Blackwell Science, LtdOxford, UKCHACephalalgia1468-2982Blackwell Science, 2004252139147Original ArticleEffect of BIBN4096BS on cerebral and systemic haemodynamics KA Petersen et al.
`
`doi:10.1111/j.1468-2982.2004.00830.x
`
`The CGRP-antagonist, BIBN4096BS does not affect cerebral or
`systemic haemodynamics in healthy volunteers
`
`KA Petersen1, S Birk1, LH Lassen1, C Kruuse1, O Jonassen2, L Lesko3 & J Olesen1
`1Danish Headache Center, University of Copenhagen and Department of Neurology, Glostrup University Hospital, Denmark 2Department of Clinical
`Physiologies and Nuclear Medicine, Glostrup University Hospital, Denmark. 3Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, Connecticut,
`USA
`
`Petersen KA, Birk S, Lassen LH, Kruuse C, Jonassen O, Lesko L & Olesen J. The
`CGRP-antagonist, BIBN4096BS does not affect cerebral or systemic haemodynam-
`ics in healthy volunteers. Cephalagia 2005; 25:139–147. London. ISSN 0333-1024
`BIBN4096BS is a CGRP-antagonist effective in the treatment of migraine. Blocking
`the receptor of a strong vasodilator involves a theoretical risk of causing cerebral
`vasoconstriction, a probability not previously investigated with BIBN4096BS.
`Seven healthy volunteers completed this double-blinded placebo-controlled cross-
`over study. The volunteers received randomly 10 min infusions of either placebo,
`2.5 mg or 10 mg of BIBN4096BS on 3 separate days. Transcranial Doppler was
`used to measure the middle cerebral artery blood flow velocity (VMCA); global and
`regional cerebral blood flow (rCBFMCA) was measured by 133-Xenon inhalation
`SPECT. The diameter of the temporal and radial artery was measured by high-
`resolution ultrasound. Systemic haemodynamics and partial pressure of CO2
`(PetCO2), and adverse events were monitored regularly. BIBN4096BS had no
`influence on global or regional cerebral blood flow, or on the blood flow velocity
`in the middle cerebral artery. There was no effect on systemic haemodynamics
`and adverse events were minor. We conclude that there is no effect of CGRP-
`receptor blockade on the cerebral or systemic circulation in humans. Circulating
`CGRP is therefore not likely to exert a vasodilatory activity in the resting state
`and the use of BIBN4096BS for acute migraine seems to be without risk of cerebral
`vasoactivity. These data suggest that BIBN4096BS is the first specific antimigraine
`drug without vasoactive effect. 䊐BIBN4096BS, CGRP-antagonism, cerebral and
`systemic haemodynamics, migraine
`
`Dr Kenneth A. Petersen, Danish Headache Center, University of Copenhagen and
`Department of Neurology, Glostrup University Hospital, KAS Glostrup, DK-2600
`Glostrup Denmark. Tel. +45 43232796, fax +45 43233960, e-mail kapetersen@dadlnet.dk
`Received 5 February 2004, accepted 20 May 2004
`
`Introduction
`Calcitonin gene-related peptide (CGRP) is probably
`one of the most potent vasodilators of human arter-
`ies (1–4). The vasoactive function of the neuropeptid
`is mediated through a receptor complex (5). Binding
`to this complex leads to an intracellular increase in
`cyclic nucleotides and vasodilatation. CGRP proba-
`bly plays a protective role against vasospasm follow-
`ing subarachnoidal haemorrhage in both animals
`and humans (6, 7). CGRP is likely to play a causative
`role in migraine headache (8, 9).
`
`Peptide fragments of calcitonin gene-related
`peptide, e.g. CGRP8-37 and [Asp31, Pro34, Phe35]
`CGRP27-37 have so far been the only available antag-
`onists of CGRP. They have been used in in vitro
`studies to characterize CGRP function and CGRP-
`receptor properties. BIBN4096BS is a novel CGRP-
`antagonist. It has been well characterized in animal
`studies and can be used safely in humans (10, 11). A
`phase-2 study gave proof that BIBN4096BS is
`effective
`in treating acute migraine headache.
`BIBN4096BS therefore represents a new principle in
`acute migraine treatment (11). One potential concern
`
`© Blackwell Publishing Ltd Cephalalgia, 2004, 25, 139–147
`
`139
`
`1
`
`EX2019
`Eli Lilly & Co. v. Teva Pharms. Int'l GMBH
`IPR2018-01427
`
`

`

`140 KA Petersen et al.
`
`of CGRP antagonism could be cerebral vasoconstric-
`tion, if CGRP exerts a tonic influence on the cerebral
`arteries.
