Vantage Point – As Eliquis limps on Xarelto dominates oral blood thinners

Vantage Point – As Eliquis limps on Xarelto dominates oral blood thinners

A speedy launch for Eliquis was probably always too much to ask, considering that it was the third novel, oral anti-coagulant to reach the market. However, the tiny sales reported by marketing partners  Bristol-Myers Squibb and  Pfizer so far this year appear to have surprised sellside analysts, many of whom had pinned huge expectations on the product.

Consensus for Eliquis sales next year has dropped 60% in the last 12 months,  EvaluatePharma data show, and currently stands at $491m. Over the same period, expectations for  Johnson & Johnson and  Bayer's Xarelto have surged – consensus for sales in 2014 has jumped by 81% and 60% in the companies' respective territories, to $1bn and $1.4bn. The  Eliquis launch is still early but the ultimate potential of this product is now less certain, as it appears that  Xarelto's broader label and dosing advantage might have been underestimated.

Missed expectations

With three novel, oral anti-coagulants reaching the market at roughly the same time – as well as Eliquis and  XareltoBoehringer Ingelheim launched  Pradaxa – differentiation was always going to be important to grab share in the biggest target market, stroke prevention in patients with nonvalvular atrial fibrillation (SPAF).

Both Eliquis and  Pradaxa showed superiority over  warfarin in preventing stroke, but only the  Bristol-Myers pill managed to reduce major bleeding over  warfarin and improve mortality. In both Europe and the US these superiority claims over  warfarin have been reflected on the  Eliquis label and many analysts assumed this would give the product an edge over the competitors.

On approval of Eliquis in the US at the end of 2012, Goldman Sachs analysts wrote that this differentiation would drive penetration and reimbursement, adding that they viewed consensus for global sales of $350m in 2013 as a "low hurdle". Cowen analysts were even more effusive: "We believe there is no compelling reason to prescribe any other anticoagulant for SPAF," they told their clients.

In reality, Eliquis has limped from the blocks. Consensus for 2013 currently stands at $129m, but even this much reduced figure looks unlikely to be hit. Second-quarter sales came in at $12m; consensus was $43m.

In its first full year on the market after being approved for stroke prevention, Pradaxa sold $875m;  Xarelto sold $582m, globally.

Taking time

Bristol-Myers and  Pfizer were not expecting an easy ride and executives cautioned as much at the time of the approval, warning investors to expect a slow rollout. Despite huge expectations and prophesies of seismic shifts in practice, the launches of all of these products have happened slower than many anticipated, with reimbursement and entrenched use of  warfarin throwing up bigger barriers than were foreseen.

It has also taken time for physicians to embrace these drugs, given the big step change in practise they represent, says Dr Ralph Sacco, chairman of neurology at the University of Miami.

"They offer tremendous benefit over warfarin – they have less bleeding risk, they are easier to use, they have less drug and food interactions. But it takes time for this to penetrate down, particularly to the community practitioner," he says.

Despite all this many analysts were still expecting Eliquis to stop  Xarelto in its tracks. But prescription data suggests that the impact has been negligible and as such the consensus view of the market for these oral thinners has shifted dramatically this year, with numbers for  Xarelto climbing back up and  Eliquis falling, producing the picture in the table below.