Webinar on Gepants with Dr. Elizabeth Leroux

0:00 so i want to start by uh thanking you
0:03 all for being here uh we are so excited
0:06 about migrant canada to uh be growing
0:08 our community and the fact there are so
0:11 many people on the line tonight means
0:13 and reminds us that there are uh
0:16 probably four million people in canada
0:18 living with migraine close to half a
0:21 million living with chronic migraine um
0:24 and it just means that people are more
0:26 aware that migraine exists and also they
0:29 are you are curious about new treatments
0:31 and want to know more so i think that’s
0:34 all all very good and very positive
0:36 things so i thank you for joining us um
0:38 here tonight
0:42 so when i give talks to uh
0:45 doctors or medical students or insurance
0:48 companies or employers i always present
0:51 a disclosure slide to uh just remind
0:54 that i do receive
0:56 payments to act as a consultant or
0:59 speaker for different pharmaceutical
1:01 companies um i also work as a volunteer
1:03 of course for migraine canada but i’m
1:05 also serving as the current president
1:07 for a canadian headache society so if
1:10 you’ve never seen me before i am a
1:11 neurologist um i am a headache
1:13 specialist 100 of my practice is seeing
1:17 headache patients now i trained in
1:19 france uh maybe 12 years ago
1:22 and practiced in montreal and then in
1:23 calgary
1:25 my passion is to
1:26 meet people with headaches and migraines
1:29 and try to make them better i learned
1:31 from them i hope they learn from me and
1:34 so this is a in a nutshell a bit who i
1:36 am and why i’m here tonight with you
1:40 so tonight’s webinar is really about a
1:43 new family of medications uh for
1:45 migraine called g pants and you might
1:48 wonder why i put uh the like the picture
1:50 of an air balloon and a light bulb it’s
1:54 because those things were once thought
1:55 to be impossible who would have thought
1:58 that humans could actually go in the air
2:01 and that we could have electricity and
2:03 why i’m putting this out there it’s that
2:05 the idea of having a scientifically
2:07 based approach to treat migraine was
2:10 once a complete like fantasy people
2:13 thought that migraine was actually just
2:15 imaginary there was no understanding of
2:17 it and there were a lot of treatments
2:19 that were not based on anything and so i
2:22 think now we are moving forward with
2:23 science and that’s really a true
2:25 progress
2:27 but then of course with more knowledge
2:29 comes more question so we have now tons
2:32 of questions about every new treatment
2:34 that comes may that be a neuromodulation
2:37 or pills or injections
2:39 so tonight we will talk about questions
2:41 on g-pans
2:43 how do they work how effective are they
2:45 um do they have side effects will they
2:48 be covered by insurance companies when
2:50 they will they arrive in canada i want
2:52 to thank everybody who sent questions in
2:54 advance that is extremely helpful for us
2:57 to prepare talks and uh it’s just so
3:00 important to uh to ask questions and
3:02 then to share in exchange
3:05 so in the um in the story of migraine
3:08 and if you if you forget like the past
3:10 ancient history and medieval times and
3:13 things like triplinations and and you
3:15 know like rose oil and very
3:18 past treatments there have been probably
3:20 now four revolutions the first one was
3:23 the arrival of what we call tryptons for
3:25 acute treatment and those arrived in the
3:28 90s and they were really a big
3:30 breakthrough because before that like i
3:32 said migraine uh had no chemical cause
3:35 it was found to be imaginary and um but
3:38 then when the triptans arrived people
3:40 started wondering you know well if i can
3:42 treat a migraine attack
3:44 with a pill that acts on serotonin well
3:46 maybe it’s not that imaginary and maybe
3:48 there’s some chemistry and neurology to
3:50 it
3:51 then in 2011 uh botox was approved in
3:54 canada for the prevention of chronic
3:57 migraine um and yes this is the same
4:00 toxin uh that we use for cosmetics but
4:02 also for all kinds of other diseases and
4:06 um so this uh brought a new aspect on
4:09 the treatment of chronic migraine
4:11 chronic migraine is having a migraine
4:15 and a mix of migraines and headaches for
4:17 more than 15 days per month since more
4:20 than three months and so people who had
4:22 never been like who had never found
4:24 relief before found relief with botox
4:27 and that also told us that no these
4:29 people were not crazy or anxious or
4:32 depressed um they had severe migraine
4:35 and once properly treated they could get
4:37 better
4:38 and then there’s the third revolution
4:40 was actually cgrp antibodies which
4:43 arrived in canada in 2018
4:46 up to now uh we have now four antibodies
4:50 so uh namely emma v gamgallity a jovi
4:53 and the yepty and if you would like to
4:55 know more about these well i invite you
4:57 to watch our other webinar on our
