Man­u­fac­tur­ing is­sues hob­ble Heron's quest to mar­ket its long-act­ing non-opi­oid painkiller

The C-suite at Paci­ra like­ly sighed in re­lief on Wednes­day, as their main ri­val, Heron Ther­a­peu­tics, was hand­ed an un­ex­pect­ed FDA re­jec­tion — re­lat­ed to man­u­fac­tur­ing con­cerns — for a com­pet­ing long-act­ing non-opi­oid painkiller for post-sur­gi­cal anal­ge­sia.

The health reg­u­la­tor has asked for ad­di­tion­al in­for­ma­tion re­lat­ed to Heron’s chem­istry, man­u­fac­tur­ing and con­trols and oth­er non-clin­i­cal da­ta — and has not iden­ti­fied any safe­ty or ef­fi­ca­cy is­sues, nor asked for ex­tra clin­i­cal stud­ies and da­ta analy­ses for the drug, HTX-011, Heron said.

Paci­ra in­vestors cheered the an­nounce­ment, lift­ing the com­pa­ny’s stock $PCRX more than 16% to $46.25 be­fore the bell. Mean­while, Heron shares $HRTX tum­bled more than 26% to $16.01 pre­mar­ket.

Heron plans to li­aise with the FDA to re­solve their con­cerns, and re­sub­mit its mar­ket­ing ap­pli­ca­tion as soon as pos­si­ble, chief Bar­ry Quart said in a state­ment.

The man­u­fac­tur­ing is­sues are like­ly solv­able, Cowen an­a­lysts wrote in a note, pre­dict­ing a new FDA de­ci­sion date in first half of next year.

As the US health reg­u­la­tor per­sists in its ef­fort to stem the tide of opi­oid abuse, over­dose and ad­dic­tion while the phar­ma­ceu­ti­cal ar­chi­tects of the pre­scrip­tion painkiller cri­sis face fierce scruti­ny, Heron Ther­a­peu­tics had de­signed the drug to take a bite out of the mar­ket that en­com­pass­es mil­lions of post­op­er­a­tive pa­tients who are can­di­dates for opi­oids. HTX-011 has shown in stud­ies to sub­due the need for opi­ates.

Heron is ini­tial­ly tar­get­ing rough­ly 13.5 mil­lion pa­tients who have un­der­gone the most painful pro­ce­dures (typ­i­cal­ly gen­er­al surgery, OB/GYN and plas­tic surgery). Many of these pa­tients are first giv­en a lo­cal anes­thet­ic like bupi­va­caine to dull the pain, but the ef­fects on­ly last about six hours or so, there­fore doc­tors tend to pre­scribe opi­oids to man­age se­vere pain that can last up to three days (de­pend­ing on the surgery).

HTX-011 is de­signed to slow­ly re­lease its two in­gre­di­ents: bupi­va­caine and the non-steroidal an­ti-in­flam­ma­to­ry drug (NSAID) meloxi­cam over a three-day pe­ri­od.

Bar­ry Quart

When you cut through tis­sue, and some­times bone, in­flam­ma­to­ry cy­tokines are re­leased. Apart from the in­flam­ma­tion that aris­es in re­sponse, these cy­tokines change the lo­cal PH of the in­ci­sion, mak­ing it more acidic (lo­cal anes­thet­ics tend to lose their po­ten­cy in acidic en­vi­ron­ments), and en­hance the sen­si­tiv­i­ty of nerve end­ings so even low lev­els of pain pro­duce a larg­er pain trans­mis­sion to the brain, Quart ex­plained in an in­ter­view with End­points News ahead of the FDA de­ci­sion.

“Adding a small amount of the NSAID meloxi­cam in­to our poly­mer for­mu­la­tion and re­leas­ing that si­mul­ta­ne­ous­ly over three days al­lowed us to block enough of that in­flam­ma­to­ry process,” Quart said. “We can show clear pain re­duc­tion for the full three days that the drug (HTX-011) is be­ing re­leased. It’s the first time — that we know of — that an ex­tend­ed-re­lease lo­cal anes­thet­ic of any kind re­gard­less of how its de­liv­ered has been able to beat bupi­va­caine so­lu­tion as stan­dard-of-care in large Phase III tri­als.”

