I didn’t think that the Industry Veteran would just ignore the comments from the Anonymous Cardiologist or the Anonymous Academic, and he doesn’t disappoint.  Unlike the Academic, at least he’s convinced that the Cardiologist is a doctor not a Crestor bag-carrier! I don’t know about you but I’m learning tons from these exchanges! So here’s the Veteran’s question:

Was the anonymous cardiologist on the grassy knoll?

The efforts of AstraZeneca’s partisans to free up your time with conspiracy theories and riffs on Pfizer must be gratifying, but their notes appear questionable.  In particular, your cardiologist may know how to complain about declining capitation rates for performing angiograms, but his knowledge of the pharmaceutical industry’s business side remains poor.

In particular, his perceptions relative to stain marketing are typical of office-based physicians.  Practitioners are not so much biased or uninformed about tactical details as they are arrogant grunts trying to pontificate on the war’s trends from foxholes.  Specifically, he adduces Pfizer’s panic over Crestor from the fact that they are cross-training their Women’s Healthcare sales group on Lipitor.

In the first place, it is often standard practice in the industry for companies to cross-train virtually all their reps on the big PCP products.  For example, specialty reps from Merck who only detail neurologists on the migraine drug Maxalt also carry Vioxx in their bags.  In the case of Pfizer reps carrying Lipitor to OB/GYNs, it remains a fact that a large segment of women who do not suffer some chronic condition receive their primary medical care from their gynecologists.  As Pfizer will next year launch Caduet, a fixed-dose combination of Lipitor and Norvasc, it is entirely appropriate that they would try to recapture some of $4 billion they will lose to generic amlodipine with an all-hands-on-deck sales effort for the new product.  Former CEO Bill Steere was an especially strong advocate of cross-training; when products such as their antibiotic Trovan hit the crapper, it allowed Pfizer to redeploy the reps they had hired for that launch into other areas.  If one is to impute panic, I hear from sources far more reliable than the umbrella man or three tramps in the railroad yard that Dave Brennan and Tony Zook (Note: respectively President & Senior VP, AstraZeneca in the United States) are running out of toilet paper in the executive bathroom due to Crestor’s slow start.

Your cardiologist’s second error consists of his effort to suggest Pfizer’s panic is leading them to make underhanded payoffs as a result of Crestor’s greater potency at reducing LDL.  Pfizer has known Crestor’s clinical profile for several years and they adopted a well conceived marketng strategy to defend against it.  Two years ago Karen Katen (Note: Kate is Exec VP, & President of the Pfizer Global Pharmaceuticals) responded to the superstatin tagline that AZ was trying to pin on Crestor with the reply, "Superstatin or superfluous statin?"  Pfizer’s idea, then as now, was that for all but the more refractory patients, Lipitor produces good LDL reduction with a demonstrated safety record.  If some self-styled lipidologist needs a Hail Mary pill to use on a familial homozygous patient before going to plasma aphoresis, then he can try Crestor until the Zocor-Zetia or the Lipitor-torcetrapib combinations appear on the market.

Your cardiologist’s main contention — that Pfizer paid the Lancet’s editors for their rant on Crestor — is really where he emulates Arlen Spector and propounds a magic bullet theory.  While conclusive proof of this would neither shock or surprise me, I tend to be highly skeptical of your man’s allegation for four reasons.

Pfizer has lawyers crawling all over it from the Neurontin whistleblower suit that the Department of Justice joined.  Any e-mail or note hinting at this sort of payoff to the Lancet could easily come up as a by-product of discovery and would seriously jeopardize the entire Lipitor franchise.  The downside risk far outweighs even the worst consequences of the Neurontin suit that involve disgorgement of all profits from off-label Neurontin sales.

My second reason for doubting a Lancet payoff is based on the fact that since the Warner-Lambert takeover, Pfizer has been a fairly disorganized company.  The two organizations were not well integrated and this problem was further exacerbated by the Pharmacia acquisition.  Unless there was a rogue contingent there operating entirely beyond control, I doubt Pfizer could exercise the coordination required for such a black bag job.

My third reason for skepticism comes from experience with the Lancet editors.  They constitute some of Big Pharma’s fiercest critics.  If Pfizer had approached them with a bag of cash, it would have become the lead story for every news outlet around the world.

Last but not least, the Lipitor people knew that a payoff was unnecessary.  When Arnold Relman comes out and says that Crestor is a me-too drug and Sidney Wolfe predicts it will prove worse than Baycol, Pfizer couldn’t buy such PR for any amount of money.

Your academic contributor stands on much firmer ground when she notes Pfizer’s impending loss of big product sales to generics.  This does not, however, substantiate any implication that Pfizer is going ballistic over Crestor.  McKinnell and his people have in place some well articulated strategies (fixed-dose combinations, co-development deals, marketing structure, others) that seek to cope with this.  I have my doubts that they’ll be able to carry it off without their sales and stock price going into a trough similar to Merck’s current one, but we’ll have to see.  Deducing current panic and payoffs from this possible scenario is too farfetched.

Alas, while I don’t care for your cardiologist’s style of thinking or his blithe ignorance of the industry, I do come down beside him in predicting that Crestor will eventually sell $2.5 billion a year as a result of hypolipidemic market growth and patent loss for Zocor and Pravachol.

I’ll step in to referee this soon, but let it be known that I’m with Oliver Stone and believe that there was more than one shooter in Dallas in 1963. And I’m somewhat with Noam Chomsky when he says that the Media "manufactures consent" based on knowing which side its bread is buttered, and he wouldn’t be quite as comfortable as some with the chinese wall between The Lancet‘s editorial board and its advertising business manager.