Triptans in the treatment of migraine: drug selection by means of the SOJA method

Multi-indication Pharmacotherapeutic Multicriteria Decision Analytic Model for the Comparative Formulary Inclusion of Proton Pump Inhibitors in Qatar

PURPOSE

The formulary inclusion of proton pump inhibitors (PPIs) in the government hospital health services in Qatar is not comparative or restricted. Requests to include a PPI in the formulary are typically accepted if evidence of efficacy and tolerability is presented. There are no literature reports of a PPI scoring model that is based on comparatively weighted multiple indications and no reports of PPI selection in Qatar or the Middle East. This study aims to compare first-line use of the PPIs that exist in Qatar. The economic effect of the study recommendations was also quantified.

METHODS

A comparative, evidence-based multicriteria decision analysis (MCDA) model was constructed to follow the multiple indications and pharmacotherapeutic criteria of PPIs. Literature and an expert panel informed the selection criteria of PPIs. Input from the relevant local clinician population steered the relative weighting of selection criteria. Comparatively scored PPIs, exceeding a defined score threshold, were recommended for selection.

FINDINGS

Weighted model scores were successfully developed, with 95% CI and 5% margin of error. The model comprised 7 main criteria and 38 subcriteria. Main criteria are indication, dosage frequency, treatment duration, best published evidence, available formulations, drug interactions, and pharmacokinetic and pharmacodynamic properties. Most weight was achieved for the indications selection criteria. Esomeprazole and rabeprazole were suggested as formulary options, followed by lansoprazole for nonformulary use. The estimated effect of the study recommendations was up to a 15.3% reduction in the annual PPI expenditure. Robustness of study conclusions against variabilities in study inputs was confirmed via sensitivity analyses.

IMPLICATIONS

The implementation of a locally developed PPI-specific comparative MCDA scoring model, which is multiweighted indication and criteria based, into the Qatari formulary selection practices is a successful evidence-based cost-cutting exercise. Esomeprazole and rabeprazole should be the first-line choice from among the PPIs available at the Qatari government hospital health services.

National Drug Formulary review of statin therapeutic group using the multiattribute scoring tool

PURPOSE

HMG-CoA reductase inhibitors (statins) are extensively used in treating hypercholesterolemia. The statins available in Malaysia include atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, and fluvastatin. Over the years, they have accumulated in the National Drug Formulary; hence, the need for review. Effective selection of the best drugs to remain in the formulary can become complex due to the multiple drug attributes involved, and is made worse by the limited time and resources available. The multiattribute scoring tool (MAST) systematizes the evaluation of the drug attributes to facilitate the drug selection process. In this study, a MAST framework was developed to rank the statins based on their utilities or benefits.

METHODS

Published literature on multicriteria decision analysis (MCDA) were studied and five sessions of expert group discussions were conducted to build the MAST framework and to review the evidence. The attributes identified and selected for analysis were efficacy (clinical efficacy, clinical endpoints), safety (drug interactions, serious side effects and documentation), drug applicability (drug strength/formulation, indications, dose frequency, side effects, food-drug interactions, and dose adjustments), and cost. The average weights assigned by the members for efficacy, safety, drug applicability and cost were 32.6%, 26.2%, 24.1%, and 17.1%, respectively. The utility values of the attributes were scored based on the published evidence or/and agreements during the group discussions. The attribute scores were added up to provide the total utility score.

RESULTS

Using the MAST, the six statins under review were successfully scored and ranked. Atorvastatin scored the highest total utility score (TUS) of 84.48, followed by simvastatin (83.11). Atorvastatin and simvastatin scored consistently high, even before drug costs were included. The low scores on the side effects for atorvastatin were compensated for by the higher scores on the clinical endpoints resulting in a higher TUS for atorvastatin. Fluvastatin recorded the lowest TUS.

CONCLUSION

The multiattribute scoring tool was successfully applied to organize decision variables in reviewing statins for the formulary. Based on the TUS, atorvastatin is recommended to remain in the formulary and be considered as first-line in the treatment of hypercholesterolemia.

Almotriptan: a review of 10 years' clinical experience

Almotriptan, a serotonin 5-HT 1B/1D agonist, was developed for the acute treatment of migraine with or without aura and has been available for 10 years. This article evaluates the wealth of experience that has been obtained with almotriptan, including large randomized clinical trials (RCTs) and post-marketing studies that more closely reflect everyday clinical practice. Initial RCTs required patients to take almotriptan when migraine pain was of moderate or severe intensity, and found that 12.5 mg provided optimal outcomes for both pain relief and tolerability. Almotriptan effectively improved 2-h pain-relief, reduced migraine-associated symptoms and demonstrated low recurrence rates. These findings were also shown in patient subgroups, such as adolescents and menstrual migraineurs. A secondary finding in these trials was that patients who took almotriptan early, when the pain was still mild, achieved better outcomes. This prompted the initiation of studies designed to assess the effect of almotriptan in early intervention. Open-label trials reported improvements in pain-free end points (2 h, 24 h), and subsequent RCTs confirmed these findings. Pharmacovigilance data from more than 100 million tablets dispensed worldwide have confirmed that almotriptan is associated with a low occurrence of adverse effects, which, in clinical trials, has been shown to be similar to that observed with placebo. The clinical evidence obtained and comparisons made over a decade of use have demonstrated that almotriptan is one of the more effective and fast-acting triptans available, with a placebo-like tolerability profile. This suggests that almotriptan is an excellent choice for patients requiring specific acute migraine treatment.

Almotriptan for the treatment of acute migraine: a review of early intervention trials

Almotriptan is a serotonin (5-hydroxytryptamine)(1B/1D) receptor agonist (triptan) that has shown consistent efficacy in the acute treatment of migraine with excellent tolerability. It is an effective, well-tolerated and cost-effective triptan, as demonstrated by improvement in rigorous, patient-orientated end points, such as 'sustained pain-free without adverse events'. Results from post hoc analyses, observational studies and well-controlled, prospective clinical trials have shown that significant improvements can be achieved if almotriptan 12.5 mg is administered within an hour of migraine onset, particularly when pain is mild, rather than waiting until pain is moderate-to-severe. Benefits were also achieved with early treatment of moderate-to-severe pain. Time-to-treatment was the best predictor of headache duration, whereas initial headache intensity best predicted most other efficacy outcomes. Early administration of almotriptan 12.5 mg not only produced rapid symptomatic relief, it also improved the patient's quality of life and ability to resume normal daily functioning. Furthermore, the efficacy of almotriptan is not significantly affected by allodynia (purported to reduce the efficacy of triptans). Thus, the excellent efficacy and tolerability profile of almotriptan administered early in a migraine attack indicate that it may be a first-line treatment option in this common, underdiagnosed and undertreated disorder.

Application of SOJA and InforMatrix in practice: interactive web and workshop tools

System of Objectified Judgement Analysis (SOJA) and InforMatrix are decision-matrix techniques designed to support a rational selection of drugs. Both SOJA and InforMatrix can be considered as strategic tools in the practical implementation of rational pharmacotherapy. In order to apply the matrix techniques to drug selection, strategic navigation through essential information (with the aim of reaching consensus in pharmacotherapy) is required. The consensus has to be reached in an interactive, communicative, collegial manner, within a professional environment. This environment is realised in the form of interactive applications in workshops and on the internet. Such interactive applications are illustrated and discussed in this article.