of Pediatric Dentistry, Stomatology Hospital, School of Stomatology, Zhejiang University School of Medicine, Zhejiang Provincial Clinical Research Center for Oral Diseases, Key Laboratory of Oral Biomedical Research of Zhejiang Province, Cancer Center of Zhejiang University, Engineering Research Center of Oral Biomaterials and Devices of Zhejiang Province, Hangzhou, China
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Benedicter N, Vogler B, Kuhn A, Schramm J, Mackenzie KD, Stratton J, Dux M, Messlinger K. Glycerol Trinitrate Acts Downstream of Calcitonin Gene-Related Peptide in Trigeminal Nociception-Evidence from Rodent Experiments with Anti-CGRP Antibody Fremanezumab. Cells 2024; 13:572. [PMID: 38607011 PMCID: PMC11011795 DOI: 10.3390/cells13070572] [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: 02/22/2024] [Revised: 03/16/2024] [Accepted: 03/20/2024] [Indexed: 04/13/2024] Open
Abstract
Calcitonin gene-related peptide (CGRP) and nitric oxide (NO) have been recognized as important mediators in migraine but their mechanisms of action and interaction have not been fully elucidated. Monoclonal anti-CGRP antibodies like fremanezumab are successful preventives of frequent migraine and can be used to study CGRP actions in preclinical experiments. Fremanezumab (30 mg/kg) or an isotype control monoclonal antibody was subcutaneously injected to Wistar rats of both sexes. One to several days later, glyceroltrinitrate (GTN, 5 mg/kg) mimicking nitric oxide (NO) was intraperitoneally injected, either once or for three consecutive days. The trigeminal ganglia were removed to determine the concentration of CGRP using an enzyme-linked immunosorbent assay (ELISA). In one series of experiments, the animals were trained to reach an attractive sugar solution, the access to which could be limited by mechanical or thermal barriers. Using a semi-automated registration system, the frequency of approaches to the source, the residence time at the source, and the consumed solution were registered. The results were compared with previous data of rats not treated with GTN. The CGRP concentration in the trigeminal ganglia was generally higher in male rats and tended to be increased in animals treated once with GTN, whereas the CGRP concentration decreased after repetitive GTN treatment. No significant difference in CGRP concentration was observed between animals having received fremanezumab or the control antibody. Animals treated with GTN generally spent less time at the source and consumed less sugar solution. Without barriers, there was no significant difference between animals having received fremanezumab or the control antibody. Under mechanical barrier conditions, all behavioral parameters tended to be reduced but animals that had received fremanezumab tended to be more active, partly compensating for the depressive effect of GTN. In conclusion, GTN treatment seems to increase the production of CGRP in the trigeminal ganglion independently of the antibodies applied, but repetitive GTN administration may deplete CGRP stores. GTN treatment generally tends to suppress the animals' activity and increase facial sensitivity, which is partly compensated by fremanezumab through reduced CGRP signaling. If CGRP and NO signaling share the same pathway in sensitizing trigeminal afferents, GTN and NO may act downstream of CGRP to increase facial sensitivity.
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Affiliation(s)
- Nicola Benedicter
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (N.B.)
| | - Birgit Vogler
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (N.B.)
| | - Annette Kuhn
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (N.B.)
| | - Jana Schramm
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (N.B.)
| | | | | | - Mária Dux
- Department of Physiology, University of Szeged, H-6720 Szeged, Hungary;
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (N.B.)
