Waiting Room Sidetalk: How Branded Drugs Get Named and More

Hey there 👋

I’m back after a long writing hiatus. To update those who don’t know, I left venture to join Truepill and help build the API infrastructure consumerizing healthcare. I needed a moment of respite and focus... rather natural when starting something new.

But now I’m back at it and reorienting this blog. I’ve been endlessly impressed by the wave of healthcare and bio newsletters / digests / talkspaces (Olivia Webb, Niko McCarty, Brendan Keeler, Chrissy Farr, Nikhil Krishnan, Biotech Clubhouse, Brian Dolan, Meera Clark, Elliot Hershberg, Lisa Suennen, Bio Eats World, Sherman Leung, Wharton’s Digital Health Hub to name a few). Everyone has their own niches and stylistic flairs. If there’s anything I could call my bit, it’s just curiosity. I might start my day with a bioRxiv preprint, ending with a nightcap and translation of Galen’s Medieval cosmology. I will absolutely waste hours reading GAO reports on pharmaceutical industry contributions to medical schools.

These posts will be sidetalk on things that I’m paying attention to in healthcare and bio. Read the sections that interest you, skip the less relevant :)

1. How Do Drugs Get Named?

N-acetyl-p-aminophenol aka acetaminophen or the brand name Panadol and Tylenol.

Perhaps naively I assumed every generic drug was named by shortening a convoluted chemical compound. Turns out there’s a body - the United States Adopted Names (USAN) Council, recognized by the FDA - that assigns nomenclature to all active drug ingredients. USAN is a partnership from the 60s between the American Medical Association (AMA), the United States Pharmacopeial Convention (USP), and the American Pharmacists Association (APhA). 

USAN maintains a list of indicative prefixes, infixes, and stems. Here’s the example process for naming a monoclonal antibody treatment (proteins that mimic the immune system's ability to fight off antigens like viruses):

  1. Prefix of any unique, distinct syllable (e.g. bix)

  2. Infix representing the target or disease (e.g. -tu/-t for tumors or -li/l for immunomodulators)

  3. Infix representing the source (the species originating the monoclonal antibody e.g. -o- for mouse or -u- for human)

  4. Stem used as a suffix (e.g. -stat for glutamine antagonists)

Put that all together and you have the name of a generic drug. I’d love to link to the full dictionary of generics but that requires a membership / coughing up $350... 

Branded drugs have a different process. A company requests FDA approval for the drug name, identifying it as the exclusive property of that company. Sometimes brand names explicitly suggest the characteristic of the drug: Lopressor lowers blood pressure and Skelaxin relaxes skeletal muscles. Pharma manufacturers can also get more imaginative. Below, Pfizer gives a glimpse into its naming gestalt:

Naming is an involved, important undertaking that can start years before drug approval. Firms contract with outside agencies to produce hundreds of possible names. Then development teams conduct market research, focus groups, visual identity solutioning, trademark clearance, phonetic analysis across languages and dialects, and handwriting analysis (*seriously*). After all, it’s critical to a global manufacturer’s brand equity and revenue after patent expiry. No one knows the generic Sildenafil citrate but everyone knows Viagra. 

2. No Surprises Act (in effect Jan 1, 2022)

Getting treated by an out-of-network (OON) provider happens way too often, especially in emergency settings and in elective surgery, driving profligate costs on the system and patient bankruptcy. This legislation restricts excessive out-of-pocket costs to the consumer from surprise and balance billing. Notably, it affects both fully-insured and self-insured employer plans that often get more flexibility.

How the act works:

  1. Commercial health plans are required to maintain up-to-date provider directories with changes processed in <48 hours. Patients using inaccurate provider directories are 4x more likely to receive a surprise out-of-network bill. A few companies already playing here like Ribbon Health and Veda

  2. Health plans have to treat OON services like they are in-network when calculating patient cost-sharing 

  3. Health plans bill the consumer and make an initial payment to the OON provider within 30 days (though there’s no minimum payment)

  4. The OON provider, if dissatisfied, can initiate arbitration / an open negotiation process with the health plan 

  5. Both parties are charged an administrative fee by the government to use a third-party arbitrator, an entity/person certified by HHS, Dept. of Labor, and the Treasury Dept. 

