Medications

4 November 2019

Combining CGRP Inhibitors with – Botox

Now that some of the new CGRP inhibitors have hit the market, studies are beginning to see how they might work with together with other treatments. At the University of Utah, the treatment includes Botox (onabotulinumtoxinA or ONA) and Aimovig (erenumab).

The patients trying the combination treatment, in this case, had already tried 3, 4, 5, or more treatments without success. Many also suffered from depression, anxiety, insomnia, and other co-morbid disorders. Most, though not all, were women.

Both ONA and the CGRP inhibitors such as Aimovig are given by injection. Botox every 12 weeks, Aimovig every 4. (The upcoming drug eptinezumab is meant to be given every 12 weeks, so it would be interesting to see how that works with ONA as well.)

The benefits of ONA are known to be inconsistent over the 12 weeks between treatments. In other words, there may be days, especially near the end, when it’s not helping the way it did at its peak. So combining it with another medication may help the situation.

In this study, which is small but ongoing, the results were not spectacular but they were promising for some patients. Slightly more than half of the patients did see significant improvement with the combination. The bulk of the rest found no improvement, although 18% found that their “headache burden” actually got worse.

So once again this is a treatment that may be a tremendous benefit to some patients. And remember, these were generally patients who have tried several other treatments without success.

One of the biggest challenges when it comes to combination treatment, and combination treatments that work with many but not all patients, is insurance coverage. It is in the best interest of insurance companies in many cases to see stable improvement of migraine symptoms. But convincing them that this is the way to go may take time.

We would be interested to hear your comments if you have tried any of the new CGRP inhibitors in combination with Botox treatment. Leave a comment!

1 November 2019

AXS-07 – New Combination Drug for Migraine in the Pipeline

James Medications, News 0

Axsome Therapeutics has a new combination abortive drug in the pipeline. At the moment it’s going by the name AXS-07.

Every new medication attempts to solve one or more problems. This one is focused on two – well, maybe three – different things. First, fast absorption. The medication needs to get into your system at full power as soon as possible.

Second, it needs to keep working long enough to really make a difference. And when we say “working”, that brings us to a third thing – alleviation of symptoms.

This medication is a combination of two medications. First, rizatriptan, an already well-known abortive drug that targets migraine specifically. The second is meloxicam, which is a type of NSAID, specifically a COX-2 NSAID. That would put meloxicam in the same class as Celebrex (celecoxib), which may be a little more familiar to you.

Axsome is using a special formulation of meloxicam (“MoSEIC™ meloxicam “) that is designed to get into your system faster and last longer. Since both of these medications attack migraine in different ways, they have the potential to attack different symptoms in a more complete way.

That’s what the developers hope. There are two trials that are starting, if you’re interested in being a party of the development of AXS-07. Both are in the USA, and all the contact information is here:

For more information, see Axsome’s site: AXS-07

10 September 2019

New Triptan Study (and is it really useful?)

James Discoveries & Stats, Medications 0

Triptans – medications that were specifically designed to fight migraine pain – come in a number of varieties. So, which ones are the most effective? A new study attempts to answer that question.

The study, published in the European Journal of Clinical Pharmacology, compared various triptan medications. Probably the most well known is sumatriptan, partly because it was the first one to come out years ago. But as we’re discussed in the past, sumatriptan doesn’t work for everyone. Some people who have not found it helpful at all have had great success with other triptans.

For more of an introduction to triptans, see 10 Triptan Facts You Need to Know Now.

So who was the “winner”? Surprisingly, it was eletriptan, a 40mg dose. The “loser” was naratriptan. Both of these were oral doses.

The difference between the two? Well, about three times more people were pain free at two hours with eletriptan than with naratriptan, so all the other triptans would fall between the two.

So – oral dose, you say. What about in injection? Or those nasal sprays? Aren’t they better?

Actually, they compared nasal sprays, oral, and subcutaneous (injections). Of course, most of the variety out there is with sumatriptan, so that’s where most of the information comes from. In short, the injections had the advantage of being quite a bit faster, but oral and nasal spray were about the same for effectiveness.

So just how useful is this information? Should everyone just run out to buy eletriptan? In oral form?

Well, there are some serious limitations with this study. As I suggested before, there’s a lot more information (and variety) for sumatriptan.

