Spherix Global Insights

June 03, 2021

Selection Drivers for Recently Prescribed Lasmiditan, Ubrogepant, or Rimegepant for the Acute Treatment of Migraine: Results from an Annual Cross-Sectional Patient Chart Audit in the United States

Authors: Virginia R. Schobel, MSc

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Influential drivers of the decision to prescribe the newly approved therapies for the acute treatment of migraine differ more within the gepant class than between the gepant and ditan classes, according to a retrospective, cross-sectional patient chart review audit.

In 2020, pharmaceutical options for acute management of migraine expanded with the US introduction of the ditan, specifically lasmiditan, and gepant, including ubrogepant and rimegepant, classes. The objective of this analysis is to understand how these agents are being used in migraine treatment by identifying patient-level drivers of physicians’ decisions to prescribe a ditan or gepant.

Fielded in September 2020, 214 US neurologists and migraine specialists completed an online survey and contributed chart review data for a retrospective, cross-sectional audit of 1,048 patients recently (≤3 months) prescribed lasmiditan (n=243), ubrogepant (n=417), or rimegepant (n=389) for the acute treatment of migraine. Selection driver analysis was performed on the 1,038 charts provided by the physician who personally prescribed the most recent acute therapy.

Patients prescribed lasmiditan were significantly more likely to have only failed one prior acute therapy compared to patients prescribed a gepant (50% vs. 40%; p<0.05) (Figure 1). No other patient demographic or disease presentation variables were significantly different between the three agents (Table 1,2; Figure 2). The decision to make a change to patients’ acute migraine therapy regimen was primarily driven by efficacy concerns (lasmiditan: 64%, ubrogepant: 67%, rimegepant: 69%; NS) (Figure 3). Among these efficacy-related treatment changes, persistent or worsening migraine attacks (43%), time to return to normal function after acute dose (18%), or lack of freedom from pain two hours after acute dose (17%) were the most frequent leading factors (Figure 4).

The most common drivers of the decision to prescribe lasmiditan were mechanism of action (47% of patients) and physician comfort/familiarity (46%) (Figure 5). Between the gepants, mechanism of action was a similarly strong driver of prescribing decisions (ubrogepant: 45%, rimegepant: 51%; NS), but physician comfort/familiarity influenced significantly more ubrogepant compared to rimegepant (49% vs. 39%; p<0.05) decisions. Significantly more rimegepant prescribing decisions were prompted by expectations related to pain freedom at two hours (rimegepant: 48% vs. ubrogepant: 36%, lasmiditan: 32%; p<0.05), time for return to normal function (rimegepant: 47% vs. ubrogepant: 38%, lasmiditan: 37%; p<0.05), and low need for redosing/use of rescue medications (rimegepant: 23% vs. ubrogepant: 14%, lasmiditan: 14%; p<0.05), as well as a preference for dosing formulation (rimegepant: 16% vs. ubrogepant: 5%, lasmiditan: 9%; p<0.05). Also, compared to ubrogepant, rimegepant decisions were also more likely to be influenced by speed of efficacy onset (rimegepant: 45% vs. ubrogepant: 35%, p<0.05; vs. lasmiditan: 38%, NS), sustained pain freedom (rimegepant: 37% vs. ubrogepant: 26%, p<0.05; vs. lasmiditan: 34%, NS), and sample or starter kit availability (rimegepant: 17% vs. ubrogepant: 10%, p<0.05; vs. lasmiditan: 10%, NS).

Among the newly approved acute treatments for migraine, lasmiditan may be used earlier in the treatment algorithm due to its mechanistic similarities to the standard-of-care triptan class. While the CGRP-mediated mechanism of action is also relevant in the decision to prescribe gepants, efficacy expectations appear more influential when selecting to prescribe rimegepant than ubrogepant.

Virginia R. Schobel is an employee of Spherix Global Insights, an independent market intelligence firm and has received no industry funding to conduct and report on this study.

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