Tuesday, January 26, 2016

Big Pharma and Antibiotic R&D - An Update

Today I went back to the book I wrote back in 2010 – Antibiotics – The Perfect Storm.  In that book I had a table showing the number of large pharmaceutical companies (>$10B in revenues) pursuing antibiotic R&D and those who were not.  I then updated that table as it stands today.  It is shown below. 

Guess what!  The names have shifted, but the numbers are the same.  Since I wrote the book, Pfizer and J&J dumped their antibiotics research programs, but Roche and Sanofi restarted theirs. I put AstraZeneca and Novartis in parentheses this time since AZ recently spun out their discovery group and is now entirely a development organization while Novartis remains schizophrenic (as far as I can tell).  Novartis has an active and dedicated antibacterial research group, but a hesitant development and commercial group (unless something has dramatically changed recently).

The players who have returned to the field since 2010, Roche and Sanofi, have yet to produce anything truly promising.  Also, I guess I should add a number of companies to the list.  Gilead had $29B in revenue in 2014, but remains a highly specialized company focusing mainly on antivirals. There may be other companies that I should have added as well – some of you will know this better than me.

This week, at the Davos conference, a group of pharmaceutical and diagnostic companies released a declaration supporting incentives for antibiotic R&D. In going down the list of signatories, the only large companies not pursuing antibiotic R&D that signed were J&J and Pfizer. Abbot, Bayer, BMS, Lilly, (Gilead), were nowhere to be seen.  As I noted for the New York Times this week, the question is, even if the incentives were to appear such that a return on investment for antibiotics was guaranteed, would some of these companies get back in the game?

The absence of signatures may tell the story.  Why? Once you have abandoned a field of research, you lose all internal expertise in that field.  Getting back in is hard and takes years.  Just ask Roche and Sanofi. Some of these companies probably feel comfortable where they are and have no desire to get back to antibiotic R&D even if there could be a return on their investment. 

The story with Pfizer may or may not be different.  I noted in November that they are pursuing a purchase of Allergan.  Allergan has the US rights to the promising AZ pipeline of antibiotics for resistant Gram negative infections and is already marketing ceftazidime-avibactam (Aycaz). This means that Pfizer would have an opportunity to get back in.  Will they take it?  Is that what their signature means? Will incentives help them decide? Who knows?

I leave the question as to whether we have made progress since 2010 or not up to you.

Wednesday, January 13, 2016

AstraZeneca Where Are You?

You will all remember that mcr-1 mediated resistance to polymyxin (colistin) emerged on transmissible plasmids last year.  How did it arise? Because Chinese farmers wanted their pigs to grow faster – so they fed them low doses of this antibiotic as a growth promoter.  I pointed out in my previous blog on this that the US allows use of polymyxin as a growth-promoting agent as well. This means that our very last, end of the road, toxic and poorly effective antibiotic for otherwise totally resistant Gram-negative infections is in serious jeopardy.  That means that WE are in serious jeopardy. By the way - since its discovery, the gene has been detected pretty much worldwide. 

These cheerful thoughts lead me to think about Astra-Zeneca?  Why?  Because they (and their partner, Allergan) have an antibiotic in their pipeline that could make a big difference here. Aztreonam-avibactam combines a monobactam (aztreonam) that is resistant to the metallo-beta-lactamases like NDM-1 with a broad spectrum B-lactamase inhibitor that will protect aztreonam from destruction by any other B-lactam hydrolyzing enzymes that might be (and usually are) present in the pathogen in question. This combination has been shown to be active in model systems (hollow fiber) suggesting that it will be highly active in vivo. Way back in 2010, David Livermore, myself and others were pleading with AZ to get aztreonam-avibactam into clinical trials so we could treat highly resistant pathogens like these.

Aztreonam-avibactam did not enter phase I clinical trials until January of 2012. Those phase I trials appear to have been completed according to clinicaltrials.gov. Here we are, four years later and that’s where we are folks. During that time, Astra-zeneca has spun out their antibiotic discovery group into a company called Entasis.  AZ has also turned their antibiotic development group, still within the parent company, into a separate business unit – a move I applauded then and still do. This means that they have their own profits coming in from their sales of ceftaroline and meropenem.  That should be plenty of money to finance the development of aztreonam-avibactam.  Not only that, but they recently received a large grant from BARDA worth up to $220 million and they have funding from the European Union for aztreonam-avibactam as well. So, you might ask, why is this development proceeding at such a tectonic pace?  If this keeps up, the drug won’t be available until my grandchildren reach my age if then.

It strikes me that, for an antibiotic like aztreonam-avibactam, that targets a tiny number of cases (at least today), the data that might be required to get regulatory approval for human use will probably be fairly minimal and could be accomplished quickly – especially in Europe where AZ holds the rights to this drug.

