If cardiology and medicine were as simple as Family Feud then ARBITER-6 would already be decided. (For those of you not familiar with it, Family Feud, as described by Wikipedia, is a TV game show “that pits two families against each other in a contest to name the most popular responses to a survey-type question posed to 100 people.”)
Now a Wall Street analyst is analyzing ARBITER 6 along the lines of Family Feud. According to a survey of 103 US physicians (31 cardiologists, 72 primary care physicians) 51% of the the primary care doctors and 80% of the cardiologists predicted that Niaspan would be superior to Zetia– although the validity of their opinion may be open to question since less than 35% of the physicians were even aware of ARBITER 6.
The survey was performed by a Leerink Swann analyst who, like the rest of Wall Street, is eagerly awaiting the results of ARBITER 6 next Monday. Most cardiologists agree that the purely scientific significance of ARBITER 6 is fairly limited, but Wall Street may be correct in believing that the financial or business significance is considerably more, well, enhanced.
Whether or not the physicians can correctly predict the outcome of ARBITER 6, the survey may have considerable value in predicting the reaction to the trial if in fact Niaspan beats Zetia. Assuming a statistically significant victory for Niaspan, the Leerink Swann report forecasts that Zetia and Vytorin prescriptions could drop by 25-30% over the next year, a much more dramatic decline than the 4% drop predicted in the absence of ARBITER 6. The report notes that in the immediate aftermath of ARBITER 6 the most important factors that will affect prescribing patterns will be formulary status and editorials in the major journals. In the long term the most important event to shape the market may be the availability of generic atorvastatin in two years, according to the report.
An article in Bloomberg news by Shannon Pettypiece quotes Steve Nissen: “The longer Zetia goes with a series of trials that are not favorable, the more questions get raised about whether it is a good choice.”
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Your reporting of ARBITER-6 on this website has been most intriguing, especially what the quants at Wall Street think (that’s a term I picked up from reading Malcolm Gladwell’s latest book – it refers to the people who mathematically quantify probabilities for trading houses).
I should note that ARBITER-6 used intima media thickness (IMT) rather than total plaque area (TPA). This may account for a result showing no difference between groups (as did ENHANCE). TPA and TPV (total plaque volume) are much more sensitive to longitudinal changes in plaque regression.
Good points about ARBITER, but you should know that these researchers aren’t the quants. Many of them are MDs or have advanced degrees in the biological sciences, and they generally have a very good feed for the issues. In general, they’re way more sophisticated than most journalists in their understanding of the issues. On the other hand, they’re only interested in the financial outcomes, so their interests and attention may be very different from the medical community.
Good point, Larry. I hadn’t realized that.
I think it’s really anyone’s guess. We don’t know what the median IMT at baseline was, so it’s impossible to say how well powered the trial was. If you go by the SANDS analysis published in JACC, ezetimibe should do great. If you go by the Oxford trial also just published in JACC, niacin should do great. My guess is that they will do equally well with no clear winner. We should also be using TPA or TPV to tease out more sensitively smaller plaque changes.
I like your coverage on this issue. It’s fascinating that two thirds of the physicians surveyed didn’t even know this trial existed.