How to assess patient preference of migraine treatments

Patient Preference in Clinical Trials for Headache Medication: The Patient's View

From a clinical point of view, the subjective preference of the patient regarding headache medication is imperative. Consequently, a new trial design for headache medication, the so-called patient preference trial, has been vividly discussed. However, some critical questions have been raised concerning preference trials, such as whether placebos should be used, the necessity of blinding, and how to assess the data if a patient does not prefer medication A over B. As patient preference is the topic, we passed these questions on to headache patients using a questionnaire, which was handed out to 1112 headache patients. Out of 612, 486 returned questionnaires were correctly completed and analysed. Complete pain relief was the most important factor for 61% of patients to qualify a therapy effective. This is in contrast to the literature, where rapid speed of onset of the drug is discussed as the most important factor for migraineurs. Regarding the study design, 80% of the patients want to decide the time-point of taking acute medication themselves. About 60% of the patients would participate in placebo-controlled clinical trials and agree that studies should be blinded. If patients had to decide between two equally effective drugs, most would vote for the drug which is available in different application forms. Furthermore, we used the same questionnaire to ask headache specialists with expertise in performing headache studies the same questions. This was mailed to and completed by 22 experts in Germany. In this article, we discuss the patient preference compared with the expert preference regarding clinic trials and drug therapy.

Tolerability of Acute Migraine Medications: Influence of Methods of Assessment and Relationship With Headache Attributes

Tolerability is an important attribute of patient satisfaction with, and consequence adherence to, migraine acute treatment. Nevertheless, the determinants of tolerability are poorly explored. Accordingly, our objectives were: (i) in subjects receiving triptans, to contrast two methods of assessing adverse events (AEs); and (ii) to explore the relationship between migraine features and treatment attributes with tolerability. We surveyed 365 migraineurs who had been using the same triptan for at least 3 months. After prospectively treating an attack, headache characteristics and treatment response were assessed using headache calendars. Subjects also completed a standardized questionnaire, first asking about any AE and then prompting patients with a list of possible AEs. We contrasted both sets of answers and conducted logistic regression to assess if headache attributes or response to therapy influenced tolerability. Using the unprompted method, AEs occurred in 11.5-36.4± of patients, depending on the triptan used. Using the prompted method, they ranged from 26.9 to 64.3±. Chest and neck tightness were spontaneously reported by 3.5± of the sample, vs. 7.4± when prompted ( P< 0.05). Chest pain was not spontaneously reported and was elicited in nine patients (2.5±, P = 0.002). Feeling groggy occurred in 5.7 and 17.5± ( P< 0.001). AEs were not a function of headache severity, disability, efficacy of the drug, time to meaningful relief with the drug or recurrence of pain. The report of AEs varies dramatically with the methods of assessment. However, tolerability is not influenced by the severity of the attacks or by medication efficacy.

The impact of osteoporosis medication beliefs and side-effect experiences on non-adherence to oral bisphosphonates

OBJECTIVE

Non-adherence to oral bisphosphonate medications is a pervasive problem that blunts their potential to prevent fractures. Using multivariate modeling, we assessed the unique contribution of six classes of variables as drivers of non-adherence to bisphosphonates: (1) beliefs about osteoporosis and its prescription drug treatment, (2) ratings of the affordability of the prescription osteoporosis medications, (3) evaluations of the convenience of the bisphosphonate dosing frequency, (4) reports of troublesome side effects, (5) ratings of aspects of the bisphosphonate dosing regimen, and (6) risk factors for fracture. These categories of predictor variables were selected for investigation because they have been suggested by clinical-trial, survey, and observational studies in osteoporosis as reasons for non-adherence among patients taking prescription osteoporosis therapy.

METHODS

Women aged 45 or older who filled a prescription for an oral bisphosphonate in January or February of 2006 were identified through a dispensing database of 3300 US retail pharmacies. Subjects received a mailed pre-notification letter from the retail pharmacy chain informing them that someone would be calling them to invite them to participate in a telephone survey about osteoporosis medications. Trained interviewers used a standardized telephone script to recruit patients. Our definition of adherence was provisionally based on database records across a 7-month period and then cross-validated using patient self-report during the telephone recruitment. We measured beliefs regarding bisphosphonate effectiveness and safety, osteoporosis health concerns, concerns regarding drug costs, dosing frequency convenience, and experienced side effects using multi-item scales. Data were collected by telephone interview. Bivariate analyses were conducted using chi(2) and t-tests, and multivariate analyses were conducted using logistic regression.

