CGRP Antibodies for Migraine Prevention – Part 2

0:00 [Music]
0:29 all right
0:31 so now we start our part two cgrp
0:34 antibodies
0:35 do they work and do they have side
0:37 effects and are they dangerous
0:39 right so this is a bit of an overview
0:42 of the research on cgrp antibodies
0:45 i will not make comparisons between
0:48 emmavig hov and galileo i’m just going
0:51 to give you
0:52 ballpark figures from science okay
0:56 what do we have in canada available at
0:58 present time
0:59 to treat migraine to prevent migraine
1:01 emmavig
1:02 m galilei ajovi v yupty
1:06 that’s the american name is likely to
1:08 come in canada in 2021 or 20
1:12 22. it’s going to be intravenous an
1:14 infusion
1:15 right the others come as
1:18 injectors or syringes and usually
1:21 there’s one dose
1:22 but there might be a loading dose and
1:24 there might be ways to
1:26 inject every three months or only every
1:28 month
1:29 um and you can just look at the cost the
1:33 light the line the last line
1:35 those are not cheap things because these
1:37 are new
1:39 antibodies bioengineered um
1:42 just for the record this goes up to
1:45 you know 500 so that would be something
1:47 like 10 to 10 12 000
1:49 per year many biological agents
1:53 antibodies for multiple sclerosis
1:56 crohn’s disease
1:57 arthritis are up to 50 000
2:00 dollars per year so these ones are
2:02 expensive but they’re not
2:04 that expensive for that type of
2:06 treatment
2:08 okay so how do they look like they do
2:11 they look like those are the boxes right
2:13 so you have the boxes with the injectors
2:16 and
2:16 gallery and angel and the emmavig sorry
2:19 come as self-injectors a bit like epipen
2:22 right and if you start these you will
2:25 learn
2:25 how to self-inject hov comes as a little
2:29 syringe
2:29 there’s pros and cons the injector you
2:32 just inject
2:33 the syringe you control it some people
2:35 like to control to inject slowly
2:38 others say i there’s no way i can
2:39 manipulate the syringe i’m going to have
2:41 the injector
2:42 others see the injector just is too fast
2:45 it hurts i prefer the syringe
2:47 it’s a matter of preference okay so will
2:50 they work
2:51 do they work for people who try them
2:54 maybe you have tried them already but
2:56 let’s have a look how do we look at
2:59 prevention success in migraine we look
3:02 at
3:02 decrease in headache days and decrease
3:05 in
3:05 acute medication intake so if you’re
3:08 taking
3:08 every month 12 trypton doses right
3:12 and then if you take something and you
3:14 go down to six trypton doses
3:16 that’s a fifty decrease and it’s a
3:19 success
3:20 depending on where you start different
3:23 responses
3:24 might be significant so let’s say you
3:27 have
3:27 10 migraine days per month and you have
3:30 50 percent better you have
3:32 four you go down to four you lose five
3:34 four days that’s great
3:35 but let’s say you have chronic and then
3:38 you have 22 days
3:40 to start with and then you have a 30
3:43 improvement so that’s still seven days
3:46 of improvement that’s actually um
3:50 significant it’s a whole week back so
3:52 that’s a problem with insurance
3:54 companies because
3:55 insurance companies based on research
3:58 they
3:58 ask for 50 response right so that’s one
4:02 of the issues we’ll discuss
4:03 later some people have super response
4:06 they are 75
4:08 better so if you start at 21 days it
4:10 means you’re down to
4:11 seven days you say 14 days that’s great
4:15 you may also see that okay you have less
4:18 attacks
4:19 maybe not that many less but they’re
4:21 less severe
4:22 you don’t throw up anymore you don’t
4:24 have to go to the emergency
4:26 and you can troll control them with your
4:28 usual therapies
4:29 so this is how we evaluate response
4:33 to prevention um and that’s also all of
4:36 this
4:36 eventually leads to a better life for
4:38 you where you can
4:40 you know plan your party and attend the
4:42 event and
4:43 and and work and maybe uh you know train
4:46 or a glass of
4:47 a glass of wine and enjoy life right
4:51 all right so that’s an example with a
4:53 migraine tracker
4:54 um so the tracker i just showed like a
