`
`ORIGINAL RESEARCH Aancus 7 .Etiatfsffiiltéilsfiiéfi _ ,
`o 2005 Adi: Dole lnformohon BV. All nghts reserved.
`
`
`
`
`
`‘
`Cost-Effectiveness Analysis of
`Rizatriptan and Sumatriptan versus
`Cafergot® in the Acute Treatment
`of Migraine
`
`Lihtta Zhrmg and [0:31 W. Hay
`
`Department of Pharmaceutical Economics and Policy, University of Southern California, Los
`Angeles, California, USA
`
`AbSlIGCl
`
`Background: Both ergotamine and selective serotonin 5-HTIBIED receptor ago-
`nists (‘triptans’) are currently used in the treatment of moderate to severe
`migraine. Ergotamine is a traditional therapy with a lower drug acquisition cost
`compared with triptans. It has been shown that triptans are more efficacious than
`ergotamine, but the higher acquisition costs and shorter duration of action are
`disadvantages of triptans compared with ergotamine.
`Objective: The purpose of this study was to provide a comparison of the
`cost-effectiveness of rizatriptan 10mg and sumatriptan 50mg tablets with that of a
`Fixed—dose combination of crgotamine tartrate plus caffeine (Cafergot®) in the
`treatment of an acute migraine attack. The cost~effectiveness of rizatriptan in
`comparison with sumatriptan was also assessed.
`Methods: Three separate decision tree models Were developed (model ]: riza»
`triptan vs Cafergot®; model 2: sumatriptan vs Cafergot®; model 3: rizatriptan vs
`sumatriptan). The time horizon was 1 year. Cost-effectiveness anaiysis was
`conducted from the societal perspective using cost and effectiveness estimates
`from the literature. All costs were converted to US dollars (2003). The costwcffec-
`tiveness ratio was expressed as incremental cost per quality-adjusted lifewyear
`(QALY) gained.
`Results: Base case evaluation showed that both rizatriptan and sumatriptan
`dominated Cafergot®. The net annual saving associated with use of rizatriptan
`was $U5622.98 per patient, with an incremental QALY of 0.001. Use of suma—
`triptan resulted in a saving of $US620.9G and an increase in QALY. The
`cost-effective ratios were not sensitive to changes in key variables such as
`efficacy, utility, drug costs, hospitalisation cost and patient preference over
`alternative therapies. The study further showed that rizatriptan is more cost
`effective than sumatriptan, as evidenced by its lower cost and greater effective-
`ness. Sensitivity analysis showed that the cost~effectiveness ratios were sensitive
`to moderate changes in drug efficacy.
`Conclusion: Rizatriptan and sumatriptan wore less costly and more effective than
`Cafergot® in the treatment of an acute migraine attack. Rizatriptan was somewhat
`less costly and more effective than sumatriptan Additional quality—of—lifc studies
`
`Page 1 of 8
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`|M~Zelg~mw
`DEPOSITION
`
`EXHIBIT
`
`Biogen Exhibit 2207
`Mylan v. Biogen
`IPR 2018-01403
`
`Page 1 of 8
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`Biogen Exhibit 2207
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`

`

`636
`Zirmrg 15’ Hay
`
`are needed to confirm the benefits of using triptans in the management of
`migraine.
`
`Background
`
`Migraine is a common illness characterised by
`periodic headache that may be accompanied by vis~
`ual and auditory disturbances. It affects approxi-
`mately 18% of women and 6% of men in the US.”
`Migraine occurs most commonly between the ages
`of 25 and 55 years in both men and women.“ From
`an economic vieWpoint, these years of an individu-
`al’s life are potentially the most productive.