4:59 youtube channel where i present in
5:02 detail what cgrp antibodies are
5:04 and now we have the fourth revolution
5:08 g-pans which are expected
5:10 hopefully somewhere in 2022 in canada
5:13 but they have been already approved and
5:15 used in the us for a little while
5:20 so i want to say just a few words about
5:21 cgrp
5:23 because um this is actually the how
5:26 these g-pans work um so the discovery of
5:29 cgrp and what does that mean so cgrp is
5:32 calcitonin gene related peptide it’s a
5:35 protein that plays a role in migraine
5:38 roughly put
5:39 this was a major scientific discovery
5:41 and to give you an idea on how important
5:44 that was
5:46 the four researchers who actually
5:47 discovered cgrp and its role in migraine
5:50 were awarded a very prestigious price
5:53 last year uh called the brain price that
5:56 comes with a nice 1.1 million pounds
6:00 of
6:02 of a
6:03 surprise for a major discovery so this
6:06 is dr peter goatsby he is a leader in
6:09 our field and why i’m showing this is
6:11 because just to tell you it took 35
6:14 years of research since the discovery
6:16 and the idea that cgrp could maybe play
6:18 a role in migraine before
6:21 the arrival of treatments on the market
6:24 so science takes a long time sometimes
6:27 but it is the way forward so i want to
6:29 thank
6:29 the scientists the researchers and also
6:32 the patients who participated
6:34 in trials this is very important
6:37 right so you know the role of cgrp
6:40 migraine i i will not go into detail
6:42 about this but roughly migraine is an
6:44 electrical and chemical storm in the
6:47 head and we think and we actually have
6:49 quite solid proof now that this pain is
6:52 caused by inflammation around the
6:55 meninges which are kind of the envelopes
6:58 of the brain and the arteries of the
7:00 blood vessels inside the brain so
7:02 the meninges and arteries are extremely
7:05 sensitive and during a migraine attack
7:07 there is an inflammation so a release of
7:10 irritant substances
7:12 that will cause pain which then you will
7:14 sense in your eyes your sinuses your
7:16 neck wherever there are nerves for pain
7:20 and so the idea here is that cgrp is
7:23 part of this kind of inflammatory soup
7:26 that will cause the pain and that by
7:28 blocking cgrp
7:30 we can improve migraine so it makes a
7:33 lot of sense when we say blocking by the
7:35 way it means that any protein to do its
7:39 job whatever it has to do in our body
7:41 usually talks to a target or we call a
7:44 receptor and so if if you just want to
7:47 stop this talk from happening you will
7:50 just bind the protein so either the the
7:53 the the cgrp for example or its receptor
7:56 with another protein so to prevent this
7:59 talk and this action
8:02 so this is a bit illustrated here so the
8:05 little chunks and i have a weird kidney
8:07 form
8:08 in gray are is the cgrp and then we are
8:12 showing a sensory nerve fiber so a
8:14 sensory nerve that carries pain signals
8:17 and
8:18 another cell that could be a blood
8:20 vessel cell or a neuron or another
8:22 sensory fiber and so cgrp wants to
8:24 connect with this receptor to tell the
8:26 receptor transmit pain signals right or
8:29 inflammation signals
8:30 and then what happens is if you put an
8:33 antibody for example so that’s the big
8:36 purple
8:37 kind of weird
8:39 shape clever form um then you can block
8:42 cgrp or its receptor
8:44 and if you use a g-pad well g-pans block
8:48 the receptor of cgrp this is what they
8:50 do okay they are a family of new drugs
8:53 what do tryptans do triptans block the
8:55 serotonin are actually sorry they are
8:57 they kind of stimulate the receptor for
8:59 serotonin so this is a bit of kind of
9:01 heavy pharmacology but just to explain
9:03 to you how much we know about the
9:05 chemical structure
9:07 of what is going on in the brain during
9:09 migraine attacks
9:10 okay
9:11 those of you who have uh already heard
9:14 about cgrp antibodies and now you’re
9:17 hearing g pants cgrpg pants right
9:20 probably comes from there um may be
9:22 wondering well we’re blocking cgrp so
9:25 what’s the difference well there are
9:27 very concrete differences antibodies
9:30 are injectable things right so they come
9:32 in
9:33 injectors that look a bit like an epipen
9:36 and
9:37 you will so people using these inject
9:39 themselves usually at home uh once a
9:42 month uh or every three months depending
9:45 uh there’s one antibody that is actually
9:47 an iv so it’s called the empty and it’s
9:50 every three months so they are they’re a
9:52 bit different but overall injectables
9:54 and last for a long time uh all
9:56 antibodies are preventives they are not
9:59 used for acute treatment and they target
10:01 either cgrp itself or its receptor
10:05 g-pans are pills and they are taken
10:08 daily every day
10:09 and here’s the thing they can be treat
10:11 they can be used as acute treatments
10:14 and preventive treatments
