Wednesday, March 23, 2011

Interview with Kenneth Hershon M.D.


Here are my notes I took when Dr Hershon was interviewed by Mimi Pham of Weeden.

Glossary: PFE – Pfizer, PFT – Pulmonary function test, COPD - Chronic obstructive pulmonary disease

Dr Hershon’s practice:

-- ADA recognized teaching hospital.
-- managed 10000 patients, higher portion of Type 1 (25%), type 2 (75%)
-- 20-25% of Type 2 are on basal insulin, in combination with Oral agents
-- patients a week - 70-90
-- done lots of phase trials of afrezza (2 & 3)
-- short, 3 mo, smaller/larger..8-10 trials using Afrezza, avg of 7-8 patients/trial. Some trials 60-80 also
-- Afrezza used in type 1 & 2

About Afrezza

-- Likes -
  size was a plus
  pts tended to use it for snacks
  one pt used it despite the cough
  pts said they wanted to use it ; asked where they can find it and use it forever
-- Dislikes about Afrezza -
  not definitive with dosing (pts with finely tuned control )
  Dr. concerned about pts who need very fine tuning, as Afrezza is not accurate enough (not an issue for Type 2)
-- They did both the 1st and 2nd generation (short trials comparing)
-- some pts in extension trials were switched from 1 to 2; they liked both
-- both devices (1 & 2) are essentially the same, only diff is the size
-- for exubera, the reality is, not that patients didn't like it, the docs didnt like it.
-- in our practice, the nurse spent 15 mins to teach exubera usage,
-- docs don't like the PFT issue (for exubera)
MNKD should take the product directly to the patient.

About Exubera

exubera launch:
  right list is small
  wrong list:
     PFE doesn't know diabetes,
     gave it to a group of reps, had no contacts/connections with endos
     PFE had the notion that the whole world was waiting for them
     didn't deal with the issues of PFT
     if they had told docs how to make $ off doing PFT's , could have been better
     PFE didn't go to the consumer first (only before a week pulling it out)
     Going to the doc was wrong, also went to academic guys first
     Pulmonary testing
     a. both pfe & mnkd trials, in both inhaled and non-inhaled, PFT goes down each year.
     b. in first 3 months, pft goes little bit more in first 3 months afrezza and then regular. it is reversible after afrezza stopped
     c. doc office, measure fev1; not expensive at all. test for copd
     d. for some pts, followup more
     e. in my practice, i'm happy to do pulmonary function test. this device is cheap, i can bill for that. this can become a profit center
     f. pft device costs couple of hundreds; you've to explain this to the doc; so it doesn't become a barrier
     g. Dr. Herhshon thinks, if explained right, it shouldn't be a barrier
-- pts on exubera , upon pull out - disappointed would be an understatement; some stock piled it- had almost for a year
-- some were switched over to afrezza; one drives from philly, manhattan to Long Island to stay on afrezza; one ball player is on afrezza
-- pts very motivated and likes afrezza
Who can take afrezza?
The biggest group is type 2 - not on good control (7-11 A1C), failing on two agents -
if PPG is high, they start using basal.
-- with afrezza, after 2 oral agents, I can start on Afrezza; anytime PPG is high, afrezza is very useful.
-- type 1 who don't want to go to pumps (pump is a better tool)
-- Afrezza can take 10% of type 2 market
-- MNKD should directly go to consumer
--                   directly go to nurse educators (as docs show resistance)
-- Nurse – On Friday afternoon nurse should educate patients
--product (afrezza) is a winner;
--this has a faster uptake compared to RAA, which may have an ultimate advantage; how will mnkd verbalize it?
--shorter - some benefit ; its different from RAA in this aspect
-- more dosages are needed
-- mnkd needs to partner - lly, novo, aventis; they need reps who know insulin
-- the lung concern is more of theoretical concern, but how do you address it?
-- Why afrezza- i get better control , i'll use it