Emgality® ▼ (galcanezumab): Jämförelse med Botulinum toxin A

Comparison With Onabotulinum Toxin A for Migraine Prevention

Please contact the manufacturer(s) of onabotulinum toxin A for information regarding use in migraine prevention.

Efficacy and Safety data from the galcanezumab phase 3 migraine prevention studies are summarized below.

Phase 3 Migraine Prevention Program

Galcanezumab has been studied in phase 3 randomized, double-blind, placebo-controlled studies in adult patients for the prevention of

• episodic migraine (EVOLVE-1 and EVOLVE-2)^1,2

• chronic migraine (REGAIN),³ and

• episodic or chronic migraine that has not benefited from 2 to 4 previous migraine prevention medication categories (CONQUER).⁴

Galcanezumab has also been studied in a phase 3, open-label, 12-month safety study (CGAJ) for the prevention of episodic or chronic migraine.⁵

The recommended dose is 120 mg galcanezumab injected subcutaneously once monthly, with a 240 mg loading dose as the initial dose.⁶ Please note that the results of a maintenance dose of 240 mg galcanezumab once monthly are also included in this response. Even though this dose has been tested in pivotal studies, it has not been approved and therefore is not recommended.

The galcanezumab doses used and duration of the migraine prevention studies are summarized in Table 1.

Table 1. Summary of Study Design in the Migraine Prevention Studies^a

	GMB Doses Studied	Study Duration
EVOLVE Studies1,2	120 mg monthlyb or 240 mg monthly	6 months double-blind
REGAIN3	120 mg monthlyb or 240 mg monthly	3 months double-blind, with optional 9-month open-label extension
CONQUER4	120 mg monthlyb	3 months double-blind,  with optional 3-month open-label extension
CGAJ5	120 mg monthlyb or 240 mg monthly	12 months open-label

Abbreviation: GMB = galcanezumab.

^a With the exception of study CGAJ, all studies were randomized, double-blind, and placebo-controlled.

^b The initial dose was administered as a 240 mg loading dose, followed by subsequent monthly doses of 120 mg.

The primary endpoint was the overall mean change from baseline in the number of monthly migraine headache days over

• 6 months for the EVOLVE-1 and EVOLVE-2 studies,^1,2 and

• 3 months for the REGAIN and CONQUER studies.^3,4

In the 12-month, open-label, safety study, the primary endpoint was the long-term safety and tolerability of galcanezumab for up to 12 months of treatment.⁵

Key Efficacy Results

Galcanezumab met the primary endpoint in the double-blind, placebo controlled phase 3 studies of galcanezumab for the prevention of episodic and chronic migraine.^1-4 

In these studies, patients treated with galcanezumab experienced a significantly greater decrease in the number of monthly migraine headache days compared to patients treated with placebo over 

• the 6-month double-blind treatment period in the EVOLVE studies,^1,2and

• the 3-month double-blind treatment period in the REGAIN and CONQUER studies.^3,4 

These results are summarized in Table 2.

Table 2. Overall Mean Change From Baseline in Monthly Migraine Headache Days

Study	Galcanezumab 120 mg	Galcanezumab 240 mg	Placebo
EVOLVE-11a	– 4.7 daysb	– 4.6 daysb	– 2.8 days
EVOLVE-22a	– 4.3 daysb	– 4.2 daysb	– 2.3 days
REGAIN3c	– 4.8 daysb	– 4.6 daysb	– 2.7 days
CONQUER4d	− 4.1 dayse	N/A	− 1.0 days

Abbreviation: N/A = not applicable.

^a Months 1 to 6; episodic migraine.

^b p<.001 vs placebo.

^c Months 1 to 3; chronic migraine.

^d Months 1 to 3; episodic or chronic migraine that has not benefited from 2 to 4 previous migraine prevention medication categories.

^e p<.0001 vs placebo.

In the double-blind, placebo-controlled studies, patients treated with galcanezumab experienced statistically significant improvement compared to placebo on several prespecified secondary endpoints, including response rates and measures of daily activities.^1-4

Efficacy measures were a secondary objective in the 12-month, open-label safety study.⁵ In study CGAJ, the overall reduction in monthly migraine headache days over 12 months was 5.6 days for galcanezumab 120 mg and 6.5 days for galcanezumab 240 mg. The reduction in monthly migraine headache days was evident at month 1 and was maintained throughout the treatment period. This study was not blinded nor placebo-controlled, and results should be interpreted with these factors in mind.

Key Safety Results

The EVOLVE-1, EVOLVE-2, and REGAIN studies were the pivotal studies and safety results have been integrated resulting in a pooled analysis of 2886 adult patients, comprised of a total of 1435 patients that received monthly doses of galcanezumab (120 mg or 240 mg) administered subcutaneously.⁷

The most commonly reported TEAEs in the integrated safety analysis were injection site reactions, including pain ( ).⁷ Constipation, pruritis (not associated with injection site) and vertigo were also considered to be adverse events associated with galcanezumab treatment.

