Spotlight On... Anti-Thrombotics, A Review of Jan-Mar 2011-- Pharma Matters Report

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Spotlight On...
ANTI-THROMBOTICS
A PHARMA MATTERS REPORT.
A REVIEW OF JANUARY-MARCH 2011. PUBLISHED MARCH 2011.

Expert therapy area review of the key market players and
deals highlights for leading areas of industry investment
and development. These insightful reviews are based on the
strategic data and insights from Thomson Reuters Pharma™
and Thomson Reuters Forecast™.

AWARDED TO THOMSON SC ENTIFIC L MITED
THE SC ENTIF C BUSINESS OF THOMSON REUTERS)

ABSTRACT
The thrombosis market is poised to change dramatically. The possibility
of engineering a replacement for warfarin, or a side-effect free oral
anticoagulant suitable for chronic thrombosis prevention has presented an
attractive opportunity for the pharma industry, and a raft of new products
are now entering the market.

A number of hotly anticipated new oral therapies are set to enter the
lucrative venous thromboembolism market with the potential to radically
change the landscape. The current market has a number of products with
acceptable efficacy profile, including low-molecular-weight heparins,
warfarin and thrombolytics. However, these products are associated with
only moderate safety profiles, and there remains an underlying opportunity
to improve outcomes. Promising new drugs such as Xarelto (launched in
2008), Eliquis (under registration) and Pradaxa (launched in 2008) are
all oral drugs which are expected to widen the venous thromboembolism
(VTE) market significantly, while also extending the prescription period.
Additionally, Thomson Reuters Forecast indicates these new-generation
drugs are set to undermine Lovenox’s current monopoly in the market.

In the arterial thrombosis setting, Effient and Brilinta have both
demonstrated superior effectiveness over the entrenched market leader
Plavix. Thomson Reuters Forecast indicates that Brilinta will emerge as the
new branded market leader in the longer term based on superiority to Plavix
and an equivalent safety profile. Thrombin receptor antagonists, including
Merck & Co’s vorapaxar also have significant potential, although bleeding
risk remains to be clarified.

PHARMA MATTERS | SPOTLIGHT ON... ANTI-THROMBOTICS

SECTION I
INTRODUCTION
Thrombosis is a widespread condition and a leading cause of death
worldwide, despite the availability of medications to treat and prevent the
condition. Deficiencies in existing therapies in terms of efficacy and safety
represent a significant revenue opportunity for pharmaceutical companies,
and with increasing rates and incidence of disease, it remains a very
significant area of unmet clinical need.

To a large extent, conventional management of thrombotic disorders still
relies on heparin, warfarin and aspirin, which have been the foundation of Aspirin is the gold standard for the
anticoagulation treatment for decades, despite significant disadvantages antiplatelet primary prevention market,
in the outpatient setting as well as for long-term use. In addition to these given its effectiveness and low cost.
mainstay treatment options, the VTE market relies heavily on the low-
molecular weight heparins such as Lovenox, while the platelet inhibitor
Plavix dominates the treatment of arterial-associated thrombosis.

However, the market has witnessed a new wave of activity in recent years,
with the introduction of new oral anticoagulants, as well as new competition Until recently, Plavix had no competition;
to rival Plavix. Consequently, the market is expected to rapidly diversify it was the only inhibitor of ADP-induced
following the penetration of these new agents. This range of new therapies platelet aggregation on the market until the
is also likely to balance out generic erosion of the current top-sellers. launch of Effient in 2009.
While most drugs currently available for the treatment of thrombosis
and associated disorders need to be administered soon after the onset of
symptoms, market winners amongst this new wave of therapies will be
easier-to-use prevention products that can be administered more safely over
a longer time frame.

The anti-thrombotics market, comprising anticoagulants, heparins and
antiplatelet sectors, grew steadily over the period of 2004 to 2009, from
$10 billion to $16.8 billion. This growth was not driven by the raft of recent
launches, as Lovenox, Plavix and warfarin still collectively occupied 84%
of the 2009 market by value. Furthermore, this dominance will come to an
end in the near term, with Lovenox generics having entered in mid-2010
and Plavix patent expiry in May 2012. As more new market entrants launch,
the number of blockbusters in the market will increase from two to seven,
but their collective sales will decline over the 2009 to 2015 period, from
$14.4 billion to approximately $12.7 billion, according to Thomson Reuters
Forecast. Accordingly, Thomson Reuters Forecast indicates the market as a
whole has already peaked once, at just over $16 billion in 2010, but following
a decline is expected to peak again in 2015 at $17.6 billion as the new market
entrants gain traction.

THROMBOSIS
A thrombus is an aggregation of platelets within the lumen of a blood
vessel. Thrombosis is caused by abnormalities in one or more of three
broad categories: blood composition, endothelial cell function, and blood
flow, and the formation of a thrombus usually stems from pathogenesis
resulting from injury to a vessel wall, stasis of blood flow, or a blood state of
hypercoagulability. The clotting system has many balances to ensure that
clot formation is appropriate, but abnormal clot formation eventually results
in ischemia and potentially infarction.

There are two distinct forms of thrombosis: that which occurs in the venous
system and that which occurs in the arterial system. The underlying causes
are usually different; arterial clots are associated with atheromatous plaque
formation and present as ischemic diseases including acute coronary
syndrome (ACS), stroke, myocardial infarction (MI), and peripheral arterial


disease (PAD). Cardiovascular procedures, such as stenting, also irritate the
arterial vasculature and can lead to clot formation. Deep vein thrombosis
(DVT) and pulmonary embolism (PE) are the major conditions arising from
thrombosis in the venous system, which usually results from a simple slowing
of blood flow due to major surgery or post-operative immobility. Atrial
fibrillation (AF), which has high risk of stroke because of stasis of blood flow in
the atria, is also treated similarly to venous thromboembolic disease.

Most disorders associated with thrombosis are initially treated in the
hospital or acute setting, which is then followed by patients requiring long-
term chronic anti-thrombotic therapy. Arterial and venous thromboses
are currently managed differently, with antiplatelet agents showing most
benefit in arterial thrombosis, while anticoagulation agents are used for the
management of venous disease, although this paradigm may change in the
longer term.

