Cost-effectiveness analysis of rizatriptan and sumatriptan versus Cafergot in the acute treatment of migraine

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Cost analysis of migraine pharmacotherapy with selective 5HT1 receptor agonists in Ukraine

The cost analysis for the relief of migraine attack using selective 5HT1-receptor agonists (frovatriptan, zolmitriptan, risatriptan, sumatriptan) of domestic and imported manufacturers in various dosages and forms of production in the proposed resource online pharmacy chains of Lviv for their efficient and cost effective applications. Among the registered drugs, most dosage forms and trade names are presented for sumatriptan; slightly less for risatriptan and zolmitriptan; for frovatriptan is only one trade name. It has been found that to relieve migraine attack with domestic drugs will be cheaper for patients than imported. Packaging with the same dosage of active ingredient, but with more tablets in the blister is more cost effective for patients. It`s the most economical to stop the migraine attack with Stopmigren (sumatriptan) at a dosage of 50 mg, packing 6 tablets in a blister, and the most valuable drug is Rapimig (zolmitriptan) at a dosage of 50 mg, packing 6 tablets in a blister.

Cost-effectiveness analysis of early versus non-early intervention in acute migraine based on evidence from the 'Act when Mild' study

BACKGROUND

In spite of the important progress made in the abortive treatment of acute migraine episodes since the introduction of triptans, reduction of pain and associated symptoms is in many cases still not as effective nor as fast as would be desirable. Recent research pays more attention to the timing of the treatment, and taking triptans early in the course of an attack when pain is still mild has been found more efficacious than the usual strategy of waiting for the attack to develop to a higher pain intensity level.

OBJECTIVE

To investigate the cost effectiveness of early versus non-early intervention with almotriptan in acute migraine.

METHODS

An economic evaluation was conducted from the perspectives of French society and the French public health system based on patient-level data collected in the AwM (Act when Mild) study, a placebo-controlled trial that compared the response to early and non-early treatment of acute migraine with almotriptan. Incremental cost-effectiveness ratios (ICERs) were determined in terms of QALYs, migraine hours and productive time lost. Costs were expressed in Euros (year 2010 values). Bootstrapping was used to derive cost-effectiveness acceptability curves.

RESULTS

Early treatment has shown to lead to shorter attack duration, less productive time lost, better quality of life, and is, with 92% probability, overall cost saving from a societal point of view. In terms of drug costs only, however, non-early treatment is less expensive. From the public health system perspective, the (bootstrap) mean ICER of early treatment amounts to €0.38 per migraine hour avoided, €1.29 per hour of productive time lost avoided, and €14,296 per QALY gained. Considering willingness-to-pay values of approximately €1 to avoid an hour of migraine, €10 to avoid the loss of a productive hour, or €30,000 to gain one QALY, the approximate probability that early treatment is cost effective is 90%, 90% and 70%, respectively. These results remain robust in different scenarios for the major elements of the economic evaluation.

CONCLUSIONS

Compared with non-early treatment, a strategy of early treatment of acute migraine with almotriptan when pain is still mild is, with high probability, cost saving from the French societal perspective and can be considered cost effective from the public health system point of view.

Sponsorship-related outcome selection bias in published economic studies of triptans: systematic review

BACKGROUND

Economic studies funded by the pharmaceutical industry are more likely to report favorable results and recommendations for the sponsor's product than are studies funded by nonindustry establishments.

PURPOSE

To determine whether clinical outcome data obtained from the same meta-analyses are used differently in various economic studies of oral triptans and whether there is an association between the study sponsorship and the choice of clinical outcome measure.

DATA SOURCES

Economic studies of triptans were identified by updating a previously published systematic review.

STUDY SELECTION

Twelve studies that used the same meta-analyses as the source of clinical outcome data were identified.

DATA EXTRACTION

Two independent reviewers extracted the essential data from the identified studies.

DATA SYNTHESIS

In the 12 appraised studies, 9 alternative measures of effectiveness were derived from the same meta-analyses. Eleven studies were industry-related, and in these the selected clinical outcome consistently favored the sponsor's product. Also the reported results suggested that the sponsor's product was more cost-effective than the competitors' products.

LIMITATIONS

The cost-effectiveness of triptans is dependent on both the definition of clinical effectiveness and the treatment-related costs. Only bias related to the selection of the clinical outcome measure has been taken into account in this review.

