Treatment Algorithms

October 2013

Key Findings from Treatment Algorithms in Migraine – Acute Treatments

Introduction:

For the estimated 35 million people in the United States who suffer from migraines, multiple prescription therapies are available that have proved effective in acutely treating migraine pain and its associated symptoms. Among approved prescription medications, the migraine-specific “triptan” drug class represents the largest—and most extensively prescribed—group of therapies. All of the molecules in this class are available as oral tablet formulations, and several are also available in non-oral formulations (e.g., nasal sprays, subcutaneous [SC] injectables), which serve as alternative treatment options for patients with precise clinical needs. Additional approved acute prescription therapies, including ergotamine derivatives and select non-migraine-specific analgesics, represent the remaining therapies that are formally approved for the acute treatment of migraine. Agents from these last two classes are generally reserved for patients who do not respond satisfactorily or are contraindicated to triptans (in the case of non-migraine-specific analgesics) or cannot tolerate triptans.

As a class, the triptans have experienced extensive generics competition; although several branded-only products remain, they too will become subject to generics competition in the coming years. Meanwhile, drug developers continue to develop new non-oral reformulations of existing triptan molecules—as well as explore drug development opportunities outside the triptan space—in the hopes of providing acute migraine symptom relief to those patients underserved by currently available products.

Using patient-level claims data, this report tracks the share of acute, prescription antimigraine drugs through lines of therapy, evaluates treatment flow, and analyzes why certain key acute therapies are chosen over others in light of the multiple acute therapeutics available.

Questions Answered in This Report:

  *   Newly diagnosed patients: Consistent with migraine treatment guidelines, the triptan drug class dominates the acute prescription treatment of migraine. What are the most common first-, second-, and third-line triptans for newly diagnosed migraine patients? Where do brand-only and recently generic triptans, including Maxalt (Merck & Co.), Relpax (Pfizer), and Zomig (AstraZeneca/Impax Pharmaceuticals), fall across the lines of acute therapy? How do the various available non-oral formulations of triptans (e.g., nasal sprays, SC injectables) fit in the acute treatment algorithm for newly diagnosed patients? What patient share do non-oral formulations garner in first, second, and third lines of therapy? What percentage of newly diagnosed migraine patients switches to later lines of acute treatment over the course of two years? To what extent are newly diagnosed patients prescribed concomitant acute prescription drugs, particularly in later lines of therapy?

  *   Recently treated patients: Triptans are also the most widely prescribed acute antimigraine therapies among recently treated migraine patients. How do the pathways to each triptan differ? How long does it take a patient to move through preceding acute therapy before receiving key acute therapies queried? What are the most typical switch patterns between triptans? For patients recently treated with a nontriptan acute therapy (e.g., dihydroergotamine SC injectable [Valeant Pharmaceuticals’ D.H.E. 45, generics]), what acute treatment(s) preceded treatment with those products? How does persistency vary among triptans? How compliant are migraine patients with orally administered triptans compared with non-oral formulations of triptans?

  *   Pathways to key therapies: Longitudinal claims data reveal relatively consistent use patterns of acute antimigraine therapies among recently treated patients. Which acute therapies have experienced marked growth or decline over the key therapy periods studied? To what extent are key acute antimigraine therapies prescribed concomitantly to recently treated patients? Which prescription therapies are most commonly prescribed as part of a regimen?  What has been the early impact of the launch of generic versions of Maxalt (rizatriptan)?

Scope:

Primary patient-level data: Quantitative findings from our analysis of data covering 40 million lives providing the most representative sample of U.S. treatment practice for Medicare and commercially insured patients. This report is delivered as a key findings slide deck and a dashboard that can be accessed using the Internet with claims that are less than six months old at the time of publication.

Patient Sample:

Patients aged 15 or older who are continuously enrolled for the complete 4.5-year study period must meet the following condition: at least two claims with a diagnosis code for migraine (International Classification of Diseases, Ninth Revision [ICD-9] diagnostic codes (346.00-346.93 [inclusive]) during the study period.

Quantified lines of therapy analysis showing exact share of each acute antimigraine agent in each line of therapy, including rate of progression between lines and length of time patients are on each line.

Newly Diagnosed Patients:

- Patient share by acute antimigraine drug class and key acute products across three lines of therapy within two years of diagnosis.

- Patient flowchart through two years of acute treatment for all first-line products, including progression rates and add/switch behavior.

- Polypharmacy and concomitant prescriptions among key acute therapies by line of therapy.

- Quarterly trending of patient share by line of therapy.

Recently Treated Patients:

- Quarterly snapshot of patient share by acute drug class and key acute products.

- Pathway to key acute therapy flowcharts tracking the preceding acute therapy patterns for all key acute therapies, including add/switch behavior.

- Brand source of business including share for continuing, new (switches/adds), and new (initial therapy) business.

- Polypharmacy and concomitant prescriptions among key acute therapies.

- Acute drug persistence and compliance.

- Quarterly trending of patient share for all key acute therapies.


Search Reports

Mentioned in this report:

  • - Allergan
  • - APR Applied Pharma Research
  • - AstraZeneca
  • - Avanir Pharmaceuticals
  • - CoLucid Pharmaceuticals
  • - Elan Pharmaceuticals
  • - Endo Pharmaceuticals
  • - GlaxoSmithKline
  • - Impax Pharmaceuticals
  • - IntelGenx
  • - Mallinckrodt
  • - Merck & Co
  • - MonoSol Rx
  • - Nautilus Neurosciences
  • - NuPathe
  • - OptiNose
  • - Ortho-McNeil
  • - Pfizer
  • - RedHill Biopharma
  • - Tesa Labtec
  • - Valeant Pharmaceuticals International
  • - Zogenix
Decision Resources Group brands include: