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Infographics of Modern Therapeutics

Introduction

The purpose of this report is to provide highlights from two posts involving infographics of modern therapeutics, since these posts were originally only listed under their months of posting, but not indicating their titles. These were as follows:

The graphs in these two posts are in addition to extensive infographics on the progression of 40 therapeutic classes, across 14 therapeutic categories, included in Progression of Modern Therapeutics, issued January 2016, and in a more extended reporting on 16 therapeutic classes, summarized in List of 16 Posts on Individual Therapeutic Classesissued January 2018.

Methodology

The data used in both of these two above referenced posts are originally from Progression of Modern Therapeutics, which covers 40 therapeutic classes from 14 therapeutic categories, and which includes a detailed description of the methodology and definitions used in this project. Note the following definitions used throughout:

  • Modern therapeutics – refers to those new drug approvals belonging to a given pharmacologic class that were first approved in the 1970’s to 1980’s timeframe and going forward, as further defined in Progression of Modern Therapeutics.
  • Pharmacologic class – refers typically to a biologic target-based or mechanism of action-related classification, but in some instances involves a chemical classification, or a mix of the two.
  • Therapeutic class – refers to new drug approvals for a given disease or indication, independent of pharmacologic class.
  • Therapeutic category – refers to approved therapeutics in a given anatomical organ or system.
  • Length of registration interest – refers to the time interval between the dates of the first and the latest new drug approval within a given pharmacologic class.

Number of Pharmacologic Classes per Therapeutic Classes

The number of pharmacologic classes per individual therapeutic classes for new drug approvals is shown in the graph below, in a descending order, for 38 of the 40 therapeutic classes covered in Progression of Modern Therapeutics. 

Click here for a larger graph. Note the wide range in the number of pharmacologic classes per therapeutic classes, ranging from 11 and 9 for Type-2 Diabetes and Multiple Sclerosis, respectively, and 8 each for Rheumatoid Arthritis and Melanoma, to 1 each for Idiopathic Thrombocytopenic Purpura and Systemic Lupus Erythematosus, and several therapeutic classes with 2 each, including Alzheimer’s Disease and Schizophrenia. Note that the mean and median for the number of pharmacologic classes per individual therapeutic classes (N=38) are 4.3 and 4.0, respectively.

New Drug Approvals per Therapeutic Classes

The number of new drug approvals for 38 of the 40 therapeutic classes covered in Progression of Modern Therapeutics is shown in the graph below, in descending order. 

Click here for a larger graph. Note the wide variability in the number of new drug approvals for the different therapeutic classes, ranging from 44 for Hypertension, 28 for HIV-1/AIDS, 27 for Type-2 Diabetes and 23 for Schizophrenia, to 1 for Systemic Lupus Erythematosus, 2 each for Idiopathic Thrombocytopenic Purpura and Idiopathic Pulmonary Fibrosis (both orphan indications) and 3 for Fibromyalgia. Note that the mean and median for the number of new drug approvals per individual therapeutic classes (N=38) are 11.5 and 9.5, respectively.

Selected Snapshots from Noteworthy Patterns in Registration Avivities

Below are two selected snapshots based on data in Progression of Modern Therapeutics, each illustrating a specific pattern in registration activities of modern therapeutics:

Snapshot #1: Two therapeutic classes showing two key pharmacologic classes with no overlaps in registration activities, i.e., H2 Receptor Antagonists and Proton Pump Inhibitors for Acid Reflux and Ulcer Disease, and Benzodiazepines and Non-benzodiazepines for Insomnia. Both examples show an abrupt switch in new drug introductions from older pharmacologic classes to newer pharmacologic classes. For a larger graph click here.

no overlap

Snapshot #2: Two therapeutic classes showing two key pharmacologic classes with overlaps in registration activities, i.e., Corticosteroids and Beta-2 Adrenergic Agonists for Asthma, and SSRI’s and SNRI’s for Depression. Both examples show concurrent new drug introductions for two dominant or somewhat similar pharmacologic classes or mechanisms of action. For a larger graph click here.

overlap

Length of Registration Interest

Perusal of the graphs for 40 therapeutic classes in Progression of Modern Therapeutics also illustrates a wide variability in the length of registration interest, i.e., the time interval between the dates of the first and the latest new drug approval within a given pharmacologic class (shown on the right hand side of the graphs). Of the more than 180 pharmacologic classes covered, it is if interest to note that 16 classes have lengths of registration interest longer than 25 years, e.g., Beta-Blockers for Hypertension (40.1 decimal years) and Typical and Atypical Antipsychotics for Schizophrenia (26.9 and 25.9 decimal years, respectively), and that lengths between 10 and 20 years are quite common for established pharmacologic classes, e.g., TNF Inhibitors for Rheumatoid Arthritis (10.5 decimal years) and PDE-5 Inhibitors for Erectile Dysfunction (14.1 decimal years).

Comments

The infographics of modern therapeutics presented in this report involve examples from two previous posts, but are highlighted here, since the original posts were only listed under their months of posting (February 2016 and June 2016), but not indicating their titles. 

The graphs and texts illustrate wide variability in new drug approvals among the different pharmacologic classes and therapeutic classes. This involves both the number of pharmacologic classes per individual therapeutic classes, and the number of new drug approvals per individual therapeutic classes. For example, the number of pharmacologic classes per individual therapeutic classes ranged from 11 (Type-2 Diabetes) to 1 (Systemic Lupus Erythematosus), and the number of new drug approvals per individual therapeutic classes ranged from 44 (Hypertension) to 1 (Systemic Lupus Erythematosus). Also noteworthy is that 16 pharmacologic classes of the more than 180 covered have lengths of registration interest longer than a quarter of a century; also note the most common interval of lengths of registration interest is 10-20 years (31 pharmacologic classes), for lengths longer than 5 years.

Note these graphs only involve new drug approvals, and do not include generics, new formulations, or new trademarks of previously approved chemical entities. Also note these graphs and texts are based on data available in early 2016; there may have been a few new drug approvals in some of the covered therapeutic classes since then, but not so much as to alter the key conclusions presented.

It is tempting to speculate what might be the reasons underlying such wide variabilities in the number of pharmacologic classes per therapeutic classes, in the total number of new drug approvals per therapeutic classes, and in the relatively long periods of registration interest for numerous pharmacologic classes, but that will be left to another time. Public discussion on these important topics, however, is very important, since at a high level, these are likely to relate to how society in general – including the academic research community, the regulatory agencies, the pharmaceutical R&D community, and patient and disease organizations – attempt to address varying degrees of scientific knowledge about disease etiology and pathophysiology, levels of research funding, commercial assessment, and different levels of unmet medical need. 

List of 16 Posts on Progression of Individual Therapeutic Classes

Introduction

Of the 40 therapeutic classes (across 14 therapeutic categories) that have examined Progression of Modern Therapeutics (last report issued in early 2016, under Reports) a more extended reporting has been made on a total of 16 therapeutic classes, under Posts. The majority of these posts involved the following subtitles: Background, Drug Approvals, Comments, and References (as appropriate), as exemplified by the post on Benign Prostatic Hyperplasia (BPH: Relying on Mechanisms First Approved a Quarter of a Century Ago, August 2016, click here), in addition to a timeline chart illustrating the individual approved drugs and their mechanisms of action.

Since these posts on individual therapeutic classes were only listed under their months of posting, the purpose of this reporting is to summarize 16 of these therapeutic classes under their therapeutic categories, including the titles of these posts.

Cardiovascular Therapeutics
Hypertension Progression of Modern Antihypertensive Therapeutics: An Example of a Mature Therapeutic Class. (December 2014) Click here.
Dyslipidemia Lipid Lowering Drugs: Steady Progress Over Half a Century. (September 2015) Click here.

Hematologic Therapeutics
Thrombosis Progression of Modern Antithrombotic Drugs: What’s Next? (January 2015) Click here.

Gastroenterologic Therapeutics
Acid Reflux and Ulcer Disease Progression of Acid Reflux and Ulcer Disease Therapeutics. (October 2014) Click here.
Irritable Bowel Syndrome IBS: Underlying Mechanism(s) Not Established but Six New Drug Approvals Since 2000. (September 2016) Click here.

Endocrinologic Therapeutics
Type-2 Diabetes Progression of Modern Therapeutics for Type-2 Diabetes. (November 2014) Click here.
Obesity Weight Reduction Drugs: Slow Progression and Innovation. (March 2015) Click here.
Osteoporosis Osteoporosis: Better Drugs and Better Scientific Understanding Needed. (July 2016) Click here.

