Neil Minkoff, MD: What is your impression of the efficacy across the 4 CGRP [calcitonin gene-related peptide] monoclonal antibodies? What are the adverse effects profiles across the 4, and how do you try to tailor those to your patient population, if at all?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: They’re all similar, in terms of the reported outcomes in clinical trials, as well as what we’re seeing in our own clinical experience now that it’s been over 2 years that we’ve had 3 of them available.

Sometimes, the adverse effect profile of erenumab might steer me away from that for a particular patient. That’s especially if they already have preexisting constipation or irritable bowel syndrome that’s predominantly constipating. Now that we have the label update, that also applies if they’ve had problems with hypertension in the past.

Thankfully, we haven’t seen huge problems for most of our patients. I have yet to encounter a patient of mine on erenumab who had a serious increase in their blood pressure or hypertensive crisis. I’ve had patients with constipation. No one wound up in the hospital with a bowel obstruction or required surgery. But these are the stories that you hear. This has now entered into my conversation when I help a patient select which they’re going to utilize.

They’ll often ask me, “Which do you think is best for me? I say, “The one that works best, and so we’re just going to have to start trying them.” It may come down to something as trivial as what the injector looks like. I’ve literally had patients choose which of the 3 home options they want based on what the device looked like.

There can be any number of factors that lead you to pick one. If they really don’t want to pick, I’ll choose at random because I like to use them all fairly equally to get a broad experience with them.

It’s only more recently that we’ve been able to offer the intravenous [IV] option, which many patients will prefer. They can come in to be treated. They don’t have to inject themselves at home. They don’t have to be stuck with a very painful needle. It’s actually less painful to have an IV catheter inserted than to have one of these things injected under the skin. It’s a relatively quick infusion with relatively few adverse events in clinical trials, and that’s what we’re seeing in our own experience, as well. Plus, it’s a once-every-3-month treatment. It’s a commitment of 4 times a year, which is much more palatable for many patients.

Neil Minkoff, MD: OK. I want to come back to some of that, but I want to make sure we’re bringing Dr Stephens in here, as well. One of the things that we hear about is how these are evaluated in terms of efficacy by an organization that’s a payer. We’re looking at the different cost-benefit ratios, in terms of safety and effectiveness. Could you could comment on how you are looking at these agents?

Kevin Stephens, Sr., MD: Yes. Again, we look at outcome data, and our data are primarily claims data. We really don’t get anything until a claim is filed, whether it’s for a pharmaceutical agent, whether it’s an office visit, hospital, or emergency department visit. That’s our primary input at which we look.

We do have prior authorization on different types of medication. If we have newer medications and so forth, many times, we ask the providers to call in to make sure that the guidelines are being followed. We go through a stepwise process from the first line of treatment. We follow the national guidelines because those are the standards of care.

That’s first, but most importantly, most of our stuff is based on outcome, which is the claim. When we look at overutilization, it’s not just 1—I need to highlight that. It’s not 1 visit to the emergency department. But it’s when you have recurrent patterns that it would indicate that you have a problem that we need to address in a much more refined way. That’s what we look for. We look for a pattern and not just an isolated event. If we have just 1 migraine event in a person, then we wouldn’t give that very much consideration. But if it’s once a month, then we would.