Management of Super-Responder to Ajovy (Fremanezumab)
Continue fremanezumab treatment at the current effective dose without modification, as sustained efficacy and excellent tolerability have been demonstrated for up to 6 months in clinical trials, with progressive improvements in quality of life and work productivity over time. 1, 2
Definition of Super-Response
A super-responder typically achieves ≥75% reduction in monthly migraine days, which occurred in 15-20% of patients receiving fremanezumab in the FOCUS study during the 6-month treatment period. 2
Recommended Treatment Strategy
Maintain current dosing regimen (either monthly 225 mg or quarterly 675 mg) based on the patient's current schedule:
Both monthly and quarterly dosing demonstrate comparable sustained efficacy through 6 months of treatment, with mean reductions of 5.1-5.5 monthly migraine days from baseline. 2
Progressive improvements continue beyond the initial 3 months, particularly in chronic migraine patients where treatment benefits are enhanced after 6 months of administration. 3
Quality of life improvements across all MSQoL domains (role function-restrictive, role function-preventive, and emotional function) continue to increase through 6 months, with mean improvements of 19.1-24.6 points. 4
Monitoring Parameters
Track the following monthly to confirm sustained super-response:
- Monthly migraine days (primary outcome measure)
- Headache days of at least moderate severity
- Days requiring acute medication use
- Patient Global Impression of Change (PGIC) scores, where 75-77% of fremanezumab-treated patients report being responders at 6 months. 4
Duration of Treatment
Continue treatment indefinitely as long as super-response is maintained:
Real-world data demonstrates sustained effectiveness up to 12 months, with chronic migraine patients showing continued reduction from baseline 20.9 days to 12.0 days at 12 months. 3
Safety profile remains favorable with low discontinuation rates (<1%) due to adverse events during extended treatment periods. 2
No evidence supports discontinuation or dose reduction in super-responders, as fremanezumab can be safely continued throughout treatment periods without interruption. 5
Safety Considerations
Monitor for uncommon adverse events, though risk remains low:
Unlike erenumab, fremanezumab has not been associated with development or worsening of hypertension in post-marketing studies, making it a safer cardiovascular option. 5
Injection-site reactions are the most common adverse event but rarely lead to discontinuation. 1
Hepatic function abnormalities occurred in only 1% of patients in phase 3 trials. 1
Common Pitfalls to Avoid
Do not reduce the dose in super-responders, as there is no evidence supporting dose de-escalation and this may compromise the excellent response achieved.
Do not discontinue treatment prematurely to "test" if the patient still needs it, as migraine is a chronic neurological disorder requiring ongoing preventive therapy.
Do not switch to a different CGRP antagonist when achieving super-response, as no direct comparative evidence shows superiority of one CGRP-mAb over another. 5