Psychopharmacologic Therapeutics
Schizophrenia and Depression Slow Progress in Psychopharmacologic Therapeutics. (September 2014) Click here.
Attention Deficit Hyperactivity DisordeADHD Therapeutics: Slow and Limited Progress. (November 2015) Click here.
Insomnia Modern Insomnia Therapeutics: Not the Barbiturates or Anxiolytic Benzodiazepines of Yore. (April 2016) Click here.

Neurologic Therapeutics
Alzheimer’s Disease Alzheimer’s Disease: Many Years to Go. (June 2015) Click here.
Migraine Migraine Therapeutics: Slow Progress Towards Precision Medicine. (December 2015) Click here.

Rheumatologic Therapeutics
Rheumatoid Arthritis Progression of Modern Therapeutics for Rheumatoid Arthritis. (October 2015) Click here.
Gout and Hyperuricemia Gout and Hyperuricemia: Reliance on Old Mechanisms. (March 2016) Click here.

Genitourinary Therapeutics
Benign Prostatic Hyperplasia BPH: Relying on Mechanisms First Approved a Quarter of a Century Ago. (August 2016) Click here.

2016 Update on Current Projects

Introduction

The Therapeutics Research Institute, a 501(c)(3) nonprofit corporation located in Saint Davids Pennsylvania, was initiated in August 2012 to examine and report on various aspects of modern therapeutics. Its website, TRI-institute.org, which contains all its reports and commentaries, became operational in August 2014.

Objectives

The objectives of the Therapeutics Research Institute (TRI-institute), which are listed at TRI-institute.org/Organization, are:

  1. To conduct scientific assessments of characteristics of drug treatments of human diseases based on available information and relevant frameworks;
  2. To analyze and report such findings by indications and therapeutic areas, pharmacological mechanisms, types of endpoints, and disease types;
  3. To co-sponsor seminars, particularly in the Greater Philadelphia region, directed at the pharmaceutical startup community, exploring lessons from the findings; and
  4. To engage in other activities related to the objectives of the corporation, that will further its mission.

Current Projects

High-level outlines of the three current projects, Progression of Modern Therapeutics, Characteristics of Therapeutic Response, and Systems Therapeutics, are shown on the graph below (click here for a larger graph).

current-projects-november-2016

Update on Current Projects

A summary Update on Current Projects, for the three current projects, are shown on the graph below (click here for a larger graph). The dates of individual reports and posts (month, year) are also shown, except those for the 17 commentaries on individual therapeutic classes.

update-on-current-projects-november-2016

Examples from Recent Work

Below are three examples from recent work, i.e., from one of the 17 commentaries on individual therapeutic classes, from an analysis of the number pf pharmacologic classes per therapeutic classes and the number of approved new molecules per pharmacologic classes, and on an updated diagram on systems therapeutis.

New Drug Molecules for Osteoporosis

Osteoporosis Graph

Above is a chart from one of the 17 posted commentaries on individual therapeutic classes, which had originally been included in Progression of Modern Therapeutics (2015 Report), this one on approved modern therapeutics for osteoporosis, from Osteoporosis: Better Drugs and Better Scientific Understanding Needed (July 2016). These commentaries have included, to name a few, Irritable Bowel Syndrome (September 2016), Benign Prostatic Hyperplasia (August 2016), Migraine (December 2015), Rheumatoid Arthritis (October 2015) and Lipid Lowering Drugs (September 2015).

Regarding osteoporosis, since 1984, a total of 9 new drug molecules have been approved for osteoporosis, in 5 pharmacologic classes. The 1995 approval of Fosamax (alendronate), the first of 4 approved bisphosphonates, represented an important milestone for this therapeutic class. The other 4 pharmacologic classes involve the SERM’s (Selective Estrogen Receptor Modulators), calcitonins, parathyroid analogs, and RANK (Receptor Activator of Nuclear factor Kappa-B) ligand. It was also commented on concerns about bone quality and the effects current osteoporosis drugs may have on bone quality, and that a new FDA draft guidance called for additional long-term nonclinical pharmacology studies (bone quality studies) to support new osteoporosis drug development.

