Aquipta, recommended by NICE, presents a new option for preventing migraines in adults with at least 4 migraine days monthly after at least 3 preventive medicines have failed.
Aquipta (Atogepant, AbbVie) is approved for preventing migraines in adults experiencing at least 4 migraine days monthly. Migraine episodes typically last between 4 to 72 hours, characterized by intense, throbbing head pain that significantly impacts daily life. Migraines can be categorized as episodic (less than 15 headache days monthly) or chronic (15 or more headache days monthly, with at least 8 having migraine features). The committee emphasized the debilitating nature of migraines, affecting various aspects of life.
However, some patients may prefer oral medications due to allergies or needle phobia, particularly for chronic migraines, where there are limited oral options available. Additionally, the shorter half-life of atogepant compared to injectable medications could benefit certain patient groups, such as those with high vascular risk or those planning conception.
Clinical experts highlighted challenges with intravenous treatments like eptinezumab due to capacity issues and varying availability of botulinum toxin type A across regions. The company argued against considering eptinezumab, botulinum toxin type A, or rimegepant as comparators due to factors like clinical practice variation and recent NICE recommendations. However, the committee deemed these medications relevant comparators for evaluating atogepant.
Clinical trials for atogepant included ELEVATE and PROGRESS, which demonstrated its efficacy in both episodic and chronic migraine populations. While ELEVATE showed a greater reduction in mean monthly migraine days (MMDs) with atogepant compared to placebo for episodic migraine, PROGRESS indicated similar results for chronic migraine. However, for chronic migraine patients who failed three preventive medicines, atogepant's efficacy remained uncertain.
The company's model, a semi-Markov state transition model, assessed treatment response at 12 weeks and included various outcomes. The committee deemed the model appropriate for decision-making. However, there was uncertainty in clinical evidence due to wide credible intervals and population mismatch in network meta-analyses.
Considering a £20,000 per QALY gained threshold, the committee found atogepant cost-effective compared to rimegepant for episodic migraine.
For chronic migraine, atogepant's costs were lower than all comparators. Therefore, the committee recommended atogepant for both episodic and chronic migraine prevention in adults, with treatment discontinuation if migraine frequency doesn't reduce by specified percentages. They also recommended choosing the least expensive suitable treatment option after discussions between patients and clinicians.
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