Atogepant May be More Cost Effective vs Rimegepant for Episodic Migraine, According to New, Indirect Comparison

A recently published indirect treatment comparison of atogepant (Qulipta; AbbVie) and rimegepant (Nurtec ODT; Biohaven), 2 FDA-approved preventive treatments for episodic migraine (EM), revealed that atogepant had substantially lower numbers needed to treat (NNT) and costs per additional responder vs placebo than rimegepant.

Investigators concluded that when treatment cost is factored in, rimegepant 75 mg is $57,206 more expensive than atogepant 60 mg, per additional responder of at least 50%.1

"Patients undergoing migraine treatment utilize health-care resources and incur costs at a higher rate than those without migraine," lead author Jessica Ailani , MD, director of the MedStar Georgetown Headache Center, et al wrote in the journal Headache.1 "As a result, AHS, [American Headache Society] guidelines state that the goals of migraine prevention are not just to reduce migraine frequency and improve quality of life but also to reduce overall costs associated with treatment. Our study suggests that atogepant 60 mg may be a more cost-effective preventive migraine treatment than rimegepant 75 mg."

In the absence of previous head-to-head trials between the 2 oral calcitonin gene related peptide inhibitors (gepants), for the preventive treatment of EM, the study authors used an indirect comparison analysis based on their pivotal phase 3 registration trials (ADVANCE [NCT03777059] and BHV3000-305 [NCT03732638], respectively). The analysis evaluated patients ability to achieve at least 50% reduction in mean monthly migraine/headache days (≥50% responder rate) as the primary efficacy outcome, calculating the number NNT and cost per additional responder vs placebo, comparing atogepant and rimegepant across various time frames (weeks 9–12 in the base case; weeks 1–12 and 9–12 for atogepant; weeks 9–12 for rimegepant).

The efficacy populations for each trial were the modified intention-to-treat (mITT) population (ADVANCE; n = 436) and the efficacy-evaluable population (BHV3000-305; n = 695). Coming into the studies, participants in BHV3000-305 had a mean of 10.3 monthly migraine days (MMDs) at baseline, while those in the atogepant 60 mg arm of the mITT group of ADVANCE had a mean of 7.8 MMDs.

Comparative Responder Rates

In the base case analysis, responder rates of at least 50% were 44.1% (95% CI, 39.4-49.0) for placebo, 64.9% (95% CI, 53.9-74.5) for atogepant 60 mg and 51.8% (95% CI, 42.9-60.6) for rimegepant 75 mg. Two scenario analyses were conducted to support the base case, in which at least 50% responder rate for atogepant was defined as reduction from baseline in all migraine days in the ADVANCE trial in weeks 1-12 (scenario 1; secondary end point) and weeks 9-12 (scenario 2; prespecified exploratory end point). For all analyses, at least a 50% responder rate for placebo was estimated by a meta-analysis of the placebo arms in both trials to account for differences in placebo effect.

Scenario 1. In the scenario 1 analysis, responder rates of at least 50% were found in 35.4% (95% CI, 27.1-44.6) of those receiving placebo, 67.5% (95% CI, 54.4-78.4) for atogepant 60 mg, and 42.7% (95% CI, 31.4-54.8) for rimegepant 75 mg.

Scenario 2. In the scenario 2 analysis, the greater than 50% responder rates were 42.4% (95% CI, 38.3-46.6) for placebo, 70.0% (95% CI, 59.7-78.6) for atogepant 60 mg, and 50.0% (95% CI, 41.5-58.6) for rimegepant 75 mg.

NNT, Cost Per Responder

The median NNT for an additional 50% or greater responder in the base case analysis was 4.8 (95% CI, 3.4-9.0) for atogepant 60 mg and 13.0 (95% CI, 5.9–75.1) for rimegepant 75 mg. In scenario 1, the median NNT was 3.1 (95% CI, 2.5–4.4) for atogepant 60 mg and 13.7 (95% CI, 6.0–80.6) for rimegepant 75 mg. For scenario 2, the median NNT was 3.6 (95% CI, 2.8–5.4) for atogepant 60 mg and 13.2 (95% CI, 5.8–77.0) for rimegepant 75 mg. Ailani and team reported consistent results for the atogepant 10 mg and 30 mg doses across all scenarios.

In the base case analysis, the median cost per responder (CPR) was $15,823 (95% CI, $11,079–$29,516) for atogepant 60 mg and $73,029 (95% CI, $32,901–$422,104) for rimegepant 75 mg. In scenario 1, the median CPR was $10,211 (95% CI, $8148–$14,335) for atogepant 60 mg and $76,979 (95% CI, $33,937–$452,882) for rimegepant 75 mg. For scenario 2, the median CPR was $11,876 (95% CI, $9,148–$17,859) for atogepant 60 mg and $73,941 (95% CI, $32,680–$432,933) for rimegepant 75 mg. Consistent CPRs were observed for atogepant 10 mg and 30 mg doses across all scenarios.

Atogepant is indicated for the preventive treatment of episodic and chronic migraine, while rimegepant is only indicated for the preventive treatment of EM. In 2024, the AHS issued a position statement on CGRP-targeting treatments, endorsing them as first-line options for the preventive treatment of migraine.2

Regarding that stance, the study authors added that, "This is especially crucial due to the frequency with which people with EM may transition to [chronic migraine], and vice versa. Given the updated statement and the results of our study, atogepant can potentially be considered a cost-effective, first-line preventive treatment option for migraine."

REFERENCES
1. Ailani J, Gandhi P, Lalla A, et al. Cost per treatment responder analysis of atogepant compared to rimegepant for the preventive treatment of episodic migraine. Headache. 2024;64(10):1253-1263. doi:10.1111/head.14824
2. Charles AC, Digre KB, Goadsby PJ, Robbins MS, Hershey A, American Headache Society. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statement update. Headache. 2024; 64(4): 333-341. doi:10.1111/head.14692