4:57 one monthly diary to show how it uh
4:59 looks like when you send to your doctor
5:02 um
5:03 here this person started with 18 days
5:06 and went back down to 11 days so that’s
5:08 a
5:08 40 response but also had less
5:12 severe days um and actually sorry had
5:15 more severe but had
5:16 less mild and moderate so that’s just an
5:19 example on how
5:20 a diary will help you to monitor your
5:22 success
5:24 okay graphs graphs are not always easy
5:27 to get but let’s let’s
5:28 let me walk through this you will see
5:31 here in the graphs in blue
5:33 that’s the placebo people who took a
5:36 sugar pill or a neutral injection during
5:38 a study
5:39 in red you have the active product in
5:42 this case
5:43 the oral medications aloe veille andra
5:46 propanol and on the right side you see
5:50 the tree antibodies so i put
5:53 little acronyms there but uh e and m is
5:56 emma vig
5:56 the middle one is m gallery and the last
5:59 one on the right side is
6:01 ajov right so this and the bar that you
6:04 see the little fine blue
6:06 line is fifty percent response so
6:08 everything that’s above that
6:10 is more than fifty percent response and
6:13 below that is forty percent
6:15 sorry forty percent of people or fifty
6:17 percent of people
6:18 so let’s look at our oral medications
6:20 that we had
6:21 so usually this 50 50 ballpark i talked
6:25 about
6:26 not everyone was reaching them right so
6:28 elleville and propanol
6:30 did not reach a really a 50 response and
6:33 trials topamax or to pyramid did but
6:35 overall the ballpark is 50.
6:37 if we look at the antibodies they do
6:40 better
6:41 they’re closer to 50 or above 50 even
6:44 for mgali
6:45 so they do reach this 50 bar of 50
6:49 improvement for episodic migraine so
6:52 episodic would be
6:54 a mean of 8 to 10 days per month of
6:56 migraine but less
6:58 than 15. okay but now if you’re here it
7:02 might be you have
7:03 chronic migraine which is the most
7:05 severe form
7:06 where you might have more than 15 20
7:09 days or
7:10 even every day a headache with some
7:13 migraines
7:14 patched over that and this is not a fun
7:16 way to live and that’s actually
7:17 one to two percent of canada canada’s
7:20 population and the world’s population so
7:23 you’re not alone in this okay so this is
7:26 the same graph
7:27 same concept blues placebo arranges the
7:30 actual treatment
7:31 and green is uh the great the gain the
7:33 difference between both
7:35 and you can see here that this is the
7:37 decrease in monthly days
7:39 so how many days do you gain and now we
7:42 compare
7:42 topermax and botox to the antibodies the
7:45 three of them
7:47 you can see that topamax and antibodies
7:49 gain approximately
7:51 six days better on amine botox fares a
7:54 bit better
7:54 with more than eight days that’s eight
7:57 days less
7:58 of migraine or headache so that’s great
8:00 remember
8:01 that this is the all the people so if
8:04 you remove the people who did not
8:06 improve
8:06 or if you look at people who did improve
8:08 a lot it means that you can
8:10 gain back like i said before 10 to 14 to
8:14 20 days
8:15 okay so if you’re a super responder so
8:18 what about people
8:19 with chronic migraine and bear with me
8:23 i have just two or three more slides
8:24 with graphs and then we’re back
8:27 to uh to no graphs um so
8:30 here are the results of chronic migraine
8:33 so chronic migraine if you want a 50
8:36 response
8:36 for topamax or botox that’s 30 to 46
8:40 people
8:41 percent of people will reach that three
8:43 to four over ten
8:44 okay antibodies it’s three to four over
8:47 ten it was very similar
8:49 right so there’s actually um we cannot
8:52 say that the antibodies are the silver
8:54 bullet they treat everyone their fifty
8:56 percent response rate
8:57 are similar to to pyramid and botox
9:00 some people are super responders to and
9:04 now you have the super response for all
9:06 antibodies
9:07 for episodic or chronic right so the
9:10 message here
9:11 is whatever you’ve tried okay and
9:14 whatever you’ve done before
9:15 to treat your migraine if you have the
9:18 software
9:18 the sensitivity if you’re determined to
9:20 respond to a cgrp antibody
