By Rex Graham
This season of pumpkin pie, mashed potatoes and rising obesity rates is a perfect time to talk turkey about the overly bearish sales estimates of Belviq and Qsymia, the obesity drugs approved by the FDA this summer.
The oft-cited $1 billion-a-year combined estimated sales for Qsymia, which is made by Vivus, Inc. (VVUS), and Belviq, made by Arena Pharmaceuticals (ARNA), should be revised upward. Why? It’s not just because of Aetna’s Nov. 20 revision to include Qsymia and Belviq “as medically necessary weight reduction medications” for its 37.3 million covered health plan members.
Two important policy shifts at the federal level – by the Centers for Medicare & Medicaid Services and the U.S. Preventive Services Task Force – also bode well for much broader coverage of weight loss prescription medicines. The shift is a logical way to cut massive health costs caused by obesity. The trajectory of policy shifts is leading experts to predict that Qsymia and Belviq will soon become covered by all private and public health insurers, including Medicare, the federal health plan for Americans aged 65 and older and younger people with disabilities, and Medicaid, the federal-state health program for low-income individuals and families.
Even the Mayo Clinic informs patients visiting its website that Qsymia and Belviq are “prescription weight-loss medications your doctor may prescribe.” Estimates of the market in the U.S. alone for obesity drugs are as high as $60 billion a year, but nobody knows for sure. Consider this: the market capitalization of Vivus currently at $1.12 billion and Arena’s market cap at $2.03 billion. Even if the obesity drug market’s eventual size is one-tenth of the highest current estimate, both companies are grossly undervalued.
Obesity policy timeline
This is a timeline of major events in a one-year period that underlie the assessment that sales of Qsymia and Belviq will be better than expected:
• November 2011: A “decision memo” by the Centers for Medicare & Medicaid Services (CMS) states: “The evidence is adequate to conclude that intensive behavioral therapy for obesity, defined as a body mass index of 30 or higher is reasonable and necessary for the prevention or early detection of illness or disability.” More intensive treatment plans, including up to 26 office visits in one year, are now expected to become part of Medicare and Medicaid coverage. (Neither Qsymia norBelviq had been approved by the FDA yet.)
• May 8, 2012: A report by U.S. Institute of Medicine and the Robert Wood Johnson Foundation estimated that the annual cost of treating obesity-related chronic disease and disability is $190.2 billion. Obviously, reducing obesity reduces obesity-related costs and “the staggering human toll.”
• June 2, 2012: The U.S. Preventive Services Task Force recommends intensive, multicomponent behavioral intervention for patients with BMI of 30 or higher to reduce weight and lower metabolic risk factors for diabetes and cardiovascular disease. (Still no decision by the FDA at this point on Qsymia or Belviq.)
• June 27, 2012: FDA approves Arena Pharmaceutical’s Belviq, along with a reduced-calorie diet and exercise, for chronic weight management of adults with BMI of 30 or higher (or BMI of 27 or greater when the individual has a weight-related condition such as high blood pressure, type 2 diabetes or high cholesterol). It was the FDA’s first approval of a weight loss drug in 13 years.
• July 17, 2012: FDA approves Vivus’ Qsymia along with a reduced-calorie diet and exercise, for chronic weight management of adults with BMI of 30 or higher (or BMI of 27 or greater when the individual has a weight-related condition such as high blood pressure, type 2 diabetes or high cholesterol).
• November 20, 2012: Aetna, a health insurance provider to 37.3 million policyholders, revised its Clinical Policy Bulletin to include Belviq and Qsymia as “medically necessary weight reduction medications.” (Each Aetna benefit plan defines which services are covered; members need to consult with benefit representatives to determine if their plan has limitations that would apply to obesity medicines.)
ObamaCare to cover obesity drugs
“Along with Aetna, many other private insurers already cover visits and obesity counseling, and ObamaCare will mandate that preventative services for obesity are covered,” said Dr. Michael Kaplan, chief medical officer of The Center for Medical Weight Loss, a Tarrytown, N.Y.-based company with 750 affiliated doctors in weight loss clinics nationwide. “ObamaCare should lead to 100 percent of the population being covered for obesity management in 2014.”