ARTERIAL THROMBOSIS
Due to the platelet’s role in the clotting process, it continues to be a key
target for the treatment of arterial-associated thrombosis. Antiplatelet
drugs can work in different ways, but they all alter platelet activation at the
site of vascular damage, crucial to the development of arterial thromboses;
activated platelets undergo shape change, aggregate, and adhere to
endothelial cell walls. Inhibition of any of these mechanisms thereby
prevents formation of the thrombus.

Platelet inhibitors can be classified according to their mechanism of action;
current drug classes include adenosine diphosphate (ADP) antagonists,
thromboxane A2 (TXA2) inhibitors, glycoprotein IIb/IIIa (GPIIb/IIIa)
antagonists, and direct thrombin inhibitors.

The only member of the TXA2 class is aspirin, which irreversibly inhibits
both isoforms of COX and blocks the formation of TXA2 that causes platelet
aggregation inhibition. GPIIb/IIIa antibodies and antagonists inhibit the
final common pathway of platelet aggregation - cross bridging of platelets
by fibrinogen binding to the GPIIb/IIIa receptor. ADP inhibitors block
the platelet-bound ADP receptor P2Y12, either reversibly or irreversibly,
inhibiting activation of the ADP-mediated GPIIb/IIIa complex and
preventing the platelets from changing shape. Direct thrombin inhibitors
block thrombin receptor protease-activated receptor-1, thus inhibiting
platelet aggregation.

PLAVIx: THE DECLINING PATRIARCH
Bristol-Myers Squibb (BMS) and sanofi-aventis’s ADP inhibitor Plavix has been
a huge success worldwide, with a broad label and strong data from four major
clinical trials resulting in Class I recommendations in many guidelines for
ACS, PAD and stroke. In ACS, over 95% of stented patients are discharged on
Plavix, and data from the CURE trial demonstrated that treatment with Plavix
reduced the risk of MI, stroke or cardiovascular death by 20%.

Driven by such strong data and following many years of physician familiarity,
the drug became the second biggest selling medicine globally, behind
Lipitor, and posted revenue of $9.5 billion in 2010. Sales are expected
to stabilize in the short term, according to Thomson Reuters Forecast,
remaining at $9.4 billion until 2011, as the incidence of disease where Plavix
is indicated continues to rise and competition remains limited.

However, Plavix is facing several headwinds. These include patent expiry in
May 2012, with numerous generics companies waiting in the wings. In addition,
the drug faces growing competition from new rival ADP receptor inhibitors


including Eli Lilly’s Effient (approved in 2009), as well as new competition from
Brilinta shows superior effectiveness over
a potentially stronger competitor, AstraZeneca’s Brilinta. Additionally, there
Plavix, according to data from the PLATO
are no new major extension trials underway, while data from the CURRENT/
study which showed a 16% relative risk
OASIS-7 trial examining higher Plavix dosing were also mixed and are not
reduction in cardiovascular events for
likely to lead to increased revenue. Thomson Reuters Forecast Consensus sales
Brilinta over Plavix.
indicate that there will be a significant drop upon patent expiry in 2012 to $5.8
billion, and continue to tail off to $2.3 billion in 2015.

EFFIENT: SLOW UPTAkE, MAY NOT BE
SUFFICIENTLY DIFFERENTIATED
Eli Lilly and Daiichi Sankyo’s Effient was approved in July 2009 in the US
with a competitive label in the ACS- percutaneous coronary intervention
(PCI) market. The drug was launched at a premium to Plavix, which Eli Lilly
stated is supported by data from a substudy of the TRITON-TIMI trial that
demonstrated reduced medical costs relative to Plavix. However, the FDA
did not allow a superiority claim relative to Plavix in the label.

The drug’s approval was based on the 13,000-patient TRITON-TIMI38 trial,
which conclusively demonstrated superiority over Plavix in PCI, although there
was increased bleeding in certain subgroups. Effient was superior to Plavix
in its primary endpoint of prevention of MI, stroke and cardiovascular death.
However, in the individual components of the primary composite endpoint,
only the reduction in non-fatal MI was significant, with positive trends seen in
the reduction of cardiovascular death and non-fatal stroke endpoints.

The fatal bleeds seen in the trial were a concern (21 for Effient versus 5
for Plavix); a benefit in cardiovascular mortality would have supported a
stronger risk-benefit profile given the increased risk of life-threatening
bleeds observed. Bleeding will likely be a significant hurdle to overcome,
and the drug is hampered by strict warnings on bleeding risk which are also
likely to limit uptake outside the PCI indication, pending additional data.
Furthermore, Plavix does not have a bolded warning against use in patients
with prior stroke, whereas Effient does. Accordingly, the drug has endured a
relatively slow start, posting sales of $115 million in 2010.

The drug also faces other headwinds and is likely to have only 2 years to
establish itself in the PCI setting before further competition comes online
with Brilinta, with the entry of generic Plavix another significant threat a
year later. However, the drug’s potency, as well as its once-daily dosing,
should garner use in patients who require more potent therapy; critical
to market share will be data from the ongoing TRILOGY study, which is
designed to demonstrate superiority over Plavix in medically managed ACS
patients. Data are expected in October 2011 and will be key to expanding
Effient’s addressable market. Thomson Reuters Forecast’s Consensus sales
rise to $734.5 million in 2015.

BRILINTA: A LESS POTENT BUT
STRONGER COMPETITOR
By contrast, AstraZeneca’s Brilinta has not shown an increased bleeding
risk. Data from the PLATO study presented in 2009 demonstrated that
Brilinta prevents cardiovascular events more effectively than Plavix. There
was an overall 16% relative risk reduction in cardiovascular events for
Brilinta over Plavix, with an 18% relative risk reduction in cardiovascular
death, a 20% relative risk reduction in MI, a 38% relative risk reduction in
stent thrombosis, and a 19% relative risk reduction in total mortality.

