Thinking Ahead: New Treatment Options for Migraine Prevention

Transcription

1 Thinking Ahead: New Treatment Options for Migraine Prevention Satellite Symposium Sunday, June 24 th, 2018 Halifax, Nova Scotia This program was developed by the CNSF, Hc3 Communications and Novartis and was planned to achieve scientific integrity, objectivity and balance. It has been approved for 1.5 hours of Royal College MOC Section 1 credits.

2 Faculty Suzanne N. Christie, MD, FRCPC Neurologist Director, Ottawa Headache Centre Assistant Professor, University of Ottawa Ottawa, ON Richard Leckey, MD, B.Sc., FRCPC Neurologist Division of Neurology Dalhousie University, Halifax, NS

3 Faculty Disclosures I, Suzanne Christie, MD, FRCPC, have received Consultant, Speaker, Investigator, Scientific Officer, Steering Committee, Advisory Board, Publication Committee honoraria from the following companies: Allergan, Amgen, Eli Lilly, Novartis and Teva

4 Faculty Disclosures I, Richard Leckey, MD, FRCPC, have received Consultant, Speaker, Investigator, Scientific Officer, Steering Committee, Advisory Board, Publication Committee honoraria from the following companies: Allergan, Genzyme, Novartis and Pfizer

5 Learning Objectives Upon completion of this program, participants will be able to: Recognize the importance of migraine and its significant burden to patients Describe the pathophysiology underlying migraine and the role of the calcitonin gene-related peptide (CGRP) pathway Identify unmet needs with currently available treatments for migraine Review recent data from evolving research and upcoming treatments for migraine prevention including CGRP antagonists

6 Program Outline 1 Introduction: Migraine in Migraine Pathophysiology 3 Migraine Treatment: Old & New 4 Practical Tips: Guidance to discuss the new treatments with patients 5 Q & A Period

7 Migraine in 2018: Burden of Disease and Treatment Challenges

8 Adapted from: Headache Classification Committee of the International Headache Society (IHS). Cephalalgia. 2013;33: Russo AF. Annu Rev Pharmacol Toxicol. 2015;55: Figure adapted from Blau JN. Lancet. 1992;339: Charles A. Headache. 2013;53: Migraine Phases and Associated Symptoms* Intensity of Symptoms or Phases Prodrome Repetitive yawning Food cravings Neck stiffness/pain Fatigue Few hours to few days Aura (20% of cases) Changes in vision Skin sensations/tingling Language problems Headache Other symptoms may include: Unusual sensitivity to light, sounds, and smells Lightheadedness and fainting Nausea and vomiting Head pain Often unilateral Tends to have a pulsating quality Can be aggravated by routine physical activity Can be associated with cutaneous allodynia * Migraine patients may not experience all phases and symptoms shown, and not all possible symptoms are listed. Illustrative only. Duration per symptom. Postdrome Repetitive yawning Food cravings Neck stiffness/pain Fatigue Few hours 5-60 min 4-72 hours to few days Time

9 Episodic and Chronic Migraine are Considered as Part of the Spectrum of Migraine Disorders Classification by attack frequency (< or 15 HD/months) 1,2 EM may evolve into CM: EM progresses to CM at the rate of 2.5% per year, and CM often remits to EM (2-year transition rate of 26%) 1,3 Episodic Migraine (EM) Headaches (untreated or unsuccessfully treated) occur <15 days/month 1 Chronic Migraine (CM) Headaches (tension-type and/or migraine) occur 15 days/month for 3 months 1 Headache has features of migraine without aura for 8 days/month 1 Highest frequency Highest unmet need - Increasing patient and societal burden 1,3 Approximately 92% of migraineurs have EM (<15 HD/month) and 8% have CM ( 15 HD/month) 4 Adapted from: 1. Katsarava Z et al. Curr Pain Headache Rep 2012; 16: The International Classification of Headache Disorders, 3rd edition (beta version) Cephalalgia 2013; 33(9) Lipton RB, Headache 2015;55;S2: Buse DC, et al. Headache 2012;52(10): CM: chronic migraine; EM: episodic migraine; HD: headache days 9

10 Polling Question Migraine attacks account for approximately what percentage of an average person s life? 1. 1% 2. 3% 3. 5 % 4. 10% 5. 15%

11 Migraine: Burden of Disease The 2016 Global Burden of Disease Study found migraine to have the highest amount of years lived with disability of the neurologic disorders and second highest of all diseases studied following low back pain The 2015 Global Burden of Disease Study found that migraine is the 3rd cause of disability in under 50s Adapted from: GBD Lancet 2017; 390: Steiner TJ et al. J Headache Pain 2016; 17(1): 104.