`Migraine has a huge social economic impact. The
`annual cost of migraine totals about $14 billion in
`the US alonelz] Indirect costs as a result of lost
`
`productivity are substantial and comprise up to
`75~90% of total costs. This is largely attributable to
`modest
`rates of medical
`consultation by mi»
`grairteurs.[3] A population-based 'study showed that
`19—44% of migraineurs never consult a doctor?“ In
`terms of the type of medical resources utilised by
`migraine patients, general practitioners figure most
`Frequently. Emergency room (ER) visits and spe—
`cialist care services also play important roles in the
`treatment of migrainelsm
`Migraine can have a substantial impact on an
`individual’s quality of life (QOL). It has been shown
`that migraineurs’ QOL scores are even lower than
`those for other patients with chronic conditions such
`as arthritis, diabetes meliitus, back pain and depres-
`sionmAs migraine is episodic, patients experience
`not only pain during acute attacks but aEso anxiety
`associated with the prospect of future attacks. In
`addition, migraineurs are at increased risk of devel-
`oping depression and other co-morbid conditions
`that would further contribute to their reduced health
`statuslsl
`
`Over the last decade, there have been considera»
`
`ble advances in the understanding and treatment of
`migraine. The advent of effective new treatments
`makes the prospect of adequately treating patients
`quite promising, which in turn will lead to a signifi—
`cant reduction in the overall economic and health-
`
`care burden of migraine.
`
`Among all the achievements in migraine man-
`agement, the development of the selective serotonin
`5—HT; 13m) receptor agonists (‘triptans’) has resulted
`in the greatest breakthrough in the treatment of acute
`migraine headache. The development of suma—
`triptan,
`the first drug in this group, dramatically
`changed acute migraine treatment. To date, seven
`triptans have become availabie in the US: almo-
`triptan, eietriptan,
`frovatriptan, naratriptan,
`riza~
`triptan, sumatriptan and zolmitriptan. Generally,
`triptans are highly effective in relieving the pain and
`nausea of a migraine attack and thus reducing work
`productivity loss. Other available treatments for mi-
`graine headache include ergotamine, NSAIDs and
`combination analgesics. Both ergotamine and the
`triptans are recommended by current medical stan—
`dards for the acute treatment of moderate to severe
`
`migraine. Analgesics, NSAIDs, and an anti-nausea
`agent are recommended for the treatment of mild to
`moderate migraine attacks.“
`Because of the associated economic impact of
`migraine and its negative impact on the health—
`related QOL of patients, the cost-effectiveness anal-
`ysis of migraine management is of great interest.
`However, while several cost—effectiveness studies of
`
`triptans in migraine are available}”"”‘1 most of these
`did not address QOL in migraine patients and com-
`parisons were generally limited to two treatment
`alternatives. Comparisons of the cost~effectiveness
`of different triptans are rare. In these studies,“°v'2'*3i
`the denominators of the cost-effectiveness ratios
`
`were usually expressed in traditional clinical out-
`comes related to headache relief instead of quality-
`adjusted life-years (QALYS).
`
`Purpose of the Study
`
`With so many drugs available for the treatment of
`acute migraine and only a limited number of cost-
`effectiveness studies in this field, an economic eval—
`uation of drugs used in the management of acute
`migraine is timeiy and necessary.
`
`’C 2005 Adis Data InformGIiOn 3V. Ali rights reserved.
`
`CNS Drugs 2005: I? (7‘)
`
`Page 2 0f 8
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`

`

`Cost Effectiveness of Rizatriptan and Sumatriptan versus Cafergot® in Acute Migraine
`
`
`Although triptans have demonstrated efficacy in
`the treatment of migraine, high acquisition cost and
`a short duration of actioan’” remain the major
`disadvantages of these drugs. The latter property
`results in a substantial probability of headache re—
`currence during a singie migraine attack. Among
`triptans, sumatriptan was the first to be developed
`and tested. It has been shown to be weil tolerated
`
`and effective in treating acute migraine headache?“
`Rizatriptan is a relatively new drug in this group and
`has proved to be more efficacious than suma-
`triptanlflzz] Furthermore, current research shows
`that rizatriptan, which is available as an oral disinte-
`grating tabiet formula, is preferred over sumatriptan
`by migraine patients}2 '1 Eletriptan has demonstrated
`similar efficacy to rizatriptan, but is less well tolerat-
`ed. Other triptans such as naratriptan and from-
`triptan demonstrated inferior response rates when
`compared with sumatriptanlzz] For these reasons we
`chose to compare surnatriptan, the original triptan
`product with the most extensive supporting research
`and patient experience, and rizatriptan, which is
`slightly preferable among the newer triptans on the
`basis of its tolerability and efficacy. However, for
`any individual patient, therapy outcomes are varia-
`ble, so that some triptans (e.g. eletriptan or almo-
`triptan) may be preferred to rizatriptan by some
`patients.
