Pfizer, Allergan and Antibiotics

With the report this week of the discovery of plasmid mediated resistance to colistin, my thoughts turn to the Allergan/Astra-Zeneca pipeline of antibiotics for highly resistant Gram-negative pathogens. Colistin is our absolute last line against these superbugs.  It’s a toxic drug that no one likes to use, that most physicians don’t even know how to use correctly, and that is now threatened with new, emerging resistance emanating from China. Allergan and AstraZeneca are now marketing ceftazidime-avibactam in the US (soon to be approved in Europe I hope) and are developing aztreonam-avibactam (at tectonic speed).  These antibiotics are active against many (but not all) of the Gram-negative superbugs for which colistin therapy is now used most often. We need these drugs to reach patients – and quickly. And that’s where my concerns about the Allergan half of the equation come in.

Pfizer has proposed an acquisition of Allergan to create shareholder value.  This will be accomplished, in large part, via savings in corporate taxes since the new company will be headquartered in Ireland – where Allergan is currently located. The Newco will then avoid a large portion of US taxes.  The New York Times article also notes that Pfizer may be planning a split into various bits and pieces where innovative drugs will remain in one company while those facing imminent or current generic competition will be part of another company.

So – you all remember Pfizer.  The company was one of the few to market penicillin just after World War II.  It was also the company that walked away from antibiotics back in 2011 believing antibiotics to be subject to regulatory uncertainty at the time and having no confidence that antibiotics would provide a reasonable return on their research investment. AstraZeneca, Allergan’s partner for the development and marketing of ceftazidime-avibactam and aztreonam-avibactam, has also jettisoned their antibiotic research group to form Entasis.  They maintain an antibiotic development group that is now a separate business unit within AZ.

Allergan’s antibiotic group has no discovery research, but does provide clinical development and microbiology support for their pipeline. Will Pfizer-Allergan keep Allergan’s antibiotic group?  Will they even keep their product pipeline?  Or will this all somehow be re-split or even just jettisoned somehow after the merger?

My sources within Allergan are very convinced that Allergan is committed to the antibiotics space – but will it remain committed under Pfizer?

Given the threats of emerging resistance to the last line antibiotics – the carbapenems – and now the new and potentially devastating threat against colistin, the only backstop for many carbapenem-resistant superbugs – it would be perfectly reasonable for the US government to insist that Allergan’s antibiotic pipeline be kept intact and on time (or even accelerated) for the US market post-merger. Will the US administration take an aggressive stance here?  Stay tuned.

Paris - Timeout

I was just getting ready to write my next blog on Saturday morning when I saw the news on the attacks in Paris. We lived and worked in Paris for three years.  The last time, in 2007-8 when I was working with Novexel, a biotech in a Paris suburb, we rented an apartment in the 11^th arrondisement where some of the attacks occurred. The apartment was on the 6^th floor (7^th for Americans) and looked out over the roofs of the city towards the Eiffel Tower. From our window on Avenue Parmentier, we looked out at the Voltaire metro station and the Mairie (town hall) for the 11^th.  The Bataclan, where gunmen and suicide bombers killed at least 89 innocents, is just a few blocks down near rue Voltaire.

As we watched French television news (thanks to the internet), we were taken back to other attacks that are engraved deeply in our emotional history.  In 1995, as I was returning from work near Blvd St. Michel on my bicycle, I passed the scene outside the metro station just after one of the bombs from that August had exploded.  A bistro had been turned into a triage center. There were already several white-draped bodies on the ground. We resolved to stop taking public transportation – but, in reality, it was impossible to function in Paris on foot and bicycle. While the bomb attacks continued sporadically into September, we went about our daily lives like everyone else.  And, like everyone else, we became defiant and worried at the same time. Terrorists are called terrorists for this reason. In the grand scheme of things, they don’t destroy countries; they destroy lives, and for those of us remaining, a certain peace of mind.

We were in France on September 11, 2001. Friends were staying with us and had arisen very early that morning to take a train from Avignon, in the south of France, to Paris to catch their plane back to Phillie. That afternoon, our refrigerator repairman asked if we had heard that there had been some sort of accident involving a plane in New York. We had no television, but we did have an internet connection. We looked and were horrified. Not long after that, we got a call from our friends’ babysitter asking if they had left.  We asked when they were expected and she told us that they were due several hours ago.  She said that she had been able to get no information on their whereabouts.

We found out later that their flight, like many others, had been diverted to Gander, Newfoundland. They were welcomed by the citizens of Gander and taken to a religious camp outside of town where they spent the next six days without their luggage but with their carry-on items.  In their case this was a case of Burgundy wine. They still go back to Gander from time to time to reunite with their Newfoundland friends and others who had been diverted there the day of the attacks.

We returned to the US on the 16^th – the first day that flights were allowed to go from Paris to Newark.  After we boarded, the captain came by to every passenger to personally ask if we were OK. On arriving, we flew over the smoking remnants of the towers.  On our drive home, we passed by the parking lot for one of the New Jersey PATH trains that takes commuters to New York every day.  There were scattered cars left by those who would never return home. Our home in the New Jersey suburbs was unchanged – but our lives would never be the same.

Watching French television over the weekend, all of these memories flooded back. We got on email and telephone to check with friends in France. So far, so good – everyone is OK including those living near the Bataclan and the cafés where the attacks took place. Many will know someone, or will know someone who knows someone, who was killed or injured Friday night. No one will ever forget.

While I continue to be passionate in my belief that we need new antibiotics – I was just unable to go there this week.

The Wild West!

Will it get wilder?

I don’t usually read Nicholas Kristoff’s columns in the New York Times – but yesterday he caught my eye. In a poignant story, he recounts the death of a 15-year-old child with emotional problems.  His death was apparently caused by an adverse drug effect from an antidepressant. Kristoff talks about the 7-fold rise in use of antipsychotic drugs among children in the last decade and questions how much of this is based on science and how much on marketing.

At the heart of Kristoff’s story, though, is the debate about allowing pharmaceutical companies to market their drugs for off-label uses. There have been a number of articles on this since a federal judge in Manhattan ruled that the FDA could not block Amarin from promoting its drug for non-approved uses based on our right to free speech.

Why this is a debate escapes me.  The most basic tenant underlying the existence of the FDA is the ability to restrict companies from marketing anything for anything as was occurring in the 19^th century.  (Of course, this still occurs for supplements – and how far has that gotten us)? Untold numbers of companies have been fined and occasionally people have gone to jail over violation of this basic power of the FDA to make companies adhere to what they have proven scientifically and what has been shown to have (we hope) an acceptable risk for a reasonable benefit.

The judge’s ruling in the Amarin case seems to have been that as long as the statements used by the company are “truthful” they should be allowed under free speech.  But what does that mean?  What is truthful? If an antibiotic representative told a physician that his/her product, approved for the treatment of epilepsy, had also been shown to be good for patients with arthritis based on a single case report – that would be truthful. Should that be allowed? What if it had been studied in several hundred patients with arthritis in an uncontrolled manner, but had never been approved by the FDA – the statement would still be truthful – but should that be allowed? Finally – what if the drug had been studied in a controlled way, and the study had been submitted to and rejected by the FDA as insufficient?  Should the representative be allowed to quote the results of the study claiming benefit?

Bureau of Chemistry 19th C.

I can tell you that negotiation over the label both here in the US and around the world, is among the most contentious that exists between governments and companies.  It even surpasses pricing discussion in importance for the industry. Why? Because you are not allowed to market what is not included in the label. And to the industry, marketing and promotion is where it’s at.  You need to have something in your label that your competitor does not have.  You have to have that lever – less frequent dosing, better activity shown in the clinic, better spectrum of activity – something that demonstrates that patients and physicians need your product in a way that cannot be satisfied with something else or something less expensive.

At the same time, companies are already allowed to provide physicians with scientific literature on request. In fact, there is an entire FDA guidance on this topic. The FDA recognizes that physicians are allowed, based on their own clinical judgment, to use drugs for purposes not contemplated in the drug label.  The agency therefore provides to the industry criteria under which dissemination of such information is permitted – but in a restricted way.  Articles provided must be from the peer-reviewed literature.  Contradicting articles, if they exist must also be provided.  A list of references on the topic must be provided.  This is all so that the health care provider can judge among all the data, which might be the best choice for his/her patients. What is wrong with this approach?

  If the power to restrict how drugs are marketed is taken away from the FDA – our Wild West of drug pricing and the free-for-all market we allow now will become even wilder.  We will be able to sell anything for anything.  Please – lets not go there.  We already have enough of that from the supplements!