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The Generosity of Drug Companies
At a major press conference this week, the Bill & Melinda Gates Foundation and 13 drugmakers, along with the World Bank, the US, Britain, and UAE, announced a joint effort to attack 10 neglected tropical diseases. The drug companies will be contributing $785 million to this effort and Gates is pledging $363 million to try to eliminate these diseases in the next decade. This is indeed a noble initiative, one that should be applauded for its ambition and scope. It will involve not just money and medicines, but also the talents of scientists at these companies who will help guide the critical research needed to make breakthroughs in eradicating these diseases. The fact that so many organizations are working together for the first time should help drive the success of this initiative.
But, for the pharmaceutical companies involved, this isn’t something new.
For decades, pharmaceutical companies have been working on programs designed to help people in the developing world. In 1987, Merck began efforts to eradicate river blindness, a disease spread by black fly bites and characterized by disfiguring dermatitis and eye lesions leading to loss of sight. Merck formed a partnership with the World Bank, the WHO, UNICEF and various ministries of health to provide free Mectizan (Ivermectin), which treats river blindness with a single annual dose, to anyone who needs it. More than 69 million Mectizan treatments are given each year across 33 different African and South American countries. The WHO estimates that 40,000 cases are prevented annually as a result of this program.
The Merck example is not unique. Zithromax (azithromycin) is a great drug to treat Chlamyida trachomatis, the bacterium responsible for causing trachoma and the leading cause of preventable blindness in the world. In 1998, Pfizer co-founded the International Trachoma Initiative (ITI) and, through the ITI, has provided over 54 million treatments of Zithromax to trachoma patients in 15 countries. This program is part of the WHO’s SAFE (Surgery, Antibiotics, Face-washing and Environmental improvement) strategy, which is designed to eradicate trachoma by 2020.
Virtually, every major pharmaceutical company has been involved in these types of efforts. GSK, AstraZeneca, Lilly, Sanofi-aventis and Novartis are all working to combat tuberculosis. Similarly, Pfizer, GSK, Novartis, Eisai and Sanofi-aventis are all working on malaria. The same can be said for AIDS and tropical diseases. In fact, the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) lists on its website 213 different efforts aimed at improving the plight of those suffering in the developing world.
Moreover, pharmaceutical companies historically have led all businesses in terms of generosity. In her Forbes article entitled “America’s Most Generous Companies” (October 10, 2010), Jacquelyn Smith reported that in 2009, according to The Chronicle of Philanthropy, six of the top 10 corporations were pharmaceutical companies. Pfizer led the list with $2.3 billion donated in total cash and product-giving. The top 10 also included Merck, Johnson & Johnson, Abbott, Lilly and Bristol-Myers Squibb.
There are cynics who will say that pharmaceutical companies are only doing this to help their image. The fact is that the companies have been doing this for so long that it is part of their culture. The men and women in these companies who help in these type of projects take great pride in this work. This new public-private partnership to combat 10 neglected diseases is a terrific initiative and hopefully will be met with great success. But for pharmaceutical companies, it is a continuation of decades of work and billions of dollars of investments.
Are Older Women on Statins at Risk For Diabetes?
One of the more interesting aspects of having a blog is getting comments from readers. It is always nice to get responses that enjoy the posts or that value my views. Of course, there are also some that suggest I don’t know what I’m talking about. I received one such comment last week which I believe merits a considered response. A couple of weeks ago, I wrote a piece entitled: “Disease Creep or Good Medical Practice?” Essentially, I was challenging the view that the use of statins to lower LDL cholesterol is an example of “disease creep” – the conversion of a risk-factor to an actual disease. Briefly, my view is that high cholesterol, while not a disease itself, is a strong predictor of heart disease in people with multiple cardiovascular risk factors and thus needs to be treated if diet and exercise aren’t sufficient to lower LDL cholesterol to recommended levels.
A few days later, I received a comment that began: “Did none of you receive the message that statin use was associated with the onset of type 2 diabetes?” The writer was referring to recent data from the Women’s Health Initiative (WHI) reported in the online edition of “Archives of Internal Medicine.” The investigation included 153,840 post-menopausal women aged 50 – 79 who were not diabetic at the start of the study. Over the course of the next 6 – 7 years, 10,242 women developed type 2 diabetes. After taking into account factors like lack of exercise and weight gain, it was determined by the WHI researchers that those on statins were 48% more likely to become diabetic than those not on statins at all.
Does this mean that statins can make older women more susceptible to diabetes? That is hard to say. It is possible that statins have effects on muscles and the liver that cause improper glucose metabolism, which could lead to diabetes. However, the WHI study is an observational study, not a prospective one and there are uncontrolled factors in an observational study. For example, women on statins may feel that they are protected from heart disease and may be eating more starches and sugars. Post-menopausal women don’t metabolize sugars well and this may be contributing to the increase in incidences of diabetes seen in this study.
