`
`ORIGINAL RESEARCH ARTICLE| 172204eybonHDosersanfa . .
`© 2005 Adis Data Information BV. All ights reserved.
`
`
`
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`Cost-Effectiveness Analysis of
`Rizatriptan and Sumatriptan versus
`Cafergot® in the Acute Treatment
`of Migraine
`Lihua Zhang and Joel W. Hay
`Department of Pharmaceutical Economics and Policy, University of Southern California, Los
`Angeles, California, USA
`
`Abstract
`
`Background: Both ergotamine andselective serotonin 5-HT pip receptor ago-
`nists (‘triptans’) are currently used in the treatment of moderate to severe
`migraine. Ergotamineis a traditional therapy with a lower drug acquisition cost
`compared withtriptans. It has been shownthattriptans 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 ofrizatriptan 10mg and sumatriptan 50mg tablets with that of a
`fixed-dose combination of ergotamine 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 1: riza-
`triptan vs Cafergot®; model 2: sumatriptan vs Cafergot®; model 3: rizatriptan vs
`sumatriptan). The time horizon was 1 year. Cost-effectiveness analysis was
`conducted from the societal perspective using cost and effectiveness estimates
`fromthe literature. All costs were converted to US dollars (2003), The cost-effec-
`tiveness ratio was expressed as incremental cost per quality-adjusted life-year
`(QALY) gained.
`Results: Base case evaluation showed that both rizatriptan and sumatriptan
`dominated Cafergot®. The net annual saving associated with use ofrizatriptan
`was $US622.98 per patient, with an incremental QALY of0.001. Use of suma-
`iriptan resulted in a saving of $US620.90 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 thatthe cost-effectiveness ratios were sensitive
`to moderate changes in drug efficacy.
`Conclusion: Rizatriptan and sumatriptan were less costly and more effective than
`Cafergot® in the treatmentof an acute migraine attack. Rizatriptan was somewhat
`less costly and more effective than sumatriptan. Additional quality-of-life studics
`
`s
`
`[2-1 8.01%5
`DEPOSITION
`EXHIBIT
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`a& Za2oau
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` Zhung & 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 alone.) 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-
`graineurs.©] 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 importantroles in the
`ireatment of migraine,5-6]
`Migraine can have a substantial impact on an
`individual’s quality of hfe (QOL). It has been shown
`ihat migraineurs’ QOL scores are even lower than
`those for other patients with chronic conditions such
`as arthritis, diabetes mellitus, back pain and depres-
`sion.“JAs migraine is episodic, patients experience
`not only pain during acute attacks but also anxiety
`associated with the prospect of future attacks. In
`addition, migraineurs are ai increased risk of devel-
`oping depression and other co-morbid conditions
`that would further contribute to their reduced health
`status.@1
`
`Overthe 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 overal] economic and health-
`care burden of migraine.
`
`Among all the achievements in migraine man-
`agement, the developmentof the selective serotonin
`5-HTigp receptor agonists (‘triptans’) has resulted
`in the greatest breakthrough inthe treatmentof 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 available in the US: almo-
`triptan, eletriptan,
`frovatriptan, naratriptan,
`riza-
`iriptan, sumatriptan and zoimitriptan. 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 mnclude 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 recommendedforthe treatment of mild to
`moderate migraine attacks.!!
`Because of the associated economic impact of
`migraine and its negative impact on the health-
`related QOL ofpatients, the cost-effectiveness anal-
`ysis of migraine management is of great interest.
`However, while several cost-effectiveness studies of
`triptans in migraine are available!!¢!®! 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,{0!2-38]
`the denominators of the cost-effectiveness ratios
`were usually expressed in traditional clinical out-
`comes related to headacherelief instead of quality-
`adjusted life-years (QALYs).
`
`Purpose of the Study
`
`With so many drugs available forthe treatment of
`acute migraine and only a limited numberof cost-
`effectiveness studies in this field, an economic eval-
`uation of drugs used in the management of acute
`migraine is timely and necessary.
`
`© 2005 Adis Data information BV. Al rights reserved,
`
`CNS Drugs 2008: 19 (7)
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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 action!!!!9} remain the major
`disadvantages of these drugs. The latter property
`results in a substantial probability of headache re-
`currence during a single 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.
