ICER: New Migraine Drugs Not as Expensive as Previously Thought

March 03, 2020 - The Institute for Clinical and Economic Review’s (ICER) final evidence report assessing the clinical effectiveness and economic value of three acute treatments for migraines had more favorable findings for two of the drugs compared to previous drafts.

The treatments analyzed in the report included lasmiditan, rimegepant, and ubrogepant. The drugs are manufacturered by Eli Lilly, Biohaven, and Allergan, respectively.

The report was reviewed at the public meeting of the Midwest Comparative Effectiveness Public Advisory Council (Midwest CEPAC) last month, one of ICER’s three independent evidence appraisal committees. 

“Following the publication of the previous iteration of our report, we worked closely with Allergan to identify high-quality evidence demonstrating additional clinical benefits for ubrogepant beyond the two-hour time point required by the FDA for the clinical trials,” David Rind, MD, ICER’s chief medical officer, said in the report. “This additional benefit, which likely also applies to rimegepant, supports a near doubling of ICER’s health-benefit price benchmark for these two treatments, and is also a key example of how ICER works closely with stakeholders to ensure we have the best evidence-based approach to capturing the full value of a product.”

ICER estimated a health-benefit price benchmark of $2,200 to $3,200 per year for all three treatments before the meeting. But prior to and immediately after the meeting, the company collaborated with manufacturers to identify additional clinical benefits. 

The benefit price benchmarks were updated to reflect the findings:

• Between $2,800 and $3,200 per year for lasmiditan
• Between $4,200 and $4,600 per year for both rimegepant and ubrogepant 

The price range reflects commonly cited cost-effective thresholds between $100,000 and $150,000 per Quality-Adjusted Life Year (QALY) gained. New involvements introduced at or below the numbers help increase overall health because they do not affect affordability or loss of insurance throughout the health system. 

Midwest CEPAC members unanimously voted that the evidence was adequate to demonstrate a net health benefit for treatment with lasmiditan, rimegepant, or ubrogepant compared with no treatment, the report highlighted. But members also uncovered that the evidence was insufficient to demonstrate superior net health benefits for any of the three treatments when compared to triptans. 

Additionally, all panelists believed the evidence was not ample to distinguish the net health benefit between rimegepant and ubrogepant, and most of the panelists found the evidence insufficient to distinguish between either of those two or lasmiditan. 

Most panelists found that the three treatments were intended for individuals with a chronic illness or specific lifetime illness and believed that all three treatments also offered an approach that ensured successful treatment of patients for whom other treatments have not been effective.  

And most also agreed that treating a patient with rimegepant of ubrogepant will both be effective to reducing complexity and improvingpatient outcomes compared to lasmiditan. 

Following the voting session, roundtable of experts including clinicians, patient advocates, and representatives from manufacturers and payers discussed what the evidence for policy and practice meant moving forward. 

Some recommendations that the experts suggested included for payers to negotiate lower prices for ubrogepant and rimegepant by offering preferential formulary to one or the other drug, or excluded one altogether. And clinical experts and patient advocates suggested to expand coverage based on metric of severity such as number of migraines per month. 

Furthermore, all experts agreed that requiring patients to try triptans prior to receiving coverage for the newer agent is reasonable if patients are eligible. Tripans are under-prescribed and many patients are weary about taking it due to side effects of vasoconstriction. 

“Attestation of clinical ineligibility or intolerance was favored by medical record documentation given the long-term nature of migraine and the difficulty of finding past medical records to document CV events or prior side effects,” the report concluded.