These potency data were less impressive than Effient, with a lower event
reduction in the primary endpoint (superiority to Plavix in the composite
endpoint) and in stent thrombosis. Importantly, however, the bleeding


profile was in line with Plavix, which should provide the differentiation to
make Brilinta a commercial hit. Furthermore, Brilinta’s reversibility will also
allow treatment discontinuation 2 days before coronary artery bypass graft
(CABG) and major surgeries (versus 5 to 7 days for Plavix and Effient). On
the downside, recommended dosing is twice-daily, while Plavix and Effient
are once-daily.

Despite these strong data, the drug has run into delays. The FDA issued
an approvable letter in December 2010 following an analysis from a North
American subgroup, which indicated a lack of benefit in 9% of patients, raising
questions about a possible interaction between Brilinta and high-dose aspirin,
commonly used in the US. AstraZeneca carried out further data analyses,
and concluded that an interaction was likely. The FDA issued a Complete
Response letter in January 2011, and will make its final decision in July 2011.

Positive label negotiations will be crucial for AstraZeneca as differentiating
the drug from Plavix will be key once generics come in. Thomson Reuters
Forecast Consensus sales indicate that Brilinta will become the leading
brand antiplatelet agent over the long term, with sales of $1.4 billion in 2015.
However, the entry of generic Plavix in 2012 will significantly temper sales.

REPORTED AND CONSENSUS FORECAST REVENUE (MILLION US$)
Plavix Efﬁent Brilinta

10000
SALES IN US $ MILLIONS

8000

6000

4000

2000

0 2009 2010 2011 2012 2013 2014 2015 YEAR*

REPORTED CONSENSUS

* Data are derived from Thomson Reuters Forecast

GLYCOPROTEIN IIB/IIIA INHIBITORS: USE IN THE
SHORT-TERM SETTING ONLY
The GPIIb/IIIa inhibitors are a class of antiplatelet agents that are frequently
used during PCI. Their use has fallen dramatically since the introduction
of Plavix, particularly as they were initially licensed based on clinical trials
using unfractionated heparin as the anticoagulant of choice. However, they
still find a place in the short-term use market, particularly in patients where
ischemic risk is high.

Merck & Co’s Integrilin is the market leader in the GPIIb/IIIa sector, with 56% of
total sales in 2009. The drug is expected to maintain market share, bolstered by
solid clinical data from the ESPRIT trial, which demonstrated a 37% relative risk
reduction for MI in patients undergoing stenting, and a favorable cost profile.
The company carried out the EARLY-ACS trial, which investigated early use of
Integrilin in high-risk ACS patients as soon as they are diagnosed. However, the
trial missed all endpoints and without this indication sales are likely to continue
to decline relative to the ADP inhibitor blockbusters, which in addition, are
orally dosed and can be used in the longer-term. Thomson Reuters Forecast
Consensus sales indicate that 2015 sales will be minor compared to the
market leaders, with sales of $200 million at that time.


Thomson Reuters Forecast also indicates declining sales for Eli Lilly and
Johnson & Johnson’s GPIIb/IIIa inhibitor ReoPro, having been clipped for
many years by positive data for Integrilin from the ESPRIT trial. Attempts
to support sales by extending usage into stroke patients failed after safety
concerns following increased rates of intracranial hemorrhage in the
AbESTT-II trial. Medicure’s GPIIb/IIIa inhibitor Aggrastat will likely remain a
third-line option.

Integrilin ReoPro

300

270

240

210

180

150 2009 2010 2011 2012 2013 2014 2015 YEAR*

REPORTED CONSENSUS


FURTHER ALONG THE ANTIPLATELET PIPELINE
Until recently, The Medicine Co (TMC)’s cangrelor, the first injectable reversible
ADP inhibitor, was in phase III development for the prevention of arterial
thrombosis in patients undergoing PCI. Unlike Plavix and Effient, platelet
activity resumes after 60 minutes, which was expected to allow flexibility should
patients require CABG. However, development in ACS was discontinued as
non-inferiority to Plavix was not observed in the company’s CHAMPION trials.
The company decided instead to focus on cangrelor as a short-term therapy to
allow safe ‘bridging’ of patients during the pre- and post-surgical periods where
patients discontinue Plavix and are at increased risk. The company believes
that the rapid onset, offset and titratable pharmacology make cangrelor a good
candidate for this potential short-term use.

Competition for Plavix from outside the ADP inhibitor class is also anticipated.
Potentially the most promising is Merck & Co’s vorapaxar, which blocks thrombin
receptor protease-activated receptor-1 thereby inhibiting platelet aggregation.
However, the drug has suffered a recent setback with the termination of one of
two pivotal phase III trials (TRACER) in ACS due to increased rates of bleeding.
Another phase III trial, TRA 2P, investigating the drug in the secondary prevention
of cardiac events post-ACS will continue, but treatment of patients included in the Vorapaxar is a first-in-class thrombin
trial with previous stroke has been terminated. receptor antagonist.

Despite this setback, vorapaxar is still being tested in 20,000 patients.
Vorapaxar’s promise was that it was conceivable that it might not cause extra
bleeding when coadministered with Plavix, which is now being called into
question. How valuable this new treatment is will depend on exactly how much
bleeding risk there is. Thomson Reuters Forecast Consensus sales currently
predicts blockbuster status by 2015, with expected sales of $1.3 billion.


VENOUS THROMBOSIS
Venous thromboembolism (VTE) is the collective term for DVT and PE, and
the most at-risk patients are those who have undergone orthopedic surgery,
notably hip or knee replacement. AF, which causes clots because of stasis of
blood flow in the atria, is also considered a venous thrombotic disease.

The current market landscape for VTE is competitive, and there are more
than ten approved products for VTE, which include anticoagulants and
thrombolytics. The market is largely dominated by generic products;
although there are few branded products, competition between the generic
and branded products is strong. In terms of efficacy, the currently marketed
products are effective in reducing total VTE events, reducing proximal DVT
events and decreasing the risk of PE; however, they are associated with
serious side effects, such as increased bleeding and thrombocytopenia.
Thus the need for new targeted therapies with improved efficacy and safety
profiles remains.