`Er‘gotamine is a traditional therapy for migraine
`and is widely available. Despite the introduction of
`the triptans, Cafergot®1 (combination of organ-
`
`mine and caffeine) is stilt a frequently prescribed
`migraine treatment throughout much of the world
`because of its low cost (compared with triptans).
`Therefore, in our study, we compared the cost—
`effectiveness of rizatriptan 10mg oraity disintegrat-
`ing tablets and sumatriptan 50mg tabiets with
`Cafergot® (ergotamine 1mg/caffeine 100mg) tablets
`in the treatment of an acute. migraine attack. A
`comparison of rizatriptan with sumatriptan was also
`performed. Since QOL is an important dimension in
`the assessment of treatment response,
`this study
`evaluated QALYS explicitly in the cost-effective-
`ness analysis.
`
`Methods
`
`This cost—effectiveness analysis was conducted
`from a societal perspective for the US migraine
`patient cohort. The time horizon was 1 year, obviat—
`ing the need for discounting of costs and treatment
`effects. Extension of the data to other countries
`
`would be straightforward to calculate, taking into
`account primarily differences in treatment costs and
`drug prices.
`
`Model and Probobiii’ry
`
`A decision tree was constructed to simulate po-
`tential outcomes once a patient suffers from an acute
`migraine attack (figure 1). Upon the initial migraine
`headache attack, a patient could decide to take riza-
`triptan 10mg, sumatriptan 50mg or Cafergot® 2mg!
`
`:Rizati'iptan
`‘3'or-.'- '2
`
`' "Eor -
`
`'
`
`
`
`No 'r'eclitre_ti¢e"'.-55J
`
`
`'itéiiéve'sj by taking
`
`Sew-"em
`3
`-- more o: the raster drug
`
`
`
`_.;_-tsn_a_a,;e stage
`
`
`
`
`_
`
`-
`
`_:
`
`
`
`
`"'_C:aiergot“f"_ 3.
`
` -.
`5; EFt'visit: .
`
`I Hospitalisalion
`
`-FteliefatL-“.R
`
`:-
`
`'
`
`
`
`.
`
`
`
`
`Fig. 1. Decision tree for the acute treatment of a first migraine attack. EFi = emergency room.
`
`1 The use of trade names is for product identification purposes only and does not imply endorsement.
`
`a 2005 Adis Data information BV. All rights reserved.
`
`CNS Drugs 2005: i9 (7)
`
`Page 3 0f 8
`
`Page 3 of 8
`
`

`

`638
`lermg 8 Hay
`
`Tabie I. Description of outcomes and utilities associated with acute therapies tor a migraine attackl‘“
`
` Outcome Utility Description
`
`A
`1
`Headache relieved by first administration of first medication, no recurrence
`8
`0.9
`Headache relieved by tirst administration of first medication, with recurrence
`C
`O
`Headache not relieved by first administration of first medication, patient chooses
`to endure attack
`
`D
`
`0.1
`
`Headache not relieved icy first administration of first medication. headache
`relieved at ER
`'
`
`Headache not relieved at ER. patient needs hospitalisation
`0
`E
`ER = emergency room.
`
`200mg for acute migraine headache relief, leading
`to different outcomes as described in table I. Each
`
`compared with Cafergot®. The probabilities of these
`events are shown in table II and table 111.