RESULTS

Of the 3274 women contacted for study participation, 1092 (33%) completed the interview and 1015 had analyzable data. Multivariate analyses showed that those most symptomatic in terms of side effects and those with the most skeptical beliefs in drug effectiveness and drug safety had odds ratios for non-adherence of 6.78 (95% CI 4.67-9.86), 5.70 (95% CI 3.65-8.92), and 2.26 (95% CI 1.49-3.42), respect ively. In multivariate models, osteoporosis health concerns, dosing frequency convenience, and concerns regarding medication costs were not statistically associated with non-adherence to bisphosphonate therapy.

CONCLUSIONS

The experience of troublesome side effects and patient beliefs regarding the effectiveness and safety of oral bisphosphonate medications prescribed for them are strongly associated with bisphosphonate non-adherence. Improving adherence to oral bisphosphonates may require providers to solicit and address patients' medication beliefs and to proactively address side effects. Limitations of our study include: (1) the study sample is not likely to be a national random sample of bisphosphonate users, and (2) some evidence of non-response bias was observed.

Osteoporosis medication profile preference: results from the PREFER-US study

Objective  To assess patient preferences for two osteoporosis medications.

Design  Women aged 50+ were surveyed via the Internet to assess preferences for two osteoporosis medication profiles. Drug A and Drug B, consistent with ibandronate and alendronate, respectively, differed by: time on market (recently vs. 10 years), dosing frequency (monthly vs. weekly), effectiveness (not proven vs. proven to reduce non‐spine or hip fracture after 3 years) and dosing procedure (60 vs. 30 min wait before eating/drinking). Each profile had the same out‐of‐pocket costs, side‐effects, potential for drug interaction and spine fracture efficacy. Patients force ranked and rated the importance of each attribute. Subgroup comparisons included diagnosed vs. at‐risk respondents and treated vs. untreated respondents.

Results  Among the 999 respondents, Drug B was preferred by 96%. Effectiveness was ranked as the most important determinant of preference (79% ranked it #1) compared with time on market (14%), dosing procedure (4%) and dosing frequency (3%). Effectiveness had the highest mean importance rating on a scale of 1 (extremely unimportant) to 7 (extremely important): mean (SD) = 6.1 (1.8), followed by time on market: 4.7 (1.7), dosing procedure: 4.6 (1.4) and dosing frequency: 4.5 (1.4). No significant differences in profile choice were found across study subgroups.

Conclusions  The drug profile showing reductions in non‐vertebral and hip fracture risk was chosen by almost all respondents. Drug effectiveness was the most important determinant of preference, while dosing frequency was the least important determinant. Incorporation of patient preferences in the medication decision‐making process could enhance patient compliance and clinical outcomes.

The cycle of migraine: Patients' quality of life during and between migraine attacks

BACKGROUND

Despite advances in therapy, the prevalence of migraine has remained constant over the past 17 years. The current diagnostic procedure for migraine does not take into account the entire cycle of migraine, which includes both the pain of the acute attack and the worry between attacks.

OBJECTIVES

This review discusses the effects of migraine on health-related quality of life. The focus is on the impact of migraine between attacks and more successful clinical management of the complete cycle of migraine in both the neurology and primary care settings.

METHODS

A search of MEDLINE (January 1997-January 2007) was conducted to determine the impact of migraine on quality of life and the need for and use of migraine preventive treatment. The search terms were migraine prevention, migraine prophylaxis, bead-ache and quality of life, migraine disability, and head-ache disability. The inclusion of specific studies was based on subjective, comparative evaluation and standard levels of evidence. Older publications were included to provide a historical perspective.

RESULTS

Worry in expectation of the next migraine attack can have negative effects on the family and social lives and work productivity of patients with migraine. The benefits of preventive pharmacotherapy for migraine may be measured over time in terms of changes in the frequency of acute attacks, impact of acute treatment on headache recurrence within the next 24 hours, and reduction in overall functional impairment. Optimizing the acute treatment outcome and reducing the frequency of episodes may help alleviate the cycle of migraine. The clinical assessment of migraine should include multiple dimensions. Several questionnaires, such as the Migraine Disability Assessment and the 6-item Headache Impact Test, have been developed to help clinicians assess the dimensions of migraine. These questionnaires should be used in conjunction with open communication techniques that elicit any underlying worry associated with migraines. Preventive therapies that have been approved by the US Food and Drug Administration include the neurostabilizers divalproex sodium and topiramate, and the beta-blockers timolol and propranolol. Despite not being approved for this indication, the antidepressant amitriptyline has shown levels of evidence of efficacy in preventing migraine in controlled trials similar to those for the approved medications.