Observational studies can yield wildly different results. Some, like the WHI study suggest negative effects of statins, others show unexpected benefits. It is interesting to note that a recent observational study suggests that taking statins may prevent death from flu. In a study entitled “Association Between Use of Statins and Mortality Among Patients Hospitalized With Laboratory-Confirmed Influenza Virus Infection: A Multistate Study” published in The Journal of Infectious Diseases (January 1, 2012), the authors reviewed the records of 3,043 older adults hospitalized with the flu in 2007/2008. Those who were on statins were 41% less likely to die from the flu over 30 days compared to those who weren’t, independent of age or flu vaccination status. An accompanying editorial to this article stated the dilemma that all observational studies pose: while there is a scientific rationale as to why statins could reduce mortality, the results might also be explained by a “healthy user bias” in that “statin users are more apt to be discriminating users of healthcare.” The editorial emphasized the need for a double-blind, placebo-controlled randomized trial of acute statin therapy in hospitalized statin-naïve, influenza infected patients to provide a definitive answer as to whether statins have protective benefits in flu patients.
Randomized prospective studies do exist for statins in diabetics. One of note is CARDS (Collaborative Atorvastatin Diabetes Study). CARDS was designed as a 6-year study and was made up of 2838 diabetes patients aged 40 – 75 with no history of heart disease. The patients were randomized to receive 10mg of atorvastatin or placebo. Over time, the LDL cholesterol levels of those on placebo remained unchanged (at about 120mg/dL, whereas those on atorvastatin had dropped to 77mg/dL on average. Surprisingly, the Data Safety Monitoring Board (DSMB) halted CARDS after only 4 years when it was found that those on atorvastatin had 35% fewer cardiovascular events, 48% fewer strokes and a death rate lowering of 27%. When the results of CARDS were reported in The Lancet (Vol. 364, 685 – 696, 2004), the authors concluded: “The debate about whether all patients with type 2 diabetes warrant statin treatment should now focus on whether any patients can reliably be identified as being at sufficiently low risk for this safe and efficacious treatment to be withheld.”
Statins are important drugs. But like any drug, they can have risks and need to be used appropriately.
When It Comes to NDA Approvals, Is 30 the New 50?
In 2011, the FDA approved 30 New Medical Entities (NMEs) filed either as New Drug Applications (NDAs – small molecules) or Original Biologic License Applications (BLAs – therapeutic biologics). This is the largest number of approvals since 36 new drugs were approved in 2004. Furthermore, on average only 23 new drugs were approved in the previous decade, so the 2011 total is pretty impressive. People are debating whether this represents a turnaround for the biopharmaceutical industry or a one year aberration. Regardless, as good as 2011 was, there is no doubt that the number of new drugs produced by the industry is significantly lower than what it produced in the 1990s.
When people talk about this issue, they always use 1996 as their starting point. In that year, the FDA approved 53 NMEs, an all-time high. However, using the 1996 data as a starting point for a productivity discussion is totally inappropriate as THAT was a one year aberration. In the early 1990s, the U.S. was undergoing a “drug lag,” that is, drugs were being approved more rapidly abroad than in the U.S. As a result, a number of drugs were languishing at the FDA for years before approval. Needless to say, Congress got involved and they realized that the FDA was under-resourced to approve drugs in a timely fashion. To solve this problem, Congress enacted the Prescription Drug User Fee Act (PDUFA), a mechanism whereby charges were levied on pharmaceutical companies for each new drug application filed. The revenues from these “user fees” were used to hire 600 new drug reviewers and support staff. This personnel increase enabled the FDA to work through the backlog of NDAs. The record number of NDA approvals in 1996 is a result of this.
(As an aside, the user fee in 1995 for a full NDA was $208,000. In 2012, the fee is $1,841,500. Considering that fewer NDAs are being filed, given the nine-fold increase in PDUFA user fees, one might wonder why all drugs can’t be approved with a six months review time.)
Nevertheless, the FDA approved 315 new drugs from 1991 – 2000. Thus, despite the progress in technologies for drug discovery and development, as well as the wealth of information that has emanated from the Human Genome Project, the number of new drugs emerging annually has dropped significantly. What may account for this? For one thing, due to industry consolidation, there are fewer companies producing new drug candidates. In 1988, the Pharmaceutical Research and Manufacturing Association (PhRMA) had 42 members. Only 11 of those companies exist today. While there are biotech companies like Amgen that have arisen over this timeframe, there haven’t been nearly enough new companies formed that could make up for this decrease in NDA-producing organizations. Back in 1990, if a new idea for treating cancer arose, 25 different companies would have jumped on it. Given the challenges inherent in R&D, one might assume that 4 or 5 of these companies would have been successful in getting such a drug approved. Things are quite different now. With fewer companies competing, the chances for success drop precipitously. Not only are there then fewer NDAs produced, you also wind up getting fewer entrants in a new class of drugs, which provides fewer choices to patients, physicians and payers.