9:23 it looks like you will and there’s
9:25 probably
9:26 three people over 10 and two people over
9:29 10
9:29 trying these drugs who will fall into
9:32 this super response category
9:34 where the the benefit will be very clear
9:37 so that’s what we hope
9:38 as clinicians that’s what you hope as a
9:40 patient
9:42 the super response so 3 over 10 if you
9:44 have episodic
9:45 2 over 10 if you are chronic
9:48 all right let’s take a little breath
9:51 there’s a lot of graphs
9:52 but i just wanted to show you what i
9:54 showed to actually your gps
9:57 this is what i show them right i’m
9:58 showing you the exact same stuff
10:00 right just to tell you what we saw in
10:03 the clinical trials about those
10:05 medications
10:07 another key question is how long should
10:10 you try them
10:11 because usually you take these injectors
10:14 and you inject yourself
10:15 every month but how many months in the
10:18 clinical trials
10:20 usually the response was seen sometimes
10:23 as early as the first month especially
10:25 for the super responders it’s like
10:27 boom you hit the right thing you get way
10:30 better
10:31 and then you’re very happy and then
10:33 usually it stays like that
10:35 but some people some people have more
10:38 severe chronic migraine
10:40 they may start from a very very deep and
10:42 tough place
10:43 and what we’ve seen as experts and we
10:46 talk among ourselves
10:47 what we’ve seen is that sometimes it
10:50 doesn’t work after one or two or three
10:52 months
10:53 sometimes you need four or five or
10:56 up to six months i would say after six
10:58 months if there’s no response whatsoever
11:01 it would be very surprising to see a
11:03 benefit from those antibodies
11:05 right so the message here is you might
11:08 get better
11:09 the first month right away but you might
11:13 need more time
11:14 than the three months that are you know
11:16 the the ballpark that they use in the
11:18 trials
11:19 is it going to last right are you still
11:22 going to be better a year later
11:24 in theory yes right so this is actually
11:27 data
11:27 from all the studies on emmavig hov and
11:31 uh and galilee showing that
11:33 three-quarters of people
11:35 that were chronic 15 plus just went down
11:39 to episodic and at one year they were
11:41 still there
11:42 so it means that somehow if you’re
11:44 chronic you have three quarter of a
11:46 chance to actually get back to episodic
11:49 doesn’t mean having no migraines but
11:51 being improved
11:52 okay so now let’s talk about
11:56 side effects because as a physician i do
11:59 prescribe
11:59 tons of pills and i know some of my
12:02 patients will get back to me
12:04 and say my god i tried this i was a
12:07 zombie
12:08 i gained weight i had a tremor i lost my
12:11 hair
12:12 uh i couldn’t think straight i had no
12:14 libido
12:15 my blood pressure went down i could not
12:17 train anymore
12:18 this is not good right that’s not what i
12:21 want for my patient
12:22 i want my patient to get better without
12:25 gaining weight or
12:27 fainting or being a zombie so side
12:30 effects
12:31 were a key problem with the drugs the
12:33 oral medications
12:34 and if you’ve tried them you might know
12:36 some of these side effects
12:39 so good news right so in the with the
12:42 actually i’ve showed you before
12:44 that the antibodies have similar
12:47 benefits a little bit better
12:49 right uh or close or a little bit less
12:51 than botox actually
12:53 but pretty close they don’t treat
12:55 everyone not everyone responds
12:57 but where they gain is that they are
12:59 better tolerated
13:01 so in clinical trials that means
13:04 thousands of patients total
13:06 less than two percent of people decided
13:08 to stop the drug
13:10 for side effects so that’s actually
13:12 pretty good because for oral medications
13:15 it’s five to ten percent so that means
13:18 that people said you know what maybe i
13:20 have a side effect but i’m gonna bear
13:21 with it
13:22 it’s not that bad it doesn’t mean there
13:24 were no side effects there were side
13:26 effects i’m gonna show you
13:27 but they were not severe enough for
13:29 people to leave the trial
13:31 so that’s actually encouraging okay what
