Saturday, November 29, 2008
Sunday, November 23, 2008
In the mainstream media today, depression has become a very common word. The global financial woes are collectively called 'economic recession' and/or 'economic depression'.Along with economic depression, the antidepressant drug market - particularly in the developed countries - is growing steadily. The hot hot market in the global pharma sector is depression. Period. Every one wants a quick fix solution, nothing like popping a pill to fight away the blues, feel high, and love oneself dearly. Diabetes carries along with it depression. And it is popularly known now,
As per IMS Health, in 2006, the maximum prescriptions dispensed in USA was for antidepressants. This was followed by lipid regulators, codeine and combinations, ACE inhibitors, beta blockers, proton pump inhibitors, thyroid hormones, seizure disorders, calcium channel blockers, and then benozodiazepines. It is important to note here that benzodiazepines are used in a broad range of psychosomatic disorders - from anxiety to convulsions. Hence, there is an overlap between antidepressant market and benzodiazepines market. WELL THAT IS THE STORY AS PER THE MAXIMUM PRESCRIPTIONS DISPENSED IN USA.
HOWEVER, GLOBALLY THE SALES PATTERNS ARE DIFFERENT, THE LIPID REGULATORS THERAPY CLASS IS THE NO. 1 IN SALES , AND VALUE WISE, ANTI-PSYCHOTICS, AND ANTI-DEPRESSANTS HAVE A POSITION OF NO. 6 AND NO.7 RESPECTIVELY. PLEASE CLICK HERE.
NOW THE MOOT POINT IS, AS THE INDIAN PHARMA MARKET EVOLVES, WILL THE ANTIDEPRESSANT MARKET EVOLVE BETTER TO BECOME A HIGH VALUE MARKET IN INDIA? IT IS DIFFICULT TO SAY, BECAUSE OF YOGA AND OTHER ALTERNATIVE HEALING SYSTEMS IN INDIA. (THIS REPORT IN INDIA TODAY SAYS THAT DIAGNOSIS AND LACK OF TREATMENT FACILITIES PLAGUE THE INDIAN DEPRESSION MANAGEMENT MARKET).
The China experience
'Removal of the stigma' and 'improving diagnosis' for market expansion
The most important aspect for marketers of anti-depressant brands is to get the market to expand through increase of the user base. How can it be done? The challenge is two pronged - one, remove the stigma attached and, two, improve the diagnosis of the ailment.
For the removal of the stigma: attached to depression, the best marketing communication approach would be to put the focus on 'IMPROVING THE PERFORMANCE AND SOCIAL LIFE' of a patient. Instead of using the word: depression, using phrases that have a positive presentation will help the cause of antidepressant and mood elevator marketers. For instance, talk about the ability of a drug (herbal or allopathic formulation) to improve social interactions, overcome stage fright, shyness, improve inter-personal relationships and communication, ability to create confidence for better negotiation, and thereby avoid adverse circumstances. Just do not talk depression, but communicate about the benefits of drug therapy for a better attitude. As such it would be an interesting marketing communication experiment to position antidepressant and mood elevator drugs as those that help create positive attitude. When the presentation is positive, the appeal will be positive.
Take the interesting case of alcohol beverage marketing: pharmacologically speaking alcohol is an addictive primary continuous depressant. But it is ironic that all ads and communication for alcohol show it as a fun drink - one that elevates mood, and is associated with celebration. Whereas the imagery for antidepressants that truly elevate mood and help manage attitude better - is that of stigma, morbidity, and sickness. THAT IS WHY MARKETING IS DESCRIBED BY AL RIES AND JACK TROUT AS A WAR OF PERCEPTIONS. Alcohol beverage marketers have ensured that the perception of the alcohol beverage brands is about positivity, fun, frolic, happiness, and being hep - whereas alcohol is actually about addiction and being a primary continuous depressant! Alcohol consumption causes inhibitions to be dropped, but that does not make it a stimulant! Alcohol only has a pretense of being a stimulant!! So the nub of the matter is that advertising, and marketing communication to physicians and patients (through patient information leaflets) should change the perception of antidepressant and mood elevator therapy class to be something positive, truly healing, and improving the attitude. That will go a long way in removal of the stigma attached to depression as a clinical disease.
