Latest Drugwonks' Blog

In today's era of medical miracles, why isn't there a drug to off-set the effects of L-Tryptophan? Let Henry Waxman stew over that one.

In the meantime, here's an FDA joke you can tell the relatives:

Pharmaceutical Executive #1: "Did you hear that we're working on a new drug that bestows immortality?"

Pharmaceutical Executive #2: "Yeah. Too bad it'll take the FDA forever to approve it."

Have a terrific holiday.
Yesterday, the Center for Medicine in the Pubic Interest (CMPI) and the Duke University Center for Research on Prospective Health Care hosted the second meeting of the Patient Centric Health Leadership Forum.

Yes, that’s patient-centric – the counterpoint to cost-based – health care.

The day was kicked off by Ralph Snyderman, Chancellor Emeritus, Duke University and Chair of the Patient Centric Leadership Forum. Dr. Snyderman made the day’s opening presentation forever memorable by making a crucial point...

... since we are all embracing the concept of a “sustainable planet,” we should understand that such a notion must begin with the essential consideration of a “sustainable individual.”

And that means a focus on “Prospective Health” with five key components:

* Health risk assessment tools
* Therapeutic evaluation tools
* Aligned health care providers
* Aligned reimbursement systems
* Motivated consumers

Difficult to be sure. But as the great health care philosopher Kermit the Frog opined, “It isn’t easy being green.”

Full transcripts of the meeting will be available shortly.

Apples & Oranges

  • 11.20.2007
The nation’s largest healthcare payers are embracing the use of what is known as “comparative effectiveness,” a fancy term for essentially evaluating different therapies for a particular condition based on their costs and efficacy. The trend is a politically popular way to help reign in the cost for drugs, devices, and procedures. And the move reflects a broader focus on cost, rather than care that is taking place at all levels of the American healthcare system.

But it’s important to move beyond criticizing comparative effectiveness in its current form, and instead towards creating a policy roadmap for integrating technologies and science that is more patient-centric into comparative effectiveness thinking.

Much the like the U.S. Food and Drug Administration created the Critical Path Initiative to apply 21st-century science to accelerate the development of personalized medicine, another national goal should be to create a Critical Path Initiative to apply new approaches to data analysis and clinical insights to promote patient-centric healthcare.

Why? Because comparative effectiveness should reflect and measure individual response to treatment based on the combination of genetic, clinical, and demographic factors that indicate what keep people healthy, improve their health, or prevent disease. First steps have been taken. For example, the Department of Health and Human Services has invested in electronic patient records and genomics. Encouraging the Centers for Medicare & Medicaid Services to adopt the use of data that takes into account patient needs would complement such efforts.

The Patient-Centric Health Leadership Forum, a joint program of the Center for Medicine in the Public Interest and the Duke University Center for Research on Prospective Health Care, will shortly initiate a Critical Path for comparative effectiveness much as the FDA developed a Critical Path for drug approval and development.

Our goal is to develop proposals to modernize the information used in the evaluation of the value of treatments. Just as the key scientific insights guiding the FDA critical path program are genetic variations and biomedical informatics that predict and inform individual responses to treatment, our goal is to establish a science-based process that incorporates the knowledge and tools of personalized medicine in reimbursement decisions: true evidence-based, patient-centric medicine.

Here's the rest of the story as explained in a new article in The Journal of Life Sciences:

http://www.tjols.com/article-421.html

Perhaps the most urgent goal of our project will be to engage CMS in our enterprise and to encourage public health officials to embrace new kinds of evidence development, partnerships with industry, the FDA, National Institutes of Health, and the new Reagan-Udall Foundation to “harness the potential of bio-information to evaluate and predict safety, effectiveness, and the value of treatments for each patient.

No Silver Bullet

  • 11.19.2007
One in 10 people over 65 – or 5.6 million Americans – will have Alzheimer’s Disease by 2010. Without interventional therapy, the number of cases is expected to rise to 13.5 million by 2050. Currently available treatments for Alzheimer’s disease provide only temporary symptomatic relief and only for some patients, while therapies under FDA review may significantly delay or reverse the course of the disease.

On this subject, an excellent piece in today’s on-line edition of The Journal of Life Sciences. It’s titled, “No Silver Bullet” and points out that, just because we do not, as of yet, have a cure for Alzheimer’s Disease, does not mean that our increased and enhanced ability to diagnonse this scourge isn’t a significant leap forward.

Here’s a link to the article:

http://www.tjols.com/article-388.html

The author, April Lynch, is a staff writer at the San Jose Mercury News, focusing on health, medicine, biotech, genomics, and environmental investigations. She has also worked as the paper’s editor for science and health coverage. She is the author of a forthcoming book on genomic medicine

According to Lynch:

“Before people develop full-blown Alzheimer’s disease, they usually experience a condition called mild cognitive impairment, or MCI. The signs of MCI, such as minor memory loss, can be so subtle that many people miss them, or dismiss them as routine “senior moments” that come with aging. Alzheimer’s researchers say that A-beta deposits and damage are already well underway in these peoples’ brains. If more of them could be caught early, and the new drugs work at limiting brain destruction, doctors could start therapy before serious illness sets in.”