Low molecular weight heparins entered the market in the mid-1990s, and
became the mainstay of DVT treatment given clinical advantages including
dose predictability, less bleeding and no thrombocytopenia. However, the
dominance that low-molecular-weight heparins have held in the VTE market
will be severely reduced over the next decade following the introduction
and market penetration of several novel oral agents. These oral agents
will offer significant advantages over this class of drugs, most notably,
Bayer’s Xarelto, BMS and Pfizer’s Eliquis and Boehringer Ingelheim’s
Pradaxa, none of which require patient monitoring. These new agents have
all targeted DVT prophylaxis as the quickest path to market, but the oral
products will not present much advantage in the acute setting, with the
largest opportunity residing in AF, medically managed ACS, and secondary
prevention of VTE.

Further growth in the market will be supported by the high incidence of the
disease, increased uptake of novel drug classes and the expected launch of
me-too candidates with improved efficacy and safety.

LOVENOx: THE BROADEST LABEL
The dominant low molecular weight heparin is sanofi-aventis’s Lovenox,
with the broadest label and largest clinical trial database. With limited
competition, sales reached $4 billion in 2009, declining slightly in 2010 to
$3.9 billion. Lovenox is indicated for the prevention of post-surgical DVT, the
prevention of DVT in medical patients, treatment of DVT with or without PE,
prevention of morbidity and mortality subsequent to unstable angina with
non-Q wave MI, and treatment of STEMI patients receiving thrombolysis and
being managed medically or with PCI. Numerous trials have demonstrated
the superiority of Lovenox over unfractionated heparin in each of these
settings, including Synergy, ExTRACT-TIMI25, Prevail and ExClaim.

Despite the strong clinical profile, the drug is facing numerous challenges.
Sales are being affected by the launch of a generic version of the drug in
mid-2010, following several attempts from sanofi-aventis to prevent the
FDA from approving a generic version based on the drug’s macromolecular
nature. In addition, further generics are expected in the EU as well as the
US, despite high regulatory hurdles for approving generic versions of this
complex molecule. However, potential competition from novel oral agents,
such as Pradaxa and Xarelto, could pose the biggest threat to the heparins
franchise. Thomson Reuters Forecast Consensus sales indicate a decline
steadily over the longer term, dipping to $2.1 billion in 2015.


ARIxTRA: OPPORTUNITY MISSED
GlaxoSmithKline (GSK)’s Arixtra, a pentasaccharide inhibitor of activated
Factor Xa, entered the market in 2002. However, the drug failed to be
a significant competitor to Lovenox as its label in the US is restricted to
prophylaxis of DVT, and gains versus low molecular weight heparins have
been modest, likely due to a slight increase of bleeding seen in orthopedic
prophylaxis trials.

The company’s efforts to extend the label to include prophylaxis in patients
with ACS seem to have been halted by two approvable letters in 2007, with
no further updates since that time. Trial data in ACS were positive, with
equivalent efficacy to Lovenox but fewer bleeds seen in the OASIS-5 trial,
and an opportunity for a competitive market position against Lovenox may
have been lost. Arixtra sales in 2010 were a mere 13% of the revenue posted
by Lovenox, and although Thomson Reuters Forecast expects Consensus
sales to rise by 2015, which is in contrast to those of Lovenox, Consensus
2015 sales of $600.1 million will mean the drug remains a minor player in
the market.

LOVENOX AND ARIXTRA: TOP SELLING VENOUS THROMBOSIS DRUGS
REVENUE (MILLION US$)

Lovenox Arixtra

5000

4060

3120

2180

1240

300 2008 2009 2010 YEAR*


xARELTO: BROAD DEVELOPMENT STRATEGY BUT IS
THERE A LIVER SIGNAL?
Competition for Lovenox from outside the heparins class has been expected
for many years but is only now materializing. AstraZeneca’s direct thrombin
inhibitor Exanta had been expected to revolutionize the oral anticoagulants
market but, following approval in DVT prophylaxis, was withdrawn in 2006
due to liver toxicity. Boehringer Ingelheim’s direct thrombin inhibitor Pradaxa
was the first oral anticoagulant to reach the market following the Exanta
disappointment, but it is Bayer’s Xarelto that may hold the greatest promise.

Xarelto is a Factor X inhibitor, a class of anticoagulants that act directly
on Factor X in the coagulation cascade without using antithrombin as a
mediator. It is Xarelto’s broad development strategy across multiple VTE
indications that is likely to be key to its future success. Xarelto launched
in Europe in 2008 for the initial indication of prevention of VTE in patients
undergoing orthopedic surgery. This approval was based on data from the
RECORD-1, -2 and -3 studies, which examined Xarelto versus Lovenox,
consistently demonstrating superiority in efficacy endpoints, with a similar
bleeding profile. However, the FDA noted concerns of hepatotoxicity and
issued an approvable letter pending further analysis of safety data from
ongoing trials. A Complete Response was submitted in January 2011.


Bayer is looking to broaden Xarelto’s label in several other potentially
more meaningful acute and chronic indications, with trials undertaken
including MAGELLAN for VTE prevention in medically ill patients, EINSTEIN
in VTE treatment and secondary prevention, and ROCKET AF for AF
prevention. These new indications will greatly expand the drug’s reach and
revenue potential, and are also likely to enable full characterization of the
hepatotoxicity risk. Data from the longer-term phase II study ATLAS ACS
TIMI46 may also alleviate toxicity concerns as the trial is studying a higher
dose over a longer time period. Thomson Reuters Forecast’s Consensus sales
build steadily, reaching $2.3 billion in 2015.

PRADAxA: POTENTIAL SEA CHANGE IN AF
Boehringer Ingelheim’s Pradaxa, an oral direct thrombin inhibitor, was the
first competitor to Lovenox to reach the US market across all classes, and
the first new oral anticoagulant to reach the US market for 50 years. It was
approved in the EU for the prevention of DVT following orthopedic surgery in
2008, and in January 2011, it stole a march on its competitors with approval
in the US for the prevention of stroke in patients with AF.