Help the GP and other specialists to diagnose underlying depression. For instance, several diseases like diabetes and thyroid pathology, and stages of life like menopause are associated with mild to moderate depression. Thus, co-prescribing of antidepressants will go a long way in market expansion.
With China increasing its antidepressants market, and antidepressant prescriptions being the #1 dispensed segment in USA it remains to be seen whether the Indian antidepressant market will take off in the near future. The aspect that antidepressant prescriptions are #1 dispensed gives a clue - patients may be shy to take on to antidepressants, however, once they are on them, they do not seem to want to give up.
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Friday, November 14, 2008
Mass doctor calls and account management approach
There is a distinct movement, in MR field-level challenges - from doctor calls to account management. There is change in the air: from brand selling to relationship management and therapy management.
The intensification of market competition, and empowerment of society and patients with access to healthcare knowledge, has led to a situation wherein it's not remunerative to focus on a large amount of doctor calls. Yes, one has to expose the product to as many doctors as possible through all available media – including through MRs. However, from the general pool of doctors, it is wise to select a subset of doctors for intensive customer relationship management. The selection of these doctors would not be merely on the size of their practice but more importantly on whether they are amenable to close and profitable relations with the MR. After all, ultimately marketing is about customer relationship management in ways as to benefit the organization.
There are more than 120000 MRs in India. Some estimates are up to 200000 MRs in India. With such a massive force of pharma salesmen, it is inevitable that some relationships between certain doctors and a MR would be better than with other doctors. This is the reason why account management approach to doctors will work as opposed mass doctor calls only.
Hence, pharma marketing strategies operate at two levels: one - the general exposure plan where messaging and other freebies are targeted to a large community of doctors, and secondly, a focus marketing strategy plan to manage intimate relationships between the marketer and certain customers (product-wise core doctors). As part of the intensive customer relationship management in the second category, the MR would provide therapy management inputs, concierge services, and other inputs to extract high volume of prescriptions.
As such, the above strategy of intensive customer relationship services to core doctors, has been followed by MRs of many a Indian company, but the scenario today is such that all companies (whether MNCs or Indian) – are forced to follow the CRM approach for key accounts.
In the key account management approach: intense CRM is to certain doctors, as opposed to mass doctor call approach - where the focus is on quantity of calls. In the account management approach, products prescribed and sold are due to the management of key accounts (or core doctors) and prescriptions generated there by.
Whether a company follows mass doctor call approach or account management approach or a mix of the two, one thing is for sure, SMILES AND GIFTS take the company a long long way.
The 'profit season' in Indian pharma is April to Sept., when sales are good and demand is high for pharma products. After that in the lean season we have the 'gift season'. This is because from Oct to Dec, festivals dot the calendar: Ganapathi pooja, Id, Durga pooja, Dasara, Diwali, Christmas, and New Year Eve celebrations. These are all gifting times for pharma companies.
A smile has a lot of significance in human relations and salesmanship. In fact, it is said: A SALESMAN IS NOT DRESSED FOR THE DAY, TILL HE WEARS A SMILE! A smile means a lot: it can indicate love, kindness, amusement, and joy. As John Mack has said in one of his blogposts, A FRIENDLY REP GETS MORE TIME WITH THE PHYSICIAN, MAKES MORE CALLS, AND DOES MORE BUSINESS. It is evident that the pharma company with more smiling MRs can do more business.
The focus of a MR while detailing and performing his in-clinic activity ought to be to get the doctor to smile, genuinely, particularly in agreement with the MR - to his points of detailing. When the MR sees a smile he is sure to win the business. A dashing MR (now a first line manager) Mr. Kiran kept a data bank of the birthdays' of his key doctors. One memorable day, Kiran wished a doctor with a bouquet and wished him Happy Birthday, after his detailing. The doctor was actually surprised as he had forgotten it was his birthday! While happy with the compliment from Kiran, he rewarded him with a good POB (personal order booking) worth Rs. 5000/-. This is a simple example. However, it reflects the importance of key account management, generating customer delight and SMILES from target doctors.
