Cost-Effectiveness of Erenumab for the Preventive Treatment of Migraine in Patients with Prior Treatment Failures in Sweden

DOI: https://doi.org/10.1007/s40273- 020- 00996- 2

Abstract-Summary The aim of the study was to determine the cost effectiveness of erenumab for the preventive treatment of migraine.

A hybrid decision-tree plus Markov model was developed to evaluate the cost effectiveness of erenumab as a migraine treatment compared with best supportive care only for patients experiencing at least 4 monthly migraine days for whom at least two prior preventive treatments had failed.

The primary outcomes were costs, migraine days, and quality-adjusted life-years

(QALYs).

The analysis was conducted from Swedish societal and healthcare system per- spectives based on total migraine, chronic migraine and episodic migraine

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populations, using a discount rate of 3% applied to both costs and health benefits and using year 2019 values.

In the base-case deterministic analyses, erenumab treatment resulted in ICERs of Swedish krona (SEK) 34,696 (€3310) and SEK301,565 (€28,769) per QALY gained in the total migraine and episodic migraine populations, respectively.

In the total migraine population, the use of erenumab resulted in a net benefit to society of SEK81,739 (€7773) per patient, assuming a willingness-to-pay threshold of SEK300,000 (€28,528) per QALY.

Our analysis suggests that erenumab is a cost-effective treatment for migraine

with a willingness-to-pay threshold of SEK300,000 per QALY.

Extended: In the base-case analysis, there was no distinction between these

patients in terms of their clinical trajectory in the model.

Given current evidence and understanding, we believe the present analysis rep-

resents a robust assessment of the CE of erenumab.

Introduction The Swedish Headache Society recommends preventive treatment should be offered to patients who experience frequent attacks (three or more disabling migraine attacks per month) or if the effect of acute medication is insufficient [463].

The goal of preventive treatment is a 50% reduction in the number of headache

days, and re-evaluation of the patient is recommended every 3–6 months.

Alleviation of migraine reduces these costs, making successful treatment of

migraine a societal investment.

The use of erenumab at a dose of 140 mg is supported by post hoc analysis of data from pivotal studies in EM and CM, in patients with at least one prior treatment failure, demonstrating a reduction in the number of MMDs versus placebo in the overall population [464, 465].

The purpose of this study is to inform healthcare decision making by assessing the cost effectiveness of erenumab versus best supportive care (BSC) in the preven- tive treatment of migraine in Sweden for patients for whom two or more preventive treatments have failed.

Methods An economic model with a decision-tree plus Markov structure was developed to assess the cost effectiveness of erenumab as a migraine treatment compared with BSC for patients with at least 4 MMDs for whom at least two preventive treatments have failed.

The model structure was predicated on the assumption that quality-adjusted life- years (QALYs) and (non-treatment-related) costs could be estimated based on the MMD frequency experienced by patients.

In both periods of the model, QALYs and (non-treatment-related) costs were accrued based on how patients were modelled to be distributed across MMD fre- quencies in each state.

The remaining proportion in the model was assumed to return to the ‘on treat- ment’ state, where patients again were subject to post-assessment negative discon- tinuation and possibly later re-entered the re-evaluation period.

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Results Mean MMD reduction at 12 weeks was greater in the erenumab 140 mg arm than in the placebo arm (5.49 and 2.20, respectively, for the total migraine population).

Erenumab had a greater proportion of responders (40.77 vs. 13.89% for the total migraine population), and responders had a greater mean MMD reduction (11.69 vs. 10.95 for the total migraine population) compared with placebo + BSC.

In the base case, the ICER for erenumab was SEK34,696 and SEK301,565 per

QALY gained for the total migraine and EM populations, respectively.

Under a willingness-to-pay (WTP) threshold of SEK300,000 per QALY, the net monetary benefit of erenumab to society was estimated at SEK81,738, SEK131,255 and − SEK238 per patient for the total migraine, CM and EM populations, respec- tively, with significant value coming from the utility gained and indirect costs saved. With the base-case analysis, lower-dose erenumab 70 mg was also cost effective,

with a higher ICER.

Discussion To US-based evaluations, the model structure included a response-based patient pathway representing the treatment guidelines typically considered by European healthcare systems.

An ICER of SEK34,696 per QALY gained was estimated for erenumab 140 mg among a total migraine population with two or more treatment failures over a 10-year time horizon and including indirect costs.

Even without indirect costs, the results show that erenumab should be considered cost effective for patients with migraine for whom two or more prior preventive treatments have failed.

The results were robust to changes in structural assumptions, and no sensitivity analysis generated an ICER over SEK300,000, except when the treatment was used exclusively in patients with EM or when a 24-week time horizon was employed, which would not account for the health benefits for patients who respond to and remain on erenumab treatment.

Conclusion Consistent with previous research, erenumab resulted in a meaningful reduction in MMD frequency and an increase in QALYs compared with BSC for patients with prior treatment failures.

The health economic evaluation presented suggests that erenumab is cost effec- tive in patients for whom two or more previous preventive treatments have failed, from both a healthcare and a societal perspective in Sweden, with a threshold value of SEK300,000 per QALY gained.

Acknowledgement A machine generated summary based on the work of Mahon, Ronan; Lang, Andrea; Vo, Pamela; Huels, Jasper; Cooney, Philip; Danyliv, Andriy; Vudumula, Umakanth; Vadapalle, Sreelatha; Maniyar, Farooq; Goadsby, Peter J. 2021 in PharmacoEconomics.

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Cost-Effectiveness Analysis of Erenumab Versus OnabotulinumtoxinA for Patients with Chronic Migraine Attacks in Greece