Benefits of modest weight loss
An estimated one-third of the total U.S. population of 311 million are obese, defined as having a body mass index (BMI) of 30 or higher, which is equivalent to a person who is 5 foot 4 weighing 175 pounds, or a person who is 6 foot 4 weighing 247 pounds. (BMI is defined as weight in kilograms divided by height in meters squared.)
A landmark 2005 study found that 27 percent of all national health care charges were associated with patients who are physically inactive, overweight and obese. More recent studies document that modest weight loss of 5 to 10 percent can significantly reduce rates of type 2 diabetes, hypertension, cardiovascular disease and other health problems. All private and public health insurance plans pay for diabetes drugs, and it’s only logical to cover obesity-prevention services and drugs that reduce rates of diabetes.
In other words, reducing obesity will save the nation some unknown percentage of the $190.2 billion it currently spends on obesity-related diseases (such as diabetes) and disability. At the same time, not all obesity treatments are cost effective: the National Weight Registry found that surgeries designed to restrict overeating don’t really work in most cases; most of those patients exercise very little, eat more high-fat foods than the norm, and gain the weight back.
Less costly approaches than surgery seem to work better. However, neither reduced-calorie diets alone, nor increased exercise alone lead to long-term weight loss. The combination of diet and exercise helps about 20 percent of people lose weight and keep it off, according to the National Weight Registry. What will help the remaining 80 percent? Combining Qsymia and/or Belviq with a low-calorie diet, exercise, routine counseling and related approaches may actually work.
Kaplan is using that approach with Qsymia and “having pretty good results in combination with intensive counseling and behavior modification” with no side effects. “In some cases we can discontinue hypertension medications and medications for type 2 diabetes,” Kaplan said. “Getting patients to lose even 10 percent of their body mass is huge because health outcomes improve dramatically even with modest weight loss.”
Checking zero-sum math
Some analysts describe the market for Qsymia and Belviq as a zero-sum game, with sales of one hurting the other. It’s easy to understand the argument: with Qsymia costing $120 to $160 a month, mostly out of pocket, and Belviq expected to cost roughly the same, a patient will use only one or the other, right? It depends.
Indeed, about 30 percent of the patients who have received Qsymia prescriptions didn’t fill them. Dr. Edward Zbella, medical director of the Tampa, Fla.-based Medi-Weightloss Clinics, said his 82 affiliated weight loss clinics plan to use the two generic drugs in Qsymia at a price of about $40 per month of treatment, rather than relying on Qsymia, with a price tag of $120 to $160 a month.
“There is no advantage for us to use Qsymia,” Zbella said. At the same time, he said a high-intensity approach of a low-calorie diet, regular exercise, counseling and weight loss drugs can be highly effective. “Type 2 diabetes is almost always due to obesity,” he said. “And older obese patients need hip and knee replacements, which are expected to increase ten-fold in the next five years, and the negative health impacts of obesity go on, and on, and on.”
However, if insurance plans are eager to avoid spending increases to treat type 2 diabetes, hypertension and cardiovascular disease, why not cover obesity drugs? Zbella said if health insurance providers cover Qsymia and Belviq prescriptions, his clinics will prescribe them.
Patients who want to lose the most weight the fastest may opt for Qsymia. Why? Patients taking it in clinical trials lost 8.6 to 9.4 percent of their body weight (compared to controls) at one year. Weight loss with Belviq was 3.0 to 3.3 percent at one year. However, Belviq has a better safety profile, and may end up being more popular for maintaining weight loss long term. Neither drug can be used during pregnancy.
“Qsymia looks like a better drug for a patient who weighs more, so we may start a patient on it, but Qsymia and Belviq are both are excellent for maintaining weight loss,” Kaplan said.
Vivus reported $453,000 in Qsymia shipments for the last two weeks of September, an amount equivalent to roughly only 3,000 prescriptions. The intentionally cumbersome online ordering from CVS Pharmacy and Walgreens hurt. The FDA required the difficult ordering process and home delivery of Qsymia as a way to limit sales to women of childbearing ages, but weight loss doctors say the FDA has gone too far if the federal government truly wants to lower the obesity rate.
