The Antibacterials Market Outlook to 2016 Competitive landscape, pipeline analysis, and growth opportunities Reference Code: BI00042-010 Publication Date: May 2011 1 About the author Business Insights has a team of in-house pharmaceutical and regulatory analysts drawn from consulting, R&D and competitive intelligence life sciences backgrounds. Our analysts specialize in providing detailed insight into the future of therapeutic drug markets and emerging pharmaceutical markets and have extensive analytical, forecasting and research experience in the pharmaceutical, biotech and outsourcing sectors. Our team maintains regular contact with industry executives to track market developments and base their market models on a wide range of proprietary drug sales, pipeline and epidemiological databases to provide up to date, accurate strategic insight on the future of the pharmaceutical market. 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The Publisher wishes to make it clear that any views or opinions expressed in this report by individual authors or contributors are their personal views and opinions and do not necessarily reflect the views/opinions of the Publisher. 2 Table of Contents About the author 2 Disclaimer 2 Executive summary 10 Disease overview and epidemiology 10 Global market analysis 10 Pipeline analysis 11 Competitive landscape 12 Chapter 1 Disease overview and epidemiology 13 Summary 13 Introduction 14 Bacterial infections 14 Respiratory tract infections 14 Urinary tract infections 15 Skin and skin structure infections 15 Gynecological infections 17 Diagnosis, treatment and management 17 Respiratory tract infections 17 Urinary tract infections 18 Skin and skin structure infections 18 Gynecological infections 19 Epidemiology of bacterial infections 19 Respiratory tract infections 19 Urinary tract infections 21 Skin and skin structure infections 22 Gynecological infections 23 Forecast epidemiology 23 3 Respiratory tract infections 23 Urinary tract infections 26 Skin and skin structure infections 27 Gynecological infections 28 Chapter 2 Global market analysis 29 Summary 29 Introduction 30 Market dynamics 30 Market analysis by drug class 31 Leading brands dynamics 34 Levaquin (levofloxacin) – Johnson & Johnson 34 Zyvox (linezolid) – Pfizer 35 Avelox (moxifloxacin) – Bayer 36 Augmentin (amoxicillin + clavulanic acid) – GSK 36 Tazocin (piperacillin + tazobactam) – Pfizer 37 Cravit (levofloxacin) – Daiichi Sankyo 38 Merrem (meropenem) – AstraZeneca 38 Cubicin (daptomycin) – Cubist 38 Primaxin (imipenem + cilastatin) – Merck & Co. 39 Zithromax (azithromycin) – Pfizer 39 Resistors of the antibacterial market 41 Growing antibacterial resistance 41 Roadblocks to attractive antibacterial market 42 Shrinking antibacterial pipeline 43 Challenging regulatory requirements 43 Drivers of the antibacterial market 45 Product lifecycle management through expanding indications and formulations 45 Combination products 46 Product development partnerships 46 Product differentiation through technological innovations 47 Monoclonal antibodies (mAbs) to combat bacterial infections 47 Global antibacterial market sales forecast 48 4 Chapter 3 Pipeline analysis 49 Summary 49 Introduction 50 Antibacterial pipeline 50 Key events in antibacterial R&D 51 Optimer to exploit Cubist’s competitive advantage to market Dificid in the US 51 Cubist settles patent infringement litigation with Teva over Cubicin 52 Merck & Co. intends to strengthen antibacterial research through BioRelix 52 GSK exercises its option with Anacor to commercialize GSK2251052 52 Zeftera withdrawn following concerns raised by the FDA and the EMA 53 Durata Therapeutics initiates Phase III trials for dalbavancin 53 Leading drugs in development 54 Profiles of key pipeline products 55 Teflaro (ceftaroline fosamil) – Forest Laboratories/Takeda/AstraZeneca 55 Dificid (fidaxomicin) – Optimer Pharmaceuticals/Astellas/Cubist 56 PTK-0786 (omadacycline) - Paratek Pharmaceuticals/Novartis 57 RX-3341 (delafloxacin) – Rib-X Pharmaceuticals 59 TR-701 (torezolid phosphate) – Trius Therapeutics/Dong-A Pharmaceutical 60 RX-1741 (Radezolid) – Rib-X Pharmaceuticals 62 ACHN-490 – Isis Pharmaceuticals/Achaogen 63 CXA-201 (CXA-101/tazobactam) – Cubist Pharmaceuticals 64 Pipeline forecast to 2016 65 Chapter 4 Competitive landscape 67 Summary 67 Introduction 68 GlaxoSmithKline 68 Overview 68 Financial performance 68 5 Marketed product portfolio 69 Augmentin (amoxicillin + clavulanate) 69 Zinnat (cefuroxime) 70 Altabax (retapamulin ointment) 71 Research and development 71 Strategic and growth analysis 72 Drivers 72 Resistors 73 Pfizer 73 Overview 73 Financial performance 74 Marketed product portfolio 74 Zyvox (linezolid) 74 Tazocin/Zosyn (piperacillin + tazobactam) 75 Zithromax/Zmax (azithromycin) 76 Tygacil (tigecycline) 76 Research & development 77 Strategic and growth analysis 77 Drivers 77 Resistors 78 Johnson & Johnson 78 Overview 78 Financial performance 79 Marketed product portfolio 79 Levaquin (levofloxacin) 79 Doribax (doripenem) 80 Research & development 80 Strategic and growth analysis 81 Drivers 81 Resistors 81 Merck & Co. 82 6 Overview 82 Financial performance 82 Marketed product portfolio 82 Primaxin (imipenem + cilastatin) 83 Invanz (ertapenem) 83 Avelox (moxifloxacin) 84 Research & development 84 Strategic and growth analysis 85 Drivers 85 Resistors 86 Novartis 86 Overview 86 Financial performance 86 Marketed product portfolio 86 Tobi (tobramycin) 87 Research & development 87 Strategic and growth analysis 88 Drivers 88 Resistors 89 Appendix 90 Scope 90 Market size methodology 90 Epidemiology 91 Market forecast 91 Abbreviations 91 7 Table of figures Figure 1: Antibacterial market resistors 41 Figure 2: Drivers of the antibacterial market 45 Figure 3: The global antibacterials’ pipeline by stage of development, 2011 51 Figure 4: Selected late-stage and recently launched antibacterials 54 8 Table of tables Table 1: Incidence of community acquired pneumonia infections in the 7MM, 2010 19 Table 2: Incidence of upper respiratory tract infections caused by streptococcus infection in the 7MM, 2010 20 Table 3: Incidence of community acquired urinary tract infections in the 7MM, 2010 21 Table 4: Incidence of bacterial skin and skin structure infections in the 7MM, 2010 22 Table 5: Prevalence of bacterial vaginosis infections in the 7MM, 2010 23 Table 6: Forecast epidemiology of community acquired pneumonia infections in 7MM, 2010–16 24 Table 7: Forecast epidemiology of upper RTIs caused by streptococcus infection in 7MM, 2010–1625 Table 8: Forecast epidemiology of urinary tract infections in 7MM, 2010–2016 26 Table 9: Forecast epidemiology of skin and skin structure infections in the 7MM, 2010–2016 27 Table 10: Forecast epidemiology of bacterial vaginosis in the 7MM, 2010–16 28 Table 11: Leading antibacterial drug classes with their mechanism of action 32 Table 12: Leading brands in the global antibacterial market ($m), 2010 34 Table 13: Leading antibacterial brands sale forecast ($m), 2010–16 48 Table 14: An overview of Teflaro 55 Table 15: An overview of Dificid 57 Table 16: An overview of PTK-0786 58 Table 17: An overview of RX-3341 59 Table 18: An overview of TR-701 61 Table 19: An overview of RX-1741 62 Table 20: An overview of ACHN-490 64 Table 21: An overview of CXA-201 65 Table 22: Sales forecast for leading drugs in development ($m), 2010–16 66 Table 23: GSK's leading antibacterial products ($m), 2010 69 Table 24: GSK’s antibacterial R&D pipeline, February 2011 72 Table 25: Pfizer's leading antibacterial products ($m), 2010 74 Table 26: J&J's leading antibacterial products ($m), 2010 79 Table 27: Merck & Co.'s leading antibacterial products ($m), 2010 83 Table 28: Merck & Co.’s antibacterial R&D pipeline, February 2011 85 Table 29: Novartis’ antibacterial R&D pipeline 87 9 Executive summary Disease overview and epidemiology Bacterial infections are extremely common, with an estimated incidence of 236m or an incidence rate of 31% in the seven major markets (7MM) in 2010 (for the three most common sites of bacterial infection respiratory, urinary tract and skin). Upper respiratory tract infections affecting an estimated 116m in the 7MM, in 2010, but are associated with low mortality in comparison with lower respiratory tract infections. Urinary tract infections are common, with an estimated incidence of 73m, translating to an incidence rate of 9.6% in 2010 in the 7MM. Urinary tract infections typically affect post-pubescent females and the elderly. In 2010, skin infections, with an incidence rate of 4.4%, resulted in 34m affected individuals in the 7MM. Although such infections are largely superficial, they can cause complications if left untreated. The prevalence of bacterial vaginosis in the 7MM was 70m, a rate of 9.4% in 2010. Global market analysis The global antibacterial market reached $43.9bn in 2010 showing a Y-o-Y decline of 2.0%. The decline was primarily due to the sales erosion of leading brands due to generic competition and lack of new product launches over the last few years. Of the competing drug classes in this market, cephalosporins occupied the leading position with over 25% share in the global antibacterials market followed by penicillins and fluoroquinolones. However, all these drug classes declined in sales in 2010. The concern regarding tendon ruptures and other tendon damage following fluoroquinolones therapy, particularly in older patients, has been one of the strongest reasons for the sales erosion of this class. 10 In 2010, Johnson & Johson’s Levaquin was the largest brand with a share of 3.1% in the global antibacterial market followed by Pfizer’s Zyvox (2.7%) and Merck & Co.’s Avelox (2.2%). Bacterial resistance is negatively impacting efficacy for a significant number of marketed drugs, leaving huge unmet need and opportunities for innovators. Despite the market attractiveness, the cost and complexities coupled with regulatory uncertainties and challenges have shifted the investment focus of pharmaceutical manufacturers from antibacterial to treatments for chronic conditions. Expanding product indications as a means of lifecycle management is one of the growing trends in the global antibacterial market. Pipeline analysis As commercial opportunity in antibacterials has become progressively more limited due to heightened competition, increasing genericization and comparatively short treatment regimens, the area is attracting reduced R&D funding from big pharma companies. Small pharmaceutical and biotech companies are performing much of the discovery and early development of antibacterials. Typically these are then out-licensed to big pharma companies for further development and commercialization. Community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP) infections are attracting research interest. Additionally, the majority of companies developing new antibiotics are targeting cell wall synthesis inhibitors, DNA topoisomerase II inhibitors, ribosomal inhibitors and methionine tRNA ligase inhibitors. Quinolones continue to lead the antibacterial pipeline due to their broad spectrum of activity followed by the glycopeptides which demonstrate efficacy against MRSA and VRE strains. Of over 199 antibacterial compounds in development, only 28% are in the late stage pipeline (preregistration and Phase III). 11 Regulatory uncertainty in antibacterials is inhibiting investment in pipeline products. Competitive landscape GSK’s antibacterial franchise recorded sales of $2.2bn (£1.4bn) in 2010 (a Y-o-Y decline of 4.4%), accounting for 6.0% to the company’s revenues in 2010. GSK is adopting a competitive pricing strategy to drive growth in emerging markets. With the reduction in Zinnat prices by 22% in first quarter of 2010, GSK has reportedly doubled sales volume of in East Africa. Zyvox was Pfizer’s leading antibacterial product with 2010 sales of $1.2bn followed by Tazocin ($952m) and Zithromax/Zmax ($415m). Aiming to reduce costs, Pfizer plans to shift its antibacterial research from US to China. Of Merck & Co.’s antibacterial products, Avelox and Invanz will to continue to grow strongly patent expiries in 2013 and 2015 respectively. Primaxin will continue to decline in sales. Due to the high number of blockbuster off-patent compounds, Novartis is expected to continue pursuing an aggressive generics development strategy for its antibacterial franchise. Due to the anticipated sales erosion of Levaquin (levofloxacin), after its patent expiry in June 2011, Johnson & Johnson shifted its focus on developing US market with Doribax by expanding the drugs indication to nosocomial infections. 12 Chapter 1 Disease overview and epidemiology Summary Bacterial infections are extremely common, with an estimated incidence of 236m or an incidence rate of 31% in the seven major markets (7MM) in 2010 (for the three most common sites of bacterial infection respiratory, urinary tract and skin). Upper respiratory tract infections affecting an estimated 116m in the 7MM, in 2010, but are associated with low mortality in comparison with lower respiratory tract infections. Urinary tract infections are common, with an estimated incidence of 73m, translating to an incidence rate of 9.6% in 2010 in the 7MM. Urinary tract infections typically affect post-pubescent females and the elderly. In 2010, skin infections, with an incidence rate of 4.4%, resulted in 34m affected individuals in the 7MM. Although such infections are largely superficial, they can cause complications if left untreated. The prevalence of bacterial vaginosis in the 7MM was 70m, a rate of 9.4% in 2010. 13 Introduction This chapter provides a background to the antibacterial therapeutic area in terms of the major indications, an overview of each of the indications, and their diagnosis, management and treatment, and forecast epidemiology to 2016. The major bacterial infections covered in this report include respiratory infections (RIs), urinary tract infections (UTIs), skin and skin structure infections (SSSIs) and gynecological infections (GIs). Bacterial infections Bacterial infections affect tissues and organs throughout the human body. The most common sites of infection are those that are exposed directly to bacteria, such as the lungs, skin, and urinary tract. The epidemiologies of these infections are analyzed in this section. Outside of these common sites of infection, CNS infections, intra-abdominal infections, cardiac and bone infections also occur, but collectively, these affect only a relatively small number of patients each year, typically those patients which have had invasive surgery or have contracted the disease in the hospital setting. Respiratory tract infections Respiratory tract infections can occur in the lower or upper respiratory tract. Lower respiratory tract infections comprise infections located below the vocal cords. The most common sites of infection are the bronchi and the lobes of the lungs. Viruses are the most common pathogens causing infections in the lungs. Notable bacterial infections include pneumonia, caused by Streptococcus pneumoniae and tuberculosis (TB), caused by Mycobacterium tuberculosis both of which are associated with high rates of mortality. Bacterial lower respiratory tract infections are common, particularly in children, the elderly and immunocompromised patients. In developed pharmaceutical markets, pneumonia is more common than TB, with substantial differences in species occurring in community acquired pneumonia (CAP) and nosocomial infections. The majority of upper respiratory tract infections (URIs) are caused by viruses. Common sites of bacterial infection include the pharynx (colonized by Streptococcus sp.), the middle ear, and the sinuses (with S. pneumoniae). 14 Urinary tract infections The urinary tract is a common site for bacterial infections, particularly in patients that are using a catheter, women, those who are sexually active, diabetics, the elderly, and patients with a malformed urinary tract. Most commonly urinary tract infections (UTIs) are caused by Escherichia coli and to a lesser extent Staphylococcus sp., but may be caused by sexually transmitted organisms such as Chlamydia and Mycoplasma sp. The symptoms of a UTI can include a higher frequency of urination, urges to urinate, burning sensations while passing urine, urinary incontinence, foul smelling urine and the presence of blood in the urine. UTIs pften reoccur, but are typically confined to the bladder and urethra. However, infection may spread to the kidneys, requiring hospitalization, and potentially posing greater risks for the spread of infection. Skin and skin structure infections Skin and skin structure infections (SSSIs) are caused by many species of bacteria, and can occur spontaneously, or in a wound, ulcer or burn. The most common uncomplicated SSSIs present limited problems for diagnosis and treatment, but following a lack of treatment, bacteria may enter underlying tissues, circulatory or lymphatic systems, causing complicated infections such as bacteremia, which are associated with high rates of mortality. Bacterial infections are associated with a variety of symptoms and treatment outcomes, which vary according to the bacterial species and the area of the body which is infected. Some of the most common forms and symptoms of bacterial infections of the skin are: Cellulitis and erysipelas Cellulitis is one of the most common forms of bacterial infection, and is usually caused by Streptococci bacteria, however other species of bacteria have also been associated with the condition. Cellulitis typically occurs within an open wound or a subcutaneous abscess. Infections are relatively common in patients with animal bites and may also result from exposure to contaminated standing water for example in a jacuzzi or spa. Cellulitis typically occurs in the lower extremities, and is associated with increased redness, changes in the textural nature of the skin, irritation, and inflammation. Occasionally, cellulites can lead to the formation of erysipelas, inflamed raised lesions of the skin, which can indicate infection of the lymphatic system. 