Risk of ischemic complications related to the intensity of triptan and ergotamine use

OBJECTIVE

To investigate whether the intensity of triptan and ergotamine use, in specific overuse, is associated with the risk of ischemic complications.

METHODS

We conducted a retrospective nested case-control study using data from the PHARMO Record Linkage System. All patients with more than one prescription for either a triptan or ergotamine were initially identified. Cases were all patients who were admitted to the hospital for an ischemic complication. Matched controls were assigned the same index date as the cases. The determinant was the intensity of use of triptans and ergotamine during 1 year preceding the index date. Overuse was defined as use of > or =90 defined daily doses during that year. Conditional logistic regression was used to estimate odds ratios (ORs), adjusting for confounders. Stratified analysis was used to estimate the risk for both patients using and those not using cardiovascular drugs.

RESULTS

A total of 17,439 patients received more than one prescription. A total of 188 cases and 689 controls were identified. Triptan overuse was not associated with an increased risk of ischemic complications (OR 0.96; 95% CI: 0.49 to 1.90). Overuse of triptans in patients concomitantly using cardiovascular drugs did not increase this risk. Overuse of ergotamine turned out to be a risk factor for ischemic complications (OR 2.55; 95% CI: 1.22 to 5.36). Patients overusing ergotamine and concomitantly using cardiovascular drugs were at highest risk (OR 8.52; 95% CI 2.57 to 28.2).

CONCLUSIONS

In general practice, triptan overuse does not increase the risk of ischemic complications. Overuse of ergotamine may increase the risk of these complications, especially in those simultaneously using cardiovascular drugs.

Reduction in the therapeutic intensity of abortive migraine drug use during ACE inhibition therapy--a pilot study

INTRODUCTION

Since a few case reports have demonstrated some beneficial effects of angiotensin converting enzyme (ACE) inhibitors in migraine prevention, we were interested in studying the impact of ACE inhibitors and angiotensin II receptor antagonists (Ang II) on the consumption of specific abortive migraine drugs and, therefore, indirectly on the frequency of migraine attacks.

METHODS

Data from a large prescription database involving 95 patients initiating a specific abortive migraine drug (ergotamine or a triptan) and subsequently treated with either an ACE inhibitor or angiotensin receptor antagonist (index group: ACE/Ang II) or diuretic (reference group) were analysed. The effects of ACE/Ang II inhibition as well as diuretic therapy on reducing the frequency of migraine attacks were assessed by measuring the mean consumption of abortive migraine drug use, in DDDs per month ('therapeutic intensity'), before, during and after ACE/Ang II or diuretic therapy. A 'therapeutic fluctuation intensity estimate' of abortive migraine drug use for all patients was likewise calculated.

RESULTS

On an individual level, the therapeutic intensity (TI) fluctuation estimate, 'during' relative to 'before' ACE diuretic therapy, was significantly larger for the ACE/Ang II group (62% reduction) than for the diuretic group (24% reduction) (p = 0.02). For patients who continued abortive migraine drug use during and after ACE/Ang II or diuretic therapy, a significantly larger reduction in this estimate was observed during ACE/Ang II inhibition (68.9%) compared to during diuretic therapy (10.5% increase) (p = 0.004). The TI fluctuation estimate, after relative to 'during', had increased by 50.3% after ACE/Ang II inhibition and had reduced by 22.2% after diuretic treatment (p = 0.1).

CONCLUSIONS

A clear reduction in the TI of abortive migraine drug use during the use of ACE inhibitors as compared to diuretic treatment was observed. Our findings may indirectly support a positive effect of ACE/Ang II inhibition on the frequency and severity of migraine attacks, as observed in other studies and reports.