Another reason for the decrease in NDA output is the result of the higher safety and differentiation hurdles experimental medicines face. For a new drug to be a commercial success these days, it needs to be differentiated from existing therapies. In addition, the FDA is requiring that new compounds are effective in treating the disease itself and not just impact markers of the disease. For example, a new compound that lowers LDL (“bad”) cholesterol might be of value, but the FDA now requires data actually showing that such an agent actually reduces heart attacks in a patient population with cardiovascular disease. In the 1990s, simply lowering LDL was enough to get FDA approval. Outcomes studies, if they were done at all, would be done after the drug was approved and marketed. Now, extensive clinical trials are needed and the new agent not only has to reduce heart attacks and strokes, it also needs to do so better than the generic statins.
The impact on industry productivity as a result of higher differentiation and efficacy hurdles can be seen in the decrease in compounds clearing late stage (Phase 3) clinical studies. In the 1990s, >90% of compounds entering Phase 3 received FDA approval. Data from Arrowsmith (Nature Reviews Drug Discovery Vol. 10, 87, February 2011) suggests that only 50% of compounds entering Phase 3 get FDA approval. Phase 3, which prior to 2000 served to confirm results from early smaller scale clinical trials, now is a major hurdle in determining a drug’s ultimate medical and commercial value. The drugs that emerge from such vigorous trials are likely to be major advances. However, fewer of these occurrences happen now than a decade ago.
For NDA approvals, the 1990s can be viewed as an era when there were many large organizations producing multiple compounds that didn’t need to be differentiated from existing therapy nor show multiple year safety and disease reduction in patients. The rules, however, have changed. The hurdles and costs for new drug development are higher than ever before. As a result, to expect the industry to produce 50 new drugs per year is unrealistic, regardless of technology advances. Thirty is the new 50.
Indian Companies Are Finding Drug R&D Pitfalls
A brief article in The Economic Times (January 2, 2012) entitled “Zydus, Eli Lilly drug discovery deal off” got very little notice, but may represent a new trend. Three years ago, the Indian company Zydus Cadila signed a research pact with Lilly to collaborate on novel drugs to treat cardiometabolic disorders. The deal had the potential to be worth up to $300 million if Zydus Cadila achieved specific milestones and compounds passed key steps in clinical development. While not a lot of information was given for the dissolution of this collaboration, I found the following comment interesting:
“Developing a new drug from scratch is getting more expensive due to increased regulatory scrutiny and high costs of clinical trials. Lowering costs through a partnership with an Indian drug firm was one way of speeding up the process, but the success rate has not been very high.”
Much has been made of the growing investment in R&D being made by Western pharmaceutical companies in places like China and India. Initially, this work was meant as a way to get laboratory work done more cheaply. However, about a decade ago, Western companies turned to their outsourcing partners to tap into their scientific talent and to broaden their search for new medicines. This blended well with the ambitions of these countries to become bigger players in the lucrative global pharmaceutical market. A few years ago, this trend was discussed by Pete Engardio and Ben Rissing in a Business Week story entitled “Big Pharma’s R&D Booster Shot” (June 11, 2008) which focused on India and highlighted the proliferation of deals, such as India’s Glenmark Pharmaceuticals liaison with Lilly and Ranbaxy’s drug-discovery alliance with Merck. The authors acknowledged that, while Indian firms were unlikely to compete in the development of new medicines overnight due to the long drug discovery-development timeline, they were clearly on the path to be eventual competitors.
But the Indian firms are now discovering how difficult this business is. The Zydus Cadila – Lilly example is not unique. Similar disappointing stories can be told for the early diabetes drugs that Dr. Reddy’s Laboratories licensed to Novo Nordisk and Novartis, or Glenmark’s anti-asthmatic compound that was licensed to Forest Laboratories. However, these setbacks shouldn’t be thought of as a failing of India’s nascent pharmaceutical efforts. They just provide further evidence of how challenging drug discovery is, no matter where it is done.
However, there could be at least one concern with India’s emerging drug pipeline. In his article “India Perseveres as Drug Discoverer” (Chemical & Engineering News, October 31st, 2011), Amruthanand Nair shows a table listing the drug candidates in advanced development from several major Indian firms, including Dr. Reddy’s, Glenmark, Piramal Life Sciences and Sun Pharma. Of the 10 compounds listed, many are mechanistically related to agents that are already on the market or they are in classes where previous compounds have had little or no success. It is hard to imagine that any of these agents will be blockbusters without long-term and expensive clinical studies that would differentiate them from current therapies. Do these small companies have the internal resources to carry out such studies? If not, they will need a major pharma partner to do this. And this comes back to the “developing a new drug from scratch” quote above. It is entirely possible that, as happened with the Zydus Cadila – Lilly deal, Western partners will be dissolving these deals unless there is compelling evidence that the compounds generated will meet not just regulatory scrutiny but also the very high hurdle that now exists for compound differentiation.
When it comes to drug discovery, the Indian pharmaceutical industry is still in its infancy. It will be awhile before the “eventual competitor” status will be realized.
