ARTICLE OPEN ACCESS CLASS OF EVIDENCE Lasmiditan is an effective acute treatment for migraine A phase 3 randomized study Bernice Kuca, BA, MS, Stephen D. Silberstein, MD, Linda Wietecha, BSN, MS, Paul H. Berg, MS, Correspondence Gregory Dozier, MPH, and Richard B. Lipton, MD, on behalf of the COL MIG-301 Study Group Ms. Wietecha [email protected] Neurology® 2018;91:e2222-e2232. doi:10.1212/WNL.0000000000006641 Abstract RELATED ARTICLE Objective Article To assess the efficacy and safety of lasmiditan in the acute treatment of migraine. Galcanezumab in chronic migraine: The randomized, Methods double-blind, placebo- Adult patients with migraine were randomized (1:1:1) to a double-blind dose of oral lasmiditan controlled REGAIN study 200 mg, lasmiditan 100 mg, or placebo and were asked to treat their next migraine attack within Page 1082 4 hours of onset. Over 48 hours after dosing, patients used an electronic diary to record headache pain and the presence of nausea, phonophobia, and photophobia, one of which was MORE ONLINE designated their most bothersome symptom (MBS). Class of Evidence Criteria for rating Results ≥ therapeutic and diagnostic Of the 1,856 patients who treated an attack, 77.9% had 1 cardiovascular risk factors in addition studies to migraine. Compared with placebo, more patients dosed with lasmiditan 200 mg were free of NPub.org/coe headache pain at 2 hours after dosing (32.2% vs 15.3%; odds ratio [OR] 2.6, 95% confidence interval [CI] 2.0–3.6, p< 0.001), similar to those dosed with lasmiditan 100 mg (28.2%; OR 2.2, 95% CI 1.6–3.0, p< 0.001). Furthermore, compared with those dosed with placebo, more patients dosed with lasmiditan 200 mg (40.7% vs 29.5%; OR 1.6, 95% CI 1.3–2.1, p< 0.001) and lasmiditan 100 mg (40.9%; OR 1.7, 95% CI, 1.3–2.2, p< 0.001) were free of their MBS at 2 hours after dosing. Adverse events were mostly mild or moderate in intensity. Conclusions Lasmiditan dosed at 200 and 100 mg was efficacious and well tolerated in the treatment of acute migraine among patients with a high level of cardiovascular risk factors. ClinicalTrials.gov identifier NCT02439320. Classification of evidence This study provides Class I evidence that for adult patients with migraine, lasmiditan increases the proportion of subjects who are headache pain free at 2 hours after treating a migraine attack. From CoLucid Pharmaceuticals (B.K.), Inc, Cambridge, MA; Thomas Jefferson University (S.D.S.), Philadelphia, PA; Eli Lilly and Company (L.W., P.H.B.), Indianapolis, IN; IQVIA (G.D.), Durham, NC; and Montefiore Headache Center (R.B.L.), Bronx, NY. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. Coinvestigators are listed at links.lww.com/WNL/A758. The Article Processing Charge was funded by Eli Lilly & Company. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. e2222 Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. Glossary FDA = Food and Drug Administration; ITT = intent-to-treat; MBS = most bothersome symptom; MIDAS = Migraine Disability Assessment; mITT = modified intent-to-treat; TEAE = treatment-emergent adverse event. Migraine is ranked by the World Health Organization as the review board at each study site. All patients provided written world’s second leading cause of disability.1 Triptans, a class of informed consent before the start of the study. The study was fi serotonin 5-HT1B/1D receptor agonists (some of which also act at registered at ClinicalTrials.gov (identi er: NCT02439320). fi 5-HT1F receptors), are the most widely used speci canti- migraine therapies.2 Triptans cause vasoconstriction by activation Study population 3–5 of 5-HT1B receptors, conferring a small risk of serious car- Key patient inclusion criteria were as follows: male or female; diovascular adverse events.6 Triptans are contraindicated in ≥18 years of age; a diagnosis of migraine with or without aura patients with certain cardiovascular conditions and events such as fulfilling the International Headache Society diagnostic criteria 16 vascular disease, hemiplegic migraine, uncontrolled hypertension, 1.1 or 1.2.1 ; a history of disabling migraine for at least 1 year; 17,18 and stroke, and product labels contain warnings for patients with a Migraine Disability Assessment (MIDAS) total score of cardiovascular risk factors.7,8 Because cardiovascular conditions, ≥11; migraine onset before 50 years of age; and a history of 3 to – events, and procedures are common in migraine9 11 and because 8 migraine attacks per month (<15 headache days per month). ≈30% to 40% of patients with migraine do not respond to triptans,12 there is a need for new acute migraine treatments. Key exclusion criteria were a history within the past 12 months of chronic migraine