Data from the phase III RE-NOVATE and RE-MODEL trials supported
approval for DVT, which demonstrated non-inferiority to Lovenox in hip
replacement surgery; rates of bleeding were similar. The phase III program
for stroke prevention in AF involved RE-LY, the largest AF trial to date, for
which data were reported in 2009. Data were impressive, with two different
doses of Pradaxa over 2 years demonstrating comparable-to-better efficacy
in preventing stroke and equal-to-lower risk of bleeding versus warfarin.
The highest dose demonstrated a 34% reduction in the incidence of stroke.
There were some issues surrounding the trial design for RE-LY, primarily as
it was open-label. However, the quality of the data are likely to outweigh
any concerns, and Thomson Reuters Forecast expects the drug to see
rapid uptake in prevention of stroke in AF, despite the FDA not allowing a
superiority claim over warfarin in the label.

The drug also faces limited competition among current injectable direct
thrombin inhibitors, including TMC’s Angiomax and Mitsubishi Tanabe’s
argatroban, which according to Thomson Reuters Forecast do not pose a
significant threat. Angiomax failed to get approval for medically managed
ACS and is now likely confined to PCI.

OVERCOMING LOVENOx: THE HURDLES FACED
Much of the success of Pradaxa and Xarelto will depend on how they can
penetrate the existing market and then expand its current scope. There are
a number of factors that could constrain their uptake. However, both drugs
are expected to be able to assert themselves in the market, and the sales
potential of Pradaxa and Xarelto remains strong.

All anti-clotting agents carry a risk of unwanted bleeding events, and the
new oral anticoagulants are no exception. Importantly, the effects of many
of the older anti-thrombotic agents can be reversed if a patient is bleeding,
whereas currently Pradaxa and Xarelto cannot be reversed quickly. Price
could be another hurdle, as both are expensive and some payers are likely to
opt for the less expensive options. Generic Lovenox will also create pricing
pressures here and will potentially lower prices across the sector.

Uptake in the VTE primary prophylaxis market may also be slow as this is
characterized by shorter periods of hospital-based therapy, where delivering
injectable agents, such as Lovenox, is not a significant disadvantage.
However, the stroke prevention in AF and prevention of recurrent VTE
indications is where the blockbuster sales will lie, and rapid uptake and deep
penetration of these drugs is expected in these markets.


Lovenox Xarelto

5000

4000

3000

2000

1000

0 2009 2010 2011 2012 2013 2014 2015 YEAR*

REPORTED CONSENSUS


FURTHER ALONG THE PIPELINE
Pradaxa and Xarelto potentially face considerable longer-term competition
from other rivals currently in development. Published in 2010, findings from
the ADVANCE-2 study show Pfizer and BMS’s Eliquis, a highly selective
Factor Xa inhibitor, is more effective than Lovenox in preventing VTE after
knee replacement surgery and not associated with increased bleeding. The
drug was filed for DVT prevention following orthopedic surgery in Europe
in March 2010, and a rolling NDA was initiated in the US for the prevention
of stroke in AF in October 2010. The AVERROES phase III data in stroke
prevention has validated both the efficacy and safety profile in this setting,
and could offer some positive points of differentiation versus Pradaxa.
However, use in patients who have had an MI will not be pursued following
an increased bleeding risk seen in the APPRAISE-2 trial. Thomson Reuters
Forecast Consensus sales indicate apixaban will begin slowly, but it is
forecast to reach $1.6 billion in 2015.

Another novel oral Factor Xa inhibitor under development is Portola’s
betrixaban. In addition to positive data in VTE prevention trials in knee
replacement surgery and stroke prevention in AF, betrixaban is the only novel
oral anti-clotting agent being tested in patients with renal malfunction.

The Factor Xa inhibitor edoxaban from Daiichi Sankyo is also targeting
approval in AF. The phase III ENGAGE AF-TIMI 48 trial is comparing
edoxaban with warfarin for the prevention of stroke and systemic embolism
in around 20,000 patients with AF and has completed recruitment.
Development for the treatment of VTE is also ongoing, though the drug
will only be filed for the prevention of VTE in orthopedic surgery in Japan.
Accordingly, Consensus sales reported by Thomson Reuters Forecast remain
low, at $140 million in 2015.

In contrast, competition to Lovenox from within the low molecular weight
heparin class has largely failed, with development of the most advanced
competitor, sanofi-aventis’s semuloparin, narrowed down to only include
oncology and DVT prophylaxis in abdominal surgery. Development in
general medical conditions and orthopedic surgery DVT prophylaxis was
discontinued; Thomson Reuters Forecast indicates Consensus sales of $283.3
million in 2015.


CONSENSUS FORECAST REVENUE (MILLION US$)
Eliquis edoxaban semuloparin

1700

1360

1020

680

340

0 2011 2012 2013 2014 2015 YEAR*

SECTION II
DEALS HIGHLIGHTS
Anti-thrombotic therapeutics belong to a broad class of drugs that include
antiplatelet agents, anticoagulants and thrombolytics, targeting a variety
of therapy areas across arterial and venous thromboembolism indications.
Deals coverage on Thomson Reuters Pharma indicates that approximately
250 deals have been forged under the ‘thrombosis’ category, some dating
back to the late 1980s.

The following deals cover some prolific players in the development of
promising anti-thrombotic agents, including sanofi-aventis, Daiichi Sankyo
and Merck & Co. This selection of notable and high-valued agreements may
provide some partnering insight into this vast therapeutic market.

