So Eli Lilly is, yes, bringing a statin of their own to market. Livalo (pitavastastin) will try to make headway based on a slightly lower price than Crestor (the big dog, after next year, among the patent-protected statins) and a different metabolic profile that might decrease drug-drug interactions.

Lilly brought this one in from Kowa of Japan, and it’s hard to see how they’ll get too many people excited about it. And while I certainly understand to need to make some money, one way or another, making it this way doesn’t add mmuch to the case for Big Pharma innovation, does it? Maybe there are enough people out there who will benefit from another alternative – but no one can say that the world was waiting for another statin, that’s for sure.

Read more from the original source
Lilly’s Statin – Yes, It Is 2010

Now there’s a completely new way to regulate HDL, and it comes from a direction you might not expect: the brain. A new paper in Nature Neuroscience demonstrates that melanocortin signaling, ghrelin and GLP-1 change HDL levels, through both altered cholesterol synthesis and uptake. Since these are involved in a number of ways in food intake and metabolism, it makes sense (in retrospect) that there would be a lipoprotein connection, but this does seem to be a dramatically direct one. (More and more, it appears that many metabolic processes that were thought to be more peripheral are under some sort of central control, actually). As the authors put it:

An integrated neuroendocrine control of food intake, body weight and glucose homeostasis, as well as cholesterol metabolism and cardiovascular lipid exposure, would connect all of the hallmarks of the metabolic syndrome. Therapies promoting the increase of HDL levels have been proposed for the prevention of atherosclerosis in humans. . . We speculate that modulation of neuroendocrine circuits may offer therapeutic opportunities to prevent cardiovascular disease.

Yes, indeed. It’s not going to be easy, though. Ghrelin and GLP-1 have already been looked at for diabetes and obesity therapy, and they’re tricky to deal with. Small-molecule ghrelin antagonists are known – as I should know – and there have been many reports of melanocortin receptor ligands as well. Of course, the question will be how many other things you might mess with at the same time, but it’s going to be very interesting and worthwhile to unravel these.

Read more here
Raising Your HDL – Through the Brain?

The drug is an aldosterone antagonist which had already been approved several years ago for heart failure and hypertension, so it’s not really a surprise that it worked in this population. But you never know, and Pfizer wanted to be able to get specifically recommended for patients of this type. And that they will.

Read more here
Pfizer Halts a Trial Early – On Good News

To pick one famous example, try cholesterol. Everyone you stop on the street will know that “high cholesterol is bad for you”. But the first thing you have to do is distinguish between LDL and HDL cholesterol – if the latter is a large enough fraction of the total, the aggregate number doesn’t matter as much. And fundamentally, there’s not a disease called “high cholesterol” – that’s a symptom of some other cluster of metabolic processes that have gone subtly off. And the endpoint of any therapy in that field isn’t really to lower the number in a blood test: it’s to prevent heart attacks and to extend healthy lifetimes, mortality and morbidity. As we’re seeing with Vytorin, it may be possible to drop the numbers in a blood test but not see the benefit that’s supposed to be there.

Another example of this came up over the weekend. The fibrates are a class of drugs that change lipid levels, although the way they work is still rather obscure. They’re supposed to be ligands for the PPAR-alpha nuclear receptor, but they’re not very potent against it when you study that closely. At any rate, they do lower triglycerides and have some other effects, which should be beneficial in patients whose lipids are off and are at risk for cardiac problems.

But are they? Type II diabetics tend to be people who fit that last category well, and that’s where a lot of fenofibrate is prescribed (as Abbott’s Tricor in the US, and under a number of other names around the world). A five-year study in over five thousand diabetic patients, though, has just shown no difference versus placebo. Again, there’s no doubt that the drug lowers triglycerides and changes the HDL/LDL/VLDL ratios. It’s just that, for reasons unknown, doing so with fenofibrate doesn’t seem to actually help diabetic patients avoid cardiac trouble.

Mortality and morbidity: lowering them is a very tough test for any drug, but if you can’t, then what’s the point of taking something in the first place? This is something to keep in mind as the push for biomarkers delivers more surrogate endpoints. Some of them will, inevitably, turn out not to mean as much as they’re supposed to mean.

One of those might well go to the 2003 deal in which Pfizer paid over a billion dollars in to acquire Esperion and their Apo-A1 Milano lipoprotein. If you’ve been following the cardiovascular field for a few years, you’ll remember the big press that this got. The Milan variant of the protein seemed to be quite effective at reverse cholesterol transport – just typing that phrase takes me back a few years, to be honest. The hope was that periodic treatments might flush the arteries out and avert atherosclerosis.

