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DRugwatch Blog > February 2012 > Good News for Bydureon, but Bad News for Dapagliflozin

Good News for Bydureon, but Bad News for Dapagliflozin

Matt KileenContributor: Christine Helliwell

Well, it has been a busy start to the year for the type 2 diabetes market, with both good and bad news from the FDA for some of the major players in this market. First came the news on the 19th of January that the FDA had issued a Complete Response Letter (CRL) for Bristol-Myers Squibb/AstraZeneca’s dapagliflozin, the first-in-class sodium glucose cotransporter-2 (SGLT-2) inhibitor. This news actually came earlier than anticipated, because the drug’s PDUFA date was scheduled for January 28th, 2012. But the news itself was not at all unexpected. As we discussed in our 'Dapagliflozin – What Now?' blog post on July 20th, 2011 on July 19th 2011 an FDA Advisory Committee voted 9-6 against recommending approval of dapagliflozin. The Committee’s concerns revolved around an excess number of cases of both breast and bladder cancer cases observed among patients taking dapagliflozin rather than a placebo or comparator drug, as well as a case of severe liver injury that was deemed to be likely to be caused by dapagliflozin. Although the overall number of cases of cancer was small, the FDA CDER’s Office of Surveillance and Epidemiology (OSE) noted that the imbalance was statistically unlikely to have occurred by chance. 

Following the Advisory Committee meeting, the FDA requested further data from recently completed and ongoing clinical trials of dapagliflozin, and pushed back the original scheduled PDUFA date from October 28th, 2011, to January 28th, 2012, in order to allow enough time for the data to be submitted and assessed. However, as we suspected, the data provided were insufficient to allay the FDA’s concerns over dapagliflozin’s safety, resulting in the issuance of the CRL. Although the precise details of the CRL have not been disclosed, AstraZeneca and BMS did report that the FDA has requested additional clinical data to allow a better assessment of the benefit-risk profile for dapagliflozin. These data will come from extensions of and follow-up to ongoing clinical trials (which we estimate will lead to a delay of up to two years before dapagliflozin is approved), but, crucially, new clinical trials may also be required. We assume that new clinical trials will only be required if the data from ongoing trials are insufficient to provide adequate reassurance of the safety of dapagliflozin. This seems unlikely, given that over 2,500 patients are still enrolled in five different trials or trial extensions, all due to finish by mid-2013. However, should one or more new clinical trials be required, then any such trial would most likely have to be large and lengthy, because the safety concerns noted so far are very rare. The expense of such a trial, and the inevitable delay to dapagliflozin’s approval, may cast a question mark over dapagliflozin’s further development. For now though, we assume that this will not be the case, and that dapagliflozin will be approved in the United States in 2014.

Another question that remains over the future of dapagliflozin is: what will happen in Europe? According to AstraZeneca’s latest pipeline update, the European regulatory submission for dapagliflozin is slated to occur during the second half of 2012. By the time the EMA comes to make a decision on the drug, at least some of the data requested by the FDA will be available, and so a straight-forward approval (most likely with warnings on the drug’s label) is more likely in Europe. And yet another question is the impact of this scrutiny of dapagliflozin’s safety on other SGLT2 inhibitors in development, in particular Johnson & Johnson’s canagliflozin and Boehringer Ingelheim/Eli Lilly’s empagliflozin, both of which are in Phase III development and expected to launch in 2014. Until a detailed analysis of late-stage clinical trial data becomes available, it is impossible to say whether these drugs are also associated with the same safety concerns as dapagliflozin. What is certain, however, is that the developers of canagliflozin and empagliflozin can expect a high level of scrutiny of their drugs’ safety profile. These companies will be watching the dapagliflozin story unfold with great interest.

Amylin and Alkermes were the recipient of better news from the FDA; their drug Bydureon (a once-weekly version of the GLP-1 analogue Byetta), was finally approved in the United States on January 27th, 2012. The NDA for this drug was originally submitted in May 2009, but approval was delayed first by issues with the product label and manufacturing procedures (leading to a CRL in March 2010), and then by a request (in the form of a second CRL in October 2010) for further clinical data including data from a thorough QT (tQT) study. These data were submitted to the FDA in July 2011, and were sufficient for the drug to be deemed approvable in January 2012. This delay dearly cost Amylin and Alkermes (and, until November 2011 when the company terminated its involvement in Bydureon and Byetta, Eli Lilly; see our November 17th, 2011 blog post 'The End of the Road for Amylin and Lilly’s Diabetes Pact' (for more on this), because it gave the once-daily GLP-1 analogue liraglutide (Novo Nordisk’s Victoza), a significant head-start after its launch in February 2010.