SANOFI-AVENTIS: AN ExTENSIVE ANTI-THROMBOTIC
PARTNERING LANDSCAPE
It is apparent that sanofi-aventis has emerged as a significant player in the
anti-thrombotics arena. The company’s involvement in the field dates back
“We look forward to the opportunity to to its earlier incarnation, Sanofi-Synthelabo.
work with Bristol-Myers Squibb to bring
Plavix, an inhibitor of ADP-induced platelet aggregation, was codeveloped
this important new compound to patients and launched by Sanofi-Synthelabo and BMS. Sanofi-Synthelabo partnered
around the world. We believe that Plavix with BMS in 1993, whereby BMS acquired worldwide codevelopment
represents an important advance in and comarketing rights outside Japan. Specific financial terms were not
treatment for a broad group of patients at disclosed. The deal is set to expire in 2013 or with the expiration of all
risk of heart attack, stroke, and peripheral patents and exclusivity rights in the individual territories.
arterial disease.”
Sanofi-Synthelabo granted Japanese rights to Daiichi Seiyaku by October
Kurt Briner, president of Sanofi pharma and 1994; financial terms for this deal were also undisclosed. In September
executive Vice president of sanofi-aventis 2005, the holding company Daiichi Sankyo was formed following the
merger of Daiichi Seiyaku and Sankyo. As a result, Daiichi Sankyo returned
Plavix rights to sanofi-aventis, as the merger included Sankyo’s potential
rival Effient; Daiichi Sankyo would continue to copromote Plavix until
Effient’s launch. In February 2007, the joint promotion agreement was
terminated, ending Daiichi Sankyo’s involvement with Plavix. Sanofi-aventis
proceeded to launch the drug alone in Japan in May 2009.

In addition to arterial thrombotics such as Plavix, sanofi-aventis has also
been involved in the development of a number of venous thrombotics.


Lovenox, a low-molecular-weight fraction of heparin, was developed and
launched by Rhone-Poulenc Rorer, which became sanofi-aventis following
Rhone-Poulenc’s merger with Hoechst in December 1999. In June 2010,
Kaken and sanofi-aventis concluded a sales and marketing agreement
for the anticoagulant. Kaken agreed to promote, disseminate and collect
information related to safety, as well as taking on marketing responsibilities
in Japan from October that year; sanofi-aventis was to remain the marketing
authorization holder. The company expected to utilize its human resources
more efficiently by outsourcing the drug’s marketing to Kaken. Financial
terms for the deal were not disclosed.

Arixtra, a synthetic pentasaccharide inhibitor of activated Factor Xa, was “Arixtra is an important medical option
originally developed and launched by Sanofi-Synthelabo in collaboration with for the prevention and treatment of deep
NV Organon (now Organon BioSciences). The product is now marketed by GSK. vein thrombosis and pulmonary embolism.
A collaborative agreement between Sanofi-Synthelabo and Organon Aligning and integrating the Adolor and
for the development of Arixtra was signed by July 1995. Joint ventures, GSK sales forces will expand our reach
equally owned by the companies, would be responsible for distribution and with Arixtra while paving the way for future
commercialization in the US, Canada and Mexico, while Sanofi-Synthelabo collaboration in the surgical market.”
remained solely responsible for marketing and commercialization in Europe
Kevin Lokay, Vice president of glaxoSmithKline
and the rest of the world, excluding Japan. Specific financial terms of the oncology and acute Care
agreement were undisclosed. In January 2004, it was reported that Sanofi-
Synthelabo planned to reacquire Organon’s rights to Arixtra, subject to
regulatory approval. By October that year, Organon had discontinued
development of the drug and returned all rights to Sanofi-Synthelabo.

Subsequently, in April 2004, Sanofi-Synthelabo reported that it was to
divest exclusive rights for Arixtra and an associated manufacturing plant to
GSK, contingent on the Sanofi-Synthelabo/Aventis merger. Financial terms
of the divestment were undisclosed. Following the successful formation of
sanofi-aventis in August 2004, Arixtra’s divestment to GSK was completed
in September. The following year, GSK signed a two-year copromotion
agreement in the US with Adolor, with GSK to provide cost reimbursement
to Adolor. However, the deal was terminated in 2006.

Sanofi-aventis is currently conducting phase III trials on semuloparin, its
ultra-low molecular weight heparin, for the potential prophylaxis of venous
thromboembolic events in medical and surgical patients. Currently, sanofi-
aventis holds worldwide rights and the program remains unpartnered.

DEAL DEAL
LICENSING PARTNER START VALUE
DRUG COMPANY COMPANY DATE (US $)*
Plavix sanofi-aventis Bristol-Myers 1993 Undisclosed
Squibb
Plavix sanofi-aventis Daiichi Sankyo October Undisclosed
1994
Lovenox Kaken sanofi-aventis June 2010 Undisclosed
Pharmaceutical
Arixtra Sanofi- NV Organon July 1995 Undisclosed
Synthelabo
Arixtra Sanofi- GlaxoSmithKline April 2004 Undisclosed
Synthelabo
argatroban Mitsubishi Sanofi-Synthelabo October Undisclosed
1993

TABLE 1: SUMMARY OF CERTAIN SANOFI-AVENTIS AGREEMENTS FOR ANTI-THROMBOTICS
* Approximate values based on the achievement of all milestones for the
principal components included in the deal.


DAIICHI SANkYO: A LICENSING PORTFOLIO WHICH
INCLUDES ARGATROBAN, EFFIENT AND EDOxABAN
Daiichi Sankyo also shares a strong interest in the licensing of promising
anti-thrombotic agents. Both Daiichi and Sanofi-Synthelabo (as Synthelabo)
inlicensed rights to Mitsubishi’s argatroban, a non-protein, arginine-related
thrombin inhibitor, indicated for chronic arterial obstruction, acute cerebral
thrombosis and heparin-induced thrombocytopenia.

Synthelabo entered into a codevelopment, sales and marketing agreement
with Mitsubishi in Europe and francophone Africa in October 1993. Financial
terms of which were undisclosed. However, by February 2000, Sanofi-
Synthelabo had dropped argatroban, thus terminating the deal.

By October 1994, Mitsubishi granted Daiichi Japanese sales and
comarketing rights to the thrombin inhibitor. Financial terms were not
disclosed. Argatroban was launched as Slonnon by Daiichi and as Novastan
by Mitsubishi.