I contacted my friends at AZ to let them know that I was going to be writing this blog.  I asked if they could comment on the development of aztreonam-avibactam.  I asked if at Entasis they were trying to discover even better inhibitors than avibactam that might deal with other resistant strains.  I also asked who it was that was head of the new business unit. No comment, no comment, no comment. Why is the name of the new business unit director a secret???  When I asked that question my friend replied – “you and I both know what its like to work for a large company.”

So – to those of you out there still depending on colistin to treat highly resistant Gram-negative infections, you better hope that mcr-1 does not arrive at your hospital before aztreonam-avibactam does.  Good luck on that.

Sunday, January 3, 2016

2015 - Year in Review

The highlights of the year 2015 for me begin with the discovery of the iChip technology by Stava Epstein and his colleagues in Kim Lewis’ lab. This technology allows the growth of previously non-cultivatable antibiotic-producing organisms from soil by simply isolating them and placing the back in the soil environment from which they came. Its elegant and holds much promise for the discovery of novel natural product antibiotics in the future. We are all awaiting further developments here.

The output of reports from Jim O’Neill’s Review on Antimicrobial Resistance continues to amaze me even if  I don’t agree with all their conclusions. The idea that incentives for the discovery and development of antibiotics could actually become reality in my lifetime is nothing less then a breath of air after the stifling nightmare of the last 15 years. I have been so inspired that I have joined the Drive-AB effort to help make this dream come true.

This year finally saw the results of Astra-Zeneca’s efforts to sell its antibiotic research, development and business franchise.  Being unable to obtain the price they were demanding (one presumes), they adopted a different strategy.  This year they spun out their discovery group into a company, Entasis, fully funded to the tune of $40 million by the mother ship (AZ).  Shortly after that, they announced the formation of an independent business unit within AZ that would encompass their antibiotics business and as well as their clinical development group. What will happen to them is still to be determined – but I will have more to say about this in the next week or so.

A big highlight for me this year, and I hope for you, too, was the appearance of my new book – The Drug Makers.  I have been gratified by the many positive comments I have received from those within and from many outside of the pharmaceutical industry.

On a down note, Tetraphase reported that their phase III trial of eravacycline for complicated urinary tract infection failed to meet its endpoint. I was especially disappointed in this news because I helped them design the trial and thought that we had done everything to assure its success. Luckily, I own no Tetraphase stock since it crashed by about 80% with this news. I am still hoping that eravacycline will make it to the marketplace since we desperately need an effective, oral antibiotic for resistant Gram-negative infections.  Eravacycline is the only drug fitting this bill on the near term horizon.

On another low point, I discussed the effect of increasing drug prices, especially for generic drugs, on public opinion and even on pharmaceutical company stock prices and on the political campaign. I suggested that the US should adopt two simple (but politically fraught) policies to deal with this issue.  (1) We should subsidize alternative manufacturers for essential medicines to prevent price gouging. (2) The US should finally begin to negotiate drug prices nationally at least on a federal level just like virtually every other country in the world.  This is guaranteed to control prices.  While some argue that it will reduce innovation globally and here in the US, I remain unconvinced and believe we should do the experiment.

There have been important issues in the FDA reboot of antibiotic development this year related to antibiotics active only against specific pathogens. I discussed this with FDA this fall.  Their problem is that they believe that they need some sort of inferential data to approve a new drug while I think there are lots of examples where this has not been the case. They are pursuing this with the President’s Advisory Council on Combatting Antibiotic Resistance. Once again, I await further developments here and you can look forward to additional blogs on this in the future.

The recent announcement of the proposed merger between Pfizer and Allergan was the subject of a blog and a recent Lancet article. My worry is that Allergan’s key antibiotic pipeline for North America based on the beta-lactamase inhibitor, avibactam, will be in jeopardy because of this merger. Pfizer is not known for its enthusiasm for antibiotics these days.

A recent court ruling suggesting that the promotion of off-label uses for drugs was protected speech raised my hackles.  If this ruling ever becomes the law of the land, it will mean that companies can sell anything for anything. Lets not go there – please.

Finally, the recent emergence of mcr-1, the plasmid-mediated gene encoding resistance to our very last line Gram-negative antibiotic polymyxin (colistin) scared the hell out of me. The gene has now been found in Asia and in Europe after having apparently emerged in China.  Why did this occur?  Because in China (and apparently here in the US) polymyxin can be used and has been used as a growth promoting agent for pigs and/or cattle. In an editorial, Josh Bloom and I suggested that this practice must stop and must stop globally.

With that, I wish you all a happy, productive and very safe 2016!