But perhaps even more importantly, there are some important reasons why one triptan may work for you and another may not. You may be taking other medications that could interact with a certain triptan. One may work better for women, or older patients.

So yes, maybe doctors and patients should pay a little more attention to eletriptan as a good option. Maybe you should even try it first (before other triptans, that is). But talk to your doctor, because she may have suggestions for you, far beyond “this happens to work better for most patients in clinical trials”. Everyone is different, with a different medical history and a different biological make up.

So how useful is this study? It’s worth raising an eyebrow and reconsidering what triptans we prioritize, as we look at it along with other trials. It also says good things about oral medications, and injections. But again, there are lots of other studies that say good things about nasal sprays – it depends on the person.

You can read the abstract here: Efficacy of triptans for the treatment of acute migraines: a quantitative comparison based on the dose-effect and time-course characteristics

30 July 2019

Cluster and Cannabis: Caution?

James Discoveries & Stats, Information, Medications 0

As is the case with many cluster or migraine treatments, reviews are mixed when it comes to cannabis. This isn’t really reason to ignore it or embrace it – uncertainty is not surprising in a treatment that has been studied as little as cannabis, for a condition that has been studied as little as cluster.

Back in 2010, the results of a questionnaire were published that gave us some early insight into just how effective cannabis was at the time. More than half of the cluster headache patients who had used cannabis felt that the results were “variable or uncertain”. But 22% said it was definitely un-useful or even made their symptoms worse. 25% felt that it was beneficial, providing at least a 50% improvement.

So that leaves us with a 75% fail, or in some cases variable effectiveness.

In a more recent European study, a THC-CBD combination was administered in a study to cluster patients as a preventative, with an extra dose administered as needed during an attack. This seemed to help, but only about as much as amitriptyline, an antidepressant often used for cluster.

An interesting side note was that the abortive dose helped some patients – and which ones? The patients who had had migraine as children. For patients who had not had childhood migraine, the extra dose did nothing at all.

Studies like these leave us with a multitude of questions – what dose is the right dose? How should it be administered? How does it compare to other more established treatments? There are so many options that successful treatment can’t be ruled out, but it will be a long time before there is solid evidence for a good treatment.

The caution comes in because, as with any new treatment, the long term effects of various versions of cannabis treatment are unknown. But more immediately, cluster headache patients should be aware that for many cannabis does make symptoms worse.

Being aware of the risks doesn’t mean you shouldn’t try the treatment. It just means that you are aware of the risks, and so can make wise decisions with your doctor about which treatment to try first.

And we hope that research continues.

For more information:

Is Cannabis Effective for Cluster Headache? (Neurology Reviews)
Cannabinoids suitable for migraine prevention (European Pharmaceutical Review)

7 May 2019

Doctors too “abrupt” as they apply Opioid Restrictions?

James Medications, News 0

In 2016, the Centers for Disease Control and Prevention (CDC) in the USA implemented new guidelines for restrictions of opioid medications. Now, as the results of the restrictions are coming to light, the CDC is expressing concern that doctors may be taking the restrictions too far.

It’s not surprising that the media attention on opioids has led to a bit of an overreaction. Although the evidence generally does suggest that prescriptions of opioids could be cut down drastically, it’s also true that they’ve helped a lot of people. Prescribing them when they’re helpful, and not rushing to get people off them, are two important concerns.

Three of the original authors of the restrictions published an article in the New England Journal of Medicine explaining:

Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations. A consensus panel has highlighted these inconsistencies,⁵ which include inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice. The panel also noted the potential for misapplication of the recommendations to populations outside the scope of the guideline.
No Shortcuts to Safer Opioid Prescribing

Although it’s certainly important to encourage patients to change when there are better treatment options, even the changes need to be done wisely. Dr. Patrice A. Harris, President-elect of the AMA and chair of the AMA Opioid Task Force, pointed out that the guidelines have been “wrongly treated as hard-and-fast rules, leaving physicians unable to offer the best care for their patients.” (source How the CDC’s opioid prescribing guidance went astray)

In the midst of all the concern about opioid overuse and overdose, doctors need to remember to put their patients first, and take a long term view.

For more information: CDC Admits Its Opioid Prescribing Guidelines Have Hurt Chronic Pain Patients