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

Monthly migraine days, tablet utilization, and quality of life associated with Rimegepant - post hoc results from an open label safety study (BHV3000-201)

Background

The objective of this study was to describe patterns in monthly migraine days (MMD) and tablet utilization, and to estimate health-related quality of life (HRQoL) measures in patients treated as needed (PRN) with rimegepant 75 mg over 52-weeks.

Methods

Eligible subjects were adults with ≥1 year history of migraine and ≥ 6 MMD at baseline, who used rimegepant 75 mg up to once daily PRN (at their discretion) for up to 52-weeks in an open-label safety study (BHV3000–201; NCT03266588). Mean MMD were calculated at each 4-week period, along with mean monthly tablets taken. Migraine-specific quality of life (MSQv2) data were mapped to EQ-5D utilities and used to characterize HRQoL over time. A published network meta-analysis was used to characterize pain hours as well as time periods spent migraine free.

Results

One thousand forty four subjects were included in this post-hoc analysis. Overall mean MMD were 10.9 at baseline and decreased to 8.9 by week 52. Tablet use remained stable over the follow-up period. A total of 0.08 incremental QALYs were associated with rimegepant use.

Conclusion

For subjects with 6 or more MMD, acute treatment of migraine attacks with rimegepant 75 mg on a PRN basis over one-year of follow-up was found to be associated with reduced MMD frequency without an increase in monthly tablet utilization, and improved HRQoL. There was no evidence of medication-related increases in MMDs when rimegepant 75 mg was used as needed for the acute treatment of migraine over 52-weeks.

Trial registration

ClinicalTrials.gov identifier NCT03266588.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01378-5.

Economic Evaluation of Treatments for Migraine: An Assessment of the Generalizability Following a Systematic Review

BACKGROUND

All health economics reviews on chronic and episodic migraine published to date underline the heterogeneity of results. Currently, the need for the generalizability of economic evaluations across different jurisdictions is considered a key issue to avoid unnecessary overlaps and to minimize the time to reimbursement decisions.

OBJECTIVE

The aim of this study was to review the economic evaluations on the prophylaxis and treatments for migraine published in the previous 10 years (since 2009) and to perform a critical assessment of their generalizability.

METHODS

We searched PubMed, EMBASE, and EconLit databases. Articles underwent a three-stage selection process. To assess the level of generalizability, we used the checklist implemented by Augustovski et al. Studies were classified as: (1) generalizable; (2) transferable; and (3) context specific.

RESULTS

In total, 227 articles were identified after running the search string and 11 studies were included in our review. Overall, none of the studies was judged as generalizable and three were judged transferable according to the established criteria.

CONCLUSIONS

Our review suggests that no evidence on the economic value of either acute or prophylactic treatments against migraine is generalizable to different jurisdictions. However, the majority of studies reporting results about prophylactic treatments were found to be transferable.

Migraine Care in the Era of COVID-19: Clinical Pearls and Plea to Insurers

Objective

To outline strategies for the treatment of migraine which do not require in‐person visits to clinic or the emergency department, and to describe ways that health insurance companies can remove barriers to quality care for migraine.

Background

COVID‐19 is a global pandemic causing widespread infections and death. To control the spread of infection we are called to observe “social distancing” and we have been asked to postpone any procedures which are not essential. Since procedural therapies are a mainstay of headache care, the inability to do procedures could negatively affect our patients with migraine. In this manuscript we review alternative therapies, with particular attention to those which may be contra‐indicated in the setting of COVID‐19 infection.

Design/Results

The manuscript reviews the use of telemedicine visits and acute, bridge, and preventive therapies for migraine. We focus on evidence‐based treatment where possible, but also describe “real world” strategies which may be tried. In each section we call out areas where changes to rules from commercial health insurance companies would facilitate better migraine care.

Conclusions

Our common goal as health care providers is to maximize the health and safety of our patients. Successful management of migraine with avoidance of in‐person clinic and emergency department visits further benefits the current urgent societal goal of maintaining social distance to contain the COVID‐19 pandemic.

Traditional acupuncture in migraine: a controlled, randomized study

OBJECTIVE

To check the effectiveness of a true acupuncture treatment according to traditional Chinese medicine (TCM) in migraine without aura, comparing it to a standard mock acupuncture protocol, an accurate mock acupuncture healing ritual, and untreated controls.

BACKGROUND

Migraine prevalence is high and affects a relevant rate of adults in the productive phase of their life. Acupuncture has been increasingly advocated and used in Western countries for migraine treatment, but the evidence of its effectiveness still remains weak. A large variability of treatments is present in published studies and no acupoint selection according to TCM has been investigated so far; therefore, the low level of evidence of acupuncture effectiveness might partly depend on inappropriate treatment.

DESIGN AND METHODS

A prospective, randomized, controlled study was performed in 160 patients suffering from migraine without aura, assessed according to the ICD-10 classification. The patients were divided into the following 4 groups: (1) group TA, treated with true acupuncture (according to TCM) plus Rizatriptan; (2) group RMA, treated with ritualized mock acupuncture plus Rizatriptan; (3) group SMA, treated with standard mock acupuncture plus Rizatriptan; (4) group R, without prophylactic treatment with relief therapy only (Rizatriptan). The MIDAS Questionnaire was administered before treatment (T0), at 3 (T1) and 6 months (T2) from the beginning of treatment, and the MIDAS Index (MI) was calculated. Rizatriptan intake was also checked in all groups of patients at T0, T1, and T2. Group TA and RMA were evaluated according to TCM as well; then, the former was submitted to true acupuncture and the latter to mock acupuncture treatment resembling the same as TA. The statistical analysis was conducted with factorial ANOVA and multiple tests with a Bonferroni adjustment.