`In the present double-blinded placebo-controlled
`study, we therefore evaluated whether effective
`CGRP-antagonism achieved by BIBN4096BS would
`alter the resting tone of cerebral and extracerebral
`arteries.
`
`Materials and methods
`
`Design and participants
`Nine healthy volunteers, five men and four women,
`were included in this double-blinded placebo-con-
`trolled triple crossover study. One subject withdrew
`her consent and one was excluded due to a knee
`injury requiring arthroscopy, both before entering
`the treatment phase of the study. In all seven healthy
`volunteers completed the study. The participants
`had an average age of 23.6 years, (range 20–28) and
`an average weight of 66.9 kg (range 54.8–82).
`BIBN4096BS 2.5 mg or 10 mg or placebo (Xylitol
`5%) was administered intravenously in a balanced
`random order over 10 min on 3 trial days separated
`by at least one week. BIBN4096BS was manufactured
`and supplied by Boehringer Ingelheim GmbH (BI).
`BI performed the blinding and randomization of the
`clinical supplies (ClinPro. version 6, Clinical Systems
`Inc. USA). The doses used in this study were deter-
`mined from preliminary data from preclinical safety
`studies performed by BI (12). The dose of 2.5 mg was
`selected since this is the minimal effective dose found
`in the proof of concept study and the possible dose
`to be taken into future studies (11). Ten mg was the
`highest dose ever tested with BIBN4096BS and since
`adverse events was dose dependent; this dose was
`selected as the high dose to be administered.
`A medical history was taken before inclusion. The
`participants had no present or previous cardiovas-
`cular, cerebrovascular, endocrine or neurological
`disorders, migraine, hypo-or hypertension. Episodic
`tension type headache with a frequency of £4 days/
`month was the only type of primary headache
`accepted. On the day of inclusion, a physical and
`a neurological examination were performed and an
`ECG and a panel of blood samples were taken.
`All participants gave written informed consent
`before inclusion. The study was approved by the
`Ethical Committee of Copenhagen County
`(KA00089gs) and the Danish Medicines Agency
`(2612–1394) and was conducted according to the
`Helsinki II declaration and the guidelines for Good
`Clinical Practice (13).
`
`Cerebral blood flow measurement
`Global and regional cerebral blood flow was mea-
`sured with 133-Xenon inhalation SPECT with a
`brain-dedicated camera (Ceraspect, DSI, Waltham,
`MA, USA). The apparatus consists of a stationary
`annular NaI crystal and a fast rotating collimator
`system. Each rotation took 10 s, thereby acquiring 1
`frame in a 30-frame dynamic protocol of 133-Xenon
`inhalation, 3 backgrounds, 9 wash-in, 18 wash-out
`using the Kanno-Lassen algorithm (14). A photoelec-
`tric window of 70–100 keV was employed. Thirty-
`two slices were reconstructed in a 64 ¥ 64 matrix
`with each pixel measuring 0.33 ¥ 0.33 cm using a
`Butterworth 1D filter (cut-off 1.5, order 6). The 32
`slices were reduced to sets of 8 transaxial slices gen-
`erated by adding 4 slices together to a total slice
`thickness of 1.32 cm.
`Attenuation correction using the Chang algorithm
`(m = 0.05 cm) and correction for nose-artefact were
`performed. The output for each pixel was the ki-value
`and flow values were estimated from these using the
`partition coefficient (l) of 0.85 (grey matter).
`A Datex Normacap 200 (Dameca, Roedovre,
`Denmark) was used for partial pressure of CO2
`(PetCO2) measurements during the CBF acquisi-
`tions. A Ceretronix XAS SM 32C (Randers, Den-
`mark) was used for the 133-Xenon administration.
`Each measurement lasted 5 min. Calculations of
`flow in the perfusion territories of the major cere-
`bral arteries were performed by fitting standard
`vascular regions of interest on the five rostral
`slices at 3.6, 5.0, 6.3, 7.6 and 9 cm above the
`orbito-meatal line. Flow in the territory of the
`MCA (rCBFMCA) was calculated as a mean of
`the left and right side.
`
`Transcranial doppler (TCD) and C-scan
`Transcranial Doppler ultrasonography (2 MHz, Mul-
`tidop X Doppler: DWL, Sipplingen, Germany) was
`used for the measurement of blood flow velocity.
`The recordings were done simultaneously and bilat-
`erally as previously described, but with handheld
`probes (15). Along the middle cerebral artery (MCA),
`a fixed point was found for the measurement. The
`fixed point was chosen as close as possible to the
`bifurcation of the anterior cerebral artery and MCA.
