Author's reply:

We thanks the comments made by Dr. Zavos. Nevertheless, some precisions must be made about them. It is known that cost-effectiveness analyses of therapies can vary from country to country in Western Europe and that these variations are not systematic (1, 2). Therefore, cost-effectiveness analyses, even those performed in a single country, can contribute to international comparisons, providing a wider perspective, according to the aims expressed by the European Commission and European Parliament on patient mobility and healthcare developments (3). Moreover our study does not contradict any of the evidences that established the advantages of rizatriptan compared to naratriptan, and it provides cost-effectiveness evidences that support them.

It is additionally necessary to mention some comments made by Dr. Zavos that, from our point of view, can reflect a severe lack of knowledge on this matter. Topiramate is not indicated for the treatment of acute migraine, but for its prevention, and this is well known by both neurologists and  general practitioners. Regarding telcagepant, another drug that was suggested in Dr. Zavos’ comments, a cost-effectiveness study about it cannot be performed until this drug is marketed and its current price is established.

References

1. Barbieri M, Drummond M, Willke R, Chancellor J, Jolain B, Towse A. Variability of Cost-Effectiveness Estimates for Pharmaceuticals in Western Europe: Lessons for Inferring Generalizability. Value Health 2005;8:10-23.

2. Drummond M, Barbieri M, Cook J et al. Transferability of economic evaluations across jurisdictions: ISPOR Good Research Practices Task Force report. Value Health 2009;12:409-18.

3. Forchielli F, Fusco M, Pessina EA, Domeniconi W, Ricciardi W. Study on Patient Mobility in the European Union. Study on Legislative Proposals on Patients’ Rights in Cross-Border Health Care. Analysis of the Proposal for a Directive of the European Parliament and of the Council on the application of patients’ rights in cross-border health and of the Communication from the Commission A Community framework on the application of patient’s rights in cross-border healthcare . Brussels: Policy Department, Economic and Scientific Policy, European Parliament, 2008.

First author of this artricle

The authors compare the cost-effectiveness of 2 well-known therapeutic agents (naratriptan and rizatriptan) for migraine in Spain and they conclude that rizatriptan was more cost-effective than naratriptan by 7.93 euros per unit of effectiveness gained.

Major Comment

The importance of this paper is very low for the following reasons:

1. It refers only to Spain and it is of limited importance to an international audience.

2. Since 1999, there have been papers published on the superior effect of rizatriptan compared to naratriptan (see for example: Bomhof M, Paz J, Legg N, Allen C, Vandormael K, Patel K. Comparison of rizatriptan 10 mg vs. naratriptan 2.5 mg in migraine. Eur Neurol 1999;42:173-9), regardless of the cost. Specifically, rizatriptan provides earlier headache relief than naratriptan, acting as early as 30 min; more patients are pain free at 2 h on rizatriptan than on naratriptan; rizatriptan provides earlier relief of associated migraine symptoms within 2 h than naratriptan and more patients have normal function at 2 h. This paper states that rizatriptan is also more cost-effective, but so what? Clinicians are already in favor of rizatriptan in terms of efficacy, and thus this paper will not change anything in the treatment option.

3. Although triptans provide effective relief from migraine for many patients, a substantial number of affected individuals are unresponsive to these compounds, and such therapy can also lead to a range of adverse effects. In this respect, newer classes of antimigraine drugs have been developed since the launch of triptans (such as topiramate and lately telcagepant). Therefore, I am not sure how a cost-effectiveness analysis of 2 older-generation drugs (with a much much lower cost than the newer generation drugs) can have an impact on the healthcare financer, as the authors claim.

I am a medical doctor treating patients at a hospital.