Allergan's Botox still a physician favorite for migraine despite CGRP push: analyst

Botox Treatment
Allergan's Botox faces a rush of CGRP challengers in migraine on the eve of its expected merger with AbbVie. (Pixabay)

With CGRP drugs on the rise in the preventive migraine market, old stalwarts like Allergan's Botox are feeling the pinch from the new competition. But a new survey says neurologists may not be so quick to give up on Botox––and that could be another win for AbbVie on the eve of its Allergan merger.

A survey of 55 neurologists showed that more physicians were likely to increase their prescriptions of therapeutic Botox for migraine prevention in the coming year than decrease, despite growing market share for CGRPs from Teva, Eli Lilly and Amgen, RBC Capital Markets analyst Randall Stanicky wrote in a note to investors Thursday.

That Botox favoritism reverses an earlier survey from last year, Stanicky said, when neurologists leaned toward decreasing Botox scripts over boosting them by a more than 20% margin. In the newest survey, the majority of neurologists––more than 55%––said they didn't expect to change their Botox prescription patterns in the coming year, Stanicky said.

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A promising report for blockbuster Botox likely comes as welcome news for AbbVie, which is in the final stages of closing its $63 billion merger with Allergan. But the survey isn't necessarily bad news for the CGRP market, which Stanicky noted is picking up share in the preventive setting and seeing growing physician support in the acute setting, as well. 

RELATED: Teva's Ajovy finally gets its autoinjector nod. Can it close the gap with Amgen, Lilly meds?

One possible beneficiary? Teva's besieged Ajovy, which is scrambling to pick up market share against more established competitors in Eli Lilly's Emgality and Amgen's Aimovig. Either way, 84% of the surveyed physicians said they intended to prescribe a CGRP in the coming year.

Thanks to the FDA's approval in January of Ajovy's autoinjector, which Emgality and Aimovig already sport, Teva's drug could be well-positioned to capitalize on that growing CGRP preference. However, Stanicky said he was "less bullish" on Ajovy's chances and said its potential growth wouldn't offset the multibillion-dollar legal overhang Teva faces for its opioid litigation.

A fourth competitor in the preventive setting, Lundbeck's Vyepti, won approval late Friday and could eventually capture up to 9% of the market, Stanicky said.

RELATED: Allergan scores year-end FDA nod for CGRP migraine med Ubrelvy, plans early 2020 launch

Another category likely to benefit from the CGRP boom is the oral CGRP group containing Allergan's Ubrelvy, which scored a nod from the FDA in December.

Stanicky wrote that surveyed neurologists saw a "meaningful place" for oral CGRPs in the acute setting for migraine, with Ubrelvy up to more 3,500 total prescriptions just weeks into its launch. Given that support, Stanicky upped peak market penetration estimates for oral CGRPs from 8% to 10%.

One key question moving forward for the CGRP class is reimbursement, where Stanicky said "heavy discounting (and sampling) have characterized early CGRP market formation as three relatively similar therapies have competed for share."

However, Botox is also facing its own difficulties with reimbursement, Stanicky wrote, helping CGRPs remain competitive with the older med.

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