Bio,
My guess is that nesiritide will replace milranone/dobutamine entirely in acute CHF, and quickly. Nobody liked milranone to begin with, but if there was no response to dopamine, there was really no other option except praying that diuresis will work or proceeding to a pump and getting on the waiting list for transplant. There's been multicenter, randomized, db, placebo controlled data for over a decade now showing that long term therapy withMilranone causes an increase in morbidity and mortality, and the data that it was actually helpful in acute use was sketchy. I expect the drug to achieve a high penetration rate rapidly, and I agree that their sales projection are low, maybe obscenely low.
I don't think it will make it's way down to folks who have stable CHF who are sitting around home, unable to climb stairs, but able to walk. It's half life in the body is short, like in the order of minutes, so I don't think there would be much benefit for outpatients who could pop in for a weekly tuneup. The strategy of hospitalizing a patient with CHF before they decompensate is already an accepted strategy for CHF management. In these cases, which probably account for more hosp that acute CHF, milranone is not used, just diuresis. I don't know if your data includes these maintenance type of admissions or just acute CHF. The question of course is will natrecor eventually be used in these "tune-up" (the body as a machine!) type of admissions. If it can be shown to reduce overall costs (length of stay primarily), then it will be.
I suspect that in a few years someone will see that natrecor therapy causes structural changes to the heart, like they did the the angiontensin inhibitors/blockers. But this is pure speculation based on the fact that it is a peptide and peptides usually can up or down regulate genetic expresion of multiple molecules, including trophic one. Of course, you would hope that then changes it induces are beneficial...
There's also a lot of work being done in using np levels to assess function in CHF. This could also open up the market I suppose. |