“It’s all kinds of paperwork; it’s a hassle and CVS and Walgreens don’t even stock them,” said Dr. Arthur Aronson, owner of Medarts Medical Weight Loss Specialists in San Diego, Calif. He sees up to 300 patients during a busy month, but refuses to prescribe Qsymia because of the prescription hassles – unless patients ask for it.
Investors understandably don’t have the patience for such glitches to be resolved. Many pulled out of Vivus because of the disappointingly slow initial sales, but it’s time for them to come back to Vivus and Arena because the insurance landscape is shifting in favor of the two companies.
New Year’s weight-loss resolutions
Already, Vivus has expanded its online distribution network for Qsymia to two additional home-delivery networks: Express Scripts and Kaiser Permanente (for its 9 million health plan members). Some analysts now predict a substantial increase in Qsymia sales in the fourth quarter. They may be correct, but as anyone who frequents a fitness club knows, almost all new members arrive, like clockwork, in January, not the fourth quarter of the year.
“Right now, it’s slow at our clinic, which is usual this time of year,” Aronson said in a pre-Thanksgiving telephone interview. “In January, patients literally line up at the doors.”
The post-holiday bump in interest in weight loss is great timing for Belviq, which should be available by then. However, it must first be “scheduled” as a controlled drug by the U.S. Drug Enforcement Administration (DEA), after which Eisai, Inc., will begin marketing it in most of North and South America (including the U.S., Canada, Mexico and Brazil). Eisai has a marketing and supply agreement with Arena.
Red tape opportunity
It’s possible that the FDA could require the same unnecessarily cumbersome online prescription ordering process for Belviq that has slowed Qsymia sales. However, Kaplan said his weight loss clinics regard the red tape as an opportunity. Office staffers sit down with patients at a computer and assist them with ordering. Patients love it. Refills are much simpler and return visits are easier on everybody.
Since reimbursable counseling sessions are now recommended as an essential part of weight loss treatment, clinics have an incentive to schedule additional patient visits. More frequent visits help ensure that patients follow through on prescription ordering, adherence to diet and exercise plans and achievement of significant weight loss.
Post-marketing diet pill studies
The FDA has required both Arena and Vivus to conduct post-marketing studies, including long-term outcomes trials to assess the effect of Belviq and Qsymia on the risk for heart attack and stroke. Until the post-marketing studies verify cardiovascular safety, many physicians won’t get out their prescription pads.
“Physicians in our practice are unlikely to significantly prescribe either the phentermine/topiramate combination [Qsymia] or lorcaserin [Belviq] in the near future,” said Umesh Masharani, a clinical professor at the UC San Francisco Diabetes Center.
Masharani points to his experience with the then-almost-magical combination of fenfluramine and phentermine, known as fen-phen. A study published in 1984 in Archives of Internal Medicine found that after taking fen-phen for 24 weeks, overweight patients lost an average of 18.5 pounds, versus 9.7 pounds in the control group receiving only individualized diets.
After sales soared in the 1990s, fen-phen crashed following the publication of a 1996 paper in the New England Journal of Medicine by researchers at the Mayo Clinic. They reported a correlation between heart valve dysfunction and fen-phen.
Lingering fen-phen fears
Today, Masharani and other diabetes specialists are quick to point out that one of the ingredients that was present in fen-phen, phentermine, also is present in Qsymia (phentermine and topiramate in extended-release form).
Patients in clinical trials taking Qsymia lost 8.6 to 9.4 percent of their body weight (compared to controls) at one year. Weight loss with Belviq was 3.0 to 3.3 percent.
“We are concerned about the adverse reactions of these drugs and the relatively modest efficacy,” said Masharani, author of the book “Diabetes Demystified.”
Masharani’s diabetes patients will have to wait for post-marketing studies to be completed before receiving a prescription for Qsymia or Belviq.
The FDA weighed the risks of waiting to approve Qsymia and Belviq versus not waiting for further studies. It came to the opposite conclusion as Masharani. The regulatory agency’s approval of the two obesity drugs recognized the obvious; the potential health gains of even modest weight loss far outweighed the potential risks of side effects. The nation’s private and public health insurance industries have come to the same conclusion.
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