CGRP antagonists and complications in patients with Raynaud’s phenomenon

CGRP antagonists may lead to microvascular complications in patients with underlying primary or secondary Raynaud’s phenomenon (RP). A retrospective observational study showed that these complications are uncommon (seen in 5.3% of patients), but that caution is warranted when CGRP agents are considered in RP patients.

CGRP antagonists can decrease reflex vasodilatory response. This may lead to exacerbation of microvascular disease in susceptible patients, for example with RP. To date, this condition is not listed as a contraindication for the use of any of the 6 CGRP modulators subjected to clinical trials. A retrospective observational study reviewed patients with diagnoses of migraine and RP who were prescribed, and exposed to, CGRP antagonists [1].

Of 169 eligible patients, 9 (5.3%) had microvascular complications. They were all female; median age was 45 years. Most (5/9) had previously diagnosed RP, of which 3 were primary and 2 secondary to scleroderma. The other 3 patients were newly diagnosed with RP. The 9 patients were using galcanezumab (n=3), erenumab (n=5), or fremanezumab (n=1). Observed microvascular complications ranged from worsening RP to digital gangrene and auto-necrosis requiring distal digit amputation (n=2). The authors observed that digital ulcerations/infarctions rarely occur in primary RP alone and almost always reflect a secondary aetiology, which may include associated connective tissue diseases or exposure to precipitating medication. Although rare, the incidence of serious adverse events warrants caution when considering the use of CGRP modulators in patients with RP.

1. Breen I, et al. Calcitonin Gene-Related Peptide Inhibitor Use for Migraine Associated with Exacerbation of Raynaud Phenomenon. S15.005, AAN 2021 Virtual Congress, 17-22 April.

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Posted on 16 June 2021