Victoza has seen strong growth since its launch, resulting in blockbuster sales in 2011, its first full year on the market. However, Victoza now faces a serious challenger in the form of the once-weekly Bydureon. Although in the head-to-head DURATION-6 study Bydureon failed to demonstrate non-inferiority to Victoza on the primary endpoint of HbA1c reduction, Bydureon is tolerated better and only requires once-weekly injections rather than the once-daily injections required for Victoza. In the near term, we expect that Victoza’s strong lead will allow it to stay well ahead of Bydureon in the race for leadership of the GLP-1 analogue space. Looking further ahead, at a ten-year horizon, the picture is somewhat different, with sales of Bydureon almost catching up with sales of Victoza. Who will be the ultimate winner is likely to be a close call that will depend heavily on the ability of the respective developers to market each drug. Given that both Victoza and Bydureon are expected to be blockbusters and big players within the type 2 diabetes space, it will be interesting to see how their relative fortunes fare.
Posted on: 2/7/2012 5:51:17 PM | with 2 comments

Tags: Christine Helliwell, Metabolic Disorders

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Christine Helliwell
I believe that no further data or information (either clinical or mechanistic) have been released regarding the potential cancer-causing capabilities of dapagliflozin (or other SGLT2 inhibitors) since the FDA Advisory Committee meeting.

As for dapagliflozin’s approvability, without knowing the precise contents of the Complete Response Letter issued by the FDA (which have not been disclosed), it is difficult to predict how approvable the drug is, and how long approval is likely to take. Our current assumption is for at least a two-year delay owing to the need to collate data from ongoing trials. However, should data from ongoing trials be insufficient to adequately rule out a risk of cancer (or liver injury), thus necessitating further, long-term, trials, then dapagliflozin’s approvability will be called into question.

The question of approvability in Europe versus the United States is an interesting one that is difficult to answer. As you may well know, there have been several recent cases of drugs being approved in Europe but delayed by regulatory hold-ups in the United States, including the anti-diabetic drug exenatide LAR (Amylin/Alkermes’ Bydureon) and the anti-dyslipidemia drug modified-release nicotinic acid/laropiprant (Merck’s Tredaptive). Our current assumption is that dapagliflozin will be approved in Europe without any regulatory delay, following its submission which is anticipated to occur towards the end of this year.
3/7/2012 10:27:18 AM

Dr M R Joshi
I just had a few questions that you may be able to help me with.

Has any new data regarding the possible bladder/Breast Ca causing properties of Dapagliflozin been presented or is it still ongoing?

What are the chances that a risk/benefit analysis will get it approved?

In terms of European approval, why would they approve it if the FDA are not?
3/5/2012 6:39:40 PM

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Post title: EASD 2014: SGLT-2 inhibitors, GLP-1 agonists, insulins, long-term study results, and speculations about triple combination therapies
Post date: 10/1/2014 3:05:08 PM
Post Summary: Contributor: Stefanie Hoffart

Between the 15th and 19th of September, the European Association for the Study of Diabetes (EASD) meeting took place in Vienna, Austria, celebrating its 50th anniversary.
Post text: Contributor: Stefanie Hoffart

Between the 15th and 19th of September, the European Association for the Study of Diabetes (EASD) meeting took place in Vienna, Austria, celebrating its 50th anniversary. One of the hot topics discussed at the conference were the SGLT-2 inhibitors, with two years treatment data now providing longer-term efficacy and safety data. Another highly appreciated topic was the GLP-1 agonists; liraglutide, with its potential usage in the obese type 2 diabetes (T2D) population, and exenatide, with its long-term DURATION-1 study, both attracting a great deal of attention and a big audience. After discussing new insulin preparations and their potential to demonstrate superiority over existing combination therapies, the conference ended with a discussion about the most-used diabetes drug in the world: metformin.

