Free investment advice

Whether physicians should sell their time to advise investment firms is currently quite controversial. Despite the high valuation of my blog, said firms are not exactly knocking down my door bidding for my time, so I decided to offer this advice for free to my readers. Here are some of the products in the allergy/asthma marketplace and how I see them.

Important caveats
1. I don't know which companies make which meds, so you'll have to figure that out yourselves.
2. I also serve as a consultant for Genentech which makes Xolair so keep that in mind.
3. I don't invest in individual stocks myself, so I don't have any particular interest in seeing one or the other do well
4. In general, you get what you pay for

Asthma Drugs

Inhaled steroids.

Flovent (fluticasone) dominates this market. I have heard that fluticasone is now off patent, but so far there is no generic form. If I were a generic drug maker I'd be pushing to get generic fluticasone to market. Once they do, I think most insurance plans will make that the preferred inhaled steroid, and push everything else to a higher copay.

Pulmicort (budesonide) comes in two forms. The respules, for use in a nebulizer, are the only approved inhaled steroid up to age 5 and therefore a goldmine. The concept that asthma is an inflammatory disease and needs regular anti-inflammatory treatment has made it out into the primary care community, so the respules are and will continue to be widely used with no competitor in site.

The Turbuhaler delivery device is okay. Good product but my sense is that almost everyone uses Flovent as the default. The drug reps are pushing value, which is good (200 doses/device with most patients using 2-4 doses/day) but not enough.

Aztra Zeneca (I had to look it up) is getting killed because they don't have a delivery device that can be used by kids ready to transition off the respules. By 3 or 4 most kids won't sit still for the respules (which take about 8 minutes via neb) and get switched to Flovent using a mask and spacer because they aren't ready for the Turbuhaler. If there were, say, a Pulmicort MDI (metered dose inhaler) all those kids would go to that, but there isn't. So sad. I guess the Astra-Zeneca CEO will have to console himself with only $50million this year, could have been a 100.

Qvar (beclamethasone) Good product, but late to market, so rarely used. Some data on better penetration of small airways, but more something people talk about than act on.

Asmanex (mometasone) dead on arrival. Yawn. I could use an alternative to Adviar; I don't need another inhaled steroid. Device is no better than Turbuhaler and we use other inhaled steroids once a day so indication for once daily dosing is no big deal

Ciclesonide (not yet approved) see Asmanex

Other drugs

Advair (fluticasone/salmetereol). Black box warning hurts, but this is enormous drug. Patients like it, doctors like it because salmeterol makes patients feel better and therefore take it more regularly. Expensive, but worth it. Not surprisingly, deemphasizing Flovent to push this for more and more patients. I'm seeing tons of patients for whom this is prescribed by PCPs. Jerome Bettis ads and asthma control test are good way to push more people onto this. I think there is a lot of undertreated asthma out there, and Advair will help a lot of it.
No competition until Symbicort (budesonide/fomoterol) comes, but the AZ reps are saying at least a year

Xolair (Omalizumab) Works great, but outrageously expensive (10-20K/yr roughly). Use will continue to increase as allergists/pulmonologists get more comfortable with it, but insurance companies starting to toughen standards. Doubt will ever be widely used for food allergy.

Singulair (montelukast) Decent product, good prospects. Recently published PREVIA trial shows effectiveness in kids with wheezing only with URIs, which is huge market and plays into parents steroid-phobia. In adults, NEJM studyallegedly showing no difference in control of mild persistent asthmatics with use of daily inhaled steroids is being pushed by reps, who say Singulair should be equal alternative in treatment of these patients. Chutzpah given that this trial incuded another leukotriene antagonist (zafirlukast) which showed absolutely NO benefit (vs. steroids which improved control on some measures). Effective marketing. Also useful in some patients with refractory urticaria, but market apparently too small to pursue this as indication.

Symbicort (budesonide/fomoterol) Studies look great, so why is it taking so long to get approved? Since fomoterol (unlike salmeterol) has rapid onset and long-acting beta-agonist properties, potential use as a "single inhaler" used both as daily controller and prn reliever is appealing (though scary to asthma specialists!). Wonder if, like Qvar and Azmacort, it will be a day late and a dollar short.

Rhinitis meds

Intranasal steroids Not much difference one to another. Flonase has best insurance coverage, at least in Pennsylvania, and I like using same med for nose and lungs. Nasonex has advantage of being approved down to 2, Rhinocort and Nasacort are widely felt to be best tolerated. Insurance coverage is key driver of use

Antihistamines Insurance dictates everyone try loratadine (now generic, was Claritin) first. Some will pay for Allegra (fexofenadine) or Zyrtec (ceterizine) or even Clarinex (desloratadine) if loratadine fails, but increasingly only for severe pathology (hives, anaphylaxis) not for run of the mill nasal allergies.

Incredibly, Singulair is starting to be covered by some insurances for allergies, despite data that it is marginally effective at all and less potent than loratadine.

Astelin (azelastine) Not effective, too many sprays, no one likes the taste.

Apparently, they are working on a nasal form of olopatadine (Patanol when used for eyes, maybe Patanasal? for nose) which might be big if effective as it would apparently have rapid onset, which steroids don't, and appeal to all the patients/parents who get palpitations whenever someone says "steroids."

Eye meds

Patanol (olopatadine) dominates this field. When I ask opthamologists what to use on tough patients awaiting optho visit for ocular steroids, they all say they use Patanol, despite some data other drops may be better

All the rest Hard to get market share. Occasional insurances will make others (e.g. Zaditor) front line but patients are all already on Patanol and don't want to switch