Number of Pharmacologic Classes per Therapeutic Classes

The above chart shows the number of modern therapeutics’ pharmacologic classes per 38 of the 40 therapeutic classes covered in Progression of Modern Therapeutics (2015 Report), from Great Variability in New Drug Approvals Among Pharmacologic Classes and Therapeutic Classes (February 2016). This graph illustrates the significant variability in the number of pharmacologic classes per therapeutic classes, ranging from as high as 11 for Type-2 Diabetes to 1 for Systemic Lupus Erythematosus and Idiopathic Thrombocytopenic Purpura. Note the mean and median values for the number of pharmacologic classes per therapeutic classes were 4.3 and 4, respectively. The same commentary also showed a wide range in the total number of new drug approvals for these therapeutic classes, ranging from 44 for Hypertension to 1 for Systemic Lupus Erythematosus; note he mean and median values for the number of new drug approvals for these therapeutic classes were 11.5 and 9.5, respectively.

Systems Therapeutics

systems-therapeutics-sep-2016

Above is the recently updated systems therapeutics diagram, from Systems Therapeutics: Updated Diagram (October 2016). The systems therapeutics diagram consists of two rows of four parallel systems components for pharmacologic and pathophysiologic processes, representing the four different levels of interaction between these processes, i.e., at the molecular level, the cellular level, the tissue/organ levels, and finally the clinical level. Where these pivotal interactions occur for individual pharmacologic classes determine the four systems therapeutics categories. These two processes are initiated by an interaction between a pharmacologic agent and a pharmacologic response element on one hand and a hypothetical intrinsic operator and an etiologic causative factor on the other, and then culminate in a therapeutic response. Each of these two processes, pharmacologic and pathophysiologic processes, have their inherent variabilities; this construct further suggests that in addition to pharmacologic processes, pathophysiologic processes also contribute to ultimate patient therapeutic response characteristics.

Ongoing and Future Directions

Progress to-date has focused on generating work on each of the three initial projects, and uploading these to the TRI-institute.org website. Work on the Characteristics of Therapeutic Response project has been hampered by the challenges in identifying appropriate publicly available databases and the best reporting formats. The most recent efforts have focused on the Systems Therapeutics project, including the recently updated diagram, and current and future efforts will include additional work in this area, e.g., examples and exhibits, as well as strengthening collaborative outreach.

2015 Report: Progression of Modern Therapeutics

The 2015 Report of Progression of Modern Therapeutics provides graphs of new drug approvals for 40 therapeutic classes from 40 therapeutic categories. These include the 25 therapeutic classes that were in the 2014 Report, any updates on these, and 15 new ones, including irritable bowel syndrome, HIV-1/AIDS, hepatitis C, malaria, melanoma, pediatric acute lymphoblastic leukemia. Click here for the 2015 Report on this website.

Comments

As with most projects there are sometimes unexpected issues that come up from time to time, and this project is no different. We will comment on three such issues at this time:

Missing approved new drugs. Since the approach used for what new drug approvals to include involves a therapeutic class centered approach rather than an NME centered approach, it is possible there may be missing drug approvals, since these may involve secondary indications of NME’s or subsequent approvals of the same compound, and would thus not be included in FDA’s annual NME listings. Any such omissions will be corrected as appropriate.

Missing approval dates. For several older drugs, the exact initial approval date may not be listed in the Drugs@FDA database, or other readily available databases. In such cases, a footnote is added to that effect on the graphs for individual therapeutic classes, e.g., pediatric acute lymphoblastic leukemia and migraine; other examples would include tuberculosis.

Off-label use. For some diseases there is considerable off-label use, and a number of drug information websites may include such use, without necessarily distinguishing between FDA approved drugs and off-label use, e.g., migraine. Such examples of clinical use are typically not included on the graphs.