10:17 so they are the first molecules that are
10:19 used for both aspects of migraine
10:21 therapy
10:22 and then you can maybe you see me coming
10:24 that at some point i will talk about the
10:26 impact on this on the risk of medication
10:29 overuse right something that we all know
10:32 about
10:33 um
10:34 so g-pens target the cgrp receptors so
10:36 roughly put those are the differences
10:39 so just to kind of illustrate this in a
10:41 bit more detail you know um uh migraine
10:44 management is always kind of a
10:46 three-pronged thing
10:48 we want to do everything that’s around
10:50 lifestyle adjustments
10:52 managing triggers and then stabilizing
10:54 the brain with regular habits
10:56 we want to treat the attack with acute
10:58 treatment and then we want to prevent
11:00 this might be basic for some of you but
11:02 i just wanted to
11:04 remind it
11:05 and then i put g pens there in yellow
11:07 just to show that g-pens are both acute
11:10 and preventive so that’s quite unique
11:14 how many g-pans are there right in this
11:16 family uh you might know that there are
11:18 seven tryptons there are four cgrp
11:21 antibodies so there’s quite a lot of
11:23 stuff out there
11:24 um so g-pans there are four of them
11:27 three of which are currently available
11:29 in the us so um the names are ubro japan
11:33 remain japan ato japan and zave japan
11:36 that’s a very funky name
11:39 so the brand names are just probably
11:41 easier to remember ubrelvi nerdtech
11:44 eulepta and zavi japan tonight to my
11:46 knowledge
11:48 does not have a brand a name yet the
11:50 companies that market those products are
11:52 avi and biohaven
11:54 and here’s the thing so they’re not
11:56 they’re not all used the same way ubro
11:59 japan so brelvi is only for acute so in
12:02 an acute treatment we want something
12:05 that works fast right so
12:07 kind of acts very quickly to treat the
12:09 attack and does not necessarily have a
12:12 very long duration in our bodies
12:14 um as for prevention
12:16 we want something that stays in our body
12:19 ideally for the day so we can take it
12:21 once a day which is easier than twice a
12:24 day
12:24 so abroad japan is an acute uh remedy
12:27 plant is both uh ato japan is a
12:30 preventive
12:32 and then zavi japan is an acute so it’s
12:34 a bit dewildering but you know
12:36 that’s that’s what it is
12:39 okay so those of you who’ve been living
12:42 with migraine for a while probably know
12:44 this um and if if you are interested
12:47 please listen to our migraine talks
12:48 podcast about acute management there’s
12:51 one on basic principles and one about
12:53 severe attacks and advanced concepts
12:56 um so usually someone with migraine will
12:58 start somewhere in a pharmacy with over
13:01 the counter analgesics
13:03 either acetaminophen a lot of many
13:06 people with migraine use caffeine which
13:08 is actually effective if unless it is
13:11 overused or used
13:13 regularly
13:14 anti-inflammatories are another very
13:16 good class to treat a migraine attack
13:18 and then the famous tryptons which we
13:20 mentioned earlier and then if the
13:22 attacks are tough then you might combine
13:24 a tryptan and an anti-inflammatory you
13:27 might eventually use special forms like
13:29 nasal sprays or injections or
13:31 suppositories and then sometimes with a
13:33 lot of nausea you might want to combine
13:36 something for nausea so this is really
13:38 and then opioids
13:40 you know anything that’s morphine
13:41 codeine percocet um
13:44 hydromorphorum dilaudid all of these are
13:46 last resort because they have a very
13:49 high risk of leading to problems namely
13:52 medication overuse headache addiction
13:54 and risks for health so that’s why we
13:56 try to stay away from opioids
13:59 so what are the problems with those
14:02 current options that we’ve had now from
14:04 for probably decades well first not
14:07 everybody is improved by these so they
14:09 may not work
14:11 some people have side effects and side
14:13 effects occur they occur with
14:15 anti-inflammatories you know with
14:16 gastric upset pain in the stomach um
14:19 they also occur with tryptons some
14:21 people do not fair very well with
14:23 tryptons and i i hear this in my clinic
14:25 every week you know the people feel
14:28 drowsy dizzy they have chest pressure
14:31 nausea the headache is is increased so
14:34 triptans can be fantastic for some
14:36 people not so good for others
14:39 also tryptons might be contraindicated
14:41 maybe you have a heart problem or you
14:44 had a stroke or you have a lot of
14:46 vascular problems like diabetes and high
14:48 blood pressure and in which case
14:51 probably your doctor is going to tell
14:52 you not to use tryptophans
14:55 anti-inflammatories cannot be used for
14:58 people for example who have um
15:00 inflammatory bowel problems like crohn’s
15:02 disease
15:03 and then
15:04 our favorite concept if you use
15:07 anti-inflammatories acetaminophen