12 Migraine: Burden of Disease Contributors to annual costs: Hospitalizations and emergency department visits Primary care and specialist visits Procedures and diagnostic tests Medication Loss of productivity Treatments that reduce headache frequency could reduce the clinical and economic burden Adapted from: Linde M, et al. Eur J Neurol. 2012;19: Munakata J, et al. Headache. 2009;49: Stokes M, et al. Headache. 2011;51: Bloudek LM, et al. J Headache Pain. 2012;13:

13 Migraine is Disabling Most bothersome symptoms associated with migraine that impacted lifestyle or work in 10% of patients Real-world data from the Adelphi Migraine US Disease Specific Program (2014) show that pain, nausea and photophobia were the key symptoms reported by patients as impacting their work and lifestyle Pulsating/throbbing pain Unilateral pain Bilateral pain Nausea Photophobia Vomiting Phonophobia Pain worsened by activity Muscle weakness/fatigue Light-headedness * * * * * * Chronic N=137 * Episodic N=1,350 * *p< Percent of patients Adapted from: Ford J et al. EHMTIC 2016, Glasgow September Abstract 173.

14 Adapted from: Steiner TJ et al. J Headache & Pain 2013, 14:1. Burch RC et al. Headache 2015;55:21. Migraine is Disabling Migraine attacks account for about 5% of an average person s life; the percentage is substantially higher in those with severe chronic migraine In the USA, headache or pain in the head is the 4 th leading cause of visits to the emergency department Depression is 3 times more common in people with migraine or severe headaches than in healthy individuals 3.1% Migraines/headaches account for 3.1% of all visits to emergency departments

15 Mean days lost in preceding 3 months Adapted from: HALT, Headache attributed lost time (including work days lost, days of household work or days on which family, social or leisure activities were lost). Steiner TJ, et al. J Headache Pain. 2014;15:31. Migraine Negatively Impacts Personal Activities In the preceding 3 months, migraine patients lost 3.2 workdays, 4.6 housework days and 2.1 social days Personal impact of migraine assessed as headache-attributed lost work, housework and social days in preceding 3 months: Eurolight project Workdays Housework Days Social Days Males Females Overall

16 Percentage of participants Disability Associated with Migraine Headache MIDAS In 2009, the International Burden of Migraine Study (IBMS) collected data on headache-related disability with MIDAS Assessed the extent to which the following activities were missed as a result of headache over the previous 3 months: Schoolwork/paid employment Household work or chores Non-work activities Total scores ranged from 0 (no disability) to 270 (very severe disability) 70% 60% 50% 40% 30% 20% 10% 0% Migraine frequency and severity of disability Episodic (N=8,227) Chronic (N=499) Migraine Frequency Grade I Grade II Grade III Grade IV-A Grade IV-B 23.3% of EM and 78.0% of CM patients, reported severe (grade IV-A) or very severe (grade IV-B) headache-related disability MIDAS = Migraine Disability Assessment test; EM: Episodic migraine; CM: Chronic migraine Adapted from: Blumenfeld AM, et al. Cephalalgia. 2011;31: MED/AMG/0013

17 Migraine is Costly EuroLight Project Cross-sectional survey in 8 countries (55% of European adult population) Mean per-person annual costs were 1222 In the UK 25 million days are lost from work or school each year because of migraine, costing 2.25 billion The cost to the NHS is 150 million per year Total annual cost of migraine in EU: 111 billion Adapted from: Linde M et al. Eur J Neurol 2012;19:703; Steiner TJ et al. Cephalalgia 2003;23:519; Headache Disorders not respected, not resourced. All-Party Parliamentary Group on Primary Headache Disorders. 2010; Shapiro RE & Goadsby PJ. Cephalalgia 2007;27: Despite its economic impact, migraine is the least publicly funded of all neurological illnesses

18 Current Challenges: Migraine is Underdiagnosed World-wide, 60% of individuals with migraine are not professionally diagnosed About 50% of patients consult a clinician There is a lack of professional training: ~ 4 hours are allocated to undergraduate training ~ 10 hours are allocated for specialist training Adapted from: WHO Atlas of headache disorders and resources in the world 2011; Pavone E et al. Cephalalgia. 2007;27:1000-4; Diamond S et al. Headache 2007;47:355.

