Melissa Laracy, PharmD Candidate, 2017

Migraine is the third most prevalent illness in the world, affecting 1 billion individuals worldwide.

Current medications available for migraines have varying efficacy and significant potential for adverse effects. Research is ongoing to develop safe, effective treatments.

A group of researchers conducted multiple studies exploring vitamin B deficiency as a contributor to migraines. Homocysteine is an amino acid that has been associated with an increased risk of several neurologic conditions, such as migraines. 

Vitamins B6, B9 (folic acid), and B12 are involved in homocysteine metabolism. Thus, the research team investigated the homocysteine-lowering effects of vitamin B supplementation and its subsequent effect on migraine control.

The researchers previously tested the effects of 2 mg folic acid, 25 mg vitamin B6, and 400 mcg vitamin B12 supplementation. They found that these doses significantly reduced homocysteine levels and migraine symptoms. Because 1 mg/day is the maximum recommended dose of folic acid, they wanted to determine whether that lower dose would be equally effective. 

 in June 2016, found that doses of 1 mg folic acid were less effective than 2 mg folic acid at reducing migraine symptoms. 

The researchers selected their trial population considering the fact that more than 70% of patients who experience migraines are females in their peak reproductive years (ages 25-55). The trial included Caucasian females between the ages of 18 and 60 years, with a 5-year history of migraines, a current diagnosis of migraine with aura, and a 1-year history of long-lasting attacks.

They randomly placed 200 patients on a daily regimen of 1 mg folic acid, 25 mg vitamin B6, and 400 mcg vitamin B12. They placed 100 patients on a placebo regimen. 

After 6 months, there was no significant reduction in homocysteine levels or migraine symptoms in the treatment group compared with the placebo group. This suggests that folic acid yields a dose-dependent reduction in homocysteine levels and migraine symptoms.

Further research is needed to determine the appropriate doses of folic acid and vitamins B6 and B12 for migraine treatment and prevention.

Articles

Migraine is the third most prevalent illness in the world, affecting 1 billion individuals worldwide.


Can Large Doses of Folic Acid Relieve Migraines?

HIV currently affects 1.2 million Americans and nearly 37 million individuals worldwide. 

As our understanding of HIV evolves and new treatments become available, HIV-infected individuals can live longer. This allows us to turn our attention to other infections in these patients. Between 2.5 and 5 million HIV-infected patients worldwide have a coinfection with hepatitis C (HCV). 

 published an article in its July 2016 supplement that discussed the management of HIV and HCV coinfections. The authors explained that recent data support HCV treatment as a priority in coinfected patients.

Antiretroviral therapy has drastically improved the lifespan of HIV-infected individuals. Liver disease currently accounts for 14% to 18% of all deaths among HIV-infected patients, making it the most common non-AIDS-related cause of death among these patients. 

Even in the absence of HCV, HIV-positive patients are at increased risk of liver disease. Several studies have provided evidence that HIV infection accelerates liver disease. However, the majority of liver disease cases in HIV-positive patients are secondary to HCV coinfection. 

HIV and HCV coinfection yields even greater risk for liver disease than either condition separately. One study revealed a 19.5% rate of cirrhosis in coinfected patients, compared with 11% in patients with HCV alone. 

Antiretroviral treatment for HIV is effective, but due to the risk of liver disease, clinicians must urge patients to also consider HCV treatment. A meta-analysis of 31 studies found that achieving sustained virologic response (SVR) for HCV yielded a 50% reduction in all-cause mortality.

HCV’s potential for rapid progression with an HIV coinfection increases the importance of prompt treatment. Approximately 33% of patients with HCV develop cirrhosis within 20 years. Coinfection increases this risk 3-fold. Studies testing rapid HCV treatment have yielded excellent results in both clinical trials and real-world applications.

The previous HCV standard of care consisted of interferon alfa-based therapies. Coinfected patients were unlikely to achieve SVR on these regimens alone. 

Direct-acting antivirals for HCV have drastically improved SVR rates and management of coinfections. Health care providers should treat HCV in coinfections the same way they treat HCV monoinfections. All treatment courses should be a minimum of 12 weeks.

Antiretroviral therapy should not be stopped during HCV treatment. As these regimens must be given concomitantly, practitioners need to be aware of the potential for drug-drug interactions:

Recommendations due to interaction(s) with HIV antiretrovirals

Only use with the following antiretrovirals: abacavir, emtricitabine, enfuvirtide, lamivudine, raltegravir, dolutegravir, rilpivirine, and tenofovir

Only use simeprevir with the following antiretrovirals: abacavir, emtricitabine, enfuvirtide, lamivudine, maraviroc, raltegravir, dolutegravir, rilpivirine, and tenofovir

Can be used with most antiretrovirals, but not efavirenz or etravirine

As velpatasvir increases tenofovir levels, recommend baseline and ongoing assessment for tenofovir nephrotoxicity