Gifts are very important in human transactions and as business tools. WHO DOES NOT LIKE TO RECEIVE GIFTS?! Even the richest crorepathy likes receiving gifts. A gift is an act of love, kindness, sacrifice, and care. It is a gesture that bonds the marketer to his customer and vice versa.
Gifting as per Indian philosophy is of three types:
Saatvic gifting is providing gifts with unconditional love. It is a very high level of thinking. For eg., true saints often give gifts with unconditional love.
Raajasic gifting is the typical business gifting procedure. There is an element of give and take. There are unwritten conditions of gifting. A MR provides a New Year eve gift to a target doctor with the intention of receiving worthy prescription support.
Taamasic gifting refers to giving a gift with unhappiness, contempt, anger, remorse, and other negative emotions.
In any case, gifts play a very important role in CRM (customer relationship management) with reference to pharma company and doctor relationship.
Say the word GIFT and perhaps the first pharma name that pops up is Himalaya Drug Company. They virtually built a huge base of goodwill and sales through regular gifting practices to doctors.
Another interesting example of rajasic gifting that I recollect from my field days is of Cipla: if they gave a costly gift (during those days gifting a fridge to a clinic was a costly gift), to a doctor, they would strike a deal - "Dr., please accept this gift and become a Monday doctor for us for about 6 months". This means, every Monday, the target doctor would give prescriptions only for Cipla products - the rest of the days in the week, he is free to prescribe other pharma products. Every Monday the concerned MR or executive would give a call to the doctor, reminding that he is a Monday doctor! It is kinda cute idea and it worked very well for the company.
With key account management practices coming in vogue in the field of pharma marketing, gifts and smiles have gained more importance.
Realizing the impact of gifting in pharmaceutical selling, OPPI and other bodies have tried to put in to practice a code of conduct with relation to gifting. CLICK HERE.
Thanks for reading this blogpost, please scroll down to read all other blogposts, do click on OLDER POSTS, whenever required to read all posts. This blogpost is put from a nearby cyber centre on 14.11.2008 at 7.30 pm.
Sunday, November 9, 2008
I GOT THE ABOVE IMAGE RELATED TO NEUROPATHY FROM HERE.
Shakespeare, the bard of Avon has said, "There is a tide in the affairs of men, which when taken at the flood, leads to a fortune". These timeless words reflect the importance of timing in creating wealth. All said and done, most of pharmaceutical and healthcare organizations, are in the business of health for wealth, while concomitantly achieving social goals. Thus, it is of utmost importance to latch on to emerging trends early and go along with the tide to gain a fortune.
Today, reflecting on diabetes and diabetic complications (NOV 14th is WORLD DIABETES DAY), one does realize that a small pot of gold awaits the patient pharma marketing warriors riding on the neuropathy disease trend.
The march of diabetes continues unabated
As per the Nov 2008 issue of Reader's Digest, p.no.57, there are about 230 million diabetics in the world, 41 million (4.10 crores) are in India. In fact, our country, India, is called the diabetes capital of the world. By 2025 the projections are that there will be 70 million diabetics in India, every fifth diabetic in the world by 2025, will be an Indian.
Type 1.5 diabetes
Newer research insights have lead to interesting facets of diabetes, so much so that diabetes researchers have now observed a new class of diabetics (Type 1 1/2!) OR (TYPE 1.5). As such, there are two major classes of diabetics: Type 1 (those that are dependent on insulin) and Type 2 (who are on diet control, lifestyle management, and oral antidiabetics). 70% to 80% of Indian diabetics are Type 2. Type 1.5 diabetics are non insulin dependent, are not overweight, and do not show significant insulin resistance.
A research study says, weight loss of 5% to 7%, exercising for 30 minutes, 5 times a day, lowers the risk of developing diabetes by 60% - this goes to show that sedentary lifestyles are the main cause of increasing diabetes in India.
Dr. Abdul Kalam, our Ex President of India, in his book India 2020 says, on page 231, about 5 to 10% of Indian population suffers from diabetes.