19 AMPP: American Migraine Prevalence & Prevention; OTC: Over the counter Adapted from: WHO Atlas of headache disorders and resources in the world 2011; Diamond S et al. Headache 2007;47:355. Current Challenges: Migraine in Undertreated Worldwide, about 50% of people with migraine are selfmedicating In the AMPP study of migraine treatment: 49% used OTC medication only 29% used prescription and OTC medication Only 1 in 8 received preventive therapy Self PCP Neurologist Alternative Others Treatment of migraine 0% 10% 20% 30% 40% 50% Percentage of patients

20 Patients, % Preventive Strategies are Being Underused Migraine patients who consulted a HCP received a diagnosis and received treatment Episodic Migraine (N=775) Chronic Migraine (N=1,254) HCP: Healthcare professional Adapted from: Lipton RB et al. Headache 2013; 53:81-92; Dodick DW et al. Headache 2016; 56:821-34

21 Proportion of Persistent Patients Preventive Strategies are Being Underused Persistence to the initial treatment was 25% at 6 months and 14% at 12 months Antidepressants Anticonvulsants Beta-blockers Analysis Time, Days Adapted from: Hepp Z et al. Cephalalgia 2017; 37:470-85

22 Patients % Reasons for Poor Adherence Side-effects and lack of efficacy are the key drivers of suboptimal adherence Satisfactory Resolution Lack of Efficacy Reasons reported by patients for discontinuation of preventive medication Antidepressants (N=205) Anti-epileptics (N=125) β-blockers (N=130) Calcium-channel blockers(n=59) Side-Effects Cost Other Adapted from: Blumenfeld AM et al. Headache 2013;53:644.

23 Clinical Challenges: Episodic Migraine Sophie 24 year-old female Student On average 4 moderate-to-severe migraines per month Takes OTC medications often combined with a triptan Migraines still take 2-3 days to resolve She is struggling with continuing with her university studies due to all these unplanned absences and impact on her productivity

24 Clinical Challenges: Chronic Migraine On average 16 headache days per month Has tried multiple preventive treatments for migraines, which have only had a minor impact on her migraine frequency and duration Marie 32 year-old female Mother of 2 children She is struggling with keeping her employment and large amount of sick days and has needed to bring in extra help with her children, which has all contributed to increased financial and emotional stress

25 Summary: Current Challenges with Migraine Treatment Underdiagnosis and undertreatment Current prophylactic drugs are repurposed from other conditions Issues with available preventive strategies, specifically efficacy and tolerability Long-term adherence can be problematic due to tolerability issues and modest efficacy Acute treatments do not demonstrate efficacy in a high percentage of cases; patients respond to acute treatment for some, but not necessarily all, attacks of migraine Comorbidities can restrict treatment choice Adapted from: Pringsheim T, et al. CMAJ. 2010;182:E269-E276. Lipton RB, et al. Headache. 2013;53:

26 Migraine Pathophysiology

27 Migraine: Pathophysiology Introduction Current thinking is that migraine is a complex condition which is thought to involve the vasculature, central and peripheral neuronal pathways involved in pain signalling, as well as inflammation While the events that actually initiate a migraine attack remain unknown, activation of the trigeminovascular system is considered key Adapted from: Amara SG et al. Nature 1982;298:240.

28 Polling Question The most abundant neuropeptide in the trigeminal system is: 1. Substance P 2. CGRP 3. Calcitonin 4. Neurokinin A CGRP = calcitonin gene-related peptide

29 The Neurological Basis for Migraine Pain Cerebrum Skull bone Subarachnoid Space (contains cerebrospinal fluid) Skull bone Dura mater Arachnoid mater Pia mater Blood vessel Cerebrum Cranial meninges Migraine headache is thought to involve the trigeminal system While the brain lacks pain receptors (nociceptors) they are present in the dura and pia of the meninges Migraine pain is transmitted from the meninges through the trigeminal nerve CGRP is the most abundant neuropeptide in the trigeminal system and is associated with migraine attacks CGRP = calcitonin gene-related peptide. Adapted from: Burgos-Vega C, et al. Prog Mol Biol Transl Sci. 2015;131: Moskowitz MA. Neurology. 1993;43:S16-S20. Goadsby PJ, et al. N Engl J Med. 2002;346: Messlinger K. Exp Brain Res. 2009;196: Pietrobon D, Striessnig J. Nat Rev Neurosci. 2003;4: Eftekhari S, et al. Neuroscience. 2010;169: Figure adapted from Burgos-Vega C, et al. Prog Mol Biol Transl Sci. 2015;131: MED/AMG/0016

