Spherix Global Insights

May 06, 2021

Oral Gepants Have Disrupted Acute Migraine Management and Look Next to Transform Preventive Treatment, According to Both Primary Care Physicians and Specialists

New research from Spherix Global Insights finds the impressive uptake of AbbVie’s Ubrelvy and Biohaven’s Nurtec ODT appears to have already blunted reliance on the subcutaneous CGRP monoclonal antibodies, with growth of Amgen/Novartis’ Aimovig, Teva’s Ajovy, and Eli Lilly’s Emgality all moderating

EXTON, Pa., May 6, 2021 /PRNewswire/ — Both AbbVie’s (formerly Allergan, an AbbVie company) Ubrelvy and Biohaven’s Nurtec ODT are viewed by primary care physicians (PCPs) as strong entrants into the acute segment of the migraine market following their early 2020 launches. Interestingly, a new study from Spherix found similar physician-reported shares for both gepants [i.e., oral calcitonin gene-related peptide (CGRP) receptor antagonists], despite Ubrelvy’s earlier launch.

In the inaugural semiannual report included in Spherix’s RealTime Dynamix™: Migraine – PCP Perspective (US) service, data collected from 96 PCPs found that, of the two gepants, direct comparison gives Nurtec ODT the advantage over Ubrelvy on most clinical metrics. Nurtec ODT best differentiates from Ubrelvy on duration of effect and convenience of patient administration among PCPs, consistent with its prevention label currently under FDA review and its unique orally dissolving tablet formulation, respectively.

Spherix has also been tracking the specialist-treated (i.e., general neurologists and migraine specialists) segment of the migraine market through their RealTime Dynamix™: Migraine (US) service on a quarterly basis since 2018. Direct comparisons between the insights garnered in each service found that while duration of effect gives Nurtec ODT a clear lead over all other assessed attributes among surveyed specialists, convenience of patient administration is a more modest differentiator of the two brands for specialists versus PCPs.

While currently only approved for the acute treatment of migraine, the gepants may already be disrupting treatment patterns in the preventive segment, especially among PCPs. For example, two-fifths of PCPs versus only one-quarter of specialists say their use of the gepants for acute migraine treatment has reduced their prescribing of the CGRP monoclonal antibodies (mAbs), specifically Amgen/Novartis’ Aimovig, Teva’s Ajovy, and Eli Lilly’s Emgality, for migraine prevention.

Analysis of Spherix data uncovered three potential ways that the gepants could be directly or indirectly impacting Aimovig, Ajovy, and Emgality trajectories and how these differ between PCPs and specialists:

  1. PCPs recommend that half of their patients (substantially more than what specialists report) should initially trial a gepant for acute treatment before prescribing a subcutaneous (SC) CGRP mAb for migraine prevention. Step-through gepant experience will likely push back incorporation of a SC CGRP mAb agent into patients’ treatment regimens and, if patients have positive responses to the gepant, decrease the potential candidate pool for these SC CGRP mAb agents.
  2. One of the top three barriers to greater uptake of Ubrelvy or Nurtec ODT for both PCPs and specialists is insurance denials for patients already on a SC CGRP mAb for prevention, with mentions especially prevalent among PCPs. This barrier is slightly more of an issue for Ubrelvy – a dynamic that will likely increase if Nurtec ODT is approved for prevention. Ultimately, physicians need to decide whether their SC CGRP mAb-treated patients should stay the course or discontinue therapy so that they can obtain formulary reimbursement for a gepant.
  3. The vast majority of PCPs are currently recommending that at least some of their patients dose Ubrelvy or Nurtec ODT at a frequency that may be preventing migraine. Again, this pattern is especially strong among PCPs compared to specialists. Risk of medication overuse headache does not appear to be a concern when gepants are dosed at a preventive frequency for either physician subgroup, although PCPs are even more optimistic about this for Ubrelvy than specialists. If off label dosing is successful, then the need for the SC CGRP mAbs would be greatly reduced among these patients.

The potential approval of Nurtec ODT as the first agent with a dual migraine indication within the next few weeks, as well as AbbVie’s atogepant for the preventive treatment of episodic migraine within the next few months, will likely increase the competitive pressure on the SC CGRP mAb therapies. Assuming all CGRP agents in development are approved, physicians believe that more of their patients will prefer an oral preventive therapy – thus favoring Nurtec ODT and/or atogepant over the SC CGRP mAbs.

It remains to be seen how the dynamic between Nurtec ODT and atogepant will play out. Nurtec ODT has the advantage of a high level of familiarity and interest in its expanded label as well as broad physician experience using the gepant as an acute therapy. However, more PCPs currently believe that their patients will prefer a once-daily tablet than an every-other-day ODT formulation – suggesting that atogepant could compete with Nurtec ODT on preferred dosing profile.

Spherix will continue to track the evolving competitive migraine landscape from the perception of both specialists and PCPs through their ongoing RealTime Dynamix™ services, as well as initiate brand-specific Launch Dynamix™ to track the first 18 months of availability assuming positive outcomes from upcoming regulatory decisions for Nurtec ODT and atogepant.

About RealTime Dynamix™
RealTime Dynamix™ is an independent service providing strategic guidance through quarterly or semiannual reports, which include market trending and a fresh infusion of event-driven and variable content with each wave. The reports provide an unbiased view of the competitive landscape within rapidly evolving specialty markets, fueled by robust HCP primary research and our in-house team of experts. Learn more about our services here.

About Spherix Global Insights
Spherix Global Insights is a hyper-focused market intelligence firm that leverages our own independent data and expertise to provide strategic guidance, so biopharma stakeholders make decisions with confidence. We specialize in select immunology, nephrology, and neurology markets.

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