`
`migraine drug is given once to abort an attack. A
`second dose can be given if headache recurs. A
`patient who does not experience relief from the first
`dose of each drug will either choose to endure the
`headache or go to the ER. When a patient chooses to
`endure the attack, no other treatments are taken. If
`
`the headache is not reiieved at the ER, hospitalisa-
`tion is required. Upon the second and following
`attacks, the patient can either stay with the same
`medication used for the first attack or switch to
`another medication.
`
`Three models were developed based on the deci—
`sion tree shown in figure 1. These were: model 1 —
`rizatriptan vs Cafergot®; model 2 — sumatriptan vs
`Cafergot®; model 3 — rizatriptan vs sumatriptan. For
`rizatriptan and sutnatriptan,
`the probabilities of
`acute relief (i.e. headache response at 2 hours) after
`medication and of headache recurrence within 24
`
`hours were obtained from the meta—analysis of 53
`trials of triptans by Ferrari ct aim] Headache re-
`sponse and recurrence rates for Cafergot® were
`obtained from the Multinational Oral Sumatriptan
`and Cafergot® Comparative Studylfl] Probabilities
`of going to the ER and hospitalisation were deduced
`from statistics showing the annual ER utilisation of
`migraine patients?” annual attack frequency/[”35]
`and triptan efficacy datami The probability of
`switching therapy during subsequent attacks was
`derived from the results of patient preference stud-
`iesm‘z"! Since there is no preference study compar-
`ing sumatriptan with Cafergot®, we assumed the
`preference rate for sumatriptan compared with
`Cafergot® would be the same as that of rizatriptan
`
`Utility Measure
`
`Because of the temporary nature of a migraine
`attack,
`it
`is difficult
`to capture patients’ utility
`change during the short period of an attack. Some
`instruments (cg. 24-hour Migraine Quality of Life
`Questionnaireml) have been specifically devised to
`measure the QOL of migraine patients during the
`24-hour period after the onset of headache attacks.
`
`Table II. Probabilities of events at a first migraine attack
`Event
`Drug
`Probability (%)
`Headache reliei alter first
`Rizatriptan
`68.6
`administrationlzz'zal
`Sumatriptan
`62.7
`Cafergottfl
`37.9
`Rizatriptan
`36.9
`Sumatriplan
`27.8
`Cafergot®
`15.3
`90
`
`Headache recurrertcei‘zz-E‘31
`‘
`
`Probability of enduring
`headache it headache not
`retieved by first
`administrationl‘4-22-94-351
`
`'
`
`Adverse eventsmzs]
`
`Dizziness
`
`Nausea
`
`Somnolence
`
`Chest pain
`'
`
`Fiizatriptan
`Sumatriptan
`Caiergot®
`Flizatriptan
`Sumatriptan
`Caiergot®
`Rizatriptan
`Sumatriptan
`Caiergot®
`Rizatriptah
`Sumalriptan
`Cafergot®
`
`5.7
`5.8
`5.3
`4.2
`6.9
`8.5
`5.5
`6.7
`2.3
`0.?
`2.4
`0.8
`94
`
`Probability oi headache relief
`in ERm22,24.251
`ER = emergency room.
`
`c 2005 Adis Data Information BV, Ail rights reserved.
`
`CNS Drugs 2005: i9 (7)
`
`Page 4 0f 8
`
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`

`

`Cost Effectiveness of Rizatriptan and Sumatrt'ptan versus Cafergot® in Acute Migraine
`
`639
`
`
`Table III. Probability of switching therapy during second and subse-
`quent migraine attacksimrzsl
`Probability
`Treatment options
`Treatment comparison
`(“/0)
`Rizalnptan vs Cafergofl‘)
`Flizatriptan
`
`CatergottE‘
`
`Rizarriptan vs sumatriptan
`Rizatriptan
`
`Sumatriplan
`
`69.9
`Keep taking rizatriptan
`30.1
`Switch to Calergot®
`Keep taking Cafergotl’t 30.!