CONCLUSION

The assessment of whether patients with migraine may benefit from preventive therapy should include the use of open communication techniques to uncover possible impairment between attacks.

An evaluation of patient preferences for osteoporosis medication attributes: results from the PREFER-US study

OBJECTIVE

To evaluate preferences for eight medication attributes that women may consider when evaluating prescription osteoporosis medications.

RESEARCH DESIGN AND METHODS

The eligible sample consisted of women aged 50 years or older who responded to the 2003 or 2004 Internet-based National Health and Wellness Survey as being diagnosed with osteoporosis, considering themselves at risk, or having a family history of osteoporosis. In this Internet survey (the PREFER survey), respondents were asked to: (1) force-rank order the eight attributes from one to eight according to their preferences and (2) separately rate the importance of each attribute on a Likert-type scale from 1 (extremely unimportant) to 7 (extremely important).

RESULTS

We collected 999 responses across 3 days from a sample of 3368 women and stopped compiling responses after achieving sample size targets. Drug effectiveness (e.g., ability to reduce the risk of fractures) was force ranked as the No. 1 preferred osteoporosis medication attribute by 37% of the sample. Side effects were force ranked as the No. 1 preferred medication attribute by 36% of the sample. Dosing frequency, dosing procedure, and formulation (i.e., how the drug is taken) were each force ranked as No. 1 by 2% or less of the sample. Drug effectiveness had the highest percentage of 'extremely important' responses (59%) followed by drug interactions (53%). Drug effectiveness was the highest-rated attribute (mean [S.D.] = 6.1 [1.6], median = 7), while dosing frequency was the lowest-rated attribute (mean [S.D.] = 4.7 [1.8], median = 5).

CONCLUSIONS

In our sample of women with a diagnosis of osteoporosis or at risk for osteoporosis, drug effectiveness was the most highly ranked and rated of eight osteoporosis medication attributes. Side effects and drug interactions were also highly ranked and rated. Healthcare providers should consider incorporating patient preferences for key medication attributes into their therapeutic decision-making processes.

Acetaminophen, Aspirin, and Caffeine in Combination Versus Ibuprofen for Acute Migraine: Results From a Multicenter, Double-Blind, Randomized, Parallel-Group, Single-Dose, Placebo-Controlled Study

OBJECTIVE

Compare the effectiveness of a combination analgesic containing acetaminophen, aspirin, and caffeine to that of ibuprofen in the treatment of migraine.

METHODS

Multicenter, double-blind, randomized, parallel-group, placebo-controlled, single-dose study. A total of 1555 migraineurs were included in the analysis. No patients were excluded solely because of severity of symptoms or degree of disability. A single 2-tablet dose for each of the 3 treatment groups: a combination product containing acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg per tablet (AAC); ibuprofen 200 mg per tablet (IB); or matching placebo. The primary efficacy endpoint was the weighted sum of pain relief (PAR) scores at 2 hours postdose (TOTPAR2) and an important secondary endpoint was the time to onset of meaningful relief.

RESULTS

There were 669 patients in the AAC group, 666 patients in the IB group, and 220 patients in the placebo group. The 3 treatment groups had similar demographic profiles, migraine histories, and baseline symptom profiles. While both active treatments were significantly better than placebo in relieving the pain and associated symptoms of migraine, AAC was superior to IB for TOTPAR2, as well as for PAR, time to onset of meaningful PAR, pain intensity reduction, headache response, and pain free. The mean TOTPAR2 scores for AAC, IB, and placebo were 2.7, 2.4, and 2.0, respectively (AAC vs. IB, P < .03). The median time to meaningful PAR for AAC was 20 minutes earlier than that of IB (P < .036).

CONCLUSION

AAC and IB are safe, cost-effective treatments for migraine; AAC provides significantly superior efficacy and speed of onset compared with IB.