`Rizatriptanis a relatively new drug in this group and
`has proved io be more efficacious than suma-
`triptan.2!22] Furthermore, current research shows
`that rizatriptan, whichis available as anoral disinte-
`grating tablet formula, is preferred over sumatriptan
`by migraine patients.? Eletriptan has demonstrated
`similar efficacy to rizatriptan, but is less well tolerat-
`ed. Other triptans such as naratriptan and frova-
`triptan demonstrated inferior response rates when
`compared with sumatriptan.) For these reasons we
`chose to compare sumatriptan, the original triptan
`product with the most extensive supporting research
`and patient experience, and rizatriptan, which is
`slightly preferable among the newertriptans 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.
`Ergotamine 1s a traditional therapy for migraine
`and is widely available. Despite the introduction of
`the triptans, Cafergot®! (combination of ergota-
`
`mine and caffeine) is still 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 orally disintegrat-
`ing tablets and sumatriptan 50mg tablets with
`Cafergot® (ergotamine lmg/caffeine 100mg)tablets
`in the treatment of an acute. migraine attack. A
`comparison of rizatriptan with sumatriptan was also
`performed. Since QOLis an Important dimensionin
`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 | 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 Probability
`
`A decision tree was constructed to simulate po-
`tential outcomes oncea patient suffers from an acute
`migraine attack (figure 1). Uponthe initial migraine
`headache attack, a patient could decide to take riza-
`triptan 16mg, sumatriptan 50mg or Cafergot® 2mg/
`
`
`
`:
`
`
`
`
`
`
`Shorts:
`: ‘Calergot™ .
`
`
`
`“Norecurrence|!
`
`eoRelief
`
`
`
`“Rizatriptan *.
`‘Relievedbytaking
`
`
`eg) Beourrenee i:
`“more of theinitial drug
`a SEOr sss
`
`
`
` “Endure altack
`
` “Norelief
`
`i.) ReliefatER .
`
`USERVisit
`
`Hospitalisalion
`
`
`
`Fig. 1. Decision trea for the acute treatment of a first migraine attack. ER = emergency room.
`
`1 The use of trade namesis for product identification purposes only and does not imply endorsement.
`
`© 2005 Adis Data Inforrnation BV. Al rights reserved.
`
`CNS Brugs 2008; 19 (7)
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`638
`Zhang & Hay
`
`Tabie !. Description of outcomes and utilities associated with acute therapies for a migraine attack!"
`Outcome
`Utility
`Description
`A
`1
`Headache relieved by firsi administration of first medication, no recurrence
`B
`0.9
`Headache relieved byfirst administration of first medication, with recurrence
`Cc
`0
`Headache notrelieved by first administration of first medication, patient chooses
`to endure attack
`
`D
`
`01
`
`Headachenotrelieved by first administration of first medication, headache
`relieved at ER
`
`0
`E
`Headache notrelieved at ER, patient needs hospitalisation
`
`ER = emergency room.
`
`200mg for acute migraine headache relief, leading
`to different outcomes as described in table I. Each
`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 orgo to the ER. Whena patient chooses to
`endure the attack, no other treatments are taken. If
`the headacheis not relieved at the ER, hospitalisa-
`lion 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 sumatriptan,
`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 et al.!?) Headache re-
`sponse and recurrence rates for Cafergot® were
`obtained from the Multinational Oral Sumatriptan
`and Cafergot® Comparative Study.) Probabilities
`of going to the ER and hospitalisation were deduced
`fromstatistics showing the annual ER utilisation of
`migraine patients,?4} annual attack frequency!!+75)
`and triptan efficacy data.2#! The probability of
`switching therapy during subsequent attacks was
`derived from the results of patient preference stud-
`ies.'!24Since 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
`
`compared with Cafergot®. The probabilities of these
`events are shownin table I and table IZ.
`
`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 (e.g. 24-hour Migraine Quality of Life
`Questionnaire?7) have been specifically devised to
`measure the QOL of migraine patients during the
`24-hour period after the onset of headacheattacks.
`
`Headache recurrence!?23!
`,
`
`Table Ji. Probabilities ot events at a first migraine attack
`Event
`Drug
`Probability (%)
`Headacherelief after first
`Rizatriptan
`68.6
`administration!#2291
`Sumatriptan
`62.7
`Cafergat®
`37.9
`Rizatriptan
`36.9
`Sumatriptan
`27.8
`Cafergot®
`15.3
`90
`
`Probability of enduring
`headache if headache not
`relieved by first
`administration!4.22.24.25)
`
`.