15 Folliculitis Folliculitis, the infection of hair follicles by Staphylococcus aureus and P. aeuroginosa, is associated with mild swelling and inflammation of the hair follicle, often resulting in the development of a pustule. A common cause of infection is via use of a contaminated jacuzzi or spa. The condition is seldom complicated and resolves quickly. Impetigo and ecthyma Impetigo is a skin infection caused by Streptococci or Staphylococci colonizing broken skin, typically following injury. Risk factors are humid and warm climates and poor hygiene. Impetigo typically appears as a cluster of vesicles that may rupture and secrete fluid produced by bacterial metabolism, which in turn commonly forms a crust. Ecthyma is a form of impetigo which is characterized by ulceration. Abcesses Cutaneous abcesses are typically caused by bacteria that naturally occur on the surface of the skin such as S aureus and result in a localized build-up of pus in the infected area, accompanied by pain and inflammation. Cutaneous abcesses are common in the perineal area, and infections typically feature organisms that are found in the feces of the patient. Subcutaneous abcesses represent serious infections that can cause tissues necrosis. Such infections typically occur in the perineal area and the extremities of the body. Subcutaneous abcesses are often caused by the migration of bacteria from a prior cutaneous infection, with symptoms resembling that associated with cellulitis. If left untreated, the infection can lead to gangrene and bacteremia. Carbuncles and furuncles Furuncles appear as raised boil-like lesions that may contain pus and necrotizing tissue. They are typically caused by infection with staphylococcus bacteria. Carbuncles are clusters of connected furuncles caused by subcutaneous infection. Both carbuncles and furuncles typically appear on the neck, face, buttocks or breasts. Risk factors are poor hygiene, humidity, diabetes, immunocompromization, and some forms of acne. Lymphadenitis and lymphangitis 16 Lymphadenitis, the infection of lymph nodes by bacteria, typically streptococci, commonly occurs as a secondary infection associated with disease such as tuberculosis, cytomegalovirus infection, herpes infection, syphilis and mononucleosis amongst other diseases. Lymphadenitis can be caused by fungal or viral infection, although bacterial infections are common causes. Lymphangitis, the infection of peripheral lymphatic channels, has a similar etiology to lymphadenitis, with a primary infection being the most common cause. If left untreated, prognosis can be poor, with a likelihood of bacteremia, and leukocytosis. Gynecological infections Bacterial vaginosis Bacterial vaginosis (BV) is the most common cause of vaginal infection and is often referred to as vaginal bacteriosis. BV is a polymicrobial syndrome associated with a change in the vaginal flora, resulting in a loss of normally present lactobacilli and the appearance of increased numbers of other bacteria such as Prevotella, Mobiluncus, Gardnerella vaginalis and Mycolasma hominis. However, the exact cause for this change remains unknown. Although BV is frequently associated with sexually transmitted infections, such as Chlamydia trachomatis and Neustria gonorrhea, it also occurs in sexually abstinent women. Diagnosis, treatment and management Respiratory tract infections Diagnosis of lower respiratory tract infections is achieved by means of a sputum sample or swab and corresponding culture. Diagnosis can be rapid and is an aid in the selection of antibiotic therapy. X-ray and other imaging techniques can be useful tools to provide assessment of the extent of the infection. The treatment of lower respiratory tract infections is linked to the species of bacteria which is identified by culture, although broad spectrum antibiotics, taking into account patient’s allergies and history of treatment are typically prescribed. For upper respiratory tract infections, an estimated 95-98% of infections are caused by viruses rather than bacteria. In cases of pharyngitis, a bacterial culture may be taken in order to determine the pathogen causing the infection, and antibiotic treatment chosen accordingly. The most common antibiotic therapies that are prescribed for the treatment of all respiratory tract infections are penicillins, fluoroquinolones and macrolides. 17 Urinary tract infections Urinary tract infections are typically diagnosed through interview and examination of the presenting patient. A urine sample may be taken, analysis of which may provide identification of the bacterial species responsible for the infection. Recurrent infections, or any infections in men, may require pyelography or ultrasonography in order to determine whether any abnormalities or lesions exist, which may be provoking an infection. In men, examination of the prostate may be necessary in order to assess whether this organ is promoting infection, particularly in older men. Treatment of urinary tract infections varies according to the bacterial species that has been identified. Fluoroquinolones and penicillin products are the most popular treatments, although cephalosporins may play an important part in treatment, particularly in hospital settings. Skin and skin structure infections Diagnosis may be undertaken by visual examination, but in rare bacteria species, a bacterial culture coupled with examination of patient history, including potential for exposure and travel may provide insight into the primary organism responsible for the infection. Treatment is with topical antibiotics if possible, although oral antibiotic therapy is typically recommended in moderate to severe infection, particularly those that are associated with a higher risk of spread or invasion into neighboring tissues. Imaging techniques may be employed to gauge the extent of the bacterial infection, and assess risk, thus further informing treatment choice. For complicated skin and skin structure infections treatment, with clindamycin, erythromycin, and doxycycline are the usual first-line treatments. Fluoroquinolones and cephalosporins are usual second-line treatment of these conditions. The key unmet need in SSSIs is that the present therapies are not very effective against the resistant strains of bacteria particularly methicillin-resistant Staphylococcus aureus (MRSA). However, there are multiple drugs under developments to target resistant organisms. 18 Gynecological infections The presence of bacterial vaginosis (BV) is suspected when a grayish white discharge covers the wall of vagina which has a pH of ≥4.5, generally ≥5.5. In BV, amines are produced in large amounts, leading to the fishy odor of the secretions. If the pH of the secretions is raised (either by semen in vivo or by potassium hydroxide in the laboratory), this odor is accentuated. This is referred to as a positive Whiff Test. Vaginosis is usually treated with the antibiotic metronidazole that can be administered either orally or in a gel form. If the vaginosis occurs simultaneously with Candida, patients are typically treated with antifungals such as butoconazole, clotrimazole, and miconazole which are administered directly into the vagina in the form of suppositories, tablets, creams or ointments. Epidemiology of bacterial infections Respiratory tract infections Penumonia is the most common lower respiratory tract infection. Table summarizes the estimated incidence of this indication in the seven major markets (7MM). Table : Incidence of community acquired pneumonia infections in the 7MM, 2010 Country Incidence (000s) Incidence (%) Share (%) 587 0.94 8.1 1,027 1.24 14.1 Italy 555 0.94 7.6 Spain 393 0.88 5.4 UK 474 0.77 6.5 Total 5EU 3,044 0.98 41.8 US 3,401 1.1 46.7 839 0.66 11.5 7,284 0.97 100.0 France Germany Japan Total 7MM Source: CDC, WHO BUSINESS INSIGHTS 19 There is limited comparable data across bacterial species causing respiratory tract infections, although data points to wide variations across countries, even in Western Europe. Higher risk populations include the elderly, children, immunocompromised, and individuals in the institutional setting. An estimated 95–100% of the population acquire at least one upper respiratory tract infection each year, although the vast majority of these infections are viral. The estimated incidence of upper respiratory bacterial infections, using the most common pathogen, Streptococcus, is summarized in the table below. Table : Incidence of upper respiratory tract infections caused by streptococcus infection in the 7MM, 2010 Country Incidence (000s) Incidence (%) Share (%) 9,743 15.6 8.4 12,425 15 10.7 Italy 8,733 14.8 7.6 Spain 6,658 14.9 5.8 UK 9,551 15.5 8.3 Total 5EU 47,210 15.2 40.8 US 49,466 16 42.8 Japan 18,949 14.9 16.4 115,625 15.6 100.0 France Germany Total 7MM Source: CDC, WHO BUSINESS INSIGHTS Due to a lack of comprehensive studies, and the low rates of reporting, diagnosis and treatment of pharyngitis, it is difficult to estimate the incidence of the disease. Therefore, estimates are based on US studies, adjusted for demographics in order to reflect the increased incidence of pharyngitis among children. Age and annual climatic conditions represent the most significant risk factors for an increased annual incidence of pharyngitis, of which only a small proportion (approximately 15–20%), are caused by streptococcus species. 20 Urinary tract infections Estimates of the incidence of UTIs across the seven major markets are summarized in the table below. Table : Incidence of community acquired urinary tract infections in the 7MM, 2010 Country Incidence (000s) Incidence (%) Share (%) 6,995 11.2 10.0 10,106 12.2 14.4 Italy 6,903 11.7 9.8 Spain 5,317 11.9 7.6 UK 6,840 11.1 9.7 Total 5EU 36,029 11.6 51.3 US 22,569 7.3 32.1 Japan 11,700 9.2 16.7 Total 7MM 70,212 9.4 100.0 France Germany Source: CDC, WHO BUSINESS INSIGHTS The incidence of UTIs is similar among the seven major markets, although due to a greater incidence of the condition in the elderly, institutionalized, patients using a catheter, and women, incidence rates vary from country to country. In community acquired UTIs, age and gender are the most important determinants of incidence, which favors countries with the highest percentage of elderly people, such as Germany, Spain and Italy. 21 Skin and skin structure infections Estimates of the incidence of skin and skin structure infections across the seven major markets are summarized in the table below. Table : Incidence of bacterial skin and skin structure infections in the 7MM, 2010 Country Incidence (000s) Incidence (%) Share (%) France 2,623 4.2 8.4 Germany 3,479 4.2 11.1 Italy 2,478 4.2 7.9 Spain 1,877 4.2 6.0 UK 2,588 4.2 8.2 Total 5EU 13,045 4.2 41.6 US 12,985 4.2 41.4 Japan 5,341 4.2 17.0 Total 31,371 4.2 100.0 Source: CDC, WHO BUSINESS INSIGHTS There is limited epidemiological data available on skin and skin structure infections due to the wide range of conditions, and difficulties in detection and surveillance. Rarer and more serious conditions such as necrotizing infections are more likely to be tracked. Skin and skin structure infections are believed to be more common in children, the elderly and institutionalized patients, particularly those with limited levels of mobility, although there are no studies available to assess the incidence of the sub-indications within this category by country and demography. 22 Gynecological infections Estimates of the prevalence of bacterial vaginosis across the seven major markets are summarized in the table below. Table : Prevalence of bacterial vaginosis infections in the 7MM, 2010 Country Prevalence (000s) Prevalence (%) Share (%) France 4,996 8 7.1 Germany 6,627 8 9.4 Italy 4,071 6.9 5.8 Spain 3,128 7 4.5 UK 5,546 9 7.9 Total 5EU 24,847 8 35.4 US 43,592 14.1 62.1 7,631 6 10.9 70,212 9.4 100.0 Japan Total 7MM Source: Business Insights, CDC, WHO, various other sources BUSINESS INSIGHTS Forecast epidemiology This section provides forecasts on the incidence of the four major bacterial infections analyzed in this report. Respiratory tract infections Table summarizes the forecast incidence of Community acquired pneumonia (CAP) over the period 2010– 2016. In the absence of any major factors exerting an influence on the prevalence of upper and lower respiratory tract infections, incidence of the infection remains in line with demographic changes. As a result the US, Germany and Japan, with the largest population are forecast to have the highest incidence. The US, Japan and Germany are forecast to feature the largest patient populations for upper RTIs over the forecast period, with the highest incidence rates forecast to continue to be in the US, France and the UK. Table summarizes the forecast incidence of upper RTIs to 2016. 23 Table : Forecast epidemiology of community acquired pneumonia infections in 7MM, 2010–16 Country 2010 2011 2012 2013 2014 2015 2016 Incidence (000s) 587 590 599 602 604 607 609 Incidence (%) 0.94 0.94 0.95 0.95 0.95 0.95 0.95 1,027 1,027 1,036 1,036 1,036 1,044 1,044 1.24 1.24 1.25 1.25 1.25 1.26 1.26 Incidence (000s) 555 555 561 562 562 562 562 Incidence (%) 0.94 0.94 0.95 0.95 0.95 0.95 0.95 Incidence (000s) 393 395 400 401 402 408 409 Incidence (%) 0.88 0.88 0.89 0.89 0.89 0.9 0.9 Incidence (000s) 474 477 485 487 489 498 500 Incidence (%) 0.77 0.77 0.78 0.78 0.78 0.79 0.79 3,044 3,052 3,090 3,097 3,104 3,142 3,148 0.98 0.98 0.99 0.99 0.99 1 1 3,401 3,430 3,491 3,521 3,551 3,613 3,643 1.10 1.10 1.11 1.11 1.11 1.12 1.12 Incidence (000s) 839 838 848 846 843 853 850 Incidence (%) 0.66 0.66 0.67 0.67 0.67 0.68 0.68 7,245 7,276 7,382 7,412 7,441 7,546 7,574 0.97 0.97 0.98 0.98 0.98 0.99 0.99 France Germany Incidence (000s) Incidence (%) Italy Spain UK 5EU Incidence (000s) Incidence (%) US Incidence (000s) Incidence (%) Japan Total 7MM Incidence (000s) Incidence (%) Source: Business Insights BUSINESS INSIGHTS 24 Table : Forecast epidemiology of upper RTIs caused by streptococcus infection in 7MM, 2010–16 Country 2010 2011 2012 2013 2014 2015 2016 9,743 9,789 9,897 9,941 9,984 10,090 10,131 15.6 15.6 15.7 15.7 15.7 15.8 15.8 12,425 12,428 12,513 12,514 12,513 12,594 12,591 15 15 15.1 15.1 15.1 15.2 15.2 8,733 8,741 8,806 8,810 8,812 8,871 8,870 14.8 14.8 14.9 14.9 14.9 15 15 6,658 6,680 6,746 6,765 6,782 6,842 6,854 14.9 14.9 15 15 15 15.1 15.1 9,551 9,593 9,698 9,742 9,786 9,894 9,939 15.5 15.5 15.6 15.6 15.6 15.7 15.7 47,210 47,331 47,758 47,869 47,972 48,384 48,476 15.2 15.2 15.3 15.3 15.3 15.4 15.4 49,466 49,892 50,636 51,069 51,503 52,260 52,697 16 16 16.1 16.1 16.1 16.2 16.2 18,949 18,910 18,991 18,938 18,879 18,940 18,869 14.9 14.9 15 15 15 15.1 15.1 116,521 117,020 118,262 118,742 119,210 120,428 120,875 15.6 15.6 15.7 15.7 15.7 15.8 15.8 France Incidence (000s) Incidence (%) Germany Incidence (000s) Incidence (%) Italy Incidence (000s) Incidence (%) Spain Incidence (000s) Incidence (%) UK Incidence (000s) Incidence (%) 5EU Incidence (000s) Incidence (%) US Incidence (000s) Incidence (%) Japan Incidence (000s) Incidence (%) Total 7MM Incidence (000s) Incidence (%) Source: Business Insights BUSINESS INSIGHTS 25 Urinary tract infections Table : Forecast epidemiology of urinary tract infections in 7MM, 2010–2016 Country 2010 2011 2012 2013 2014 2015 2016 6,995 7,028 7,123 7,155 7,186 7,280 7,310 11.2 11.2 11.3 11.3 11.3 11.4 11.4 10,106 10,108 10,192 10,193 10,193 10,274 10,272 12.2 12.2 12.3 12.3 12.3 12.4 12.4 6,903 6,910 6,974 6,977 6,979 7,038 7,037 11.7 11.7 11.8 11.8 11.8 11.9 11.9 5,317 5,335 5,397 5,412 5,425 5,482 5,492 11.9 11.9 12 12 12 12.1 12.1 6,840 6,870 6,963 6,994 7,026 7,121 7,153 11.1 11.1 11.2 11.2 11.2 11.3 11.3 36,091 36,183 36,584 36,668 36,747 37,073 37,144 11.6 11.6 11.7 11.7 11.7 11.8 11.8 22,569 22,763 23,274 23,473 23,672 24,194 24,397 7.3 7.3 7.4 7.4 7.4 7.5 7.5 11,700 11,676 11,774 11,742 11,705 11,790 11,746 9.2 9.2 9.3 9.3 9.3 9.4 9.4 70,212 70,512 71,560 71,850 72,134 73,172 73,443 9.4 9.4 9.5 9.5 9.5 9.6 9.6 France Incidence (000s) Incidence (%) Germany Incidence (000s) Incidence (%) Italy Incidence (000s) Incidence (%) Spain Incidence (000s) Incidence (%) UK Incidence (000s) Incidence (%) 5EU Incidence (000s) Incidence (%) US Incidence (000s) Incidence (%) Japan Incidence (000s) Incidence (%) Total Incidence (000s) Incidence (%) Source: Business Insights BUSINESS INSIGHTS 26 Skin and skin structure infections Table summarizes the forecast incidence of skin and skin structure infections over the period to 2016. Table : Forecast epidemiology of skin and skin structure infections in the 7MM, 2010– 2016 Country 2010 2011 2012 2013 2014 2015 2016 2,623 2,635 2,711 2,723 2,734 2,810 2,821 4.2 4.2 4.3 4.3 4.3 4.4 4.4 3,479 3,480 3,563 3,563 3,563 3,646 3,645 4.2 4.2 4.3 4.3 4.3 4.4 4.4 2,478 2,481 2,541 2,543 2,543 2,602 2,602 4.2 4.2 4.3 4.3 4.3 4.4 4.4 1,877 1,883 1,934 1,939 1,944 1,994 1,997 4.2 4.2 4.3 4.3 4.3 4.4 4.4 2,588 2,599 2,673 2,685 2,697 2,773 2,785 4.2 4.2 4.3 4.3 4.3 4.4 4.4 13,045 13,078 13,422 13,453 13,482 13,824 13,850 4.2 4.2 4.3 4.3 4.3 4.4 4.4 12,985 13,097 13,524 13,640 13,755 14,194 14,313 4.2 4.2 4.3 4.3 4.3 4.4 4.4 5,341 5,330 5,444 5,429 5,412 5,519 5,498 4.2 4.2 4.3 4.3 4.3 4.4 4.4 31,371 31,505 32,390 32,522 32,650 33,537 33,661 4.2 4.2 4.3 4.3 4.3 4.4 4.4 France Incidence (000s) Incidence (%) Germany Incidence (000s) Incidence (%) Italy Incidence (000s) Incidence (%) Spain Incidence (000s) Incidence (%) UK Incidence (000s) Incidence (%) 5EU Incidence (000s) Incidence (%) US Incidence (000s) Incidence (%) Japan Incidence (000s) Incidence (%) Total Incidence (000s) Incidence (%) Source: Business Insights BUSINESS INSIGHTS 27 Gynecological infections Table 10 summarizes the forecast prevalence of bacterial vaginosis to 2016. Table : Forecast epidemiology of bacterial vaginosis in the 7MM, 2010–16 Country 2010 2011 2012 2013 2014 2015 2016 4,996 5,020 5,106 5,129 5,151 5,237 5,258 8 8 8.1 8.1 8.1 8.2 8.2 6,627 6,628 6,712 6,713 6,712 6,794 6,793 8 8 8.1 8.1 8.1 8.2 8.2 4,071 4,075 4,137 4,139 4,140 4,199 4,198 6.9 6.9 7 7 7 7.1 7.1 3,128 3,138 3,193 3,202 3,210 3,262 3,268 7 7 7.1 7.1 7.1 7.2 7.2 5,546 5,570 5,657 5,683 5,709 5,797 5,824 9 9 9.1 9.1 9.1 9.2 9.2 24,847 24,911 25,284 25,342 25,397 25,763 25,812 8.0 8.0 8.1 8.1 8.1 8.2 8.2 43,592 43,968 44,660 45,042 45,425 46,131 46,516 14.1 14.1 14.2 14.2 14.2 14.3 14.3 7,631 7,615 7,723 7,701 7,678 7,777 7,748 6 6 6.1 6.1 6.1 6.2 6.2 70,212 70,512 71,560 71,850 72,134 73,172 73,443 9.4 9.4 9.5 9.5 9.5 9.6 9.6 France Prevalence (000s) Prevalence (%) Germany Prevalence (000s) Prevalence (%) Italy Prevalence (000s) Prevalence (%) Spain Prevalence (000s) Prevalence (%) UK Prevalence (000s) Prevalence (%) 5EU Prevalence (000s) Prevalence (%) US Prevalence (000s) Prevalence (%) Japan Prevalence (000s) Prevalence (%) Total Prevalence (000s) Prevalence (%) Source: Business Insights BUSINESS INSIGHTS 28 Chapter 2 Global market analysis Summary The global antibacterial market reached $43.9bn in 2010 showing a Y-o-Y decline of 2.0%. The decline was primarily due to the sales erosion of leading brands due to generic competition and lack of new product launches over the last few years. Of the competing drug classes in this market, cephalosporins occupied the leading position with over 25% share in the global antibacterials market followed by penicillins and fluoroquinolones. However, all these drug classes declined in sales in 2010. The concern regarding tendon ruptures and other tendon damage following fluoroquinolones therapy, particularly in older patients, has been one of the strongest reasons for the sales erosion of this class. In 2010, Johnson & Johson’s Levaquin was the largest brand with a share of 3.1% in the global antibacterial market followed by Pfizer’s Zyvox (2.7%) and Merck & Co.’s Avelox (2.2%). Bacterial resistance is negatively impacting efficacy for a significant number of marketed drugs, leaving huge unmet need and opportunities for innovators. Despite the market attractiveness, the cost and complexities coupled with regulatory uncertainties and challenges have shifted the investment focus of pharmaceutical manufacturers from antibacterial to treatments for chronic conditions. Expanding product indications as a means of lifecycle management is one of the growing trends in the global antibacterial market. 