Rimegepant Cuts Barbiturate Use in Migraine Patients

Barbiturate use among migraine patients significantly decreased after initiating treatment with rimegepant, a calcitonin gene-related peptide (CGRP) antagonist used for migraine treatment and prevention, results of a large claims analysis indicate.

Investigators noted a 27% drop in the amount of butalbital dispensed and a 32% decrease in the total number of prescriptions filled following rimegepant initiation. In addition, 50% of migraine patients discontinued use of barbiturates with rimegepant.

“Barbiturates are interesting because, beyond migraine, they’re not really used for much at this point. I think what this study shows is that when people are given a better option, they will take it,” study investigator Noah L. Rosen, MD, director of the Headache Center and associate professor of neurology and psychiatry at Zucker School of Medicine at Northwell Health, Great Neck, New York, told Medscape Medical News.

“We took it upon ourselves to look at real-world claims data because it really shows what people are actually doing. And one of the things this analysis shows is that rimegepant helps decrease the use of these older medications, which often are not benign,” he added.

The findings, from a real-world administrative claims study, were presented at the American Headache Society (AHS) Annual Meeting 2023.

Abuse, Dependence Risk

Butalbital carries a risk of abuse and physical dependence, has neurologic side effects, and can increase the risk of medication overuse headache. Treatment guidelines discourage the use of barbiturates for the acute treatment of migraine. Despite this, butalbital and its combinations are still widely prescribed, study investigator Rosen noted.

“These were very common, nonspecific treatments that had been available for many decades and were really one of the mainstays of treatment until more migraine-specific medications came out with the use of triptans. But because they are cheap and because they remain the only short-acting barbiturates in the United States, they are still being used,” Rosen said.

To explore the association between initiation of therapy with rimegepant and barbiturate use, the investigators analyzed prescription claims data from a longitudinal pharmacy commercial claims database for 689,425 migraine patients treated with rimegepant from September 2019 through November 2022.

In all, 34,486 migraine patients used butalbital in the 6 months prior to initiating treatment with rimegepant. Patients ranged in age from 32 to 59 years, and 89.2% were women.

Analysis of the claims data showed a 26.7% decrease in mean monthly butalbital milligrams dispensed (from 1012 mg at baseline to 742 mg at follow-up) and a 32.0% decrease in total butalbital prescription fills (mean Rx fills at baseline, 0.47; mean Rx fills at follow-up, 0.32). Additionally, the barbiturate discontinuation rate was 49.4% after rimegepant initiation.

Meaningful Discontinuation Rate

Commenting on the findings for Medscape Medical News, Elizabeth Loder, MD, MPH, professor of neurology, Harvard Medical School and Brigham and Women’s Hospital, in Boston, Massachusetts, said barbiturates are still being used to treat migraine and other headache types.

“They definitely have drawbacks, but they are inexpensive, whereas the newer medications such as rimegepant are expensive and not very easy for patients to get. It’s good to see that patients who were using butalbital-containing medications overall used less of them once rimegepant was prescribed,” said Loder.

The discontinuation rate of almost 50% seems meaningful and represents important progress in the effort to reduce use of butalbital-containing medications, she added.

“We still don’t know if these changes represent patient choice or preference or whether prescribers stopped prescribing butalbital even if patients wished to continue. That isn’t uncommon, because many doctors try to avoid butalbital,” Loder said.

The study demonstrates the importance of preventive treatment, Huma U. Sheikh, MD, CEO, NY Neurology Medicine, PC, a private migraine clinic in New York, told Medscape Medical News.

“This is a great study showing that it is so much more important to get patients on a preventive and to actually treat the reason they are having headaches, instead of just giving them a nonspecific medication to treat one of their symptoms,” Sheikh said.

“Once patients are on a preventive for their migraine, then overall, they’re not needing as much pain medication. We know that taking a lot of pain medications over time causes a lot of side effects, including medication overuse headaches. So, this really highlights the importance of using the preventive,” she said.

The study was sponsored by Biohaven/Pfizer. Rosen has been on the speaker panel for AbbVie/Allergan, the advisory board for AbbVie, Biohaven, Eli Lilly, and Lundbeck and has received research support from Eli Lilly and Teva. Loder and Sheikh have disclosed no relevant financial relationships.

American Headache Society (AHS) Annual Meeting 2023: Abstract IO-06. Presented June 17, 2023.

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