15:09 tryptons and especially opioids on a
15:12 regular basis that may lead to having
15:15 more and more headache which we call
15:18 chronification getting chronic so this
15:21 sometimes bear the name medication
15:23 overuse headache which is kind of a
15:25 science name um but we friendly call it
15:28 a rebound headache
15:31 okay so let’s let’s get started so i
15:33 will present a bit of data on the effect
15:35 of g-pans as acute treatments and then
15:38 as preventive treatments
15:40 just so you know a lot of these slides
15:42 i’ve presented to actually doctors very
15:44 recently so we’re this is all very new
15:47 in canada in the states it’s been going
15:49 on for a while but here it is very
15:50 recent
15:52 so are gpans effective to treat a
15:54 migraine attack
15:56 you know a motto at migraine canada is
15:58 one size does not fit all because we
16:01 know there’s so much diversity in
16:03 migraine for symptoms triggers and
16:06 response to therapy that you know you
16:09 could have a fantastic response to a
16:10 triptan when your friend is a
16:12 catastrophe the truth tender that
16:14 doesn’t help the same applies to g-pens
16:17 some people
16:18 really get well with them and others do
16:20 not but if we look at statistics over
16:23 groups right so i’ll show you
16:26 those numbers on the right part um so
16:29 when we look at the an acute treatment
16:31 for migraine we look at four things
16:34 right we look at two hours and then 24
16:36 hours right what happens on a short
16:39 period of time and then
16:41 later
16:42 um so do you have pain relief you know
16:45 do you get to a mild degree of pain are
16:47 you better or do you are are you
16:49 pain-free which is even better of course
16:52 so we look at two hours for both pain
16:54 relief and pain-free and then what
16:56 happens at 24 hours pain relief and
16:59 pain-free that’s pretty sensible
17:01 so let’s look at the numbers so let’s
17:03 say you take a gpant for an attack
17:06 your chance of having pain relief at two
17:09 hours is 40 40 to 50
17:12 and your chance of still having pain
17:15 relief at 24 hours 35 so some people
17:18 recur i mean the pain comes back we all
17:20 know this
17:22 and then the risk or the chance of being
17:23 pain-free which is what we want is 20
17:27 um and then it’s not 23 hours 24 15
17:32 are still pain-free so it’s not
17:34 magical it’s not a cure but definitely
17:36 for some people it does work
17:39 and then i i’m kind of sorry for this
17:41 very complicated graph but i just wanted
17:44 to give you a bit of a ballpark and the
17:46 key message is here right you you see
17:48 all these bars and it’s probably a bit
17:50 confusing but on the left side you see
17:52 triptans and on the right side you see g
17:55 pens
17:56 and the idea in blue you have you know
17:58 the two hour pain relief being somewhat
18:01 better at two hours you can see the blue
18:03 bars arrive around 50 to 60 percent
18:06 right
18:07 then if you look at the yellow bars
18:10 which are you know sustained pain-free
18:12 or the orange bars which is sustained
18:14 pain relief like being better really
18:16 longer or later
18:18 we can see that trypton seem to be a
18:20 little bit higher a little bit better
18:23 so this actually correlates to what i
18:25 hear from my us colleagues and they say
18:28 that g-pans do not seem to be quite as
18:31 effective as tryptons but once again it
18:34 varies depending but if you look at a
18:36 group of people the chance of having a
18:39 great success with a triptan is probably
18:41 a bit higher
18:42 nevertheless some people do not respond
18:45 to tryptons or have side effects or like
18:47 i mentioned so very good options with
18:49 effectiveness
18:51 side effects
18:52 what could happen
18:54 well nausea somnolence and dry mouth
18:58 were the key side effects um and if you
19:00 compare the placebo because even people
19:02 who take a placebo can actually have
19:04 side effects well we call that the
19:06 nocebo response
19:08 um so we roll japan here 50 milligram
19:11 and 100 milligram
19:13 you can see that nausea you know so
19:16 there’s actually it’s interesting here
19:17 to see that the higher dose of your bro
19:19 japan seems to have a bit more side
19:21 effects
19:22 no surprise there um so let’s say you
19:24 take the higher dose of abroad japan you
19:27 will have maybe four percent risk of
19:29 nausea 2.5 percent risk of being
19:31 summoned and 2.1 risk of dry mouth and
19:35 it is higher than if you take a placebo
19:38 some you know i just wanted to mention
19:40 in the studies there were no serious
19:43 adverse events so something that a risk
19:45 of harm to the body no death that’s good
19:48 and but more importantly there were no
19:51 adverse events that led to someone
19:53 deciding not to take the drug again so
19:55 it means that these drugs seem to be
19:57 very well tolerated
20:00 and then i showed you you know that
20:03 the results for effectiveness and saying