29 Introduction This chapter gives an overview of the global antibacterials market, with competitive analysis of the leading antibacterials brands, and drug classes. Key brands are profiled. The chapter also highlights the challenges and drivers of the antibacterial market. Market dynamics The global antibacterial market reached $43.9bn, showing a Y-o-Y decline of 2.0% in 2010. The decline was primarily due to infiltration of generics which led to sales erosion of a number of leading brands, including Pfizer’s Tazocin and Johnson & Johnson’s (J&J) Levaquin, and lack of new product launches over the last few years. The bacterial infections market can be broadly categorized into community acquired and hospital acquired bacterial infections. Although, the prevalence of community acquired bacterial infections is also on a rise, hospital acquired bacterial infections are growing at a higher rate due to increased incidence of resistant bacteria in hospital settings. The community market is highly dominated by the generic brands while the sale of branded antibacterial products is primarily driven by the hospital sector. Nosocomial (hospital acquired) infections is the most attractive segment in the antibacterial space with growing antibiotic resistance and significantly higher mortality and morbidity rate. Due to the nature of bacterial infections, mutations rapidly lead to the development of drug resistance over the course of treatment particularly in hospital settings. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycinresistant enterococci (VRE), Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter species represent the most important drug resistant pathogens that have been the focus of antibacterial R&D activity in recent years. However, this may lead to an over-crowded market with similar products fighting for their share of the market. Thus, the uptake and commercial success of the drug will be highly dependent on the market entry strategy of the company. First mover advantage will be a major factor for success. It will be challenging to to differentiate late-entering drugs and gain market share. Despite this, the nosocomial drug market is expected to dominate the antibacterial market in the near term. 30 Cephalosporins formed the largest drug class in 2010, with over 25% share in the global antibacterial market, followed by broad-spectrum penicillins (20%) and fluoroquinolones (15%) in 2010. However, all the major drug classes including cephalosporins, penicillins and fluoroquinolones witnessed declining sales in 2010. GSK, Pfizer, Johnson & Johnson (J&J) and Merck & Co. were the leading players in the global antibacterial market in 2010. Tazocin, Levaquin, Augmentin, Zyvox, and Avelox were the key brands accounting for 12.4% of the total antibacterial market in 2010. Market analysis by drug class The major drug classes in the antibacterial therapeutic category include: cephalosporins penicillins fluoroquinolones macrolides carbapenems. 31 Table : Leading antibacterial drug classes with their mechanism of action Drug class Mechanism of action Drugs Brands Cephalosporins Cell wall synthesis inhibitors ceftobiprole, ceftaroline cephalexim, cefixime Rocephin, Fortum, Suprax, Flomox, Zinnat, Keflex Penicillins Cell wall synthesis inhibitors piperacilin, flucloxacillin Augmentin, Zosyn, Amoxil, Tazocin, Floxapen Fluoroquinolones Nucleic acid synthesis inhibitors gatifloxacin, moxifloxacin, levofloxacin Avelox, Levaquin, Tavanic, Cravit, Ciproxin Macrolides Protein synthesis inhibitors clarithromycin, telithromycin, azithromycin Zithromax, Klacid, Clarith, Azithromycin, Dalacin, Ketek Carbapenems Cell wall synthesis inhibitors meropenem, imipenem Merrem, Primaxin Source: Business Insights BUSINESS INSIGHTS Cephalosporins Cephalosporins are part of the beta-lactams group and work by interfering with the synthesis of the bacterial cell wall. Some may be given orally but most are given by injection. They are typically the second choice antibiotic, their main uses being in pneumonia, septicemia, meningitis, sinusitis, and UTIs. Unwanted side effects are similar to those seen with the penicillins, such as stomach upset, nausea, vomiting, and diarrhea. However, all these side effects are mild in nature and subside with time. Despite their second-line usage, cephalosporins have a broader spectrum of activity and are more potent than penicillins. In 2010, cephalosporins were the leading drug class with over 25% sales share of the global antibacterials market. Penicillins Penicillin was the first modern antibiotic from the beta-lactam group and acts by interfering with the synthesis of bacterial cell walls. Despite the age of the class, penicillins remain the most widely used antibiotics, owing to their broad activity base and good safety profile. They remain the drugs of choice for many clinical uses, 32 including bacterial meningitis, skin infections, pharyngitis, middle ear infections, bronchitis, gonorrhea, and syphilis, among other infections. They can be taken orally, although different products are absorbed to different degrees and thus, in some cases, injection may be more efficacious. They are well tolerated and toxic side effects are rare, although allergic reactions such as rashes and fever occur in about 10% of patients. In 2010, penicillins accounted for around 20% of the total antibacterial sales. Fluoroquinolones Fluoroquinolones work by inhibiting a bacterial enzyme called DNA gyrase, which prevents bacterial DNA from coiling, so preventing replication. Fluoroquinolones are broad spectrum antibiotics but are particularly effective against many gram-negative bacteria, including many organisms that are resistant to penicillin. Taken orally or by injection, their main uses are in UTIs. Fluoroquinolones have seen sales erosion due to a decline in the sales of oral fluoroquinolones and a rise in resistant strains of bacteria. Macrolides Macrolides interfere with bacterial protein synthesis by attaching to bacterial ribosomes (the cellular constituents that read RNA as a template for protein synthesis). Their spectrum of activity is similar to that of penicillins (although they are mainly effective against gram-positive bacteria) and they have proven useful alternatives in penicillin-sensitive patients. They are typically administered orally, with the main side-effects being gastrointestinal disturbances. Carbapenems Carbapenems, a beta-lactam antibiotic, was developed from thienamycin, a naturally-derived product of Streptomyces cattleya. Carbapenems have been highly effective against multiple bacterial infections including Escherichia coli, however, the recent discovery of drug resistance to carbapenem antibiotics is raising a global concern. Most of the nosocomial strains of Acinetobacter are antibiotic-resistant which is a notable challenge. 33 Leading brands dynamics The key 10 brands in the global antibacterials market generated sales of $8.7bn accounting for 19.9% of the market in 2010. J&J’s Levaquin was the largest brand with a share of 3.1% in the global antibacterial market followed by Pfizer’s Zyvox (2.7% ) and Merck & Co.’s Avelox (2.2%). Table : Leading brands in the global antibacterial market ($m), 2010 Brands Generic name Sales 2010 ($m) Sales growth 2010 (%) Market share 2010 (%) CAGR 2006–10 (%) Levaquin levofloxacin 1,357 -12.5 3.1 -3.0 Zyvox linezolid 1,176 3.1 2.7 10.7 Avelox moxifloxacin 984 -1.0 2.2 3.5 Augmentin amoxicillin + clavulanic acid 966 -6.3 2.2 2.3 Tazocin piperacillin + tazobactam 952 94.9* 2.2 -0.5 Cravit levofloxacin 820 -17.5 1.9 -8.8 Merrem meropenem 817 -6.3 1.9 7.8 Cubicin daptomycin 625 16.2 1.4 33.8 Primaxin imipenem + cilastatin 610 -11.5 1.4 -3.5 Zithromax azithromycin 415 -3.5 0.9 -10.2 8,721 -0.1 19.9 1.1 Others 35,156 -2.5 80.1 4.3 Total 43,877 -2.0 100.0 3.7 Key brands total Note: *2009 sales included only six months sales from Wyeth and 2 months sales through Pfizer. Source: company reports, PharmaVitae BUSINESS INSIGHTS Levaquin (levofloxacin) – Johnson & Johnson Levaquin is a broad-spectrum fluoroquinolone drug with activity against wide range of gram-positive and gram negative pathogens including S. aureus (not MRSA), Streptococcus pneumoniae (including multiple drug-resistant), Streptococcus pyogenes, E. coli, Haemophilus influenzae, Chlamydia pneumoniae, Legionella pneumophila, Proteus mirabilis, and Mycoplasma pneumoniae. The drug inhibits the activity of 34 DNA gyrase, a type II topoisomerase, and topoisomerase IV, which are necessary for bacterial cell wall synthesis. The drug was initially developed by Daiichi Sankyo and commercialized under the brand name Cravit in Japan in 1993. Later, in 1997, it was launched in the US under the brand name Levaquin through a licensing agreement with J&J; in 1998 the brand was introduced in Europe as Tavanic. Levaquin has been approved for multiple expanded indications since its launch, for instance in 2007, Levaquin was approved for the treatment of complicated UTIs (cUTIs) and acute polynephritis; in 2005 the FDA approved Levaquin for five-day course for the treatment of acute bacterial sinusitis. The product is available as an oral solution, tablet, and as an intravenous formulation. Levaquin is covered by a composition-of-matter patent through December 20, 2010 held by Daiichi Sankyo, which includes a threeyear Hatch-Waxman extension; this same patent also covers the method of manufacture and its use as an anti-microbial. The FDA granted an additional six months of pediatric exclusivity to Levaquin in 2008 which has extended Levaquin’s patent exclusivity to June 2011 instead of December 2010. In 2010, sales of Levaquin declined to $1.4bn, a contraction of 12.5% on 2009. The entire fluoroquinolones category saw falling sales in 2010, primarily due to the litigations on fluoroquinolones about causing tendon ruptures and other tendon damage particularly in older patients. Levaquin is expected to face further sales erosion after its patent expiry in June 2011. Zyvox (linezolid) – Pfizer Zyvox is an oxazolidinone antibiotic indicated for treatment of resistant gram-positive infections, which account for over 50% of critical bacterial infections. Zyvox, a bacteriostatic, acts by binding on the ribosomal 50S subunit, thus inhibiting protein synthesis. Zyvox was first launched in the US in 2000, and was subsequently launched in other major markets including Japan, France, Germany, Italy, Spain, and the UK in 2001. Zyvox was approved for MRSA in Japan in 2007. Zyvox is one of six drugs approved for MRSA infections, including vancomycin, Cubicin, Tygacil, Vibativ and recently launched Teflaro. Zyvox biggest advantage over competitor products is its 100% oral bioavailability and rapid absorption with no cross-resistance with other antibiotics. This oral/intravenous switching enables physicians to initiate intravenous therapy in the hospital and smoothly transition patients to the oral 35 formulation for out-patient usage, which results in early discharge of patients from hospital, thus saving additional costs associated with extended hospital stays. Moreover, Cubicin’s ineffectiveness in community and hospital acquired pneumonias and increasing resistance to vancomycin in this indication is expected to further strengthen Zyvox’s position in the market. Zyvox was one of the leading brands in the global antibacterial market in 2010 with sales of $1.2bn and Y-o-Y growth of 3.1%. Avelox (moxifloxacin) – Bayer Avelox, a fourth-generation fluoroquinolone with a broad spectrum of activity against gram-positive and gram-negative bacteria, was launched in 1999 in the US and Europe. Bayer markets Avelox in the 7MM except the US while Merck & Co. markets the brand in the US. Avelox can be taken once-daily, for five days for the treatment of acute exacerbation of chronic bronchitis, as opposed to seven-day therapy with BMS’ Tequin (gatifloxacin). Avelox is also indicated for skin and skin structure infections (SSSIs) and can be administered orally and intravenously. The drug inhibits the activity of deoxyribonucleic acid (DNA) gyrase and topoisomerase IV enzymes which are required for the replication of bacterial DNA. The brand had been growing through expanded indications, for instance, in June 2005, Avelox was granted an additional indication for the treatment of SSSIs. In November 2005, the drug was approved for treatment of intra-abdominal infections, further increasing the addressable market opportunity. Avelox had worldwide sales of $984m in 2010, a Y-o-Y sales decline of 1.0%. Avelox sales are expected to decline significantly in the near term primarily due to uptake of generics, particularly after the patent expiry of Levaquin in 2011, in addition to growing safety and resistance concerns surrounding the use of fluoroquinolone drugs due to associated risk of fulminant hepatitis, Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Augmentin (amoxicillin + clavulanic acid) – GSK GSK's Augmentin is an antibacterial drug launched in 1984 in the US. It is a penicillin antibiotic indicated for the treatment of pneumonia, bronchitis, sinusitis and urinary tract, ear, and skin infections. Amoxicillin is a semi-synthetic antibiotic that provides bactericidal activity against a wide range of gram-positive and gramnegative bacteria. However, amoxicillin is also prone to degradation by beta-lactamases and thus it is not 36 active against organisms that produce these enzymes. Clavulanic acid, on the other hand, is a beta-lactam that is structurally similar to penicillins and has the ability to make beta-lactamase enzymes inactive. Clavulanic acid is particularly effective against plasmid-mediated beta-lactamases, a clinically important class that is commonly associated with transferred drug resistance. The combination of clavulanic acid and amoxicillin in Augmentin prevents the degradation of amoxicillin by the beta-lactamase, effectively extending its spectrum to cover even bacteria that are generally resistant to amoxicillin. Augmentin is suitable for adults pediatric patients over 40kgs. Augmentin sales declined by 6.3% to $966m in the year to 2010. Augmentin generated $450m sales from emerging countries in 2010, while the sales from the US were $17m and $371m from Europe. GSK has sold its penicillin manufacturing facility and the US marketing rights of Augmentin to Dr Reddy’s, a generic drug company based in India. GSK will continue to market Augmentin in rest of the geographies except the US. Augmentin’s broad coverage of pathogens, oral availability, and relatively lower price than competitors is driving the growth in emerging markets including BRIC. Tazocin (piperacillin + tazobactam) – Pfizer Tazocin is an intravenous antibiotic combination product consisting of piperacillin (semi-synthetic penicillin) and tazobactam (beta lactamase inhibitor). Tazocin is indicated for the treatment of patients with moderate to severe infections caused by piperacillin resistant, piperacillin/tazobactam-susceptible strains. Tazocin administration is limited to hospital settings as it is only available in an injectable formulation. The drug was developed by Taiho Pharmaceutical in Japan and was in-licensed to Pfizer (then Wyeth) for marketing in the US (Zosyn) and Europe (Tazocin). Tazocin was commercialized in 1994 in Europe. In 2001, Taiho entered into an agreement with Taisho Pharmaceutical to market the drug in Japan. The brand sales were eroded due to generic competition after its patent expiry in 2008. Although, Tazocin is is meeting generic competition, due to formulation differences, marketed generics should not be administered with aminoglycosides for example, according to a safety update by the MHRA. This complication combined with Tazocin’s strong brand in the global antibacterial market will help to protect sales from generic erosion. In 2010, Tazocin generated sales of $952m. 37 Cravit (levofloxacin) – Daiichi Sankyo Cravit is a broad-spectrum fluoroquinolone drug with activity against a wide range of gram-positive and gram-negative bacteria. Cravit is indicated for the treatment of bacterial conjunctivitis, sinusitis, chronic bronchitis, community acquired pneumonia (CAP), pneumonia caused by penicillin-resistant strains of Streptococcus pneumoniae, SSSI, cUTI and acute pyelonephritis. The brand was launched by Daiichi Sankyo in Japan in 1993 and since than the brand has been granted approvals for treating 43 indications and 32 species of bacteria, due to its superior efficacy and safety profile. While the brand was initially approved for oral administration in 100mg dosage, in July 2009, Cravit was approved as a once-daily administration in 500mg for antibacterial treatment. In January 2011, a new intravenous formulation of Cravit was approved in Japan. Daiichi Sankyo is struggling to sustain the market share of Cravit through expanded therapeutic indications. With an aim to penetrate in the ASEAN (Association of Southeast Asian Nations) region, Daiichi Sankyo, granted the marketing rights for Cravit to Ranbaxy in March 2011,. Kyowa Hakko Bio was marketing Cravit in these regions prior to transferring the marketing rights to Ranbaxy. Cravit recorded sales of $820m in 2010, exhibiting 17.5% decline in the sales over previous year. Merrem (meropenem) – AstraZeneca Merrem is a broad spectrum, beta lactamase resistant carbapenem drug developed by Dainippon Sumitomo, and licensed to AstraZeneca. The drug acts by inhibits bacterial cell synthesis. Merrem is indicated for treatment of multiple infections including lower RTIs, UTIs, gynecological infections, bacterial meningitis , septicemia, and complicated/uncomplicated skin and skin structure infections caused by a range of grampositive, gram-negative and anaerobic bacteria. In 2010, Merrim captured 1.9% of the antibacterials market by generating sales of $817m, a Y-o-Y decline of 6.3%. Cubicin (daptomycin) – Cubist Cubicin was approved in September 2003 for the treatment of complicated SSSIs caused by gram-positive microorganisms including both susceptible and resistant strains of S. aureus (MSSA and MRSA). Cubicin 38 was the first of the cyclic lipopeptides drugs, which work by binding bacterial cell membranes and causing depolarization of membrane potential. As a result, protein, DNA, and RNA synthesis is inhibited thus leading to cell death. In May 2006, the FDA approved an expanded label for Cubicin for the treatment of S. aureus bloodstream infections (bacteremia), including right-sided infective endocarditis caused by MRSA and MSSA. In January 2006, Cubicin received approval from the EMEA for the treatment of cSSSIs where the presence of gram-positive bacteria is confirmed or suspected. Prior to approval, Cubist entered a licensing agreement with Chiron for the development and commercialization of Cubicin in the UK. Chiron subsequently launched the product in the UK and the Netherlands in March 2006 and in Germany in April 2006. In December 2006, Cubist licensed development and commercialization rights of Cubicin to AstraZeneca in China and Merck & Co. in Japan. Cubicin will benefit from patent protection in the US through 2019. Although, the launch of new treatment options against MRSA will compete with Cubicin, the brand is well placed to sustain sales until its patent expiry. In August 2010, the FDA revealed the association of intravenous Cubicin with eosinophilic pneumonia and suggested Cubist to include the information in the "Warnings and Precautions" and "Adverse Reactions, Post-marketing Experience" sections of the drug label. In 2010, sales of Cubicin grew by 16.2% on the previous year, reaching $625m. Primaxin (imipenem + cilastatin) – Merck & Co. Primaxin is a potent broad spectrum antibacterial agent for intravenous administration and is indicated for the treatment lower respiratory tract infections, UTIs, intra-abdominal infections (IAIs), gynecological infections, bacterial septicemia, bone and joint infections, SSSIs, endocarditis, and polymicrobic infections. Having been approved in 1985 in the US, the wide-spectrum of antimicrobial activity of has been the key to the Primaxin’s success. The brand sales were growing until 2009 due to absence of generic competition, however, post patent protection sales are eroding radically. Showing a Y-o-Y decline of 11.5%, Primaxin garnered sales of $610m in 2010. Zithromax (azithromycin) – Pfizer Zithromax indicated for the treatment of CAP, was originally developed by Pliva. In 1986, Pfizer aquired exclusive marketing rights for Zithromax in Western Europe and the US. Zithromax was commercialized in 39 1992 in the US and the product’s commercial success had been driven by its broad efficacy, compliance advantages, favorable side-effect profile and a range of formulations that cater to a vast spectrum of the patient population. The blockbuster status of the Zithromax franchise faltered after the patent expiry across all the major markets, having first lost patent protection in the US in November 2005, followed by Japan and the majority of markets in the EU in 2006. In an attempt to extend the lifecycle of Zithromax and to counter the loss in sales due to generic attrition, Pfizer launched Zmax, a one-dose-only azithromycin treatment for mild-tomoderate acute bacterial sinusitis (ABS) and CAP in adults, which was granted approval in the US and EU in June and September 2005, respectively. Despite the transfer of a large proportion of its sales force and marketing expenditure from Zithromax, Zmax has not sold well. Entry of generic azithromycin has also hampered the market penetration of Zmax. High costs coupled with concerns over adverse events such as gastrointestinal complications with once-daily dosing regimen has impacted the brand. Another strategy employed by Pfizer to maintain a share of the azithromycin market was the launch of its own generic azithromycin through its subsidiary, Greenstone. In November 2005, the FDA approved a generic version of azithromycin. While Pfizer’s generic azithromycin may enable the company to retain a comparatively minor share of the macrolide market, sales of the class as a whole are likely to contract due to increasing resistance. In 2010 Zithromax/Zmax generated sales of $415m, a Y-o-Y decline of 3.5%. 