Newer formulations of the triptans: advances in migraine management

Migraine is a common, frequently incapacitating, headache disorder that imposes a substantial burden on both the individual patient and society. The last two decades have witnessed an explosion in our understanding of the pathophysiology of migraine, and in our development of an efficacious and diverse therapeutic armamentarium. There are several routes of drug administration available to patients with migraine. All the serotonin 5-HT(1B/1D) receptor agonists (triptans) are available as oral tablets (sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, frovatriptan and eletriptan). Only sumatriptan is available as a subcutaneous injection. Some triptans are also available via newer routes of administration, including orally disintegrating tablets (rizatriptan and zolmitriptan), rectal suppositories (sumatriptan) and intranasal sprays (sumatriptan and zolmitriptan). Oral disintegrating tablets and other non-oral triptan routes (subcutaneous, intranasal, rectal) are a useful alternative to conventional oral tablets for patients who have difficulty swallowing pills or prefer not to do so, and for patients whose nausea and/or vomiting precludes swallowing tablets and/or makes the likelihood of complete absorption unpredictable. This is important because epidemiological studies in migraine reveal that the vast majority of patients (>90%) have experienced nausea during a migraine attack and more than 50% have nausea with the majority of attacks. Similarly, most (almost 70%) have vomited at some time during an attack and of these patients, almost one-third vomit in the majority of attacks. The newer formulations, rapidly dissolving tablets and intranasal sprays, afford patients the opportunity to use abortive therapy without the need for liquids, at anytime and anywhere, at the onset of a migraine attack. Furthermore, the intranasal sprays are absorbed rapidly and have a prompt onset of action allowing for significant pain free rates versus placebo as early as 15 minutes post administration. The ability to administer treatment early in a migraine attack and have a rapid onset of action is particularly important in acute migraine treatment in order to prevent the development of central sensitisation. While many patients and physicians choose conventional oral tablets because of familiarity and ease of administration, the newer formulations, oral disintegrating tablets and intranasal sprays, should be given consideration as first-line agents in selected patients.

Integrating the triptans into clinical practice

The triptans (selective serotonin agonists) are becoming the first-line alternatives in the acute pharmacological treatment of migraine, at least for attacks of moderate-to-severe intensity. Although clinical trials demonstrate significant differences in efficacy between triptan tablets, they often appear similar in efficacy when used in clinical practice, particularly after dose adjustments. Most patients with migraine consider drugs that can be administered orally to be the most user-friendly. However, gastrointestinal absorption may be impaired during migraine attacks because gastric motility is inhibited, and there is a risk that nausea during the attack will culminate in vomiting. Furthermore, in addition to their antimigraine properties, triptans may prolong the gastric emptying time. For this reason the absorption of any triptan taken orally during the migraine attack will be erratic and treatment effects inconsistent. Despite these barriers to good efficacy and high reliability, the tablet is the most commonly used triptan formulation.

An open preference study with sumatriptan 50 mg and zolmitriptan 2.5 mg in 100 migraine patients

Understanding factors influencing patients' preference will improve guidance to make rational choices in expanded symptomatic migraine treatment. The objective of this open-label, cross-over study was to explore patients' preferences for sumatriptan 50 mg vs. zolmitriptan 2.5 mg tablets, focusing on factors influencing this preference. One hundred consecutive migraine patients attending our clinics were asked to treat three attacks with each medication and then fill out a preference questionnaire. Ninety-four migraineurs completed the trial and 42 (44%, 95% CI 34-58%) reported that they preferred zolmitriptan 2.5 mg over sumatriptan 50 mg tablets and 27 (29%, 20-38%) preferred sumatriptan 50 mg. The remaining 25 (27%, 18-36%) did not show any preference. For the initial treatment of the attacks, there were more patients needing just one tablet of zolmitriptan 2.5 mg compared with sumatriptan 50 mg (67 vs. 39%). The reasons for preference among those 69 patients who had shown preference for either of the two triptans were: a faster onset of action (speed of onset) (73%), a longer duration of the effects (39%), fewer adverse events (35%) and lower price (13%). Only one-quarter of the studied migraine population thought that sumatriptan 50 mg and zolmitriptan 2.5 mg were equivalent, which suggests that most migraine patients differentiate between triptans. A faster onset of action (speed of onset) was the most important reason for preference.