Random Observations and Comparisons

A perusal of this 2015 Report suggests a few lessons learned, including the following random observations and comparisons:

  • Note significant recent advances in new drug approvals for hepatitis C, melanoma, cystic fibrosis, idiopathic pulmonary fibrosis, and irritable bowel syndrome, to name just a few.
  • Note recent introductions of new pharmacologic classes or mechanisms of action for type-2 diabetes, dyslipidemia, multiple sclerosis, pulmonary arterial hypertension, and rheumatoid arthritis, to name just a few.
  • Note no new introductions of new pharmacologic classes for depression (MAO inhibitors, tricyclics, SSRI’s/SNRI’s) and schizophrenia (typical and atypical antipsychotics) since the late 1980’s.
  • Contrast melanoma with 8 new drug approvals since 2010 with childhood acute lymphocytic leukemia with most drugs from the 1950’s, 1960’s and 1970’s.
  • Contrast plaque psoriasis with 7 new drug approvals with systemic lupus erythematous with 1 new drug approval since 2000.
  • What do thrombolysis and acid reflux/gastric ulcer have in common? No new drug approvals since 2000/2001.

The two prior annual update reports (2013 Report and 2014 Report) contained different summary graphics, which are not included in the 2015 Report; these will be addressed in future posts.

2015 Update on Current Projects

Introduction

The Therapeutics Research Institute, a 501(c)(3) nonprofit corporation, was initiated to examine and report on various aspects of modern therapeutics. Its website, TRI-institute.org, which contains its reports and commentaries, became operational in August 2014.

Update on Current Projects

Progress on the three initial projects of the TRI-institute and planned work are summarized in the chart below (click for a larger chart).

 Update on Current Projects

Progression of Modern Therapeutics

This primary focus of this project involves the development of a database, graphics and reports of new drug approvals for individual therapeutic classes, sorted by pharmacologic classes and years of approval. The latest published report (2014 Report) includes 25 therapeutic classes. A separate report has been published on orphan drug approvals for metabolic disorders. Furthermore, a total of eight brief commentaries have been posted on individual therapeutic classes that were already addressed in the reports.

Planned work includes 1) updating the annual reports, which will also be expanded to include additional therapeutic classes, including oncologic therapeutics, exemplified by childhood malignancies, 2) exploring relationships and lessons across therapeutic and pharmacologic classes, and 3) continuing commentaries on selected individual therapeutic classes.

Therapeutic Response Characteristics

This project focuses on the development of a database involving therapeutic response characteristics of approved new drugs, including therapeutic response variability and range, from minimum and average to maximum responses. An initial project outline has been proposed, and a commentary has been posted on the ultimate positive response, i.e., cure.

Planned work includes 1) developing a pilot project on therapeutic response characteristics of several therapeutic classes, selected from those completed under the project on “Progression of Modern Therapeutics”, and 2) proposing a summary of the ideal therapeutics performance parameters and measures.

Systems Therapeutics

This project focuses on the interactions of pharmacologic and pathophysiologic processes resulting in a therapeutic effect. An initial diagrammatic framework has been proposed, which includes four systems therapeutics categories, ranging from the molecular level, through the cellular and tissue/organ level, to the clinical level.

Planned work includes 1) developing several examples of individual pharmacologic and pathophysiologic interactions, involving each of the systems therapeutics categories, for several therapeutic and pharmacologic classes, and 2) making any refinements or additions to the initial diagrammatic framework, in part based on learnings from the examples developed.

Comments

In 1980, Dr. Paul P. Beeson published a paper in the journal Medicine (1), where he reviewed and compared treatments recommended in the first (1927) and fourteenth (1975) editions of the Cecil Textbook of Medicine (2). In 1927, only 6% of diseases had treatments considered to be “effective”, “helpful”, or “highly effective”, whereas in 1975, half a century later, this percentage had increased to 50%.

It is noted that the project on “Progression of Modern Therapeutics” starts approximately around the time Dr. Beeson’s assessment ends. It is also noted that in the time period between 1976 and 2014, a total of approximately 1,000 new drugs have been approved by FDA, i.e., meeting regulatory requirements for approval, and importantly, these include the majority of today’s effective treatments. These considerations emphasize the importance of continuing examination of various aspects related to the evolution of modern therapeutics, and what can be learnt from those. These are the fundamental objectives of the Therapeutics Research Institute, that led to its initial three projects.

References

1) Beeson PP. Changes in medical therapy during the past half-century. Medicine, 59:79-99, 1980.

2) Beeson, PP, McDermott W, Cecil RL. Textbook of Medicine, Edition 14, Saunders, Ken & Georgie, 1975.

Refer to other section on this website, particularly Projects, Reports, and Posts.