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We read with interest the excellent editorial from Goadsby “A triptan too far?”.1 As he points out, both neurologists and general practitioners are now faced daily with the problem of which triptan to choose. However, we think that it is difficult to choose between the different triptans and their dosages from the figures therapeutic gain and therapeutic penalty. The efficacy for 5 mg zolmitriptan, for example, is somewhat higher than for 100 mg sumatriptan, but this is acquired at the cost of more adverse events. To make a choice between the different options, it might be appropriate to relate the increased therapeutic gain with the increase in therapeutic penalty.
Therapeutic gain on the x axis is defined as headache response (moderate/severe to nil/mild) at 2 hours−headache response to placebo. Therapeutic penalty on the y axis is defined as adverse event rate on active drug − adverse event rate on placebo. Data are given as 95% Cls. The dashed line indicates the rTG/TP for sumatriptan 100, which acts as a reference. The following triptans are included: sumatriptan 50 mg (s 50), sumatriptan 100 mg (s 100), naratriptan 2.5 mg (n 2.5), zolmitriptan 2.5 mg (z 2.5), and zolmitriptan 5 mg (z 5).
It is therefore useful to compare the ratio therapeutic gain/therapeutic penalty (rTG/TP) for the different triptans and their dosages. This direct comparison is allowed as the compounds all belong to the family of the triptans and therefore the characteristics of the adverse events are expected to be comparable.
As Goadsby suggests, the principles he outlines could be applied to the newer triptans when they become available. We propose the addition of a figure in which the therapeutic gain on the x axis is plotted against the therapeutic penalty on the y axis (figure). Here as well, it is …