Oral Candidiasis in a Migraine Patient Taking Erenumab and Galcanezumab: a Case Report
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MEDICINE
Oral Candidiasis in a Migraine Patient Taking Erenumab and Galcanezumab: a Case Report Neal Joshi 1 & Michael McAree 1 & Katelyn Klimowich 1 & Kathleen Cahill 1 & Deanna Janora 1 Accepted: 17 April 2020 / Published online: 11 May 2020 # Springer Nature Switzerland AG 2020
Abstract Currently, there are three FDA-approved injectable calcitonin gene-related peptide (CGRP) antagonists, namely erenumab-aooe, galcanezumab-gnlm, and fremanezumab, all approved in 2018. There is no documented evidence of any fungal infections with these medications. We report a patient with oral candidiasis after administration of erenumab and galcanezumab for migraine headaches. Per the literature, the presence of candida stimulates sensory neural tissue to release CGRP, which then in turn leads to the signaling of dendritic cells to release vital cytokines such as interleukin-23 (IL-23) (Kashem et al. in Trends Immunol. 37(7):440–50, 2016). CGRP is involved in the cutaneous exposure to antigens, leading to its release and subsequent signaling pathway. The disruption of this cascade could lead to a decrease in the innate immune response to candida infection, thus leading to its proliferation. A 48-year-old female with a diagnosis of migraine headache presents with oral candidiasis after anti-CGRP medications, erenumab, and galcanezumab, an adverse effect not yet reported to our knowledge. Long-term anti-CGRP effects on human physiology are not yet understood due to the relatively novelty of these medications. We review the literature to support our proposition that CGRP is involved in antifungal immunity, and its antagonism incurs susceptibility to candidiasis. Keywords Candidiasis . Fungal immunity . Erenumab . Galcanezumab . Fremanezumab . Calcitonin gene-related peptide . CGRP . Migraine
Background Calcitonin gene-related peptide (CGRP) has been linked as a potential causative agent in the pathophysiology of the development of migraine headaches [1]. As a result, a new class of Neal Joshi and Michael McAree contributed equally to this work. This article is part of the Topical Collection on Medicine * Neal Joshi [email protected] Michael McAree [email protected] Katelyn Klimowich [email protected] Kathleen Cahill [email protected] Deanna Janora [email protected] 1
Rowan University School of Osteopathic Medicine Neuromuscular Institute, Stratford, NJ, USA
medications, the CGRP-receptor antagonist monoclonal antibodies, was developed [2]. There are currently three FDAapproved injectable CGRP antagonists, namely erenumaba o o e ( N o v a r t i s [ 3 ] ) , g a l c a n e z u m a b - g n l m ( Te v a Pharmaceuticals [4]), and fremanezumab (Eli Lilly and Company [5]) that were all approved in 2018. These medications are delivered via subcutaneous injection. The most common side effect of each of these drugs is injection site reaction and each medication carries the risk of a life-threatening allergic reaction to the medication itself or any of its ingredients. There is no documented evidence of oral candidiasis or other fungal
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