What are the considerations for managing hypertension in patients starting anti-CGRP (calcitonin gene-related peptide) medications like erenumab (aimovig), galcanezumab (emgality), or fremanezumab (ajovy)?

From the Guidelines

Patients starting anti-CGRP medications for migraine should have their blood pressure monitored regularly, as these medications may cause hypertension as a side effect. Before initiating treatment with erenumab (Aimovig), galcanezumab (Emgality), or fremanezumab (Ajovy), baseline blood pressure should be measured and documented. For patients with pre-existing hypertension, ensure blood pressure is adequately controlled before starting these medications. During treatment, blood pressure should be checked at follow-up visits, particularly within the first month of therapy and then periodically thereafter. If a patient develops new or worsening hypertension while on anti-CGRP therapy, consider adjusting antihypertensive medications rather than immediately discontinuing the anti-CGRP treatment. Common antihypertensive options include ACE inhibitors, ARBs, calcium channel blockers, or diuretics at standard doses, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The mechanism behind anti-CGRP associated hypertension relates to CGRP's natural vasodilatory properties; blocking this peptide can reduce vasodilation and potentially increase blood pressure. Patients should be educated about monitoring their blood pressure at home and reporting significant changes (systolic >140 mmHg or diastolic >90 mmHg), as suggested by the 2018 standards of medical care in diabetes 1. If hypertension becomes severe or difficult to control despite antihypertensive therapy, consider consulting with a cardiologist and evaluating the risk-benefit ratio of continuing anti-CGRP treatment.

Some key considerations for managing hypertension in patients starting anti-CGRP medications include:

• Monitoring blood pressure regularly, especially in the first month of therapy
• Adjusting antihypertensive medications as needed to control blood pressure
• Educating patients on monitoring their blood pressure at home and reporting significant changes
• Considering consultation with a cardiologist if hypertension becomes severe or difficult to control
• Evaluating the risk-benefit ratio of continuing anti-CGRP treatment in patients with uncontrolled hypertension.

It is also important to note that the treatment of hypertension in patients with diabetes should include lifestyle modification and pharmacological therapy, with a goal of achieving a blood pressure of less than 130/80 mmHg, as recommended by the 2018 standards of medical care in diabetes 1. In patients with heart failure, the treatment of hypertension should include drugs that have been shown to improve outcomes, such as ACE inhibitors, ARBs, beta blockers, and aldosterone receptor antagonists, as recommended by the 2007 treatment of hypertension in the prevention and management of ischemic heart disease guideline 1.

Overall, the management of hypertension in patients starting anti-CGRP medications requires careful monitoring and adjustment of antihypertensive therapy, as well as consideration of the underlying cardiovascular risk factors and comorbidities.

From the FDA Drug Label

Development of hypertension and worsening of pre-existing hypertension have been reported following the use of AIMOVIG in the postmarketing setting. Many of the patients had pre-existing hypertension or risk factors for hypertension. There were cases requiring pharmacological treatment and, in some cases, hospitalization Hypertension may occur at any time during treatment but was most frequently reported within seven days of dose administration. In the majority of the cases, the onset or worsening of hypertension was reported after the first dose. Monitor patients treated with AIMOVIG for new-onset hypertension, or worsening of pre-existing hypertension, and consider whether discontinuation of AIMOVIG is warranted if evaluation fails to establish an alternative etiology.

The mechanism of anti-CGRP medicines like erenumab (Aimovig) causing hypertension is not explicitly stated in the label. However, it is known that:

• Hypertension has been reported in patients taking erenumab, with many cases occurring within seven days of dose administration.
• Patients with pre-existing hypertension or risk factors for hypertension may be more likely to experience worsening of hypertension.
• Monitoring of blood pressure is recommended for patients taking erenumab, and discontinuation of the medication may be necessary if alternative causes of hypertension cannot be established. Key points to consider when managing hypertension in patients starting anti-CGRP medications like erenumab include:
• Monitoring of blood pressure
• Assessment of risk factors for hypertension
• Management of pre-existing hypertension
• Discontinuation of erenumab if alternative causes of hypertension cannot be established 2

From the Research

Mechanism of Anti-CGRP Medicines Causing Hypertension

• The exact mechanism of anti-CGRP medicines causing hypertension is not fully understood, but studies suggest that CGRP plays a role in vasodilation and may act as a safeguard during cerebral and cardiac ischemia 3.
• Blockade of CGRP or its receptor may lead to increased blood pressure, as observed in some patients treated with anti-CGRP monoclonal antibodies 4, 5.

Considerations for Managing Hypertension

• Patients with pre-existing hypertension may be more likely to experience a significant increase in blood pressure when treated with anti-CGRP monoclonal antibodies 5.
• Regular blood pressure monitoring is recommended for patients starting anti-CGRP medications, especially those with a history of hypertension 4.
• Physicians should be aware of the potential risk of developing hypertension in patients treated with anti-CGRP (receptor) antibodies and consider adding this to treatment guidelines 4.

Comparison of Anti-CGRP Medications

• Studies have compared the efficacy and safety of different anti-CGRP medications, including erenumab, fremanezumab, and galcanezumab 6, 7.
• While these medications have shown excellent efficacy and tolerability, there may be differences in their effects on blood pressure and other parameters 6.
• Switching between anti-CGRP medications may be a viable option for patients who experience ineffectiveness or adverse effects, including hypertension 7.