CONCLUSIONS

The results of published economic studies of triptans are conflicting and biased. There is a tendency to select clinical outcome measures that support the sponsor's product. This leads to concern about the possible poor applicability of these results in decision making.

Cost effectiveness of pharmacotherapy for the prevention of migraine: a Markov model application

BACKGROUND

There are few data about the cost effectiveness of prophylactic medications for migraine. Clinical trials have shown several preventive agents to be useful in reducing the frequency of migraine attack while having tolerable side effects.

OBJECTIVE

To compare the cost effectiveness of adding preventive treatment to abortive therapy for acute migraine with abortive therapy for acute migraine alone in the primary care setting.

METHODS

A Markov decision analytic model with a cycle length of 1 day, a time horizon of 365 days and three health states was used to perform an analysis comparing the cost effectiveness and utility of five treatments for migraine prophylaxis (amitriptyline 75 mg/day, topiramate 100 and 200 mg/day, timolol 20 mg/day, divalproex sodium 1000 mg/day or propranolol 160 mg/day) with treatment of acute migraine alone for the management of migraine in the primary care setting. One-way and probabilistic sensitivity analyses were performed to test the robustness of the results.

RESULTS

The expected total annual cost for the use of preventive agents ranged from $US2932 to $US3887, compared with $US3960 for the use of abortive medications only. In the baseline analysis, use of each of the five preventive agents generated more quality-adjusted life-years (QALYs) and incurred lower costs compared with abortive medications only. Monte Carlo Simulation suggested that amitriptyline 75 mg/day was most likely to be considered a cost-effective option versus the other five therapies, followed by timolol 20 mg/day, topiramate 200 mg/day, topiramate 100 mg/day, divalproex sodium 1000 mg/day and propranolol 160 mg/day when the willingness-to-pay (WTP) for society is <$US18 000 per QALY gained.

CONCLUSIONS

Preventive medications appear to be a cost-effective approach to the management of migraine in the primary care setting compared with the approach of abortive treatment only. Among those preventive agents, probabilistic sensitivity analysis suggests that, when the societal WTP is <$US18 000 per QALY gained, amitriptyline 75 mg/day is most likely to be considered a cost-effective option.

Economic evaluation of pharmacotherapy of migraine pain: a review of the literature

This paper reviews the economic evaluation literature on pharmacotherapy for migraine and identifies important trends and gaps in the literature. Given the tremendous economic burden of migraine and the availability of various therapies for migraine treatment, economic evaluation of alternative therapies plays a critical role in identifying the most cost-effective therapy to optimize health care resource allocation and clinical decisions. Particularly, physicians and clinical administrators are expected to take an active role in resource allocation decisions at the clinical level. Thus, it is important for them to be familiar with the economic evaluation in migraine pain management, and most importantly, methodologies of economic analyses and the associated shortcomings of published estimates. In this paper, the methodological characteristics of these studies are examined and their results are compared and interpreted. Alternative treatment and health outcome measures are defined and data sources described while methods for assessing the direct and indirect costs are explored. Directions for future research are identified and discussed.

The burden of migraine in the United States: current and emerging perspectives on disease management and economic analysis

OBJECTIVES

Migraine is often perceived as a low-impact condition that imposes a limited burden to society and the health-care system. This study reviews the current understanding of the burden of migraine in the U.S., the history of economic understanding of migraine treatment and identifies emergent trends for future studies evaluating clinical and economic outcomes of migraine treatment.

METHODS

This study traced the history of economic articles published on migraine by performing a literature search using PubMed MEDLINE database and ancestral searches of relevant articles. The intention was not to provide an exhaustive review of every article or adjudicate between studies with different findings.

RESULTS

Migraine affects millions of individuals worldwide, generally during the most productive years of a person's life. Studies show that migraineurs are underdiagnosed, undertreated, and experience substantial decreases in functioning and productivity, which in turn translates into diminished quality of life for individuals, and financial burdens to both health-care systems and employers. Economic evaluations of migraine therapies have evolved with new clinical developments beginning with cognitive-behavioral therapy, introduction of triptans, concern over medication overuse, and emergence of migraine prophylaxis. Now recent clinical studies suggest that migraine may be a progressive disease with cardiovascular, cerebrovascular, and long-term neurologic effects.

CONCLUSIONS

Migraine imposes a substantial burden on patients, families, employers and societies. The economic standards by which migraine and treatment are evaluated have evolved in response to clinical developments. Emerging evidence suggests that migraine is a chronic and progressive disease. If confirmed, approaches to acute and prophylactic treatments and economic evaluations of migraine treatment may require major reconsideration.