Incidence and determinants of antidepressant drug use in migraine patients

The purpose of this retrospective, follow-up study was to characterise the use of antidepressant medication in a defined migraine population and evaluate the determinants thereof. Data was obtained from the PHARMO-RLS prescription database. Our migraine population (2,517 people) included patients having commenced specific migraine drugs, ergotamine or sumatriptan, for the first time from January 1 1992 to December 31 1998. The corresponding date was termed the 'index date'. Non-migraine patients, those not having used any medication specific for migraine, were selected and equally matched (n=2,517). The cumulative incidence of initiating antidepressant treatment was estimated during two-year observation periods prior to and after the index date. Several demographic and comedication characteristics were assessed as potential determinants of antidepressant drug use within the migraine population. Other determinants included usage patterns ("therapeutic intensity") of ergotamine and sumatriptan, defined as the absolute number of Defined Daily Doses (DDDs) dispensed per patient during one year prior to initiation of antidepressant therapy. A total of 300 migraine patients (11.9%) and 213 non-migraine patients (8.5%) had initiated antidepressant treatment in the two-year period prior to or in the two-year period after the index date (RR adj 1.4; 95% CI 1.2-1.7). The cumulative incidence of initiation of antidepressant treatment for the migraine population was 3.0% per year prior to and 3.2% per year after the initiation of specific migraine analgesia. The concomitant use of benzodiazepines (RR adj 4.7; 95% CI 3.5-6.3), migraine prophylactic medication (RR adj 2.1; 95% CI 1.6-2.8) and heavy therapeutic intensity use of specific migraine analgesia, defined as >/=150 DDDs per year were highly predictive of antidepressant drug use within the migraine population. In conclusion, compared to the non-migraine population, the initiation of antidepressant treatment was only slightly higher in the migraine population. A number of determinants within the latter were found to be strongly associated with antidepressant drug use, the nature of which most likely reflects an increased severity of migraine whereby therapeutic needs are higher.

Migraine prophylactic medication usage patterns in The Netherlands

This study aims to investigate usage patterns of specific migraine prophylactic medications in ergotamine and triptan patients commencing this treatment for the first time during 1 January 1992 until 31 December 1998. Usage patterns of specific migraine prophylactic drugs were evaluated for each patient by accessing data from a large prescription database and were characterized as continued, switch or stop use during the patient observation period. Several patient and medication-related factors were explored in order to identify a possible relationship with the specific usage pattern defined. Approximately 75% of the study population (n = 729) had terminated (stop or switch) prophylactic treatment after 1 year. Age < 40 years (relative risk (RR) 1.9; 95% confidence interval (CI) 1.2-3.2) and the concomitant use of non-steroidal anti-inflammatory drugs (RR 3.2; 95% CI 1.2-5.5) or specific abortive migraine drugs resulted in a faster onset of treatment modification (switch). Overall, migraine prophylactic treatment is used for a relatively short period, probably attributable to the common limitations associated with migraine prophylaxis, such as poor compliance and/or limited therapeutic efficacy. Patterns of use can be influenced by a variety of factors, including age, type of prescriber and certain co-medication. Patient interview studies are required to clarify these issues further.

Single use of sumatriptan: a patient interview study

OBJECTIVE

To investigate the possible reasons associated with the use of a single prescription of sumatriptan.

BACKGROUND

A few population-based studies concerning the usage patterns of sumatriptan have revealed a relatively high incidence (approximately 40%) of sumatriptan users who utilize only a single prescription of the drug.

DESIGN AND METHODS

Using automated prescription data from 11 community pharmacies, we identified single and multiple sumatriptan prescription recipients. The data were collected from May 1, 1998, to April 30, 2000. Several patient- and medication-related variables possibly associated with single recipiency of sumatriptan were analyzed. In addition, single recipients of sumatriptan were invited for an interview and asked a number of questions related to their clinical status and their experience with the medication.

RESULTS

Four hundred ninety-five, first-time users of sumatriptan were identified during the patient selection period, of whom 38% were single recipients of sumatriptan. Of the latter, 102 patients were considered eligible for interview. Reasons for terminating treatment after only 1 prescription included: inefficacy and/or occurrence of side effects, 78% (n=79); uncertain diagnosis of migraine, 39.2% (n=40); and reduction in headache frequency, 33.3% (n=34). Almost half of the population had terminated treatment without having consulted their physician. More than half relied upon the use of over-the-counter (OTC) analgesics after having tried sumatriptan. Compared to multiple users of sumatriptan, single recipients were far less likely to have used another form of migraine treatment prior to (odds ratio, 0.35; [95% confidence interval, 019 to 0.67]) and after (odds ratio, 0.34 [95% confidence interval, 0.19 to 0.63]) initiating sumatriptan. Furthermore, single recipients had demonstrated an increased tendency towards benzodiazepine use prior to receiving sumatriptan (odds ratio, 1.80 [95% confidence interval, 1.00 to 3.28]).

CONCLUSIONS

Single use of a sumatriptan prescription reveals some issues that may impact negatively the provision of effective migraine management. These include: rapidly developing dissatisfaction with the treatment provided and a lower tendency to seek out medical care. Our results also suggest that the drug may be used (inappropriately) as a diagnostic tool.