Disease Creep or Good Medical Practice?
The American Heart Association has been monitoring deaths due to cardiovascular disease (CVD) in the U.S. for over a century. While the CVD death rate grew steadily for most of the 20th century, it leveled off and then began to drop somewhat over the past 25 years. Nevertheless, CVD is still the leading cause of death in the U.S. with 600,000 people dying annually, which accounts for more than 25% of all deaths in the country. The direct costs associated with treating heart disease amount to over $80 billion/year and indirect costs attributed to loss of productivity exceed $60 billion/year.
Despite the progress made in moderating the CVD death rate, it is still a major disease. Furthermore, as the obesity epidemic continues in the U.S., recent headway is liable to be counteracted by the increase in obesity, which is already resulting into a concomitant increase in type 2 diabetes, a precursor to heart disease. Even with improvements in diagnosis and treatment, better understanding of risk factors, reductions in smoking, etc., CVD is going to remain a major health problem for decades.
Diet and exercise are keys to staying healthy, not just to ward off heart disease and diabetes but other diseases as well. Yet, there are times when medical treatment becomes a necessary add-on to preventing heart attacks and strokes. It is not a coincidence that the lowering of CVD deaths occured at the advent of statins such as Zocor (simvastatin) and Lipitor (atorvastatin), drugs that lower LDL cholesterol which is a key factor in the formation of atherosclerosis. These medicines have been shown to be both effective and safe for long-term use.
Thus, it is stunning to see an essay like Jeanne Lenzer’s “Disease Creep: How we’re fooled into using more medicine than we need” (December 22, 2011). Lenzer’s views can be summarized in her quote below:
“Elevated cholesterol is not a disease. It doesn’t cause symptoms. It is a risk factor. People with high cholesterol levels are somewhat more likely to develop a heart attack or stroke, but they are at far less risk than individuals who already have cardiovascular disease. This is the definition of disease creep: when pre-conditions or risk-factors are treated as if they are the same as the actual disease state.”
In Lenzer’s utopia, you wouldn’t get a statin until AFTER you have already had a heart attack. The problem is that many first heart attacks are fatal – you don’t get a second chance to go on statin therapy then. She is correct in saying that just having high cholesterol alone does not justify taking a statin to prevent a heart attack or stroke. But CVD risk factors also include male sex, older age, family history of heart disease, post-menopause, smoking, obesity, high blood pressure, diabetes and stress. If a patient presents to a physician with multiple risk factors and if diet and exercise have not been effective in lowering cholesterol levels to those recommended by the American Heart Association, that physician would be remiss if the patient wasn’t prescribed a statin. Waiting for a patient to first have a heart attack or stroke before providing such treatment would be irresponsible.
Lenzen implies in her article that the prophylactic use of statins may only prevent 1 in 50 heart attacks. I don’t necessarily agree with that number, but let’s say that is correct. There are 785,000 first heart attacks/year in the U.S. Even employing Lenzen’s assumptions, the use of statins in the overall treatment paradigm of patients with multiple CVD risk factors would prevent thousands of heart attacks or strokes annually. Now that the most-studied statins like simvastatin and atorvastatin are generic, it would seem like the cost-benefit of statin use to prevent first heart attacks is non-controversial. This isn’t “Disease Creep” – it is simply good medical practice.
The Perils of R&D in Well-Trodden Areas
To most working in pharmaceutical R&D, it became clear a decade ago that the era of novel anti-hypertensive research was coming to a close. The blood pressure market was saturated with many safe and effective drugs, most of which were generic or soon to be so. These treatments included diuretics, beta blockers, alpha blockers, angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). Thus, it was pretty surprising that Novartis pursued renin inhibition, yet another type of mechanism for blood pressure lowering. This approach was not novel. In fact, scientists had been working on trying to discover and develop novel renin inhibitors since the early 1980s. For a variety of reasons, most companies had abandoned their efforts by 2000 as it was no longer clear that a renin inhibitor would have any benefit over existing therapies.
Thus, it was pretty surprising that Novartis continued in this field and brought aliskerin (sold as Tekturna or Rasilez) to market in 2007. The fact that Novartis scientists were able to find such an agent after decades of research in an area where many had failed was remarkable. Aliskerin was indeed a potent blood pressure lower. It significantly lowered blood pressure for a full 24 hours when given as a single dose and added efficacy when dosed on top of other blood pressure medications. But its blood pressure lowering effects weren’t dramatically better than existing therapies. Was aliskerin too late to market for it to be a commercial success? Renin is an enzyme that initiates the first step in what is called the “renin-angiotensin (RAS) cascade” that ultimately produces the blood pressure regulating peptide angiotensin 2. But the ACE inhibitors and ARBs both also target the RAS cascade, so many questioned whether aliskerin would offer meaningful advantages over existing agents. Why would payers be willing to pay a premium price for a new unproven agent without superiority data?
