Infrequent or Non-Response to Oral Sumatriptan does not Predict Response to Other Triptans—Review of Four Trials

Gothenburg Migraine Clinic, Gothenburg, Sweden.
Cephalalgia (Impact Factor: 4.89). 03/2006; 26(2):98-106. DOI: 10.1111/j.1468-2982.2005.01010.x
Source: PubMed


A migraineur can claim to be an infrequent responder ('non-responder') to an oral triptan independent of which triptan he or she is presently using. Four trials of an alternative triptan (zolmitriptan/rizatriptan; eletriptan; naratriptan; almotriptan) in patients with a history of infrequent response to oral sumatriptan were compared and contrasted in terms of study design, patient characteristics, and efficacy and tolerability of the triptan under investigation. Unfortunately, none of the reported studies used an appropriate parallel design, which would have had the non-responding triptan (oral sumatriptan) in one arm and without encapsulation. While the four trials differed in terms of study design (open-label vs. placebo-controlled), definition of sumatriptan 'non-responder' (retrospective vs. prospective) and pain intensity at baseline (30% severe to 70% severe), all four demonstrated that lack of response to sumatriptan did not predict lack of response to an alternative triptan. Changing triptans resulted in 2-h pain-relief rates of 25-81% in patients with a history of poor response to sumatriptan. It can be concluded that migraine patients who respond infrequently to sumatriptan should be switched to a different triptan, as lack of response to one triptan does not predict likelihood of responsiveness to another. A review of the available evidence suggests that almotriptan may be one of the most appropriate choices for an alternative triptan.

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    • "More than 30% of patients and up to 40% of migraine attacks fail to respond to a particular triptan, either because of suboptimal efficacy or tolerability issues [32]. Although patients who respond poorly to one triptan may respond better to another, most patients discontinue triptan treatment without trying another kind [33]. For many patients, satisfactory responses to over-the-counter (OTC) drugs and NSAIDs, as well as concomitant use of prophylactic agents, may impede the need to seek for medical help and further prescription of triptans. "
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    ABSTRACT: Background: The persistence of triptan use among newly prescribed users is low in the United States and European countries. However, triptan refill patterns in Asian primary care practices have not been well described. Methods: Data from the National Health Insurance Research Database in Taiwan were used to conduct a retrospective cohort analysis from 2005 to 2008. All participants were followed for 2 years after receiving a new triptan prescription. Refill and 2-year retention rates of newly prescribed triptans were calculated, and predictors of the first triptan refill and 2-year retention were analyzed. Results: Of the 13,951 participants with a new triptan prescription (99.9% sumatriptan), 67.4% were prescribed by a neurologist, 67.4% were prescribed at least one prophylactic agent for migraine. Of them, 34.3% adhered to the newly prescribed triptan at the first refill, 0.01% switched to another triptan, and 40.9% switched to a non-triptan acute migraine medication. The 2-year retention rate was 4.0%. The frequency of headache-related neurologic visits for 1 year before the index date, first prescription of triptan or other acute medications, first triptan prescription by a neurologist, and prophylactic use were associated with higher first refill rates. The frequency of headache-related neurologic visits 1 year before the index date and first triptan prescription by a neurologist were related to higher 2-year retention rates. Diabetes mellitus and first triptan prescription at a local medical clinic were associated with reduced probability of continued triptan use at the first refill and 2 years. Conclusions: Similar to Western societies, the refill and 2-year retention rates were low in new users of triptans. Frequency of neurologic visits and triptan prescription by a neurologist were significant predictors of adherence.
    The Journal of Headache and Pain 08/2014; 15(1):48. DOI:10.1186/1129-2377-15-48 · 2.80 Impact Factor
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    ABSTRACT: The purpose of this paper is to review six recently completed trials (three double-blind, three open-label) providing valuable data on efficacy and tolerability of almotriptan in `real world' settings.In a randomized double-blind trial, almotriptan 12.5 mg and zolmitriptan 2.5 mg achieved similar efficacy rates whereas almotriptan was associated with a lower rate of triptan-associated adverse events (AE). In another randomized double-blind trial, almotriptan patients achieved significantly higher 2-h pain-free, 2-h pain-relief and sustained pain-free rates than those receiving ergotamine plus caffeine. A third double-blind trial, enrolling patients with a history of poor response to sumatriptan (confirmed in a prerandomization attack), showed that patients receiving almotriptan had significantly higher 2-h pain-free, 2-h pain-relief and sustained pain-free rates compared with those receiving placebo.An open-label trial found similar rates of preference for almotriptan and rizatriptan 10 mg; similar rates were also seen for 2-h pain free, 2-h pain relief and sustained pain free. The German Migraine Register (open-label) found triptans to be associated with greater treatment satisfaction than non-specific agents; almotriptan and sumatriptan were linked to the highest levels of patient satisfaction. Another open-label satisfaction study showed that in comparison with previous therapies, almotriptan was associated with higher rates of pain relief, tolerability, resumption of normal activities, and the use of only one dose.In summary, the high levels of efficacy and tolerability reported for almotriptan 12.5 mg in earlier placebo-controlled clinical trials can be reproduced in `real-world' clinical settings, and are consistent with previous trials showing almotriptan to have the ideal profile for an acute migraine treatment, that is, a balance between high efficacy and low AEs.
    Drugs 12/2005; 66(Suppl 3):17-25. DOI:10.2165/00003495-200666003-00004 · 4.34 Impact Factor
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