40 Resistors of the antibacterial market The antibacterial market has a high level of unmet need. Despite this, most pharmaceutical companies are shifting focus to other therapeutic areas, primarily due to high R&D costs and declining R&D productivity in addition to the uncertainties in the regulatory regime. In response, the FDA and other regulatory bodies are planning to provide incentives for companies investing in antibacterial research. Figure illustrates resistors of the antibacterial market. Figure : Antibacterial market resistors Uncertain regulatory environment Empty pipeline Declining R&D productivity Antibacterial market resistors Antibiotic resistance Rising R&D costs Source: Business Insights BUSINESS INSIGHTS Growing antibacterial resistance The development of antibiotic resistance is a rising global concern in the antibacterial space. Although It creates a opportunities for the drug industry, as new anti-infectives are constantly needed to target resistant organisms, it is very challenging for the companies to discover novel products and new classes of antibiotics for both hospital and community acquired bacterial infections. A major opportunity in antibacterial drug 41 development is in treatment of nosocomial (hospital acquired) infections which are becoming more resistant and are associated with significant mortality and morbidity. Due to the nature of bacterial infections, mutations often rapidly lead to the development of drug resistance bacteria over the course of treatment. Resistance also comes from poor patient compliance and ill-advised use of antibiotics particularly in hospital settings. The three classes of antibiotic-resistant pathogens that are emerging as a major threat globally are: methicillin-resistant Staphylococcus aureus (MRSA) multidrug-resistant (MDR) and pan-drug-resistant (PDR) gram-negative bacteria MDR and extensively-drug-resistant (XDR) strains of Mycobacterium tuberculosis (MDR-TB and XDRTB). Although, gram-negative bacteria are less prevalent than MRSA, they cause infections that are difficult to treat. Although, the strains of Mycobacterium tuberculosis are a growing concern in many emerging counties, the US and other developed countries is also has reported cases of multi drug-resistant tuberculosis (MDRTB) and extensively drug-resistant tuberculosis (XDR-TB). The treatment for these infections lasts for around two years and often causes multiple side-effects. Many national health authorities have launched initiatives to in response to this threat. In April 2011, the Chinese government announced its plans of strict regulation on antibacterial drugs whilst holding hospital authorities to account for any improper use of antibacterial drugs. Roadblocks to attractive antibacterial market Although antibacterials are a potentially attractive market with significant unmet needs, many pharmaceutical manufacturers are restricting themselves from developing antibacterial drugs due to low return of investment as compared with other therapeutic categories. Continuously evolving resistant pathogens not only present a development challenge, they also shorten the lifecycle of any approved product. The cost and complexities involved in antibacterial drug development have shifted the investment focus of big pharma companies from antibacterial to long-term treatment of chronic conditions and vaccines. Moreover, there are many uncertainties and challenges associated with designing the clinical trials for antibacterial drugs. Guidance issued by CDER in November 2010 suggested that trial sponsors re-evaluate ongoing and completed non42 inferiority (NI) trials to ensure that there is adequate scientific basis for the effect size of the active control and the NI margin. This presents a further barrier to approval. This will also be applicable for the clinical trials which have been reviewed. In the backdrop of failure of large investments to discover novel antibacterial drugs most of the pharmaceutical companies have exited from antibacterial research, despite a growing clinical need. Shrinking antibacterial pipeline The antibacterial pipeline is relatively empty with few products in late stages clinical development. In the last three decades only two new classes of antibiotics, oxazolidinones and cyclic lipopeptides, have been introduced. Small biotech and pharmaceutical companies have started to focus on the antibacterial research to fill the void, however the majority of the developmental programs have been out-licensed to multinational companies due to limited financial capabilities of small companies to conduct late-stage clinical trials. Antibacterials present extra challenges for clinical trials, demanding more complex designs, which reduces the attractiveness of the area. As discussed in the following section, high regulatory barriers are also inhibiting the antibacterial pipeline. Challenging regulatory requirements The clinical development of an antibacterial drug differs from other therapeutic categories with respect to the trial design, analysis, and interpretation. There are significant challenges in designing informative, ethical, and scientifically appropriate clinical trials for antibacterial drugs. For the development of an antibacterial drug the sponsor has to conduct non-inferiority trials in comparison with a currently registered antibacterial drugs. Prior to 2001, a delta value of 15% was used to determine non-inferiority, which means that a new drug could be up to 15% lower in efficacy than the reference drug and still be within the lower limit of the 95% confidence interval of the reference products efficacy, and so be deemed non-inferior. Later in 2001, the FDA recommended use of a delta value of 10%. For many trials this necessitated a doubling of the sample size. However, the challenge with 10% delta was that by the time clinical trial ended, the comparator would have changed and the study results will become irrelevant. Following this announcement, most of the companies 43 put their clinical trials on hold which led to the FDA choosing the delta value on a case to case basis. Still the challenge with conducting non-inferiority trials is defining a margin of inferiority to assess the performance of the new molecule. In the absence of clinical data of earlier approved drugs, it becomes even more difficult. Another challenge with conducting clinical trials is enrolling patients, for instance, the requirement of enrolling patients with serious acute bacterial infection is very challenging as the patient may not be willing to wait for treatment to be enrolled in the clinical trials and if the patient is treated with antibiotics before enrollment, it will be difficult to assess the efficacy of the drug being developed. However, to address these challenges, the FDA has recently published regulatory draft guidelines for multiple indications including community acquired bacterial pneumonia, use of non-inferiority trials to support antibacterial approval, hospital acquired bacterial released pneumonia and ventilator associated bacterial pneumonia, and acute bacterial skin and skin structure infections to clarify the regulatory expectations for antibacterial clinical trials. 44 Drivers of the antibacterial market The following figure depicts the major drivers of the antibacterial market Figure : Drivers of the antibacterial market Product lifecycle management through expanding indications and formulations Monoclonal antibodies (mAbs) to combat bacterial infections Combination products Antibacterial market drivers Product differentiation through technological innovations Product development partnerships Source: Business Insights BUSINESS INSIGHTS Product lifecycle management through expanding indications and formulations As the antibacterial market is getting highly competitive, companies are leaving no stone unturned to maximize the profits from the existing drugs. More often, companies are expanding the indications of the drug, or issuing their drugs with a new administration route. In antibacterials, oral to intravenous switching is one of key factors defining the success of the drug. This is primarily because the oral/intravenous switching enables physicians to initiate intravenous therapy in the hospital and smoothly transition them to the oral formulation for out-patient usage, which results in early discharge of patients from hospital, thus saving additional costs associated with extended hospital stays. Physicians also prefer antibiotics which are available in both the forms as they will not have to change the prescription when the patients are discharged from hospital. For example, Daiichi Sankyo announced launch of Cravit intravenous injection in Japan, in 45 January 2011. The oral form of Cravit has been marketed in Japan since 1993 and both oral and intravenous forms were being marketed in other markets including Singapore. Combination products Most of the pharmaceutical manufacturers are developing combination products in an aim to broaden activity spectrum in addition to combating the growing bacterial resistance. Forest Laboratories is developing CAZ104 a combination of ceftaroline and NXL-104, which is presently undergoing Phase II clinical trials for the treatment of cIAI and cUTI. CAZ-104 has a broad spectrum of activity and is claimed to be effective against resistant gram-negative infections, including resistant pseudomonas infections. Forest has acquired the US and Canadian developmental rights to CAZ-104 from Novexel. Cubist is developing CXA-201, a combination of CXA-101 and tazobactam, as the first-line intravenous therapy for the treatment of multiple serious nosocomial gram-negative bacterial infections. CXA-201 is presently undergoing Phase II clinical trials. CXA101 is currently being studied in Phase II trials for the treatment of cUTI, while tazobactam is a betalactamase inhibitor. Product development partnerships Declining R&D productivity and rising costs are exerting pressure on the pharmaceutical manufacturers to enter into collaborative partnership with small biotech and research companies. These small companies usually have strong R&D capabilities but do not have sufficient capital for conducting multicentre late stage clinical trials. Most of these small companies out-license the product after taking it through the early clinical development phase. These agreements usually include one-time payment for obtaining the rights in addition to the milestone payments on completing designated developmental phase and royalties on sales. For instance, GSK entered into research collaboration agreement with Anacor Pharmaceuticals for the discovery, development and commercialization of antibacterial and anti-viral drugs in October 2007. While both GSK and Anacor were responsible for the development of molecules, GSK had an exclusive option to license each compound from preclinical to further development and commercialization of the drug. In July 2010, GSK announced its plan to exercise its option to exclusively develop and commercialize GSK2251052 46 (AN3365), a systemic antibiotic with novel mechanism of action with the potential to be the first new class antibacterial for the treatment of complicated UTIs. Product differentiation through technological innovations In the crowded market of antibacterials, manufacturers have to continuously innovate to differentiate their products from competitors. The innovations could be in the form of a novel mechanism of action, new drug class or technological innovations. In October 2010, Merck & Co. entered into a research collaboration with BioRelix to strengthen its antibacterial research capabilities. The collaboration will enable Merck & Co. to leverage Riboswitch technology, an innovative drug discovery technology, to identify molecules with activity against multiple bacterial targets. One possible avenue of innovation in the field is the use of nanotechnology for the treatment of the resistant pathogens such as MRSA. The Institute of Bioengineering and Nanotechnology and IBM are evaluating the possibility of using nanotechnology for treating bacterial infections. According to the researchers, the new antimicrobial agents will target the infected area for systemic delivery of the drug. Monoclonal antibodies (mAbs) to combat bacterial infections Growing antibiotic resistance and generic competition has led pharmaceutical manufactures to investigate biologics as a development area for antibacterials. There are a significant number of monoclonal antibodies being developed for the treatment of bacterial infections, however the majority of them are still at early stage of development. Although, researches have been going on from a long time to evaluate the potential of antibodies for bacterial infections, there are currently no FDA approved antibacterial monoclonal antibody products. The present pipeline for monoclonal antibody includes products target to target P. aeruginosa and Clostridium difficile. Merck’s Phase II compound MK3415A, being developed as an intravenous formulation for the treatment of C. difficile associated diarrhea, is a combination of MDX1388 and MDX066, two novel fully human monoclonal antibodies of C. difficile Toxin A and Toxin B respectively. Merck is also evaluating Staphylococcus aureus antibodies, which is presently in pre-clinical stage of development. Crucell is evaluating antibacterial antibodies for the treatment and prevention of hospital-acquired bacterial infections 47 using MAbstract technology, which is presently in pre-clinical development. It is believed that mAbs will command a premium price, thus limiting its administration to cases where present treatment is unavailable or against resistant pathogens. Global antibacterial market sales forecast The global antibacterial market is expected to continue witnessing declining sales in the 7MM, however the antibacterial market is expected to exhibited modest growth in the emerging markets particularly BRIC countries. The key brands in the market will continue to face generic competition which will lead to further sales erosion during the forecast period. The global antibacterial market is expected to witness influx of new drugs during 2014–2015. Table : Leading antibacterial brands sale forecast ($m), 2010–16 Brands Sales 2010 ($m) Sales 2011 ($m) Sales 2012 ($m) Sales 2013 ($m) Sales 2014 ($m) Sales 2015 ($m) Sales 2016 ($m) CAGR 2005-09 (%) Levaquin 1,357 347 34 35 34 32 31 -46.8 Zyvox 1,176 1,231 1,255 1,273 1,277 912 614 -10.3 Avelox 984 1,578 1,290 1,309 1,311 944 644 -6.8 Augmentin 966 972 978 982 986 989 991 0.4 Tazocin 952 506 396 325 263 204 178 -24.4 Cravit 820 621 561 506 423 343 268 -17.0 Merrem 817 733 741 749 757 766 773 -0.9 Cubicin 625 716 800 879 947 986 1,010 8.3 Primaxin 610 563 573 571 564 557 544 -1.9 Zithromax 415 397 382 370 359 350 342 -3.2 Others 35,156 36,653 37,748 38,208 38,739 40,033 41,180 2.7 Total 43,877 44,316 44,759 45,207 45,659 46,115 46,576 1.0 Source: PharmaVitae, Business Insights BUSINESS INSIGHTS 48 Chapter 3 Pipeline analysis Summary As commercial opportunity in antibacterials has become progressively more limited due to heightened competition, increasing genericization and comparatively short treatment regimens, the area is attracting reduced R&D funding from big pharma companies. Small pharmaceutical and biotech companies are performing much of the discovery and early development of antibacterials. Typically these are then out-licensed to big pharma companies for further development and commercialization. Community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP) infections are attracting research interest. Additionally, the majority of companies developing new antibiotics are targeting cell wall synthesis inhibitors, DNA topoisomerase II inhibitors, ribosomal inhibitors and methionine tRNA ligase inhibitors. Quinolones continue to lead the antibacterial pipeline due to their broad spectrum of activity followed by the glycopeptides which demonstrate efficacy against MRSA and VRE strains. Of over 199 antibacterial compounds in development, only 28% are in the late stage pipeline (preregistration and Phase III). Regulatory uncertainty in antibacterials is inhibiting investment in pipeline products. 