`
`Adverse eventsl21.25]
`
`Dizziness
`
`Nausea
`
`Somnalence
`
`Chest pain
`’
`
`Probability of headacherelief
`in ER422.24.25)
`ER = emergency room.
`
`Rizatriptan
`Sumatriptan
`Calergot®
`Rizatriptan
`Sumatriptan
`Cafergat®
`Rizatriotan
`Sumatriptan
`Cafergot®
`Rizatripian
`Sumatziptan
`Calergot®
`
`87
`5.8
`5.3
`4.2
`6.9
`8.5
`5.5
`67
`2.3
`OF
`24
`0.8
`94
`
`© 2005 Adis Data Infermatian BY, Ail rights reserved.
`
`CNS Grugs 2005: 19 (7)
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`Cost Effectiveness of Rizatriptan and Sumatriptan versus Cafergot® in Acute Migraine
`
`639
`
`
`Table Wl. Probability of switching therapy during second and subse-
`quent migraine attacks®161
`Probability
`Treatment options
`Treatment comparison
`()
`Rizairiptan vs Cafergot®
`Rizatriptan
`
`Cafergoie
`
`Aizatripian vs sumatriptan
`Rizatiptan
`
`Sumatriptan
`
`69.9
`Keep taking rizatriplan
`30.4
`Switch to Cafergai®
`Keep taking Cafergot® 30.1
`Switch to rizatriptan
`69.9
`
`Keep taking rizatriptan
`Switch to sumatriptan
`Keep taking
`sumatriptan
`Switch to rizatriptan
`
`64.3
`35.7
`35.7
`
`64.3
`
`Sumatriptan vs Gafergot® 4
`Sumatriptan
`
`69.9
`
`Keep taking
`sumatriptan
`30.1
`Switch to Cafergot®
`Keep taking Cafergat® 30.1
`Switch to sumatriptan
`69.9
`[n the absence of specific data, preference rates for
`sumatriptan versus Cafergot® were assumed to be the same
`as for rizatriptan versus Cafergcot®.!24)
`
`Cafergot®
`
`a
`
`However, there is only modest correlation between
`measurements on these instruments and those of
`other scales, such as disability measures.23) Without
`a wansformation algorithm, it ig 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!"l In that study, the investigators de-
`rived utility values associated with each outcome
`using the Quality of Well-Being measure.?") Usili-
`lies ofdifferent outcomes associated with eachtreat-
`ment arm§ are showed in table I. However, we
`assigned the utility of hospitalisation as zero instead
`of adopling 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 makeslittle 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 fevels 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
`QALYinthis study because of the lack of published
`data measuring patients’ utilities over a long period
`of time (e.g. 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.
`
`Cosis
`
`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; (11) drug acquisition cost; and
`(ili) cost of hospital drugs and medical supplies.
`Indirect costs included patient
`travel and waiting
`time,
`The cost of visiling a physician was obtained
`from the Resource-Based Relative Value Scale
`(RBRVS).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 [AWP]).64 We
`discounted the AWP by 20% since most people
`belong to health plans that receive substantial dis-
`_ counts from AWP.The costto treat migraine in the
`ER,based on physician and facility fees for 3 hours,
`was obtained from the study of Linbo et al"! This
`ER cost did not include medication and potential
`EEG costs. Therefore, we added the costs of EEG
`and medications, which include intravenous (FV)
`dihydroergotamine, metoclopramide and IV fluids.
`
`© 2005 Adis Sata Information BY. All rights reserved.
`
`CNS Drugs 2005; 19 (7)
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`
`
`Zhang & Hay
`
`Table IV. Cost estimates for the first migraine attack
`Direct costs
`Unit cost (SUS)
`43.81
`3.21
`
`14.35
`14.30
`1.84
`0.51
`
`0.19
`0.64
`0.22
`1092.78
`
`4851.70
`
`Visit to physician’s office!®!
`Pharmacist dispensing teel*l
`Migraine drug acquisition"
`Rizatriptan 10mq ODT
`Sumatripian 50mg tablet
`Calergot® 2mg/200mg
`Dimenhydrinate 50mg
`Adverse effect
`
`Rizatriptan
`Sumatriptan
`Cafergot®
`ER cost!*!