Novartis tried to show the medical importance of aliskerin by conducting a number of long-term outcomes studies to demonstrate its advantages. One of these was called ALTITUDE (ALiskerin Trial In Type 2 Diabetics nEphropathy). Novartis described the trial as follows:
“The placebo-controlled Phase 3 ALTITUDE study is the first trial to investigate Rasilez/Tekturna for more than one year in a specific population of patients with type 2 diabetes and renal impairment. These patients are known to be at high risk of cardiovascular and renal events. In the study, Rasilez/Tekturna was given in addition to optimal cardiovascular treatment including an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB).”
ALTITUDE was an events driven study involving 8,600 patients and it was monitored by an independent Data Safety Monitoring Board (DSMB). Novartis was hoping to show that aliskerin, when added to conventional therapy, delayed heart and kidney complications in the type 2 diabetes population. Basically, Novartis hoped that in addition to lowering blood pressure aliskerin would also have protective effects for organs like the kidney. In studies like this, it is the role of the DSMB to monitor the progress of patients on a periodic basis in order to determine how well the novel treatment is working.
On December 20, Novartis announced that the DSMB recommended that the ALTITUDE study be halted. To great surprise, they found that the trial arm that contained aliskerin after 18 – 24 months resulted in an INCREASED incidence of non-fatal stokes, renal complications, hyperkalemia and hypotension in this high risk study population. As a result, Novartis immediately halted promotion of aliskerin-based products for use in combination with ACE inhibitors or ARBs. For some unknown reason, aliskerin doesn’t seem to have organ protective properties, but its use appears to cause unforeseen toxicities when given in combination with other blood pressure lowering medications.
This is a terrible result for Novartis and is likely to cause the demise of this drug. Matthew Herper’s Forbes story on this event contained the following quote from Texas cardiologist Dr. John Osborne, who summarizes the situation that Novartis now faces:
“The Novartis hypertension franchise is now DOA, obviously. Furthermore, this class of DRIs has died with the death of this drug… Furthermore, given this data, why would one use this molecule anyway?”
A few lessons can be drawn from this.
1) Going after a new mechanism where there are already excellent treatments on the market is always very risky, especially when generics are already present or on the horizon. This isn’t limited to anti-hypertensives. For example, an area like LDL-cholesterol lowering is very well-served with statins. Any new LDL-lowering agent would have to be very special for payers and physicians to accept it. The same thing can be said for anti-histamines, anti-ulcer agents, etc. R&D resources are best spent in areas of major medical need, where a new medicine can make a difference.
2) If you still believe your new drug has something to offer patients, despite the fact that good medicines already exist in this therapeutic area, it behooves you to do key clinical studies before filing the NDA. My guess is that, despite the fact that Novartis has generated income over the past 4 years with aliskerin, the R&D, manufacturing and launch costs for this drug were pretty high and not compensated for the sales to date.
3) This type of result further supports conservatism by regulatory authorities. I wouldn’t be surprised if the FDA uses this case as an example of why they want more Phase 3 studies carried out BEFORE approval in order to justify registration of a new drug in a therapeutic area already well served.
When a drug fails, it is not an event that impacts only one company. Presumably, other R&D organizations will learn from this and design future clinical development programs appropriately. For regulatory agencies, one would hope that this type of result won’t cause further conservatism and cause them to increase the demands placed upon companies charged with the discovery and development of new medicines. Finally, this is another example that can be used to teach the critics of the drug industry that the work pharma does is challenging and highly risky – yet important to the health of us all.
A Holiday Gift From Merck’s Ken Frazier
These are quotes that a pharmaceutical R&D supporter like myself loves:
“The most sustainable strategy is innovation.”
“Science and translating science into medically important products has always been at the core of how (we) define ourselves in the world.”
“Science and innovation are in the DNA of the company.”
These sentiments don’t come from the head of a biotech company or a scientist who is the CEO of a pharmaceutical company like John Lechleiter at Lilly. Rather, they come from Ken Frazier, Merck’s first-year CEO, a lawyer by training. As reported by Christopher Weaver, Frazier defended his commitment at a recent breakfast hosted by The Wall Street Journal. Frazier’s views, unfortunately, aren’t embraced by Wall Street. Merck’s stock has stagnated in Frazier’s first year whereas that of Pfizer has increased by about 25%, partially as a result of the latter’s commitment to slash its R&D budget.
Frazier has not been rash in crafting Merck’s research budget. In fact, the combined R&D budget for Merck and its acquired company, Schering-Plough, was $8.6 billion in 2009. If Merck not only kept this budget but rather increased it by 5% annually, it would project out to be almost $10 billion in 2012. Instead, Frazier is planning on a spending about $8 billion on R&D in 2012 – still a hefty amount but meeting that goal requires cuts to the new combined R&D organization. Nevertheless, Frazier is finding himself defending this spending to Wall Street critics. His response?
