Table 1 Patients with temporally-associated inflammatory complications of CGRP inhibition
From: Inflammatory complications of CGRP monoclonal antibodies: a case series
Patient | Comorbidities | Concomitant medications | Headache history | CGRP mAb treatment | Response to CGRP mAb | Complication (Onset of Cx) | Diagnosis of complication | Management of complication |
|---|---|---|---|---|---|---|---|---|
Case 1 56 M | BMI 28.4 kg/m2 Rheumatoid arthritis (quiescent), anxiety, dyslipidaemia, pulmonary fibrosis | Rosuvastatin, atenolol, fenofibrate | CM 3 oral preventatives, onaB | Erenumab, single dose | – | Autoimmune hepatitis (D14 of Rx) | Specialist diagnosis, biopsy proven | CGRP agent ceased. Stabilised with steroid and azathioprine |
Case 2 67F | BMI 23.5 kg/m2 Chronic fatigue syndrome, fibromyalgia, hypertension, constipation | Candesartan, pregabalin, esomeprazole, clomipramine, naratriptan | CM 11 oral preventatives, onaB | Erenumab, 15 months | > 75% reduction MMD | Ocular Susac’s syndrome (12 months of Rx) | Specialist diagnosis | CGRP agent ceased. No further flares, or progression to brain/auditory involvement with IVIg, aspirin, prednisolone, mycophenolate. |
Case 3 44F | BMI 20.8 kg/m2 | Zolmitriptan | CM 7 oral preventatives, onaB | Erenumab, single dose | > 75% reduction MMD | DRESS Syndrome (D26 of Rx) | Specialist diagnosis, biopsy proven | CGRP agent ceased. Resolved within four weeks tapering 1 mg/kg prednisolone. |
Case 4 32F | BMI 35 kg/m2 | Topiramate | CM 3 oral preventatives | Erenumab, 6 months transitioned to Fremanezumab, 5 months | > 75% reduction MMD | Granulomatosis with polyangiitis (5 months of Rx) | Specialist diagnosis, biopsy proven | CGRP agent ceased. Complication ongoing with prednisolone and methotrexate. |
Case 5 20F | BMI 18.9 kg/m2 IgG4 disease, GORD, osteoporosis, adrenal insufficiency | 10 mg Prednisolone, gabapentin, calcitriol, propranolol, tapentadol, nortriptyline, CBD oil, omeprazole | CM 6 oral preventatives, onaB | Galcanezumab, single dose | – | Severe polyarthralgia (D4 of Rx) | Specialist diagnosis | CGRP agent ceased. Complication improved 30% but ongoing |
Case 6 45F | BMI 32.3 kg/m2 Psoriasis, chronic fatigue syndrome, Lyme disease | Roxithromycin, tinidazole, minocycline, n-acetyl cysteine, naratriptan, botulinum toxin, rosuvastatin | CM 3 oral preventatives, onaB | Galcanezumab, single dose | None | Severe exacerbation of psoriasis (PASI score 16) (D2 of Rx) | Specialist diagnosis, biopsy proven | CGRP agent ceased. Complication improved (PASI 2) with steroid cream and methotrexate. |
Case 7 41F | BMI 25.6 kg/m2 Psoriatic arthritis (previously controlled > 5 years on adalimumab), osteopenia | Adalimumab, pantoprazole, gabapentin, verapamil, amitriptyline, fenofibrate, naratriptan | CM 5 oral preventatives, onaB | Erenumab, single dose | > 50% reduction MMD | Flare of psoriatic arthritis (5 months of Rx) | Specialist diagnosis | CGRP agent ceased. Complication improving with steroids and change in biological therapy. |
Case 8 46F EH | BMI 31 kg/m2 Asthma | Propranolol, microgynon, Symbicort, PRN Maxalt | CM 7 oral preventatives, onaB | Erenumab, 18 months | > 50% reduction MMD | Urticarial eczema (16 months of Rx) | Specialist diagnosis | CGRP agent ceased. Complication improving with topical steroids, emollients, UVB therapy |