Alopecia Associated with CGRP Monoclonal Antibodies

Transcript:

Hello! This is Riya Gandhi, associate editor for The Dermatologist. In this interview, Dr Tosti discussed the findings of the cases series and literature review on alopecia as an emerging adverse event to CGRP monoclonal antibodies.

Dr Antonella Tosti, MD, is a professor of dermatology at the University of Miami's Miller School of Medicine in Miami, Florida.

The Dermatologist: Can you provide an overview of the background and objectives of your study on alopecia as an emerging adverse event to calcitonin gene-related peptide (CGRP) monoclonal antibodies?

Dr Tosti: This study started because we saw patients with this problem, and these antibodies are now a very important treatment for headache, and so it's more and more utilized by patients. And so the people working at University of Miami on this topic, they had a patient with a very severe problem, and of course, it's a very difficult problem to solve, because both the hair loss and the headache are a very important problem for the patients. And so they involved me for this reason in this study, and in this way, we understood... We had evaluated the different patients, and decide that probably this adverse event is due to a type of telogen effluvium.

The Dermatologist: In your study, you presented two cases of patients experiencing hair loss after using CGRP monoclonal antibodies. Can you elaborate on the details of these cases and the timeline of hair-loss onset and resolution?

Dr Tosti: Both these patients had very severe hair loss, so even if the patient that had the headache really needed the antibodies, they had to stop the treatment because of the hair loss. And that's very unusual, because many medications cause hair loss, of course, but sometimes the hair loss is not so severe to require interruption of the medication.

The Dermatologist: Your research highlighted a potential mechanistic link between CGRP and hair growth, with implications for the development of alopecia. Could you delve deeper into this mechanism and the role of CGRP in hair-follicle development?

Dr Tosti: CGRP is a part... The growth of the hair follicle is regulated by many different molecules, and this one is one of those molecules. It's not the unique molecules, but of course, as I said before, what we believe is that the way that these patients develop the hair loss is telogen effluvium. So this means that the hair follicles, normally they have a phase where they produce the hair and then they have a phase when they rest, and in this way, the resting phase is someone induced by these molecules.

The Dermatologist: Your study discussed the considerations from managing alopecia as an adverse event in patients benefiting from CGRP monoclonal antibody treatment for migraine prevention. Could you elaborate on these considerations and potential approaches to managing this adverse event?

Dr Tosti: Managing the adverse event may be difficult sometimes. Patients may have this side effect with one monoclonal antibody and do not have the same side effect with another drug, so maybe changing the drug can be a possibility. In that study, we didn't really evaluate the possible efficacy of treatment of hair loss in these patients. For instance, we didn't evaluate if this can be really prevented by a treatment, because it's more a case report than any study. So maybe I believe the future would be to try to understand if there is a way that we can prevent this with drugs that interfere with hair loss, for instance oral minoxidil or new drugs.

The Dermatologist: Given the limitations of the US Food and Drug Administration adverse event reporting system and other potential contributing factors to hair loss, how would you recommend healthcare professionals and patients approach the assessment and management of alopecia related to CGRP monoclonal antibody therapy?

Dr Tosti: I think it's very important to report these side effects to the FDA. And often what happens, the doctors... Everything is done very, very fast. And doing a report is additional time, but I really believe this should be reported, because we don't know the importance of the problem. My feeling is it's a common side effect, and so this is important to know. To other doctors who know, because many doctors don't even think that this can be a real side effect.

The Dermatologist: What implications do your findings have for the broader understanding of adverse events associated with CGRP inhibitors and their potential effects on hair-related mechanisms?

Dr Tosti: I don't think our finding right now provide a broader understanding. This is just something we observed, we described, and the beginning for people to know and to start collecting the data to define how common this side effect is and how important it is for the patients. Because patients with very, very severe migraine, they said, "Okay, I would prefer to keep my migraine than losing my hair."

The Dermatologist: Are there any tips or insights you would like to share with your dermatologist colleagues regarding alopecia as an emerging adverse event to CGRP monoclonal antibodies?

Dr Tosti: Yes. That's what I said before. I believe that dermatologists should know that, because it's something that many dermatologists don't know and maybe don't even ask their patient with hair loss if they're doing this treatment. So let's include this treatment among questions that we have to ask our patients with hair loss and try to understand how big the problem is.

Reference:
Ruiz M, Cocores A, Tosti A, Goadsby PJ, Monteith TS. Alopecia as an emerging adverse event to CGRP monoclonal antibodies: cases series, evaluation of FAERS, and literature review. Cephalalgia. 2023;43(2):3331024221143538. doi:10.1177/03331024221143538