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Friedrich N, Németh K, Tanner M, Rosta J, Dobos I, Oszlács O, Jancsó G, Messlinger K, Dux M. Anti-CGRP antibody galcanezumab modifies the function of the trigeminovascular nocisensor complex in the rat. J Headache Pain 2024; 25:9. [PMID: 38243174 PMCID: PMC10799508 DOI: 10.1186/s10194-024-01717-2] [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: 12/23/2023] [Accepted: 01/14/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Monoclonal antibodies directed against the neuropeptide calcitonin gene-related peptide (CGRP) are effective in the prevention of chronic and frequent episodic migraine. Since the antibodies do not cross the blood brain barrier, their antinociceptive effect is attributed to effects in meningeal tissues. We aimed to probe if such an antibody can be visualized within the dura mater and the trigeminal ganglia following its administration to rats and to examine if the activity of the trigeminovascular nocisensor complex is influenced by this treatment. METHODS Effects of the anti-CGRP antibody galcanezumab on the trigeminovascular nocisensor complex was examined by measuring release of sensory neuropeptides and histamine from the rat dura mater. Deposits of galcanezumab were visualized by fluorescence microscopy in the trigeminal ganglion and the dura mater. RESULTS Fluorophore-labelled galcanezumab was detected in the dura mater and the trigeminal ganglion up to 30 days after treatment affirming the long-lasting modulatory effect of this antibody. In female rats, seven days after systemic treatment with galcanezumab the capsaicin-induced release of CGRP was decreased, while that of substance P (SP) was increased in the dura mater. In control rats, release of the inhibitory neuropeptide somatostatin (SOM) was higher in females than in males. Stimulation with high concentration of KCl did not significantly change the release of SOM in control animals, while in rats treated with galcanezumab SOM release was slightly reduced. Galcanezumab treatment also reduced the amount of histamine released from dural mast cells upon stimulation with CGRP, while the effect of compound 48/80 on histamine release was not changed. CONCLUSIONS Galcanezumab treatment is followed by multiple changes in the release of neuropeptides and histamine in the trigeminal nocisensor complex, which may contribute to the migraine preventing effect of anti-CGRP antibodies. These changes affecting the communication between the components of the trigeminal nocisensor complex may reduce pain susceptibility in migraine patients treated with CGRP targeting monoclonal antibodies.
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Affiliation(s)
- Nadine Friedrich
- Department of Physiology, University of Szeged, Dóm Tér 10, 6720, Szeged, Hungary
| | - Krisztina Németh
- Chemical Biology Research Group, Institute of Organic Chemistry, Research Centre for Natural Sciences, Magyar Tudósok Krt. 2, 1117, Budapest, Hungary
| | - Martin Tanner
- Department of Physiology, University of Szeged, Dóm Tér 10, 6720, Szeged, Hungary
| | - Judit Rosta
- Department of Physiology, University of Szeged, Dóm Tér 10, 6720, Szeged, Hungary
| | - Ildikó Dobos
- Department of Physiology, University of Szeged, Dóm Tér 10, 6720, Szeged, Hungary
| | - Orsolya Oszlács
- Department of Physiology, University of Szeged, Dóm Tér 10, 6720, Szeged, Hungary
| | - Gábor Jancsó
- Department of Physiology, University of Szeged, Dóm Tér 10, 6720, Szeged, Hungary
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, 91054, Erlangen-Nuremberg, Germany
| | - Mária Dux
- Department of Physiology, University of Szeged, Dóm Tér 10, 6720, Szeged, Hungary.