To pick up only a few of those main points:

Empagliflozin’s 104 week study (EMPA-REG H2H-SU)

In a randomized, double-blind, active comparator, Phase III study (EMPA-REG H2H-SU), Boehringer Ingelheim/Eli Lilly’s SGLT-2 inhibitor empagliflozin demonstrated sustained reductions in HbA1c over 104 weeks as an add-on to metformin therapy, as well as  reductions in body weight and blood pressure (BP). In comparison to glimepiride, empagliflozin achieved significantly greater reductions from baseline in HbA1c, body weight, and systolic BP (-0.11%, -4.5%, and -5.6%, respectively). Physicians complimented the study design in general; however, they raised concerns about the representativeness of the study, given that glimepiride had not been fully up-titrated to the maximum dose during the trial.

Fixed dose combination (FDC) therapies

Another study compared the empagliflozin/linagliptin FDC against each of the single therapies alone, showing a persistent (although not completely additive) HbA1c lowering effect. However, this was not the case for all patient populations and strengths of the drug, as the FDC with only 10 mg empagliflozin did not show significantly better results compared to 10 mg empagliflozin monotherapy in patients with HbA1c ≥8.5% at baseline. Nonetheless, the presenter stated that the superior efficacy results in certain subgroups ‘opens thoughts’ about triple combination therapies of empagliflozin, linagliptin, and metformin. However, if we look at the recent reaction of the FDA, polypills certainly failed to impress the advisory committee: the FDA has turned down NDAs for both a combination of beta-blocker and angiotensin receptor blocker (nebivolol/valsartan) and a combination of an antihypertensive, aspirin, and a statin.  In terms of insulin combinations, physicians at the EASD conference did not seem impressed about the combination injection IDegAsp (70% insulin degludec + 30% insulin aspart), despite reductions in the number of injections per day, and therefore patient burden by up to 50%.

Liraglutide 3.0 mg, the SCALE study

The GLP-1 agonist liraglutide 3.0 mg is currently being investigated in the SCALE study. After 56 weeks, liraglutide 3.0 mg showed greater improvements in glycemic control and systolic BP versus placebo, and greater improvements in HbA1c reduction than the 1.8 mg formulation. However, this reduction was not significant in patients achieving HbA1c <7.0%, and was modest in patients achieving HbA1c < 6.5%, which raised the question among physicians whether it is worth the additional anticipated cost (possibly double the price of liraglutide 1.8 mg). During the off-treatment follow-up study, weight regain occurred with both liraglutide doses, although mean weight loss from baseline remained significantly greater in the 3.0 mg group compared to placebo. In my opinion it would have been interesting to see half the patients remain on liraglutide (both doses) for the extended 12 weeks, and then compare the results to the patients’ off-treatment to show superiority in weight loss compared to those not on liraglutide.  Also, the question remains whether the weight loss effect is not mainly induced by nausea, as physicians claim that the weight curves rise following one year of treatment, with the weight loss curve over time matching the nausea curve. Exenatide’s long-term DURATION-1 study did not help to resolve those questions about weight regain, but at least 50% of the patients were able to maintain their HbA1c goal (either less than 7%, or 6.5%) over the six-year treatment period.

Some final thoughts and ideas for drug companies:

Over all, physicians were mainly concerned about safety signals such as lipase activity or pancreatitis in the GLP-1 analogues. Also, they appreciated glucagon measures during studies throughout the different drug classes. However, the majority of physicians would prefer to see trials comparing novel agents with active comparators rather than with placebo. Likewise, meta-analyses were not appreciated, as they do not provide the exact same baseline measures, durations, patient populations, and therapies, and therefore are not representative. Nonetheless, the vibe throughout the conference was positive. Physicians agreed that governments and the industry should work together to provide outcomes data and sustainable results, not just ‘to make someone rich’.
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Post title: Statins: Add Them to the Drinking Water?
Post date: 8/18/2014 1:07:35 PM
Post Summary: Contributors: Tim Blackstock and Stefanie Hoffart