  6. Final offers from both parties must be issued within 30 days 

  7. Arbitrator determines final payment by considering median in-network rates, demonstrations of good faith, patient acuity, and case mix offered by the facility

Accelerating a sometimes months/years-long denial and appeal process to <60 days is going to be a big change.

Potential business opportunity: an AI-based arbitrator. When I worked at Oscar Health, which bought, gutted, and modernized a claims system over several years, I remember the sheer amount of time and labor that *still* went into claims negotiations. Mechanisms for arbitration will still be inefficient and inconsistent if we depend on manual processes. As reimbursement data from the recently implemented hospital pricing transparency rule improves, there’s a near future of automated “best” adjudication. 

Cedar’s OODA Health acquisition might have been rather prescient. This could also be a future revenue cycle product of Turquoise Health.

3. Demystifying the Relationship Between Drugs and Human Gut Bacteria 

The microbiome may be in vogue but Martina Klünemann has investigated the relationship between therapeutic drugs and the microbiome since 2013. Following 2018 research that claimed an astonishing 1 in 4 drugs affect our gut, she was the lead author on a recent paper about bioaccumulation

Profiling 15 drugs and 25 strains of representative metabolic diversity (375 bacteria-drug pairs), Klünemann and her colleagues found at least 70 interactions where microbiota absorbed / didn’t metabolize the drug or changed a bacterium’s own metabolization. These interactions impact the availability and efficacy of a drug, and can produce side effects like weight gain. 

What’s sorely needed is “a systematic mapping of reciprocal interactions between drugs and gut bacteria.” Wouldn’t you want to know that the drugs you take work the way you think? As the researchers point out in their conclusion, it may lead us to uncovering deleterious secondary effects and important immunological responses that we didn’t know / were misattributed. 

An aside: are there any synthetic gut projects out there?

4. O Dentist, Where Art Thou?

The legendary Alexandra Elbakyan (long may she reign) released 2 million new papers to celebrate 10 years of Sci-Hub providing free access to research. In the announcement, she turned around some quick analysis on Elsevier’s citations database: medicine leads in productivity by number of published articles… dentistry falls way at the bottom. 

The lack of research is so stark that there’s even an article asking:

Dental and vision are separate from health insurance primarily because dentistry and optometry are relatively new medical practices. Dentists historically yanked out bad teeth; optometrists were craftsmen providing corrective lenses. We’ve come to see the mouth as a reflection of general well-being in the past 50 years. Longevity podcaster Dr. Peter Attia and Dr. Patricia Corby of Penn Dental have discussed a host of conditions associated with oral health from herpes and diabetes to cancers, HIV, and Crohn’s. The oral cavity has the 2nd largest and diverse microbiota after the gut.

There are some new clinical research models like practice-based research (PROH), enabling dentists and academics to run studies outside of university settings. But I’d like to see more creative multi-disciplinary research. Quip, with its large consumer reach, could launch a research institute and sponsor decentralized studies. Family medicine / pediatrics, pathology, immunology, and neurology are specialties that can steward oral research.

People who disproportionately suffer the worst oral health are the poor, disabled, and minority groups. That behooves us to take oral health seriously as a research area - and integrate oral care more meaningfully into overall health.

5. An Ask on FAANG and Biotech

I’ve started researching moves that Apple, Facebook, Amazon, Google, etc. are making in biotech. Please reach out if you or anyone you know has intel! 

6. Interesting Tweets / Links:

  • Warby Parker gets into digital health for vision prescription renewals

  • Spinout.fyi is a new database listing entrepreneurial students and researchers commercializing their inventions

That’s all for now, catch ya next time.

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Disclosure: I don’t have a copywriter so yolo on the typos. This post does not represent the views of my employer. I am a scout for a16z’s bio team.

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