Introduction
Aimovig (erenumab-aooe) is a monoclonal antibody medication developed by Amgen and Novartis for the preventive treatment of migraine. It represents a novel class of migraine-specific therapies that target the calcitonin gene-related peptide (CGRP) pathway, offering a targeted approach for patients with episodic or chronic migraine who have not responded adequately to conventional preventive treatments.
Mechanism of Action
Aimovig is a human monoclonal antibody that selectively binds to the calcitonin gene-related peptide (CGRP) receptor. CGRP is a neuropeptide implicated in migraine pathophysiology, as it promotes vasodilation, neurogenic inflammation, and pain transmission during migraine attacks. By competitively blocking the CGRP receptor, erenumab inhibits CGRP-mediated signaling, thereby reducing the frequency and severity of migraine attacks without causing vasoconstriction.
Indications
Aimovig is FDA-approved for the preventive treatment of migraine in adults, including:
- Episodic migraine (4-14 migraine days per month)
- Chronic migraine (≥15 headache days per month, with ≥8 being migraine days)
Dosage and Administration
Standard dosing: 70 mg subcutaneous injection once monthly Alternative dosing: 140 mg subcutaneous injection once monthly (may provide additional efficacy for some patients) Administration:- Administer subcutaneously in the abdomen, thigh, or upper arm
- Pre-filled autoinjector or pre-filled syringe
- Allow to reach room temperature for 30 minutes before injection
- Rotate injection sites
- Renal impairment: No dosage adjustment necessary
- Hepatic impairment: No dosage adjustment necessary
- Elderly: No dosage adjustment necessary
- Pregnancy: Use only if potential benefit justifies potential risk
- Pediatrics: Safety and effectiveness not established
Pharmacokinetics
Absorption: Bioavailability approximately 82% following subcutaneous administration Distribution: Steady-state volume of distribution approximately 3.9 L Metabolism: Degraded via proteolytic enzymes throughout the body (typical of monoclonal antibodies) Elimination: Half-life approximately 28 days Time to steady state: Approximately 3 monthsContraindications
- Hypersensitivity to erenumab or any component of the formulation
Warnings and Precautions
Hypertension: Monitor blood pressure, especially in patients with pre-existing hypertension Constipation: May occur with serious complications; monitor and manage appropriately Hypersensitivity reactions: Although rare, anaphylaxis and angioedema have been reported Immunogenicity: Potential for anti-erenumab antibodies development (low incidence)Drug Interactions
No formal drug interaction studies conducted. However:
- No expected interactions with cytochrome P450 substrates
- Theoretical potential for interactions with other CGRP antagonists
- No clinically significant interactions identified in clinical trials
Adverse Effects
Most common adverse reactions (≥3% and more frequent than placebo):- Injection site reactions
- Constipation
- Muscle spasms
- Pruritus
- Severe constipation with complications
- Hypertension
- Hypersensitivity reactions
Monitoring Parameters
- Migraine frequency and severity (headache diary)
- Blood pressure (baseline and periodically)
- Bowel function and constipation symptoms
- Injection site reactions
- Signs of hypersensitivity
- Patient adherence and response to therapy
Patient Education
Administration:- Proper injection technique and site rotation
- Storage requirements (refrigerate at 2-8°C, protect from light)
- Do not freeze or shake
- Maximum benefit may take 3-6 months
- Maintain regular dosing schedule
- Continue headache diary to track progress
- Report severe constipation or abdominal pain
- Monitor blood pressure regularly
- Seek immediate medical attention for signs of allergic reaction
- Inform healthcare providers about all medications
- Continue other migraine triggers management
- Maintain regular follow-up appointments
References
1. Goadsby PJ, Reuter U, Hallström Y, et al. A Controlled Trial of Erenumab for Episodic Migraine. N Engl J Med. 2017;377(22):2123-2132. 2. Tepper S, Ashina M, Reuter U, et al. Safety and efficacy of erenumab for preventive treatment of chronic migraine: a randomised, double-blind, placebo-controlled phase 2 trial. Lancet Neurol. 2017;16(6):425-434. 3. Aimovig [package insert]. Thousand Oaks, CA: Amgen Inc.; 2021. 4. Dodick DW, Ashina M, Brandes JL, et al. ARISE: A Phase 3 randomized trial of erenumab for episodic migraine. Cephalalgia. 2018;38(6):1026-1037. 5. FDA Approval Letter: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2018/761077Orig1s000Approv.pdf 6. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache. 2019;59(1):1-18.