or other forms of primary or secondary ffi Lasmiditan is a high-a nity, highly selective 5-HT1F receptor chronic headache disease (e.g., hemicranias continua) or agonist that acts on the trigeminal system without causing va- medication-overuse headache with a headache frequency of ffi 13 soconstriction because of its low a nity for 5-HT1B receptors. >15 headache days per month; initiation of or change in mi- Lasmiditan is being developed as an acute therapy for migraine graine preventive medication within 3 months before screen- to address significant unmet needs in patients with cardiovas- ing; and known coronary artery disease, clinically significant cular risk factors, those with stable cardiovascular disease, or arrhythmia, or uncontrolled hypertension. Patients at increased patients who respond poorly to their current treatment. In risk for seizures were also excluded. a phase 2B study, oral lasmiditan was safe and effective in the acute treatment of migraine.14 In this first phase 3, prospective, Study design randomized, double-blind, placebo-controlled study to assess This randomized, double-blind, placebo-controlled study was the efficacy and safety of lasmiditan (200 and 100 mg) in the initiated on April 27, 2015, and completed on August 12, acute treatment of migraine, patients with cardiovascular risk 2016. Patients were enrolled by study site personnel at 99 factors were intentionally enrolled. This phase 3 pivotal trial, centers in the United States. with a prespecified modified intent-to-treat (mITT) analysis population, was conducted under Special Protocol Assessment At the screening visit (visit 1), patient eligibility was assessed, and fi with the US Food and Drug Administration (FDA).15 patients were randomized (1:1:1) to a rst dose of lasmiditan 200 mg, lasmiditan 100 mg, or placebo. Patients were also ran- domly allocated to a second dose of lasmiditan or placebo for Methods rescue or recurrence of migraine (patients in the lasmiditan Primary research question 200 mg group were randomized [2:1] to lasmiditan 200 mg or This study in patients with migraine headache pain was con- placebo as the second dose; patients in the lasmiditan 100 mg ducted to evaluate the efficacy of lasmiditan 200 and 100 mg vs group were randomized [2:1] to lasmiditan 100 mg or placebo as placebo as measured by the proportion of patients who became the second dose; and all patients in the placebo group received headache pain free (primary endpoint 200 mg, key secondary placebo as the second dose). Patients were instructed not to treat fi endpoint 100 mg) and most bothersome symptom (MBS) free an attack until their eligibility had been con rmed by phone (key secondary endpoint) at 2 hours. This study provides Class (within 7 days) after completion of all screening evaluations, I evidence that for adult patients with migraine, lasmiditan including laboratory tests. increases the proportion of subjects who are headache pain free at 2 hours after treating a migraine attack. Patients were randomized through a central randomization process by interactive response technology. Patients were Standard protocol approvals, registrations, stratified (yes or no) for use of concomitant migraine preventive and patient consents medication. A randomization number and study drug card The study was conducted in accordance with the International number were assigned to each patient. Study drugs (lasmiditan Conference on Harmonisation Good Clinical Practice guide- and matching placebo, manufactured by Aptuit, Verona, Italy) line and local regulatory requirements. The study protocol was took the form of white, film-coated tablets with no markings approved by an independent ethics committee or institutional provided in double-blinded treatment packs containing 2 doses. Neurology.org/N Neurology | Volume 91, Number 24 | December 11, 2018 e2223 Ineligible patients had their end-of-study visit (visit 2) within Scale.20 A treatment-emergent adverse event (TEAE) was 7 days of phone contact to return the study drug. defined as an event that started or worsened after the first dose of study medication (i.e., it did not present with the migraine) Eligible patients entered an outpatient treatment period in and occurred within 48 hours of the last dose. which they were asked to treat their next migraine attack within 4 hours of onset, provided that the headache severity The electronic diary also documented the use of rescue/ was either moderate or severe and not improving. Patients recurrence medication and any other concomitant medication recorded their response to the first dose over the next 48 that had not been recorded at the screening visit. hours using an electronic diary.