`Switch to rizatriptan
`69.9
`
`Keep taking rlzatriptan
`Switch to sumatriptan
`Keep taking
`sumatriptan
`Switch to rizatriptan
`
`64.3
`35.7
`35.?
`
`64.3
`
`Sumatrrptan vs Cril‘r-irgm'E “
`Sumatriptan
`
`69.9
`
`Keep taking
`sumatriptan
`30.1
`Switch to Cafergotl‘D
`Keep taking Caiergot® 30.!
`Switch to sumatriptan
`69.9
`in the absence at specific data, prelerence rates for
`sumata‘ptan versus CalergottE were assumed to be the same
`as lor rizalrlptan versus Cafergott‘flfiml
`
`Cafergot®
`
`a
`
`However, there is only modest correlation between
`measurements on these instruments and those of
`
`other scales, such as disability measureslzsl Without
`a transformation algorithm, it is also impossible to
`convert QOL measures to health utility to be used
`for QALY calculations. Therefore, in this analysis,
`we adopted the utility values from the study by
`Evans et ai.“” In that study, the investigators de-
`rived utility values associated with each outcome
`
`using the Quality of Well-Being measure?” Utili-
`ties ofdifferent outcomes associated with each treat—
`
`ment arms are showed in table i. However, we
`assigned the utility of hospitalisation as zero instead
`of adopting the negative utility number used in the
`study by Evans et al.“” This is because health
`economics researchers are generally opposed to
`negative utilities
`(implying that certain disease
`states are even worse than death). For the purposes
`of resource allocation it makes little sense to spend
`money to improve someone’s health from a state
`worse than death to that of death, given that there are
`substantial unmet needs among patients with posi—
`tive levels of health utility.
`
`Although there might have been additional QA-
`LY loss during the non-migraine time (because of
`anxiety and distress between migraine attacks), this
`was not factored into calculations of incremental
`
`QALY in this study because of the lack of published
`data measuring patients’ utilities over a long period
`of time (eg. 1 year) for different treatment options.
`Since most migraine headaches are relieved during
`hospitalisation, if not in the ER, the probability of a
`patient experiencing anxiety or distress during non—
`migraine time would be the same for different treat—
`ment arms. Therefore, it was assumed that the addi—
`
`tional difference in QALYs occurring between mi—
`graine attacks for different treatment arms would be
`cancelled out unless treatment options exerted large
`differential effects on patients’ utility between mi-
`graine attacks.
`
`Costs
`
`Reflecting a societal perspective, costs were
`evaluated for relief from migraine attack after the
`first dose of medication, for subsequent doses of
`medication if headache recurred, and for subsequent
`ER visit and hospitalisation. All costs were ex-
`pressed in US dollars (2003). Direct costs included:
`(i) physician visit cost; (ii) drug acquisition cost; and
`(iii) cost of hospital drugs and medical supplies.
`Indirect costs included patient
`travel and waiting
`time.
`
`The cost of visiting a physician was obtained
`from the Resource-Based Relative Value Scaie
`
`(RBRVSN-wl We assumed that patients needed to
`visit a physician during subsequent attacks only if
`they wanted to switch to an alternative therapy.
`Drug acquisition costs were from the 2003 Red
`Book (Average Wholesale Price [AWPDP‘H We
`discounted the AWP by 20% since most people
`belong to health plans that receive substantial dis-
`_ counts from AWP. The cost to treat migraine in the
`ER, based on physician and facility fees for 3 hours,
`was obtained front the study of Linbo et {11.931 This
`ER cost did not include medication and potential
`EEG costs. Therefore, we added the costs of EEG
`and medications, which include intravenous (IV)
`dihydroergotamine, metoclopramide and IV fluids.
`
`a“. 2005 Adis {Data information BV. All rights reserved.