Com­bin­ing HTX-011 with two over-the-counter oral anal­gesics (ac­eta­minophen and ibupro­fen) has yield­ed im­pres­sive re­sults in help­ing post-op pain pa­tients re­main opi­oid free in two stud­ies pub­lished by Heron this year.

In a 63-pa­tient study, 90% of pa­tients re­ceiv­ing HTX-011 with the OTC anal­gesic reg­i­men did not re­quire opi­oids to man­age their post­op­er­a­tive pain through 72 hours post her­nia surgery, com­pared to 51%, 40% and 22% of pa­tients re­ceiv­ing HTX-011, bupi­va­caine and a place­bo, Heron re­vealed in Jan­u­ary. Fol­low up af­ter 28 days showed 81% of pa­tients re­mained opi­oid-free.

Biren Amin

“We con­sid­er these re­sults as com­pelling, and sup­port­ing a best-in-class pro­file in post-op pain based on sig­nif­i­cant­ly more opi­oid-free pa­tients and sub­stan­tial­ly low­er opi­oid use. HTX-011 could of­fer the on­ly op­tion of opi­oid-free pre­scrip­tion at dis­charge, which re­mains a high pri­or­i­ty in the bat­tle against opi­oid abuse,” Jef­feries’ Biren Amin wrote in a note that month.

Apart from bupi­va­caine, HTX-011 will com­pete with Paci­ra Phar­ma­ceu­ti­cals’ J&J-part­nered, long-act­ing post-op painkiller Ex­par­el, which gen­er­at­ed net sales of about $331 mil­lion last year. Ex­par­el’s main in­gre­di­ent is al­so bupi­va­caine and the drug has been ap­proved by the US reg­u­la­tor since Oc­to­ber 2011 as a treat­ment for post­sur­gi­cal anal­ge­sia.

In a note pub­lished in March, SVB Leerink an­a­lysts wrote that while “Ex­par­el does a good job re­duc­ing opi­oid use for post-op pain; HTX-011 could do this bet­ter,” cit­ing a KOL sur­vey. “…it (Ex­par­el) has done a good job in re­duc­ing opi­oid use and hos­pi­tal­iza­tion time in its post-op­er­a­tive pa­tients, the du­ra­tion of ef­fi­ca­cy is in the 24-36 hour range. As such, this KOL be­lieves the longer po­ten­tial du­ra­tion of ef­fi­ca­cy and the in­stil­la­tion method of HTX-011 will re­sult in ini­tial use of the prod­uct. But up­on avail­abil­i­ty of both prod­ucts, this KOL be­lieves hos­pi­tals will run their own pi­lot stud­ies in var­i­ous sur­gi­cal mod­els to see how they com­pare to one an­oth­er.”

Over half the pa­tients Heron is tar­get­ing are re­ceiv­ing bupi­va­caine, and about 4% are get­ting Ex­par­el — the rest are get­ting var­i­ous “caines” such as li­do­caine, Quart said. “While we ob­vi­ous­ly ex­pect to take a cer­tain part of Ex­par­el mar­ket share…our pri­ma­ry tar­get is the 96% of pa­tients who are re­ceiv­ing…short-act­ing lo­cal anaes­thet­ics.”

Paci­ra, which un­veiled plans to swal­low a com­pa­ny that makes a sys­tem that us­es in­tense­ly cold ther­a­py on a spe­cif­ic nerve to re­lieve pain to com­ple­ment its flag­ship Ex­par­el treat­ment and for­ti­fy its pain fran­chise in March, is set to re­port is first-quar­ter re­sults on Thurs­day.

Year-on-year Ex­par­el rev­enue growth for 2019 is es­ti­mat­ed at 23%, Jef­feries an­a­lysts pre­dict­ed in a note last week. “(D)es­pite the strong re­cent (Ex­par­el) re­sults…cur­rent pen­e­tra­tion rates re­main very low…and the mar­ket is cer­tain­ly large enough to ac­com­mo­date two or more play­ers. In fact, we think the ad­di­tion­al voice of an­oth­er mar­ket­ing team rais­ing aware­ness for non-opi­oid post-sur­gi­cal pain op­tions ar­guably helps all mar­ket par­tic­i­pants. And per­haps most im­por­tant­ly, we view the sit­u­a­tion as less like ‘Coke vs Pep­si’ and more to the point that if un­bundling and ac­cess con­tin­ue to im­prove, all com­peti­tors in the seg­ment ben­e­fit.”

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