13:33 are the side effects
13:35 injection side reactions so those drugs
13:38 may cause
13:38 redness swelling of the skin uh
13:42 it can happen it can get sometimes
13:45 pretty bad you know it looked it
13:46 swollen big and red discuss that with
13:49 your doctor
13:50 right if it happens sometimes it can be
13:52 managed
13:53 sometimes you have to stop um so that’s
13:56 something we can see and that’s
13:58 probably more than two percent of
14:00 patients probably around five
14:02 to ten percent constipation is common
14:05 in the studies we didn’t see it that
14:07 much but you know a lot of people
14:09 are taking illeville which is very
14:11 constipating some of them are taking
14:14 codeine or opioids very constipating uh
14:17 some people have constipation to start
14:18 with
14:19 so usually constipation is probably
14:22 probably one person over five for
14:25 emmavig
14:26 maybe a bit less with the two others
14:30 usually it’s mild to moderate and it can
14:32 be managed with
14:33 diet or laxatives or stuff but it is a
14:36 problem so if if you are
14:37 known to have severe constipation this
14:40 is this should be
14:41 discussed with your doctor allergy
14:44 may happen okay with these all of these
14:46 products
14:47 uh we call that hypersensitivity
14:50 reaction you know what
14:51 hives or a swelling of the of the the
14:53 throat that kind of thing
14:55 it may happen it is rare but it can
14:57 happen fatigue and muscle pains are
14:59 flu-like symptoms
15:00 right feeling feeling tired having pain
15:03 joint pains
15:04 um that has been reported and then some
15:07 people have reported a transient
15:09 increase in headache so that’s when we
15:12 see the most commonly
15:14 now if you go to social media and
15:18 support groups
15:19 you will see a bunch of other side
15:22 effects
15:23 right nightmares panic attacks sleep
15:26 issues
15:27 weight gain weight loss hair loss and
15:30 it’s a bit surprising to us
15:32 because when we um we discuss with the
15:35 big american clinics where they have
15:37 thousands of people they don’t see that
15:39 that often
15:41 so why is that well first it’s possible
15:44 that in real life
15:45 people are different than the people who
15:48 go to these studies
15:49 and maybe people have more problems more
15:51 medications you know
15:53 and they have more side effects so this
15:56 is not new
15:57 it’s it’s not new actually usually side
15:59 effects in real life
16:00 are always a bit more than in the
16:02 studies
16:03 so it might be that they’ve been
16:05 underestimated on the other side it’s
16:08 also possible to have what we call the
16:10 nocebo effect
16:12 some people take a sugar pill and they
16:15 have a benefit we call that placebo it’s
16:17 great
16:18 some people take a sugar pill and they
16:20 have side effects that’s kind of a dark
16:22 side of placebo
16:24 and it happens and we know because in
16:26 studies we give
16:27 tons of sugar pills to people and they
16:29 they still have side effects
16:31 and those are mediated by expectations
16:34 so they think they’re going to get bad
16:35 and they don’t get bad
16:37 it’s it’s exactly like placebo but
16:38 reverse um
16:40 and the other problem is that people who
16:42 do go to support groups
16:44 and those support groups are great
16:46 people do support each other it’s very
16:48 important
16:49 but those are usually not happy campers
16:51 they are not people
16:52 who are super responders because then if
16:55 you’re doing
16:56 so much better usually you stop going to
16:58 the support group
16:59 so it might be that in support groups
17:02 there’s a bit of an
17:03 over representation of people who have
17:06 side effects
17:06 just be careful with that if you go and
17:09 remember
17:10 that these medications are usually way
17:12 better tolerated
17:14 than the oral medications whatever
17:16 happens
17:17 if you have a reaction to a product any
17:20 product
17:21 always talk about about it with your
17:23 healthcare provider
17:25 okay are there people who cannot take
17:28 the cgrp antibodies
17:30 i didn’t mention it there because i
17:31 don’t do peeds but anyone below 18.