Statins are one of the most commonly prescribed drugs, and Pfizer’s Lipitor (atorvastatin) still holds the record for the highest peak sales of any prescription drug. The general consensus of thought leaders in the field of lipid disorders and CVD prevention is that the benefits of statins outweigh the risks, although this applies more for secondary prevention that primary prevention.
Post text: Contributors: Tim Blackstock and Stefanie Hoffart

Statins are one of the most commonly prescribed drugs, and Pfizer’s Lipitor (atorvastatin) still holds the record for the highest peak sales of any prescription drug. The general consensus of thought leaders in the field of lipid disorders and CVD prevention is that the benefits of statins outweigh the risks, although this applies more for secondary prevention that primary prevention. However, the widespread use of statins has long generated an undercurrent of concern over the potential for negative effects in such a large population. Various issues have been raised, ranging from their lack of benefit in women through to safety concerns, and the debate has been fired up by the release of new guidelines recommending even broader use of these agents. In November 2013, the ACC and AHA published new guidelines that included a recommendation for statin therapy in patients with an estimated ten-year risk of atherosclerotic cardiovascular disease (ASCVD) of 7.5 percent or higher. Then, in July 2014, the UK’s National Institute for Health and Care Excellence (NICE) released guidelines recommending that patients with a ten-year risk of CVD that exceeds 10 percent should be treated with atorvastatin 20 mg. NICE estimates that if half of the lower risk primary prevention group take statins, an extra 4,000 deaths from heart attack could be saved, and 8,000 strokes and 14,000 non-fatal CV events could be prevented.

However, both sets of guidelines have received mixed feedback. In a letter to NICE, UK experts expressed concerns about a variety of topics like the medicalization of healthy individuals and the true levels of adverse events. For them, the benefits are simply not convincing enough to justify five million people being started on a drug for life. NICE argued their case in a letter of their own. Various experts and professional organizations have also expressed concerns over the U.S. guidelines, including a group from the Mayo Clinic that has just published their opinion here. Debate also continues over the safety of the class: new-onset diabetes, myopathy, and cognitive problems are all associated with statin use. But, as is the case with a lot of scientific research, the quality varies, and different studies have found different results. This has led to a dispute over safety research published in the BMJ, which, because of the common use of these drugs, has been picked up by the lay press.

So, how will all of this affect prescribing and sales of statins? Will we see the public health equivalent of them being added to the drinking water? The guidelines’ recommendations are based on a wealth of solid evidence showing CV benefit with statin use, and encourage a discussion between physicians and patient over taking statins. In addition, the statins are now almost all available as generics making them inexpensive and more accessible. However, the fact that the class is almost totally genericized is likely to mean there will be little impact on sales, despite the increasing prevalence of dyslipidemia. Moreover, the ongoing controversy about the guidelines, combined with the slow and often limited adoption of guidelines by the average physician, suggests to us that there will not be a mass shift in physician practice. You can lead a physician to statins in the water, but you can’t make them drink.

Stefanie Hoffart, M. Sc., is a Research Associate and Tim Blackstock, M.B. Ch.B., M.Phil., is a Business Insights Analyst in the Cardiovascular, Metabolic and Renal Disorders team at Decision Resources Group.

In-depth analysis of type 2 diabetes, with accompanying epidemiology driven sales forecast models, are presented in Decision Resources Group’s Type 2 Dyslipidemia Pharmacor, available here. A new edition of this product is planned for November 2014.
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Post title: The Biosimilar Train Leaves the Station, Only to Face an Uphill Climb
Post date: 8/13/2014 11:23:09 AM
Post Summary: Contributor: Chris Lewis

Faced with the onslaught of high-cost specialty drugs—a reality brought to the fore by the high-priced hepatitis C drug Sovaldi—many plan sponsors no doubt heaved a sigh of relief at the first U.S. filing for approval of a biosimilar last month.
Post text: Contributor: Chris Lewis

Faced with the onslaught of high-cost specialty drugs—a reality brought to the fore by the high-priced hepatitis C drug Sovaldi—many plan sponsors no doubt heaved a sigh of relief at the first U.S. filing for approval of a biosimilar last month.

But for every shred of hope pinned on the ability of biosimilars to moderate the rising specialty drug trend, there’s a counterbalancing dose of reality that gives payers pause when planning for meaningful cost savings from these biologic imitators.

