Dual Immunoglobulin, Aimovig Therapies Safe for MG, Migraines, Report Says

Aimovig (erenumab) and the investigational immune therapy subcutaneous immunoglobulin (SCIg) can safely be used simultaneously to treat migraines and myasthenia gravis, according to a recent case report.

Both treatments were found to be effective at treating their individual conditions in the same patient and did not show any clinically evident interactions or adverse events, the researchers said.

The case report, “Erenumab Plus Subcutaneous Immunoglobulin in a Patient With Comorbid Chronic Migraine and Myasthenia Gravis,” was published in the journal Headache.

Migraines and systemic autoimmune diseases — in which the body’s immune system attacks its healthy cells by mistake — frequently occur together. Thus, there is a need to identify treatments for both diseases that can be safely administered at the same time.

In this report, a group of Italian researchers described the case of a 30-year-old obese woman treated at the hospital for chronic migraines and generalized myasthenia gravis (MG).

She had been having migraines since she was a child, and in 2018 they became chronic. When she sought treatment for the migraines, she reported having severe headaches approximately 25 days per month.

Most of these attacks were disabling and did not respond to triptans and nonsteroidal anti-inflammatory drugs, which are commonly prescribed to treat migraines. Additionally, she either did not respond to other oral preventive therapies, or could not be prescribed alternative migraine treatments due to contraindications, meaning they could be harmful to her.

For her MG, the patient was initially treated with the steroid prednisone and the immunosuppressant azathioprine. Despite that treatment, she still experienced muscle weakness, one of the hallmarks of the disease.

Due to her consistent use of prednisone, a corticosteroid, she ended up developing other diseases, including obesity, Cushing’s syndrome, osteoporosis, and cataracts.

The woman was started on a 70 mg monthly dose of Aimovig, a medication normally used to prevent migraines in adults, in March 2019. Shortly after starting that treatment, her monthly number of migraine days dropped from 25 to three, and she experienced no adverse events.

A few months later, her steroid doses had to be reduced (tapered) due to side effects. With steroid tapering, she experienced a worsening of her migraines, which began occurring around 12 days per month.

As a result, her physicians decided to increase her monthly dose of Aimovig to 140 mg in July 2019. The new dosage led to a significant reduction in the number of migraine attacks. At the end of that July, she was started on monthly subcutaneous immunoglobulin (SCIg) treatment, to which she responded favorably.

SCIg is an investigational immune therapy from CSL Behring that is being studied for the treatment of MG. It is currently approved to treat primary immunodeficiency diseases under the brand name Hizentra.

The therapy, which is given as an under-the-skin injection, consists of a pool of immunoglobins (antibodies) that are purified from the blood of many healthy donors and injected into the patient. This pool of antibodies includes those that are involved in the body’s defense mechanism against infected and diseased cells. However, the exact mechanism by which SCIg works in MG is not yet known.

At last follow-up, the patient was still receiving Aimovig, at a monthly dose of 140 mg, and SCIg. Not only did the frequency of her migraines continued to lessen — to two days of migraines per month — but she also was able to control her MG with SCIg.

“To our knowledge, this is the first case of concurrent treatment with erenumab and SCIg in the same patient,” the researchers said. “The 2 treatments remained effective for their conditions and there were no clinically evident interactions or adverse events.”

While the patient has not been followed long-term, this single-case study suggests that Aimovig and SCIg can be co-prescribed. Nevertheless, the authors noted they “cannot exclude that the improvement of migraine after erenumab was by chance because of spontaneous fluctuations in migraine frequency or even a direct effect of SCIg on pain.”

However, they added that the response reported by the patient was “excellent” over a period of six months.

“Given the comorbidity between migraine and systemic autoimmune diseases, the use of concurrent treatments like that of our patient might be frequently required,” the researchers said. “Real-life data from different centers pooling together their experience … are warranted to gain more insights on the issue.”