Fremanezumab for preventing migraine

Overview

In Bradford, people affected by complex migraine, beyond what can be managed by their own GP practice, are diagnosed and manged in a primary care neurology service by GPs with an extended reach (GPwERs) in headache. This service has reduced unnecessary referrals into secondary care. When new specialist migraine treatments were approved by NICE, we wanted to use our clinical expertise within the community neurology service to prescribe these medications as per NICE guidelines without the need to refer eligible patients into secondary care. This was to avoid strain on an already overstretched secondary care service, utilise local expertise in headache care, and to avoid unnecessary wait times for patients already managed in a specialist service.

A distinct advantage of management in a primary care service is that the prescribing clinician has access to the whole clinical record. This means that specialist treatment can be strictly offered only to patients meeting NICE eligibility criteria, as we are able to see the doses and duration of first-line migraine treatments that have already been tried.

One challenge to utilising the injectable CGRP monoclonal antibody (mAb) receptor antagonists fremanezumab, erenumab and galcanezumab was the requirement that these medications are prescribed according to the 'commercial arrangement'. This requires involvement of a pharmaceutical industry supported home care company to deliver the medication to the patient. We needed support from the trust pharmacy team who had well established working relationships with these companies, as this was beyond our capacity and expertise in primary care.

A second challenge was the need for a 'wet signature' on the prescription. This precludes the option to send digital prescriptions.

With support from the integrated care board, and agreement from the trust pharmacy team and neurology service, we developed a pathway for sending prescriptions from our GPwERs to the hospital home care pharmacy service, and then to the home care companies. Our patients are now able to receive CGRP mAbs as per NICE guidance and remain cared for in a primary care setting.

We have developed an integrated digital process within our clinical system for completing the counselling and the 3 necessary forms.

Patients who meet eligibility criteria for rimegepant or atogepant can have their prescriptions issued directly by our service as there is no requirement for prescribing according to a commercial agreement or a wet signature.