NICE does not recommend erenumab for migraine prevention
In a final appraisal determination, NICE has not recommended erenumab (Aimovig) for the prevention of migraine, confirming previous draft guidance.
Erenumab is a monoclonal antibody that works by binding to calcitonin gene-related peptide (CGRP) receptors thus preventing the binding of CGRP – a neuropeptide believed to have an important role in the pathophysiology of migraine. It received an EC marketing authorisation in July 2018, and was launched in the UK the following September. It is licensed for the prophylaxis of migraine in adults who have at least four migraine days per month, and this was the indication under review in the NICE appraisal. It is administered by subcutaneous injection at a recommended dose of 70mg every four weeks, although some patients may benefit from 140mg every four weeks.
In its appraisal, NICE notes that for people whose migraine has not responded to at least three oral preventive treatments, trial evidence shows that erenumab 140mg is more clinically effective than best supportive care for preventing chronic (≥15 headache days a month) or episodic (<15 headache days a month) migraine. However, it remains uncertain whether erenumab is more clinically effective than botulinum toxin type A for chronic migraine, and there is not enough evidence to show that it is cost-effective in episodic migraine compared with best supportive care. Erenumab costs £386.50 per dose at the list price; however, an NHS discount to this price would have applied if the drug had been recommended.
The NICE decision is in contrast to that of the Scottish Medicines Consortium, which accepted erenumab for restricted use within NHS Scotland in April this year, for patients with chronic migraine in whom at least three prior prophylactic treatments have failed.
There are now two other anti-CGRP monoclonal antibodies on the market for the prevention of migraine: galcanezumab (Emgality), which received an EC marketing authorisation in November 2018, and for which a NICE appraisal is planned to commence in November 2019; and fremanezumab (Ajovy), licensed in March 2019, guidance on which is expected in January 2020.