20:05 okay you know maybe they don’t work as
20:06 well as strip tens but this is hot from
20:09 the press
20:10 from the international conference we had
20:13 uh virtually recently and it just
20:15 confirmed something we know
20:18 it’s that if you treat a migraine attack
20:20 treating early is the good way to go the
20:23 more you wait the less chance of success
20:25 you have we know this
20:28 so this was shown for triptans we know
20:30 for nsaids and for g-pans it’s the same
20:33 story
20:34 so let’s look at the table here
20:36 so two hour paint three getting
20:39 completely free at two hours post taking
20:41 the dose
20:42 if you treat when the pain is mild you
20:45 have 55 percent of chance of being pain
20:48 free that’s actually almost double
20:50 the chance if you treat if you wait to
20:53 have mud or if you the pain is already
20:55 moderate to severe for example you wake
20:57 up with it right
20:59 and then return to normal function
21:00 that’s an important thing
21:02 being able to just go back to whatever
21:04 your plans are for the day
21:06 60
21:08 if you treat when mild 42
21:11 if you treat when moderate or severe
21:14 so that’s a very important concept in
21:16 acute treatment and it does apply to
21:18 g-pens
21:19 then
21:20 a lot of you have a lot of attacks and
21:23 then you are told by your doctor
21:24 probably
21:26 well
21:26 you know if you have more than 10 days
21:29 per month of migraine you cannot treat
21:31 early all the time because then you will
21:34 kind of have rebound headaches or
21:36 medication overuse
21:37 so this overuse catch-22 is really a
21:40 plague if you have frequent headaches um
21:44 up to 50
21:45 of people who have chronic migraine will
21:48 kind of have this overuse
21:51 tag on them because they fit those
21:52 criteria which is namely taking
21:55 something more than 10 days per month
21:57 and then more headaches leads to more
21:59 medications and you get caught in this
22:02 kind of vicious cycle
22:04 of medication overuse and chronic
22:06 migraine
22:08 so the idea here and that’s where it’s
22:11 interesting that to remember that uh
22:13 g-pans are both acutes and preventives
22:16 is that in theory um if you use a g-pant
22:19 on a repeated basis
22:21 well it might become like a bit of a
22:23 preventive
22:25 so the idea is that g-pans are not
22:27 supposed to cause medication overuse
22:30 headache um now i want to be cautious
22:32 because there’s no absolute proof of
22:34 this um but we have some data in the
22:38 rats you know the rats and the mice we
22:39 use them for research a lot
22:42 so there are models where we look at
22:44 mice and rats and we check by giving
22:46 them pills or drugs do they develop
22:51 something that looks like medication
22:53 overuse do they become
22:55 hypersensitive to pain
22:57 and if you give a rat a tryptan or
23:00 opioids we know they are more sensitive
23:03 to pain by different techniques and this
23:05 does not happen if you give a rat a
23:07 gpant
23:08 so it seems to be quite uh encouraging
23:11 and so the idea is that you know there
23:13 would not be medication over you so no
23:15 restrictions in theory to use cheapens
23:18 on a regular basis as they could kind of
23:21 get close to being prevented
23:24 okay so now talking about prevention
23:26 just a segway to this uh this next
23:28 section are depends effective to prevent
23:31 migraine
23:32 um you know so so i i won’t dig deep
23:35 into that but just to remind you when we
23:38 study prevention drugs well we’ll look
23:40 at a lot a bunch of things but one of
23:42 these things is the decrease in headache
23:44 days per month so example someone who
23:47 has eight day per month at the beginning
23:50 and has a 50 response will go back from
23:54 eight or go down to four days per month
23:56 right not a cure no zero but still much
24:00 improved
24:01 someone who’s a 75 percent responder or
24:04 sometimes we call this a super responder
24:06 will actually go down by six days so
24:08 down to two days per month
24:10 and now with cgrp antibodies we even
24:13 have
24:14 actually 100 responders
24:16 if you start higher let’s say you are on
24:19 the edge of chronic you have like 12 to
24:21 14 days per month of headache of
24:23 migraine attacks well if you’re a 50
24:26 responder you’ll get down to seven days
24:28 per month and if you’re a super
24:30 responder you’ll get down to maybe
24:32 um
24:33 [Music]
24:35 maybe like sorry some maybe four to five
24:38 days per month
24:39 so frequency is one thing but then i
24:41 hear a lot from my patients in my office
24:43 about other things
24:45 my triggers are not a problem anymore
24:47 the attack is less intense i’ll have
24:50 less migraine symptoms like sensitivity
24:52 to lighter sounds um i can treat easily
24:55 easily like if i take a trip down let’s
24:57 say it works now i can plan my
24:59 activities so that’s the idea those are
25:02 the things we look at in studies