`The same fix-point was used for each individual and
`for each recording, for which the signal was opti-
`mized. Based upon the envelope curve (the spectral
`TCD-curve), a time-average mean (Vmean) over
`approximately four cardiac cycles or four seconds
`was calculated by the built-in software (TCD7.40x
`
`© Blackwell Publishing Ltd Cephalalgia, 2004, 25, 139–147
`
`2
`
`

`

`Effect of BIBN4096BS on cerebral and systemic haemodynamics
`
`141
`
`for MDX). The final measure used for each time
`point was an average of four cycles (VMCA). Simulta-
`neously with the TCD recording, end-tidal PetCO2
`(POET; Criticare Systems, Waukesha, WI, USA) was
`measured using a mask loosely covering the nose
`and mouth of the subject.
`A high-resolution ultrasound scanner, C-scan
`(Dermascan C, 20 MHz, bandwidth 15 MHz, Had-
`sund Denmark) (16), was used for the direct mea-
`surement of the diameter of the temporal and radial
`artery. The temporal artery diameter was measured
`at the frontal branch of the superficial temporal
`artery; both the temporal and radial recordings were
`done on the volunteer’s left side. To ensure that TCD
`and C-scan were done in the same place during the
`repeated measurements on the separated trial days,
`marks were drawn on the skin. After the last record-
`ing on the first trial day, the coordinates of the marks
`were stored for re-use on the following trial days.
`
`Recording of adverse events (AEs)
`The intensity/severity of the AEs were graded mild,
`moderate or severe and their relationship to study
`medication was classified as related or not related.
`The volunteers were questioned for the presence of
`AEs every 15 min during the study from T0 (base-
`line) to T240 (end of study day). In between question-
`ing the participants self-reported any changes that
`they might experience. After discharge the partici-
`pants recorded AEs every hour until 24 h after the
`infusion of placebo or BIBN4096BS.
`
`Plasma sampling for BIBN4096BS concentration
`measurements
`Plasma samples of BIBN4096BS were taken at the
`following time points: TBaseline(- 10),
`, T30, T60 and T180
`T /91
`on each trial day in Vacutainer® EDTA K3 10 ml
`glasses. Samples were stored on ice for a maximum
`of 30 min before
`centrifugation
`for 10 min
`(2000 r.p.m) at 4∞C. Plasma was stored at -20∞C
`until analysed at Boehringer Ingelheim Pharma
`GmbH & Co. (KG, Biberach Germany).
`
`2
`
`Analytical determination of BIBN4096BS in plasma
`The procedures were conducted in accordance with
`current international guidelines (17). BIBN4096BS
`was analysed by high performance liquid chroma-
`tography coupled to tandem mass spectrometry
`(HPLC-MS/MS) using [D8]-labelled BIBN4096BS as
`internal standard. The assay comprises sample clean
`up by automated solid phase extraction in the 96-
`
`© Blackwell Publishing Ltd Cephalalgia, 2004, 25, 139–147
`
`well plate format. Chromatography was achieved
`on an analytical C18 reversed-phase HPLC column
`with gradient elution. The substances were quanti-
`fied by HPLC-MS/MS in the positive electro spray
`ionization mode. Assay performance during the
`study was assessed by back-calculation of calibra-
`tion standards, tabulation of the standard curve fit
`function parameters and measurement of quality
`control samples. No interference of endogenous
`compounds was observed in human blank plasma
`and in predose samples. The linear calibration
`curves for undiluted samples covered a range of
`plasma concentrations from 0.5 to 500 ng/ml for
`BIBN4096BS. The validation data document the
`specificity, accuracy and precision of the HPLC-MS/
`MS assay employed for the study.
`
`Trial procedures
`Participants met at the clinic at 0800h and had
`abstained from coffee, tea, and caffeine containing
`beverages, tobacco and medication except oral con-
`traceptives for 8 h prior to the meeting time. The
`volunteers were headache free. They were placed
`in supine position. Two
`intravenous catheters
`(Optiva*2, 18G, Johnson & Johnson, Ethicon S.p.A.,
`Italy) were inserted in the cubital veins, one for the
`infusion of placebo or BIBN4096BS and the second
`for blood withdrawal. After an adjustment period of
`at least 30 min, baseline measurements of CBF, VMCA,
`temporal and radial artery diameter, blood samples,
`blood pressure (BP), heart rate (HR) and ECG were
`recorded. At time T0, placebo or BIBN4096BS (2.5 mg
`or 10 mg) was infused by a time and volume con-
`trolled infusion pump (Braun® perfusor, B. Braun
`Melsong AG, Germany) over 10 min.
