 Treatment Algorithms --
July 2008
 In This Issue...
Introduction:
Although levodopa (Bristol-Myers Squibb’s Sinemet, Roche’s
Larodopa, UCB/Schwarz Pharma’s Parcopa, generics) is the gold-standard
symptomatic therapy for Parkinson’s disease (PD), physicians often try to delay
initiation of levodopa, particularly in younger patients, because long-term use
of the drug leads to motor response complications. This desire on the part of
physicians to give levodopa-sparing therapies for as long as possible has been
a major driver of sales growth for the non-ergotic dopamine agonists,
Boehringer Ingelheim’s Mirapex (pramipexole) and GlaxoSmithKline’s Requip
(ropinirole), and of these agents’ use in early lines of treatment for PD. The
recent launch of UCB/Schwarz Pharma’s Neupro (rotigotine) offered a new
treatment option for PD patients by delivering dopamine agonist therapy through
a once-daily patch formulation; however, this agent’s prospect in the market
are handicapped by its in the United States in March 2008 as well as some
interviewed experts’ belief that this drug is not as effective as either
Mirapex or Requip. Teva’s monoamine oxidase-B (MAO-B) inhibitor, Azilect (rasagiline),
is also seeking to gain a foothold in first-line treatment for PD. Although new
formulations (e.g., the once-daily formulations of Requip, GlaxoSmithKline/Skye
Pharma’s Requip Modutab, and of Mirapex, Boehringer Ingelheim’s Mirapex ER) and novel
drugs (e.g., Newron/Merck Serono’s MAO-B inhibitor safinamide, Solvay’s partial
dopamine agonist pardoprunox) are anticipated to launch through 2010, the U.S.
PD market also faces market contraction owing to Requip’s recent patent expiry
(as of May 2008). Using patient-level claims data, as well as insight from 151
surveyed specialists and PCPs, this report determines the share of each
currently marketed drug by line of therapy, why key drugs are chosen over
others, and how physicians predict that this dynamic will change over the next
two years.
Questions Answered in This Report:
- Lines of therapy: Although the American Academy of Neurology (AAN) provides evidence-based treatment guidelines for PD,
treatment choice in PD is highly individualized. How much patient share do
dopamine agonists gain in first-line therapy? How much first-line patient share
is devoted to Mirapex versus Requip? How many newly diagnosed patients receive
Azilect versus generic and branded formulations of selegiline?
- Pathways to key therapies: Although dopamine agonists and
MAO-B inhibitors experience use in first-line treatment, these agents also see
use in patients who experience increasing "off" times and motor response
complications with levodopa treatment. How does the use of Mirapex and
Requip differ by line of therapy? What drugs are used directly before these
agents and how long does it take for patients to switch over? How
quickly do patients move to Novartis/Orion’s Stalevo, the triple combination
therapy that combines levodopa-carbidopa with the catechol-O-methyltransferase
(COMT) inhibitor, entacapone?
- Physician behavior: PD patients can be treated by
neurologists or primary care physicians (PCPs) but our survey results suggest
that different factors drive prescribing within each clinical setting. How
do neurologists and PCPs differ in their prescribing of dopamine agonists and
levodopa first line? What factors drive each specialty when making drug choices?
Which agents do they believe offer the best efficacy for delaying levodopa, for
prolonging levodopa’s therapeutic effect, and for dementia associated
with PD?
- Forecast: The recall of Neupro has changed surveyed physicians’
attitude toward this agent. How do surveyed physicians anticipate using
Neupro when it becomes available again? What key events will bring about the
most significant changes in their prescribing? How do surveyed physicians
anticipate integrating Requip Modutab and Novartis’s recently-launched patch
formulation of Exelon (rivastigmine) into their treatment of PD?
Includes:
Primary research: Quantitative results from our
survey of 151 physicians (76 neurologists and 75 PCPs):
- Physician opinion on how drug use differs by patient severity.
- Most influential drug attributes when physicians choose between
agents.
- Anticipated changes in the line of therapy in which physicians
use key agents.
Primary patient-level data: Quantitative findings
from our analysis of data covering 55 million lives from more than 80
geographically diverse U.S. health plans:
- Quantified lines of therapy analysis showing exact share of each
agent in each line of therapy, including rate of progression between lines and
length of time patients are on each line.
- Progression flowcharts through one year of treatment for newly-diagnosed
patients receiving each of the following first line agents: generic
levodopa-carbidopa fixed-dose combinations (FDCs), Sinemet immediate release
(IR), Sinemet controlled-release (CR), Parcopa, Mirapex, Requip, amantadine,
Azilect, Zelapar, Eldepryl, generic selegiline, Stalevo, Comtan, Aricept,
Razadyne, bromocriptine, trihexyphenidyl, benztropine, and antipsychotic agents.
- Flowcharts tracking the preceding therapy patterns for patients
taking each of the following key therapies: generic levodopa-carbidopa FDCs,
Sinemet IR, Sinemet CR, Parcopa, Mirapex, Requip, Neupro, amantadine, Azilect, Zelapar,
Stalevo, Comtan, Aricept, Razadyne, and Exelon.
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