Triptans in the Italian population: a drug utilization study and a literature review
© Springer-Verlag 2008
Received: 19 December 2007
Accepted: 30 January 2008
Published: 4 March 2008
Previous studies performed in selected populations show a poor utilization of triptans for migraine. The objectives of our study were to establish patterns of triptans utilization in a large sample, covering 1/10 of Italian population (5.57 millions), and to perform a review of published studies on this topic. We investigated drug prescription database collected during 2006 from 33 health authorities distributed in 8 different regions. About 0.6% of the subjects received at least one prescription of triptans in 1 year: 77.7% were females and 22.3% males. Age distribution shows that 9.5% of patients were aged above 65, and received prescriptions for 8.2% of packages. The review of the literature suggests that these percentages of utilization are common to several countries, and shows that occasional triptan users who received only one prescription in 1 year are a large percentage (40–60%); moreover, a minor population of triptan users utilize a large amount of total triptans. Finally triptans are frequently prescribed in people aged above 65 years, a population in which triptans are contraindicated or not recommended. Our study and the analyzed ones indicate suboptimal treatment of migraine patients with triptans and also an incorrect use in some patients (triptan abusers, elderly).
Since the commercialization of the new antimigraine drug sumatriptan about 20 years ago, scientific societies, pharmaceutical companies and headache specialists, have tried to highlight the migraine pathology in the population, arguing that it was underestimated. In the following years many other drugs, in the pharmacological class of triptans, became available.
The average percentage of migraine in the world is regarded as around 9% of the overall population . However, until today, migraine remains under-diagnosed and under-treated in at least 50% of patients, and less than 50% of migraine patients had consulted a physician [1, 2]. The efficacy of triptans has been shown in several randomized, double-blind, placebo-controlled trials . However these studies were carried out in selected populations and under controlled conditions. Utilization patterns of specific anti-migraine drugs in community patients and the experiences of patients with these drugs in real life setting have been studied less extensively. Recently we have performed a study evaluating triptans utilization in a health authority in Tuscany covering about 225,000 residents [4, 5]. We have extended this study to establish the patterns of use of triptans in a large sample of Italian population  and review other studies on this topic.
Materials and methods
Study on the Italian population
In the reimbursement system of the Italian National Health Service, all prescribed drugs included within the essential level of assistance (LEA) are recorded by regional health authorities in association with the demographic characteristics of patients. Therefore, medication records of individual patients are quite complete in drugs prescription databases. This allows for accurate investigations in drug utilization in our setting. The patterns of triptans prescription in the 33 health authorities distributed in 8 Italian regions were investigated. The population studied was 5.57 millions inhabitants, that represents 9.5% of the Italian population. We analysed prescription database using the ATC classification (Anatomical Therapeutic Chemical classification) NO2CC: triptans, dispensed during 1 year (2006).
Dosage units contained in triptans packages available in Italy in 2005–2006
Tablet 50–100 mg
Suppository 25 mg
Nasal spray 10–20 mg
Injection 6 mg
Tablet 2.5 mg
Soluble tablet 2.5 mg
Tablet 5–10 mg
Soluble tablet 10 mg
Tablet 20–40 mg
Tablet 12.5 mg
Tablet 2.5 mg
Tablet 2.5 mg
Studies were identified through a Medline search on Internet (Pubmed Medline, 2000 version; address http://www4.ncbi.nlm.nih.gov/PubMed/). This search covered the period from 1991 to June 2007.
Study on the Italian population
Demographic characteristics of the population studied
Pattern of triptans utilization in a sample of 5,549,731 Italian residents
The distribution of triptan packages prescribed was: rizatriptan 26%, sumatriptan 20.1%, almotriptan 17.3%, zolmitriptan 13.9%, eletriptan 12.6%, frovatriptan 10%.
Prevalence of triptan users
Prevalence of triptans users in population studies
Percentage of new users of triptans
The prevalence of triptans utilization in migraine patients in different countries was reported to be 3–19% (average 10%) , while other population studies show a similar prevalence: 7.5% , 8% , 9.8% . Therefore the percentage of triptan utilization in the population has a good relation to the pathology, showing that less than 10% of patients use a triptan.
Frequency of triptan use
Lohman et al.  report that 12.5% of triptan users utilized more than one drug product and received 25% of the total number of dosage units. Ifergane et al.  report that, among patients who filled more than one prescription, 14.3% tried a second triptan; in this group 52.1% purchased only one prescription of the new triptan. Tepper et al.  showed that 91% of the patients remained on the same triptan during the study period. In conclusion 10–15% of triptans users change the type of triptan during the period of 1 year.
Percentage of probable triptans abusers among triptan users
Sondergaard (Denmark 2000) 
Lugardon (France 2002) 
Lohman (Netherlands 2001) 
Dekker (Netherlands 2005) 
Pavone (Italy 2005) 
Perearnau (France 2003) 
A consistent percentage of triptans is prescribed for people over the age of 65. In the Italian population this percentage is 7.6–9.5% [5, 6], higher than that reported (3.2–3.5%) in the France population [10, 27]. A previous study shows that sumatriptan users over 65 years were 3% . This is a population at major risk of hypertension and cardiovascular diseases, and it is also a population in which clinical trials have been not performed and so triptans are not recommended.
A very low percentage (about 10%) of migraine patients utilized triptans.
When utilized, triptans were prescribed only once in a year in a large percentage (40–60%) of patients.
A minority of patients (5–10%) utilize a large amount (40–45%) of triptans, and some of these are classified as triptans abusers.
A considerable percentage of triptans are prescribed in people aged over 65.
The low percentage of triptans users can be due to the low rate of diagnosis of migraine and the high utilization of over-the-counter drugs (OTC). Less than 50% of people suffering from migraine are not recognized by their general practitioner as having migraine and less than 30% of these have adequate management of migraine . Possible causes of underdiagnosis and management by general practitioner are: poor time to spend with the patient, complexity of diagnostic criteria of IHS , variability of the clinical manifestations in migraine patients [30, 31], high utilization of OTC drugs , and high cost of triptans.
The authors would like to thank Marno Institute (Castelnuovo Misericordia, Livorno, Italy) for their valuable collaboration in managing the data on triptans prescription.
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