Once-daily oral atogepant for the long-term preventive treatment of migraine: Findings from a multicenter, randomized, open-label, phase 3 trial

Abstract

Objective: To assess long-term safety, tolerability, and efficacy of once-daily oral atogepant 60 mg in adults with migraine.

Background: Atogepant is an oral, small-molecule, calcitonin gene-related peptide receptor antagonist approved for the preventive treatment of episodic migraine.

Methods: A 52-week, multicenter, randomized, open-label trial of adults (18-80 years) with migraine. Lead-in trial completers or newly enrolled participants with 4-14 migraine days/month were enrolled and randomized (5:2) to atogepant 60 mg once daily or oral standard care (SC) migraine preventive medication. The primary objective was to evaluate the safety and tolerability of atogepant; safety assessments included treatment-emergent adverse events (TEAEs), clinical laboratory evaluations, vital signs, and Columbia-Suicide Severity Rating Scale scores. Efficacy assessments (atogepant only) included change from baseline in mean monthly migraine days (MMDs) and the proportion of participants with reductions from baseline of ≥50%, ≥75%, and 100% in MMDs.

Results: The trial included 744 participants randomized to atogepant 60 mg (n = 546) or SC (n = 198). The atogepant safety population was 88.2% female (n = 479/543) with a mean (standard deviation) age of 42.5 (12.0) years. TEAEs occurred in 67.0% (n = 364/543) of participants treated with atogepant 60 mg. The most commonly reported TEAEs (≥5%) were upper respiratory tract infection (10.3%; 56/543), constipation (7.2%; 39/543), nausea (6.3%; 34/543), and urinary tract infection (5.2%; 28/543). Serious TEAEs were reported in 4.4% (24/543) for atogepant. Mean (standard error) change in MMDs for atogepant was -3.8 (0.1) for weeks 1-4 and -5.2 (0.2) at weeks 49-52. Similarly, the proportion of participants with ≥50%, ≥75%, and 100% reductions in MMDs increased from 60.4% (310/513), 37.2% (191/513), and 20.7% (106/513) at weeks 1-4 to 84.2% (282/335), 69.9% (234/335), and 48.4% (162/335), at weeks 49-52.

Conclusion: Daily use of oral atogepant 60 mg for preventive treatment of migraine during this 1-year, open-label trial was safe, well tolerated, and efficacious.

Keywords: atogepant; calcitonin gene-related peptide; gepant; migraine; migraine preventive.

FIGURE 1

Participant disposition. ^aSC migraine prevention medication arm was included to contextualize hepatic laboratory data; efficacy outcomes were not collected in the SC arm; SC medication was selected by the investigator from an approved list in the protocol. ITT, intent‐to‐treat; mITT, modified intent‐to‐treat; N/A, not applicable; SC, standard care

FIGURE 2

Change from baseline in number of monthly migraine days with once‐daily atogepant 60 mg (mITT population). Mixed‐effects model for repeated measures includes visit as a fixed effect, the baseline value as a covariate, and baseline‐by‐visit as an interaction term, with an unstructured covariance matrix. LS, least squares; mITT, modified intent‐to‐treat population

FIGURE 3

Proportion of responders with ≥50%, ≥75%, and 100% reduction in monthly migraine days (mITT population). For each individual, a percentage reduction in MMDs during each respective treatment period was calculated relative to the 28‐day baseline period. The percentage of all participants achieving a ≥50%, ≥75%, and 100% reduction in MMDs is plotted for each treatment period. LS, least squares; mITT, modified intent‐to‐treat; MMD, monthly migraine day

FIGURE 4

Change from baseline in number of monthly acute medication use days (mITT population). Mixed‐effects model for repeated measures includes visit as a fixed effect, the baseline value as a covariate, and baseline‐by‐visit as an interaction term, with an unstructured covariance matrix. LS, least squares; mITT, modified intent‐to‐treat