Using patient-centered endpoints to determine the cost-effectiveness of triptans for acute migraine therapy.

The objective of this study was to use the patient-centered efficacy measurements of sustained pain free and sustained pain free with no adverse events to compare the relative cost-effectiveness of 6 oral triptans in the treatment of acute migraine. Adverse event and sustained pain-free rates were obtained from a comprehensive meta-analysis of 53 clinical trials of oral triptans. Efficacy and tolerability were assumed to be independent. Average wholesale prices were in US dollars as of May 10, 2004. The meta-analysis of oral triptans reported that almotriptan 12.5 mg (Axert) exhibited the highest sustained pain-free rate (25.9%), with the lowest rate associated with eletriptan 20 mg (Relpax) (10.6%). In addition, almotriptan 12.5 mg possessed the lowest overall absolute adverse event rate (14.2%), with the highest adverse event rate exhibited by eletriptan 80 mg (53.9%). To attain 100 sustained pain-free patients, almotriptan 12.5 mg and rizatriptan 10 mg (Maxalt) proved to be the most cost-effective triptans, costing $7120 and $7427, respectively; the least cost-effective were naratriptan 2.5 mg (Amerge) ($13,736) and eletriptan 20 mg ($16,104). To attain 100 sustained pain-free with no adverse events patients, almotriptan 12.5 mg was the most cost-effective triptan ($8298) and the least cost-effective were eletriptan 20 mg ($25,521) and eletriptan 80 mg ($29,614). At average wholesale prices as of May 10, 2004, almotriptan 12.5 mg achieved the highest level of cost-effectiveness using either sustained pain free or sustained pain free with no adverse events as endpoints.

Pharmacoeconomics: the cost of prophylactic migraine treatments.

Migraine preventive medications considered effective reduce headache frequency by 50 percent in approximately 50 percent of treated patients. In spite of similar effectiveness, these medications vary tremendonsly in their prices. Knowledge of medication prices and employing cost-effective strategies may greatly reduce treatment costs.

Cost considerations of acute migraine treatment.

OBJECTIVE: To provide medication price data and cost-reducing strategies for the acute treatment of migraine. METHODS: Retail prices for common acute care medications were found at http://www.drugstore.com. Cost-reduction tactics were obtained from literature searches and clinical experience. RESULTS: Several strategies can reduce cost without sacrificing treatment outcome. In mild to moderate migraine, low-priced nonsteroidal anti-inflammatory drugs can be used as first-line medications due to their proven efficacy and favorable tolerability. For patients with more severe migraine, implementing a stratified care approach-using migraine-specific medications early in acute treatment-is cost-effective for most patients. Stratified care not only improves outcome and decreases disability, but also reduces cost. Pill splitting and early administration of triptans within an attack enhance their value. Supplying rescue medications, such as opioids, sedatives, and phenothiazines, can prevent emergency department visits. Minimizing multiple dosing of triptans and reducing utilization of expensive health care resources are key factors in reducing the cost of effective migraine treatment. An important affordability factor for patients with co-payments is the number of triptan pills per package. Sumatriptan, naratriptan, and frovatriptan each contain 9 tablets per package, while most other triptan packages contain 6. Current triptan retail prices (per unit) include: Amerge 1 and 2.5 mg, 17.78 dollars; Axert 6.25 and 12.5 mg, 16.31 dollars; Frova 2.5 mg, 13.89 dollars; Imitrex 50 mg, 14.96 dollars; Imitrex 100 mg, 14.41 dollars; Imitrex Nasal Spray 20 mg, 21.61 dollars; Imitrex SQ 6 mg, 50.26 dollars; Maxalt 5 and 10 mg, 15 dollars; Maxalt-MLT 5 and 10 mg, 15 dollars; Relpax 40 mg, 13.58 dollars; Zomig 2.5 mg, 13.67 dollars; Zomig 5 mg, 15.89 dollars; Zomig-ZMT 2.5 mg, 13.67 dollars; and Zomig-ZMT 5 mg, 15.89 dollars. CONCLUSIONS: Practitioners can optimize the use of health care dollars without compromising quality of care through awareness of cost-saving treatment strategies, as well as price variations among medications.

Laboratory monitoring of OxyContin (oxycodone): clinical pitfalls.

