Strong points included the perspective of two independent experts. Weaker points: incomplete discussion of costs, insufficient analysis of the evidence, and some questions bordering on disease-mongering.
Migraine headaches are a common cause of pain and debility in people who suffer from them. Fortunately there are good medications to treat the range of frequency and severity seen in clinical practice. This new product probably will fill a small but potentially important niche. First, many migraine suffers have infrequent and not too severe symptoms. For these individuals, over-the-counter, inexpensive medicine like acetaminophen, ibuprofen, and others with or without caffeine work fine. For more frequent and severe episodes, there are migraine preventive medicines. The triptan class of medicines is generally used for individuals who have severe migraines that don’t respond to over-the-counter medicines whether used infrequently as stand alone medicines or with preventive medicines when breakthroughs occur. For most triptan users, oral medicines when used at the start of symptoms don’t cause serious stomach problems and work to relieve symptoms quickly. However, some patients have severe nausea that prevent taking the pills or result in vomiting before the medicine is absorbed and can work. For these individuals, injections, intranasal spray or pills with stomach-settling medicines are used. These are the patients in whom a skin patch approach should be compared. This placebo trial says the medicine works. The real question patients want to know is whether it works better than standard medicines and in whom. As we think about cost – one needs to consider whether an expensive new formulation provides enough new benefit to justify its likely hefty cost.
The story says it’s “not clear” how much the new patch will cost, which is accurate, but Bloomberg was able to provide a ballpark estimate from a company official, who said it would be in the $95 range. Since this HealthDay piece references the same Bloomberg story when discussing the planned launch of the new product, we’re not sure why it didn’t pass along the $95 figure as well. We’re pleased that the story at least raised the issue of cost, but we’ll fault it for not providing detail that was easily available. You’d also like to see the cost per migraine episode of this medicine vs. alternatives.
The story provides active and placebo group response rates for patients in the Zecuity studies, which we’ll call good enough for a satisfactory. However, the story doesn’t compare these results with injection and nasal spray treatments — the other options that are available for patients with severe nausea who can’t tolerate pills. That information would have been helpful.
According to the story, “The most frequent side effects were pain at the site of application along with tingling, itching, warmth and discomfort.” We’ll call this adequate for a satisfactory, but it would have been helpful to know how often these adverse effects occurred, especially since the FDA had previously delayed approval of the product based in part on safety concerns. In addition, there was no mention of other adverse effects that have been associated with triptan use, such as atypical pain and pressure sensations (e.g. tightness in the chest and throat constriction). The story did mention that triptans can be harmful for patients with heart disease or who are taking SSRI antidepressants.
It’s clear that the evidence consists of placebo-controlled trials that were sufficient to gain FDA approval for the product.
But we look for more. The patch contains sumatriptan, which is also available in pill, shot and nasal form. How the patch results compare to these formulations seems to be a crucial piece of information to allow readers to assess the quality of the data. Does the patch work as quickly as the nasal or injection deliveries? These are pretty key pieces of information that the story could have dug deeper to include.
There was also no independent comment on the significant placebo response:
Two thoughts give us pause as we think about this criterion.
The story didn’t explore or reference the claim, made by an expert source, that “Migraine patients tend to be underdiagnosed and undertreated and inappropriately treated.” While this pinged on our disease-mongering radar, the available epidemiologic evidence does appear to support this contention. But the story didn’t reference that evidence.
The other, broader question is how often migraine suffers need alternatives to pills. How often is the nausea so bad that the intranasal, injection or patch methods would even be needed? We also can’t be sure – even if migraines are undertreated or inappropriately treated – whether the patch would do anything to change this. The story mentions that some people have nausea and vomiting so bad that they can’t take a pill, but knowing how many migraine sufferers there are and how many fit that description is the question.
To fail to explore these questions is on the borderline of cheerleading for a new delivery method (the patch) for an old drug (sumatriptan) without reporting on sufficient evidence (data) for true need in comparison with what’s already available.
Based on a brief Web search, the two expert sources quoted in the story don’t seem to have any conflicts of interest related to this issue.
The story mentions alternative delivery systems for migraine medication, including pills, sprays, and injections (although as mentioned above, it doesn’t compare the efficacy of these different approaches). The story could have also mentioned that there are a variety of non-triptan drugs, including NSAID pain relievers, that can be effective for treating acute migraine attacks.
The story estimates, from a company source, that this produce will be available toward the end of 2013.
This will be the first skin patch available for delivery of migraine medication, so its novelty isn’t in question.
There is enough original reporting that we can be sure this wasn’t based on a press release.