For those following the War Againist Alzheimers, you may also want to read the recent CMPI report on the potential economic impact that new treatments for Alzheimer's disease could have on the U.S. economy. The study was sponsored by ACT-AD, a coalition of 49 national organizations seeking to accelerate development of potential cures and treatments for Alzheimer’s disease. The full report can be found here:

http://cmpi.org/reports.php

The fight against Alzheimer’s Disease is another clarion call for the expeditious pursuit of the Critical Path Initiative.
Here’s a headline right out of 2004:

“McCain Calls for Drug Reimportation”

According to an AP report, Senator John McCain said he wants to again allow the importation of prescription drugs from Canada as a way to bring health care costs under control.

The Arizona senator, speaking to reporters about a mile from the Canadian border and just across the river from New Hampshire, said too much of health care costs are based on high drug prices.

"If we are going to control health care cost, we need to control the rising costs of pharmaceuticals," McCain said.

Except that’s not true. Drug costs represent about 11.5% of the American health care spend. Hospital costs represent over 30%. What’s a better bargain: time spent in the hospital, or drugs that keep Americans healthy and productive?

That’s a good question to ask Senator McCain during the next debate.

The Senator also blamed drug costs for rising insurance premiums.

That’s also not true. Consider this, from 1998 to 2003; insurance companies increased their premiums by an average of $104.62 per person. During that same time period prescription-drug costs increased by $22.48.

Are the majority of Americans with private health insurance spending more for drugs? Yes — because their insurance companies are paying less. In 2000, people under 65 with private health insurance paid 37.2 percent of the cost of their prescription drugs costs out of their own pockets. (Not surprisingly, this leads many Americans to believe that their increased out-of-pocket expenses are because of higher drug costs.) The truth is that the growth in prescription-drug co-payments outpaced the growth rate of prescription drug prices four to one.

"These are drugs being reimported. They go to Canada and then they can come back in. It's a strawman to say that a country like Canada could not be responsible for safe drugs to be brought into our country. Many of them are manufactured in Canada, as you know," he said.

Yep – heard that one before. And very untrue. The drugs that are being sold to Americans by Canadian internet pharmacies come from the EU – and are not even legal for sale in Canada. The McCain scheme (it cannot really be called a “plan”) would not provide Americans with the “same drugs Canadians get.” That’s just a fact. What we would get are drugs from all the nations of the EU – the UK as well as Latvia; France as well as Portugal -- with no real quality control or reliable chain of custody. And if you don’t believe this causes safety problems, just ask the folks over at the MHRA.

The hard fact, Senator McCain, is that there is no such thing as “Canada-only re-importation.” It’s just a snake-oil soundbite.

And, for a guy who positions himself as the no BS candidate, we expect better.
Mostly excellent choices -- with the best at the top -- Mark McClellan, "the hardest working man in American health care" as the foundation's chair.

Other members are:

Georges C. Benjamin, M.D., Executive Director, American Public Health Association

William Brody, President, The Johns Hopkins University

Helen Darling, President, National Business Group on Health

Cal Dooley, President and CEO, Grocery Manufacturers Association

Michael Doyle, Ph.D., Regents Professor and Director, Center for Food Safety, University of Georgia

Joseph M. Hogan, President and CEO, GE Healthcare

Kay Holcombe, Senior Health Policy Advisory, Genzyme Corporation

Sharon Levine, M.D., Associate Executive Medical Director, The Permanente Medical Group

Gary Neil, M.D., Group President, Johnson & Johnson Pharmaceutical Research & Development

Phillip A. Sharp, Ph.D., Institute Professor, Center for Cancer Research, Massachusetts Institute of Technology

Ellen V. Sigal, Ph.D., Chair and Founder, Friends of Cancer Research

Tadataka Yamada, M.D., President, Global Health Program, Bill & Melinda Gates Foundation

Diana Zuckerman, Ph.D., President, National Research Center for Women and Families
Two views on the subject. One from me in today's New York Post which argues that Hillary should go first in explaining her view on whether illegal immigrants should receive free cancer care in the Empire State.. another from The New Republic claiming it we owe to the public health to do so. No, illegals owe it to themselves to stay healthy and we owe it to ourselves to make health care affordable on the open market. We don't owe it to them to provide free healthcare.

http://www.nypost.com/seven/11162007/postopinion/opedcolumnists/hill__illegals_health_care_351972.htm

http://www.tnr.com/politics/story.html?id=55c072cf-0d36-41e2-a4e3-388af9a360da&p=2
According to the Associated Press, "The Food and Drug Administration announced proposed rules Thursday to reduce potential conflicts of interest among outside experts who advise the government on approval of drugs and other regulated products. The experts would have to disclose any financial ties to the industry under review."

Rather than being treated as experts, AdComm members will now be treated as suspected felons. Not only will they have to fill out a form disclosing the potential conflicts -- but now they must also explain why they should still be able to advise the agency.