Managed care pharmacists and benefit specialists were cautioned about the limitations of the biosimilar movement during a panel session at the Pharmacy Benefit University conference near Chicago in early August.

What made the discussion particularly topical was the announcement a couple of weeks earlier that Sandoz, the generic pharmaceuticals division of Novartis, filed the first U.S. license for a biosimilar under the FDA’s biosimilar pathway. The approval process for filgrastim—which references Amgen’s neutropenia drug Neupogen—is expected to take at least 10 months, said Stephen Cinchy, managing director of Monarch Specialty Group, a healthcare consulting firm.

The Affordable Care Act directed the FDA to develop a pathway for development of biosimilar versions of biologically produced pharmaceuticals. Although the guidelines are still in draft form, companies are free to pursue biosimilar development through what’s known as the 351(k) pathway. This path is untested in the United States and greatly differs from the generic pathway for traditional drugs.

Because biologics are large, complex molecules that are manufactured in living cells, they cannot be copied identically, as is the case with traditional small-molecule drugs. Biosimilars must meet the standard of being highly similar to the originator product, with no clinically meaningful difference to the patient, explained Gary Okano, director of biotechnology engagement for Amgen.

Aside from defending Neupogen from biosimilar competition, Amgen is among the pharmaceutical companies racing toward biosimilar development to meet the demand for lower-cost specialty drugs. Amgen is pursuing biosimilar alternatives to high-profile rivals Humira and Remicade in the rheumatoid arthritis space.

Based on biosimilar products expected to launch through 351(k), and their impact on referenced branded drugs, Decision Resources Group’s Biosimilars Advisory Service forecasts that healthcare savings will reach nearly $9 billion annually in the United States by 2022.

However, payers cannot count on the up-to-80-percent savings in drug costs they have experienced with generics. Because biosimilars face much higher costs of production—including the requirement of clinical trials—the projected price difference between biosimilars and their reference products are more in the 15 percent to 30 percent range. That’s not to mention the expensive legal patent and market access battles that lie ahead.

Monarch’s Cinchy told conference-goers that companies marketing the innovator products are ready to pull out the big guns to keep biosimilars at bay. “The list of tools and weapons that they’re going to be essentially assembling to respond to biosimilars is deep and wide,” he said.

Plan sponsors can expect that companies will sweeten the rebate pot to protect the market share of innovator products. “Many of the innovator products today have rebates,” Cinchy said. “If a biosimilar comes forward with a price discount, but no rebate, the net difference, if I push through a biosimilar, might be zero or something much less than the face value of that discount.”

Meanwhile, companies are defending their branded specialty drugs by introducing new formulations—which Cinchy termed “bio-betters”—that make the drug more attractive to the patient, for instance, through less-frequent dosing.

There are other unknowns that constrain the potential of the biosimilar market, including safety concerns, the yet-undetermined naming convention for biologics, and whether states will pass laws to allow pharmacies to automatically substitute reference products with approved biosimilars.

In addition, getting patients to embrace biologic alternatives will take a huge educational effort, considering payers have struggled to get them to embrace generics. Physicians appear ready to prescribe biosimilars, according to Decision Resources Group. “The majority of U.S. specialists that we’ve surveyed expect to use biosimilars, but the rate and depth of their acceptance is highly variable by specialty and even the specific biologics that they prescribe,” said Kate Keeping, DRG senior director of biosimilars research.

Whatever the obstacles, the biosimilar train has left the station and is gaining speed. It may deliver plan sponsors from the imposing crush of specialty drug costs, and they will be sure to get on board so as not to miss any opportunity to tame costs that are rising by double-digit rates each year.