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Tanaka M, Szabó Á, Körtési T, Szok D, Tajti J, Vécsei L. From CGRP to PACAP, VIP, and Beyond: Unraveling the Next Chapters in Migraine Treatment. Cells 2023; 12:2649. [PMID: 37998384 PMCID: PMC10670698 DOI: 10.3390/cells12222649] [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: 09/05/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Migraine is a neurovascular disorder that can be debilitating for individuals and society. Current research focuses on finding effective analgesics and management strategies for migraines by targeting specific receptors and neuropeptides. Nonetheless, newly approved calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) have a 50% responder rate ranging from 27 to 71.0%, whereas CGRP receptor inhibitors have a 50% responder rate ranging from 56 to 71%. To address the need for novel therapeutic targets, researchers are exploring the potential of another secretin family peptide, pituitary adenylate cyclase-activating polypeptide (PACAP), as a ground-breaking treatment avenue for migraine. Preclinical models have revealed how PACAP affects the trigeminal system, which is implicated in headache disorders. Clinical studies have demonstrated the significance of PACAP in migraine pathophysiology; however, a few clinical trials remain inconclusive: the pituitary adenylate cyclase-activating peptide 1 receptor mAb, AMG 301 showed no benefit for migraine prevention, while the PACAP ligand mAb, Lu AG09222 significantly reduced the number of monthly migraine days over placebo in a phase 2 clinical trial. Meanwhile, another secretin family peptide vasoactive intestinal peptide (VIP) is gaining interest as a potential new target. In light of recent advances in PACAP research, we emphasize the potential of PACAP as a promising target for migraine treatment, highlighting the significance of exploring PACAP as a member of the antimigraine armamentarium, especially for patients who do not respond to or contraindicated to anti-CGRP therapies. By updating our knowledge of PACAP and its unique contribution to migraine pathophysiology, we can pave the way for reinforcing PACAP and other secretin peptides, including VIP, as a novel treatment option for migraines.
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Affiliation(s)
- Masaru Tanaka
- HUN-REN-SZTE Neuroscience Research Group, Hungarian Research Network, University of Szeged (HUN-REN-SZTE), Danube Neuroscience Research Laboratory, Tisza Lajos krt. 113, H-6725 Szeged, Hungary;
| | - Ágnes Szabó
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis u. 6, H-6725 Szeged, Hungary; (Á.S.); (D.S.); (J.T.)
- Doctoral School of Clinical Medicine, University of Szeged, Korányi fasor 6, H-6720 Szeged, Hungary
| | - Tamás Körtési
- HUN-REN-SZTE Neuroscience Research Group, Hungarian Research Network, University of Szeged (HUN-REN-SZTE), Danube Neuroscience Research Laboratory, Tisza Lajos krt. 113, H-6725 Szeged, Hungary;
- Faculty of Health Sciences and Social Studies, University of Szeged, Temesvári krt. 31, H-6726 Szeged, Hungary;
- Preventive Health Sciences Research Group, Incubation Competence Centre of the Centre of Excellence for Interdisciplinary Research, Development and Innovation of the University of Szeged, H-6720 Szeged, Hungary
| | - Délia Szok
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis u. 6, H-6725 Szeged, Hungary; (Á.S.); (D.S.); (J.T.)
| | - János Tajti
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis u. 6, H-6725 Szeged, Hungary; (Á.S.); (D.S.); (J.T.)
| | - László Vécsei
- HUN-REN-SZTE Neuroscience Research Group, Hungarian Research Network, University of Szeged (HUN-REN-SZTE), Danube Neuroscience Research Laboratory, Tisza Lajos krt. 113, H-6725 Szeged, Hungary;
- Department of Neurology, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis u. 6, H-6725 Szeged, Hungary; (Á.S.); (D.S.); (J.T.)