`All measurements, except BP, HR and CBF were
`recorded at 15 min intervals for 3 h (the study
`period). BP and HR were measured every 5 min for
`the first 30 min and thereafter every 15 min using an
`automatically inflating cuff (Omega 1400, In vivo
`Research Laboratories Inc. Copiagne, NY, USA). For
`safety reasons BP, HR, EKG and adverse events were
`monitored for an additional hour, after the end of the
`3-h study period.
`Three SPECT-scans were done: at baseline, at
`60 min and at 180 min. The estimated perfusion
`(rCBFx) in the area of a given artery (x) in the
`brain is depending on the mean blood flow velocity
`(Vmean(x)) and the cross-sectional area, p ¥ r2, of the
`artery. The following equation is valid for the
`regional cerebral blood flow:
`rCBF(x) = Vmean (x) ¥ p ¥ r2.
`
`3
`
`

`

`142 KA Petersen et al.
`
`If the CBF is unchanged the following equation is
`valid:
`
`2
`
`(
`) ¥
`=
`-
`D D iameter
`V
`V
`1
`100
`MCA1
`MCA
`D Diameter is the relative percentage change in
`diameter; VMCA1 is the mean blood flow velocity
`before infusion of BIBN4096BS or placebo and VMCA2
`the velocity at a specific time point after or during
`the infusion (18, 19). Global CBF and rCBFMCA were
`corrected for PetCO2 changes by 2% per mmHg
`change in PetCO2 (20) and VMCA by e0.034 per mmHg,
`when required (21).
`
`the univariate analysis, the area under the curve
`(AUC), calculated on percentage changes of global
`CBF, rCBFMCA, VMCA, temporal and radial artery
`diameter and peripheral haemodynamic from base-
`line, was used.
`
`Results
`Baseline values of the measurements are summa-
`rized in Table 1. No significant difference was found
`between the baseline values of the three different
`trial days.
`
`Statistics
`Baseline was calculated as the mean of the measure-
`ments of time point T-20 and T-10. Values are pre-
`sented as means ± SD. P < 0.05 was considered
`significant. All data processing was performed using
`SPSS statistical software version 10.0 (Chicago, IL,
`USA).
`For changes over time on each trial day all record-
`ings were analysed by a univariate analysis of vari-
`ance with the factors time and participant included
`in the model. Due to the risk of mass significance,
`data were reduced to five points of interest: baseline,
`T30, T60, T120 and T180. If a significant change was
`found, a Dunnett’s multiple comparisons test was
`performed to localize the change. Absolute values
`were used for the statistical analysis.
`For the comparison of differences between the
`three trial days (placebo, BIBN4096BS 2.5 mg, and
`BIBN4096BS 10 mg) a univariate analysis of variance
`was performed, treatment and participant was
`included in the model. As a summary measure for
`
`Haemodynamics
`One CBF measurement was not included in the
`analysis, due to technical problems with the delivery
`of 133-Xenon (time 60 min on the trial day with
`administration of BIBN4096BS 10 mg). There was
`no significant difference in rCBFMCA (Left) (P = 0.74),
`rCBFMCA (Right) (P = 0.3), rCBFMCA (P = 0.49), or global
`CBF (P = 0.46) between the 3 treatment groups (pla-
`cebo, BIBN4096BS 2.5 mg and 10 mg). No significant
`changes over time were found for either global CBF
`or rCBFMCA on the three trial days (Fig. 1). PetCO2
`showed no significant changes over time on any of
`the treatment days or between treatment days
`(P = 0.18).
`Since PetCO2 during TCD recordings were per-
`formed independently and at separate time points
`from the PetCO2 during the CBF recordings, the
`obtained data on PetCO2 were analysed separately.