Incidence and determinants of migraine prophylactic medication in the Netherlands

OBJECTIVE

To estimate and examine the incidence and determinants of initiation of migraine-prophylactic therapy as well as the corresponding drug of choice over a period of 5 years following the use of specific abortive migraine drugs.

METHODS

By accessing data from a large prescription database, an identification of patients treated with ergotamine or a triptan from 1 January 1994 to 31 December 1998 was made. The cumulative incidence of initiation of migraine-prophylactic drugs (beta-blockers, serotonin antagonists, specific calcium antagonists, amitriptyline, clonidine and valproic acid) was estimated in patients following the use of ergotamine or a triptan. An assessment of the migraine-prophylactic drug of first choice was also performed. A few baseline determinants were analysed to highlight a possible association with the initiation of prophylactic therapy: age, gender, type of abortive migraine drug use and year of prophylaxis. Additional determinants included the analysis of drug-utilisation patterns, such as the consumption and switch patterns of abortive migraine drug use as well as co-medication use prior to prophylaxis. For this particular analysis a reference group (patients not having commenced prophylaxis) was selected from the initial study population.

RESULTS

After having satisfied eligibility criteria, a total of 3999 first-time users of ergotamine and triptans were included of whom 479 (12%) had initiated migraine-prophylactic therapy. This corresponded to an incidence density of 6.0 per 100 person-years and was highest for patients younger than 45 years and for multiple abortive migraine drug users. The incidence fell considerably from 12.0 person-years in 1994 to 5.1 person-years in 1998. More than half of the patients had been prescribed a beta-blocker as the migraine-prophylactic drug of first choice by both general practitioners and neurologists. The use of antidepressants and/or benzodiazepines and oral contraceptives was significantly higher in patients starting prophylaxis compared with those who did not. The consumption of abortive migraine drug use (4.0 defined daily doses per month vs 3.7 defined daily doses per month), and switch patterns (27.1% vs 30.9%) were similar for patients starting and not starting prophylaxis.

CONCLUSION

The overall incidence of initiation of migraine-prophylactic therapy following the use of abortive migraine analgesics was 6.0% per year and fell considerably during 5 years of the study. Beta-blockers were the migraine-prophylactic drugs of first choice for general practitioners and neurologists. In our study we could not determine any factors clearly associated with the initiation of migraine prophylaxis besides prior use of antidepressants and benzodiazepines. A future assessment of the usage patterns of migraine-prophylactic drugs may provide detailed information concerning the effectiveness and tolerability.

Reduction in the intensity of abortive migraine drug use during coumarin therapy

OBJECTIVE

To investigate the impact of coumarin therapy on migraine attack frequency.

BACKGROUND

Sporadic case reports and clinical studies have described beneficial effects of coumarin therapy on migraine severity.

DESIGN AND METHODS

A retrospective follow-up study based on a prescription database covering a population of 450 000 was conducted. All patients using an abortive migraine drug (ergotamine or sumatriptan) and subsequently treated with either coumarin (index group) or low-dose acetylsalicylic acid (control group) were analyzed. The impact of coumarin and low-dose acetylsalicylic acid on the frequency of migraine attacks was assessed by measuring the intensity of ergotamine and sumatriptan use, in defined daily doses per month per patient, before and during coumarin or acetylsalicylic acid treatment. In addition, a "therapeutic intensity reduction" was determined for each patient.

RESULTS

The study population consisted of 92 patients; 35% had been prescribed coumarin and 65% had been prescribed low-dose acetylsalicylic acid after the initiation of ergotamine or sumatriptan. Two thirds of the study population was treated with ergotamine. Overall, ergotamine and sumatriptan use for the coumarin cohort decreased from 6.4 defined daily doses per month prior to coumarin treatment to 3.0 defined daily doses during coumarin treatment, compared with a reduction from 5.2 defined daily doses per month to 4.4 defined daily doses per month for the low-dose acetylsalicylic acid cohort (P>.05). The therapeutic intensity of ergotamine and sumatriptan use was significantly decreased by 40% for the coumarin cohort, compared with 4.7% for the low-dose acetylsalicylic acid cohort (P=.004).

