We believe the anti-platelet market will receive significant attention at this year's European Society of Cardiology (ESC) Congress.  Of particular interest will be the data for mid-stage products from Novartis / Portola (elinogrel) and Eisai (E5555).  These data will allow for a greater understanding of the sales potential of these agents and the development path they may take to reach the market. There will also be presentations addressing non-responsiveness to sanofi-aventis / BMS Plavix; Plavix non-responsiveness may provide sales opportunities for emerging anti-platelets, such as Eli Lilly / Daiichi Sankyo's Effient and AstraZeneca's Brilinta.

Phase II data for elinogrel treatment in patients undergoing non-urgent (including elective) PCI will be presented.  Although the anti-platelet market is highly competitive, and will be even more so at the time of elinogrel's potential launch in 2014, the drug has an interesting differentiating feature: development in both oral and IV formulations. Such an attribute could promote use of IV elinogrel in the acute setting, establishing the patient on the therapy, and thereby facilitating a switch to oral elinogrel in the more lucrative long-term setting.

The potential for triple anti-platelet therapy will also be revisited at this year's ESC, with data from two Phase II trials for Eisai's E5555.  We believe avoiding direct competition with agents used in dual anti-platelet protection, such as sanofi-aventis / BMS Plavix, Eli Lilly / Daiichi Sankyo's Effient, and AstraZeneca's Brilinta, may allow for easier market access, but there will be a difficult balance between added benefit, safety, and cost with the addition of a third ant-platelet, particularly in more cost conscious markets.  It should also be noted that the commercial potential for E5555 faces a more direct threat as Merck's vorapaxar, which is also a protease-activated receptor-1 (PAR-1) antagonist, is expected to enter the market ahead of E5555.

The release of these data for elinogrel and E5555 will allow for a greater understanding of the sales potential of these agents, and the development path they may take to reach the market.  We believe E5555 currently lacks any notable differentiating features to vorapaxar; as such these data will be crucial in determining whether the product is indeed worthy of progression to Phase III development. To illustrate the lucrative nature of the anti-platelet market, Plavix, the sales leading anti-platelet, recorded sales of $9.8bn in 2009. However, if launched, uptake of these mid-stage development products will be restricted by the availability of generic Plavix and a greater physician familiarity with earlier to market anti-platelets such as Effient wand Brilinta.

We expect the topic of testing for Plavix non-responsiveness to garner significant attention, with several key presentations focusing on this subject. To date Effient has failed to take significant market share from Plavix and as a result of the slow uptake we believe the sales potential of the product has been lowered. Highlighting the potential risks of Plavix non-responsiveness may carve out a niche market opportunity for alternative anti-platelets, including Effient. In mid-July Eli Lilly, Daiichi Sankyo and Accumetrics launched a strategic collaboration in the U.S. to increase physician awareness about anti-platelet therapy and the role of platelet function testing.  Although we no longer expect Effient to reach blockbuster status by 2016, an uptick in sales growth may be gained by adopting this strategy.  AstraZeneca's anti-platelet Brilinta would also benefit from greater physician awareness of Plavix non-responsiveness.  Data from the PLATO genetic sub-study, which looked at outcomes of Brilinta verses Plavix treatment in ACS patients with a genetic predisposition for Plavix non-responsiveness, will be presented at the congress.

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