Cost-effectiveness of rimegepant oral lyophilisate compared to best supportive care for the acute treatment of migraine in the UK

AIMS

Migraine is the most common disabling headache disorder and is characterized by recurrent throbbing head pain and symptoms of photophobia, phonophobia, nausea, and vomiting. Rimegepant 75 mg, an oral lyophilisate calcitonin gene-related peptide antagonist, is the first treatment approved for both the acute and preventative treatment of migraine, and the first acute therapy approved in over 20-years. The objective was to assess the cost-utility of rimegepant compared with best supportive care (BSC) in the UK, for the acute treatment of migraine in the adults with inadequate symptom relief after taking at least 2 triptans, or for whom triptans are contraindicated or not tolerated.

MATERIALS AND METHODS

A de novo model was developed to estimate incremental costs and quality-adjusted life years (QALYs), structured as a decision tree followed by Markov model. Patients received rimegepant or BSC for a migraine attack and were assessed for response (pain relief at 2-h). Responders and non-responders followed different pain trajectories over 48-h cycles. Non-responders discontinued treatment while responders continued treatment for subsequent attacks, with a proportion discontinuing over time. Data sources included a post-hoc pooled analysis of the phase 3 acute rimegepant trials (NCT03235479, NCT03237845, NCT03461757), and a long-term safety study (NCT03266588). The analysis was conducted from the perspective of the UK National Health Service and Personal Social Services over a 20-year time horizon.

RESULTS

Rimegepant resulted in an incremental cost-utility ratio (ICUR) of £10,309 per QALY gained vs BSC, which is cost-effectiveness at a willingness to pay threshold of £30,000/QALY. Rimegepant generated +0.44 incremental QALYs and higher incremental lifetime costs (£4,492). Improved QALYs for rimegepant were a result of less time spent with severe and moderate headache pain.

CONCLUSION

This study highlights the economic value of rimegepant which was found to be cost-effective for the acute treatment of migraine in adults unsuitable for triptans.

Health State Utility Mapping of Rimegepant for the Preventive Treatment of Migraine: Double-Blind Treatment Phase and Open Label Extension (BHV3000-305)

INTRODUCTION

The objectives of this study were to (1) report long-term health-related quality of life (HRQoL) outcomes among patients using rimegepant preventatively in BHV3000-305 (NCT03732638) open-label extension (OLE) and (2) map Migraine-Specific Quality of Life questionnaire version 2.1 (MSQv2) to EQ-5D-3L utility values over the double-blind treatment (DBT; 0-12 weeks) and the OLE (13-64 weeks) to assess the influence of treatment on these values.

METHODS

This was a post hoc analysis using data from a rimegepant study for the prevention of migraine (BHV3000-305). Adult patients with migraine took either rimegepant 75 mg or placebo every other day (EOD) during the DBT phase. All patients received rimegepant during the OLE. MSQv2 was measured at baseline, weeks 12, 24, and 64. A validated algorithm was used to map MSQv2 scores to EQ-5D utilities.

RESULTS

Baseline data were available for 347 patients treated with placebo and 348 treated with rimegepant in the DBT period, who continued to the OLE. Baseline EQ-5D utilities were similar between trial arms: 0.598 for placebo and 0.614 for rimegepant. EQ-5D improved from baseline to week 12 and utilities increased by + 0.09 for placebo and + 0.10 for rimegepant (p value = 0.011). By 24 weeks, at which point patients who were originally randomized to placebo had received rimegepant 75 mg EOD for 12 weeks, HRQoL measures (MSQv2 and EQ-5D) were similar across groups, demonstrating rapid onset of treatment effect. This HRQoL improvement was durable out to 64 weeks.

CONCLUSION

Compared to placebo, treatment with rimegepant 75 mg was associated with greater improvement in EQ-5D utilities during the 12-week DBT phase. Patients originally randomized to placebo experienced a similar improvement in EQ-5D utilities after switching to rimegepant during the OLE, demonstrating that benefits are realized within 12 weeks of active treatment. This preventive effect was durable out to 64 weeks and was associated with an additional increase in HRQoL over time.

