FORMULARY MANAGEMENT A Comparison of the Cost-Effectiveness of Almotriptan and Sumatriptan in the Treatment of Acute Migraine Using a Composite Efficacy/Tolerability End Point

igraine causes substantial patient suffering and high costs to managed care organizations and employers. Triptans (5-HT1B/1D receptor agonists) are effective and relatively safe for the acute treatment of migraine. Initial treatment with a triptan is recommended when the migraine is judged moderate to severe or in migraine of any severity when nonsteroidal anti-inflammatory drugs and combination analgesics have failed to relieve symptoms. Acute treatment of migraine with sumatriptan, the first available triptan, has been shown to reduce migraine-related health care utilization. For example, Lofland et al. showed significant reductions in the mean number of migraine-related physician office visits, emergency department visits, and medical procedures in the 6 months after sumatriptan therapy compared with the 6 months before sumatriptan was used. They also showed that initiation of sumatriptan in patients previously treated with nontriptan therapy was cost effective and had an economic benefit for patients, employers, and society. Almotriptan was introduced in the United States in 2001 and has been shown to be efficacious and well tolerated in placebo-controlled clinical trials. Direct comparative trials of sumatriptan and almotriptan have shown that these agents have similar efficacy for relieving migraine pain but that almotriptan 12.5 mg was associated with a significantly lower rate of adverse events compared with sumatriptan 50 mg (including a specific comparison for chest pain) and 100 mg. A meta-analysis of data from 53 placebo-controlled trials of oral triptans found that a significantly greater proportion of patients achieved a sustained pain-free state with almotriptan 12.5 mg compared with sumatriptan 100 mg. Almotriptan 12.5 mg also had a significantly lower rate of all adverse events, chest adverse events, and central nervous system adverse events than sumatriptan 100 mg. Key results from this meta-analysis, for almotriptan and sumatriptan, are shown in Table 1. In the present study, we use results from this meta-analysis to compare the cost-effectiveness of almotriptan with that of sumatriptan from a U.S. health care payer perspective.