30 Migraine Involves Activation of Peripheral and Central Components of the Trigeminal System Pathophysiology includes: Trigeminovascular activation 1. Peripheral vasodilation and neurogenic inflammation 2. Peripheral afferent signals to trigeminal ganglion (TGG) 3. CNS pain signals relay to higher order structures (i.e. TNC and cortex) CGRP neuropeptide is enriched in the migraine pathway 1. Meninges Neuropeptides Neurogenic inflammation and vessel dilation 4. Headache pain TNC 3. Second-order brainstem neurons 2. Trigeminal ganglion Activation of pain signaling Image adapted from Bigal ME, et al. Arq Neuropsiquiatr. 2009;67(2-B): The key pathway for pain in migraine Trigeminovascular input from the meningeal vessels passes through the trigeminal ganglion and synapses on second-order neurons in the brainstem before being relayed to the sensory cortex. CGRP = calcitonin gene-related peptide; CNS = central nervous system; TGG = trigeminal ganglion; TNC = trigeminal nucleus caudalis. Adapted from: Russo AF. Annu Rev Pharmacol Toxicol. 2015;55: Bigal ME, et al. Arq Neuropsiquiatr. 2009;67(2-B): MED/AMG/0016

31 Migraine Pain Starts with Abnormal Activation of the TGVS The cause of migraine is unclear but involves abnormal activation of the TGVS Trigeminal nerve Smooth muscle cell / postsynaptic neuron TGVS activation causes release of various neuropeptides at the meninges: Calcitonin CGRP Neurokinin A Substance P These peptides can induce neurogenic inflammation Inflammation and dysregulation contribute to a feed-forward loop, causing migraine 65 CGRP = calcitonin gene-related peptide; TGG = trigeminal ganglion; TGVS = trigeminovascular system. Adapted from: Burgos-Vega C, et al. Prog Mol Biol Transl Sci. 2015;131: Raddant AC, Russo AF. Expert Rev Mol Med. 2011;13:e36. Russo AF. Annu Rev Pharmacol Toxicol. 2015;55: Pietrobon D, Moskowitz MA. Annu Rev Physiol. 2013;75: Demarquay G, Mauguière F. Headache. 2016;56: MED/AMG/0016

32 A Feed-forward Loop in the TGVS Creates a State of Hypersensitivity and Sustained Pain Trigeminal nerve fiber Cortex Thalamus 1. Activation of TNC of the brainstem 4. Meningeal nociceptive receptors transmit signal back to TGN 3. Collateral axons release proinflammatory peptides to meninges and vessels 2. Signal transmitted to the trigeminal ganglion Meninges Inflammation MIGRAINE 5. Feed-forward loop creates hypersensitivity TGN = trigeminal nerve; TGVS = trigeminovascular system; TNC = trigeminal nucleus caudalis. Adapted from: Demarquay G, Mauguière F. Headache. 2016;56: Akerman S, et al. Br J Pharmacol. 2002;137: Capuano A, et al. Mol Pain. 2009;5:43. MED/AMG/0016

33 Polling question: Which of the following statements is FALSE? 1. CGRP is a 37-amino acid neuropeptide derived from the gene encoding calcitonin 2. CGRP functions as a messenger in nerve cells and as a vasodilator 3. In the trigeminocervical complex, CGRP acts on second-order neurons to activate spinothalamic pathways 4. CGRP levels are decreased in migraine sufferers 5. Triptans suppress CGRP release from trigeminal nerves CGRP = calcitonin gene-related peptide

34 What is Calcitonin-related Gene Peptide (CGRP)? CGRP is a 37-amino acid neuropeptide derived from the gene encoding calcitonin. It functions as a messenger in nerve cells and as a vasodilator. CGRP exists in two forms in humans: the α form predominates CGRP is found in the peripheral and central nervous systems. This is formed from the alternative splicing of the calcitonin/cgrp gene located on chromosome 11. CGRP is found in the enteric nervous system. This differs in 3 amino acids. CGRP = calcitonin gene-related peptide Adapted from: Amara SG et al. Nature 1982;298:240

