With insurance coverage and patient cost frequent barriers to greater anti-CGRP brand uptake irrespective of the availability of free drug voucher programs, topiramate and Allergan’s Botox continue to be US neurologists and migraine/headache specialists’ most preferred and most prescribed migraine preventive therapies, according to a new report from Spherix Global Insights
EXTON, Pa., /PRNewswire/ January 24, 2019 ― In the US migraine prevention market, Amgen and Novartis’ Aimovig is benefiting from its first-to-market position in the anti-calcitonin gene-related peptide (CGRP) class, which first saw the advent of competition following the September 2018 approvals of Teva’s Ajovy and Eli Lilly’s Emgality. In the current wave of the ongoing quarterly RealTime Dynamix™: Migraine Prevention (US) report series, almost all US neurologists and migraine/headache specialists (n=104) surveyed in late November/early December 2018 reported having initiated at least one patient on Aimovig. In comparison, only about half of physicians had clinical experience with Ajovy or Emgality two months after their respective launches, with Ajovy slightly outpacing Emgality. Similarly, with an additional four months on the market, self-reported Aimovig share of preventive-treated patients was more than Ajovy and Emgality shares combined for both the episodic and chronic migraine segments. Although launched in the same month, Ajovy share is higher than Emgality share for both patient types, with Ajovy share of episodic migraine preventive therapy twice that of Emgality, benefiting from higher brand awareness, a broader prescriber base, and perceptions of easier access/sample availability. Despite the fact that topiramate and Amgen’s Botox continue to dominate within the chronic migraine segment, physicians reported similar episodic migraine prevention shares for Aimovig and Botox, reflecting Botox’s more narrow chronic migraine prevention label.
All three anti-CGRP brands were launched with a free drug voucher program offering patients access to therapy at no cost for at least 12 months while insurance coverage is being pursued. In the month previous to fielding, physicians estimated that more Aimovig prescriptions were payer-approved with patients started on paid drug compared to Ajovy and Emgality. Few of these Aimovig claims required resubmission before obtaining approval. However, physician perceptions of brand performance on favorable coverage on insurance plans (an extremely important brand choice attribute for two-thirds of physicians) does not differ significantly between the three brands. Among those recent prescriptions still pending coverage decisions, almost three-quarters of Emgality-intended patients were being treated with free drug from Eli Lilly, while only three out of five Aimovig-intended patients were being treated were free drug from Amgen or Novartis. Ajovy falls between the two competitors with two-thirds of intended patients treated with free drug from Teva pending coverage decision. In comparison, almost all Botox prescriptions were approved and, among those still pending, only 30% were being treated with free drug. With few recent anti-CGRP prescriptions denied by payers and not resubmitted, Spherix estimates that more than 90% of prescriptions currently pending payer approval should transition to paid scripts.
Regardless of the extensive use of voucher programs, the most frequent barrier to trial or further uptake for each of the anti-CGRP brands is insurance coverage, while brand discontinuations are frequently the result of insurance coverage issues or high out-of-pocket cost to patients. Close to one-third of physicians believe that the respective companies are not meeting their expectations for insurance coverage of their brands. Granted these are typical issues for newly launched brands, such physician-reported concerns underscore the importance of reducing prior authorization burden and highlighting copay assistance in order to ease the transition of patients from free drug and bolster persistency rates. The company that can best provide this support for prescribers will be well positioned to successfully compete during brand selection points in the treatment algorithm.
Even with the introduction of the novel anti-CGRP class, physicians are currently most likely to select topiramate as their most preferred preventive therapy for episodic migraine and Botox and topiramate for chronic migraine, reflecting self-reported share patterns. Preference for topiramate (including Janssen’s Topamax, Supernus’ Trokendi XR, Upsher-Smith’s Qudexy XR, generics) for episodic migraine prevention is predominantly driven by efficacy and cost expectations. For chronic migraine prevention, efficacy expectations underlie physicians’ preference for Botox and efficacy and cost expectations for topiramate. However, a number of physicians also mention topiramate’s oral dosing profile and efficacy against comorbidities/lack of weight gain as competitive benefits. For those physicians who most prefer Aimovig or Ajovy, efficacy is a common preference driver although safety plays a larger role in Aimovig preference and dosing profile and access in Ajovy preference. Few physicians selected Emgality as their most preferred preventive therapy.
Over the next few years, the nascent anti-CGRP class is poised to potentially double with Alder’s eptinezumab, Allergan’s atogepant, and Biohaven’s rimegepant all in late-stage clinical development. Unfortunately, for all three products, unaided awareness is nonexistent and reported familiarity is low among US physicians ─ even for eptinezumab with an upcoming Q1 2019 biologics license application (BLA) planned. When asked about preferred dosing profiles, assuming similar efficacy, physicians estimate that one-third of their patients would want an oral anti-CGRP therapy dosed once a day, whereas few patients would prefer a quarterly intravenous anti-CGRP infusion. Indeed, among physicians at least moderately familiar with two or more of the anti-CGRP therapies in development, preference for atogepant and rimegepant is driven by their oral dosing profiles, while the potential for superior efficacy compensating for the substantially less preferred intravenous dosing profile underlies preference for eptinezumab.
RealTime Dynamix™: Migraine Prevention (US) is an independent report series published on a quarterly basis. The series provides a close-quarters analysis of key performance metrics, focusing on brand gains and losses, industry contact rates, familiarity and adoption patterns of recently launched products (e.g., Aimovig, Ajovy, and Emgality) and awareness of products in development. Product perceptions, disease awareness and attitudes, practice management and other topics are rotated throughout the year to provide an ongoing probe of the crucial drivers of change. The next wave of research will be published in March 2019.
About Spherix Global Insights
Spherix Global Insights is an independent business intelligence and market research company, specializing in renal, autoimmune, neurologic and rare disease markets. Our aim is to apply our commercial experience and unique relationships within core specialty markets to translate data into insight, enabling our clients to make smarter business decisions.
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