Oral, injectable, or IV? Experts break down CGRP options
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“Patient preference is key to optimal migraine management. Patients may prefer oral vs parenteral; may prefer monthly or quarterly dosing vs daily dosing; may prefer a medication that is administered in the healthcare setting vs home.” — Amaal J. Starling, MD, associate professor of neurology, Program Director of the Headache Medicine Fellowship at Mayo Clinic
CGRP-targeted therapies are the first-line treatment for migraine as recommended by the American Headache Society.[] But which CGRP therapy is best for your patient?
“The main differences between the CGRP-targeted therapies include whether it is a small molecule or a monoclonal antibody, route of administration, dosing schedule, insurance coverage, and to a lesser extent, side effects," Leon Moskatel, MD, a clinical assistant professor of adult neurology and an expert in headache medicine at Stanford, tells MDLinx. "Insurance coverage of the medications can also vary between plans. The good news is that these medications all have similar levels of efficacy, so we can aim to pick which one best suits the patient."
When it comes to deciding which is the most suitable, experts say it is important to work closely with the patient. “In an ideal situation, it is important to meet the patient where they are at,” says Amaal Starling, MD, an associate professor of neurology and Program Director of the Headache Medicine Fellowship at Mayo Clinic.
“What is the patient looking for in a therapy? Patient preference is key to optimal migraine management. Patients may prefer oral vs parenteral; may prefer monthly or quarterly dosing vs daily dosing; may prefer a medication that is administered in the healthcare setting vs home. Although not medically appropriate, the practical fact is that often the patient’s insurance dictates which medication can be offered to the patient,” Dr. Starling says.
Oral CGRP therapies
Oral CGRP therapies may be preferred by patients who don’t like needles or don’t have access to an IV infusion center. Examples of oral CGRP therapies include ubrogepant, atogepant, and rimegepant.[]
“The benefits of the oral CGRP therapies are that patients swallow a pill, so patients do not have to worry about injecting themselves. Additionally, because these drugs have much shorter half-lives, patients who may be hesitant to try a monthly medication can be reassured that if the medication is not a good fit then it can be stopped quickly,” Dr. Moskatel says.
However, he also notes a downside of oral CGRP-targeted therapies: "They do have more interactions with other medications relative to the injectable or IV CGRP-targeted therapies.”
“Rimegepant is unique in that it can be used for either acute or preventive treatment,” says Dr. Starling.
Subcutaneous CGRP therapies
Subcutaneous CGRP therapies are administered via a self-administered injection. Examples include erenumab, fremanezumab, and galcanezumab.[]
According to Dr. Moskatel, there are both positives and negatives to this approach. “The main benefit with the injectable CGRP therapies is that they can be administered monthly or quarterly, meaning that patients do not need to worry about them on a daily basis. That said, some patients may be unable or prefer not to perform these injections," he says.
IV CGRP therapies
IV CGRP therapies, such as eptinezumab[], offer many positives, but experts note access can be an issue.
“With the IV CGRP therapy, patients receive it quarterly through an infusion center or service, which means they only receive treatment four times per year and do not have to do an injection at home. Patients who may have experienced an injection-site rash with the injectable CGRP-targeted therapies do not have that occur with the infusion,” Dr. Moskatel says. “The main downside with the IV CGRP therapies is that administration requires either access to an infusion center or a home infusion service, and not all patients may have easy access to these.”
That said, programs and support services are available to help patients navigate these logistical and financial barriers.
Read Next: Why CGRPs are failing your chronic migraine patients—and what to do about it