Some patients have headaches that are refractory to standard treatments, and they require chronic administration of opioid analgesics. The use of opioids in a clinical setting must be closely monitored due to the medications' potential for addiction, abuse, and fatal interactions. Limited access to opioids and the demand for them outside the clinical setting leads to another danger. Patients can mislead their providers into prescribing opioids, intending to sell the medications instead of using them to alleviate their own pain. For protection of the patient, as well as the community, it is vital that such activity be prevented. We recently encountered a patient we suspected of abusing or misusing OxyContin (oxycodone). In order to determine whether the patient was taking the medication as prescribed, we ordered a urine-based immunoassay drug screen. The results were negative; the patient appeared to not have oxycodone in his system. Based on these results, we dismissed the patient from our practice. At the patient's request, a second test was performed, this time using gas chromatography-mass spectrometry. It indicated that the patient did indeed have sufficiently high levels of oxycodone in the urine. The minimum level threshold was too high to detect the presence of oxycodone in the immunoassay. We would like to help prevent future misunderstandings such as we experienced. To do so, we will first present the case of our patient, followed by a discussion of the actions taken. Finally, we will provide an overview of analgesic monitoring systems.

Rofecoxib in the prevention of perimenstrual migraine: an open-label pilot trial.

OBJECTIVE: To investigate the effectiveness of rofecoxib in the prevention of perimenstrual migraine. BACKGROUND: Nonsteroidal anti-inflammatory drugs have demonstrated benefit in reducing the frequency and intensity of menstrual migraine when administered perimenstrually. Anti-inflammatory drugs, however, may not be well tolerated and can produce gastrointestinal irritation. Rofecoxib, a selective cyclooxygenase-2 inhibitor, has anti-inflammatory and analgesic properties, and a significantly improved gastrointestinal tolerability profile. METHODS: A pilot study was conducted in which patients with a history of menstrually associated migraine and experiencing at least one migraine monthly during the perimenstrual period were enrolled. Patients who completed a baseline diary for the first month were randomized to receive either rofecoxib 25 mg or 50 mg daily for 10 days, starting 5 days before menstrual flow. Headaches experienced during this 10-day period were recorded in the patient's diary. Patients continued rofecoxib for 2 consecutive menstrual cycles. Mean migraine frequency, intensity, and duration as well as patient's level of functioning during the 2 cycles were compared with baseline. RESULTS: Fourteen patients completed baseline and rofecoxib dosing for 2 menstrual cycles. Mean migraine frequency decreased from 5.6 to 2.6 migraines per menstrual cycle (P=.005). Eight (57%) of 14 patients had a > or = 50% reduction in headache frequency. No significant improvement in headache intensity, duration, and functional impairment were observed. Both doses of rofecoxib were well tolerated with no statistical difference in patient response between the doses. CONCLUSION: Rofecoxib at a perimenstrual daily dose of 25 or 50 mg demonstrated a significant reduction in frequency of perimenstrual migraine. A double-blind, placebo-controlled trial of rofecoxib in the prevention of perimenstrual migraine is warranted.

Efficacy of topiramate in migraine prophylaxis: a retrospective chart analysis.

OBJECTIVE: Topiramate, a broad-spectrum anticonvulsant with multiple mechanisms of action, may be effective in preventing migraine headaches. We report the results of a retrospective chart review of patients treated with topiramate for prophylaxis of migraine. METHODS: Patients with a diagnosis of migraine who had at least one follow-up visit after > or =4 weeks on topiramate were eligible; 69 patients (56 women and 13 men) aged 18 to 68 years met these criteria. Charts were reviewed for frequency of mild or moderate/severe headaches at the start of topiramate (baseline) and at all subsequent visits up to 24 weeks. RESULTS: The 28-day frequency of moderate/severe migraines declined significantly from baseline to end of treatment (10.6 +/- 8.4 to 7.4 +/- 7.7, respectively; P = 0.0004), whereas that of mild headaches did not demonstrate a significant change (from 11.8 +/- 8.9 to 11.0 +/- 10.0). Among the 38 patients who had not responded previously to >or =9 preventive medications, the monthly frequency of moderate/severe (but not mild) headaches decreased significantly from baseline to end of treatment. Patients who previously had not responded to <9 prior medications experienced significant declines in both mild and moderate/severe headaches. The most common adverse events were paresthesias, drowsiness, diarrhea, decreased appetite, and weight loss. Twenty-seven patients discontinued topiramate therapy, 20 as a result of adverse events and 7 due to lack of response. CONCLUSION: Topiramate may be effective in reducing the frequency of both mild and moderate/severe migraine headaches. In particular, topiramate may offer relief to patients with moderate/severe migraines who do not respond to other treatments.