`increased significantly over time after
`PetCO2
`BIBN4096BS 10 mg (P = 0.005), the increase was
`from 39.5 ± 3.1 mmHg
`at
`to
`time T120 and
`
`Table 1 Baseline values of measured variables (mean ± SD), no significant changes were seen between the three trial days
`(ANOVA)
`
`BIBN4096BS
`
`Measured variables
`
`Global CBF (ml/100 g brain tissue/min)
`rCBFMCA (ml/100 g brain tissue/min)
`rCBFMCA(left) (ml/100 g brain tissue/min)
`rCBFMCA(right) (ml/100 g brain tissue/min)
`PetCO2 (CBF) (mmHg)
`PetCO2 (TCD) (mmHg)
`VMCA (cm/s)
`Artery (temporal) (mm)
`Artery (radial) (mm)
`Systolic BP (mmHg)
`Diastolic BP (mmHg)
`Heart rate (BPM)
`
`Placebo
`
`47.7 ± 3.8
`47.4 ± 3.9
`46.9 ± 3.9
`47.7 ± 3.8
`39.6 ± 3.6
`38.1 ± 4.5
` 82 ± 16
`0.98 ± 0.36
`2.25 ± 0.44
` 106 ± 14
` 63 ± 11
` 49 ± 4
`
`(2.5 mg)
`
`48.2 ± 9.1
`48.1 ± 9.4
`47.4 ± 9.1
`48.7 ± 9.7
`39.8 ± 3.7
`37.6 ± 3.8
` 79 ± 16
`0.88 ± 0.3
`2.29 ± 0.29
` 108 ± 10
` 62 ± 5
` 50 ± 3
`
`(10 mg)
`
`49.6 ± 4.4
`49.3 ± 4.7
`48.1 ± 5
`50.6 ± 4.6
`39.6 ± 2.8
`39.5 ± 3.1
` 83 ± 15
`0.89 ± 0.3
`2.31 ± 0.49
` 114 ± 9
` 63 ± 8
` 49 ± 5
`
`© Blackwell Publishing Ltd Cephalalgia, 2004, 25, 139–147
`
`4
`
`

`

`Effect of BIBN4096BS on cerebral and systemic haemodynamics
`
`143
`
`PetCO2 (mmHg)
`
`100
`
`90
`
`80
`
`70
`
`60
`
`50
`
`40
`
`30
`
`Infusion period
`
`100
`
`90
`
`80
`
`70
`
`60
`
`50
`
`40
`
`VMCA (cm ¥ sec–1)
`
`30
`Baseline
`
`0 15 30 45 60 75 90 105120135150165180
`Time (minutes)
`Figure 2 (a) PetCO2-uncorrected VMCA values (mean ± s.e.m)
`are illustrated, units for data on left y-axis, 䊏 placebo;
`▲ BIBN4096BS 2.5 mg; 䊉 BIBN4096BS 10 mg. (b) the
`corresponding PetCO2 values (mean ± s.e.m) are plotted with
`reference to the right y-axis, 䊏 placebo; ▲ BIBN4096BS
`2.5 mg; 䊉 BIBN4096BS 10 mg.
`
`For none of the measured systemic haemody-
`namic variables a significant change between the
`three treatment groups was found: systolic blood
`pressure (BP) (P = 0.15), diastolic BP (P = 0.52), and
`HR (P = 0.42). Table 2 summarizes the measure-
`ments of BP and heart rate. There were no ECG
`changes at any time in any of the three treatment
`arms.
`An analysis over time of each treatment day
`showed no statistically significant change of the
`diastolic BP. When administering BIBN4096BS
`2.5 mg a significant change in systolic BP was seen
`over time (P = 0.03), this was not seen on the two
`other trial days. HR changed significantly over time
`after placebo and 2.5 mg (P = 0.01 and P = 0.02).
`Changes after placebo occurred at T60 and T180, and
`after BIBN4096BS 2.5 mg at T180. No change was seen
`after BIBN4096BS 10 mg (P = 0.4).
`
`Adverse events
`Thirty-six AEs were recorded either by the investi-
`gator or the volunteers. Two of the AEs occurred on
`placebo days, 16 and 18 with BIBN4096BS infusion,
`2.5 mg and 10 mg. Of the 36 AEs, 16 were considered
`to have no relation to the study medication. The 20
`remaining AEs that were considered related to study
`medication were graded as mild 16, or moderate 4.
`Of these 20 AEs, 13 were registered on days with
`infusion of BIBN4096BS 10 mg, and 7 after 2.5 mg.
`The AEs with a relation to BIBN4096BS and on pla-
`cebo days are listed in Table 3.
`
`60
`
`55
`
`50
`
`45
`
`40
`
`Infusion period
`
`Baseline
`
`0 15 30 45 60 75 90 105120135150165180
`Time (minutes)
`
`Cerebral blood flow (ml 100 g brain tissue/min)
`
`Figure 1 Measurements of the regional cerebral blood flow in
`the area supplied by MCA on the three different treatment
`days are shown (mean ± s.e.m). 䊏 Placebo; ▲ BIBN4096BS
`2.5 mg; 䊉 BIBN4096BS 10 mg.
`
`41.6 ± 3.5 mmHg. There were no significant differ-
`ences between treatment days (P = 0.29). TCD
`recordings (VMCA) were analysed with and without
`correction for PetCO2 changes. Both the uncor-
`rected and corrected VMCA decreased significantly
`over time on placebo days (P = 0.02 and P = 0.01),
`the decrease was seen at T120 and T180. No changes
`were seen with BIBN4096BS 2.5 mg (P = 0.38 and
`P = 0.33). When administering BIBN4096BS 10 mg
`a significant (P < 0.001) decrease in corrected VMCA
`from 83 ± 15
`to 72 ± 12 cm/s occurred,
`the
`decrease was seen at T120; without PetCO2 correc-
`tion a significant change was not seen (P = 0.12).
