Resource impact statement
NICE has recommended atogepant as an option for preventing migraine in adults who have at least 4 migraine days per month, only if at least 3 preventive medicines have failed.
Stop atogepant after 12 weeks if the frequency of migraine does not reduce by:
- at least 50% in episodic migraine (defined as fewer than 15 headache days per month)
- at least 30% in chronic migraine (defined as 15 or more headache days per month, with at least 8 of those having features of migraine).
If people with the condition and their clinicians consider atogepant to be 1 of a range of suitable treatments, after discussing the advantages and disadvantages of all the options, use the least expensive. Take account of administration costs, dosage, price per dose and commercial arrangements.
These recommendations are not intended to affect treatment with atogepant that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
We expect the resource impact of implementing the recommendations in England will be less than £5 million per year (or approximately £8,800 per 100,000 population, based on a population for England of 56.6 million people).
This is because atogepant is a further treatment option. Uptake of atogepant would displace other calcitonin gene-related peptide (CGRP) receptor antagonists, and the overall cost of treatment for this patient group will be similar.
Atogepant is an oral tablet that may be preferrable when compared with other CGRP receptor antagonists that are administered by subcutaneous injection or intravenous infusion.
The list price of atogepant is £182.16 for 28 tablets (excluding VAT; company information).
An updated resource impact template is provided for completion at a local level. This is because there are five other CGRP receptor antagonists recommended by NICE for migraine. These are eptinezumab (TA871) fremanezumab (TA764) erenumab (TA682) galcanezumab (TA659) and rimegepant (TA906). TA871, TA764, TA682 and TA659 have discounts that are commercial in confidence. The price of each option can be input into the template to assess the resource impact. The prices for atogepant and rimegepant are included in the template because they do not have a confidential commercial arrangement.
To improve usability, the template has been simplified using average treatment durations for each treatment option, which can be amended locally. This is possible because CGRP receptor antagonists have been in use for some time (since 2020), therefore the number of people with migraine who are starting, stopping and continuing treatment can be assumed to have reached a steady state each year. The resource impact template covers all treatment options and updates and replaces the previous NICE resource impact templates that were published for these topics.
The local resource impact template allows users to model local service arrangements.
In NHS hospital trusts, the payment mechanism is determined by the responsible commissioner and depends on the technology being classified as high cost. Both atogepant and rimegepant have a list price which allows flexibility for prescribing. Please see the table below for the commissioners, providers and prescribing setting of each treatment.
| Treatment | Comissioner | Provider |
Prescribing setting |
|
Atogepant (oral tablet) |
ICBs | NHS hospital trusts – neurology or primary care GP services | Secondary care acute hospital trusts (headache clinic) or primary care GP |
|
Rimegepant (oral tablet) |
ICBs | NHS hospital trusts – neurology or primary care GP services | Secondary care acute hospital trusts (headache clinic) or primary care GP |
|
Eptinezumab (IV infusions) |
ICBs | NHS Hospital trusts – neurology | Secondary care acute hospital trusts (headache clinic) |
|
Fremanezumab (subcutaneous injection prefilled pen) |
ICBs | NHS Hospital trusts – neurology (homecare services) | Secondary care acute hospital trusts (headache clinic) |
|
Erenumab (subcutaneous injection prefilled pen) |
ICBs | NHS Hospital trusts – neurology (homecare services) | Secondary care – acute hospital trusts (headache clinic) |
| Galcanezumab (subcutaneous injection prefilled pen) | ICBs | NHS Hospital trusts – neurology (homecare services) | Secondary care – acute hospital trusts (headache clinic) |
Abbreviations: ICB, integrated care board.
The committee concluded that both atogepant and rimegepant could eventually be prescribed in primary care.There is also potential for people receiving both treatments to be monitored in primary care and for follow-up appointments to be done by GPs. But it recognised that specialist referral and treatment management would likely be needed before atogepant or rimegepant could be used in primary care.
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