35 Where are CGRP and their Receptors Located? CGRP and CGRP receptors are widely expressed throughout the body. Of importance to migraine, CGRP and CGRP receptors are found in the central nervous system (CNS) and throughout the trigeminovascular system. Binding studies showed: Co-expression of CLR and RAMP-1 in smooth muscle of human cranial vessels CGRP and CGRP receptor expression in the dura mater and the trigeminal ganglion In the spinal cord, CGRP expression in un-myelinated fibres (C-fibres); CGRP receptor expression in myelinated fibres (A-delta-fibres) In humans, CGRP binds densely in the cerebellum Adapted from: Giamberardino MA et al. Intern Emerg Med 2016; 11: Tso AR et al. Curr Treat Options Neurol 2017;

36 CGRP Plays a Pivotal Role in Migraine Vasodilation PAIN PHOTOPHOBIA PHONOPHOBIA CGRP Meningeal vessel Trigeminal nerve fibers Pial vessel Cortex CGRP CGRP antibodies/antagonists Skull Dural mast cell degranulation leading to neurogenic inflammation Dura mater Arachnoid mater Subarachnoid space Pia mater White matter Vasodilation Trigeminal nerve caudalis CGRP antagonists CGRP = calcitonin gene-related peptide Trigeminal ganglion CGRP antagonists? CGRP antibodies/antagonists Adapted from: Russell FA et al. Physiol Rev 2014;94:1099.

37 CGRP and the Trigeminovascular System Cranial vasculature Trigeminal ganglia Spinal trigeminal nuclei In the trigeminocervical complex, CGRP acts on second-order neurons to activate spinothalamic pathways Receptors CGRP AM 1 AM 2 AMY 1 Cell types Satellite glia Endothellial Vascular smooth muscle Other glial Hormones CGRP AM Direction of release Trigeminal neuron Trigeminal neuron To thalamus Neuron CGRP = calcitonin gene-related peptide Adapted by: Walker CS and Hay DL. Brit J Pharmacol 2013;170 :

38 (pmol/l) Trigeminal Ganglion Stimulation Increases CGRP in the Cranial Circulation 120 TG Stimulation Control Activation of the trigeminal ganglion increased levels of substance P-like and CGRP-like immunoreactivity. These findings suggested a putative role of these peptides in the pathophysiology of migraine. CGRP = calcitonin gene-related peptide 0 CGRP Substance P CGRP Substance P Cat Human Adapted from: Goadsby PJ et al. Ann Neurol 1988;23:193-6.

39 CGRP pmol/l jugular CGRP Levels are Increased in Migraine Sufferers Migraine without Aura * Migraine with Aura * During migraine attacks (with or without aura) CGRP levels increase in the extracerebral circulation (external jugular blood) Only CGRP levels are elevated; there is no change in other peptides thought to be involved in pain transmission 0 CGRP = calcitonin gene-related peptide; CONT = Control Adapted from: Goadsby PJ et al. Ann Neurol 1990;28: Cont Rest Attack Cont Rest Attack * p<0.001

40 pmol/l Sumatriptan Suppress CGRP Release from Trigeminal Nerves Sumatriptan acts via presynaptic 5-HT1B/D receptors to suppress CGRP release from trigeminal nerves Control Migraine Post-Sumatriptan CGRP VIP SP CGRP = calcitonin gene-related peptide: 5-HT = serotonin; VIP: vasoactive intestinal peptide; SP: substance P Adapted from: Goadsby PJ et al. Ann Neurol 1993;33: Edvinsson L & Linde M. Lancet 2010;376: Treatment with sumatriptan normalized the increase in CGRP levels seen in acute migraine, with relief of headache pain

41 BOTOX Inhibits CGRP Release Clinical and preclinical studies demonstrated that BOTOX acts via direct and indirect peripheral and central nociceptive pathways through the inhibition of the release of neuropeptides including CGRP Synaptic vesicle OBOT-A Nerve terminal CGRP SP SNAP-25 (-) SNAP-25 (-) OBOT-A Synaptic cleft CGRP receptor NK1 receptor CGRP = calcitonin gene-related peptide; OBOT-A = Onabotulism toxin A; NK = Neurokinin; SP = Substance P; SNAP = synaptosomal-associated protein Adapted from: Szok D et al. Toxins 2015; 7:

42 Do CGRP-targeted Agents Need to Cross the Blood-brain Barrier? The trigeminal ganglion is a key site of action for CGRP in migraine CGRP and CGRP receptors are expressed in the trigeminal ganglion. As the trigeminal ganglion is expressed outside the blood-brain barrier (BBB), therapeutic agents do not need to penetrate the BBB to act. Small to medium-sized neurons Satellite glial cells Large neuron CLR/RAMP1 Vessel, CLR/RAMP1 expression in smooth muscle cell layer Lumen Co-expression CLR/RAMP1 CGRP expression CGRP = calcitonin gene-related peptide Adapted from: Eftekhari S et al. Brain Res 2015; 1600:93.