`
`Hospitalisation cost!)
`Indirect cost
`
`17.75
`Patient travel and wailing time!
`ER = emergency room; ODT = orally disintegrating tablet.
`
`as set out
`in the 2003 Red Book. The costs of
`hospitalisation were obtained from a study of health-
`care utilisation by migraine patients from a Medi-
`eaid population.54! 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 LaborStatistics.4)
`Cost estimates are provided in table IV.
`
`Cost-Effectiveness Analysis
`
`Cost-effectiveness analysis was performed using
`the following formulae:
`1. QALY = [expected utility of the first attack +
`expected utility of the following attacks x (annual
`attack frequency —1) + expected utility of non-
`migraine days]/365;
`2, Incremental QALYs = difference in QALY in
`each treatment arm;
`3, Expected annual costs = expected costsof the first
`attack + expected costs of the following attacks x
`{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.
`
`Attack frequency was assumedto be 36 times per
`year.!325] About one-half of these attacks are mod-
`erate to severe; 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.
`
`Results
`
`Base-Case Evaluation
`
`the use of both
`Fromthe 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 forthe treatment of an acute migraine attack
`resulted in negative cost-effectiveness ratios. There-
`fore, triptans were strictly dominantin the treatment
`of acute migraine compared with Cafergot®. The
`study further showed that rizatriptan dominates su-
`matripian, as evidenced by the negative cost-
`effectiveness ratio (lable V).
`
`Sensitivity Analysis
`
`Sensitivity analysis showed that fromthe societal
`perspective, the cost-effective ratios were not sensi-
`
`Table V. Cost-effectiveness base case evaluations from the socie-
`tal petspactive
`Medel
`
`Incremental
`cost SUS
`~622.98
`Rizatriptan vs Cafergat®
`820.90
`Sumatriptan vs Gafergot®
`—-433.45
`Rizatriptan vs sumatriptan
`QALY = quality-adjusted life-year.
`
`incremental
`QALY
`0.0040
`0.0007
`0.0001
`
`2005 Adis Data Information BV.Alt rights reserved.
`
`CNS Drugs 2005: 19 {7}
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`Cost Effectiveness of Rizatriptan and Sumatriptan versus Cafergot® in Acute Migraine
`
`64]
`
`
`tive to changes in key variables, mcluding drug-
`acquisition costs, hospitalisation cost, probabilities
`of headache relief at the ER and patient preference
`over altemative therapies. The results of the riza-
`triptan versus sumatriptan model were sensitive to
`moderate changes in efficacy. Assuming that other
`parameters remain unchanged, a 5% decreasein the
`efficacy of rizatriptan would makeit no better than
`sumatriptan (data not shownin table V). Although
`the uncertainty of utility measure was of major
`concer, sensitivity analysis showed that all three
`cost-effectiveness
`ratios were not
`sensitive to
`changes in this specific parameter.
`
`Discussion
`
`In this study, we applied the technique of deci-
`sion tree modelling™) to assess the cost-effective-
`ness ofrizatriptan and sumatriptan versus Cafergot®
`in the acute treatment of migraine. Based on cost
`data in the US and taking a societal perspective, our
`study showedthat 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 al.!! 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 $Can1675 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 subsequentattacks in their analy-
`sis.
`We further compared the cost-effectiveness of
`rizalriptan and sumatriptan in the acute management
`of migraine. According to our model, the use of
`rizatriplan 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-
`iriptan for subsequent attacks actually reduces the
`differences between the therapies, since rizatripian
`dominates sumatriptan.
`Our study has some limitations. It was based on
`several assumptions made about the utility of differ-
`ent oulcomes associated with alternative therapies
`of migraine. As the utility values were obtained
`
`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’ QOLis 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
`climical data to conclusively rank all triptans for all
`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.
`
`Conclusion
`
`This study showed that rizatriptan and suma-
`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.
`
`Acknowledgemenis
`
`Financial 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,
`
`Ned
`
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`Correspondence and offprints: Dr Joel W. Hay, Department
`of Pharmaceutical Economics and Policy, University of
`Southern California, 1540 Alcazar Street, CHP-140, Los
`Angeles, CA 90089-9004, USA.
`E-mail: jhay@usc.edu
`
`© 2005 Adis Data information BY. All rights reserved.
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`CNS Drugs 2005; 19 (7)
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