Table 3. Common^a TEAEs Reported ≥2% Among Galcanezumab-Treated Patients During Phase 3 Double-Blind Treatment: Migraine Prevention^7,8

TEAEb	PBO N=1451 n (%)	GMB 120 mg N=705 n (%)	GMB 240mg N=730 n (%)	GMB Pooled N=1435 n (%)
Injection site pain	138 (9.5)	71 (10.1)	85 (11.6)	156 (10.9)
Nasopharyngitis	94 (6.5)	52 (7.4)	31 (4.3)c	83 (5.8)
URTI	60 (4.1)	31 (4.4)	36 (4.9)	67 (4.7)
Injection site reaction	14 (1.0)	22 (3.1)d	45 (6.2)d	67 (4.7)d
Dizziness	41 (2.8)	20 (2.8)	20 (2.7)	40 (2.8)
Injection site erythema	20 (1.4)	20 (2.8)c	29 (4.0)d	49 (3.4)d
Sinusitis	31 (2.1)	20 (2.8)	19 (2.6)	39 (2.7)
UTI	33 (2.3)	19 (2.7)	18 (2.5)	37 (2.6)
Fatigue	34 (2.3)	17 (2.4)	16 (2.2)	33 (2.3)
Injection site pruritis	2 (0.1)	15 (2.1)d	24 (3.3)d	39 (2.7)d
Neck pain	21 (1.5)	15 (2.1)	6 (0.8)	21 (1.5)
Abdominal pain	24 (1.7)	13 (1.8)	6 (0.8)	19 (1.3)
Cough	19 (1.3)	12 (1.7)	13 (1.8)	25 (1.7)
Oropharyngeal pain	13 (0.9)	10 (1.4)	12 (1.6)	22 (1.5)
Bronchitis	17 (1.2)	9 (1.3)	11 (1.5)	20 (1.4)
Influenza	34 (2.3)	8 (1.1)	20 (2.7)	28 (2.0)
Constipation	8 (0.6)	7 (1.0)	11 (1.5)c	18 (1.3)c
Migraine	14 (1.0)	7 (1.0)	12 (1.6)	19 (1.3)

Abbreviations: GMB = galcanezumab; MedDRA = Medical Dictionary for Regulatory Activities; PBO = placebo; TEAE = treatment-emergent adverse event; URTI = upper respiratory tract infection; UTI = urinary tract infection.

^a ≥2% after rounding (at least 1.5% before rounding) in any galcanezumab-treated group and greater than placebo.

^b MedDRA version 19.1 was used.

^c p<.05 vs placebo.

^d p<.001 vs placebo.

The CONQUER study was not included in the integrated safety analysis. While the safety profile in the CONQUER study was consistent with the established safety profile of galcanezumab, the most commonly reported TEAE  in this study was nasopharyngitis.⁴

Study CGAJ was used to evaluate longer term safety, which showed that the incidence rates for TEAE adjusted for exposure did not increase with longer treatment duration.⁷

Therapeutic Indication

Galcanezumab is indicated for the prophylaxis of migraine in adults who have at least 4 migraine days per month.⁶

The recommended dose is 120 mg galcanezumab injected subcutaneously once monthly, with a 240 mg loading dose as the initial dose.⁶

References

1. Stauffer VL, Dodick DW, Zhang Q, et al. Evaluation of galcanezumab for the prevention of episodic migraine: the EVOLVE-1 randomized clinical trial. JAMA Neurol. 2018;75(9):1080-1088. http://dx.doi.org/10.1001/jamaneurol.2018.1212

2. Skljarevski V, Matharu M, Millen BA, et al. Efficacy and safety of galcanezumab for the prevention of episodic migraine: results of the EVOLVE-2 phase 3 randomized controlled clinical trial. Cephalalgia. 2018;38(8):1442-1454. http://dx.doi.org/10.1177/0333102418779543

3. Detke HC, Goadsby PJ, Wang S, et al. Galcanezumab in chronic migraine: the randomized, double-blind, placebo-controlled REGAIN study. Neurology. 2018;91(24):e2211-e2221. http://dx.doi.org/10.1212/WNL.0000000000006640

4. Mulleners WM, Kim BK, Láinez MJA, et al. Safety and efficacy of galcanezumab in patients for whom previous migraine preventive medication from two to four categories had failed (CONQUER): a multicentre, randomised, double-blind, placebo-controlled, phase 3b trial. Lancet Neurol. 2020;19(10):814-825. http://dx.doi.org/10.1016/S1474-4422(20)30279-9

5. Camporeale A, Kudrow D, Sides R, et al. A phase 3, long-term, open-label safety study of galcanezumab in patients with migraine. BMC Neurol. 2018;18(1):188. http://dx.doi.org/10.1186/s12883-018-1193-2

6. Emgality [summary of product characteristics]. Eli Lilly Nederland B.V., The Netherlands.

7. Bangs ME, Kudrow D, Wang S, et al. Safety and tolerability of monthly galcanezumab injections in patients with migraine: integrated results from migraine studies. BMC Neurol. 2020;20(1):90. http://dx.doi.org/10.1186/s12883-020-01675-7

8. Data on file, Eli Lilly and Company and/or one of its subsidiaries.

Glossary

MHD = migraine headache day

▼ This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions.