Mercy NeuroScience Institute

Erenumab is a monoclonal antibody that targets the calcitonin gene-related peptide (CGRP) receptor and is approved for the preventative treatment of migraine in adults. CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension. While there has not been evidence of hypertension in preclinical models or clinical trials, post-marketing data suggest erenumab may be associated with hypertension. This led to a warning in the United States Food and Drug Administration prescribing information for erenumab. To determine the frequency of worsening blood pressure (BP) after initiation of erenumab in patients with migraine and how this is associated with hypertension. This is an observational retrospective cohort study evaluating patients at a tertiary headache or neurology department. Systolic and diastolic BPs were compared between the initial visit prior to initiation of erenumab, and follow-up visit while on erenumab. Worsening BP was defined as moving from a lower stage to a higher stage of BP, as defined by the American Heart Association. Serious adverse vascular events were also recorded. A total of 335 patients were included in the final analysis (mean [SD] age of 45.7 [14.40] years, 83.9% [281/335] female). At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The median (interquartile range) time to follow-up appointment from initial appointment was 20.5 (13.3-35.3) weeks. The mean (SD) BP at baseline was systolic 124.7 (15) mmHg and diastolic 77 (11) mmHg, and at follow-up was systolic 124.0 (15) mmHg and diastolic 77.8 (9) mmHg. Overall, 23.3% (78/335) of all patients had worsening BP, whereas 13/225 (3.9%) patients had improvement in their BP. Patients with atrial fibrillation were more likely to develop worsening BP (odds ratio, 4.9, 95% confidence interval 1.12-21.4; p = 0.035). There was no association between worsening BP and pre-existing hypertension, sex, body mass index, or age. One patient had non-ST elevation myocardial infarction attributed to a hypertensive emergency while on erenumab. We found that 23.3% of patients initiated on erenumab may have developed worsening BP, suggesting the need for BP monitoring in patients initiated on erenumab.

Elevations in intracranial pressure (ICP) constitute neurological emergencies, and a significant amount of time in the neurological critical care unit (NCCU) is spent diagnosing and treating increased ICP. It is pivotal to understand the signs of increased ICP, and treatment should be implemented without delay. Most institutes utilize an algorithmic-based approach for ICP management. This chapter will review the etiologies and diagnosis of increased ICP and will summarize our treatment algorithm. The available evidence for each intervention will be discussed.

BACKGROUND: Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that affects the central nervous system (CNS). It has been reported that autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus have reduced arterial compliance and increased resistance to blood flow. PURPOSE: The primary purpose of this study was to examine systemic vascular resistance (SVR) and total vascular impedance (TVI) in patients with Relapse-Remitting MS (RRMS) compared to healthy age-matched controls. METHODS: Fifty-eight men and women between the ages of 18-64 years were separated into 8 different groups; young (≤40 years old) control men (n=13), old (≥41 years old) control men (n=8), young men RRMS (n=5), old men RRMS (n=2), young control women (n=14), old control women (n=8), young women RRMS (n=4), old women RRMS (n=11) who volunteered for this study. Total vascular impedance and systemic vascular resistance were measured by using the Pulse Contour Analysis (PCA), which analyzes blood pressure waveforms. A 2-way ANOVA (gender x group) was used to explore differences in the outcome variables with p≤0.05 set for statistical significance. RESULTS: A 2-way ANOVA showed there was no significant gender effect, however there was a significant group effect (p=0.048). The young controls had a significantly lower TVI than the young and old MS. Where, the young controls showed a significantly lower SVR than the old controls and the old MS. CONCLUSION: TVI and RSV are significantly compromised in individuals with MS, compared to age-matched controls, thus, indicating there is a systemic effect of an inflammatory process with in the CNS.