New preventive treatments for migraineBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2507 (Published 13 June 2018) Cite this as: BMJ 2018;361:k2507
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We all want lower drug costs. Incredible drug prices are putting people into poverty or bankruptcy, and making them chose between medical care and other necessities. Nevertheless, persons with migraine should not be discriminated against when it comes to the pricing of the new migraine medicines.
There are some assumptions in Drs. Burch and Rayhill’s editorial which should be corrected. These same mistakes are also imbedded in the flawed ICER (Institute for Clinical and Economic Review) methodology. Let me name a few. As the non-responders drop out of treatment, the remaining patients will have a much greater reduction in migraine frequency, hence the value of treatment increases over time in a manner improperly calculated by ICER and not alluded to by Drs. Burch and Rayhill. A prevented day presumably prevents the prodrome and the postdrome of migraine, whose values not calculated by ICER. Successful migraine treatments benefits to caregivers and dependents are not considered in ICER’s or Drs. Burch and Rayhill’s assumptions. No serious attempt was made to calculate improvement in the co-morbid conditions that accompany migraine and improve with treatment.
Some blame may rest on pharmaceutical companies for the high price of new innovative treatments. But in the United States, the cost to payers will be far less than the wholesale price suggests, once the system of rebates is enacted. Unfortunately, the list price will often be used to calculate the patients’ co-pays. Pharmacy benefit managers will make enormous profits while adding little of value. All the while, a fair share of the blame for high drug costs belongs to the regulators who jack up the cost of research and never feel the consequences, and the methodologists who forget that better is the enemy of the good and multiply the cost of research as an intellectual exercise.
Here are some reasons why the high cost of the new CGRP antibody treatments is beneficial to patients with migraine.
1 -- Migraine patients in particular need innovative treatments.
The high prices of new innovative drugs is a major driver of further innovation. Who would risk the hundreds of millions of dollars it takes to bring a new drug to market if there is no profit to be made?
Patients with migraine have not had an innovative medicine designed just for them since sumatriptan in 1993. Before that it was methysergide in 1962. Compare that to multiple sclerosis – it is not a coincidence that the astonishingly high prices of MS drugs and a period of amazing and varied drug development have occurred in the same disease.
2 – The migraine patients’ QALY (Quality Adjusted Life Year) or DALY (Disability Adjusted Life Year) is just as valuable as someone’s with any other disease.
The ICER process has just completed its’ evaluation of the new CGRP Antibodies for migraine. Despite a methodology that discriminates against persons with migraine and other chronic diseases, the antibodies fared reasonably well at the current list price. Yet Drs. Burch and Rayhill called out drug manufacturers for their prices. Are they suggesting that the migraine patient’s DALY or QALY is not as valuable because it belongs to a person with migraine?
3 – You value what you pay for.
There is a basic psychology that you value what costs you money, and you take for granted that which does not. A diamond is valued because it is expensive. Psychotherapy is less effective if it is free or inexpensive. A drug is perceived as less valuable if its’ cost is low. If the cost of care is low, people (except the patient) will think the value of successful care is low, and then they will think, as they do now, that the value of caring for persons with migraine is low.
There is a cancer in the drug pricing system. Costs are out of control. On the other hand, migraine is a heavily stigmatized disease (1,2), and the resources that should have been allocated to it never have been. We need to find the best solutions to lower drug costs for society in general, and not discriminate against migraine patients in their moment of hope. We should not cut off the flow of innovation that has just been opened, devalue the impact of migraine disease, and further devalue the person who bears that disease.
William B. Young, MD, FAAN, FAHS, FCPP
Professor of Neurology,
Thomas Jefferson University, Philadelphia PA
1 - Young WB, Park JE, Tian IX, Kempner J. The Stigma of Migraine. PLoS One. 2013;8.
2 - Kempner J. Not Tonight: Migraine and the Politics of Gender and Health. Chicago: University of Chicago Press 2014.
Competing interests: Alder — Advisory Board/Consultant (04/2018 – 04/2019) Allergan — Advisory Board/Consultant (05/2017 - 05/2018) Amgen — Speakers Bureau (11/2017 - 11/2019) Avanir — Advisory Board (10/2016 - 11/2016) Lilly — Advisory Board (01/2018 - 12/2018) Promius — Advisory Board (02/2018 - 02/2019) Supernus — Advisory Board/Consultant (11/2015 - 10/2017) Teva — Speakers Bureau (02/2018 - 12/2019) RESEARCH Alder 02/2015 - 09/2016 (PI) Allergan 09/2014 - 08/2016 (PI) Amgen 08/2015 - present Autonomic Technologies 07/2015 - present (PI) Colucid 09/2015 - 01/2018 Cumberland 06/2011 - present Dr. Reddy Laboratories 02/2017 - 01/2018 Eli Lilly 10/2016 - present Merz 05/2013 – 12/2016 Novartis 07/2016 - present PCORI 03/2017 - present Scion 01/2017 - present Teva 01/2017 - present Zosano 01/2018 - present