The most common complication in diabetics is neuropathy, ie., disease of the nerves. The Indian Practitioner, Oct 2008, p.no.622, says about 19% to 28% of diabetics suffer neuropathy. Neuropathic pain is said to affect 16% of diabetics.
Back of the envelope calculations
Let us say there are 50 million diabetics in India ie., 5 crores (1 million = 10 lakhs, 100 lakhs = 1 crore). This means there are 1.4 crore diabetics suffering neuropathy (@ 28%), and 80 lakh diabetics suffer neuropathic pain (@ 16%).
Diabetes is not the only cause of neuropathy, - HIV, herpes, toxins, alcohol, and cancer chemotherapy also cause neuropathy.
In the US, neuropathic pain management business is 2.6 billion USD. Lyrica (pregabalin) from Pfizer, and Cymbalta (duloxetine) from Eli Lilly, are the mainstay drugs, their patents will expire in 2013 & 2018, respectively. In India, gabapentin is used frequently for neuropathic pain management.
Market development and Management of neuropathy
Neuropathy, particularly diabetic neuropathy, is not well understood. A lot of research is on. To manage this condition with drug treatment - antidepressants too are used. Regular type of NSAIDs (ie., non steroidal anti inflammatory drugs like diclofenac and combination drugs) are also clinically attempted, and morphine analogues are used clinically.
Dietary supplements/drugs like alpha lipoic acid, and methylcobalamin have good scope in diabetic neuropathy management as per clinical studies.
However, a lot of new drugs are in the pipeline of various companies targeting neuropathy.
One of the major aspects of neuropathy is that this irreversible condition is frequently under-diagnosed. A LOT OF SOCIAL GOOD AND COMMERCIAL GAIN DEPENDS ON A MARKET BUILDING APPROACH BY PHARMA AND HEALTHCARE MARKETERS.
Diagnosis camps: The camp approach (camps sponsored by pharma companies) is vital to create vibrations in the market, increased consciousness, and increase the no. of diagnosed cases. For eg., osteoporosis was a not so-popular indication in clinical practice a few years back. When pharma marketers organized a no. of free osteoporosis diagnosis and treatment camps (with the aid of DEXA or DXA machines), the market bloomed, and a lot of social good was achieved. Similar success followed the strategic camps for hepatitis B vaccination (by the way Gardasil the cervical cancer vaccine has been launched on a very low note in India - without much publicity, wonder why?).
Thus, consistently organizing neuropathy detection camps particularly for diabetics will usher in a new age of clinical management of neuropathy in India. To detect neuropathy particularly in diabetics, an instrument called vibrometer is used, where the vibration perception threshold (VPT) is measured.
Creating the buzz is vital: It will certainly not suffice if the camps alone are conducted. A buzz is required in the public media and through posters and other print materials at healthcare points (clinics, chemists, diagnostic labs, gyms and Yoga centers, and other healthcare service providers). ONE SHOULD ENGAGE THE DOCTORS AND PATIENTS ON THIS ISSUE FOR THE BUZZ.
One interesting approach is to use the mobile to create the buzz for neuropathy:
For eg., let us say 500 doctors (spread across India) are identified to participate in a series of neuropathy diagnosis camps. As per this approach, each of these doctors will receive daily sms updates on how the camps are progressing India wide. For eg., one message can be Dr. Manjunath of Bangalore has had excellent response to his neuropathy diagnosis camp, 25 new cases detected with mild neuropathy on first day, 14 cases of moderate neuropathy detected. Another sms message can be Dr. Venkat of Chennai is very happy with Brand A benefits in mild neuropathy - good response for Brand A seen within 24 hours of therapy in 50% of patients. ONE MORE MESSAGE CAN BE: Dr. Singh's Delhi diabetic neuropathic camp inaugurated today morning by the Chief Minister of Punjab, 500 patients attend camp on first day .... SO ON.
Today, like Shakespeare has advised, one has to ride on the tides - to gain a fortune. Neuropathy is an emerging area of clinical management with significant commercial appeal.
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Monday, November 3, 2008
Modern lifestyle has led to a boom in the market for pharmacological and non-drug management of the so-called lifestyle diseases. Yoga evangelists like Baba Ramdev are riding on this lifestyle disease wave. Examples of lifestyle diseases include: cardiovascular disease, cancer, diabetes, obesity, and respiratory diseases like COPD, and asthma.
