Where do monoclonal antibodies against the CGRP receptors fit into the treatment algorithm for patients with migraine?

VanderPluym et al report post-hoc analyses from 2 clinical trials to evaluate the effects of fremanezumab on patient’s functional status on their headache free days1. Neurology characterizes the evidence as level 2 that fremanezumab increases normal functional performance on headache free days. The results were robust to multiple functional measures and to both migraine subsets, episodic (8-14 days of headache per month) and chronic (>15 days of headache per month). The authors rightfully describe their findings as exploratory given that these results were not the pre-specified outcomes of these trials. They also point out that the increase in functional performance on headache free days might be just because of the increase in headache free days overall rather than any additional effect on function.

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Diabetic peripheral neuropathy pain and pharmacotherapy

Waldfogel et al performed a systematic review of pharmacotherapy for diabetic peripheral neuropathy pain. Similar to four previous systematic reviews, they conclude that serotonin reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and pregabalin are effective medications for this highly prevalent condition. In contrast to previous studies, they conclude that gabapentin is not effective while oxcarbazepine is effective.

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What data should be collected in ambulatory neurology clinics?

In Feasibility of the Collection of Patient-Reported Outcomes in an Ambulatory Neurology Clinic, Moura et al describe the collection of patient reported outcome measures (PROMS) including the modified Rankin Scale (mRS), quality of life in epilepsy (QOLIE), and the PROMIS-10 physical and mental health scores. PROMIS is an NIH-sponsored initiative to promote the use of methods and measures for collecting outcomes. Moura et al collected the information directly from patients using iPads in the waiting room of a large, academic neurology clinic, and almost half of the more than 6000 patients participated. The authors take the ‘glass-half-full’ interpretation that the 49% participation rate indicates that data collection is feasible. However, the ‘glass-half-empty’ interpretation should also be considered because 51% of the subjects either declined or could not participate. The study also demonstrates that patients with English as their preferred language, who were married, privately insured, and attended general neurology clinic were more likely to participate. The authors correctly point out the potential for vulnerable populations to be left out if measures to increase their participation are not used. However, the biggest question remains: what data should be collected in ambulatory neurology clinics? Just because we can collect this data does not mean that we should. The resources needed to start collecting this type of data and the effort from physicians to review and interpret them is not trivial. Small and single neurology practices will find this effort even more daunting. Prior to engaging in efforts to collect large amounts of data from our neurology patients, we must have confidence that the information will not lead us astray and that there is utility of this information. Are we collecting this data for clinical or research reasons? Does the data positively impact patient care? Unfortunately, there is much to learn, but Moura et al have provided an essential first step.

New Editors’ Perspective on Innovations in Care Delivery section

Healthcare innovations are frequently in the news and factors influencing care delivery are evolving at a fast pace. Most of what you hear though is not specific to neurology. The Innovations in Care Delivery section aims to fill this void. The initiation of this section by Bob Gross and Ray Dorsey demonstrates the commitment of the journal Neurology to publishing rigorous health services research aiming to describe, develop, test, implement, or evaluate the impact of the many organizational, behavioral, social, financial, and technological factors that influence neurologic care delivery, health, and well-being. Your submissions on these topics will be of strong interest here. This section also curates relevant articles, and utilizes blogs, podcasts, and interviews, to extend information and discussions on these important topics. The Innovations in Care Delivery section will also be a resource for collaboration and training. Soon, this site will maintain a list of data sources and persons experienced in using these. Available large databases create substantial opportunities for hypothesis generating research, and new discoveries about trends and the impact of healthcare delivery changes. Finally, we will work closely with the policy and practice sections of the American Academy of Neurology to keep you up-to-date on the most important issues regarding neurologic care delivery.