17:34 so any kid or teen that’s that’s like
17:37 that there are trials
17:39 in children and teenagers but they’re
17:41 not there yet so health canada does not
17:43 allow cgrp antibodies for young people
17:47 apart in this study cgrp
17:50 does play a role in pregnancy if you are
17:52 planning
17:53 a pregnancy or if you are pregnant you
17:55 should not be taking these meds
17:58 and because the entire body stay in your
18:00 system for quite a bit
18:01 you should probably stop taking
18:03 antibodies four to five
18:06 months before even starting conceiving
18:08 okay so this
18:09 is really something you have to think
18:11 about if you’re a woman
18:12 and if you’re talking or thinking about
18:15 having a child
18:16 breastfeeding it’s a matter of caution
18:20 so usually we do not recommend to take
18:22 those drugs during breastfeeding
18:24 discuss with your doctor cgrp plays a
18:27 role
18:28 in our vascular bodies and vascular
18:30 system blood pressure you know the heart
18:32 the kidney the brain
18:34 so at present time there’s no formal
18:36 contraindication
18:38 in kind of the label of health canada
18:40 but many of us experts
18:42 we will be cautious if we have patients
18:45 who have a lot of vascular
18:46 issues you know uncontrolled diabetes
18:49 hypertension
18:50 recent heart problems that kind of thing
18:52 it’s caution
18:54 discuss this with your physician because
18:55 there’s no official rule
18:57 but you may hear about it if you suffer
18:59 from a lot of vascular troubles
19:01 severe constipation i talked about it
19:04 and in the studies
19:05 usually the studies have not included
19:07 above 65 apart from some studies within
19:10 galilee
19:11 so this also you may be declined by
19:13 insurance companies for that reason so
19:15 discuss with your physician and i have
19:17 to underline that
19:18 because i’m actually telling you a lot
19:20 of medical stuff here
19:22 and i my my goal is to help you but uh i
19:25 have
19:26 also have to just be careful uh not to
19:29 give you you know the holy bible uh
19:31 thing and maybe it wasn’t clear
19:33 uh and maybe uh maybe i didn’t think
19:36 about your particular case discuss with
19:38 your doctor
19:39 whatever medical treatment you’re doing
19:42 okay so
19:42 the big question before we discuss
19:45 coverage
19:46 is is there one best
19:49 antibody the answer is no they haven’t
19:52 been compared to one another
19:54 the all the studies actually showed very
19:57 similar results so it’s the same thing
19:59 as the whole headache medicine mojo
20:03 or rule which is one size does not fit
20:07 all
20:07 so you may have to try one and then
20:10 another who knows
20:11 so let me show you because maybe you
20:14 you’ve tried one and you want to try
20:15 another
20:16 let me show you data that’s that’s done
20:19 by a guy i know dr larry robbins
20:22 in the states in chicago um and he has a
20:25 big clinic
20:25 so he recorded the patients that he
20:28 switched
20:29 and who started with let’s say emmavig
20:32 was the first to market
20:33 switched to him galilee or jovi and then
20:36 he actually looked at if people were
20:38 switching
20:39 because they did not respond because
20:42 they had side effects
20:43 or or because the insurance was not
20:46 covering anymore and they wanted to
20:48 switch to have some financial support
20:51 from a new antibody so as you can see if
20:54 you switch for
20:55 financial reason which is the fourth
20:58 column financial
20:59 well you have a good chance of
21:01 responding you know 50 to 60 percent
21:03 chance of response and those were very
21:06 tough patients so it’s a 30
21:08 response another 50. so if you switch
21:11 because
21:11 your company your insurance is not
21:13 covering you have and you responded to
21:15 the entire body
21:16 of course you have a good chance of
21:18 responding to another
21:20 if you switch because the first one
21:22 didn’t work
21:23 then you have a lower chance but you
21:25 still have a chance probably around 20