49 Introduction This chapter covers key late-stage pipeline drugs, providing analysis of completed and ongoing clinical trials, with forecast sales through 2016. The chapter also includes key R&D events in the antibacterial market and profiles of key late-stage/recently launched drugs. The antibacterial market is presently witnessing the development of drugs targeting hospital and community acquired bacterial infections to address the unmet need for treating resistant organisms including MRSA and gram-negative infections. Antibacterial pipeline Figure illustrates the global antibacterials pipeline by stage of development. The global antibacterials pipeline represents a key opportunity for pharmaceutical companies, with over 199 compounds believed to be in development. However, only 28% of the total drugs being developed forms a part of the late stage pipeline (Pre-registration and Phase III). The development of innovative drugs is restricted due to the increased genericization in the industry and strict regulatory guidelines, which drives pharmaceutical manufacturers to focus on easy to develop and cost effective drugs. In the extreme examples, the patent protected drugs are even launched only a year earlier or in the year of patent expiry, which results in a major revenue loss to the company developing the drug as its reduces the exclusivity period of the drug. 50 The global antibacterials’ pipeline by stage of development, 2011 Figure : Number of pipeline compounds 100 91 90 80 70 60 50 37 40 25 30 27 20 11 8 10 0 Preclinical Phase I Phase II Phase III Pending approval Approved Phase of development Note: Includes extended indications trials. Source: MedTRACK BUSINESS INSIGHTS Key events in antibacterial R&D Optimer to exploit Cubist’s competitive advantage to market Dificid in the US In April 2011, Optimer announced an exclusive two-year co-promotion deal with Cubist to market Dificid (fidaxomicin) in the US. Dificid, a macrocyclic antibiotic indicated for the treatment of C. difficile infection,is currently being reviewed for approval by the FDA. Optimer will be responsible for obtaining FDA approval, manufacturing, and distribution in the US, while Cubist will deploying its sales force medical affairs team to market the drug in the US. Under the terms of the agreement, Cubist will receive quarterly service fees of $3.8m for two years following the commercialization of Dificid in the US, in addition to $5m in the first year and $12.5m in the second year subject to achieving mutually agreed annual sales targets. Although, Optimer plans to build its own sales force of around 100 sales representatives to target 1,100 hospitals, the collaboration is expected to 51 significantly expand the market reach of Dificid by providing access to over 2,000 hospitals accounting for over 90% of hospital C. difficile cases. Cubist settles patent infringement litigation with Teva over Cubicin In April 2011, Cubist announced the settlement of patent infringement litigation of Cubicin with Teva. Under the settlement Teva will be able to sell a generic version of Cubicin by 2017 (2018, if Cubist obtains a sixmonth extension under pediatric exclusivity rules). However, if any other generics firm enters the market earlier than Teva will be allowed to enter at that time. Cubicin, generated total sales of over $625m in 2010, over 90%of which were in the US. The brand is expected to achieve sales of over $1bn before its patent expiry. In Q1 2009, Teva submitted an ANDA to the FDA for seeking approval to market a generic version of Cubicin. Cubist reacted by filing a patent infringement suit against Teva for US Patent 6,468,967 and 6,852,689 expiring in September 2019 and RE39,071 expiring in June 2016. However, to avoid the risk of losing the court battle, Cubist entered into an agreement with Teva providing rights to market the generic version after patent expiry of Cubicin. Merck & Co. intends to strengthen antibacterial research through BioRelix In October 2010, Merck & Co. entered into a collaboration with BioRelix to strengthen its antibacterial research capabilities. The collaboration will allow Merck & Co. to leverage Riboswitch, an innovative drug discovery technology, to identify molecules with activity against multiple bacterial targets. While both the companies will be responsible for conducting preclinical studies, Merck will undertake the clinical evaluation of the molecules for further development. Under the terms of the agreement, BioRelix will receive an upfront fee and research funding in addition to receiving milestone payments and royalties on any approved products. GSK exercises its option with Anacor to commercialize GSK2251052 In July 2010, GSK announced its plan to exercise the option to exclusively develop and commercialize GSK2251052 (AN3365). GSK2251052 is a systemic antibiotic with novel mechanism of action with the 52 potential to be the first new class antibacterial for the treatment of complicated UTIs, complicated intraabdominal infections, HAP and VAP. In early stage studies, GSK2251052 showed robust activity against multi-resistant gram-negative bacteria without showing any cross resistance to existing antibiotics. Anacor received an option exercise fee of $15m in addition to receiving developmental and commercialization milestone payments apart from royalties on product sales. GSK had entered into research collaboration agreement with Anacor Pharmaceuticals for the discovery, development and commercialization of antibacterial and anti-viral drugs in October 2007. The agreement allowed GSK to utilize Anacor's proprietary boron-based chemistry for use against selected targets. While both GSK and Anacor were responsible for the development of molecules, GSK had an exclusive option to license each compound from preclinical to further development and commercialization of the drug. Contingent on achieving certain milestones, Anacor is eligible to receive development and milestone payments up to $84m in addition to commercial milestones. Zeftera withdrawn following concerns raised by the FDA and the EMA The sale of Zeftera (ceftobiprole), a broad-spectrum antibiotic for the treatment of cSSSIs is being discontinued in Canada following the rejection of the drug by the FDA and the EMA. In 2008 the drug was positively evaluatied by the FDA, however, the regulator later released its negative opinion about Zeftera in 2009 stating its concern over the conduct of the clinical studies. It is believed that the clinical trials were not GCP compliant, which raised concerns over the overall results of the trials. The drug was initially developed by Basilea Pharmaceuticals and licensed to J&J in 2005. However, following the Zeftera’s non-approval, J&J terminated the agreement with Basilea. While the FDA has indicated that Basilea will have to conduct two Phase III trials prior to re-filling the drug for approval, the EMA has not disclosed the requirement of obtaining the marketing authorization. It is expected that it will take more than three years for Zeftera to be available in major markets. Durata Therapeutics initiates Phase III trials for dalbavancin In April, 2011, Durata Therapeutics attained the global rights for the development and commercialization of its lead candidate dalbavancin, an intravenous lipoglycopeptide indicated for the treatment of acute bacterial 53 SSSIs. In December 2009, Durata acquired the rights to develop and commercialize dalbavancin in almost all geographies including North America and the European Union from Pfizer, except Japan, which was acquired from RaQualia in December 2010. In April 2011 Durata initiated a randomized, double-blind, Phase III trial to compare the efficacy and safety of dalbavancin with vancomycin under a Special Protocol Assessment (SPA) in agreement with the FDA,. The SPA demonstrates the FDA’s approval of the trial design. Leading drugs in development The following section analyzes the performance and potential of recently approved and most promising latestage drugs in development for the treatment of various antibacterial infections. The following figure illustrates the key drugs in late-stage development and recently approved status in the antibacterial market. Figure : Selected late-stage and recently launched antibacterials Teflaro Dificid omadacycline delafloxacin TR-701 Radezolid ACHN-490 CXA-201 Phase II Phase III Source: Business Insights Approved/ filed BUSINESS INSIGHTS 54 Profiles of key pipeline products Teflaro (ceftaroline fosamil) – Forest Laboratories/Takeda/AstraZeneca Overview Teflaro is a fifth-generation cephalosporin which was approved by the FDA for the treatment of communityacquired bacterial pneumonia (CABP), and acute bacterial skin and skin structure infections in October 2010. Teflaro is N-phosphono prodrug of ceftaroline, a derivative of a fourth-generation cephalosporin. Forest Laboratories markets the product as Teflaro in the US. In August 2009, Forest Laboratories entered into a definitive agreement with AstraZeneca to co-develop and commercialize ceftaroline in all markets excluding the US, Canada and Japan. The drug is expected to dominate the broad-spectrum market due to its favorable safety and efficacy profile as demonstrated in clinical trials. Table : An overview of Teflaro Brand name Teflaro Generic name ceftaroline fosamil Company Forest Laboratories/Takeda/AstraZeneca Indication Community-acquired bacterial pneumonia and acute bacterial skin and skin structure Mechanism of action Bacterial cell wall synthesis inhibitor Status Approved in the US, pre-registration in EU, Phase III in Japan Source: Business Insights BUSINESS INSIGHTS Clinical Teflaro has been evaluated in a number of trials: two Phase III clinical trials, FOCUS I and II for CABP, and two Phase III clinical trials for cSSSI, CANVAS I and II. Teflaro was found to be well-tolerated in all the clinical trials. Diarrhea, nausea, and rash were the common adverse reactions that occurred in >2% of patients, administered with Teflaro. FOCUS I and II studies evaluated Teflaro for the treatment of moderate to severe CABP. The clinical trials assessed the efficacy, safety, and tolerability of a five to seven day treatment regimen of Teflaro 600mg 55 administered twice daily, in 1,241 patients. While, FOCUS I clinical results demonstrated a clinical cure rate of 86.6% in Teflaro treated group versus 77.7% for ceftriaxone, FOCUS II studies demonstrated a cure rate of 82.1% for the Teflaro treated group versus 77.2% for ceftriaxone treated patients in the clinically evaluable population. Teflaro demonstrated a cure rate of 85.5% in patients infected with Streptococcus pneumoniae, as compared with 68.6% in ceftriaxone treated patients. However, the company has not disclosed the cure rates in MRSA patients. The CANVAS I and II studies evaluated Teflaro in 1,396 adult patients for the treatment of complicated skin infections caused by gram-positive and gram-negative bacteria. Teflaro demonstrated a clinical cure rate of 91.6% as compared with 92.7% in the vancomycin/aztreonam group. Teflaro achieved a favorable tolerability profile with relatively low discontinuation rate of 3.0% as compared with 4.8% for the vancomycin treated patients. Dificid (fidaxomicin) – Optimer Pharmaceuticals/Astellas/Cubist Overview Dificid is a narrow-spectrum macrocyclic antibiotic for the treatment of Clostridium difficile infection (CDI) and prevention of recurrences while used for treating initial stage of C. difficile infection. The infection is a common cause of hospital-acquired diarrhea. Optimer Pharmaceuticals submitted the marketing authorization application to the EMA in July 2010, and filed NDA for Dificid in November 2010. The FDA has granted six-month priority review to Dificid, and assigned a Prescription Drug User Fee Act (PDUFA) goal date of May 30, 2011 for the review. Dificid acts by inhibiting RNA polymerase activity, a bacterial enzyme, which results in the death of C. difficile. In February 2011, Optimer Pharmaceuticals collaborated with Astellas to develop and commercialize Dificid in Europe and few Middle East, Africa and the CIS countries. Under the terms of the agreement Optimer received an upfront payment of €50m ($69.2m) and additional cash payments of €115m after regulatory and commercial milestones. Moreover, the company will also be entitled to receive royalties on sales of Dificid. In April 2011, Optimer Pharmaceuticals announced an exclusive two-year agreement with Cubist to co-market Dificid in the US. 56 Optimer Pharmaceuticals has received a favorable response by the Anti-Infective Drugs Advisory Committee (AIDAC) for Dificid and the drug is expected to be approved by in 2011. Optimer Pharmaceuticals is also developing an oral formulation for pediatric C. difficile infection treatment and treatment of patients in intensive care units and elderly patients. Table : An overview of Dificid Brand name Dificid Generic name Fidaxomicin Company Optimer Pharmaceuticals/Astellas/Cubist Indication Clostridium difficile infection Mechanism of action Bacterial protein synthesis inhibitor, RNA polymerase inhibitor Status Pre-registration in EU Source: Business Insights BUSINESS INSIGHTS Clinical Optimer Pharmaceuticals conducted two multicenter, randomized, double-blind Phase III trials for Dificid. These studies evaluated a primary endpoint of clinical cure and a secondary endpoint of C. difficile recurrence up to four weeks post therapy. In both the trials, Dificid achieved the primary endpoint of clinical cure and demonstrated a lower recurrence rate and higher global cure rate as compared with Vancocin. Collectively both the studies enrolled 1,165 patients with the diarrhea associated with the infection. While, Dificid achieved a cure rate of 91.9% vs. 90.2% for Vancocin, recurrence rates were 13.0% for Dificid and 24.6% for Vancocin, and the global cure rates .were 78.6% for Dificid and 66.4% for Vancocin. Additional data from the second Phase III trial demonstrated significant reduction in recurrence rates and higher global cure rates as compared with Vancocin in both the hyper-virulent BI/NAP1/027 and the non-BI strain subgroups. Adverse events reported were similar for both the drugs. PTK-0786 (omadacycline) - Paratek Pharmaceuticals/Novartis Overview 57 Paratek Pharmaceuticals is developing Omadacycline, a broad-spectrum antibiotic, as a tablet and intravenous infusion under a licensing agreement with Novartis. Omadacycline, currently in Phase III, is being evaluated for the treatment of bacterial infections including cSSSIs, moderate-to-severe CAP, MRSA, multidrug-resistant Streptococcus pneumoniae (MDRSP) and vancomycin-resistant enterococci. Omadacycline acts by inhibiting bacterial protein synthesis and efflux mediated tetracycline resistance. In August 2009, Paratek Pharmaceuticals entered into a collaborative agreement with Novartis to co-develop and market omadacycline worldwide. Under the terms of the agreement, Paratek will be entitled to receive milestone payments and royalties in addition to the upfront payment. Table : An overview of PTK-0786 Generic name omadacycline Company Paratek Pharmaceuticals/Novartis Indication cSSSIs, CABP, MRSA, MDRSP Mechanism of action Bacterial protein synthesis inhibitor Status Phase III Source: Business Insights BUSINESS INSIGHTS Clinical Paratek Pharmaceuticals is conducting a randomized, evaluator-blinded, Phase III clinical trial for omadacycline to compare the safety and efficacy of omadacycline with linezolid for the treatment of adult patients with cSSSIs. In Phase II trials, omadacycline safety and efficacy was studied against Zyvox in patients suffering from cSSSIs. The Phase II study was a multi-center, randomized, investigator-blinded, comparative clinical trial and enrolled 234 patients with cSSSI requiring initial intravenous (IV) therapy. Patients were randomized to receive up to 14 days treatment of either omadacycline 100mg once-daily IV with 200mg once-daily oral step-down or Zyvox 600mg twice-daily IV with 600mg twice-daily oral step-down. Omadacycline achieved the primary safety and tolerability endpoint, and reported no distinct incidence or adverse events with none of the patients discontinuing the treatment with omadacycline. The clinical cure 58 rate of omadacycline treated patients was higher at 98.0% as compared with a clinical cure rate of 93.2% for Zyvox in the clinically evaluable population. RX-3341 (delafloxacin) – Rib-X Pharmaceuticals Overview Delafloxacin is being developed by Rib-X Pharmaceuticals under the licensing agreement with Wakunaga Pharma, for the treatment of cSSSIs. It is a next generation fluoroquinolone and acts by inhibiting the bacterial DNA gyrase. Delafloxacin is presently undergoing Phase III clinical trials, following positive results from its Phase II trials, in which it demonstrated a significantly higher activity against gram-positive organisms, including quinolone-resistant strains and MRSA. The company claims that delafloxacin is 16 times more effective than levofloxacin, ciprofloxacin, gatifloxacin and moxifloxacin against ciprofloxacin resistant MRSA. Rib-X Pharmaceuticals is developing both oral and intravenous formulations of this compound. Table : An overview of RX-3341 Generic name Delafloxacin Company Rib-X Pharmaceuticals Indication Complicated skin and skin-structure infections Mechanism of action Bacterial nucleic acid synthesis inhibitor; DNA gyrase inhibitor Status Phase III Source: Business Insights BUSINESS INSIGHTS Clinical Delafloxacin has been examined in 12 Phase I and three Phase II clinical trials that enrolled 1,300 patients collectively. In both the clinical phases delafloxacin is found to be efficacious and safe. While delafloxacin intravenous formulation demonstrated superior efficacy in Phase II clinical trial for cSSSI as compared with tigecycline, its oral formulation showed no evidence of phototoxicity or QTc prolongation in Phase I studies and demonstrated superior efficacy in both Phase II clinical trials for CAP and bronchitis as compared with levofloxicin. In the Phase II trials delafloxacin achieved a clinical cure rate of 92.5% to 97.2% vs. 91.2% for 59 Tygacil treated patients in the clinically evaluable population. Delafloxacin was found to be safe and well tolerated with lower rates of adverse events. In September 2010, while presenting at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy, Rib-X Pharmaceuticals announced that among multiple studies presented at the conference, delafloxacin demonstrated higher potency at the site of infection as compared with other leading approved drugs including the most difficult to treat fluoroquinolone resistant gram-positive and resistant gram-negative bacteria. TR-701 (torezolid phosphate) – Trius Therapeutics/Dong-A Pharmaceutical Overview Torezolid phosphate, a second generation oxazolidinone is being developed for acute bacterial skin and skin structure infections (ABSSSI), in both intravenous and oral formulations. Torezolid phosphate is chemically different from first generation oxazolidinones reportedly having higher efficacy and a broader spectrum of activity against serious gram-positive infections, including MRSA. Presently, linezolid is only marketed first generation oxazolidinone for serious gram-positive infections. The clinical studies suggests that torezolid phosphate will present strong competition to linezolid, due to its higher efficacy, convenient dosing, shorter duration of therapy, lower frequency of resistance, activity against linezolid-resistant bacterial strains and fewer drug interactions. Trius has plans to develop torezolid phosphate for treatment of multiple indications, including ABSSSI, CABP, HAP, ventilator acquired pneumonia (VAP) and bacteremia. Trius is also conducting non-inferiority clinical trials in its Phase III studies in compliance with the new protocols outlined in the FDA draft guidelines for ABSSSI. While, Dong-A Pharmaceutical is developing the drug in Korea, Trius has the worldwide developmental and commercialization rights to torezolid phosphate. 