Cardiometabolic disease refers to a combination of cardiovascular disease and metabolic dysfunction. The patients of cardiometabolic disease have cardiovascular disease and an accompanying endocrinological or metabolic disorder like diabetes. Cardiometabolic diseases are also a part of the lifestyle diseases.
Cardiovascular disease refers to diseases of the heart & blood vessels. 80% of deaths due to cardiovascular diseases occur in developing countries. In fact, 28th Sep is celebrated as World Heart Day to highlight the growing cardiovascular risks. By 2015, there will be 100% rise in deaths due to cardiac ailments in India as per WHO. In Japan in the meantime deaths due to cardiovascular diseases have decreased by 60%!
Heart attack, TIA (transient ischemic attacks), strokes and leg attack (peripheral vascular disease) are manifestations of cardiovascular disease. As per ORG IMS Sep 2008, the Indian market of cardiovascular disease management drugs is Rs. 3584.17 crores per annum and growing at 18%.
Primary prevention or leading a healthy lifestyle – is essential to reducing the cardiovascular disease burden. A daily routine of at least 10000 steps is a must for a healthy lifestyle. In fact, lack of exercise increases the body's risk of developing heart disease by 150 per cent. Quitting smoking, right management of stress, and a healthy diet are a part of healthy lifestyle.
High blood pressure – hypertension – can be reduced by supporting diuresis and vasodilation. As such, excessive calcium ions in the muscle cells of heart and blood vessels, causes increased contraction of actin and myosin (the contractile proteins). This results in excessive contractions of heart and blood vessel muscles. Hence, increased pumping of blood by the heart and increased contraction of blood vessels leads to increased cardiac output (more blood being pumped out by the heart) and vasoconstriction (blood vessels contract, decreasing the lumen of the blood vessel) respectively. This leads to increased blood pressure (ie., the lateral pressure of blood exerted on the blood vessel walls through which it is flowing).
A new approach in the clinical management of hypertension is by establishing ion-water balance across the cell membrane, and preventing entry of excessive calcium ions in to the cells, thereby reducing excessive vasoconstriction. To establish normal ion-water balance across the cells, and maintain normal cell volume the body has natural organic osmolytes. Myo-inositol and taurine are two important organic osmolytes that help in maintaining ion-water balance across the cell membrane.
Uncontrolled hypertension leads to kidney damage (one in 10 Indians suffer kidney disease), blood vessel damage, heart attack, and congestive cardiac failure.
Obesity, diabetes, and hypertension are the chief causes of CVS diseases. A key component of unhealthy lifestyle is SMOKING. When a cigarette is smoked, the person inhales 250 to 400 toxic chemicals (50 of them being carcinogens). The chemical poisons inhaled during cigarette smoking is known to cause endothelial dysfunction. The first stage of atherosclerosis (thickening and hardening of blood vessel walls, leading to loss of elasticity) is endothelial dysfunction (the innermost lining of blood vessels does not function normally). Smoking increases the chances of heart disease by two fold.
The world over, gastrointestinal and anti-infective pharma markets are big bucks. However, cardiometabolic disease, onco segment, and other lifestyle disease markets are growing in size rapidly.
A boost to metformin
Metformin is an oldie goldie drug in the management of diabetes. Currently, there is a school of thought gaining traction in medical circles, to make metformin the ABSOLUTE first line of therapy. The reasons are not just pharmacological; it is also about, patient compliance due to metformin's pocket friendly price.
Further, there is new and exciting information that metformin helps in reigning in mortality due to heart disease in diabetics. Now, that is powerful information. The strength of metformin is the great amount of valuable clinical experience backing it.
Metformin seems to be fated to becoming an evergreen drug in the management of diabetes (particularly Type 2), the world over.
Managing diabetic complications: 'serious stand alone markets'
In the management of cardiometabolic disease, it is not just blood sugar control, the management of diabetic complications too is emerging as serious stand alone markets for pharma marketers. There are various drugs and dietary supplements available, to effectively manage diabetic complications.