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Maddahi A, Warfvinge K, Holm A, Edvinsson JCA, Reducha PV, Kazantzi S, Haanes KA, Edvinsson L. Progesterone distribution in the trigeminal system and its role to modulate sensory neurotransmission: influence of sex. J Headache Pain 2023; 24:154. [PMID: 37957603 PMCID: PMC10644471 DOI: 10.1186/s10194-023-01687-x] [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: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Women are disproportionately affected by migraine, representing up to 75% of all migraine cases. This discrepancy has been proposed to be influenced by differences in hormone levels between the sexes. One such hormone is progesterone. Calcitonin gene-related peptide (CGRP) system is an important factor in migraine pathophysiology and could be influenced by circulating hormones. The purpose of this study was to investigate the distribution of progesterone and its receptor (PR) in the trigeminovascular system, and to examine the role of progesterone to modulate sensory neurotransmission. METHODS Trigeminal ganglion (TG), hypothalamus, dura mater, and the basilar artery from male and female rats were carefully dissected. Expression of progesterone and PR proteins, and mRNA levels from TG and hypothalamus were analyzed by immunohistochemistry and real-time quantitative PCR. CGRP release from TG and dura mater were measured using an enzyme-linked immunosorbent assay. In addition, the vasomotor effect of progesterone on male and female basilar artery segments was investigated with myography. RESULTS Progesterone and progesterone receptor -A (PR-A) immunoreactivity were found in TG. Progesterone was located predominantly in cell membranes and in Aδ-fibers, and PR-A was found in neuronal cytoplasm and nucleus, and in satellite glial cells. The number of positive progesterone immunoreactive cells in the TG was higher in female compared to male rats. The PR mRNA was expressed in both hypothalamus and TG; however, the PR expression level was significantly higher in the hypothalamus. Progesterone did not induce a significant change neither in basal level nor upon stimulated release of CGRP from dura mater or TG in male or female rats when compared to the vehicle control. However, pre-treated with 10 µM progesterone weakly enhanced capsaicin induced CGRP release observed in the dura mater of male rats. Similarly, in male basilar arteries, progesterone significantly amplified the dilation in response to capsaicin. CONCLUSIONS In conclusion, these results highlight the potential for progesterone to modulate sensory neurotransmission and vascular responses in a complex manner, with effects varying by sex, tissue type, and the nature of the stimulus. Further investigations are needed to elucidate the underlying mechanisms and physiological implications of these findings.
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Affiliation(s)
- Aida Maddahi
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University Hospital, Lund, Sweden.
| | - Karin Warfvinge
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Rigshospitalet Glostrup, Copenhagen, Denmark
| | - Anja Holm
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Rigshospitalet Glostrup, Copenhagen, Denmark
- Center for RNA Medicine, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jacob C A Edvinsson
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University Hospital, Lund, Sweden
| | - Philip Victor Reducha
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Rigshospitalet Glostrup, Copenhagen, Denmark
- Center for RNA Medicine, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Spyridoula Kazantzi
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Rigshospitalet Glostrup, Copenhagen, Denmark
- Center for RNA Medicine, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kristian A Haanes
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Rigshospitalet Glostrup, Copenhagen, Denmark
- Department of Biology, Section of Cell Biology and Physiology, University of Copenhagen, Copenhagen, Denmark
| | - Lars Edvinsson
- Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University Hospital, Lund, Sweden
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Rigshospitalet Glostrup, Copenhagen, Denmark
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Vogler B, Kuhn A, Mackenzie KD, Stratton J, Dux M, Messlinger K. The Anti-Calcitonin Gene-Related Peptide (Anti-CGRP) Antibody Fremanezumab Reduces Trigeminal Neurons Immunoreactive to CGRP and CGRP Receptor Components in Rats. Int J Mol Sci 2023; 24:13471. [PMID: 37686275 PMCID: PMC10487893 DOI: 10.3390/ijms241713471] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
Treatment with the anti-CGRP antibody fremanezumab is successful in the prevention of chronic and frequent episodic migraine. In preclinical rat experiments, fremanezumab has been shown to reduce calcitonin gene-related peptide (CGRP) release from trigeminal tissues and aversive behaviour to noxious facial stimuli, which are characteristic pathophysiological changes accompanying severe primary headaches. To further decipher the effects of fremanezumab that underlie these antinociceptive effects in rats, immunohistochemistry and ELISA techniques were used to analyse the content and concentration of CGRP in the trigeminal ganglion, as well as the ratio of trigeminal ganglion neurons which are immunoreactive to CGRP and CGRP receptor components, 1-10 days after subcutaneous injection of fremanezumab (30 mg/kg) compared to an isotype control antibody. After fremanezumab treatment, the fraction of trigeminal ganglion neurons which were immunoreactive to CGRP and the CGRP receptor components calcitonin receptor-like receptor (CLR) and receptor activity modifying protein 1 (RAMP1) was significantly lowered compared to the control. The content and concentration of CGRP in trigeminal ganglia were not significantly changed. A long-lasting reduction in CGRP receptors expressed in trigeminal afferents may contribute to the attenuation of CGRP signalling and antinociceptive effects of monoclonal anti-CGRP antibodies in rats.