Follow Chris Lewis on Twitter @ChrisLewisDRG
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Post title: AstraZeneca Strengthens Its Position on Respiratory Therapeutics
Post date: 8/12/2014 4:17:19 PM
Post Summary: Contributor: Sangha Mitra

Last month, AstraZeneca took a major step to build up its respiratory franchise by striking a deal for the commercial rights to Almirall’s respiratory portfolio. The transaction, which is expected to complete by the end of 2014, could be worth up to $2.1 billion. It comprises an initial upfront payment of $875 million to Almirall and up to $1.22 billion in additional payments tied to performance, both regulatory and commercial, milestones.
Post text: Contributor: Sangha Mitra

Last month, AstraZeneca (AZ) took a major step to build up its respiratory franchise by striking a deal for the commercial rights to Spanish group Almirall’s respiratory portfolio. The transaction, which is expected to complete by the end of 2014, could be worth up to $2.1 billion. It comprises an initial upfront payment of $875 million to Almirall and up to $1.22 billion in additional payments tied to performance, both regulatory and commercial, milestones. AZ CEO Pascal Soriot had previously identified the respiratory therapy area as one of his key growth drivers, in an attempt to prove AZ can deliver value to shareholders independently, when the company rejected Pfizer’s takeover bid earlier this year. These new assets will provide AZ immediate access to on-market revenues as well as create long-term value through strategic fit of Almirall’s complementary drug pipeline and inhaled device capabilities for the treatment of both asthma and chronic obstructive pulmonary disease (COPD). In the short-term, the deal gives AZ access to Almirall’s share of revenue from the currently marketed long-acting muscarinic antagonist (LAMA), Eklira/Tudorza. AZ will also acquire selected European and Canadian rights to this drug from Almirall while U.S. rights will remain with Actavis. These sales will contribute to AZ’s sales at a time when respiratory sales begin to decline due to the loss of patent protection for its blockbuster drug, Symbicort (a fixed-dose combination of budesonide and formoterol).

Almirall's decision to sell-off its respiratory franchise may seem surprising, since respiratory was its leading therapeutic area and accounted for 30percent of its 2013 sales. However, the high cost of large clinical trials and heavy marketing expenditure ensure that it would be challenging for Almirall to compete against industry heavyweights such as GlaxoSmithKline and AZ. Therefore, selling the franchise to the more-experienced AZ, while retaining a stake in its development, is a notable win for Almirall.  The sale of these products and programs will allow the company to reduce costs and risk while retaining an important economic interest in the franchise’s potential success. In addition, Almirall will be able to move more aggressively in other specialty areas of focus including dermatology, where the company seeks to become a global player and can build up this business with its substantially increased financial resources.

Unfortunately, while Almirall’s assets will certainly grow AZ’s respiratory franchise, the overall impact on the company may not be enough to thwart shareholders from agitating for the board to accept a sweetened takeover offer from Pfizer or another potential suitor. Pfizer desperately needs a promising acquisition to boost growth, and AZ - due to its size, tax inversion opportunity and valuation - remains a compelling target.

Sangha Mitra is a business insights analyst on the Immune and Inflammatory team at Decision Resources Group.
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Post title: AMG-416 on the Horizon: What Does this Mean for Other Renal Therapies?
Post date: 8/1/2014 11:23:09 AM
Post Summary: Contributor: Jihan Khan

AMG-416 is being developed as a calcimimetic agent administered intravenously, which would be the first IV calcimimetic to the SHPT market. It is designed to bind and activate the calcium-sensing receptor on the parathyroid gland, thereby causing decreases in PTH.
Post text: Contributor: Jihan Khan

On July 17th 2014, Amgen announced positive Phase 3 results for AMG-416 (formerly known as velcalcetide) for the treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) receiving hemodialysis (HD).

First, a bit of background on SHPT – it is a disorder that develops early as an adaptive response to declining kidney function when the parathyroid glands increase the production of parathyroid hormone (PTH) in an effort to maintain normal levels of serum calcium and phosphorus. Ultimately, excess PTH production proves inadequate for maintaining normal serum calcium and phosphorous levels, which in turn can lead to significant clinical consequences. AMG-416 is being developed as a calcimimetic agent administered intravenously, which would be the first IV calcimimetic to the market. It is designed to bind and activate the calcium-sensing receptor on the parathyroid gland, thereby causing decreases in PTH.