43 Targeting CGRP or the CGRP Receptor? Therapeutic monoclonal antibodies have been developed that inhibit the activity of CGRP at the CGRP receptor. However, the cross-talk inhibition is different. Monoclonal antibodies to the CGRP receptor Only inhibit function at the CGRP receptor Leaving other calcitonin-family receptors functionally intact To date, only one monoclonal antibody therapeutic targets the CGRP receptor: Erenumab Monoclonal antibodies to the CGRP ligand Inhibit the function of CGRP at all calcitonin-family receptors To date, 3 monoclonal antibodies to the CGRP ligand are in development: Eptinezumab, Fremanezumab, Galcaenzumab CGRP = calcitonin gene-related peptide Pellesi L, et al. Clin Pharmacol Drug Dev. 2017; 6(6):

44 Therapeutic Monoclonal Antibodies vs. Small Molecule Therapies Monoclonal antibodies Larger (~150 kd); mainly extracellular Target-specific Parenteral administration Longer dosing interval (half-life: days to weeks) Not eliminated via hepatic, renal or biliary routes Lower risk of drug-drug interactions Small molecule therapies Smaller (<1 kd); able to enter cells and cross bloodbrain barrier Less specific Oral administration possible Shorter dosing interval (half-life: hours) Elimination via hepatic, renal and/or biliary routes Drug-drug interactions possible Adapted from: Silberstein S et al., Headache 2015;55:1171.

45 Benefits of Therapeutic Monoclonal Antibodies No toxic metabolites (broken down to constituent amino acids) Restricted distribution Pharmacokinetics allow for longer dosing intervals (half-life days to weeks) Do not have a high degree of off-target toxicity Adapted from: Wang W, et al. Clin Pharmacol & Therapeutics. 2008;84: Tabrizi MA, et al. Drug Discov Today. 2006;11: Foltz IN, et al. Circulation. 2013;127: Silberstein S et al. Headache 2015;55:1171.

46 Summary: Migraine Pathophysiology Migraine is a complex condition which is thought to involve the vasculature, central and peripheral neuronal pathways involved in pain signalling, as well as inflammation Activation of the trigeminovascular system is considered key and leads to the release of neuropeptide, induction of neurogenic inflammation contributing to a feed-forward loop, causing migraine Growing evidence suggests that CGRP plays a pivotal role in migraine prevention and treatment Based on this, small molecules and monoclonal antibodies have been developed to inhibit CGRP and its receptor CGRP = calcitonin gene-related peptide

47 Migraine Treatment: Old and New

48 Polling Question Which of the following classes of medications do you use most often for migraine prophylaxis? 1. Antihypertensive 2. Antidepressant 3. Antiepileptic 4. Vitamins/minerals 5. Other

49 Adapted from: AAN = American Academy of Neurology. Silberstein SD. Neurology. 2000;55: Migraine is a Neurologic Condition with Recurrent Attacks Varying in Frequency, Duration, and Disability General principles of management Establish a diagnosis Encourage patients to identify and avoid migraine triggers Educate migraine sufferers about their condition Develop formal management plan, individualize treatment, and consider comorbidities Empower patients to be actively engaged in their treatment; track their progress Set realistic patient goals; discuss expected benefits of therapy

50 Migraine Treatment Goals (AAN/ASH Guidelines) AAN and AHS treatment goals for acute and prophylactic therapy Acute 1,2 Prophylatic 2,3 1. Treat attacks rapidly and consistently without recurrence 2. Restore the patient s ability to function 3. Minimize the use of back-up and rescue medications 4. Optimize self-care and reduce subsequent use of resources 5. Be cost-effective for overall management 6. Have minimal or no adverse events Adapted from: AAN = American Academy of Neurology; AHS = American Headache Society. 1. Marmura MJ, et al. Headache. 2015;55: Silberstein SD. Neurology. 2000;55: Silberstein SD. Continuum. 2015;21: Reduce frequency, duration, or severity of attacks 2. Enhance responsiveness to acute therapy 3. Improve the patient s ability to function 4. Reduce disability 5. Reduce healthcare costs The goals of acute and prophylactic therapies are distinct but complementary