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Affiliation(s)
- Birgit Vogler
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (B.V.); (A.K.)
| | - Annette Kuhn
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (B.V.); (A.K.)
| | | | | | - Mária Dux
- Department of Physiology, University of Szeged, H-6720 Szeged, Hungary;
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany; (B.V.); (A.K.)
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9
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Hong JB, Lange KS, Overeem LH, Triller P, Raffaelli B, Reuter U. A Scoping Review and Meta-Analysis of Anti-CGRP Monoclonal Antibodies: Predicting Response. Pharmaceuticals (Basel) 2023; 16:934. [PMID: 37513846 PMCID: PMC10385131 DOI: 10.3390/ph16070934] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/15/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
Calcitonin gene-related peptide-targeted monoclonal antibodies (CGRP mAbs) are increasingly being used as preventive treatments for migraine. Their effectiveness and safety were established through numerous randomized placebo-controlled trials and real-world studies, yet a significant proportion of patients do not respond to this treatment, and currently, there is a lack of accepted predictors of response to guide expectations, as data from studies so far are lacking and inconsistent. We searched Embase and MEDLINE databases for studies reporting on predictors of response to CGRP and/or CGRP-receptor (CGRP-R) mAbs, defined as a 30% or 50% reduction in monthly headache or migraine days at varying durations of follow-up. Quantitative synthesis was performed where applicable. We found 38 real-world studies that investigated the association between various predictors and response rates. Based on these studies, good response to triptans and unilateral pain with or without unilateral autonomic symptoms are predictors of a good response to CGRP(-R) mAbs. Conversely, obesity, interictal allodynia, the presence of daily headaches, a higher number of non-successful previous prophylactic medications, and psychiatric comorbidities including depression are predictive of a poor response to CGRP(-R) mAbs. Future studies should confirm these results and help to generate more tailored treatment strategies in patients with migraine.
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Affiliation(s)
- Ja Bin Hong
- Department of Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Humboldt University and Free University Berlin, 10117 Berlin, Germany
| | - Kristin Sophie Lange
- Department of Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Humboldt University and Free University Berlin, 10117 Berlin, Germany
| | - Lucas Hendrik Overeem
- Department of Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Humboldt University and Free University Berlin, 10117 Berlin, Germany
- Doctoral Program, International Graduate Program Medical Neurosciences, Humboldt Graduate School, 10117 Berlin, Germany
| | - Paul Triller
- Department of Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Humboldt University and Free University Berlin, 10117 Berlin, Germany
| | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Humboldt University and Free University Berlin, 10117 Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité (BIH), 10117 Berlin, Germany
| | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Corporate Member of Humboldt University and Free University Berlin, 10117 Berlin, Germany
- Universitätsmedizin Greifswald, 17475 Greifswald, Germany
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10
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Benedicter N, Messlinger K, Vogler B, Mackenzie KD, Stratton J, Friedrich N, Dux M. Semi-Automated Recording of Facial Sensitivity in Rat Demonstrates Antinociceptive Effects of the Anti-CGRP Antibody Fremanezumab. Neurol Int 2023; 15:622-637. [PMID: 37218978 DOI: 10.3390/neurolint15020039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/24/2023] Open
Abstract
Migraine pain is frequently accompanied by cranial hyperalgesia and allodynia. Calcitonin gene-related peptide (CGRP) is implicated in migraine pathophysiology but its role in facial hypersensitivity is not entirely clear. In this study, we investigated if the anti-CGRP monoclonal antibody fremanezumab, which is therapeutically used in chronic and episodic migraines, can modify facial sensitivity recorded by a semi-automatic system. Rats of both sexes primed to drink from a sweet source had to pass a noxious mechanical or heat barrier to reach the source. Under these experimental conditions, animals of all groups tended to drink longer and more when they had received a subcutaneous injection of 30 mg/kg fremanezumab compared to control animals injected with an isotype control antibody 12-13 days prior to testing, but this was significant only for females. In conclusion, anti-CGRP antibody, fremanezumab, reduces facial sensitivity to noxious mechanical and thermal stimulation for more than one week, especially in female rats. Anti-CGRP antibodies may reduce not only headache but also cranial sensitivity in migraineurs.
