Name Game, Game Change?

I’m thinking “game” this weekend because the Patriots are in the Super Bowl, again, and I will need to watch it like the rest of Boston. I only watched my first football game two years ago when, surprise surprise, the Patriots were in the Super Bowl. Every sports fan knows the Patriots, I am told. It’s easy to cheer for your home teams when the names (Red Sox, Patriots, Bruins, Celtics) endure for decades. It’s harder when it’s the drug companies that make your factor concentrate. There’s a lot of game changing going on lately.

The news was announced just three days ago: Biogen, maker of Eloctate and Alprolix, has spun off its hemophilia division, which has now become an entirely separate and new company called Bioverativ.

Biogen’s two revolutionary products, the first ones with a longer half-life, were game changers. Now there are a few more choices for longer half-life products, but these were the first and were rolled out with much fanfare. Then boom! Three years later, Biogen doesn’t want them anymore.

This is just a reminder to us patients that this is a marketplace, and we are consumers. And companies need to make business decisions—hence the “game.” As consumers, it’s up to us to understand how the game is played, and who are the players. The names have been changing, more rapidly than I can keep up with in the specialty pharmacy arena, and those are truly game changers.

In the factor concentrate manufacturing arena, we had two name changes just in the last few months: Biogen to Bioverativ, and Baxalta to Shire. But this has been happening for years in our community, so here’s a review. It’s worth knowing the players—of which YOU, the consumer, are the most important!

Remember Alpha? Those of you who use Alphanate or Alphanine may wonder why these drugs are called that when sold by the Spanish company Grifols. Simple: Grifols bought Alpha Therapeutics hemophilia therapies years ago and simply kept the drugs’ names the same. (It’s hard to change a drug’s name.) In 2011, Grifols also bought Talecris, making it the third-largest global manufacturer of plasma-derived therapies. Oh, and Talecris? It was a spin-off from Bayer, which didn’t want to keep plasma-therapies anymore. Bayer’s plasma-product Koate-DVI went to Talecris, and Bayer kept Kogenate FS. If you look at the Koate-DVI packaging, you’ll still see the Bayer primary color line around the box!

Baxter Healthcare produced factor concentrates like Recombinate, Advate, Hemofil M and FEIBA. It spun off its hemophilia division, which became an independent company called Baxalta. That didn’t last long. Shire, an Irish pharmaceutical company, liked what it saw and scooped it up. All the former Baxter/Baxalta products now belong to Shire.

The biggest name changer is CSL Behring. I knew it in 1987 as Armour Pharmaceutical. Then in 1996, Armour and Behringwerke (a Geman company) formed a joint venture known as Centeon. Things happen fast: in 1999, Centeon became Aventis Behring. Why? Armour’s parent companies (Rhone-Polenc Rorer and Hoechst) merged to become Aventis. Meanwhile, CSL (an Australian plasma therapies manufacturer) acquired ZLB Blood Transfusion Services. In 2004, CSL acquired Aventis Behring, to form ZLB Behring, later called CSL Behring.

(There’s a comprehensive timeline of this interesting company here.)

Genetics Institute: anyone remember that? They developed BeneFIX and ReFacto (no longer on the market). It evolved into Wyeth, and then was bought by pharma giant Pfizer Inc.

Bayer is one that seems to have stayed the same, but it’s had name changes too. Bayer bought Cutter Labs in 1978 and Miles Labs in 1979. In 1995, they all became Bayer. I think Novo Nordisk (Denmark) has stayed the same… so far!
And some companies dropped out altogether, like the American Red Cross.  And new ones entered, like Octapharma (Switzerland) and Kedrion (Italy), tapped to distribute Koate DVI for Grifols. And Aptevo Therapeutics… oh, which was owned by Cangene (Canada) first, then Cangene was bought by Emergent Biosolutions in 2014! And they all originated from Inspirational Biopharmaceuticals, which in 2013 sold all its product rights to them, and dropped out of the game.

More passes than Tom Brady!

Whew! It’s amazing tracking the history of just the name changes: but we also need to know products. We are tracking who makes what on our website Hemophilia Factor Chart by Brand, available as a download. We are updating it all the time… a necessity to keep track of this ever-changing game, and business.

