It could get ugly

There’s a very old saying that’s all fair in love and war, but whoever said that never meet a pharmaceutical rep. Although there aren’t as many as there used to be reps can play a pivotal role when it comes to launching a new drug. There is no question that formulary position is a critical piece of the puzzle and that reps have less access to physicians than ever but still they do play a role. The upcoming launch of Rybelsus® the oral GLP-1 from Novo Nordisk will put this role to the test.

As we anticipated Lilly reps are already harping on the rather complex dosing regimen for Rybelsus. Being the good soldiers they are and with their commission checks at stake they are telling physicians that it’s easier to inject Trulicity once a week than it is to take Rybelsus daily and quite frankly they aren’t wrong. Still Rybelsus is an oral and that fact alone will create interest.

The reality is the majority of physicians, primary care physicians in particular are just as afraid of the needle as their patients are. Keep in mind 80% of the diabetes patient population are treated by PCP’s not endos. PCP’s who often follow the path of least resistance when prescribing meds for their patients and lest face facts pills even a pill with a complex dosing regimen will viewed as better than any injection even one as simple as Trulicity.

Pills also fit very nicely into the physician patient narrative, most of these patients are used to taking multiple medications so what’s the big deal to add one more. Remember Rybelsus is not a front line but add on drug and like all GLP-1’s promotes weight loss which will make it an even easier sell to the patient.

The real issue we see isn’t which drug is better rather what the patient reaction will be. Not only is the dosing rather complex the drug is titrated. The patient starts with a 3mg dose for 30 days then moves to 7mg and then possibly 14mg if the 7mg isn’t getting the desired results. Which is exactly where the problem comes in as how does the physician know if the drug isn’t working because the patient failed to follow the dosing regimen or whether the drug just isn’t working. The patient will say they are doing it right each and every day, but we all know that patients don’t exactly tell the truth and nothing but the truth.

Sure Novo has a fallback position as if the patient doesn’t like the pill they can switch to their once weekly GLP-1 Ozempic. Yet this argument would play right into Lilly’s hands. The Novo reps cannot on one hand say that the Rybelsus dosing regimen is easy and then say well if the patient finds the dosing regimen to complex, they can always switch to Ozempic.

Getting this right is not big for Novo it’s huge. Most analysts see Rybelsus as a for sure blockbuster with sales estimates ranging from $5 to $7 Billion by 2025. This of course assumes the drug which we anticipate will get off to a string start maintains its momentum. That in a nutshell is the critical question will once in use by the general diabetes will patients put up with the daily rigors of its complex dosing regimen. Should patients report back to their physicians that doing this day after day is just too much then Novo has a big problem on their hand.

As we have said before this is one of the most widely watched drug launches, we can remember. Novo has bet the farm on Rybelsus and even with flawless execution may not achieve the desired results. Lilly as we anticipated is gearing up for battle and has already begun their ground attack. Once again, these two diabetes heavyweights are going to slug it out and what could be an epic battle.