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Affiliation(s)
- Nicola Benedicter
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany
| | - Birgit Vogler
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-University, D-91054 Erlangen, Germany
| | | | | | - Nadine Friedrich
- Department of Physiology, University of Szeged, H-6720 Szeged, Hungary
| | - Mária Dux
- Department of Physiology, University of Szeged, H-6720 Szeged, Hungary
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11
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Szewczyk AK, Ulutas S, Aktürk T, Al-Hassany L, Börner C, Cernigliaro F, Kodounis M, Lo Cascio S, Mikolajek D, Onan D, Ragaglini C, Ratti S, Rivera-Mancilla E, Tsanoula S, Villino R, Messlinger K, Maassen Van Den Brink A, de Vries T. Prolactin and oxytocin: potential targets for migraine treatment. J Headache Pain 2023; 24:31. [PMID: 36967387 PMCID: PMC10041814 DOI: 10.1186/s10194-023-01557-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/28/2023] [Indexed: 03/28/2023] Open
Abstract
Migraine is a severe neurovascular disorder of which the pathophysiology is not yet fully understood. Besides the role of inflammatory mediators that interact with the trigeminovascular system, cyclic fluctuations in sex steroid hormones are involved in the sex dimorphism of migraine attacks. In addition, the pituitary-derived hormone prolactin and the hypothalamic neuropeptide oxytocin have been reported to play a modulating role in migraine and contribute to its sex-dependent differences. The current narrative review explores the relationship between these two hormones and the pathophysiology of migraine. We describe the physiological role of prolactin and oxytocin, its relationship to migraine and pain, and potential therapies targeting these hormones or their receptors.In summary, oxytocin and prolactin are involved in nociception in opposite ways. Both operate at peripheral and central levels, however, prolactin has a pronociceptive effect, while oxytocin appears to have an antinociceptive effect. Therefore, migraine treatment targeting prolactin should aim to block its effects using prolactin receptor antagonists or monoclonal antibodies specifically acting at migraine-pain related structures. This action should be local in order to avoid a decrease in prolactin levels throughout the body and associated adverse effects. In contrast, treatment targeting oxytocin should enhance its signalling and antinociceptive effects, for example using intranasal administration of oxytocin, or possibly other oxytocin receptor agonists. Interestingly, the prolactin receptor and oxytocin receptor are co-localized with estrogen receptors as well as calcitonin gene-related peptide and its receptor, providing a positive perspective on the possibilities for an adequate pharmacological treatment of these nociceptive pathways. Nevertheless, many questions remain to be answered. More particularly, there is insufficient data on the role of sex hormones in men and the correct dosing according to sex differences, hormonal changes and comorbidities. The above remains a major challenge for future development.