Under the Tuscan Sun: A Company Branches Out

Beautiful hills of Tuscany

I spent last week in Italy. IIt was quite a change from two weeks in India. All I need is Indonesia and I will have done my Eat, Pray, Love hemophilia pilgrimage. Except I managed to eat in India, pray in Italy…. The rest has yet to be seen!

I spent a few days in Florence before heading slightly north for the real purpose of my trip. Florence is a city I studied intensely as a teen. While other girls were going to dances, I studied the Renaissance and became quite an “expert” at a young age. I copied paintings of the masters, as I loved art, and when I first arrived at age 17, knew more about where to go than our high school guide. So returning for my fourth time, I resolved to wander the streets and churches, revisit the masters, and stand
in awe of the treasures of Italy. Nothing man-made captures my stunned, silent
respect and worship like the statue of David.
On day four I headed to Lucca, to visit a pharmaceutical company called Kedrion. Kedrion came to our attention in the US a few years ago when it was contracted by Grifols to handle distribution of Koate-DVI, a plasma-derived factor VIII product. Originally produced by Bayer, it was divested, along with all the Bayer plasma division, to Talecris. Eventually Talecris was bought by Grifols. But the US government, leery that Grifols now had two plasma derived FVIII products, required Grifols to have a different company handle distribution of Koate-DVI. Enter Kedrion.
Kedrion may be new to the US, but not to Europe. Kedrion is a leading global pharmaceutical company specializing in the development, production and distribution of a wide range of protein products derived from human plasma. The company’s products are used to treat hemophilia, immune deficiencies, infectious diseases and other serious medical conditions in over 60 countries. The company owns four production facilities: two in Italy,
one in Hungary and one in the United States (currently leased to Grifols).
I was thrilled to be offered a tour of the production plant. The plant is nestled among the Tuscany hills in Lucca, an ancient city famed for its fortress-like walls that protect the denizens, once Romans in 180 BC. The scenery—snow capped mountains rolling away to the sea; petite, puffy clouds touching down on factories and churches— is breathtaking from the patio of the Renaissance (how appropriate) hotel, perched on a mountain and once owned by the Marcucci family, which also owns Kedrion.
I had dinner the night before the tour with Paolo Marcucci, CEO of Kedrion, and wife Paola Pardini, whom I have met before and who sponsor 17 children through Save One Life. With us was also Danilo Medica, Italy country manager for Kedrion, who I had also met before at a WFH event. Social events are always lovely with Italians, who know the fine art of socializing, eating and drinking, and offering sincere and mutual respect
and hospitality.

Laurie at Kedrion plant, with Charles Waller

So my purpose in visiting was to see the
plant, and learn more about this newcomer to the US market. Also, Kedrion has
been for a few years now our largest single donor of factor products to
Project SHARE, my factor donation program. We are now collaborating on ways to
secure even more factor to donate to the regions of the world where the 75%
live—those people with hemophilia with little or no access to treatment. Like…
some of the places I had just seen in India.

First, a snapshot: Kedrion was founded by the Marcucci family; current CEO Paolo is son of the founder. It offers technology transfer of plasma collection to Macedonia, Turkey, and Iran, as well as plasma-derived product sales to about 60 countries. It has 15 plasma collection centers (nine of which are in the US). About 95% of its products are plasma derived. Kedrion is one of the few factor manufacturers that is
considered part of a government healthcare system. About 75% of the company is owned by the Marcucci family; 25% is owned by government.
Kedrion experienced enormous growth in the past few years. Its business used to be only in Italy until just 2007; now it’s been global for five years. A dominant 60% of its business is international, part of this switch attributed to production acquisition sites in the US. It has a FV product in the pipeline, even though there are only 5-6 patients with FV deficiency in Italy. Clearly, Kedrion continues to have its eyes set on the world.
And hemophilia in Italy? There are 3,481 hemophilia A patients; 1,688 are severe, 1,320 mild, and 473 moderate. In 2013, FVIII consumption was about 555 million IU, with plasma-derived product use actually increasing, driven by IT therapy for inhibitor patients.  Still, recombinant products dominate the hemophilia market, at 66% of sales.
On a frosty Wednesday morning, I removed my jewelry, washed my hands thoroughly, suited up, and entered the plant with my hosts, to tour how plasma products are made. The plant fractionates 1 million liters (about 264,172 gallons) every year, using 24,000 liter tanks. First I watched a film on the plant: how plasma arrives, is checked, monitored and inventoried. How plasma is separated by centrifuge creating cryo paste for fractionation. There are 480 employees in Lucca, and the plant operates 7 days a week, 24 hours a day. It will be closed over Christmas for maintenance and
cleaning. The instruments and suites where products are made are cleaned daily.