What's next? Fingerprinting?
Jonathan Cohn, in an otherwise excellent and thoughtful piece in The New Republicv on how to shift health care systems to a value based reimbursement approach (from a single payer perspective) , resorts to the shibboleth that drug companies are not very innovative as if this is somehow their fault and by design. He relies on the totally useless work of Marcia Angell and Merrill Goozner, neither of whom know much about drug discovery and development and what they do write is selective and misleading.

First, if drug development and discovery were so easy it wouldn't be so expensive. Success rates have fallen not be design. Would any one want to invest $800 billion in a drug only to have it fail. But it happens all the the time. Incrementalism by the way is the norm of science and all things whereas the ability to use one medicine or insight to transform or extend life is rare indeed. Yet Cohn falls into the trap all amateurs fall into and believes that if drug or biotech companies tried a little harder they could nail it. That's arm chair quarterbacking at it's worst. If you think it's so easy to hit a Jaba Chamberlain splitter, why don't you try out for the Bosox and hit it not once every 1000 times but one out of three times. Hit .300 and you are in the Hall of Fame. My brother has worked for a drug company for 20 years and has 3 of the drugs he has worked on approved. That's a lot.

Now as to the heavy lifting. This notion that NIH discovers everything is just not true. The amount of collaboration is astounding and is what separates the US from other parts of the world. Angell and Goozner lie outright to avoid describing the partnerships that shape innovation in America and depict a Golden Age that never existed. Angell asserts that every breakthrough drug started without drug company involvement. She claims that Gleevec, the first cancer drug to target cancerous cells without side effects, was developed without any real input from Novartis, the company that makes the product. Angell says that Brian Druker, a cancer researcher at Oregon Health and Science University, said that Novartis showed little interest in the cancer compound until he discovered its tremendous properties. The real story--from the Journal of the National Cancer Institute--reflects the risky and collaborative nature of drug development, which requires massive capital and biopharmaceutical know-how to turn discoveries into effective treatments. An academic researcher and private company, working together, launched a revolution in the treatment of cancer. You wouldn't know it by reading Angell.

Goozner makes the same claim about drugs developed by Amgen. Everyone involved knows better.

Similarly both Goozner and Angell disdain the revolution in personalized medicine thereby ignoring genomic based science, something that Senator Obama has taken leadership on in the Senate along with Senator Richard Burr.

For instance, The Truth About the Drug Companies also claims there is no real evidence that any one drug is better than another or that most medicines really do much at all. And Angell goes as far as to say: "the idea that patients respond differently to me-too drugs is merely an untested and self-serving hypothesis." Rather, she says, "one or two drugs will do" for most medical conditions. And Goozner still can't figure out the difference between a surrogate end point like blood pressure and a genetic marker which both predicts and controls disease progression.

Cohn's article in the New Republic tries to argue that value based reimbursement can let people have the best of both worlds in a single payer system. I disagree. But he gets the point that health care is an investment and that innovation is valuable. I would recommend that he go beyond Goozner and Angell to understand the role the private sector plays in promoting innovation and just how difficult real invention is.

http://www.tnr.com/politics/story.html?id=53e206dd-c286-43b1-9c5b-079e81ab3474
The recent session of the WHO’s Intergovernmental Governmental Working Group (IGWG) ended without consensus. And that’s a good thing considering that many of the issues on the table would have resulted in a screeching halt to medical progress.

The IGWG discussions were completely void of innovators -- with pharmaceutical researchers relegated to the sidelines. In their place were activists who are unwilling (and seemingly unable) to engage in any discussion that does not begin and end with removing systems of intellectual property (IP) protection for medicines.

As with many of their ilk, these activists believe in freedom of speech – as long as what you say supports their position. Otherwise you’re a capitalist tool. Their grasp on the truth is, well, questionable.

Consider this statement from our comrades over at Médecins Sans Frontières:

“Patents are not a relevant factor in stimulating R&D and bringing new products to the market.”

Really? What about HIV/AIDS, one of the WHO’s “neglected diseases,” where all of antiretrovirals currently in existence were developed under patent protection.

If their grasp on the truth is questionable, their chutzpah is unlimited.

Consider a recent editorial the latest publication of The Lancet where officials of the Thai military junta attack comments offered by patient organizations and other groups to the open forum of the IGWG.

“The issue that attracted the most responses was intellectual property (IP), which was cited in 43 of 68 submissions. Although we were not surprised to see that 11 of 12 organisations directly affiliated with the pharmaceutical industry supported strong IP protection, it was surprising that 14 patient advocacy groups took a similar position, which in several cases was the only point raised in their submissions; three professional associations also took similar positions … We declare that we have no conflict of interest."

This last comment is made after they state that, "We strongly suggest that contributors to public hearings must disclose any conflicts of interest, as required of authors submitting papers to peer-reviewed journals."

The authors did not declare that the Thai Ministry of Health owns the Government Pharmaceutical Organization (GPO) -- and that the GPO stands to significantly benefit financially from a proposed IGWG agenda strongly supports compulsory licensing.

Well, what’s good for the goose is good for the gander. Transparency should cut both ways – even in Geneva.
CMPI

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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