“What we are really trying to do is run the company to create sustainable long-term value for our shareholders… The problem with R&D is that it’s not always consistent. It’s not like engineering where you can incrementally innovate and make another version of the iPhone… If you look in the past, there have been other fallow periods for R&D, but over the long-term, science has always made progress.”
There are tremendous medical needs now facing people around the globe. Alzheimer’s Disease (AD) is a problem that is getting worse as the population ages. The societal costs are enormous. There are a number of compounds that are in clinical development that are hoped to slow or even reverse AD. The problem is that these clinical trials are long and expensive to run. The same can be said for the clinical trials needed to discover and develop new treatments for many other diseases such as obesity, diabetes, heart disease and osteoporosis. Gone are the days when one can simply show that a compound stops bone loss in an osteopenic woman. Instead, long-term studies are needed to show that such a drug reduces fractures in this population. Physicians, payers and regulatory agencies are requiring these types of studies before justifying prescribing such new medicines to patients.
Big pharmaceutical companies are the only organizations with the resources and talent to do this. But substantial R&D budgets are required to capitalize on the exciting new opportunities being uncovered by genomics. One can argue that the Mercks of the world are serving the national interest by making these large investments because, if they don’t do these studies, no one else will. So kudos to Ken Frazier for having the courage to stand up to the R&D naysayers. Perhaps his commitment to R&D will return Merck to the status of the World’s Most Admired company, a title they owned in the late 1980s.
Consultants Might Have More Credibility If They Had Their Facts Right
Big Pharma often finds itself Wall Street’s whipping boy. Why? Analysts are looking for immediate answers from an industry built on proving–and disproving–hypotheses. Unfortunately, the result is often misguided analysis, as happened last week when the firm Oliver Wyman issued a white paper entitled “Beyond the Shadow of a Drought – The Need for a New Mindset in Pharma R&D.”
Before last week, I had never heard of Oliver Wyman, which describes itself as follows:
“Oliver Wyman is a leading global management consulting firm that combines deep industry knowledge with specialized expertise in strategy operations, risk management, organizational transformation and leadership development.”
Given my history in this field, I was eager to read this paper as this is a topic close to my heart. Wyman’s analysis, however, was disappointing as it, for the most part, rehashes a lot of what has been discussed by others over the past few years. What really surprised me, though, was that a number of the Oliver Wyman “insights” were based on misinformation. One of these purported insights that particularly stood out to me was Wyman’s take on Pfizer’s torcetrapib program.
In order to better understand how off-base Wyman’s white paper is, it’s important to understand torcetrapib’s history.
As most people know, statins have revolutionized the treatment of heart disease. They act by lowering LDL, the so-called “bad cholesterol,” and multiple long-term studies have shown that these drugs, in combination with diet and exercise, can effectively reduce the potential of heart attacks and strokes in patients with heart disease. But many researchers have believed that lowering LDL is only addressing part of the heart disease problem. Intriguing data have built up over the years showing that if one could effectively raise HDL, also known as “good cholesterol,” further progress could be made in reducing heart disease.
The problem that scientists have faced in this field is that not a lot is known about raising HDL and so trying to accomplish this feat in the laboratory has proven quite challenging. An exception involves the emerging biology around a protein known as “Cholesteryl-Ester Transfer Protein (CETP).” Back in 1990, a report in The New England Journal of Medicine described a Japanese family who, due to a genetic defect, didn’t produce CETP and as a result had very high HDL levels and low incidence of cardiovascular disease. Because of this observation, a number of companies, including Pfizer, sought to come up with an inhibitor of CETP to test in heart patients. The rationale was pretty simple: by inhibiting CETP, the new drug would raise HDL thereby mimicking the situation in the Japanese family who were born without this protein. Theoretically, the CETP inhibitor would reduce heart disease maybe as well as statins. In a dream scenario, the combination of statins and CETP inhibitors would reverse heart disease, enhancing the quality of life of hundreds of millions of people.
Finding inhibitors of CETP proved to be very challenging and most companies gave up. Pfizer almost did as well. But through hard work, creativity and a bit of luck, the CETP inhibitor torcetrapib was found. It successfully cleared preclinical toxicology studies and entered clinical trials in 1999, eight years after the discovery program began. The initial clinical results were astonishing. Patients on torcetrapib had increases of HDL of 100% or more – an unprecedented finding. Even better, torcetrapib also caused a modest decrease in LDL; however, when torcetrapib was added to Lipitor (atorvastatin), not only was the HDL elevation maintained, but LDL drops of 40 – 60% were seen. The lipid remodeling that was achieved with this combination had never been seen with any therapy.