The market for managing diabetic complications is nascent and growing rapidly due to increasing consciousness of diabetes and its complications. Of the All India Pharma market which is worth Rs. 33604 crores with growth of 13%, the market for drugs used in diabetes is valued at Rs. 1756 crores and growing at 20%. . An example of a hot sub-market in the diabetes segment is the diabetic neuropathic market (disease of the nerves in diabetics). This is the hottest segment of the drug markets for diabetic complications.
Diabetic neuropathy – it is the most common complication of diabetics. The prevalence in India is supposed to range from 19% to 28% of diabetics. The prevalence increases with age and duration of diabetes. Concomitant factors like increased blood lipid levels, smoking etc increase occurrence and intensity of diabetic neuropathy.
Signs and symptoms of diabetic neuropathy:
- numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers
wasting of the muscles of the feet or hands
indigestion, nausea, or vomiting
diarrhea or constipation
dizziness or faintness due to a drop in blood pressure after standing or sitting up
problems with urination
erectile dysfunction in men or vaginal dryness in women
Osmotic stress on the cell membrane is common in diabetics and hypertensives. In hyperglycaemic patients, sorbitol and reactive oxygen species levels rise leading to osmotic stress on cells. These osmotic changes lead to neuropathic pain. Organic osmolytes may have a role in helping manage neuropathy.
Methylcobalamin 1500 mcg and alpha lipoic acid 300 mg per day are useful in arresting the progression of diabetic neuropathy and its severity. (The Indian Practitioner, Oct 2008, p.nos. 621 to 628).
The kidney connection
The renal basis of hypertensive cardiovascular disease is becoming more and more evident. The importance of the kidney in hypertension, is due to the group of cells called JUXTAGLOMERULAR cells. These cells secrete an enzyme called renin. This enzyme converts angiotensinogen - a protein circulating in blood - to angiotensin 1. Angiotensinogen is produced by the liver and put in to the blood circulation.
Angiotensin 1 is then further converted in to angiotensin 2 by another enzyme angiotensin converting enzyme (ACE). Angiotensin 2 is a potent vasoconstrictor (constricts or contracts blood vessels). This increases blood pressure. Further, angiotensin 2 through its influence on a hormone called aldosterone increases absorption of water from kidneys (the water comes from the filtered blood), and shifts it back to blood. This increases blood volume. The net result: increased blood pressure.
The most popular antihypertensive drugs on the kidney system are the ACE inhibitors that inhibit activity of angiotensin converting enzyme. There are angiotensin 2 antagonists like losartan sodium, and new off-the-block drugs are renin antagonists.
The haemodynamic equation
So ultimately what do all these antihypertensive drugs do? They either decrease the vascular resistance (ie., cause blood vessels to dilate) or decrease the cardiac output (ie., blood pumped out by heart in one minute) or decrease both ie., vascular resistance and cardiac output. This is encapsulated in the haemodynamic equation:
BP (blood pressure) = PVR X CO
In this equation, PVR is the peripheral vascular resistance, which depends on the diameter of the blood vessels. The CO factor is cardiac output. This depends on the force of contraction of heart, heart rate, and the blood volume.
Antihypertensive drugs tend to decrease the heart rate, or force of contraction, or blood volume (by increasing the urine output), or cause vasodilation (increase blood vessel diameter).
The final conclusion
Cardiometabolic diseases are causing immense morbidity and mortality world wide. Developing countries are not spared nor are the developed countries safe from these diseases. Pharma marketers have donned their war gear for waging a war against cardiometabolic disease. However, they are just one front, the Govt. and NGOs need to launch massive communication exercises to create a lot of societal consciousness on cardiometabolic diseases. For eg., NACO is an organization to help fight AIDS. Similarly, we need a specialized apex body to lead the communication battle to ensure increased focus on cardiometabolic disease – a killer disease on the prowl.
THANKS FOR READING THIS BLOGPOST, PLEASE SCROLL DOWN AND CLICK ON OLDER POSTS AS AND WHEN REQUIRED, TO READ OTHER POSTS. This blogpost is put up at 7.45 pm on 3.11.2008 .