And there things seemed to stay, hung up in that “promising therapy” zone. At the time, Pfizer was going to be the biggest thing ever in cardiovascular, what with Lipitor, with their CETP inhibitor torcetrapib, and with Apo-A1 Milano coming along at the same time. That dream is a pile of wreckage now, of course – Pfizer has de-emphasized the whole area. Esperion itself was spun back out in 2008 as a much smaller operation, minus the lipoprotein it came in with, and now Apo-A1 Milano itself has been sold off to The Medicines Company. For $10 million up front.

Yep, Pfizer gets $0.01 billion back from its $1.25 billion investment – well, more if things work out, but you’d have to think that most of that money is just gone. But I can’t really say that this is just Pfizer’s own problem, or just their own folly. This sort of thing can happen to any organization, and the larger it is, the more likely it is to make some sort of Big Move which then sends it falling down the stairs. After all, if you’re trying to affect the future of a huge company, you have to do huge things, right? And these huge things take on a momentum of their own – witness another Pfizer disaster, Exubera. That inhaled insulin was going to be a billion-dollar drug, no question about it, and no one could tell the company any different. Well, except their customers.

But again, I don’t see these things as coming from some particularly Pfizery mindset. Any other drug company of that size would probably have done things equally catastrophic, and as they get larger, the others surely will find their own open manholes to step confidently into. Since this is the first post of the new year, here’s a resolution I wish the industry would consider: no big mergers in 2010. No gigantic sense-of-urgency do-this-deal-now productions, please. Let’s try to do what we do better, rather than just do more of it.

That should lower LDL, and help with several other cardiovascular risk factors at the same time. Isis and their partner Genzyme have just announced that a trial of the drug in patients with homozygous familial hypercholesterolemia showed significant LDL reductions (25 per cent). These people are already maxed out on statin therapy, and still have huge LDL levels, so this does seem to represent an advance.

And Genzyme knows all about getting drugs through for very small patient populations (and charging accordingly) – they’re definitely a good partner for this sort of drug. But both they and Isis would like for mipomersen to be used more widely. The next target are patients with the heterozygous form of hypercholesterolemia, and then they’ll try to move on to various other statin-intolerant patients with risky LDL levels.

Isis could use a success. They were the first to get an antisense therapy approved (Fomiversen), but it really has never brought in much revenue. Mipomersen, as an injectable, is never going to go out and take over the world like the stating drugs, but it could still be a winner in its own (larger) niche.

Read the original article at In the Pipeline – Mipomersen – It Still Works

It hasn’t been an easy ride. Since 1990, several compounds have failed in the clinic or in preclinical tox testing. The most recent disappointment was in 2006, when pactimibe (Daiichi Sankyo) not only failed to perform against placebo, but actually made things slightly worse.

Lipid handling is a tough field, because every animal does is slightly differently. There are all sorts of rabbit strains and hamster models and transgenic mice, but you’re never really sure until you get to humans. Complicating the story has been the discovery that there are two ACATs. ACAT-1 is found in macrophages (and the foam cells that they turn into) and many other tissues, and ACAT-2 is found in the intestine and in the liver. Which one to inhibit is a good question – the first might have a direct effect on altherosclerotic plaque formation, while the second could affect general circulating lipid levels. Pactimibe hits both about equally, as it turns out.

Now a second study of that drug has been published this spring. This one was going on at the same time as the earlier reported one, and was stopped when those results hit, but the data were in good enough shape to be worked up, and the company paid for the continued analysis. The new results look at patients with familial hypercholesterolemia, who got pactimibe along with the standard therapies. Unfortunately, the numbers are of a piece with the earlier ones: the drug did not help, and actually seemed to increase arterial wall thickness. I think it’s safe to say, barring some big pharmacological revelation, that ACAT inhibitors are a dead end for atherosclerosis.

I bring this up for two reasons. One is that the group that was working next door to me on ACAT was the same group that discovered (quite by accident) the cholesterol absorption inhibitor ezetimibe, known as Zetia (and as half of Vytorin). Although its future is very much in doubt, it’s for sure that that compound has been a lot more successful than any ACAT inhibitor. The arguing goes on about how helpful it’s been (and will go on until we see the next trial results for another couple of years), but it’s already made it further than ACAT.

And that’s actually my second point. I suspect that almost no one in the general public has ever heard of ACAT at all. But it’s been the subject of a huge amount of research, of time and work and money. And while we’ve learned more about lipid handling in humans, which is always valuable, the whole effort has been an utter loss as far as any financial return. I have no good way of estimating the direct costs (and even worse, the opportunity costs) involved with this target, but they surely add up to One Hell Of A Lot Of Money. Which is gone, and gone with hardly a sound outside the world of drug development. And this happens all the time.

Read the original article at In the Pipeline – Farewell to ACAT, and to Lots of Time and Money, Too

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