Top 3 Retail and Mail Order Trends

Join Tom Kerr as he interviews Nikki Wilson, Senior Director of Clinical Pharmacy Services to dig into part one of our Annual Drug Trends Series. In this short video they’ll discuss standout trends from our most recent retail and mail order data focusing on decreasing opioid trends and significant jumps in migraine and respiratory medications. 

Tom Kerr (TK): Hello and thanks for joining us today as we take a deeper dive into Enlyte’s Annual Drug Trends Analysis Report. I'm Tom Kerr, and today we'll be discussing three main observations from part one of the report. The trend data will be covering here reflects all calendar year, retail and mail order transactions built through Enlyte Pharmacy Solutions in 2022 and 2023. Joining me today is Nikki Wilson, Senior Director, Clinical Pharmacy Services.

TK: Nikki, thanks for joining us. 

Nikki Wilson (NW): Thanks, Tom. Excited to get started. 

TK: All right. So let's get started and ask this first question we have here. Can you give us a brief overview of what we're seeing when it comes to drug trends. 

NW: Yeah. So standouts from the most recent data that you just described reflected continual decreasing opioid trends across our programs with the largest drop we've actually seen in the last several years. And we saw fairly significant jumps in costs for both migraine medications as well as respiratory meds last year.

TK: Okay, great. And let's, start with the opioid trends in 2023. What did you see from the data specifically within the retail and mail order space? 

NW: Yeah. So jumping into that opioid usage trend, we saw those continued declines in 2023. And as I mentioned, our utilization per claim was down 9.7% and our cost per claim was down 7.2%. And that was some of the biggest drops we've seen.

NW: Those have steadily been sort of leveling off over the last several years, as we've sort of caught up with, everything that we're trying to control in that space. And another thing that really jumped out from this last year's data was sustained-release opioids, those long-acting opioids, those dropped by more than 10%, last year as supported by prescribing guidelines. And one of the reasons those would be prescribed is usually more for ongoing or long-term pain, where we need dosing on a schedule and ODG recommendations support those as long as they're used, around maybe a surgery or are minimally used.

NW: And so first-line agents would be some of those short-acting opioids. We don't like to see a huge use in our sustained release. We have, as I think it's an industry seeing this trend continue for reasons of the prescribers are becoming more educated about the opioid epidemic, the dangers of opioids, educating patients, our industry certainly does a very good job of assisting with controls and utilization. State regulations are catching up and sometimes limiting those dispensing quantities.

NW: So number of reasons that we're seeing this go down. So overall very positive things overall. So interestingly we saw opioid alternatives that are commonly prescribed to manage acute and chronic pain also dipped last year. So those dipped, although to a lesser degree compared to opioids, could be a reflection of declines across all classes.

NW: Noting overall prescription trends had a 5.2% drop in utilization proclaim and then notably, NSAIDs utilization. Those nonsteroidal anti-inflammatory drugs, those were down 3% and anticonvulses were down 7.4%. And the non-tricyclic antidepressants were down 6.1%. And all those are often prescribed as opioid alternatives when it comes to pain complaints. 

NW: Another metric that we track really closely as an indicator of risk when it comes to opioids is morphine equivalent dose just, leveling out the dosages across all the different potencies of different opioids that are out there to be taken, and the guidelines support a low MED or anything, below 50 is considered generally progressing towards the safe standard. So we look at high MED prescription specifically anything we define as 90 and above. And those prescriptions continued to decline for the ninth consecutive year. Our high MED scripts are down 14% in 2023, and the average MED per script was also down 1.5%. So both of those are positive changes and follow guideline-based recommendations. 

TK: Great. And as you mentioned, migraine and respiratory meds experienced cost increases in 2023. Can you talk about what may have been behind that trend? 

NW: Yes. Well, overall, the top therapeutic classes had decreases in cost and utilization by claim. As we just saw the data showed that those two classes in particular experienced a jump in cost per script and both rose by over 10%.

NW: Utilization per claim was up 17% in the migraine class as well. So not only was cost rising there, but we also saw a pretty significant jump in the utilization per claim. Both those classes were also among our top five therapeutic categories to experience brand, average wholesale price, or AWP increases in 2023, which would have, of course, contributed to the upward trends in cost per script. In the brand AWP for respiratory meds rose 3.5% and the brand AWP for migraine meds rose and just under 1%. So also contributing for those migraine medications was, as I mentioned, that 17% jump in utilization per claim, while all other top therapeutic classes actually saw decreases in utilization. So they were the only one that jumped. Now, we had report out in 2023 looking at the 2022 data compared to 2021.

NW: And that was the first year that 2022 year was the first year to see migraine medications break into the top ten therapeutic classes by cost, which I think is a tribute to what we're seeing within that class. Overall, as specialty, injectable and new branded products continue to enter the market in that category in 2023. So the report we're really seeing, looking at this data this year, the 2023 migraine meds were the number ten class ranked by cost and respiratory meds, which have consistently been ranking among that top ten therapeutic classes by cost within the last few years. That climbed from the number four spot to the number three spot.

TK: Okay, Nikki. So let's focus further on migraine and respiratory categories and their cost rankings in 2023. What specific medications were driving these trends in retail and mail order channels? 