TRIAL REGISTRATION

NCT03732638.

Frequency and age at occurrence of clinical manifestations of disease in patients with hypophosphatasia: a systematic literature review

Background

Hypophosphatasia (HPP) is a rare, inherited, metabolic disease caused by tissue-nonspecific alkaline phosphatase deficiency, characterized by bone mineralization defects and systemic complications. Understanding of the clinical course and burden of HPP is limited by its rarity. This systematic literature review and synthesis of case report data aimed to determine the frequency and timing of clinical HPP manifestations and events.

Methods

Case reports and series of patients with HPP who had been followed longitudinally for ≥1 year were identified. Demographics and clinical data of interest, identified through consultation with clinical experts in HPP, were extracted. Occurrences of clinical manifestations/events of interest were categorized, classified by age at first reported occurrence of HPP manifestations and visualized over time. Clinical manifestations/events considered to contribute to the clinical burden of HPP were identified. Kaplan–Meier curves were used to estimate the median (range) age at first occurrence of the most frequently reported manifestations/events.

Results

From the 283 studies that met the inclusion criteria, 265 patients with HPP with ≥1 year of longitudinal follow-up were identified (median [interquartile range] age 4 [0–34] years; 45% male). The types of clinical manifestations/events of interest experienced by individuals with ≥1 such manifestation/event (n = 261) often differed between older and younger patients. Most (94%) of the 265 patients experienced ≥1 manifestation/event deemed to contribute to the clinical burden of HPP; premature tooth loss (53.5%), fractures (35.8%), pain (33.6%), and gross motor/ambulation difficulties (30.9%) were most frequently reported. The median (range) age at first reported occurrence of respiratory symptoms, cranial abnormalities, and premature tooth loss ranged from 0.3 to 10 years, whereas the median age at first reported occurrence of fractures, pain, gross motor/ambulation difficulties, and surgery ranged from 33 to 70 years.

Conclusions

HPP is associated with a high clinical burden of disease, regardless of age at first reported occurrence of HPP manifestations. Over an individual’s lifetime, the types of manifestations/events experienced can change and multiple HPP-related clinical manifestations/events can accumulate. These observations may reflect evolution and progression of the disease.

Electronic supplementary material

The online version of this article (10.1186/s13023-019-1062-0) contains supplementary material, which is available to authorized users.

The burden of treatment-resistant depression: A systematic review of the economic and quality of life literature

BACKGROUND

Major depressive disorder (MDD) is a global public health concern. In particular, treatment-resistant depression (TRD) represents a key unmet need in the management of MDD. A systematic review of the epidemiological and economic literature on the burden associated with an increasing number of treatment steps due to TRD/non-response within an MDD episode was performed to quantify the burden of TRD.

METHODS

Studies were identified in the PubMed/Medline databases through April 27th, 2017. Articles were limited to full-length peer-reviewed journal publications with no date restrictions. Economic and patient health-related quality of life (HRQoL) data on non-response by the number of treatment steps were quantified and, where appropriate, compared across studies; otherwise, comparative data within studies were reported.

RESULTS

The 12 studies on economic burden found an association between increasing levels of TRD/non-response and elevations in direct and indirect costs. Likewise, the 19 studies studying HRQoL burden found that increasing levels of TRD/non-response correlated with reduced patient HRQoL and health status.

LIMITATIONS

TRD is defined inconsistently, which results in notable heterogeneity between published studies and poses methodological challenges for between-study comparisons. It is unknown if the increased economic and patient HRQoL burden are due to factors associated with TRD/non-response in addition to those due to depression persistence or severity.

CONCLUSIONS

A consistent trend was observed such that medical costs increased and patient HRQoL and health status decreased by increasing level of TRD/non-response within an MDD episode. These findings highlight the need for improved therapies for TRD to help reduce disease burden.

An in vitro study of alginate oligomer therapies on oral biofilms

OBJECTIVES

The in vitro effect of a novel, oligosaccharide nanomedicine OligoG against oral pathogen-related biofilms, both alone and in the presence of the conventional anti-bacterial agent triclosan, was evaluated.