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Affiliation(s)
- Anna K Szewczyk
- Doctoral School, Medical University of Lublin, Lublin, Poland
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Samiye Ulutas
- Department of Neurology, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Tülin Aktürk
- Department of Neurology, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Corinna Börner
- Department of Pediatrics - Dr. von Hauner Children's Hospital, LMU Hospital, Division of Pediatric Neurology and Developmental Medicine, Ludwig-Maximilians Universität München, Lindwurmstr. 4, 80337, Munich, Germany
- LMU Center for Children with Medical Complexity - iSPZ Hauner, Ludwig-Maximilians-Universität München, Lindwurmstr. 4, 80337, Munich, Germany
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Federica Cernigliaro
- Child Neuropsychiatry Unit Department, Pro.M.I.S.E. "G D'Alessandro, University of Palermo, 90133, Palermo, Italy
| | - Michalis Kodounis
- First Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Salvatore Lo Cascio
- Child Neuropsychiatry Unit Department, Pro.M.I.S.E. "G D'Alessandro, University of Palermo, 90133, Palermo, Italy
| | - David Mikolajek
- Department of Neurology, City Hospital Ostrava, Ostrava, Czech Republic
| | - Dilara Onan
- Spine Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Chiara Ragaglini
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100, L'Aquila, Italy
| | - Susanna Ratti
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, 67100, L'Aquila, Italy
| | - Eduardo Rivera-Mancilla
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sofia Tsanoula
- Department of Neurology, 401 Military Hospital of Athens, Athens, Greece
| | - Rafael Villino
- Department of Neurology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Karl Messlinger
- Institute of Physiology and Pathophysiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Antoinette Maassen Van Den Brink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tessa de Vries
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
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12
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Exploring Novel Therapeutic Targets in the Common Pathogenic Factors in Migraine and Neuropathic Pain. Int J Mol Sci 2023; 24:ijms24044114. [PMID: 36835524 PMCID: PMC9959352 DOI: 10.3390/ijms24044114] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Migraine and neuropathic pain (NP) are both painful, disabling, chronic conditions which exhibit some symptom similarities and are thus considered to share a common etiology. The calcitonin gene-related peptide (CGRP) has gained credit as a target for migraine management; nevertheless, the efficacy and the applicability of CGRP modifiers warrant the search for more effective therapeutic targets for pain management. This scoping review focuses on human studies of common pathogenic factors in migraine and NP, with reference to available preclinical evidence to explore potential novel therapeutic targets. CGRP inhibitors and monoclonal antibodies alleviate inflammation in the meninges; targeting transient receptor potential (TRP) ion channels may help prevent the release of nociceptive substances, and modifying the endocannabinoid system may open a path toward discovery of novel analgesics. There may exist a potential target in the tryptophan-kynurenine (KYN) metabolic system, which is closely linked to glutamate-induced hyperexcitability; alleviating neuroinflammation may complement a pain-relieving armamentarium, and modifying microglial excitation, which is observed in both conditions, may be a possible approach. Those are several potential analgesic targets which deserve to be explored in search of novel analgesics; however, much evidence remains missing. This review highlights the need for more studies on CGRP modifiers for subtypes, the discovery of TRP and endocannabinoid modulators, knowledge of the status of KYN metabolites, the consensus on cytokines and sampling, and biomarkers for microglial function, in search of innovative pain management methods for migraine and NP.
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13
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Baraldi C, Lo Castro F, Ornello R, Sacco S, Pani L, Guerzoni S. OnabotulinumtoxinA: Still the Present for Chronic Migraine. Toxins (Basel) 2023; 15:59. [PMID: 36668879 PMCID: PMC9865956 DOI: 10.3390/toxins15010059] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023] Open
Abstract
OnabotulinumtoxinA (BT-A) is one of the few drugs approved for the preventive treatment of chronic migraine (CM). Despite this, some aspects of its mechanism of action are still a matter of debate, and the precise magnitude of BT-A effects needs to be completely elucidated. BT-A acts primarily upon trigeminal and cervical nerve endings, by inhibiting the release of inflammatory mediators such as calcitonin gene-related peptide, as well as reducing the insertion of ionotropic and metabotropic receptors into the neuronal membrane. These actions increase the depolarization threshold of trigeminal and cervical nerve fibers, thus reducing their activation. The central actions of BT-A are still a matter of debate: a retrograde axonal transport has been postulated, but not clearly assessed in humans. Clinically, the efficacy of BT-A in CM has been assessed by large, randomized placebo-controlled trials, such as the Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials. Those results were also confirmed in a wide range of open-label studies, even for long-term periods. Recently, novel findings have led to a better understanding of its pharmacological actions and clinical usefulness in migraine prevention. This narrative review summarizes, updates and critically revises the available data on BT-A and its possible implementation in chronic migraine. Moreover, the current role of BT-A in CM treatment has been discussed.