60 Table : An overview of TR-701 Generic name torezolid phosphate Company Trius Therapeutics/Dong-A Pharmaceutical Indication Acute bacterial skin and skin structure infections Mechanism of action Bacterial cell wall synthesis inhibitor Status Phase III Source: Business Insights BUSINESS INSIGHTS Clinical Trius is currently conducting Phase III clinical trials for the treatment of cSSSI infections, following the favorable results from Phase II trials completed in June 2009. In August 2010, Trius initiated its Phase III study for torezolid phosphate to evaluate the safety and efficacy of 200mg oral dose once daily for six days of treatment as compared with oral 600mg Zyvox twice daily for 10 days for the treatment of ABSSSI, a new classification for cSSSI. Trius is also conducting a special populations study and a study to assess the PK, safety, and tolerability of TR-701 FA and its active metabolite in adolescents. The primary endpoint measure was the cessation of spread of skin lesions and absence of fever in 48 to 72 hours. The aim of the trial was also to evaluate non-inferiority in six day oral torezolid phosphate treatment as compared with that oral 10 day linezolid treatment at 48 to 72 hours. Trius plans to develop the intravenous formulation of torezolid in ABSSSI, and oral and intravenous formulations for the treatment of CABP, HAP, VAP, bacteremia, and osteomyelitis. The Phase II clinical study enrolled 180 patients and evaluated the safety, tolerance, and efficacy of 200mg, 300mg, and 400mg doses of torezolid phosphate once-daily for five to seven days of treatment. Torezolid phosphate achieved clinical cure rates of 98% for the 200mg dose, 94% for the 300mg dose, and 94% for the 400mg dose, in the clinically evaluable population. The drug achieved clinical cure rates of 100% when treated with 200mg dose, 93% with 300mg dose, and 95% with 400mg dose. All the dosage of torezolid 61 phosphate were found to be well tolerated, however some adverse events such as nausea, diarrhea, vomiting, and headache were also reported. RX-1741 (Radezolid) – Rib-X Pharmaceuticals Overview Radezolid, a novel oxazolidinone antibiotic, is being developed by Rib-X Pharmaceuticals for the treatment of CAP and uncomplicated skin and skin-structure infections (uSSSI). The drug which is being developed in both oral and intravenous formulation has a broad spectrum of coverage with increased activity against gram-positive organisms as compared with other oxazolidinones. Radezolid uses Rib-X’s proprietary antibiotic discovery process with an aim to achieve broader bacterial spectrum and increased activity against gram-positive bacteria. Presently, Zyvox (linezolid) is the only marketed oxazolidinone worldwide. Radezolid is expected to present strong competition to Zyvox, as it has demonstrated a superior microbiological activity than linezolid against gram-positive bacteria, including potent activity against linezolid resistant bacteria in the clinical trials. Table : An overview of RX-1741 Brand name Radezolid Generic name Radezolid Company Rib-X Pharmaceuticals Indication Community-acquired pneumonia and uncomplicated skin and skinstructure infections Mechanism of action Bacterial cell wall synthesis inhibitor Status Phase II Source: Business Insights BUSINESS INSIGHTS Clinical Radezolid, which is being developed in both oral and intravenous formulations, has completed two Phase II clinical trials for the treatment of CAP and uSSSI. In the Phase II multicenter randomized double-blind clinical trial, radezolid was studied to evaluate the safety and efficacy for the treatment of mild to moderate CAP. The study which enrolled 160 patients, administered three different oral doses of the drug: 300 mg once 62 daily, 450 mg once daily and 450 mg twice daily for seven to 10 days. Radezolid achieved comparable efficacy across all three doses, with clinical cure rates of 78% to 92% in the clinically evaluable population and superior activity against multiple CAP bacteria. In October 2008, Rib-X Pharmaceuticals announced the results from a Phase II clinical trial of radezolid for the treatment of uSSSI at the 48th ICAAC Infectious Diseases Society of America (IDSA) annual meeting. The multicenter, randomized, open label, comparative study which enrolled 150 patients evaluated the safety and efficacy of radezolid in comparison with linezolid for the treatment uSSSI. The open label trial met both its primary and secondary endpoints. In the poster presentation the company reported the clinical cure rates of radezolid as 97.4% at a dosage of 450 mg once daily; 94.4% at a dosage 450 mg twice daily; and 97.4% for patients treated at a dosage of 600 mg twice daily in the clinically evaluable population. ACHN-490 – Isis Pharmaceuticals/Achaogen Overview ACHN-490, a broad spectrum second-generation aminoglycoside, is being developed for the treatment of multi-drug resistant gram-negative bacterial infections. ACHN-490 acts by inhibiting bacterial protein synthesis and uses aminoglycoside technology licensed from Isis Pharmaceuticals. In clinical trials, ACHN490 demonstrated broad-spectrum activity against multi-drug resistant gram-negative bacteria, including E. coli and MRSA. In January 2006, Isis Pharmaceuticals entered into an agreement with Achaogen to develop and commercialize ACHN-490 worldwide. Under the terms of the agreement, Isis Pharmaceuticals received an upfront payment of $1.5m of Achaogen stock, and a milestone payment of $1m in 2009, of which $0.5m in cash and $0.5m in Achaogen securities. In addition, Isis Pharmaceuticals will receive total milestone payments of $33.5m following the completion of key clinical, regulatory and sales milestones. The company will also receive royalties on sales of drug following its approval. 63 Table : An overview of ACHN-490 Brand name - Generic name - Company Isis Pharmaceuticals/Achaogen Indication Methicillin-resistant Staphylococcus aureus Mechanism of action Bacterial cell wall synthesis inhibitor Status Phase II Source: Business Insights BUSINESS INSIGHTS Clinical In September 2009, Achaogen completed a Phase I study on ACHN-490 and initiated Phase II study in August 2010. ACHN-490 demonstrated broad spectrum activity against multi-drug resistant gram-negative bacteria in the in-vitro and in-vivo studies. An international double-blind randomized comparator-controlled Phase II study is being conducted to evaluate ACHN-490 for the treatment of complicated urinary tract infections (cUTI). The study, which was initiated in March 2010, aims to enroll 225 patients. The primary endpoint will be to evaluate the microbiological eradication in modified intent to treat population and microbiologically evaluable population, while the secondary endpoint will be to assess the clinical cure rate in cUTI.. Patients will be administered intravenous ACHN-490 at two different doses and compared with patients receiving a standard approved intravenous treatment for cUTI/acute pyelonephritis (AP). Patients with a clinical diagnosis of cUTI/AP will be randomly assigned to any one of three treatment regimens. The study is expected to be completed by November 2011. CXA-201 (CXA-101/tazobactam) – Cubist Pharmaceuticals Overview CXA-201, a combination of CXA-101 and tazobactam, is being developed as a first-line intravenous therapy for the treatment of certain serious gram-negative bacterial infections prevalent in hospitals, including multidrug resistant (MDR) Pseudomonas aeruginosa. The company believes that the broad spectrum and activity 64 against resistant P. aeruginosa strains will differentiate CXA-201 from currently marketed drugs and compete heavily with Zosyn. CXA-201 was added to Cubist pipeline following the acquisition of Calixa Therapeutics in December 2009. The acquisition gave Cubist the rights to develop and commercialize Calixa’s lead compound, CXA-201, and other products including CXA-101 (under license from Astellas Pharma) worldwide except select Asia-Pacific and Middle East countries. Table : An overview of CXA-201 Brand name - Generic name - Company Cubist Pharmaceuticals Indication Complicated urinary tract infections, complicated intra-abdominal infection, nosocomial pneumonia Mechanism of action Bacterial cell wall synthesis inhibitor Status Phase II Source: Business Insights BUSINESS INSIGHTS Clinical Cubist is presently conducting Phase II clinical trials of CXA-201 for the treatment of cUTIs and complicated intra-abdominal Infections (cIAI), and Phase I clinical trials for nosocomial pneumonia (NP). The regulatory uncertainty on clinical trials requirements for nosocomial pneumonia indication has pushed it behind the cUTI and cIAI indications. In June 2010, Cubist initiated a multicenter double-blind randomized Phase II study enrolling 120 patients, to compare the safety and efficacy of intravenous CXA-201 with an active comparator in patients with cIAI. Cubist aims to file a New Drug Application for CXA-201 by mid 2013. Pipeline forecast to 2016 Apart from three compounds, most of the pipeline compounds are expected to be launched after 2013. Business Insights analysis indicates that ceftaroline fosamil and CXA-201 will take a lead over other pipeline 65 drugs by 2016, as these drugs have potential to satisfy key unmet need and have shown higher efficacy against resistant bacteria. Table : Sales forecast for leading drugs in development ($m), 2010–16 Compounds Generic Sales 2011 ($m) Sales 2012 ($m) Sales 2013 ($m) Sales 2014 ($m) Sales 2015 ($m) Sales 2016 ($m) Teflaro ceftaroline fosamil 50 120 200 260 325 426 Dificid fidaxomicin – 25 80 95 125 160 PTK-0786 omadacycline – 20 90 150 180 200 RX-3341 delafloxacin – – – – 70 100 TR-701 torezolid phosphate – – – 75 125 111 CXA-201 CXA-101/tazobactam – – – 45 135 253 Source: Business Insights BUSINESS INSIGHTS 66 Chapter 4 Competitive landscape Summary GSK’s antibacterial franchise recorded sales of $2.2bn (£1.4bn) in 2010 (a Y-o-Y decline of 4.4%), accounting for 6.0% to the company’s revenues in 2010. GSK is adopting a competitive pricing strategy to drive growth in emerging markets. With the reduction in Zinnat prices by 22% in first quarter of 2010, GSK has reportedly doubled sales volume of in East Africa. Zyvox was Pfizer’s leading antibacterial product with 2010 sales of $1.2bn followed by Tazocin ($952m) and Zithromax/Zmax ($415m). Aiming to reduce costs, Pfizer plans to shift its antibacterial research from US to China. Of Merck & Co.’s antibacterial products, Avelox and Invanz will to continue to grow strongly patent expiries in 2013 and 2015 respectively. Primaxin will continue to decline in sales. Due to the high number of blockbuster off-patent compounds, Novartis is expected to continue pursuing an aggressive generics development strategy for its antibacterial franchise. Due to the anticipated sales erosion of Levaquin (levofloxacin), after its patent expiry in June 2011, Johnson & Johnson shifted its focus on developing US market with Doribax by expanding the drugs indication to nosocomial infections. 67 Introduction This chapter focuses on the performance of the five leading players in the global antibacterials market in 2010. It also provides a detailed description of each company's financial performance, key marketed products, R&D focus and strategic growth analysis. GlaxoSmithKline Overview GSK is a research-based pharmaceutical company, engaged in the manufacture and marketing of prescription drugs and vaccines. Its prescription drugs range across various therapeutic categories including anti-infectives, dermatology, women’s health, diabetes, cardiovascular disease, central nervous system conditions, and respiratory diseases. The company was incorporated in 1999 and is headquartered at London. GSK is present in over 100 countries through its subsidiaries and most of its research activities are conducted from its facilities in the UK, US, Belgium and China. In 2010, GSK was the one of the leading companies in the global antibacterial market with 2010 sales of $2.2bn (£1.4bn). GSK’s antibacterial portfolio showed a Y-o-Y decline of 4.2% in 2010. The decline was primary due to decline in sales of Augmentin, GSK’s flagship antibacterial brand, which accounted for 44.8% of the total antibacterial sales of GSK in 2010. Augmentin was heavily impacted by the generic competition and garnered sales of $966m (£625m) at a Y-o-Y decline of 6.3% in 2010. Financial performance In 2010, GSK achieved total sales of $36.2bn (£23.4bn), a Y-o-Y decline of 1.3%. This decline can be attributed to revenue lost to generic competition. In 2010, GSK’s antibacterial franchise recorded sales of $2.2bn (£1.4bn), a Y-o-Y decline of 4.4%. The therapeutic area accounted for 6.0% to the total company’s revenues. GSK’s antibacterial business is heavily dependent on the emerging markets, from where it generated 43.6% of its sales in 2010. Europe with 2010 sales of $829m (£536m) and a contribution of 38.4% remained the other important region for the company. GSK’s antibacterial portfolio demonstrated a decline in 68 sales in all the regions, primarily due to lack of patented products and intensified generic competition. However, the decline was significantly higher in the US as compared with Europe and emerging markets. Augmentin, the key product in GSK’s antibacterial portfolio, accounted for 44.8% of the total antibacterial sales with revenues of $966m (£625m) in 2010. Although, Augmentin also demonstrated a decline in sales in all the regions in 2010, its relatively lower cost than other branded peers, and strong physician brand awareness was instrumental in making it one of the leading antibacterial products particularly in emerging countries. Marketed product portfolio GSK’s marketed product portfolio is extensive and features a range of products, the majority of which are positioned for continued sales growth. GSK's portfolio in the global antibacterial market is led by Augmentin, a broad-spectrum penicillin antibiotic, however the brand demonstrated a negative Y-o-Y growth of 6.3% in 2010. Other key antibacterial products in the GSK portfolio include Zinnat, Altabax, Fortum and Amoxil. Table : GSK's leading antibacterial products ($m), 2010 Product Generic Sales 2010 Sales growth 2010 (%) CAGR 2006–10 (%) Augmentin amoxicillin + clavulanate 966 -6.3 2.3 Zinnat aefuroxime 202 -4.3 -5.4 Fortum aeftazidime 147 -13.7 -13.6 Amoxil amoxicillin 124 -0.6 -0.7 Altabax retapamulin ointment 24 20.3 – Source: Company reports, PharmaVitae BUSINESS INSIGHTS Augmentin (amoxicillin + clavulanate) GSK's Augmentin is an antibacterial drug launched in 1984 in the US. It is a penicillin antibiotic indicated for the treatment of pneumonia, bronchitis, sinusitis and urinary tract, ear, and skin infections. Amoxicillin is a semi-synthetic antibiotic that provides bactericidal activity against a wide range of gram-positive and gramnegative bacteria. The combination of clavulanate and amoxicillin in Augmentin prevents the degradation of 69 amoxicillin by beta-lactamase, effectively extending its spectrum to cover even bacteria that are generally resistant to amoxicillin. Although, Augmentin can be consumed at any time, absorption of clavulanate potassium is relatively higher when taken along with food than the fasted state. Augmentin is suitable for adults as well as pediatric patients over 40kg in weight. Augmentin recorded sales of $966m (£625m) globally. Most of these sales came from emerging markets ($450m), and Europe ($371m). 2010 US sales were $17m. The brand has been thriving in the emerging markets owing to its strong brand name and competitive pricing. In first quarter of 2010, GSK reduced the prices of its antibacterial products particularly Augmentin by around 50% in the emerging countries including Brazil, China, India, Indonesia and Thailand, which increased sales volumes in these geographies. Zinnat (cefuroxime) Zinnat is an oral pro-drug of cefuroxime, a second generation cephalosporin antibiotic. It is a broad spectrum antibiotic with activity against a range of gram-positive and gram-negative bacteria and acts by inhibiting the synthesis of the bacterial cell wall. Zinnat is indicated for the treatment of a wide range of respiratory infections including tonsillopharyngitis, sinusitis, otitis media, and pneumonia in addition to uncomplicated UTIs, complicated UTIs, SSTIs, acute uncomplicated gonorrhoea and Lyme disease. It is suitable for adult and patients and pediatric older than three months. Zinnat is found to be resistant to numerous betalactamases produced by bacteria which cause penicillin resistance. The main markets for Zinnat are China, Turkey, Spain, Poland, Greece, Germany, Romania, Vietnam, Philippines, UAE and Saudi Arabia. Zinnat’s principal competitors are second-generation cephalosporins such as BMS’ Cefzil. The majority of these are generic, causing Zinnat to be sold in a price-sensitive market. Zinnat, on account of its intramuscular formulation also competes with Roche’s Rocephin, which is viewed to be the gold standard Injectable cephalosporin treatment against which Zinnat suffers from an inferior dosing schedule. Opportunities for Zinnat remain limited owing to widespread generic competition and new generation cephalosporins. However, GSK is adopting a competitive pricing strategy to drive the growth of Zinnat in least developed countries. For instance in East Africa GSK reduced the prices of Zinnat by 22% in the first 70 quarter of 2010 to drive sales growth and the price reduction is believed to have doubled sales volumes of Zinnat in East Africa. Altabax (retapamulin ointment) Altabax, a pleuromutilin antibacterial, is indicated for the treatment of impetigo caused by Staphylococcus aureus or Streptococcus pyogenes and is suitable for use in patients aged nine months or older. Altabex was approved in 2007 in the US and Europe and is marketed as Altargo in Europe. Altabex, is a new class of antibiotic that acts by inhibiting bacterial protein synthesis by binding to the 50S subunit of the bacterial ribosome thus making it inactive. Altabax has shortened the therapy duration and frequency of application in and is required to be used twice daily for a five-day period while other prescription topical antibacterials are used three times daily for up to 12 days. Moreover, it does not show any cross-resistance to other established classes of antibacterials. Although, Altabax demonstrated a strong uptake in the first year of launch achieving sales of $17m (£11m), it faced intense competition in the topical antibiotic market against multiple generic competitors, including generic mupirocin and fusidic acid. In April 2010, GSK received a warning for Altabax for its misleading promotional literature which indicated a broader indication, in addition to superiority claims and minimized important risk information. Research and development GSK’s research activities are carried out of its centers located in the UK, US, Belgium and China. The company has 13,000 employees in R&D, of whom 85% work in pharmaceutical R&D. In 2010, GSK invested 15.7% of the net revenues to R&D activities. Although the company has a robust pipeline with over 30 late stage compounds, most of its pipeline antibacterial products are in early stage of clinical investigations. Table details GSK’s antibacterial R&D pipeline. 