25:04 okay
25:05 so what uh do we just to give you a
25:07 ballpark estimate if you take oral stuff
25:10 you know through cyclics amitriptyline
25:12 ellaville endural the pyramid all those
25:15 drugs that can stabilize the brain and
25:18 be a good preventive for migraine
25:21 well oral preventives for migraine the
25:23 ballpark response for a 50
25:25 improvement are 40
25:28 right so those are the numbers here then
25:30 you can see the orange and blue and and
25:32 green bar
25:33 um those are the results from the the
25:35 studies so overall you try preventive
25:38 you have four chances on 10 to get
25:41 better 50
25:42 or more right so those were the studies
25:44 on the orals if you’d like to know more
25:46 about prevention of migraine basics how
25:49 to try stuff uh please
25:51 listen to our podcast on migraine talks
25:56 okay so let’s look at the numbers for
25:57 the 50 response rates for
26:00 cgrp antibodies and ato japan
26:03 um so you can see that it’s closer to 50
26:06 or 60 so the effectiveness of those
26:09 drugs blocking cgrp
26:12 seems to be better than the oral
26:14 preventives but i mean we cannot compare
26:17 apple and oranges um but just to give
26:19 you a little bit of ballpark so does
26:22 everybody respond no is this a miracle
26:24 or a cure no but can it change someone’s
26:27 life if you’re a good responder
26:29 absolutely
26:31 right side effects again
26:33 so what are the key side effects of
26:35 atoji pants in the studies and remember
26:38 studies are not real life those are
26:40 people who participate to a clinical
26:42 trial and they might be a bit healthier
26:44 than some than the usual population
26:47 fatigue nausea and constipation right
26:50 those were the side effects that were
26:52 seen
26:53 especially at higher doses and those
26:56 some side effects were noted about two
26:58 to three percent compared to the placebo
27:01 so once again a good vulnerability and
27:04 there was no a lot of us are always
27:06 concerned by the liver uh are the drugs
27:09 impacting our liver and those the g-pans
27:11 are metabolized in the liver there were
27:13 no liver abnormalities above the placebo
27:16 rate found
27:19 then a lot of you might have chronic
27:21 migraine and might ask me what about
27:23 chronic migraine results what i’ve
27:25 showed you was only for episodic
27:27 migraine well stay tuned because we
27:30 don’t have the results yet of course
27:32 there will be studies but they’re not
27:33 out yet so hopefully
27:36 the results will look like the results
27:38 we get with cgrp antibodies as well
27:41 which is probably 40
27:44 of 50 response and 20
27:48 of super response i apologize for all
27:51 the percents and percents it’s just the
27:53 way that that we scientific the people
27:55 we describe results
27:57 we don’t like to say it works or it
27:58 doesn’t work like we we like percent
28:02 all right so here now are questions that
28:04 were sent to us by uh by people
28:06 uh who contacted us
28:09 so what about using g pens long term so
28:11 on average so first one question on
28:13 average how long does it take to
28:15 experience a benefit
28:17 so
28:18 on average in these studies the benefit
28:20 was seen
28:22 after three months but in some people
28:24 the benefit shows even after one or two
28:27 weeks so once again there’s diversity
28:29 some people get better super quick
28:32 and others it takes longer and as an
28:34 example with cgrp antibodies um
28:38 for people who are chronic and and uh in
28:40 a deep state of chronic um sometimes we
28:43 wait six months just to make sure
28:46 because some people just like
28:48 consistently improve and improve and
28:49 improve and then they reach a good
28:51 response after a few more months but i
28:53 would say if you have episodic migraine
28:56 let’s say you have 8 10 12 days per
28:58 month and you try a jeep hand
29:00 after probably one to two to three
29:03 months you should have a good idea of um
29:06 your response
29:08 okay another question
29:09 with long-term use
29:11 will the medication become less
29:13 effective sometimes we call that
29:15 wear-off or in medical latin
29:18 tachyphylaxis to sound fancy
29:21 we don’t know and we don’t know because
29:24 those drugs have not been on the market
29:26 at all japan and remai japan for
29:28 prevention they’ve not been out there
29:30 enough so we know this um in the studies
29:33 about cgrp antibodies we thought there
29:36 was no wearing off on the long term but
29:37 then in real life it looks that some
29:40 people they get better initially and
29:42 then after eight months or a year they
29:44 have aware of they’re not as good as
29:46 they were why is that we don’t know so
29:49 we’ll need to study this and look at the
29:51 facts
29:52 can we take them on the long term all
29:54 our life this is a question all my
29:56 patients ask me you see am i going to
29:58 take this all my life
30:00 so i usually tell people to think maybe