`However, no significant difference in VMCA was
`found between placebo and the two different doses
`of the CGRP-antagonist, P = 0.18 (PetCO2 corrected)
`and P = 0.73 (uncorrected, Fig. 2). When calculating
`the percentage diameter changes, no difference was
`seen between treatments P = 0.68 (uncorrected).
`The luminal diameter measurement of the tem-
`poral and radial artery revealed no significant dif-
`ference between
`the
`three
`treatment groups
`(P = 0.36
`temporal artery and P = 0.33 radial
`artery). On placebo days the temporal artery signif-
`(P = 0.04)
`icantly
`increased
`in diameter
`from
`0.98 ± 0.36 mm to 1.09 ± 0.30 mm (T120) and at time
`point T60 the radial artery significantly (P = 0.046)
`increased from 2.25 ± 0.44 mm to 2.41 ± 0.38 mm.
`When infusing BIBN4096BS 2.5 mg no changes
`were seen. On days when BIBN4096BS 10 mg was
`infused the temporal artery increased significantly
`(P = 0.02) from 0.89 ± 0.30 mm to 1.17 ± 0.39 mm
`(T30).
`
`© Blackwell Publishing Ltd Cephalalgia, 2004, 25, 139–147
`
`5
`
`

`

`144 KA Petersen et al.
`
`Table 2 Summary of peripheral haemodynamics (mean ± SD), all time points are not included. No significant difference between
`the three treatment groups was seen for any of the measure variables
`
`Systolic blood pressure (mmHg)
`
`Diastolic blood pressure (mmHg)
`
`Heart rate (BPM)
`
`BIBN4096BS
`
`BIBN4096BS
`
`BIBN4096BS
`
`Placebo
`
`2.5 mg
`
`10 mg
`
`Placebo
`
`2.5 mg
`
`10 mg
`
`Placebo
`
`109 ± 14
`110 ± 12
`110 ± 10
`105 ± 12
`107 ± 14
`106 ± 9
`111 ± 10
`111 ± 11
`
`110 ± 13
`112 ± 9
`107 ± 8
`104 ± 8
`108 ± 9
`112 ± 10
`109 ± 13
`115 ± 12
`
`110 ± 5
`111 ± 5
`114 ± 8
`112 ± 8
`107 ± 9
`109 ± 10
`109 ± 7
`114 ± 9
`
`64 ± 8
`62 ± 6
`64 ± 3
`62 ± 9
`60 ± 8
`65 ± 11
`63 ± 4
`66 ± 7
`
`64 ± 8
`64 ± 3
`62 ± 6
`61 ± 6
`61 ± 6
`65 ± 8
`61 ± 9
`67 ± 7
`
`63 ± 9
`62 ± 8
`66 ± 6
`66 ± 8
`66 ± 5
`65 ± 5
`67 ± 4
`67 ± 9
`
`50 ± 5
`51 ± 6
`51 ± 6
`56 ± 8
`50 ± 7
`53 ± 6
`58 ± 8
`58 ± 8
`
`2.5 mg
`
`53 ± 3
`55 ± 3
`51 ± 5
`53 ± 5
`57 ± 11
`57 ± 7
`53 ± 8
`60 ± 7
`
`10 mg
`
`52 ± 6
`55 ± 6
`51 ± 8
`54 ± 7
`54 ± 8
`52 ± 9
`55 ± 4
`55 ± 6
`
`Time
`(Min)
`
`0
`10
`30
`60
`90
`120
`150
`180
`
`Table 3 Adverse events. In this table, BIBN4096BS and placebo related adverse events are described by: number of occurred
`AEs, severity and dose on which they occurred
`
`BIBN4096BS
`
`Rating
`
`Placebo
`
`2.5 mg
`
`10 mg
`
`Mild
`
`Moderate
`
`Severe
`
`n =
`Occurrences
`
`Parasthesia*
`Headache
`Heat sensation
`Flushing†
`Skin rash‡
`Itching §
`Rhinitis
`Dizziness
`
`–
`–
`–
`1
`–
`–
`–
`1
`
`2
`2
`1
`–
`1
`–
`1
`–
`
`4
`2
`2
`3
`1
`1
`–
`–
`
`5
`3
`3
`3
`2
`–
`1
`1
`
`*Head, neck and chest, †face and chest, ‡place of infusion, §scalp.