METHODS

The effect of OligoG±triclosan was assessed against established Streptococcus mutans and Porphyromonas gingivalis biofilms by bacterial counts and image analysis using LIVE/DEAD(®) staining and atomic force microscopy (AFM). The effect of triclosan and OligoG surface pre-treatments on bacterial attachment to titanium and polymethylmethacrylate was also studied.

RESULTS

OligoG potentiated the antimicrobial effect of triclosan, particularly when used in combination at 0.3% against S. mutans grown in artificial saliva. OligoG was less effective against established P. gingivalis biofilms. However, attachment of P. gingivalis, to titanium in particular, was significantly reduced after surface pre-treatment with OligoG and triclosan at 0.01% when compared to controls. Light microscopy and AFM showed that OligoG was biocidal to P. gingivalis, but not S. mutans.

CONCLUSIONS

OligoG and triclosan when used in combination produced an enhanced antimicrobial effect against two important oral pathogens and reduced bacterial attachment to dental materials such as titanium, even at reduced triclosan concentrations. Whilst the use of triclosan against oral bacteria has been widely documented, its synergistic use with OligoG described here, has not previously been reported. The use of lower concentrations of triclosan, if used in combination therapy with OligoG, could have environmental benefits.

CLINICAL IMPORTANCE

The potentiation of antimicrobial agents by naturally occurring oligomers such as OligoG may represent a novel, safe adjunct to conventional oral hygiene and periodontal therapy. The ability of OligoG to inhibit the growth and impair bacterial adherence highlights its potential in the management of peri-implantitis.

Antioxidant capacity of lycopene-containing foods

Increased consumption of tomatoes and tomato products has been associated with decreased cancer risks. One fat-soluble compound identified in tomatoes which may be responsible for this association is lycopene. There may, however, be other antioxidants present in tomato-based foods, and total antioxidant capacity may be another way to rate the health benefits of these foods. In this work, we examined the Trolox-equivalent antioxidant capacity (TEAC) of aqueous and organic extracts of lycopene-containing foods: ketchup, fresh tomatoes, tomato paste, tomato sauce, tomato soup, tomato juice, vegetable juice, canned tomatoes and watermelon. Antioxidant activity in these food extracts was greater in the aqueous versus organic fractions, except for watermelon and tomato sauce where the levels were similar in the two fractions. Lycopene levels in the food samples tested, however, were relatively greater in the organic fractions, with the exception of the two juices, which had similar levels in the two fractions, and two highly concentrated tomato products, tomato paste and ketchup, which had relatively higher lycopene levels in the aqueous fractions. The foods with the highest antioxidant capacity per serving overall (tomato soup was highest) did not have the highest lycopene levels. This indicates that it may be important to consume a variety of tomato-containing products in order to obtain the largest variety of dietary antioxidants possible.

Seminal plasma trace metal levels in industrial workers

This study compares the seminal plasma trace metal levels of hospital workers with groups of industrial workers in a petroleum refinery, smelter, and chemical plant. The metals measured were the essential metals (copper, zinc, nickel, cobalt, and manganese) and the toxic metals (lead, cadmium, and aluminum). The group mean +/- SE metal level for each group (50 subjects per group) was calculated, and the statistical significance of the group mean differences of the industrial groups with the hospital group (control) was determined by the Student's t-test. The differences observed in the smelter group were increased copper and zinc (p < or = 0.001) and decreased nickel, cobalt, and manganese (p < or = 0.001, < or = 0.01). The refinery group differences were increased copper, zinc, and nickel (p < or = 0.001) but decreased cobalt and manganese (p < or = 0.001). The chemical group differences were increased zinc (p < or = 0.001) and decreased cobalt (p < or = 0.001). The seminal plasma levels of the toxic metals lead and aluminum were increased in each of the industrial groups (p < or = 0.001). Concurrent differences were (1) decreased accumulation of nickel, cobalt, and manganese in the smelter group, (2) decreased cobalt and manganese in the refinery group, and (3) only decreased cobalt in the chemical group.