21:27 if we just look roughly maybe
21:30 around 25 30 percent chance so you’re
21:32 still still worth trying
21:33 right and if you switch because you have
21:36 side effects it’s a bit similar
21:38 and that seems to be the case for
21:39 switching between hov and gallery
21:42 aimovig so is we need more data
21:46 but i think this is important for those
21:47 of you thinking about switching an
21:50 antibody to another part three
21:53 welcome to part three cgrp antibodies
21:56 coverage
21:57 and access um so
22:01 we have said and we have discussed
22:03 together
22:04 that first cgrp antibodies are
22:07 a groundbreaking new scientific thing in
22:10 migraine world
22:11 because for the first time we target
22:14 something we know
22:15 that plays a role in migraine that’s new
22:17 so scientifically it’s great
22:19 we know that all the studies on cgrp
22:22 antibodies
22:23 have shown effectiveness not for
22:25 everyone
22:26 so maybe 50 percent of people with
22:28 episodic migraine
22:30 40 of people with chronic migraine will
22:33 improve
22:34 by half or more and there’s maybe 25 30
22:38 percent chance of being a super
22:39 responder
22:40 which is great still 40 to 50 to 60
22:44 percent of people
22:45 will not respond to those drugs and it’s
22:47 okay i mean it’s
22:48 science is still evolving there might be
22:50 other targets other things
22:52 um they are well tolerated for a
22:55 majority of people
22:56 and they are safe to use over years up
22:59 to five years we have data for mlv
23:01 so that’s what we have that’s what we
23:04 are so now
23:06 will my insurance cover them all right
23:10 so this is this is where we entered a
23:13 world of coverage in canada
23:15 and you have to remember and i didn’t
23:17 know you know we don’t
23:18 learn that stuff in medical school
23:20 because medical school is about medicine
23:23 it’s not about
23:23 insurance companies but soon enough when
23:26 you’re a doctor
23:27 you discover that you have to deal with
23:29 insurance companies if you want to help
23:31 people
23:32 so in canada there’s between 50 and 60
23:36 of people who are insured by private
23:38 payers
23:39 sun life ssq manulife blue cross green
23:42 shield
23:43 name it one thing i learned and it’s
23:45 very crucial
23:46 is that you cannot just say sun life
23:49 covers ambiality
23:50 or ssu covers hov
23:53 they have plans and the plans can be the
23:56 super you know
23:57 top vip plan or it can be the little
24:00 plan
24:01 for you know a smaller employer for
24:03 example you can’t
24:05 ever be sure that your private insurer
24:08 will cover uh these medications
24:12 in the public side public is complicated
24:14 because
24:15 it’s like first we have different public
24:17 system in all different provinces
24:20 and so what usually happens is that
24:23 the drug is examined by something called
24:26 catis which which is the canadian agency
24:29 for drug
24:30 technologies and health and they look at
24:34 the results you know what i’ve just
24:35 shown you
24:36 and they look at the cost and then they
24:38 say okay
24:39 is this a good product that we want in
24:41 canada so first health canada
24:43 sorry first half canada says the product
24:46 works and it’s safe
24:48 then cadet says okay is this something
24:50 that we
24:51 public covers or insurers should cover
24:54 should pay for
24:55 and then there’s something called the
24:57 pcpa which is a pharmacological alliance
25:00 of canada or something like that
25:02 and they do negotiations about the cost
25:05 right they don’t have that in the states
25:07 and that’s probably why the states is
25:09 paying
25:10 humongous costs for their meds right
25:14 so that’s overall a good system and
25:16 sometimes the private payers
25:18 listen to what’s or look at what’s going
25:20 on in the public world
25:22 and they kind of adapt to it okay
25:26 so um which is done by novartis
25:29 emmavig has been evaluated by calif
25:33 and they have had a positive
25:35 recommendation okay so that’s very good
