Real-world effectiveness of fremanezumab in patients with migraine switching from another mAb targeting the CGRP pathway

This is a


Introduction
This article summarizes an observational, prospective, two-country study of fremanezumab treatment outcomes entitled "Real-world effectiveness of fremanezumab in patients with migraine switching from another mAb targeting the CGRP pathway: A subgroup analysis of the Finesse Study". 1 That research paper evaluates the efficacy of fremanezumab -one of 4 anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) -in migraine patients with prior anti-CGRP pathway mAb treatment.

Study design and results
The study recruited 1,071 patients, but eventually included 867, as the remaining patients did not have complete data.All patients were treated with fremanezumab monthly (225 mg) or quarterly (675 mg).
Primary endpoints -proportion of patients with a ≥50% reduction in monthly migraine days (MMDs).

Results after 3 months of treatment with fremanezumab
3. Acute medication use: -in all patients, it decreased from 9.7 ±5.0 to 4.9 ±3.7 days per month; -in EM patients, it decreased to 3.8 ±3.1 days; -in CM patients, it decreased to 6.3 ±3.9 days.

What was the discussion of the key results of the study?
-Erenumab was approved by the European Medicines Agency (EMA) earlier than ligand-acting mAbs; therefore, most of the included patients had previously undergone therapy with this mAb.-Studies evaluating the switching of antibodies from different groups are few, and limited to single cases or retrospective studies.-Differences in the efficacy of mAbs are attributed to their mechanisms of action, including effects on the blood-brain barrier (BBB).-Functional magnetic resonance imaging (MRI) studies showed different responses of the central nervous system (CNS) to the ligand and receptor antibodies.Galcanezumab reduced activity in the left thalamus, hypothalamus and bridge areas, while erenumab specifically reduced activation in the insula, thalamus, cerebellum, and operculum.-It seems that a large number of patients and broad inclusion criteria for patients with comorbidities better reflect real situations than phase 3 clinical trials.

What are the key practice points for clinicians?
-Different mechanisms of action of mAbs may affect their efficacy, safety and/or tolerability in patients with migraine.-Patients who have not responded to one class of mAbs may benefit from switching to another class.-It seems that a switch to mAb with a different mechanism of action would be most beneficial.

What are the perspectives for further research?
-The determinants of a response to a particular class of antibodies are still under investigation.There are more and more real-life studies suggesting that certain personal characteristics, migraine features, and comorbidities determine better responses to treatment, but long-term observations based on large groups of patients are needed. 2-4-An important issue in the coming years will be the development of guidelines for the duration of prophylactic treatment, including the determination of the time point after which anti-CGRP drugs can be considered ineffective. 5,6Future studies should also answer the question of whether combining prophylactic therapies in a single patient can improve treatment efficacy and which combinations would be most beneficial. 7-Research is currently underway to identify new targets for migraine treatment. 8,9ior presentation This is a summary of a peer-reviewed article published previously in the Journal of Headache and Pain (https://doi.org/10.1186/s10194-023-01593-2).