“This collaboration reinforces our Effient, a P2Y12 inhibitor of ADP-induced platelet aggregation, was
commitment to cardiovascular research developed and launched by Daiichi Sankyo (formerly Sankyo) and Eli Lilly.
The companies signed a Letter of Intent to develop the drug in December
and expands our growing portfolio 2000, and agreed to copromote in the US and comarket in the rest of the
of antithrombotic compounds. We world, excluding territories where Eli Lilly had exclusive sales and marketing
are looking forward to a long and rights. Development responsibility would be shared between the companies,
productive relationship with Sankyo, and UBE Industries was designated as the manufacturer of the bulk
a company widely recognized for its material. Eli Lilly agreed to pay Sankyo a signing fee, milestone payments
and royalties on sales of the product. Daiichi Sankyo agreed to copromote
cardiovascular expertise and innovation.” the drug in Mexico with Eli Lilly, under a Eli Lilly affiliate in the region.
august m Watanabe, mD and executive Vice
president of Science and technology for Lilly Daiichi Sankyo is also currently developing the Factor Xa inhibitor edoxaban
as an anticoagulant for the prevention of venous thromboembolic events,
including stroke; the company expects approval in 2011. The program is
unpartnered, and Daiichi Sankyo hold worldwide rights.

DEAL DEAL
argatroban Mitsubishi Daiichi Seiyaku October Undisclosed
1994
Effient Daiichi Sankyo Eli Lilly December Undisclosed
2000
Effient UBE Industries Sankyo December Undisclosed
2000

TABLE 2: SUMMARY OF CERTAIN DAIICHI AGREEMENTS FOR ANTI-THROMBOTICS



MERCk & CO: ESTABLISHED ARTERIAL THROMBOSIS
THERAPEUTICS AGREEMENTS
Merck & Co has also established its position in the development of arterial “We are very pleased to have Schering-
thrombosis therapeutics. Following Merck & Co’s merger with Schering-Plough
Plough, with its extensive capabilities
in November 2009, the company is currently developing the oral thrombin
receptor antagonist vorapaxar for the secondary prevention of cardiac events in and drug development experience, as
patients with prior MI or PAD. Merck expects to file an NDA in 2011. The program our worldwide partner for Integrelin.
is unpartnered, with Merck & Co holding exclusive worldwide rights. We believe this agreement will help us
to realize the full potential of Integrelin
Merck & Co also holds interests in various AstraZeneca products, including
the P2T receptor antagonist Brilinta, under a First-Option Agreement.
and help us build the resources we need
In March 2010, AstraZeneca notified Merck & Co that it would exercise in an effective and efficient manner.”
the First Option related to the relinquishment of Merck & Co’s rights. Vaughn m Kailian, president and
Brilinta has been launched in the UK and Germany for the prevention of Ceo of Cor therapeutics
atherothrombotic events in adults with acute coronary syndromes. There are
currently no other agreements for the product.

Integrilin, a synthetic cyclic heptapeptide GPIIb/IIIa antagonist and platelet
aggregation inhibitor, derived from rattlesnake venom, was codeveloped
and launched by Schering-Plough (now Merck & Co) and drug originator
COR Therapeutics (now Millennium). The companies entered a worldwide
collaborative development and commercialization agreement in April 1995.
Under the deal terms, the companies would copromote and share profits in
North America, and Schering-Plough retained the right to launch the drug in
Europe and assist COR in training a US cardiovascular sales force. COR would
receive a $20 million licensing fee, milestone payments of approximately $100
million, and royalties on European sales for a specified period, after which the
company could copromote in the territory and share profits. COR received
its first milestone payment, worth $24 million, in June 1998, triggered by
Integrilin’s approval in the US. Approval in the EU in August 1999 triggered a
further $12 million milestone payment. Schering-Plough returned European
marketing rights to Millennium in June 2004, retaining ex-European rights
(including US copromotion rights). However, by the following year, Schering-
Plough had acquired exclusive US development and commercialization
rights. Millennium would receive $35.5 million upfront and royalties for the
US lifespan of Integrilin (set as $85 million annually for the following 2 years).
Millennium would also receive approximately $45 to $50 million for the
purchase of existing product inventories.

Other deals for Integrilin include a collaboration between COR, Schering-
Plough and Genentech to copromote the drug with tenecteplase and
recombinant alteplase in hospitals across the US, signed in January 2001,
an exclusive European marketing rights deal with GSK in June 2004, and a
manufacturing agreement with Peptisyntha by May 2010.

DEAL
LICENSING PARTNER DEAL START VALUE
COMPANY COMPANY DATE (US $)*
COR Therapeutics Merck & Co April 1995 ~ $375 million
Genentech COR Therapeutics January 2001 Undisclosed
and Schering-
Plough
Millennium GlaxoSmithKline June 2004 Undisclosed
Pharmaceuticals
Peptisyntha Millennium May 2010 Undisclosed
Pharmaceuticals

TABLE 3: SUMMARY OF AGREEMENTS FOR INTEGRILIN


Aggrastat, a non-peptide GPIIb/IIIa receptor antagonist, was developed
by Merck & Co, and is currently marketed by Medicure in the US and Iroko
Pharmaceuticals in ex-US markets. Merck & Co’s Japanese affiliate Banyu
has held development and marketing rights in Japan since December 1996.

Initially, Guilford obtained exclusive commercial rights in the US, Puerto
Rico, Virgin Islands and Guam from Merck & Co in October 2003. Guilford
agreed to pay Merck & Co $84 million, as well as royalty payments based
on net sales until December 2012. However, in August 2006, following MGI
Pharma’s acquisition of Guilford, Medicure bought the US commercialization
rights from MGI Pharma for $19 million. Medicure would also pay Merck &
Co certain royalty payments. In January 2010, it was reported that Medicure
was seeking partners for outlicensing the product.

Iroko acquired all ex-US commercial rights from Merck & Co in January
2008; deal terms were undisclosed. Since then, Iroko has sublicensed rights
to Aspen PharmaCare Australia. Subsequently, Aspen PharmaCare Australia
granted Handok rights to market the drug in Korea by August 2009.