51 Acute Treatment Strategies (CHS) Mild to Moderate Attack Acetaminophen Ibuprofen ASA diclofenac potassium for oral solution diclofenac potassium tablets naproxen sodium ± metoclopramide Moderate to Severe Attack / NSAID Failure + a Triptan later for rescue if necessary Adapted from: Worthington et al., Can J Neurol Sci 2013;40:S1-S80 NSAID w Triptan Rescue NSAID ± metoclopramide ASA: acetylsalicylic acid; NSAID: non-steroidal anti-inflammatory drug; SC: subcutaneous Triptan Triptan ± metoclopramide Sumatriptan, SC injection, nasal, oral Zolmitriptan, nasal, oral, wafer Rzatriptan, oral, wafer Naratriptan, oral Eletriptan, oral Almotriptan, oral Frovatriptan, oral

52 Refractory Migraine: Rx treatment Strategies (CHS) Refractory Migraine Triptan + NSAID Triptan + NSAID w/ rescue Dihydroergotamine Triptan + NSAID (simultaneously) ± metoclopramide SC: subcutaneous; IM: intramuscular; NSAID: non-steroidal anti-inflammatory drug Adapted from Worthington et al., Can J Neurol Sci 2013;40:S1-S80 Triptan + NSAID (simultaneously) ± metoclopramide + 1 for rescue later (as necessary) of: Ketorolac Indomethacin Prochlorperazine Chlorpromazine Dexamethasone or prednisone Opioid combination analgesic (last resort) Dihydroergotamine (nasal, or SC, IM self inj.) ± metoclopramide

53 How Do Physicians Choose Between Treatment Options? It can be difficult to decide between treatment options Decisions are made on a case-by-case basis and taking into account any comorbidities, the patient s age and history of side effects and response to previous medications Goal is to choose the most efficacious and best tolerated option for each patient Other considerations: When selecting a triptan, choose a non oral route (NS or SC) for patients that vomit If patients wake up with a migraine that is already severe, SC sumatriptan as a good option For patients that are sensitive to side effects, choose almotriptan or naratriptan which have a better side effect profile than the other triptans NS = nasal spray; SC = subcutaneous Adapted from: Expert Opinions

54 New Treatment Strategies: Targeting CGRP Small molecules (gepants) were developed specifically for migraine prevention These small molecules are orally administered and can cross the blood brain barrier Six gepants were found to be effective in acute migraine treatment Two of these were found to be associated with elevated transaminase levels when used for prevention in some patients There are currently newer gepants in clinical development (e.g. ubrogenpant, rimegepant) CGRP = calcitonin gene-related peptide Adapted from: Diener HC et al Lancet Neurol 2015; 14: Silberstein S et al. Headache 2015; 55:

55 CGRP Target in Migraine: Monoclonal Antibodies 4 mabs are currently in development for migraine prevention: Eptinezumab / Erenumab /Fremanezumab / Galcaenzumab All have CGRP targeted mabs were statistically superior to placebo in: 1. Primary endpoint: Reducing monthly migraine days (MMD) 2. Secondary endpoints may include: 50% responder rates Disability Change in moderate/severe headache days Change in monthly cumulative hours of headache mabs = monoclonal antibodies; CGRP = calcitonin gene-related peptide Adapted from: Giamberardino MA et al. Intern Emerg Med 2016; 11:

56 CGRP Target in Migraine: Monoclonal Antibodies All have shown: A quick onset with a meaningful clinical effect in the first month Short-term safety and tolerability comparable to placebo Most common treatment-related adverse event was injection site reaction of mild to moderate severity with subcutaneous injections. Adapted from: Giamberardino MA et al. Intern Emerg Med 2016; 11: Tso AR et al. Curr Treat Options Neurol 2017;

57 Decrease in the Number of Migraine Days CGRP mabs Significantly Decrease the Number of Migraine Days 1 Baseline Month 1 Month 2 Month 3 0 Fremanezumab for prevention of episodic migraine: p< Primary endpoint analysis (Weeks 9-12) Placebo p< p<0.001 p< p< p< mg 675 mg Baseline mean migraine days: 11.5 (placebo), 11.5 (225 mg), 11.3 (675 mg) mabs = monoclonal antibodies; CGRP = calcitonin gene-related peptide Adapted from: Bigal ME, et al. Lancet Neurology 2015; 14: 1081.