On this tour I was able to watch albumin
being made. Albumin is the part of plasma used to bulk-up factor concentrates,
to allow them to be injectible. Alessandro, plant manager and our guide, explained
about different classes assigned to manufacturing suites (A-D), based on sterility
and cleanliness. As each product goes through each manufacturing phase, the
requirements for cleanliness gets more and more complex.

It’s not just that things must be sterile. In the suite, people come and go; there is air, exhalations, and ventilation. The air itself, pressurized like in an
airplane, to push air out if there is a breach, must be monitored constantly. You want a low level of environmental pollutants such as dust, airborne microbes, aerosol particles and chemical vapors. Levels of contamination are specified by the number of particles per cubic meter at a specified particle size. Instruments protruding out of the wall measure constantly the ambient air, and would signal an alarm if the air contained undesirable things in it at a level considered potentially harmful.
We watched as lab employees handled the sterile vials into which the albumin would be placed, all by machine to reduce human contact. The rubber stoppers were placed, and the machines sealed it with
the foil. I learned something new: I always thought the rubber stopper might be at risk to cause a breach of integrity of the vial if the vial got too hot or cold. But Alessandro assured me these stoppers are powerful and not likely to contract or expand with different temperature. It really is about temperature control to keep the protein from degredating and becoming less effective, less powerful.
Speaking of power, the plant must have power at all times. What of there was a black out, someone asked? Kedrion is self-sufficient in power, Alessandro explained. They produce energy themselves
using methane gas production.
Last, we learned about the “KQP”: Kedrion Quality Program, an eight step system, using among other things, regular
qualified donors, NAT testing, pathogen inactivation, and TSE agents, to assure that the products are safe.
The Italian Health System is complex, making me realize we aren’t the only ones with healthcare budgetary woes. With 19 regions that are traditionally independent, 645 public hospitals, 50 HTCs, and an ongoing economic crisis, the federal government is trying to consolidate hospitals, and is asking for additional cost reductions from
industry. And yet Kedrion must continue to fractionate Italian blood and return plasma-derived products back to the various regions.
One concern is that Italy’s not self-sufficient in any product. Consumption is growing faster than production, but consumption includes imported products at much higher per unit prices. In the face of an economic crisis, slashed healthcare budgets, the question is: can Italy use the products it has already to alleviate demand?
So that’s the point of my visit: in April 2013, Italian laws have changed regarding plasma. Previously Italian plasma had to be used by Italians, but now the law allows Italian regions to recover costs
by selling the plasma products to other countries. Or maybe, donating? To India, to Africa? We will see.
The name Kedrion comes from the Greek language for lemon tree (or juniper or citrus, depending on your source). Its symbol represents the deep roots Kedrion has in Italy, where the company was
built on Italian plasma and by a family dynasty, and its branches go out into the air, the world. I’m hoping they continue to branch towards developing countries, to patients waiting to know this unique company and benefit from its products.
To learn more about Kedrion:
Great Book I Just Read
Brunelleschi’s Dome by Ross King

The perfect book for reading while in Florence. My hotel was about 200 feet from Santa Maria del Fiore, and when I
stepped into the cobblestone streets each morning, the massive façade, capped by the
astounding dome, greeted me. This book goes into great detail about what it
took to create the 37,000 ton dome, one of the largest cupolas in the world,
completed in 1436. It took 16 years to complete (over 100 for the Cathedral itself!),
and the architectural construction was filled with competition, craftiness and creativity. Brunelleschi
invented all kinds of new ways to transport marble, to hoist the marble. He was
a genius of architecture, and this Dome today still awes and impresses. This
story is compelling, and shows the potential of man to create and persist. Brunelleschi
was foiled many times, faced many obstacles, but finished it, leaving behind
one of the most prominent and important symbols of the Renaissance. A must read
for anyone going to Florence. But a fabulous book on any account. I climbed the
436 stairs to the top and was rewarded with a breathtaking view of Florence, one
of my favorite cities. It boggles the mind how this could have been created, at
such a time, with such vision. You’ll never look at a church steeple or
basilica the same again once you read this. Five/five stars!
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