Monday, February 04, 2013

Apixaban's Rocky Sales Start

"Dr. Fisher, I'm so glad I caught you!"

I looked at the table.  It was a nice spread: a full complement of oriental chicken, broccoli and beef, and a few other assorted entrees.

And so began the marketing push for the latest novel oral anticoagulant, apixaban, to be marketed as Eliquis by both drug giants Bristol-Meyer Squibb Company and Pfizer, Inc. to those of us who think about these things.  So refined are these company's networks that access to physicians remains relatively simple.  Oh sure, there are Sunshine rules and Cloudy Day rules, but the reality is, if the drug company wants their drug sold, they know how to find us.  They know when we're in clinic or in the lab, and they work it.

And nothing works like food.

But apixaban, oh, er, Eliquis, is now not so novel.  It's trial data appeared in the New England Journal of Medicine 15 Sep 2011, but the drug quickly went stealth as the FDA decided whether it believed their data or not.  The review was glacial, it seemed, especially given the one-month FDA turn-around that apixaban's rival one-a-day Factor Xa inbibitor, rivaroxaban (Xarelto),  enjoyed after its publication in the same journal just the week before.   That's right: it took over a year for the FDA to decide that it would permit release of apixaban to the American marketplace.


We were not encouraged to ask this question.  Instead, the ill-prepared sales force was sent out to the field to tap the shoulders and fatten the bellies of their most likely prescribers, unarmed with these specifics while hoping we'd forget.  "It's a Factor Xa inbibitor," she said.

No kidding.

And they were unarmed about other data, too, like patient compliance rate taking the twice-a-day drug or clotting incidence if the drug doses were inadvertently missed.   I wanted to know if the drug would be prescribed by our EMR system now.  I wanted to know if I'd have to fill out a pre-authorization request for the drug, like their competitor.  I wanted to know how well the prothrombin complex concentrates (PCCs) and activated prothrombin complex concentrates (aPCCs) work at reversing the drug.  I wanted to know how much the drug would cost my patients.

You know, practical stuff.

Instead, the sales representative rifled through the package insert, flustered.  "Well, here's our handy-dandy discount card," she said, "For just $10 a month..."

"What happens after the first year?  How much will my patients see their co-pay balloon to?" I asked.

"I think they can re-apply..."

Suddenly, the food didn't look so great anymore.



Anonymous said...

As for me and my house, we will
"stick" with Coumadin, be consistent in Vitamin K intake, and be grateful
there is an antidote if the anti-coagulator gets too good at anti-ing. BTW, these drug trials don't even bother testing. The patient population is the guinea pig.
Pretty sad all around

Anonymous said...

Apixaban offers clear benefits for a certain patient population. There is no denying it, & the patients in the trial were typical patients seen in hospitals/clinics requiring anticoagulation but also have renal disease/insufficiency. Reps are often quite obtuse, & the fact she couldn't elaborate on a possible antidote to the biggest concern is embarassing. I would have asked about PCCs too, as a 4th year student who listens to ACCEL cds and reads on To person above reference these trials: ARISTOTLE, RELY, ROCKET.

Anonymous said...

Don't blame the salesman. PCCs are probably not "in Label".

Anonymous said...

As a hospital employee who is now dependent upon the financial success of the institution, why would I divert patients from the coumadin clinic with these new anticoagulants? Medicare pays the coumadin clinic the same as an office visit with me. The new anticoagulants send precious health care dollars to big pharma with their big margins while starving my employer of desperately needed funds on ever shrinking margins as CMS imposes cuts.

Anonymous said...

Your hospital actually makes money INR testing??