`
`CNS Drugs 2005: 19 (7)
`
`Page 5 0f 8
`
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`

`

`2110123 8 Hay
`
`
`Table N. Cost estimates for the first migraine attack
`Direct costs
`Unit cost (SUS)
`Visit to physician’s olficelzi
`43.81
`Pharmacist dispensing teem
`3.21
`Migraine drug acquisitionli"i
`Flizatriptan 10mg ODT
`Sumatriptan 50mg tablet
`Cafergotit) 2mgi200mg
`Dimenhydrinate 50mg
`Adverse effect
`
`14.35
`14.30
`1.84
`0.51
`
`Ftizatriptan
`Sumatriptan
`Cafergot®
`ER cosh“!
`
`Hospitalisation costi331
`Indirect cost
`
`0.19
`0.64
`0.22
`1092.78
`
`4851.70
`
`17.75101
`Patient travel and waiting timeia‘“
`EFl = emergency room; ODT = orally disintegrating tablet.
`
`Attack frequency was assumed to be 36 times per
`yearling About one-half of these attacks are mod-
`erate to severedl ‘1 therefore, the attack frequency of
`moderate to severe migraine was 18 times per year
`(the number that was used in the above formulae).
`
`Sensitivity Analysis
`
`Because of the uncertainty of the parameters,
`sensitivity analysis was conducted to test whether
`the model was sensitive to changes of particular
`variables. Univariate sensitivity analysis was carried
`out on key parameters including drug cost, cost of
`hospitalisation, utility associated with each outcome
`(but not hospitalisation), efficacy of each medica»
`tion, probability of headache relief in the ER and
`probability of switching therapy at subsequent at-
`tacks.
`
`as set out
`
`in the 2003 Red Book. The costs of
`
`Results
`
`hospitalisation were obtained from a study of health—
`care utilisation by migraine patients from a Medi—
`caid population?“ The costs of treating adverse
`effects were based on hospitalisation costs as a
`result of cardiovascular events. Calculations of pa-
`tient travel and waiting time costs were based on
`average hourly compensation rates for all occupa—
`tions from the US Bureau of Labor Statistics?“
`
`Cost estimates are provided in tabie IV.
`
`Cost-Effectiveness Analysis
`
`Cost—effectiveness analysis was performed using
`the following formulae:
`1. QALY a [expected utility of the first attack +
`expected utility of the following attacks x (annual
`attack frequency -1) 4- expected utility of non—
`migraine days]/365;
`2. Incremental QALYS = difference in QALY in
`each treatment arm;
`
`3. Expected annual costs 2 expected costs of the first
`attack + expected costs of the following attacks ><
`(annual attack frequency -1);
`4. Incremental costs = difference in expected annual
`costs in each treatment arm;
`5. incremental cost—effectiveness ratio = incremen—
`
`tal costs/incremental QALYs.
`
`Base-Case Evaluation
`
`the use of both
`Front the societal perspective,
`rizatriptan and sumatriptan resulted in savings (neg-
`ative incremental cost) and improved health out-
`comes compared with Cafergot®. Use of these two
`triptans for the treatment of an acute migraine attack
`resulted in negative cost-effectiveness ratios. There-
`fore, triptans were strictly dominant in the treatment
`of acute migraine compared with Cafergotfl The
`study further showed that rizatriptan dominates su—
`matriptan, as evidenced by the negative cost—
`effectiveness ratio (table V).
`
`Sensitivity Analysis
`
`Sensitivity analysis showed that from the societal
`perspective, the cost-effective ratios were not sensi-
`
`Tabte V. Cost-ehectiveness base case evaluations treat the socie-
`tal perspective
`Model
`
`Incremental
`cost SUS
`4322.98
`Rizatriptan vs Calergot®
`4520.90
`Sumatriptan vs t’Jalergota
`-433.45
`Fiizatriptan vs sumatriptan
`QALY = quality-adjusted lite-year.