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Affiliation(s)
- Carlo Baraldi
- Department of Biomedical, Metabolic and Neural Sciences, PhD School in Neurosciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Flavia Lo Castro
- Department of Biomedical, Metabolic and Neural Sciences, Post Graduate School of Pharmacology and Clinical Toxicology, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Raffaele Ornello
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
| | - Luca Pani
- Department of Biomedical, Metabolic and Neural Sciences, Pharmacology Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Department of Psychiatry and Behavioral Sciences, University of Miami, Miami, FL 33136, USA
- VeraSci, Durham, NC 27707, USA
- Department of Specialist Medicines, Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, AOU Policlinico Di Modena, 41124 Modena, Italy
| | - Simona Guerzoni
- Department of Specialist Medicines, Digital and Predictive Medicine, Pharmacology and Clinical Metabolic Toxicology-Headache Center and Drug Abuse, Laboratory of Clinical Pharmacology and Pharmacogenomics, AOU Policlinico Di Modena, 41124 Modena, Italy
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14
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Reducha PV, Bömers JP, Edvinsson L, Haanes KA. Rodent behavior following a dural inflammation model with anti-CGRP migraine medication treatment. Front Neurol 2023; 14:1082176. [PMID: 36908624 PMCID: PMC9995475 DOI: 10.3389/fneur.2023.1082176] [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: 10/27/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
Background Migraine is a widespread and prevalent disease with a complex pathophysiology, of which neuroinflammation and increased pain sensitivity have been suggested to be involved. Various studies have investigated the presence of different inflammatory markers in migraineurs and investigated the role of inflammation in inflammatory models with complete Freund's adjuvant (CFA) or inflammatory soup added to the dura mater. Objective The aim of the current study was to examine whether application of CFA to the dura mater would cause behavioral alterations that are migraine relevant. In addition, we investigated the potential mitigating effects of fremanezumab, a CGRP (calcitonin gene-related peptide) specific antibody, following CFA application. Methods Male Sprague-Dawley rats were randomly divided into six groups: fresh (n = 7), fresh + carprofen (n = 6), fresh + anti-CGRP (n = 6), sham (n = 7), CFA (n = 16), CFA + anti-CGRP (n = 8). CFA was applied for 15 min on a 3 × 3 mm clearing of the skull exposing the dura mater of male Sprague-Dawley rats. We applied the Light/Dark box and Open Field test, combined with the electronic von Frey test to evaluate outcomes. Finally, we observed CGRP immunoreactivity in the trigeminal ganglion. Results No differences were observed in the Light/Dark box test. The Open Field test detected behavior differences, notably that sham rats spend less time in the central zone, reared less and groomed more than fresh + carprofen rats. The other groups were not significantly different compared to sham rats, indicating that activation of the TGVS is present in sham surgery and cannot be exacerbated by CFA. However, for the allodynia, we observed specific periorbital sensitization, not observed in the sham animals. This could not be mitigated by fremanezumab, although it clearly reduced the amount of CGRP positive fibers. Conclusion CFA surgically administered to the dura causes periorbital allodynia and increases CGRP positive fibers in the trigeminal ganglion. Fremanezumab does not reduce periorbital allodynia even though it reduces CGRP positive fibers in the TG. Further work is needed to investigate whether CFA administered to the dura could be used as a non-CGRP inflammatory migraine model.
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Affiliation(s)
- Philip V Reducha
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Glostrup, Denmark.,Section of Cell Biology and Physiology, Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | - Jesper P Bömers
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Glostrup, Denmark.,Department of Neurosurgery, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Lars Edvinsson
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Glostrup, Denmark.,Division of Experimental Vascular Research, Department of Clinical Sciences, Lund University Hospital, Lund, Sweden
| | - Kristian A Haanes
- Department of Clinical Experimental Research, Glostrup Research Institute, Copenhagen University Hospital, Glostrup, Denmark.,Section of Cell Biology and Physiology, Department of Biology, University of Copenhagen, Copenhagen, Denmark
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