71 Table : GSK’s antibacterial R&D pipeline, February 2011 Compound Mechanism of action Phase GSK1322322 Polypeptide deformylase inhibitor II GSK2251052 Leucyl t-RNA synthetase inhibitor (oral & iv) I Source: Company reports BUSINESS INSIGHTS GSK1322322, currently in Phase II, is a novel class antibacterial compound which is being developed in oral formulation for the treatment of bacterial skin and skin structure infections. It acts by inhibiting bacterial peptide deformylase (PDF) function. In January 2011, GSK completed a randomized double-blind multicenter Phase IIa to assess safety, tolerability and efficacy of GSK1322322 vs linezolid for the treatment of acute bacterial skin and skin structure infections. GSK is developing GSK2251052 under license from Anacor Pharmaceuticals. GSK2251052 is a novel boron-based, small-molecule candidate that targets the bacterial enzyme leucyl tRNA synthetase. The compound is being developed for the treatment of cUTI, complicated intra-abdominal infections, HAP and ventilator associated pneumonia (VAP). In pre-clinical studies GSK2251052 demonstrated robust activity against multi-resistant broad range of gram-negative bacteria, including E. coli, Klebsiella pneumoniae, Citrobacter spp, Serratia marcescens, Proteus vulgaris, Providentia spp, Pseudomonas aeruginosa and Enterobacter spp. Moreover, it did not show any cross resistance to existing classes of antibiotics. Strategic and growth analysis Drivers GSK2251052 described above could provide a large boost for the company, given that it would represent the first in a new class of antibacterial drugs 72 GSK’s sale of penicillin manufacturing site in Bristol and divestiture of Augmentin and Amoxil in the US to Dr Reddy’s would enable GSK to divert its resources and efforts on growing these brands in emerging geographies. While, Augmentin saw sales erosion in the US after its patent expiry, the product’s sales are growing in Europe and emerging countries. The company is expected to drive sales in the emerging markets through aggressive pricing. Resistors Generic competition to major antibacterial brands remained the key impediment to growth of the company’s antibacterial portfolio as a whole, with generic versions of Augmentin, a major blockbuster product exerting a drag on continued growth. Scrutiny of Altabax for misleading promotional literature described above may be detrimental in the growth of the brand which is already facing intense generic competition. A further resistor is that company does not have any late stage compounds in its antibacterial pipeline. Pfizer Overview Pfizer, a global biopharmaceutical company, is engaged in the discovery, development, manufacture and marketing of prescription medicines, vaccines, nutritional and consumer health products for humans and animals. The company primarily has two operating business segments including Biopharmaceutical and Diversified. The Biopharmaceutical segment includes five customer-focused units including, primary care, specialty care, oncology, established products, and emerging markets. The Diversified segment includes animal health, consumer healthcare, nutrition and capsugel. Following the acquisition of Wyeth in October 2009, the specialty care customer-focused unit expanded to include vaccines. Pfizer is realigning its business operations to better identify and address local market dynamics and customer needs. In 2010, Pfizer generated sales of $67.8bn, including revenue generated through products formerly belonging to Wyeth. Cardiovascular and metabolic diseases products were the highest contributor to Pfizer’s total revenues in 2010. Following the acquisition of Wyeth in 2009, the company changed its business unit structure and antibacterials became a part of the Biopharmaceutical segment. 73 Financial performance In 2010, the biopharmaceutical segment generated sales of $58.5bn, 28.8% growth over 2008, while the overall revenues were $67.8bn. This also includes the revenues generated from Wyeth’s operations. Pfizer’s four key antibacterial products collectively generated sales of $2.9bn in 2010. Zyvox was the leading antibacterial product with 2010 sales of $1.2bn followed by Tazocin and Zithromax/Zmax which generated sales of $952m and $415m respectively in 2010. Marketed product portfolio Pfizer’s marketed antibacterial product portfolio is overwhelmingly built on the successful antibacterial brands from Wyeth’s portfolio. Pfizer’s antibacterial franchise was heavily dependent on Zithromax, however after its patent expiry the brand sales showed significant decline due to generic competition. To compensate the loss Pfizer also released a generic version of azithromycin across several markets and launched Zmax, a onedose-only azithromycin treatment for mild-to-moderate acute bacterial sinusitis (ABS) and CAP in adults. Table : Pfizer's leading antibacterial products ($m), 2010 Product Generic Sales 2010 Sales growth 2010 (%) CAGR 2006–10 (%) Zyvox linezolid 1,176 3.1 10.7 Tazocin* piperacillin + tazobactam 952 417.4 -0.5 Zithromax/Zmax azithromycin 415 -3.5 -10.2 Tygacil* tigecycline 152 232.7 – Note: *Wyeth products, only Pfizer 2009 sales included. Source: Company reports, PharmaVitae BUSINESS INSIGHTS Zyvox (linezolid) Pfizer’s Zyvox (linezolid) was initially approved in the US in April 2000 for the treatment of cSSSIs and nosocomial pneumonia, including those caused by MRSA. Zyvox inhibits protein synthesis through binding to the ribosomal 50S subunit. In December 2002, Zyvox was approved for use in paediatric patients and subsequently received approval for diabetic foot infections in July 2003. Marketed in Japan since 2001 for 74 the treatment of infections associated Vancomycin Resistant Enterococcus (VRE), Zyvox received approval for an additional indication in April 2006 for the treatment of infections associated with MRSA. This labelling extension is expected to further contribute to the strong sales growth of Zyvox across the major pharmaceutical markets. Zyvox is available in interchangeable intravenous and oral formulations and currently the only drug available in both forms for MRSA. The oral formulation of the drug has 100% bioavailability bringing an advantage over other drugs which are only available in an intravenous formulation. Physicians also prefer Zyvox over other available drugs as its availability in both oral and intravenous formulation provides a smooth transition from intravenous administration in hospitals to oral for out-patient usage. In 2010, Zyvox registered sales of $1.2bn, an increase of 3.1% over previous year, primarily due to growth in emerging markets and Europe. However, the sales in the US were negatively impacted by stagnant market growth and intense generic competition. Tazocin/Zosyn (piperacillin + tazobactam) Tazocin is an intravenous antibiotic combination product consisting of piperacillin (semi synthetic penicillin) and tazobactam (beta-lactamase inhibitor). Tazocin is indicated for the treatment of patients with moderate to severe infections caused by piperacillin resistant, piperacillin/tazobactam-susceptible strains of indicated organisms. Tazocin administration is limited to hospital settings as it is only available in an injectable formulation. At the time of its launch, Tazocin was administered as a six times daily intravenous infusion for the treatment of hospital acquired pneumonia. In 2003, the FDA approved a new dosage regime for Tazocin which involved a four times daily requirement for the intravenous infusion. This reduction of two doses resulted in lowering of costs for hospitals in addition to an increase in convenience and comfort for patients. Fluroquinolones such as moxifloxacin which have demonstrated equivalent efficacy in the treatment of complicated intra abdominal infections (cIAI) with lower dosing regimens, multiple dosing remains one of the major disadvantages for Tazocin. Moreover, the brand sales have been eroded due to intensified generic competition since patent expiry in 2008. Although, Tazocin is expected to encounter generic competition, it will continue to be a strong brands in the global antibacterial market, primarily due to limited compatibilities of 75 the generics with other drugs in comparison with Tazocin and strong brand recognition. In 2010, the brand recorded sales of $952m. Zithromax/Zmax (azithromycin) Zithromax is indicated for the treatment of CAP and the product’s success can be attributed to its broad spectrum, compliance advantages, favorable side-effect profile and a range of formulations that cater to a vast range of the patient population. However, Zithromax sales started to decline after its expiry across all the major markets in 2005 and 2006. With an aim to extend the lifecycle of Zithromax and counter the loss in sales due to generic competition, Pfizer launched Zmax, a one-dose-only azithromycin treatment for mild-tomoderate acute bacterial sinusitis (ABS) and CAP in adults, which was granted approval in the US and EU in June and September 2005, respectively. Despite this, Zmax could achieve limited market penetration due to the availability of cheaper generic versions of azithromycin. Pfizer launched its own generic azithromycin through its subsidiary, Greenstone. While Pfizer’s generic azithromycin enabled the company to retain a comparatively minor share of the macrolide market, the macrolide class as a whole has been declining due to increased resistance. Zithromax/Zmax generated sales of $415m, a Y-o-Y decline of 3.5% in 2010. The brand still accounted for 3.5% of the total antibacterial market in 2010. Tygacil (tigecycline) Tygacil, a former Wyeth product, was the first market entrant in a new class of antibiotics, the glycylcyclines, and received FDA approval in May 2005 in the US and in May 2006 in the Europe. It was initially approved as a single-agent, intravenous therapy for the treatment of cIAI and cSSSI but was granted approval for treatment of CABP in adults in March 2009. While Tygacil as a glycylcycline, a new class of tetracyclines, the drug is a semi-synthetic derivative of minocycline and has demonstrated potent activity against tetracyclineresistant gram-positive and gram-negative pathogens. Due to its unique structure, which enables it to bind 30S ribosomal unit and inhibit protein translation, Tygacil is unaffected by ribosomal alteration and efflux, the two major mechanisms of tetracycline resistance. As such Tygacil has a broader spectrum of activity than traditional tetracyclines. 76 However, concerns have ben raised over the increased mortality risk as compared with other drugs which are being used to treat various serious complications. In September 2010, Pfizer updated the warnings and precautions and adverse reactions sections of the label following the FDA warning pertaining to the increased risk of mortality associated with Tygacil. This was later acknowledged by the EU's CHMP and suggested that the product should be administered only for the treatment of cIAI and cSSSI, and used when other antibiotics are unsuitable, while closely monitoring patients for the development of superinfections, specifically pneumonia. In 2010, the product generated sales of $324m, however, the unfavorable safety profile is expected to negatively impact product sales in the near term. Research & development In 2010, Pfizer’s R&D spending was $9.4bn, an increase of 20% over 2009. By the end of 2010 the company had 24 compounds in Phase III. Apart from developing new products, Pfizer’s research activities are also focused on improving the effectiveness of the existing products and discovering expanded indications. Pfizer’s late-stage antibacterial pipeline includes two products: Tygacil which is in Phase II trials for bacterial pneumonia and moxidectin which is in a Phase III trial for onchocerciasis. The company is planning to shift its antibacterial research team from the US to China, primarily to reduce costs. Pfizer intends to improve its margins through reduced labor and infrastructure costs in China. Strategic and growth analysis Drivers Zyvox is the one among the six MRSA drugs to be approved for the treatment for severe bacterial infections. An additional advantage is its availability in both oral and intravenous formulation for the treatment of community acquired and hospital acquired pneumonias. The acquisition of Wyeth has also strengthened Pfizer position in the antibacterial market, with the addition of Tazocin and Tygacil in the antibacterial portfolio. Pfizer intends to penetrate in the antibacterial market through expanding indications of its existing products and through the introduction of new formulations. In November 2010, Pfizer introduced PrZmax SR in 77 Canada, a new antibiotic formulation with once-daily treatment regimen for acute bacterial sinusitis, acute bacterial exacerbations of chronic bronchitis and mild CAP. Resistors Zithromax sales are rapidly declining following the launch of generics in the market. Pfizer’s Zithromax brand franchise including Zmax recorded a negative CAGR of 10.2% during between 2006 and 2016. Zyvox has however been at the centre of safety concerns, which showed that Pfizer’s product was associated with an increasing level of mortality over a range of comparator treatments. Given that Zyvox is being positioned for an indication with severe unmet need that of bloodstream infections, in which mortality is already high, the negative findings may be detrimental for Zyvox brand equity. Pfizer has lost developmental rights of dalbavancin, a novel lipoglycopeptide with activity against grampositive bacteria, to Durata Therapeutics. Durata has initiated the Phase III clinical trials for the drug. Pfizer’s weak antibacterial pipeline coupled with the loss of dalbavancin is expected to inhibit the growth of Pfizer’s antibacterial portfolio in the long-run. Johnson & Johnson Overview Johnson & Johnson (J&J), incorporated in New Jersey in 1887, is involved in the research and development, manufacturing and sale of healthcare related products. It operates through three business segments, namely consumer, pharmaceutical, and medical devices and diagnostics. The consumer segment primarily includes baby care, oral care, skin care, wound care and women's healthcare, as well as nutritional and OTC pharmaceutical products. The pharmaceutical segment comprises products ranging across multiple therapeutic categories including anti-infectives, antipsychotics, contraceptives, cardiovascular products, and anti-virals. The pharmaceutical products are distributed directly to retailers, wholesalers and health care professionals for prescription use. The Medical devices and diagnostics segment includes products which are primarily used by physicians, nurses, therapists, hospitals, diagnostic laboratories and clinics. With over 250 operating companies, J&J is present in almost all the countries across the globe. 78 Financial performance In 2010, J&J reported total sales of $61.6bn, a decline of 1.3% on 2009. This decline can be attributed to the sales lost due to OTC product recalls and prevailing generic competition in the pharmaceuticals segment. The antibacterial franchise showed declining sales due to the sales erosion of J&J’s flagship product Levaquin, which witnessed a sharp decline of 12.4% in 2010. The decline is primarily due to higher penetration of generics in the US market as compared with other developed regions. Levaquin sales are concentrated in the US market, which accounted for over 95% of sales in 2010. Marketed product portfolio J&J’s antibacterial franchise is relatively mature with few products retaining patent exclusivity. Revenue generation of J&J’s antibacterial franchise hinges heavily upon the performance of Levaquin (levofloxacin). J&J’s doripenem, originally developed by Japanese drug major Shionogi pharmaceuticals, was approved by the FDA under the brand name Doribax for the treatment of complicated urinary tract and intra-abdominal infections in October 2007 and has demonstrated a rapid uptake from the first year of its launch. Table : J&J's leading antibacterial products ($m), 2010 Product Generic Sales 2010 Sales growth 2010 (%) CAGR 2006–10 (%) Levaquin levofloxacin 1,357 -12.5 -3.0 Doribax doripenem 215 147.3 – Source: Company reports, PharmaVitae BUSINESS INSIGHTS Levaquin (levofloxacin) Levaquin is the flagship antibacterial brand of J&J and contributed around 2% to the total sales of the company in 2010. The brand sales were driven by several differentiated indications, particularly multi-drug resistant strains of CAP, acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, nosocomial pneumonia, complicated skin infections, pyelonephritis and prostatitis. The product which is available as an oral solution, tablet, and intravenous formulation is covered by a composition-of-matter 79 patent through December 20, 2010 held by Daiichi Sankyo, which includes a three-year Hatch-Waxman extension; the same patent also covers the method of manufacture and its use as an anti-microbial. However, a pediatric extension granted by the FDA in 2008 has extended the patent exclusivity until June 2011. Levaquin had worldwide sales of $1.4bn in 2010, of which US accounted for over 95% with 2010 sales of $1.3bn. In 2010, Levaquin sales showed a Y-o-Y decline of 12.4% primarily due to the decline in the overall antibacterial market and intensified generic competition. Levaquin is expected to suffer from substantial sales erosion after its patent expiry in June 2011. Doribax (doripenem) Doribax, a carbapenem antibiotic, was approved by the FDA for the treatment of complicated urinary tract and intra-abdominal infections in October, 2007. The drug was first approved in Japan in September, 2005 and launched in a nebulized (inhaled) version in June, 2006. Ortho-McNeil markets Doribax in the US through its institutional franchise. Doribax inhibits the synthesis of bacterial cell membrane through inactivating multiple essential penicillin-binding proteins (PBPs). Doribax has been granted approval for the treatment of nosocomial pneumonia (NP), including ventilator-associated pneumonia (VAP), however, in the US, the FDA has requested additional information prior to approving Doribax for these additional indications. Doribax exhibited greater in vitro activity against Pseudomonas aeruginosa isolates and is active against MRSA with a broader spectrum of activity than the currently marketed carbapenems. In February 2010, J&J announced that Doribax was recommended for the treatment of certain high-risk cIAIs, in the January 2010 edition of Clinical Infectious Diseases, an important guidelines publication. The updated recommendations are expected to help physicians to treat patients with life-threatening bacterial infections. Witnessing a strong growth of around 150%, the drug garnered sales of $215m in 2010. Doribax is expected to exhibit strong sales until 2012, and the brand will witness sales erosion thereafter due to its patent expiry in mid July/September 2012. Research & development J&J invested around $7bn in research and development activities in 2010. In emerging markets, J&J’s research strategy is focused on developing the drugs based on the requirements of the domestic market. 