30:03 shorter term you know a year two years
30:05 three years and then we re-evaluate how
30:08 are things
30:09 um
30:10 so once again we don’t know if as a
30:12 scientist i cannot answer this question
30:14 i mean we we hope yes
30:16 um but then we will see how it goes
30:19 after years and years
30:21 very very probably because they are so
30:23 well tolerated and there’s no red flags
30:25 so far
30:26 probably they can be used on the long
30:29 term
30:30 and so that’s what we hope for
30:32 will it cause irreversible side effects
30:34 so far we don’t see any irreversible
30:38 side effects so that’s very reassuring
30:41 medicine is medicine human bodies are
30:43 human bodies
30:44 you know of course when there’s a new
30:47 drug around we often we always keep a
30:50 close eye what’s going on are there any
30:53 unexpected things so there will be a
30:55 close watch on security like we do with
30:57 any new treatment but so far these drugs
31:00 seem to be pretty well tolerated and
31:03 quite safe
31:05 okay can we use g-pants with other
31:08 medications can patients take g-pants
31:10 with tryptans
31:13 yes because tryptons were actually used
31:16 during the studies on prevention so
31:18 patients could use their trip tents so
31:21 no contraindication there
31:22 anti-inflammatories same thing
31:25 people in studies could use their
31:27 anti-inflammatories no problem
31:29 um
31:30 botox botox is easy because botoxes can
31:33 be combined with pretty pretty any pill
31:35 so that’s a nice aspect of botox it’s a
31:37 local thing does not
31:39 interact with pills
31:41 and then the question is what about
31:43 combining a g-pant with a cgrp antibody
31:46 you know they act on the same thing cgrp
31:49 or its receptor um
31:52 so are they going to kind of is it
31:53 useful uh is it is it could it be there
31:56 be a risk
31:57 so so far i can tell you in the states
32:00 um
32:01 a lot of people do combine them so far
32:03 it seems okay um but is it effective i
32:06 think we need more uh observation to uh
32:09 learn that
32:11 but i’ll give you a bit of a piece of
32:13 something that’s uh discussed among
32:15 specialists this is kind of a high-level
32:17 data
32:18 um
32:19 some people who use antibodies at the
32:21 end of the month
32:23 they will have aware of so they say
32:25 their last week is tough like it’s like
32:27 the entire body is is is kind of
32:29 disappearing and then the migraines
32:31 creep back up
32:32 um and so in this aware of in the
32:34 studies it wasn’t clear but in real life
32:38 we see it 20 to 34 25 20 35 have it or
32:43 report it at least
32:45 and so could we and this is just
32:47 something that experts talk about uh no
32:50 research i’m not recommending it
32:52 um would it be possible to say well the
32:55 antibody works for three weeks and then
32:57 we can patch with if like a g pen for a
33:00 week um no official report on that but
33:03 i’m just telling you how you know we’re
33:05 we’re just put in those situations where
33:07 we have to think and we have to observe
33:10 and ask ourselves questions
33:12 and find the answers and make sure that
33:14 we’re just progressing
33:16 based on facts
33:18 more questions um are there patient gpan
33:22 trial happening in canada now
33:24 if so is there a possibility of new
33:26 patients participating in the trials
33:29 this is such a great question and you
33:31 know it it’s so great that people want
33:33 to participate in research
33:35 now if you want to find a research you
33:38 can go on
33:39 clinicaltrials.gov this is a public free
33:41 website it’s very official
33:44 and then you can actually just do a
33:45 search on and and say i want a study on
33:48 migraine a gpant in canada and you say
33:51 search
33:52 at present time i didn’t find any study
33:55 ongoing
33:57 and then another study another question
33:59 was could the g-pans be a treatment for
34:03 vestibular migraine
34:05 i i have a specialized clinic with an
34:07 ent so i see tons of vestibular migraine
34:11 i know how disabling this is
34:13 i really hope i saw my first case today
34:16 of a patient
34:18 who really uh went get got better with a
34:21 cgrp antibody and had vestibular
34:23 migraine and both the headache and the
34:25 vestibular symptoms got better but um
34:28 then i went to pubmed which is our kind
34:30 of favorite place for doctors to look
34:33 for data and vestibular migraine gpant
34:36 retrieved no results so so far there’s
34:39 nothing
34:40 published on it but of course it is on
34:43 our radar
34:45 so when are gpans coming to canada um we
34:48 don’t have a date believe me we ask uh
34:51 abby which is the company that is
34:53 marketing uh bro japan and ato japan and
34:56 i suspect some some of them might be
34:59 listening tonight
35:01 we’re we’re just asking them on a
35:02 repeated basis when when
35:06 so as soon as we know we will let you
35:08 know so we don’t have a date now but we
35:11 it should be in 2022.