58 Percentage of Responders CGRP mabs Significantly Increase Responder Rates (short-term) 100% Galcanezumab Placebo Galcanezumab for prevention of migraine: Responder rates at 12 weeks 75% 50% 25% Secondary (OR 2.88) 70% 45% Exploratory post-hoc analysis (OR 2.54) Exploratory post-hoc analysis 49% (OR 2.16) 27% 32% 17% 0% >50% Reduction >75% Reduction 100% Reduction mabs = monoclonal antibodies; CGRP = calcitonin gene-related peptide Adapted from: Dodick DW, et al. Lancet Neurol 2014; 13: 885. *Exploratory post hoc analysis

59 Percentage of Patients with 50% Reduction in Migraine Days per Month CGRP mabs Significantly Increase Responder Rates (long-term) mabs = monoclonal antibodies; CGRP = calcitonin gene-related peptide Adapted from: Goadsby PJ et al. NEJM. 2017;377: Placebo Erenumab, 70 mg Erenumab, 140 mg Percentage of patients with 50% reduction at months 4-6 Placebo, 26.6% Erenumab, 70 mg, 43.3% (odds ratio vs. placebo, 2.1) Erenumab,,140 mg, 50.0% (odds ratio vs. placebo, 2.8) Months

60 Points Points CGRP mabs Improved Impact of Migraine on QoL Measures (MPFID) Change from baseline at month Change in Mean Physical Impairment Score (N=955) Erenumab 70 mg Erenumab 140 mg P<0.001 for both Placebo Change in Impact on Everyday Activities Scores (N=955) Erenumab 70 mg Erenumab 140 mg -5.9 P<0.001 for both Placebo -3.3 Erenumab 70 mg and 140 mg reduced impact of migraine on QoL measures. mabs = monoclonal antibodies; CGRP = calcitonin gene-related peptid; MPFID = Migraine Physical Function Impact Diary Adapted from: Goadsby PJ et al. NEJM. 2017;377:

61 Average HIT-6 Scores for 75% Responders With Any Study Dose CGRP mabs Improved Impact of Migraine on QoL Measures (HIT-6) Change in HIT-6 scores for patients with chronic migraine achieving 75%, response rate following infusion of eptinezumab or placebo (N=616) Baseline Week 4 Week 12 mabs = monoclonal antibodies; CGRP = calcitonin gene-related peptide; HIT = Headache Impact Test Adapted: Lipton R et al. AAN Abstract 165.

62 Change in monthly migraine days CGRP mabs Significantly Decreased Monthly Migraine Days in Chronic Migraine Placebo (n=281) Erenumab 70 mg (n=188) Erenumab 140 mg (n=187) Baseline Week 4 Week 8 Week mabs = monoclonal antibodies; CGRP = calcitonin gene-related peptide Adapted from: Tepper S et al. Lancet Neurol 2017; 16:

63 CGRP mabs: Clinical Trial Results: Tolerability Summary No clinically significant change seen in vitals or ECGs No change in hepatic enzymes judged to be treatment related AEs in similar proportion to placebo group Most common AE was injection site reaction of mild to moderate severity for SC injections No SAEs reported Long term safety remains unknown (trials were usually 3 months duration), further study needed SAE: Serious adverse event; AE: Adverse event; SC: sub-cutaneous Adapted from: Tso AR et al. Curr Treat Options Neurol 2017;

64 Polling Question Do you talk to your patients about new medications that are coming to market? 1. Yes 2. No 3. It depends

65 Practical Tips: Guidance to discuss the new treatment with patients

66 Practical Guidance for Talking to Your Patients about New Medications Discussion points with patients can include: Purpose of medication Treatment options How the medication works How the medication is administered Duration of therapy, reminder that this is a long-term disorder and the patient needs to be involved in their own management Goals of therapy How effectiveness will be monitored Adverse effects and how to deal with them - drug specific issues

67 New options are coming Sophie Episodic Migraine providing hope for your patients like Sophie and Marie Marie Chronic Migraine

68 Key Points Migraine greatly impacts patients quality of life and impacts them personally and professionally Current unmet needs remain in terms of finding treatments that are effective, tolerable and patients will continue to take. CGRP monoclonal antibodies were developed for migraine-specific targets and have demonstrated good efficacy in episodic and chronic migraine

69 Key Points Tolerability data to date are promising, although long-term safety needs to be established These new treatment options provide hope for migraine patients for whom current options are either ineffective or poorly tolerated

70 Q & A