The combination of torcetrapib and atorvastatin (T/A) became a major focus not just for Pfizer but for the entire cardiovascular field. As the early clinical data for T/A emerged, other companies that had previously given up their efforts in looking for CETP inhibitors jumped back in the hunt. But although T/A uniquely modified the lipid profile of patients with heart disease, its ultimate value was not yet established. The long-term benefits of altering heart disease with CETP inhibition were still hypothetical. Furthermore, at the end of the Phase 2 studies, it was found that T/A caused a small, but reproducible increase in blood pressure. However, based on the known association between atherosclerosis, blood pressure and cardiovascular disease, the large increase in HDL was expected to provide benefits that would be far greater than any harm caused by the small blood pressure increase. To prove this, Pfizer had to carry out an extensive Phase 3 program which included a multiple year study in patients with heart disease with the hope of showing that patients with heart disease fared better on T/A than they did with Lipitor (atorvastatin) alone. This was a pretty high hurdle. Pfizer wasn’t content to test T/A versus a placebo; rather, it chose to test T/A against Lipitor, the premier statin that had a successful track record in reducing cardiovascular disease.
The Phase 3 program wasn’t cheap. Overall, it was projected to cost $800 million. But such an extensive and expensive plan was necessary. Pfizer realized that even if this program was successful, T/A would be competing with generic statins such as simvastatin and eventually atorvastatin itself. For physicians to be willing to prescribe T/A, for payers to be willing to pay for T/A, and for patients to be willing to take T/A, the clinical program needed to show that it was a drug of clear value.
By now, most know of the result of the Phase 3 outcomes trial. In late 2006, this study was halted by the Data Safety Monitoring Board (DSMB) responsible for overseeing the study. The reason for halting the trial was an imbalance in all-cause mortality in the T/A patients as compared to those on atorvastatin. In other words, T/A was not better than Lipitor alone; in fact, it was worse in reducing heart attacks and stroke.
This result stunned cardiologists around the world. One of the more telling comments was from the renowned Dr. Steven Nissen of the Cleveland Clinic, who said: “These studies further demonstrate the great difficulty in developing therapies to disrupt the atherosclerotic disease process.”
So that’s the history. Now here is the Oliver Wyman version of the story.
“Five years ago several companies—Pfizer, Merck, and Roche amongst others—were pursuing CETP inhibitors, an important new class of HDL-raising therapies. Pfizer, with torcetrapib, was in the lead, and by combining the new agent with Lipitor, they had the opportunity to create an efficacy fortress and extend the significant value of their lipid therapy franchise. But speed was of the essence if the combo was to launch before Lipitor lost exclusivity. Despite having seen signals of increased hypertension in Phase II studies, Pfizer chose to move forward with a landmark 25,000-patient Phase III trial. Unfortunately, the trial showed conclusively that torcetrapib increased cardiovascular events rather than reducing them. In contrast to Pfizer, Merck chose to slow development of its CETP inhibitor, anacetrapib, to investigate the hypertension signal. They proceeded only after they found that it appeared to be a torcetrapib-specific effect, and was not class-wide. In results shared at the 2010 AHA, Merck showed that anacetrapib raises HDL by 138 percent, without the side effects of the Pfizer molecule. What is this worth? Analyst (sic) currently project that anacetrapib will achieve peak sales ranging from $3 billion to $5 billion.”
Oliver Wyman uses this example to justify one of the tenets of its paper, which is, “speed kills” and that thoughtful, more deliberate clinical development processes are needed for pharmaceutical R&D to regain success. Its analysts believe that rushing torcetrapib through clinical development was a mistake, that “overemphasizing speed leads to throwing good money after bad” and that it is “better to slow things down to get a perspective on a molecule.” The implication is that Pfizer would have been far better off if it had taken the more thoughtful route used by Merck. Unfortunately, Oliver Wyman doesn’t know what it is talking about.
As was stated above, it was generally believed that the dramatic HDL elevating effects of torcetrapib would be of far greater clinical importance than the relatively minor blood pressure elevating effects caused by torcetrapib. Furthermore, the patients in this study were already on blood pressure lowering medications, thus their hypertension was being controlled. This was not just Pfizer’s belief. Some of the world’s leading cardiologists, like Dr. Nissen, were not only advising Pfizer on the torcetrapib program, but they were also carrying out the clinical trials. Raising HDL was viewed as the “holy grail” in cardiovascular research. Heart physicians around the world were anxiously awaiting the results from the torcetrapib studies. It wasn’t a matter of going fast to maximize profits – this was state-of-the-art science.
When the torcetrapib trial was halted, everyone in the field was shocked. Suddenly, the promise of CETP inhibition had evaporated. Experts began to question whether raising HDL would have ANY benefit in patients with heart disease. Merck, which had planned to launch their Phase 3 program at about the same time that Pfizer halted theirs, instead put their program on hold for a year as they tried to evaluate what to do. Yes, anacetrapib didn’t raise blood pressure, but perhaps the CETP mechanism was flawed. After a year of intense internal debate, Merck decided to go ahead with anacetrapib clinical studies, but in a slower fashion than they originally had planned. Their first phase 3 trial, reported at the American Heart Association meeting in 2010, showed that anacetrapib can be safely administered to patients with heart disease for 18 months with dramatic HDL elevation and LDL lowering without undo consequences. They are now running the crucial large scale Phase 3 outcomes study that, hopefully, will show that CETP inhibition can confer additional benefits in heart patients when compared to statin therapy alone.