25:38 because if it was declined and they said
25:41 no
25:41 public’s not going to cover then that
25:44 would have been the end of it or
25:46 a very bad place but now it’s covered
25:48 i’ll show you the criteria in just one
25:50 sec
25:51 um and overall in canada there’s zero to
25:54 ten percent of people depending of
25:56 province
25:57 that have to pay out of pocket and if
26:00 you don’t have any coverage
26:01 there’s no you have to pay that’s just
26:03 that’s just we’ve we’ve had some
26:05 comments from people
26:06 on groups or on our facebook i don’t
26:09 have coverage what do i do
26:11 well that’s that’s really too bad but
26:13 you may actually consider
26:14 trying to get coverage because it’s a
26:16 it’s a difficult situation
26:19 all right so let’s let’s look at the
26:20 criteria okay
26:22 so if you have private coverage and
26:24 those are criteria
26:26 that the private the private people
26:28 insurance companies
26:30 they decide based on their own analysis
26:33 of the drug so usually basic things
26:37 for private is that you have to have
26:39 eight or more days of migraine per month
26:42 to start with in canada health canada
26:45 just approved in galilee
26:47 jovi and emovig for four days of
26:50 migraine per month and plus okay so
26:53 medically wise
26:54 you could have it if you have four more
26:56 but private insurance and public
26:58 actually said well
26:59 four per month is it’s not worth the
27:01 cost
27:02 so we won’t cover it with eight plus
27:05 and you have to have tried or and failed
27:09 or not tolerated at least two and
27:11 sometimes three
27:13 okay so that’s for private so usually if
27:15 you have private your dog will say great
27:18 let’s start
27:18 this and this entire body i’m gonna fill
27:21 this form
27:22 and prove that you have eight days and
27:24 then you’ve tried one two three
27:26 and then you’re good to go for public
27:29 payers so public payers at present time
27:31 um cadif only evaluated emmavig right
27:35 so m gallery uh was with it was not
27:38 submitted to cadiz so we don’t know
27:39 what’s going to happen there
27:40 and hov has been presented to cadiz but
27:44 is on hold at present time we’ll see
27:45 what will happen
27:46 but let’s look at the criteria for
27:48 emmavig that
27:49 has been recommended first there’s no 8
27:52 plus you need to have
27:54 chronic 15 days of headache or migraine
27:59 you need to have failed or not tolerated
28:03 or have a contraindication to two
28:06 or three previous trials
28:09 um and then here’s a little
28:12 weird thing if you have failed
28:15 four or more and then there’s
28:18 for no efficacy then you cannot have
28:21 emmavig
28:23 so it puts you in a weird place right
28:24 because what if you failed not enough
28:27 you cannot have it
28:28 if you fail too much you cannot have it
28:30 so i’ll tell you the little
28:32 trick here and you may share that with
28:34 your doctor
28:35 the two or three previous trials can be
28:38 for efficacy
28:39 or side effects or contraindications
28:42 but the failures are only for failures
28:45 no efficacy
28:46 so it means in theory you can have tried
28:50 five drugs but two you had side effects
28:53 and you’re good to go all right so this
28:56 is a little little twist but i think
28:57 it’s useful
28:58 um and then they also will ask for your
29:01 number of days per month they may
29:03 ask for specific questionnaires which we
29:05 have in the app
29:07 and then they will recommend for six
29:10 months
29:10 okay patient support programs
29:13 if you have been on so those are support
29:16 programs that the companies
29:18 the pharma companies so this is um
29:20 novartis uh eli lilly and teva
29:23 they support to the to offer a bridge or
29:26 financial support they pay for the drug
29:29 virtually when you start it
29:31 um so emma vig their support this part
29:33 of terminated in september
29:35 lily is still ongoing um and teva just
29:38 started
29:39 but for pride people with private
29:41 coverage only they’re not going to