Amgen obtained AMG-416 as part of the acquisition of KAI Pharmaceuticals, Inc. in July 2012 and these are the first results to be reported from the Phase 3 program - analysis of the data presented shows that the study met primary and all secondary endpoints. 75.3 percent of patients achieved a > 30 percent reduction from baseline in PTH compared with 9.6 percent in the placebo arm, a statistically significant result. Secondary endpoints included the percent change from baseline in serum phosphorus (P) concentration (mean changes of -9.63 percent and -1.60 percent among patients in the AMG-416 and placebo arms, respectively) and corrected calcium (cCa) concentration (mean changes of -6.69 percent and 0.58 percent among patients in the AMG-416 and placebo arms, respectively). Both of these secondary endpoint results were statistically significant.1 

The TreatmentTrends®: Nephrology (US) Q2 2014 report published in June 2014 focuses on the management of SHPT and provides insights into physician perceptions of SHPT, based on primary market research of 203 U.S. nephrologists, and I thought I would share some findings from the report that highlights the potential opportunity for manufactures in this space. The report asks physicians for their perceived use of PTH modifiers such as nutritional vitamin D (NVD) products, active vitamin D (AVD) products, and calcimimetic agents such as Sensipar, in addition to other areas of nephrology, including phosphate binders, ESAs and IV/oral iron, but we will discuss these other areas at a later point in time.

In the PTH modifier market, Amgen’s Sensipar is indicated for the treatment of SHPT in patients with CKD on dialysis and is taken orally. According to Amgen’s 2013 annual report, Sensipar generated sales in excess of $1 billion in 20132 and according to Amgen’s recent press release, total Sensipar sales increased 15% for the second quarter of 2014 versus the second quarter of 2013.3 In TreatmentTrends®: Nephrology (US) Q2 2014, surveyed nephrologists reported that nearly 40 percent of their HD patients and over 30 percent of their peritoneal dialysis (PD) patients were on Sensipar. However, after reviewing AMG-416’s product profile, surveyed nephrologists estimated 36 percent of their dialysis patients as likely candidates for AMG-416 treatment, based on AMG-416’s Phase 2 data alone. We are looking forward to how the positive findings from the Phase 3 trial will change nephrologists’ perceptions of AMG-416 in our TreatmentTrends®: Nephrology (US) Q3 2014 report, scheduled to publish in September 2014.

Assuming FDA approval, it will be interesting to see if AMG-416 stands to gain patient share at the expense of Sensipar, given the more convenient dosing option with AMG-416 for dialysis patients. Or, perhaps this was Amgen’s plan all along to develop a new product to extend the patent life of their PTH modifier business given Sensipar’s patents are expiring in 2015 and 2016 in the U.S.2

The report also asks nephrologists a series of barriers to increased Sensipar use and patient non-compliance was cited second most often by surveyed nephrologists, and for patients who receive dialysis treatment three times a week in the United States, things are looking positive for AMG-416 as an effective calcimimetic agent that can be administered intravenously with HD to help treat SHPT, which may improve compliance similar to the high perceived compliance of ESAs in the dialysis setting.

Renal treatments are interrelated and should use of calcimimetics increase with greater compliance with AMG-416, it will interesting to see what impact in use, if any, it will have on some of the other renal medications, most predominately phosphate binders and AVD. Today, we know that Sensipar may also be sometimes used to treat phosphorous, calcium and PTH and perhaps binder and AVD use will ultimately be impacted as well with greater use of calcimimetics. The chart from TreatmentTrends®: Nephrology (US) Q2 2014 below shows some of the reasons why nephrologists use Sensipar.

Results from a head-to-head study evaluating AMG-416 compared to Sensipar is expected next year.4

JIhan Khan, Ph.D. is a business insights analyst on the Cardiovascular, Metabolic and Renal Disorders team at Decision Resources Group.

Amgen news release, July 17, 2014 http://www.amgen.com/media/media_pr_detail.jsp?releaseID=1948573
2 Amgen 2013 annual report and 10-K, March 27, 2014 http://investors.amgen.com/phoenix.zhtml?c=61656&p=irol-reportsannual
3 Amgen press release, July 27, 2014 http://investors.amgen.com/phoenix.zhtml?c=61656&p=irol-newsArticle_Print&ID=1952691&highlight=
4 Head-to-head study of AMG 416 and cinacalcet (Phase 3), July 24, 2014 (last verified) http://clinicaltrials.gov/ct2/show/NCT01896232?term=AMG+416%2C+sensipar&rank=1
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