RESULTS

A total of 127 patients completed the study (33 dropouts): 32 belonged to group TA, 30 to group RMA, 31 to group SMA, and 34 to group R. Before treatment the MI (T(0)) was moderate to severe with no significant intergroup differences. All groups underwent a decrease of MI at T(1) and T(2), with a significant group difference at both T(1) and T(2) compared to T(0) (P < .0001). Only TA provided a significant improvement at both T(1) and T(2) compared to R (P < .0001). RMA underwent a transient improvement of MI at T(1). The Rizatriptan intake paralleled the MI in all groups.

CONCLUSIONS

TA was the only treatment able to provide a steady outcome improvement in comparison to the use of only Rizatriptan, while RMA showed a transient placebo effect at T1.

Impact of topiramate migraine prophylaxis on workplace productivity: results from two US randomized, double-blind, placebo-controlled, multicenter trials

OBJECTIVE

We conducted this study to determine whether topiramate at 100 mg/d for the treatment of migraine headache is associated with improved productivity in the workplace.

METHODS

Results were derived from two randomized, double-blind, placebo-controlled trials among migraineurs. The number of hours of absenteeism (A), presenteeism (P), and total lost productivity (TLP) (A + P) were calculated. Results were not adjusted for multiplicity.

RESULTS

A total of 325 (162 in the topiramate group and 163 in the placebo group) of 449 subjects were included. Per person mean monthly A rate was only significantly less for individuals within the topiramate group (1.0 hours per person) versus those in the placebo group (1.5 hours per person) for month 3 (P < 0.05). Per person mean P and TLP rates were significantly lower for individuals in the topiramate group versus those in the placebo group for months 1 through 5 (P < 0.05).

CONCLUSIONS

Findings suggest that topiramate, compared with placebo, is associated with decreased workplace presenteeism and TLP.

Development and validation of a selective and robust LC–MS/MS method for high-throughput quantifying rizatriptan in small plasma samples: Application to a clinical pharmacokinetic study

An analytical method based on liquid chromatography with positive ion electrospray ionization (ESI) coupled to tandem mass spectrometry detection (LC-MS/MS) was developed for the determination of a potent 5-HT(1B/1D) receptor agonist, rizatriptan in human plasma using granisetron as the internal standard. The analyte and internal standard were isolated from 100 microL plasma samples by liquid-liquid extraction (LLE) and chromatographed on a Lichrospher C18 column (4.6mm x 50mm, 5 microm) with a mobile phase consisting of acetonitrile-10mM aqueous ammonium acetate-acetic acid (50:50:0.5, v/v/v) pumped at 1.0 mL/min. The method had a chromatographic total run time of 2 min. A Varian 1200 L electrospray tandem mass spectrometer equipped with an electrospray ionization source was operated in selected reaction monitoring (SRM) mode with the precursor-to-product ion transitions m/z 270-->201 (rizatriptan) and 313.4-->138 (granisetron) used for quantitation. The assay was validated over the concentration range of 0.05-50 ng/mL and was found to have acceptable accuracy, precision, linearity, and selectivity. The mean extraction recovery from spiked plasma samples was above 98%. The intra-day accuracy of the assay was within 12% of nominal and intra-day precision was better than 13% C.V. Following a 10mg dose of the compound administered to human subjects, mean concentrations of rizatriptan ranged from 0.2 to 70.6 ng/mL in plasma samples collected up to 24h after dosing. Inter-day accuracy and precision results for quality control samples run over a 5-day period alongside clinical samples showed mean accuracies of within 12% of nominal and precision better than 9.5% C.V.

SER-1, a Caenorhabditis elegans 5-HT2-like receptor, and a multi-PDZ domain containing protein (MPZ-1) interact in vulval muscle to facilitate serotonin-stimulated egg-laying

Serotonin (5-HT) stimulation of egg-laying in Caenorhabditis elegans is abolished in ser-1 (ok345) animals and is rescued by ser-1 expression in vulval muscle. A PDZ binding motif (ETFL) at the SER-1 C-terminus is not essential for rescue, but facilitates SER-1 signaling. SER-1 binds specifically to PDZ domain 10 of the multi-PDZ domain protein, MPZ-1, based on GST pulldown and co-immunoprecipitation. mpz-1 is expressed in about 60 neurons and body wall and vulval muscles. In neurons, GFP-tagged MPZ-1 is punctate and colocalizes with the synaptic marker, synaptobrevin. The expression patterns of ser-1 and mpz-1 overlap in 3 pairs of neurons and vulval muscle. In addition, MPZ-1 also interacts with other GPCRs with acidic amino acids in the -3 position of their PDZ binding motifs. mpz-1 RNAi reduces 5-HT stimulated egg-laying in wild type animals and in ser-1 mutants rescued by muscle expression of SER-1. In contrast, mpz-1 RNAi has no effect on 5-HT stimulated egg-laying in ser-1 mutants rescued by expression of a truncated SER-1 that lacks the C-terminal PDZ binding motif. The overexpression of MPZ-1 PDZ domain 10 also inhibits 5-HT stimulated egg-laying. These studies suggest that the SER-1/MPZ-1 interaction facilitates SER-1 mediated signaling.