29:43 bridge people
29:44 with public coverage which is really
29:46 unfortunate but
29:47 that’s the the decision um the patient
29:50 support programs will assist you
29:52 in uh with coverage criteria and
29:55 negotiations
29:56 i’ll tell you how they do that they will
29:58 support you with injections and
30:00 questions
30:01 and then they will they may provide a
30:03 copay so let’s say your insurance
30:05 company says
30:06 are we going to pay 80 they might
30:08 provide a copay of 20
30:10 so you don’t pay anything which is great
30:12 and that can be on the long term
30:14 so those are the patient support
30:16 programs and your doctor
30:18 has to fill a form to register you to
30:21 these
30:22 right and then your doctor will have to
30:24 probably deal
30:26 with the insurance companies to tell
30:28 them
30:29 this patient needs this drug this
30:30 patient has triso and so this patient is
30:32 disabled
30:34 and please do provide and pay and cover
30:37 so i i just have to say here just please
30:40 remember that your doctor we are doing
30:43 this we want to help
30:45 it takes tons of our time um and we’re
30:47 doing this because insurance companies
30:49 ask us and the pharma industry ask
30:51 us um but this is this is really a part
30:54 that takes a lot of time
30:56 and hopefully somehow we’ll find ways to
30:58 do this
30:59 faster and better for you guys but this
31:01 is something that is a burden
31:03 on us and we really wish that it was
31:06 more simple for
31:07 everyone sick right so what are we doing
31:10 and we’re about to
31:12 finish before i take questions um
31:15 migraine canada is working for access to
31:19 therapy
31:21 that’s one of our goal you know we want
31:23 to raise awareness we want to bring some
31:25 support
31:26 medical information but we are also
31:28 working on
31:29 access to care and this is a bit what we
31:31 call advocacy and it’s going to be a
31:33 topic of
31:34 dr lena uh in november for on our next
31:37 webinar
31:38 so we did participate and you did
31:41 guys you did fill surveys and you
31:44 participated
31:45 to the catholic and ils process ines is
31:47 the the cadif of quebec
31:49 okay that’s a group of people who look
31:51 at drugs and they decide if public
31:53 coverage is going to
31:54 cover or not um we did send letter to
31:57 caliph
31:58 we did send letters to health ministries
32:01 to start telling them that those are
32:02 important medications for people with
32:04 migraine
32:06 we are in the process of sending letters
32:08 and formation to major private payers to
32:11 try to
32:12 negotiate what are we defending well
32:15 we’re defending you know we want we want
32:18 people to be able to try those
32:20 medications
32:21 and if they’re responders that’s great
32:23 so we want public coverage
32:25 we want less restrictions so more people
32:28 can try
32:28 we would like to have more flexibility
32:30 in the definition of response
32:32 not ask for a 50 response or more you
32:35 know and chronic should be 30 percent
32:38 and we also ask for the difficult
32:40 situation of combination with botox
32:42 where most of insurance companies refuse
32:45 to cover for that but for some of you
32:47 some of you with you know deep chronic
32:49 migraine botox with an antibody is the
32:52 key
32:53 so we will need your voice stay tuned uh
32:56 now i’ve covered everything i hope
33:00 you enjoyed it and now i’m going to um
33:03 just underline that access to migraine
33:06 care
33:07 it’s a teamwork and it’s you it’s your
33:10 physician
33:11 it’s your network it may be your
33:13 employer and migraine canada
33:15 wants to help and wants to be there
33:17 we’re growing we’re young
33:18 but please please please um share about
33:21 what we’re doing if you believe in this
33:23 cause
33:24 um and help us to grow because the
33:27 bigger we are
33:28 the stronger we’ll be and believe me
33:30 with four million people with migraine
33:32 in the country
33:33 um we should be able to make a
33:36 difference
33:40 [Music]