`
`1
`1
`–
`1
`–
`1
`–
`–
`
`–
`–
`–
`–
`–
`–
`–
`–
`
`6
`4
`3
`4
`2
`1
`1
`1
`
`BIBN4096BS plasma concentration
`No detectable BIBN4096BS levels were recorded
`in predose or placebo samples. Plasma concen-
`trations above detection level were recorded for
`all participants during the active drug adminis-
`tration (Fig. 3). The time courses of plasma con-
`centration of BIBN4096BS following intravenous
`infusion were characterized by a rapid increase
`in plasma concentrations during infusion, fol-
`lowed by a rapidly declining distribution phase,
`and
`then by a slower
`terminal phase. The
`plasma concentrations of BIBN4096BS just before
`the end (
` minutes) of an intravenous infu-
`91
`2/
`sion of 10 mg over 10 min had a mean maxi-
`mum observed concentration (Cmax) of 768.71 ±
`136.85 ng/ml. Three hours after
`the end of
`administration, the mean plasma concentration
`was about 6% of the corresponding Cmax value.
`After 2.5 mg BIBN4096BS, Cmax was 202 ±
`47.72 ng/ml and the three hours value 4% of its
`corresponding Cmax.
`
`Discussion
`This is the first human study of the effect of a novel
`CGRP-antagonist, BIBN4096BS, on the cephalic and
`peripheral circulation in healthy volunteers. We
`found that BIBN4096BS compared to placebo in rest-
`ing healthy volunteers had no significant effect on
`cerebral blood flow or the diameter of the middle
`cerebral artery. In addition, no effect on the extra-
`cranial arteries or systemic haemodynamics was
`recorded. These data suggest that circulating CGRP
`does not exert a sustained vasodilator activity in
`humans under resting conditions. The possibility
`that BIBN4096BS does not cross the blood–brain bar-
`rier (BBB), dictates some caution on conclusions
`regarding the function of CGRP released from
`perivascular nerves.
`
`CGRP in the regulation of cerebral haemodynamics
`CGRP is found throughout the human body. In the
`cerebral circulation, the peptide has primarily been
`
`© Blackwell Publishing Ltd Cephalalgia, 2004, 25, 139–147
`
`6
`
`

`

`Effect of BIBN4096BS on cerebral and systemic haemodynamics
`
`145
`
`antagonist could be expected to induce vasoconstric-
`tion of cerebral arteries and/or arterioles. Based
`upon the measurements performed in this study, no
`vasoconstriction occurred in the middle cerebral
`artery or in the arterioles. We therefore suggest that
`in healthy volunteers the neuropeptide has no influ-
`ence on the resting vascular tone of cerebral arteries.
`CGRP is believed to play a pivotal role in migraine
`pathogenesis. Administration of CGRP to migraine
`patients induces an immediate headache in 8 out of
`9 and a delayed migraine attack, fulfilling the IHS
`criteria, in 3 out of 9 (8). The implication of CGRP in
`migraine pathogenesis was further substantiated by
`the finding of the clinical antimigraine efficacy of
`BIBN4096BS (11).
`
`BIBN4096BS
`In animals and human cell-lines, the selectivity of
`BIBN4096BS for the CGRP-receptor compared to
`CGRP-related binding sites such as calcitonin, amy-
`lin and adrenomedullin, has been demonstrated. It
`has an approximately 200-fold higher affinity for
`the primate compared to the non-primate receptor
`(10, 28). In vivo studies performed in marmosets and
`rats have all confirmed the inhibitory effect of the
`antagonist on CGRP-mediated responses, induced
`either indirectly by electrical stimulation of the
`trigeminal ganglion or by
`intravenous CGRP
`administration (10, 29). In isolated human temporal,
`cerebral pial arteries, and coronary arteries
`BIBN4096BS effectively inhibited CGRP elicited
`dilatation. The BIBN4096BS was equally effective
`in intracranial and coronary arteries (3, 30). High
`concentration of BIBN4096BS (10 nM) administered
`before and during precontriction with KCl in the
`tissue bath had a tendency to induce a small and
`inconsistent vasoconstriction (3). Compared to the
`maximal average plasma levels after 10 mg of
`BIBN4096BS in this study the dose possibly induc-
`ing vasoconstriction was 10 times larger. The con-
`striction was not readily explained and in contrast
`to the finding that 300 nM/kg of BIBN4096BS
`increased mesenteric blood flow by approximately
`10% in anaesthetized rats (31).
`By nature BIBN4096BS is hydrophilic and is
`unlikely to pass the BBB, however, no data exists to
`confirm this.
