In Reply Charles disagrees with our recommendation that less expensive preventive treatments for migraine should be tried before the new calcitonin gene–related peptide (CGRP) and CGRP receptor monoclonal antibodies.1 The existing scientific evidence suggests that the new antibody treatments are not more effective than many existing therapies.2 In the absence of clearly superior efficacy, prudence suggests that less expensive treatments of comparable benefit and with a well-understood safety profile should be used first. The monoclonal antibodies appeared to be well-tolerated in trials, but accumulating experience since their approval suggests that adverse events are more common in clinical use. In particular, severe constipation, nausea, and fatigue have emerged as treatment-limiting adverse effects for some patients.3,4
Loder EW, Burch RC. Consideration of Costs and Open-Label Studies of Erenumab—Reply. JAMA Neurol. Published online December 21, 2018. doi:10.1001/jamaneurol.2018.4141
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