35:14 now the question of cost you know how
35:16 much will the g-pans cost and will they
35:19 be covered by my public or private drug
35:22 plan
35:23 money money money you know very
35:25 legitimate question
35:28 um in the u.s the brelvi is a hundred us
35:33 dollars for one pill right so if you
35:36 google this you can find it on different
35:39 kind of online buying places at 85
35:42 for one pill that’s costly you know a
35:45 trip 10 will be 10 15 bucks per pill or
35:49 even less depending on your pharmacy
35:52 so we are waiting to know you know what
35:55 what cost will be proposed for canada
35:57 because we know canada is different than
35:59 the us the system is different um
36:03 uh pharma pharma companies are not
36:05 regulated the same way we don’t deal
36:08 things the same way so
36:09 hopefully the cost will be lower
36:12 because as you know private insurance
36:15 and public insurance people
36:18 look at cost effectiveness what do you
36:20 get for your buck right so if my taxes
36:23 pay for this drug
36:25 what is the outcome what am i paying for
36:28 and so they are looking with very very
36:30 fancy studies and analysis and
36:32 statistics and i hate statistics
36:34 personally um
36:36 but they are very useful
36:38 is the cost justified by the results by
36:41 the outcomes of any treatment they look
36:44 at like all chemotherapy medications uh
36:48 seizure drugs any drug um is evaluated
36:51 by caliph which is a canadian agency for
36:54 assessment
36:55 health canada of course looks at the
36:57 safety of the drug and the effectiveness
36:59 and then cadith looks at its kind of
37:01 cost effectiveness
37:03 and then pcpa which is the pan canadian
37:06 pharmaceutical alliance uh look
37:08 negotiates the cost of drugs so it’s a
37:11 process that takes years
37:13 um
37:14 and so the criteria right
37:17 that
37:18 might actually be used to say yes you
37:21 can have this drug or not we’ll pay for
37:23 it or not will depend on the price
37:26 and will depend on you know just also
37:29 results from research so let’s say they
37:31 could say i’m just making this up okay
37:34 okay you can have a g-pad if you have
37:37 episodic migraine and you have let’s say
37:40 eight days per month or more and you
37:43 have tried and failed or not tolerated
37:46 two or three oral preventives those are
37:49 very close to the criteria of the cgrp
37:52 antibodies
37:54 for ubro japan for example
37:56 well maybe they will say you have have
37:58 to fail or cannot take
38:00 tryptans and how many tryptons you you
38:02 must try i don’t know
38:04 so all of this is in the air we don’t
38:06 know yet all right but it’s if it the
38:09 cost is high
38:11 very likely there will be criterias and
38:13 forms to fill and all that stuff
38:16 and so that’s where i strongly encourage
38:18 everybody with migraines and of course
38:20 my patients i i we we do this together
38:23 uh to have a headache diary um it can be
38:26 a paper it can be migraine buddy but a
38:29 favorite in canada is the canadian
38:31 migrant tracker very simple it’s not
38:33 very fancy like it’s it’s simple simple
38:36 um but it it can help you have results
38:39 uh and fill certain questionnaires so
38:41 you can have those numbers to give to
38:44 your doctor so the the insurance company
38:46 can know how you are doing with numbers
38:49 and not only impressions
38:52 and finally before we break for
38:54 questions um
38:55 what will migraine canada do to help
38:58 people access gpants
39:00 right um well we we want to work we want
39:03 to help right we want people to access
39:05 treatments whatever they are so
39:08 we participate to these cad submissions
39:10 based on your insights
39:12 we advocate to pcpa uh to and to
39:15 emphasize the importance of access and
39:17 believe me if there was no patient
39:18 association it would um uh send a very
39:22 poor message so it’s great that we are
39:24 there to bring your voice uh we discuss
39:26 with health ministries to support the
39:28 reimbursement of treatments by drug plan
39:30 so we push on the health ministries to
39:32 say that migraine matters
39:34 um we interact with private payers and
39:37 employers to raise awareness i just gave
39:39 a talk on to benefits canada french and
39:42 english last week which was very well
39:44 received on the impact of migraine in
39:46 the workplace
39:47 so those are all conversations that we
39:50 keep going
39:51 it takes time but i think this is very
39:54 important work and i want to thank a
39:56 huge thanks to wendy and randa and all
39:58 the migraine canada board and all our
40:00 volunteers who make this possible so
40:03 thanks for that
40:04 um i encourage you to look at our
40:06 resources podcasts pdfs you know to go
40:09 on our advocacy page to investigate the
40:11 migraine tree which is a great resource
40:14 to watch our webinars and invite people
40:17 talk about migraine tell the people you
40:19 know so we can grow our community
40:22 so as an ending you know there’s nothing
40:24 you know never say there’s nothing else
40:26 to do because at present times there’s
40:28 really a lot of options for you out
40:30 there maybe you’ve tried a lot of these
40:32 already
40:33 but there are a lot of things to do and
40:36 g-pans are uh will be added to the
40:38 migraine tree um actually in the acute
40:41 treatment section and the preventive
40:43 treatment section
40:45 so the idea now is with new treatments
40:48 well we can reverse the vicious cycles
40:50 of migraine decrease the stigma
40:52 encourage people to treat migraine
40:55 have more researchers do research have
40:57 more doctors treating it and just
40:59 breaking all those you know like bad
41:02 things from the past about migraine give
41:05 it an image of hope empower patients
41:07 which we are doing tonight and have
41:09 better outcomes happy people living
41:11 their lives god thank you and i’ll take
41:13 questions now
41:15 surrender should i um all right
41:18 sharing
41:19 um
41:20 yeah we can do that
41:23 um unless i don’t because i don’t think
41:25 i’m gonna go back to the slides so okay
41:27 if you think you will not let’s uh let’s
41:29 just stop sharing and i’ll start thank
41:32 you so much for this uh really really
41:34 important presentation very timely and i
41:37 think you covered so many areas and uh
41:40 and that’s really really valuable for
41:42 everybody
41:43 um i am we have a few questions we have
41:46 time for a few questions so i’m going to
41:47 start
41:49 [Music]