80 Although J&J is highly active in research for the treatment of infectious diseases, presently its pipeline is dominated by antivirals. The company is presently developing Doribax for the treatment of nosocomial pneumonia in the US. While it was approved for the treatment of nosocomial pneumonia in the Europe in 2008, the FDA requested J&J to conduct additional clinical trials to gain approval in the US. Doribax conducted two multicenter, open-label, randomized, active-controlled Phase III trials to assess the efficacy of the drug against nosocomial pneumonia. The FDA Advisory Committee found 500mg dosage of Doribax at one-hour and four-hour infusion regimens safe and effective for the treatment of nosocomial pneumonia and VAP. However, the committee suggested that Doribax did not demonstrate sufficient noninferiority margin for nosocomial pneumonia and requested additional studies to gain approval. Doribax has demonstrated a strong sales uptake in the first year of its launch. Approved for nosocomial pneumonia would provide strong sales boost. Strategic and growth analysis Drivers Current growth in J&J’s antibacterial franchise is driven by the performance of the Levaquin (levofloxacin), which continues to maintain patent exclusivity until June 2011. The performance of this franchise is expected to be boosted by Doribax, its latest new antibacterial product. The company is presently developing Doribax for the treatment of nosocomial pneumonia in the US, which would be strong driver for the company.. Resistors J&J’s current growth driver, Levaquin, is expected to lose patent exclusivity in June 2011. The brand is expected to witness a sharp decline in sales due to potential at-risk launch by generic drug manufacturers. J&J was developing ceftobiprole, a novel cephalosporin antibiotic for the treatment of cSSTIs, with activity against MRSA and pathogens resistant to vancomycin, under licensing agreement with Basilea. However, after the rejection of ceftobiprole by the FDA, J&J returned the global developmental rights to Basilea. It was a major setback for J&J’s weak antibacterial pipeline. J&J has shifted its focus from antibacterial to anti-viral research. Under the licensing agreement with Furiex Pharmaceuticals, J&J had an option to regain rights to JNJ-Q2, an investigational broad-spectrum 81 fluoroquinolone antibiotic, however the company granted the developmental rights to Furiex Pharmaceuticals. It has been reported that antibacterial are a low R&D priority for J&J.. Merck & Co. Overview Merck & Co. is one of the leading pharmaceutical companies worldwide, with a diverse product offering across a broad range of therapeutic areas, a strong pipeline and extensive global reach. In 2009, Merck and Schering-Plough merged. The company has only one reportable segment: Pharmaceuticals which includes human health pharmaceutical and vaccine products. Merck & Co. has a worldwide presence and markets its products either directly or through joint ventures. Merck & Co. has a strong infectious diseases product portfolio, however it is dominated by anti-viral drugs. The key antibacterial products in its marketed portfolio are Primaxin, Avelox and Invanz. The sales of Primaxin have been declining sharply since its patent expiry and approval of multiple generics. Avelox is a broad-spectrum fluoroquinolone antibiotic and demonstrated a strong growth in 2010. Merck & Co. markets Avelox only in the US. Invanz is a broad-spectrum carbapenem antibiotic and its unique antimicrobial spectrum makes it more suitable for community-acquired infections and outpatient intravenous therapy. Financial performance Merck’s total 2010 sales were $46.0bn and the three key antibacterial brands accounted for 4.3% of the company’s total revenues with 2010 sales of around $1.2bn. Primaxin was the leading product in Merck’s antibacterial product portfolio with 2010 sales of $610m followed by Invanz and Avelox with sales of $362m and $316m in 2010. Among the key antibacterial brands, Primaxin was the only drug to witness an 11.5% decline in sales in 2010, as both Avelox and Invanz are patent protected and expected to show strong sales growth until the patent expiries in 2013 and 2015 respectively. Marketed product portfolio The key marketed products in Merck & Co.’s portfolio are listed below. 82 Table : Merck & Co.'s leading antibacterial products ($m), 2010 Product Generic Sales 2010 Sales growth 2010 (%) CAGR 2006–10 (%) Primaxin imipenem + cilastatin 610 -11.5 -3.5 Invanz ertapenem 362 23.5 27.0 Avelox moxifloxacin 316 378.8 – Source: Company reports, PharmaVitae BUSINESS INSIGHTS Primaxin (imipenem + cilastatin) Primaxin, a broad-spectrum beta-lactam antibiotic, is indicated for the treatment of serious lower RTIs, UTIs, intra-abdominal infections, gynecologic infections, and SSTIs caused by a range of gram-positive and gramnegative bacteria. The drug is a combination of imipenem and the dehydropeptidase inhibitor, cilastatin in a 50:50 ratio. Primaxin can either be administered intravenously or intramuscularly, and has a twice-daily dosing regimen. While, imipenem targets penicillin-binding proteins, inhibiting the synthesis in bacterial cellwall, Cilastatin acts by inhibiting dehydropeptidase-I, the renal enzyme that metabolizes and inactivates imipenem, thus improving urinary recovery of imipenem. Primaxin has been losing sales to Merrem due to a more limited range of indications than Merrem. While Primaxin is believed to be more efficacious for treating gram-positive bacteria, Merrem is considered to be highly efficacious against gram-negative bacteria. The growing incidence of gram-negative infections, is working in favor of Merrem over Primaxin. Moreover, the brand has also lost patent exclusivity in all geographies. Primaxin is expected to witness further sales erosion in the near term. In 2010, the brand recorded sales of $610m, a decline of 11.5% over 2009. Invanz (ertapenem) Invanz is a broad-spectrum, parenteral carbapenem antibiotic with activity against cephalosporin-resistant bacteria and anaerobes. Invanz was approved by the FDA in November 2001 and is administered once daily. Carbapenems have traditionally been reserved for second-line treatment of nosocomial infections especially extended-spectrum betalactamase (ESBL) producing Klebsiella species which are resistant to 83 beta-lactam anti-infectives including cephalosporins. However, Invanz is being used as a first-line agent. Invanz is indicated for the treatment of intra-abdominal infections, cSSSIs, complicated UTIs, acute pelvic infections and diabetic foot infections. The bactericidal activity is demonstrated by targeting PCBs thus inhibiting the bacterial cell-wall synthesis. Invanz recorded sales of $362m in 2010 and is expected to see strong growth until the loss of exclusivity in 2016. Avelox (moxifloxacin) Bayer/Schering-Plough’s Avelox is indicated for skin and skin structure infections. Avelox carries more strongly worded warnings against heart rhythm disturbances than do its competitors in this class, however Avelox is not associated with phototoxicity. Loss of market share to ciprofloxacin generics has been less in the US than in other markets, given that Cipro is used mainly for urinary tract infections and Avelox for respiratory tract infections. In June 2005, Avelox was granted an additional indication for the treatment of skin and skin structure infections, which increased the market opportunity for Avelox. The brand recorded sales of $316m in 2010 and is expected to achieve peak sales in 2013, thereafter the sales will decline due to patent expiry in Q1 2014. Research & development In 2010, Merck & Co.’s R&D spending was $8.1bn, which accounted for 18.2% of the total revenues recorded by the company. Merck’s R&D activities are focused on multiple therapeutic categories including infectious disease, oncology, cardiovascular disease, diabetes and obesity, respiratory disease, immunology, and dermatology, neurosciences, ophthalmology, women's health and endocrine. The company presently has only two antibacterial compounds in development. In infectious diseases the company’s research is focused on anti-virals and vaccines. 84 Table : Merck & Co.’s antibacterial R&D pipeline, February 2011 Compound Mechanism of action Phase MK 3009 (daptomycin) Bacterial cell membrane permeability inducer Filed in Japan MK3415A Clostridium difficile toxin binder II Source: Company reports BUSINESS INSIGHTS MK 3009 (daptomycin) is a novel lipopeptide indicated for the treatment of cSSSIs caused by gram-positive bacteria including MRSA. The drug is approved and being marketed in all major markets including the US and Europe, however the drug is presently filed for approval in Japan. In 2007, Merck & Co. and Cubist entered into a licensing agreement for the development and commercialization of daptomycin in Japan. Banyu, Merck's wholly owned local subsidiary is developing MK 3009. The drug is expected to exhibit the same strong sales growth as it has seen in the other markets. Merck is also developing MK3415A, a combination of MDX1388 and MDX066 (or CDA-1 and CDB-1) for the treatment of C. difficile associated diarrhea. MDX1388 and MDX066 are two novel fully human monoclonal antibodies of C. difficile Toxin A and Toxin B respectively. MK3415A is being developed as an intravenous injectable formulation and is presently undergoing Phase II clinical trials. Strategic and growth analysis Drivers Avelox and Invanz are the major drivers of Merck & Co.’s antibacterial franchise The brands are patent protected until 2013 and 2015 respectively and are expected to exhibit strong growth in the coming years. Additionally, as mentioned above, if the company can secure approval for daptomycin in Japan the drug is likely to drive uptake and growth Furthermore, Merck is developing MK 3415A, a combination of monoclonal 85 antibiodies, which is expected to expand its prescription base, as no monoclonal antibodies have been approved for antibacterial infections so far. Resistors Merck & Co.’s antibacterial brand Primaxin has been losing sales to Merrem due to its limited range of indications than Merrem. The growing incidence of gram-negative infections, is working in favor of Merrem than Primaxin as Primaxin is believed to be more effective against gram-positive infections. Moreover, the brand has been negatively impacted by generics following its patent expiry in 2009. Novartis Overview Novartis is engaged in research, development and manufacturing of healthcare products including branded and generic pharmaceuticals, vaccines and non-prescription consumer healthcare products. It operates through four divisions: Pharmaceuticals, Vaccines and Diagnostics, Sandoz (generics) and Consumer healthcare. Novartis operates in approximately 140 countries and is headquartered at Basel, Switzerland. In 2010, Novartis garnered total sales of $50.6bn, an increase of 14% over 2009. The pharmaceutical division was the largest division, contributing 60% of revenues in 2010. Financial performance Novartis recorded total revenues of $50.6bn, witnessing a Y-o-Y increase of 14% in 2010. Revenues derived from Novartis’ marketed antibacterial product portfolio are heavily weighted towards generic antibacterials. The expanded indication approval of Cubicin for the treatment of both methicillin-sensitive and resistant Staphylococcus aureus (MSSA and MRSA) bloodstream infections (bacteraemia) and heart infections have added to the company’s growth. Marketed product portfolio Novartis markets a range of generic antibacterial, including branded and generic versions of Augmentin (amoxicillin clavulanate) as well as amoxicillin, ampicillin, cefazolin and penicillin. Novartis, which also markets Cubicin in the Europe, gained the rights through acquisition of the Chiron Corporation. 86 Tobi (tobramycin) Tobi (tobramycin) is an aminoglycoside which has been available for intravenous administration since 1975. Originally developed by PathoGenesis, Chiron acquired Tobi through acquisition in August 2000. Tobi has been approved as an inhaled antibiotic for the treatment of cystic fibrosis (CF) and is indicated to treat P. aeruginose infections, a common cause of lung infections in CF patients. Tobi continues to be the gold standard inhaled antibiotic therapy among the CF patient population, registering sales of $279m in 2010. Coupled with the product’s established clinical profile, Tobi also maintains a competitive advantage due to the drug’s inhalation route of administration, which targets drug delivery to the site of infection in the lung. Tobi is currently used in combination with the Pari LC Plus reusable nebulizer and a DeVilbiss Pulmo-Aide air compressor, which deliver high concentrations to the site of infection while minimizing systemic toxicities. Whilst highly efficacious, the costs associated with this delivery system are high when compared with competing products such as Genentech's Pulmozyme (dornase alfa). Research & development Innovations are the core of Novartis’ R&D activities and its pharmaceutical R&D pipeline has 143 projects in clinical development. In 2010, Novartis invested 16% of its total net sales in R&D. However, Novartis’ antibacterial pipeline is relatively weak with two key antibacterial compounds in clinical development, PTK 0796 and Tobi-TIP. Table : Novartis’ antibacterial R&D pipeline Compound Mechanism of action Phase PTK 0796 Bacterial Protein Synthesis Inhibitor III Tobi-TIP Clostridium difficile toxin binder Pending approval in Europe and Phase III in other geographies Source: Company reports BUSINESS INSIGHTS PTK 0796 (omadacycline), a broad-spectrum antibiotic, is being developed as tablet and intravenous infusion under a licensing agreement with Paratek. Omadacycline, currently in Phase III, is being studied for the 87 treatment of bacterial infections including complicated skin and skin structure infections, moderate-to-severe community acquired bacterial pneumonia, MRSA, multidrug-resistant Streptococcus pneumoniae (MDRSP) and vancomycin-resistant enterococci. Omadacycline is expected to be studied for other potential indications including CABP. Novartis is extending its Tobi franchise with the developmental drug Tobi-TIP, a powder formulation of tobramycin that is inhaled directly into the lungs using a T-326 inhaler. Tobi-TIP uses Nektar's Advanced Pulmonary Delivery technology for the treatment of Pseudomonas aeruginosa infections in cystic fibrosis patients associated lung infections. In September 2009, the drug was approved in the EU, and is expected to be filed in 2011 in the US. Strategic and growth analysis Drivers Novartis’ has signed an exclusive worldwide collaborative licensing agreement with Paratek, for the development, manufacture and commercialization for its lead broad-spectrum antibiotic, PTK 0796. It is the only once-daily, oral and intravenous MRSA active compound in clinical development. Tobi’s extended franchise, Tobi-TIP is also expected to expand the market for Novartis as it is administered through a handheld device which offers convenience. Cubicin is also expected to drive growth of Novartis antibacterial portfolio due to superior efficacy and patent protection through 2019. Novartis markets a range of key antibacterial products including branded and generic versions of Augmentin (amoxicillin clavulanate) as well amoxicillin, and penicillin. Although the majority of these products are expected to grow, however, the profit margins are very low and the sales are difficult to sustain due to intense competition. Due to the high number of blockbuster off-patent compounds, Novartis is expected to continue pursuing an aggressive generics development strategy in its antibacterial franchise. 88 Resistors Although Novartis has taken steps to further develop and reinvigorate its small antibacterials portfolio, dependence on in-licensing and acquisitions may inhibit growth. The company is plowing its efforts into research in vaccines rather than antibacterials. 89 Appendix Scope The Antibacterial Market Outlook to 2016 provides comprehensive coverage of the global antibacterial market, incorporating disease overview and detailed epidemiological analyses of the major indications. This report makes a comprehensive assessment of the marketed product portfolios, R&D pipelines, sales forecast, and the competitive landscape for the major players. Further, this report highlights the key market challenges and drivers, and R&D events, with a thorough analysis of the competitive dynamics of leading brands to enable you to identify growth brands, key drug classes and leading players through to 2016. Key diseases covered in this report bacterial infections respiratory tract infections urinary tract infections skin and skin structure infections gynecological infections Market size methodology The leading products and companies in the global antibacterial market were identified using companyreported sales sourced from PharmaVitae and company annual reports. Where applicable, reference was also made to multiple secondary resources, in-house databases, scientific journals, and analyst reports to derive additional insights into currently marketed drugs. 90 Epidemiology The epidemiology of relevant indications is derived from the cohort studies. The epidemiology forecast is extrapolated based on the cohort studies and forecast population changes sourced from the US Census Bureau. The forecast does not take into account any genetic, cultural, environmental, social, or racial changes to population demographics that could have an impact on disease epidemiology in the various markets. Market forecast To forecast future market sizes, regression analysis was used to establish a forward-looking baseline trend. This baseline was then adjusted to take into account future events that are not reflected by the historical trend. Examples of these events include: The launch of new products, with peak sales forecasts based on expected patient numbers and expected price. Patent expirations, generic competition, any ongoing patent litigation, or restricted label warnings (black box warnings). Product extensions based on superior administration/dosage profiles, expanded indications, or postmarketing studies. For biologics, the likely entry of biosimilars/follow-on biologics in the developed (mostly the US and EU) and developing countries, and the competitive dynamics that these may introduce post-approval. Special consideration is also given to the impact of first-in-class, novel drugs that result in a paradigm shift in the treatment algorithm in therapy areas and diseases with significant unmet medical need. Abbreviations 7MM: Seven major markets ABS: Acute bacterial sinusitis 91 ABS: Acute bacterial sinusitis ABSSSI: Acute bacterial skin and skin structure infections AIDAC: Anti-infective drugs advisory committee AP: Acute pyelonephritis BV: Bacterial vaginosis CABP: Community-acquired bacterial pneumonia CAP: Community acquired pneumonia CE: Clinically evaluable CF Cystic fibrosis cIAI: Complicated intra-abdominal infections cUTIs: Complicated urinary tract infections GIs: Gynecological infections IAIs: Intra-abdominal infections ICAAC: Interscience conference on antimicrobial agents and chemotherapy LRTIs: Lower respiratory tract infections MDR: Multidrug-resistant MDRSP: Multidrug-resistant streptococcus pneumoniae MRSA: Methicillin-resistant staphylococcus aureus MSSA Methicillin-sensitive staphylococcus aureus 92 NP: Nosocomial pneumonia PBPs: Penicillin-binding proteins PDF: Peptide deformylase PDR: Pan-drug-resistant PDUFA: Prescription Drug User Fee Act QD: Once daily RI: Respiratory infections ROI: Return on investment SSSIs: Skin and skin structure infections TB: Tuberculosis UTIs: Urinary tract infections VAP: Ventilator acquired pneumonia VAP Ventilator-associated pneumonia VRE: Vancomycin-resistant enterococci VRE: Vancomycin resistant enterococcus XDR: Extensively-drug-resistant 93
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