CONCLUSIONS

We observed that coumarin treatment was clearly associated with a reduction in the therapeutic intensity of abortive migraine drug use in comparison with low-dose aspirin treatment. This suggests that, overall, the coumarin cohort had experienced a substantial reduction in the frequency of migraine attacks during anticoagulation treatment. Our findings, as well as those of others, justify a controlled clinical trial to further establish the effects of coumarin therapy on migraine severity and its possible role in the prophylactic management of patients suffering from migraine.

Patterns of ergotamine and sumatriptan use in the Netherlands from 1991 to 1997

The objective of this study was to assess usage patterns of ergotamine and sumatriptan over a period of 6 years, primarily to evaluate the impact that sumatriptan has had on the prescription of ergotamine. This study used ergotamine and sumatriptan prescription data representing inhabitants of eight cities in the Netherlands and covering the period of 1991-1997. The yearly incidence of new users between 1991 and 1997 was estimated for both drugs as well as for the drug of first choice to be prescribed to patients initiating specific abortive migraine treatment with either ergotamine or sumatriptan. Intra-individual ergotamine and sumatriptan usage patterns, characterized by single (incidental), continuous (rate of retention) or switch use, were examined for five patient cohorts, each for a follow-up period of 1 year. During the year of sumatriptan introduction (1991-1992), the overall incidence of new use for both drugs was highest (5.4 per 1000 inhabitants). Hereafter, a substantial reduction of more than 50% was observed. From 1992 to 1996, the yearly incidence of ergotamine first-time use was significantly higher than that of sumatriptan and up to 1996 ergotamine was more than twice as likely than sumatriptan to be prescribed to patients initiating specific abortive treatment. Hereafter, sumatriptan was as likely as ergotamine to be prescribed as the drug of first choice, which coincided with the full reimbursement of sumatriptan tablets. Overall, neurologists were more likely than general practitioners (GPs), to prescribe sumatriptan as the drug of first choice. Approximately half of the total study population were identified as single-time users. This phenomonen occurred more frequently in the ergotamine cohorts. The sumatriptan cohorts displayed a slight yet significant stronger retention rate compared with the ergotamine cohorts. The overall impact of sumatriptan on ergotamine use in The Netherlands was marginal, predominantly due to GP's adherence to migraine treatment guidelines and reimbursement policies concerning sumatriptan tablets. Overall, incidental use was relatively high and may reflect the reported difficulties in diagnosing migraine, lack of patient-doctor consultation, or that anticipated benefits of the drug were not achieved. Further study is required to clarify these issues.

An evaluation of community pharmacy records in the development of pharmaceutical care in The Netherlands

An electronic patient database linking prescribes with a Dutch community pharmacy consortium was evaluated in a subset of the population of Noordwijk (11,760 patients out of a total of 25,600). The pharmacy database (a file of 41 disease contra-indications representing a subset of the prescribers' medical diagnosis) was studied in order to assess its value for the accurate discrimination of target patient groups within the community and for support to the pharmaceutical care of individual patients. The aim was to examine the application of the pharmacy records to pharmaceutical care, tested by measuring the accuracy of the pharmacy database to predict the community public health profile; and, more specifically, the accuracy to identify three potential target groups for pharmaceutical care. The records of patients with angina, chronic respiratory disease and diabetes (n = 1116), representing 65% of the total pharmacy morbidity records, were studied in detail and verified by the files and texts of the prescriber's individual patient records. From samples of patients (n = 273) from the three patient groups, the extent and nature of co-morbidity, polypharmacy (drug entities prescribed annually) and drug therapy instability (prescription changes to dose or dose form annually) were characterised. Angina patients showed the most comorbidity, 46% having three or more additional diseases; chronic respiratory disease patients showed most drug therapy instability; and insulin-dependent diabetic patients received most polypharmacy per disease. The pharmacy database predicted the prevalence of 10 of 23 relevant disease categories (representing 51% of the total morbidity on the medical records). However, the prevalences of eight categories were underestimated and of five categories overestimated. Of the three patient groups, 73% of patients appeared on both the pharmacy and the medical database. Of the total co-morbidity recorded for these patients, 68% of records were common to both databases. The database discrepancies (32%) were due to morbidity omitted (12%) and morbidity unverified (10%) on the pharmacy database, together with morbidity omitted from the medical database (10%). The current pharmacy database provides a limited view of morbidity. A strategic approach to pharmaceutical care requires pharmacists and prescribers to verify and share patient information if patient groups and individuals within a group are to be usefully targeted.