Rizatriptan in the treatment of migraine

Migraine is a common, disabling disorder associated with considerable personal and societal burden. Current guidelines recommend triptans for the acute treatment of migraine unlikely to respond to less effective therapies. Rizatriptan is a second-generation triptan available in tablet or orally disintegrating tablet (wafer) formulations that offers several advantages over other members of its class. Rizatriptan is rapidly absorbed from the gastrointestinal tract and achieves maximum plasma concentrations more quickly than other triptans, providing rapid pain relief. Clinical trials have shown that rizatriptan is at least as effective or superior to other oral migraine-specific agents in the acute treatment of migraine, and has more consistent long-term efficacy across multiple migraine attacks. Rizatriptan has a favorable tolerability profile, and patients have reported greater satisfaction and a preference for rizatriptan over other migraine-specific agents. Improvements in quality of life reported with rizatriptan are consistent with its favorable efficacy and tolerability profiles. Notably, multi-attribute decision models that combine clinical data with patient- and physician-reported treatment preferences have identified rizatriptan as one of three triptans closest to a hypothetical "ideal". The efficacy and tolerability of rizatriptan for the acute treatment of migraine have thus been well established.

Rizatriptan: a pharmacoeconomic review of its use in the acute treatment of migraine

Rizatriptan (Maxalt; Maxalt-MLT; Maxalt-Melt) is an oral serotonin 5-HT(1B/1D) receptor agonist (triptan) used in the acute treatment of migraine with or without aura in adults. Rizatriptan 5 mg and 10 mg are effective in relieving the symptoms of migraine and the 10 mg dose provided faster pain relief than sumatriptan 50 mg, naratriptan 2.5 mg, ergotamine/caffeine 2 mg/200 mg and possibly zolmitriptan 2.5 mg, while displaying similar tolerability. Two cost-utility analyses performed from a societal perspective indicated that rizatriptan 10 mg was dominant over ergotamine/caffeine 2 mg/200 mg, sumatriptan 50 mg or 100 mg, naratriptan 2.5 mg, zolmitriptan 2.5 mg and analgesic-based usual care in the acute treatment of migraine. In one analysis also performed from the perspective of a healthcare payer, rizatriptan was still dominant over naratriptan, sumatriptan and zolmitriptan. Rizatriptan was cost effective compared with usual care with an incremental cost per quality-adjusted life-year (QALY) gained of 31,845 Can dollars (2002 values) and an incremental cost per additional attack aborted of 49.82 Can dollars. A modelled cost-effectiveness analysis conducted from a healthcare payer's perspective indicated that almotriptan 12.5 mg was more cost effective than rizatriptan 10 mg as a result of better tolerability. The incremental cost per additional successfully treated patient (defined as being sustained pain free without adverse events) with almotriptan was 6.94 US dollars (1999 values). In other nonmodelled cost-effectiveness analyses, rizatriptan 10 mg, eletriptan 40 mg and almotriptan 12.5 mg most consistently displayed the greatest cost effectiveness in different analyses using different clinical endpoints. A modelled analysis of the costs of migraine-related productivity losses in US corporations indicated that the use of rizatriptan rather than usual care to treat migraines could result in annual cost offsets of approximately 84-118 US dollars (2000 values) per employee in lost productivity avoided. An intervention study in Spanish postal service workers demonstrated that replacement of usual care with rizatriptan reduced the mean per-patient cost of lost productivity per migraine attack from 34.47 euros (2001/2002 values) before the intervention to 13.94 euros and 4.59 euros for the first and second post-intervention migraine attacks. In conclusion, rizatriptan is one of the more clinically effective and therefore cost-effective oral triptans available for the acute treatment of migraine. The available data from cost-utility analyses suggest that rizatriptan is more cost effective than ergotamine/caffeine, simple analgesics, naratriptan, zolmitriptan and sumatriptan. The economic value of rizatriptan depends on the payer's perspective, as the greatest savings can be expected to be achieved in terms of reduced migraine-related loss of work productivity compared with less effective treatments. For healthcare payers, the high acquisition cost appears to be at least partly offset by reduced migraine-related healthcare resource use when compared with usual care. The comparative cost effectiveness of the newer triptans requires further elucidation from comprehensive direct comparisons.