`
`incremental
`QALY
`0.0010
`0.0007
`0.0001
`
`e 2005 Adis Data Information BV. All rights reserved.
`
`CNS Drugs 2005: 19 (7)
`
`Page 6 0f 8
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`

`Cost Effectiveness of Rizatriptan and Sumatriptan versus Cafergot® in Acute Migraine
`
`
`641
`
`tive to changes in key variables, including drug—
`acquisition costs, hospitalisation cost, probabilities
`of headache relief at the ER and patient preference
`over'alternative therapies. The results of the rim-
`triptan versus sumatriptan model were sensitive to
`moderate changes in efficacy. Assuming that other
`parameters remain unchanged, at 5% decrease in the
`efficacy of rizatriptan would make it no better than
`sumatriptan (data not shown in tabie V). Although
`the uncertainty of utility measure was of major
`concern, sensitivity analysis showed that all three
`cost-effectiveness
`ratios were not
`sensitive to
`
`changes in this specific parameter.
`
`Discussion
`
`the study result might be
`from only one study,
`limited and thus generalisation of the result remains
`a problem. Another problem arises from the QOL
`measurement in migraine patients. As migraine is an
`episodic event, patients’ QOL is affected, not only
`during attacks, but also between attacks. Because of
`the lack of data of this kind for all treatment options
`discussed in this study, we were unable to take into
`account possible changes in patients’ QOL between
`attacks. Finally, there is insufficient head—to—head
`clinical data to conclusively rank all triptans for alt
`patients. It is quite likely that certain patients re-
`spond better to some triptans than others in ways
`that are not fully captured in existing reported
`clinical studies.
`
`In this study, we applied the technique of deci—
`sion tree modellingml to assess the cost-effective—
`ness of rizatriptan and sumatriptan versus Cafergot®
`in the acute treatment of migraine. Based on cost
`data in the US and taking a societal perspective, our
`study showed that treating acute migraine with riza-
`triptan and sumatriptan instead of Cafergot® was
`cost effective. This result was consistent with previ—
`ous research conducted by Evans et alfilu In their
`study of a Canadian population, they showed that
`from the social perspective, using sumatriptan in-
`stead of caffeine/ergotamine resulted in an incre-
`mental cost of $Canl675 and an incremental QALY
`of 0.22 per patient per year However, these investi-
`gators did not incorporate the possibility of switch—
`ing therapy during subsequent attacks in their analy-
`sis.
`
`We further compared the cost-effectiveness of
`rizatriptan and sumatriptan in the acute management
`of migraine. According to our model, the use of
`rizatriptan results in both net savings and increased
`QALYs. It should be pointed out that the fact that
`modelled patients are assumed to switch to riza-
`triptan for subsequent attacks actually reduces the
`differences between the therapies, since rizatriptan
`dominates sumatriptan.
`Our study has some limitations. It was based on
`several assumptions made about the utility of differ—
`ent outcomes associated with alternative therapies
`of migraine. As the utility values were obtained
`
`Conclusion
`
`This study showed that rizatriptan and surna—
`triptan are both more cost—effective than Cafergot®
`in the treatment of an acute migraine attack. Riza-
`triptan was also demonstrated to be somewhat more
`cost—effective than sumatriptan. However,
`future
`head—to-head triptan clinical trials and QOL studies
`are needed to confirm the benefits of using specific
`triptans in the management of migraine.
`
`Acknowledgements
`
`Financiai support for this research was provided by Merck
`in an unrestricted educational grant. The authors have no
`further conflicts of interest that are directly relevant to the
`content of this study.
`
`La)
`
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`Correspondence and offprints: Dr 1001 W. Hay, Department
`of Pharmaceutical Economics and Policy, University of
`Southern California, 1540 Alcazar Street, CHP—HG, Los
`Angeles, CA 90089-9004, USA.
`Email: jhay@use.edu
`
`© 2005 Adis Data information BV. Ail rights reserved.
`
`CNS Drugs 2005: 19 (7)
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