But this remains a controversial field. Interestingly, back in 2006, Pfizer had a compound with a similar profile to anacetrapib in Phase 2 studies when the torcetrapib results were found. Clearly, Pfizer has chosen to get out of the CETP area of research and not advance this compound further, despite the sales projections, as quoted by Oliver Wyman, being made by analysts for the Merck compound. Unfortunately, the torcetrapib results raised more questions than provided answers. Perhaps the work being done by Merck and other companies will answer whether there is value in CETP inhibition.
The Oliver Wyman paper implies that rapid execution of clinical programs is done in a heedless and reckless fashion, and that is a fatal flaw which is contributing to the lack of Big Pharma success. This is absurd. I am not so naïve to think that being first to market is not factored into a company’s decision-making process. But this is true for any company in any industry. Oliver Wyman’s implications are misguided, at best, and seem to be based upon uninformed research that relies more upon popular opinion than on actual data. Oliver Wyman is only the most recent offender. Misinformed analysts have long heralded the death of Big Pharma. Why? Most of Wall Street’s doomsday scenarios are attributed to a lack of understanding about what actually happens in labs. Ours is an industry in which we are tasked with proving scientific hypotheses, a challenge that is more often frustrating than it is gratifying. The scientific aspect of what we do is so interwoven with Big Pharma’s economic concerns that there exists a tenuous relationship between scientists needing years to prove theory and analysts demanding results. That there would be confusion and frustration is unavoidable. What is avoidable, however, is the perpetration of misinformation by analysts unwilling or unable to do the necessary research to provide accurate insight.
Diet and Exercise Are Important – But Often Insufficient
The stories are heartwarming. A person is vastly overweight and finally decides to do something about it. Through determination, hard work and a newfound discipline, this person loses 25, 50 or even 100 pounds, thereby changing his or her life. Perhaps it is a woman who wants to have a child and is told that bearing a child would be life-threatening if she didn’t lose a significant amount of weight. Perhaps it’s a man who has been ridiculed all his life who decides that he is tired of the verbal abuse. You may have seen these scenarios played out on Dr. Oz or Oprah, or perhaps on the reality show, The Biggest Loser. Seeing the changes in these people’s lives after such a physical transformation can be inspiring.
I am a big supporter of diet and exercise. I once heard a doctor say that if you can somehow put the benefits of exercise in a pill, you’d have a wonder drug. Yet, despite the obvious benefits and the importance of diet and exercise, recent studies suggest that for the majority of the obese population, just diet and exercise won’t be enough.
If you are worried about the obesity epidemic in the US, two recent New England Journal of Medicine articles might further concern you. One is entitled “Comparative Effectiveness of Weight-Loss Interventions in Clinical Practice” (NEJM, 365;21, 1959 – 1968, November 24, 2011) and the other is “A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice” (same issue, 1969 – 1979). Essentially, these papers are similar in that they look at the effectiveness of different interventions in primary care practices by physicians who were trying to help their obese patients gain better control of their health. On average, the patients in these studies had a body mass index (BMI) of about 35 ( e.g., a height of 5’7” and a weight of 220 pounds) and had at least one cardiovascular risk factor (high blood pressure, plasma glucose, or cholesterol). Both studies had control groups who received usual physician care. In the behavioral intervention study, besides the control group, one group received additional face-to-face counseling and the other group received advice remotely (telephonic or email). In the obesity treatment study, the control group was compared to those who received monthly lifestyle counseling and another group who received enhanced counseling plus meal replacements and weight-loss medications.
The good news is that in both studies, those patients who were getting enhanced treatment, be it extra counseling on behaviors, more frequent sessions with their doctors or physician assistants, or enhanced life-style counseling, all had sustained statistically significant weight-loss after two years. The amount of weight loss wasn’t trivial – it was on the order of 5%. Even if the counseling was done remotely, the results were meaningful. Thus, extra time spent by primary care physicians and their associates can make a difference in helping their patients lose weight.
But the disappointing news is that even with the loss of 5% of body weight, these patients are still obese. For the aforementioned person who loses 5% from their 220 pound frame, their new weight is 209 pounds and their BMI is 34 – still well in the obese range. When you consider that the Center for Disease Control statistics for 2010 show that there are now 12 states where more than 30% of the adult population is obese, the loss of 5% body weight is just a small step to where we must get to in order to improve the nation’s health.
Obesity is a disease and its impact on the future health of the US cannot be trivialized. Lifestyle changes are very important and can’t be minimized. But for millions of Americans, this isn’t nearly enough. Undoubtedly, the future for obesity treatment will necessitate a three-pronged effort that includes diet/exercise, life-style changes and new drugs. For the latter, both the FDA and the pharmaceutical industry need to work together to help find safe and effective treatments to enhance a physician’s armamentarium to deal with this problem.
Drug Truths 