Migraine-Specific Biologics Treat Severe Headaches

Migraines are quite common, with about 15.3% of People 18 years or older reporting a extreme headache within the earlier 3 months; that determine has remained steady for a number of many years.1

Migraines are recurrent complications of average to extreme depth that are inclined to intrude with each day life features.2 Signs embrace gastrointestinal issues, nausea, sensitivity to gentle, and vomiting. Migraines are attributable to the activation of trigeminal sensory nerves resulting in a launch of neuropeptides, corresponding to calcitonin gene-related peptide (CGRP), neurokinin A, pituitary adenylate cyclase-activating polypeptide, and substance P. Lately, biologics have been launched to the market which can be authorized for migraine prophylaxis by focusing on CGRP. The authorized brokers (eptinezumab, erenumab, fremanezumab, and galcanezumab) work by binding on to the CGRP ligand or receptor.


Eptinezumab (Vyepti) is a humanized IgG1 monoclonal antibody that’s particular for a CGRP ligand and blocks its binding to the receptor.3 Eptinezumab’s really helpful dosing is 100 mg intravenous infusion each 3 months. The next dose of 300 mg each 3 months could also be thought of for many who have a poor response with a 100-mg dose for continual and episodic migraine.

Each 100- and 300-mg dosing regimens had been studied through the PROMISE 1 trial (NCT02559895). The research enrolled adults with a historical past of episodic migraine (4-14 headache days per 30 days, at the least 4 migraine days); 665 people had been randomized to obtain a placebo, 100 mg, and 300 mg each 3 months for 12 months. The first efficacy finish level was outlined because the change from baseline in imply month-to-month migraine days (MMD) over months 1 to three. There have been statistically considerably decrease MMD with each the 100 mg (-0.7 MMD; P=.018) and the 300 mg (-1.1 MMD; P < .001) doses of eptinezumab in contrast with the placebo.

The PROMISE 2 research (NCT02974153) enrolled topics with a historical past of continual migraine (15-26 headache days per 30 days, at the least 8 migraine days), and 1072 people had been randomized to obtain a placebo or a 100-mg or 300-mg dose of eptinezumab each 3 months for six months. The first finish level was change from baseline in month-to-month migraine days over months 1 to three. The 100- (-2.0 MMD; P < .001) and 300-mg doses (-2.6 MMD; P < .001) demonstrated statistically important MMD discount.


Because the science neighborhood is gaining information about CGRP pathology, clinicians are studying concerning the potential elevated cardiovascular threat accompanied by a long-term blockade of the CGRP pathway. Consequently, subgroup analyses had been carried out on a 4 double-blind, placebo-controlled trials to evaluate the hyperlink between erenumab use and vascular hostile occasions (VEs).4 The subgroup analyses included 2443 topics. Whatever the dose acquired (70 mg/mo, 140 mg/mo), incidence of VE was not statistically distinction from the people who acquired the placebo. Though this data will not be immediately relevant to eptinezumab, it provides worth as a reference level.

There may be not enough security knowledge to find out whether or not eptinezumab will or won’t improve cardiovascular threat. Each the PROMISE 1 and PROMISE 2 research set an inclusion criterion that excludes people with a historical past of heart problems.3 A cardiovascular occasion was not a big hostile occasion reported in each trials. Security knowledge will proceed to be monitored via postmarketing surveillance.


Because the science neighborhood gathers extra knowledge on immunogenicity, you will need to differentiate between neutralizing antidrug antibodies (NAbs) and nonneutralizing antibodies (non-NAbs).5 NAbs bind to the biologic drug molecule and inhibit the pharmacologic exercise. Though non-NAbs bind to biologic drug molecules with out affecting pharmacologic exercise, this may increasingly have an effect on pharmacokinetics. Additionally it is essential to do not forget that scientific significance of immunogenicity is variable from one particular person to a different. To successfully apply immunogenicity in scientific follow, the science neighborhood might want to obtain standardization of immunogenic assays.

Immunogenicity formation with eptinezumab remedy is a possible concern as it’s with 3 different biologic merchandise that concentrate on CGRP. Within the PROMISE 1 research, the antibody growth price was 20.6% with the 100-mg dose and 41.3% with the 300-mg dose.3 Within the PROMISE 2 research, the antibody was developed in 18.3% with the 100-mg dose and 34.9% with the 300-mg dose. Nonetheless, there may be uncertainty concerning the scientific manifestations of eptinezumab’s immunogenicity growth. Extra knowledge will have to be monitored via postmarketing surveillance.


As extra remedy choices focusing on CGRP are launched, class results, corresponding to a lower in cardiovascular threat, immunogenicity, and MMD will likely be always monitored and evaluated. Though there therapies are nice choices for these experiencing migraines, decoding immunogenicity knowledge and making use of them in scientific follow could be a problem, to not point out that immunogenicity is an space of consideration not solely with the CGRP brokers but additionally in different biologic merchandise, as it may well have an effect on a product’s effectiveness and security. Immunogenicity will likely be a dialogue matter amongst clinicians for a few years. As pharmacists, you will need to perceive the mechanism of CGRP brokers and advise sufferers and prescribers accordingly.


David Kim, PharmD, MPH, is chief of pharmacy operations with the 92nd Medical Group, US Air Power. He’s on army go away from Mayo Clinic in Rochester, Minnesota.


1. Burch R, Rizzoli P, Loder E. The prevalence and influence of migraine and extreme headache in the US: fi gures and traits from authorities well being research. Headache. 2018;58(4):496-505. doi:10.1111/head.13281

2. Headache: migraine and tension-type. In: DiPiro JT, DiPiro CV, Ellingrod V, Schwinghammer TL, eds. Pharmacotherapy Handbook. McGraw-Hill Skilled Publishing; 2021.

3. Vyepti. Prescribing data. Lundbeck Seattle BioPharmaceuticals; 2020. Accessed June 14, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/761119s000lbl.pdf

4. Kudrow D, Pascual J, Winner PK, et al. Vascular security of erenumab for migraine prevention. Neurology. 2020;94(5):e497-e510. doi:10.1212/WNL.0000000000008743

5. Cohen JM, Ning X, Kessler Y, et al. Immunogenicity of biologic therapies for migraine: a evaluation of present proof. J Headache Ache. 2021;22(1):3. doi:10.1186/s10194-020-01211-5



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