NW: Sure. So if we're going to look at the top three medications in each of those categories, ranked by cost, remembering that that's where our largest cost increases were by therapeutic class, they were in the respiratory meds, which dropped by 14.7%, and migraine medications that were up by 10.2%. So looking at what's behind the trend, the top three meds, let's look first at the migraine category within the class. The top three meds were some of those novel agents that have hit the market in recent years, starting as early as 2018. The last one on our list was released in 2020 to address the prevention and treatment of migraines in a new way. And if you listened in at all last year, I went into pretty good detail on the mechanism of action of this newer class, the newer category of migraine medications.

NW: But all of the top three that fall within our top costs fall within that CGRP receptor antagonist category. that's stands for calcitonin gene related peptide. It's a neurotransmitter that actually plays a really major role in migraine attacks. And when it's released, it attaches to CGRP receptors, which end up causing pain, inflammation, vasodilation, all the things that sort of lead to a migraine attack symptom, unlike other agents that work on the presynaptic serotonin receptors.

NW: So drugs that we have on the market today, a lot of the triptans like Imitrex and Zomig and Maxalt, which come in a lot of different forms and have been around since the 90s. These CGRP receptor antagonists target the receptors postsynaptic. So sort of after the release of all that other stuff, and they block the CGRP proteins from binding. So they essentially block migraine pain and signaling, even if there's already a release present.

NW: So they're very effective. But they are all brand only newer to the market, as I mentioned. And we have seen some AWP increases in those spaces as well. All of the AWP for these top three were up from the 2022 data.

NW: So we have the majority of our spend making up about a third, just under a third of the cost within the migraine class coming from Nurtec orally disintegrating tablets. It's rimegepant, it's for sublingual or oral use, and almost $2,000 as an average AWP per script in that class, or in that drug category. And then Ubrelvy tablets were number two by cost at about 16%. Ubrogepant again, another CGRP inhibitor.

NW: And those are, a little bit less in utilization. But the, the $1,600 price tag is what contributed to costs there. And then the last in the number three category was Aimovig Autoinjector. It’s erenubmab, it's a subcutaneous once a month injection given in the abdomen, the thigh, the upper arm. And it's primarily for preventative treatment of migraine. So the injections taken with you on a scheduled basis once a month and it prevents migraine, a little bit less costly. About $971 per script with those were really rounding out the cost increases within the migraine class. 

NW: And if we look then at the medications within the respiratory class that were driving spend in 2023 for retail and mail order, the top three medications there include two agents typically prescribed for the management of asthma or chronic obstructive pulmonary disorder, COPD, and one very costly specialty agent indicated for the treatment of pulmonary fibrosis and interstitial lung disease.

NW: So the top spot was taken by Trelegy Elipta. Both Trelegy and Spiriva, the number three, both contain a long acting anticholinergic drug umeclidinium and it's the anticholinergic in Trelegy. And when those are in the and when those are taken on a consistent daily basis for ongoing management of the underlying condition, whether that's asthma or COPD, they work by, basically blocking certain muscarinic receptors in the smooth muscle of the airways, which essentially leads to broncho dilation or opening up those airways. So they're taken on an ongoing sort of long term basis to prevent those attacks or to prevent, breathing difficulties from COPD. In addition, Trelegy has two other agents in its formulation. It's got that anticholinergic than it has an inhaled corticosteroid, fluticasone and it has vilanterol, which is a long-acting-beta2-adrenergic agonist with good evidence in long term airway broncho dilation. The steroid has anti-inflammatory effects, and the long-acting-beta2-adrenergic agonist exhibit effects that target the primary receptors or the beta two receptors in the bronchial smooth muscle, leading to relaxation.

NW: They also have effects that block the release of some of the mediators of immediate hypersensitivity from cells, especially from mast cells, which have been shown to trigger asthma attacks and broncho constriction. So all of those are working together. Just basically to open the airway is make breathing more easy, easier. OFEV, on the other hand, our number two drug in the respiratory class by spend contains nintedanib kinase inhibitor indicated in the management of fibrosing lung diseases. And it essentially works by binding to these various kinase receptors and blocking their signaling and their role in the pathogenesis of and fibrotic tissue remodeling of interstitial lung disease. So that's a condition that's really marked by inflammation and scarring, also known as pulmonary fibrosis, that make it difficult for the lungs to get enough oxygen. So whether there's damage from maybe a chemical agent or on the job, somehow there's some sort of lung damage that leads to this condition. This might be a reason that that would be used in comp.

NW: The medication itself OFEV actually received Orphan Drug Designation when it was first approved by the FDA in 2014, a designation given when a disease is rare or the condition affects fewer than 200,000 people in the United States. So it's a very important drug, but it's extremely costly. You might notice the script volume within the respiratory class was actually much less than 1%, but it still was number two by cost at 16%. because of that $14,843 price tag average per script.

NW: So having big impacts also convened within that specialty category, which we'll talk about in an upcoming report. 

TK: Yeah, this is great. Lots of great insight here. Nikki, thank you so much for taking the time to go through it. And, we're looking forward to future discussions from the Drug Trends Report in the next few weeks. as for now, this concludes our review of the top three observations within our 2023 retail and mail order trends. Thanks for joining us. And stay tuned for more drug trends analysis as we continue to produce content throughout the year. Thank you.