Well, it was not a dull evening around the In the Pipeline headquarters last night. I submitted a link to Reddit for my post yesterday about Retrophin and Thiola, and that blew up onto that site’s front page. The Corante server melted under the impact, which isn’t too surprising, since it’s struggling at the best of times. (A site move really is coming, and no, I can’t wait, either, at this point.)
But then, to my great surprise, Martin Shkreli (CEO of Retrophin) showed up in the Reddit thread, doing an impromptu AMA (Ask Me Anything), which I have to say takes quite a bit of aplomb (or perhaps foolhardiness – I don’t think too many other CEOs of any publicly traded corporations would have done it). But not too long after that, the entire thread vanished off the front page, and off of r/News, the subreddit where I’d submitted it.
Then I got a message from one of the moderators of r/News, saying that I’d been banned from it, and going on to say that I would likely be banned from the site as a whole. After having been on Reddit for seven years, that took me by surprise. As best I can figure, the thread itself was reported to r/Spam by someone, and the automated system took over from there. Over the years, I’ve submitted links to my blog posts, and Reddit, or some parts of it, anyway, has been notoriously touchy about that. The last time I submitted such a link, though, was back in February (and before that, August of 2013), so I’m not exactly a human spam-bot. We’ll see what happens. Update: I was banned for some hours, but I’ve been reinstated.
But back to Retrophin, Thiola, and Martin Shrkeli. The entire Reddit thread can still be read here, via a direct link, although it can’t be found in r/News any more. If you look for a user named “martinshkreli”, you can see where he gets into the fray (I’m “dblowe” on the site, or perhaps I was?). You’ll note that he gives out his cell phone, office phone, and e-mail, which again is not your usual CEO move – you have to give him that, although it does seem a bit problematic from a regulatory/compliance angle. So what arguments does he make for the Thiola price increase?
From what I can see, they boil down to this: patients themselves aren’t going to be paying this increased price – insurance companies are. And Retrophin is actually going to be working on new formulations for the drug, which no one has done previously. He seems to have implied that the previous company (Mission Pharmacal) was reluctant to raise the price and take the public outcry, and stated (correctly) that Mission was having trouble keeping the drug in supply. He claims that the current price is still “pretty low”, and that he does not expect any pushback from the eventual payers. There was also quite a bit about the company’s dedication to patients, their work on other rare diseases, and so on.
He and I didn’t cross paths much in the thread. I tried asking a few direct questions, but they weren’t picked up on, so my take on Shkreli’s answers will show up here. He’s correct that the drug’s availability was erratic, and he may well be correct that its price was too low for a company to deal with it properly. But if so, that does make you wonder what Mission Pharmacal was up to, and how they were sourcing the material.
He’s also correct that Retrophin is planning to work on new formulations of the drug. But when you look at the company’s investor presentation about Thiola, all that comes under a slide marked “Distribution and Intellectual Property”. The plan seems to be that they’ll introduce 250mg and 500mg dosages, at which time they’ll discontinue the current 100mg formulation. Later on, they’ll try to introduce a time-release formulation, at which time they’ll discontinue the 250mg and 500mg forms. You can argue that this is helping patients, but you can also argue that it’s making it as difficult as possible for anyone else to show bioequivalence and enter the market as well, assuming that anyone wants to.
And as I mentioned yesterday, the company does seem to care about someone else entering the market. My questions to Shkreli about the “closed distribution” model mentioned on the company’s slides went unanswered, but the only interpretation I can give them is that Retrophin plans to use the FDA’s risk management system to deny any competitors access to their formulations, in order to try to keep themselves as the sole supplier of Thiola in perpetuity. Patents at least expire: regulatory rent-seeking is forever.
Also left out of Shkreli’s comments on Reddit are the issues on the company’s slide titled “Pharmacoeconomics”, where it says (vis-a-vis the other drug for cystinuria, penicillamine):
Current pricing of Thiola® – $4,000 PPPY
– Penicillamine pricing- $80,000-$140,000
• Thiola could support a significant price increase
Personally, I think that’s the main reason for Retrophin’s interest. You’ll note that the price hike takes Thiola’s cost right up to the penicillamine region (the price of that one is another story all its own). But to a first approximation, that’s business. I’ve defended some drug company pricing decisions on this site before (although not all of them), so what’s different this time?
I’ve been thinking hard about that one, and here’s what I have so far. I think that pricing power of this sort is a powerful weapon. That’s the reason for the patent system – you get a monopoly on selling your invention, but it’s for a fixed period only, and in return you disclose what your invention is so that others can learn from it. And I think that this sort of pricing power should be a reward for actually producing an invention. That’s the incentive for going through all the work and expense, the (time-limited) pot of gold at the end of the rainbow. I have a much lower opinion of seeing someone ram through a big price increase just because, hey, they can. Thiola has nothing to do with the patent system – it’s off patent. What this situation looks like to me is regulatory rent-seeking. Celgene seems to be doing that too, with thalidomide (as mentioned yesterday), which is why they’re being taken to court. Retrophin is betting that Thiola just isn’t a big enough deal for anyone to go to that trouble, once they tell them to buzz off by using Celgene’s strategy.
Businesses can, though, charge what they think the market will bear, and Retrophin’s contribution to cystinuria therapy so far is to have realized that the market will bear a lot more than people had realized. But in an actual market, it would be easier for someone else to come in and compete on price. What Retrophin is planning is to use regulatory loopholes to keep anyone else from doing so, with no time limit until someone at the FDA does something about it. Cloaking this in a lot of noble-sounding talk about being the company that really cares about cystinuria patients is a bit stomach-turning. In my opinion.