DEAL
LICENSING PARTNER DEAL START VALUE
COMPANY COMPANY DATE (US $)*
Merck & Co Banyu December 1996 Undisclosed
Pharmaceutical
Merck & Co Guilford October 2003 $84 million (plus
Pharmaceuticals royalties)
Merck & Co Iroko January 2008 Undisclosed
Pharmaceuticals

TABLE 4: SUMMARY OF AGREEMENTS FOR AGGRASTAT


BRISTOL-MYERS SqUIBB AND PFIzER ENTER
BILLION-DOLLAR DEAL FOR ELIqUIS
“We’re very pleased to collaborate with One of the highest valued anti-thrombotic deals on Thomson Reuters
Bristol-Myers Squibb on the worldwide Pharma covered a collaborative agreement between Pfizer and BMS for
Eliquis signed in April 2007.
commercialization of apixaban, which
has the potential to be a best- in-class Eliquis, a follow-on compound to BMS’s oral Factor Xa antagonist
product and would represent an excellent razaxaban, is a potential anticoagulant in development for a number of
strategic fit with our global cardiovascular thromboembolic indications.
franchise. We see significant opportunities
BMS granted Pfizer worldwide rights to codevelop Eliquis for a range
for an orally active anticoagulant of venous and thrombotic conditions. Pfizer agreed to pay $250 million
with the clinical profile apixaban has upfront, 60% of the development costs and up to $750 million in
demonstrated to date, particularly because milestones. Commercialization expenses and profits would be shared
of the clear need for new treatments equally between the companies.
to combat thrombosis and stroke.”
Jeffrey B Kindler, Chairman and Ceo of pfizer


xARELTO: A PARTNERSHIP BETWEEN
ORTHO-MCNEIL AND BAYER
Xarelto, an oral direct Factor Xa inhibitor indicated for the prevention “The collaboration with Bayer HealthCare
of venous thromboembolism in adults undergoing elective knee or hip
strengthens our growing cardiovascular
replacement surgery, has been developed and launched by Bayer and its
partner Ortho-McNeil. franchise. We share a common vision with
Bayer and look forward to contributing
The companies agreed in October 2005 to jointly develop and market Xarelto to the successful development of this
worldwide. Ortho-McNeil acquired exclusive marketing rights in the US for the promising compound by capitalizing
cardiology, primary care and hospital specialty markets, whilst Bayer retained
on our clinical and commercial
an option to copromote Xarelto in the US hospital and specialty markets.
Bayer would also retain sole ex-US marketing rights. As part of the financial expertise in the area of thrombosis.”
terms of the deal, Bayer would receive an upfront payment, milestone Joe Scodari, Worldwide Chairman of
payments of up to $290 million and royalties of up to 30%. pharmaceuticals group at Johnson & Johnson

DEAL DEAL
Eliquis Bristol-Myers Pfizer April 2007 < $1 billion
Squibb
Xarelto Bayer Ortho-McNeil October < $290
Pharmaceutical 2005 million +
royalties

TABLE 5: NOTABLE HIGH-VALUE DEALS FOR ANTI-THROMBOTICS

CONCLUSION
As expected, pharma giants such as sanofi-aventis, Daiichi Sankyo and
Merck & Co feature prominently in the development of some of the most
significant and promising anti-thrombotic therapeutics. The continued
presence of established companies like GSK, AstraZeneca, BMS and
Eli Lilly further illustrates the importance of the field and any potential
interest for investment. However, it is worth noting that the portfolio of
established and promising anti-thrombotics covered by Thomson Reuters
Forecast involve little or no partnering activity, eg Merck & Co’s vorapaxar,
sanofi-aventis’s semuloparin, Daiichi Sankyo’s edoxaban and Boehringer
Ingelheim’s Pradaxa, potentially representing an opportunity for partnering
activity. Other proprietary agents have started to emerge, which may
also dramatically affect the deals landscape of well-established products
currently on the market.

Notably, Portola (the US spin-off company from Millennium) forged two
noteworthy deals in 2009, each worth approximately $0.5 billion. The deals
covered three anti-thrombotic agents, all currently in phase II development.
In February 2009, the company granted Novartis exclusive worldwide
rights to develop and commercialize iv and oral formulations of the platelet
aggregation inhibitor elinogrel, as part of a deal worth up to $575 million
plus royalties. Later in July, the company granted Merck & Co worldwide
rights to develop and commercialize Factor Xa inhibitor betrixaban, under a
deal worth up to $470 million plus royalties. Such deals may support wide-
ranging transition in the market as it continues to progress and diversify.


Vast potential exists for novel anticoagulant and antiplatelet agents despite
considerable overlaps between patient populations. The heparins and Plavix
form the mainstay of arterial thrombosis management; these act through
different mechanisms, but both suffer from a predisposition to increased
bleeding. New competition is now entering the market that will rival Plavix’s
market domination in arterial thrombosis, most notably Brilinta and Effient,
which have shown superiority over Plavix. Brilinta is the stronger competitor,
with comparable rates of bleeding as Plavix; AstraZeneca will be keen to
negotiate superiority over Plavix into the label to ensure it can defend its
market position when Plavix generics enter in 2012.

In terms of the venous market, Exanta was the first oral anticoagulant in 50
years and expected to revolutionize the market and steal market share from
the existing market leader Lovenox. However, the drug resulted in post-
approval liver toxicity, and subsequently withdrawn. New oral competition
is now arising from Xarelto and Pradaxa, which have both shown promise in
trials of the most lucrative long-term stroke prevention in AF indication.

Overall, the safety hurdles in the anti-thrombotics sector remains high, and
new agents will have to demonstrate superior effectiveness that outweighs
any increased bleeding risk. Furthermore, new agents will require outcomes
data for full market penetration. However, paradigm shifts towards long-
term secondary prevention in both the arterial and venous thrombosis
markets, as well as oral prophylaxis in the venous category, mean that both
markets are poised to change dramatically to finally achieve that most
elusive of goals, the complete replacement of warfarin.


NOTES


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