Comparison of sperm viability with seminal plasma metal levels

This study compares the semen levels of lead (Pb), cadmium (Cd), and aluminum (Al) in relation to live sperm in semen samples from 64 apparently healthy men. The measured levels were separated into live sperm count tertiles (<25% [18 subjects], 25-50% [26 subjects], and >50% [20 subjects]). The mean +/- SD for each group was calculated, and the difference between the means of the high and low tertiles were compared by ANOVA. Significant differences were observed between the high and low live sperm groups for Pb (p < 0.01) and Al (p < 0.05), but not Cd. Spearman's rank correlation between sperm viability and the semen plasma metal levels showed a direct relation to Mg (p < 0.05). However, there was an inverse relation to lead (p < 0.001), cadmium (p < 0.01), and aluminum (p < 0.01). There was no significant correlation between Ca and Zn. Linear regression between the live sperm counts and semen level of the three metals show that metal levels were inversely correlated with the percentage of live sperm (p < 0.001, < 0.01). Apparently, the presence of these metals in the environment and in seminal plasma exerts a toxic effect on sperm.

Effect of ascorbic acid supplementation on the sperm quality of smokers

OBJECTIVE

To determine the effect of ascorbic acid supplementation on the sperm quality of heavy smokers.

DESIGN

Microscopic examination of semen for 1 month during supplementation with placebo or ascorbic acid at dose levels of 200 or 1,000 mg/d.

SETTING

Department of Obstetrics and Gynecology, The University of Texas Medical Branch.

PARTICIPANTS

Seventy-five men (20 to 35 years old) randomly divided into one of three supplementation groups: placebo, 200 mg and 1,000 mg of ascorbic acid.

MAIN OUTCOME

Improvement in sperm quality as compared with presupplementation levels and between the three treatment groups.

RESULTS

The placebo group showed no improvement in sperm quality. The groups receiving ascorbic acid showed improvement in sperm quality with most improvement in the 1,000-mg group. Pearson's correlation showed statistically significant relationships between the weekly group means of serum and seminal plasma ascorbic acid levels and sperm qualities.

CONCLUSIONS

Ascorbic acid supplementation of heavy smokers in excess of 200 mg/d results in improved sperm quality.

Simultaneously occurring condylomata acuminata, carcinoma in situ and verrucous carcinoma of the vulva and carcinoma in situ of the cervix in a young woman. A case report

A case of simultaneously occurring condylomata acuminata, carcinoma in situ and verrucous carcinoma of the vulva and carcinoma in situ of the cervix was seen in a 26-year-old woman. In situ DNA hybridization on sections of the condyloma acuminata and verrucous carcinoma yielded DNA sequences for human papillomavirus 6.

Carcinoma in situ of the vulva. A clinicopathologic study of 50 cases

The authors reviewed 50 cases of carcinoma in situ of the vulva treated at the University of Texas Medical Branch, Galveston, from 1975 to 1984. Sixty-two percent of the patients were premenopausal. The most frequent complaint was vulvar itching. Twenty-six percent of the patients were asymptomatic. Recurrences were frequent (25%) and were associated with multifocal lesions, involved surgical margins and the bowenoid histologic type. Superficially invasive carcinoma was detected in 8% of patients, mostly postmenopausal women with simplex histologic types. Immunohistochemical studies failed to detect papillomavirus- or herpesvirus-associated antigens in any of the cases. Follow-up of 48 patients from six months to ten years revealed no mortality from invasive cancer.

