Rob---
"....the results of HOPE are not unexpected when considered in the context of all the previous work done with ACE-Inhibitors."
I would have to disagree. It's true that preliminary results were released in May, after the trial was stopped for ethical reasons in March. Thus, the report in Barcelona in one sense merely corroborated the preliminary results. But the full report carries much more weight, and I understand that it is in press in a major medical journal. So, in addition, it has survived the peer-review process.
It may also be argued that it is intuitively reasonable that ACE inhibition should reduce events, in that alleviation of CHF and hypertension alone will reduce morbidity and mortality. But what the HOPE trial adds is that even when these effects are adjusted for, ramipril still has a persistent beneficial effect on outcome, even on those who do not have hypertension or CHF. This is, to me, neither intuitively reasonable nor expected. Besides, it's one thing for a result to be reasonably expected, but quite another to demonstrate that empirically. The former helps design trials, the latter changes practice patterns----far more important to KING and KING shareholders, of course.
Previous trials with ACE inhibitors have focussed on CHF and/or hypertensive patients. This is the first data, to my knowledge, which demonstrates clear benefit in primary (and secondary) prevention of coronary events, whether hypertension or CHF is present or not. This opens the market to millions in the US alone (KING's market) who would previously have had no indication for ACE inhibition at all. For example, a 45 year old male, asymptomatic, normotensive, with no evidence of heart failure, but a strong family history and diabetes would very definitely be a candidate for ramipril therapy.
And, other ACE inhibitors could not really be substituted, because the HOPE trial used ramipril, and other ACE inhibitors may not have the same effects on prevention, due to their differences among one another. Only clinical data could show benefit one way or another, and I would doubt whether other pharmaceutical companies would bother to embark on such a trial; they would have to show clear benefit not just over placebo, but also over ramipril. This is unlikely. The best they could hope for would be to demonstrate equivalence, but even this is unlikely for most ACE inhibitors. Then, they would have to try to take away market share from ramipril, obviously an uphill battle, particularly so if only equivalence could be demonstrated.
Will it reach 50% or even 20% of ace-inhibitor market share. Not a chance!
I'm not sure. I would like to know what leads you to say this. I would think that a major---and likely irrestible---selling point to physicians would be:
"Doc, why not switch all your patients currently taking ACE inhibitors to Altace? You will be giving them all the benefit they have been getting from their ACE inhibitor, plus you will be reducing their risk of a heart attack or stroke, independently of the effects of the medication on heart failure or blood pressure."
But, even if this does not result in a lot of physicians switching their ACE inhibitor patients to ramipril, you still have the clear indication---which no other ACE inhibitor has---of primary prevention in patients at risk but who have no symptoms. Many (if not most) patients currently on lipid lowering therapy would fall under this category for exactly the same reason they are on lipid lowering therapy---to reduce risk of a heart attack or death. Plus, diabetics as well would fall under this category.
Sell on news!
Probably a good idea, but I could certainly understand a long term hold position as well. FWIW, I sold half my position today, and will probably sell the other half very soon, perhaps tomorrow (don't want to get too greedy and shoot myself in the foot....<gg>)
Regards,
Walkingshadow |