`The present study showed no effect on any of the
`measured variables, in particular no vasoactive effect
`was seen after BIBN4096BS 2.5 mg and 10 mg com-
`pared to placebo. Flushing and dilatation of the
`temporal artery after the highest dose occurred in
`three participants, in none after 2.5 mg and in one
`
`20
`
`40
`
`60
`
`80
`
`100 120 140 160 180
`
`(a)
`300
`
`200
`
`100
`
`0
`Baseline
`
`(b)
`
`1000
`
`750
`
`500
`
`250
`
`Plasma BIBN4096BS (ng/ml)
`
`0
`Baseline
`
`20
`
`80 100 120 140 160 180
`40 60
`Time (minutes)
`
`Figure 3 Plasma concentrations of BIBN4096BS (ng/ml)
`measurements are shown for the individual participants.
`(a) Plasma concentrations after administration of 2.5 mg
`BIBN4096BS (b) Plasma concentrations after administration of
`10 mg BIBN4096BS. Blood samples were drawn from the
`opposite cubital vein of infusion at the following time points:
`10 min before start of the BIBN4096BS infusion and
`, 30, 60
`91 2
`and 180 min post infusion start. Analysis was performed
`using HPLC-MS/MS.
`
`localized to perivascular sensory c-fibre terminals,
`originating in the trigeminal ganglion (22). When
`released, CGRP induces vasodilatation mediated
`through receptor binding and intracellular increase
`of cyclic nucleotides.
`The CGRP-receptors, CGRP-1 and GCRP-2 are
`part of a receptor family also including the adrenom-
`edullin receptor (23). The differentiation of ligand
`affinity within the receptor family is ascribed to the
`binding of receptor activity modifying proteins
`(RAMPs) to the calcitonin receptor like receptor
`(CRLR) (5).
`It has been suggested, in animal experiments, that
`CGRP increases CBF (24). Furthermore CGRP seems
`to be involved in the cerebral vasodilatation in
`response to hypotension (25), in postocclusive hyper-
`aemia (26) and in cortical spreading depression (27).
`If CGRP plays a role in the regulation of the vas-
`cular tone of cerebral arteries or CBF in human
`volunteers, the administration of a potent CGRP-
`
`© Blackwell Publishing Ltd Cephalalgia, 2004, 25, 139–147
`
`7
`
`

`

`146 KA Petersen et al.
`
`this was caused by
`after placebo. Whether
`BIBN4096BS cannot be excluded, but both vasodila-
`tation and flushing was also seen on placebo days.
`Flushing after 10 mg of BIBN4096BS has been
`reported elsewhere (12). Vasodilatation and flushing
`might therefore occur, although our numbers are
`too small for any definite conclusion. 3 participants
`recorded a mild headache on four occasions after
`administration of BIBN4096BS 2.5 mg (n = 2) and
`10 mg (n = 2), none after placebo. The headache was
`reported between 5 and 9 h after the infusion of
`the compound. It cannot be concluded whether the
`compound induced this or it was a coincidence.
`However, headache has been reported on pre-
`vious occasions following the administration of
`BIBN4096BS (11, 32).
`To clarify the interpretation of our findings, a
`descriptive analysis based on the least detectable
`diameter changes of the MCA was carried out. This
`assessment was based on the calculated diameter as
`described by Dahl et al. (18). The analysis was per-
`formed as a comparison (paired t-test) between pla-
`cebo and the highest dose of BIBN4096BS (10 mg)
`since the higher dose was the most likely to induce
`vasoactive changes. The 95% confidence interval
`was -5.4% to 3.5%, indicating that the study was
`powered to detect a vasocontriction larger than 5.4%
`and a vasodilatation larger than 3.5%.
`
`Adverse events and safety
`There were more adverse events after BIBN4096BS
`than after placebo. There seemed to be a dose-depen-
`dent trend towards increased drug related adverse
`events. However, all adverse events were mild or
`moderate and none lead to discontinuation of the
`infusion. Even 10 mg of BIBN4096BS, which is four
`times higher than the clinically effective dose (11),
`had no vasoactive effect, within the limitation of
`the study, in the cerebral or the extracerebral vascu-
`lar bed. This suggests cerebrovascular safety of
`CGRP-antagonism
`in
`the
`treatment of acute
`migraine.
`
`Acknowledgements
`The used technical equipment was partly sponsored by The
`Villum Kann Rasmussen Foundation, The Toyota Foundation,
`and The Simon Fougner Hartmann Foundation. A special
`thank to Lene Elkjær and Kirsten Bruunsgaard for excellent
`technical support and Dr Kirsten Kassøe for making every-
`thing work perfect. Boehringer Ingelheim sponsored the
`study and provided BIBN4096BS. The authors were indepen-
`dently responsible for the study design, data analysis and
`manuscript.
`
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