Locally aggressive granular cell tumor causing priapism of the crus of the clitoris. A light and ultrastructural study, with observations concerning the pathogenesis of fibrosis of the corpus cavernosum in priapism

A case of focal priapism of the clitoris caused by a microscopic granular cell tumor (GCT) is described. This neoplasm is considered locally aggressive because it invades the lumens of peripheral cavernous sinuses of the crus of the clitoris. Caverns adjacent to those invaded by tumor exhibit stasis, telangiectasia, and necrosis of the smooth muscle of the trabecular wall. These alterations lead to telescoping collapse and compression of the cavernous spaces and culminate in fibrosis. Ultrastructurally, replicated basal lamina is found surrounding clusters of granular cells. We suspect that the multilayered lamina, in addition to being produced by tumor cells, is derived from the trabecular endothelium surrounding the caverns invaded by the GCT. The replication of the basal lamina may be provoked by cycles of injury and repair to these vessels caused by repeated episodes of prolonged vascular stasis. A peculiar large vein with perforating branches was observed in the center of the cavernous spaces of the crus. This vein is not found in normal crura and, therefore, represents a morphologic adaptation created to drain the cavernous spaces.

Decreased response of human milk leukocytes to chemoattractant peptides

To test the hypothesis that neutrophils and macrophages in human milk may not defend by classical inflammatory mechanisms, experiments were conducted to ascertain whether adherence, orientation, and directed motility of these leukocytes would be enhanced by exposure to chemoattractant peptides including N-formyl-L-methionyl-L-phenylalanine and N-formyl-L-methionyl-L-leucyl-L-phenylalanine and C5a generated from zymosan activated human serum. Adherence and spatial orientation were tested on coverglasses and in Zigmond chambers, and chemotaxis was examined by Boyden chambers and a subagarose technique. Whereas, the adherence, orientation, and directed movement of adult peripheral blood neutrophils and monocytes were significantly enhanced by those chemotactic agents, human milk leukocytes failed to respond. The failure of the response of human milk leukocytes was not due to alterations in maternal peripheral blood leukocytes but appeared to be due partially to inhibitors in human milk. The experiments suggest that human milk leukocytes may be modified in the mammary gland to protect by noninflammatory mechanisms.

Retropubic urethrocystopexy: vaginal approach

A modification of the classic Marshall-Marchetti-Krantz (MMK) operation which includes suspending the urethrovesical junction to the pubis by the vaginal approach is presented. This offers the advantages of a shorter operating time, the lack of an abdominal incision, and the concomitant repair of other pelvic anatomic defects through the vagina, with a cure rate at least equal to, if not better than, that associated with the abdominal route. The study group of 25 patients had less morbidity, a 1-day decrease in hospital stay, and 1 1/2 fewer days of catheter drainage compared to a matched control group of MMK operations done abdominally in this preliminary report. A 96% cure and improvement rate of the symptoms of stress incontinence was shown at the 6-week postoperative visit. This compares to a 92% rate in the control series of abdominal MMKs. The permanency of the procedure will have to be evaluated critically as more cases are added and sufficient time elapses to see if these good initial results hold up.

The obstetrical management of conjoined twins

A pair of conjoined twins (thoracopagus) was delivered abdominally after antepartum diagnosis. Obstetrical planning is more likely to be successful with antepartum diagnosis, which can be done only if the possibility of conjoining is considered with each twin gestation. Once a twin gestation is suspected, ultrasonography should be performed for confirmation. Conjoined twins should be suspected in a gravid mother with multiple gestations and an abnormal fetal attitude. When the images cannot be separated on ultrasonography, amniographic examination, using a double contrast medium of oil-water, should demonstrate dye in the gastrointestinal tract and a union between the twins, as well as establish the presence of a monoamniotic sac. Because of increased fetal morbidity and mortality of vaginal delivery in monoamniotic twins, even if not conjoined, elective cesarean section at term will ensure the best chance for fetal survival.

The ultrastructural response of human endometrium to medroxyprogesterone acetate

Medroxyprogesterone acetate is a steroid compound similar to progesterone in structure and function. Thirty women were given 150 mg. of medroxyprogesterone intramuscularly, and samples of the endometrium were examined by light and electron microscopy. The initial response of normal human endometrium was maturation and then inhibition. By 50 days after injection, the atrophic changes began to reverse, and by Day 90, after injection the tissue resembled normal proliferative endometrium. A previously undescribed nuclear inclusion body is present; however, its significance is unclear at this time. On the basis of ultrastructural changes, medroxyprogesterone appeared not to exert a significant influence on the endometrium past 90 days at this dosage.