Metabolic Disease and the Three Bears of Drug Development
Discovering Goldilocks treatments in oncology, immunology and neurology
In 2024, the top three disease areas — oncology, immunology, and neurology —accounted for 66% of clinical trial starts, according to IQVIA. Oncology led the way with a 41% share, while immunology (14%) and neurology (11%) experienced a decline in clinical trial starts since 2019, dropping by 39 and 57 trials, respectively. Increases in oncology and obesity related trials made up the difference, increasing by 223 and 78 respectively. The number of clinical trial starts reached 5,318 in 2024, a number near identical to 2019’s 5,316, indicating a return to pre-pandemic levels. US headquartered companies accounted for 35% of these.
The loss of exclusivity (LoE) due to expiring patents on high-revenue products will translate to losses of more than US$300 billion in sales through 2030. The patent cliff will drive M&A; 77% of executives in a Deloitte survey expect M&A to increase in 2025. M&A reveal which indications Big Pharma expects to see the greatest returns. “We are focused on high growth markets with high unmet medical needs. In innovative medicine, we are focused in oncology, immunology and neuroscience,” acknowledged Joaquin Duato, chairman and CEO of J&J at the JPMorgan Healthcare conference in January.
27 deals were announced in 2024 with values above US$2 billion, including nine in oncology and three in neurology. Assessing the top 10 pharma companies shows oncology as the clear favorite, representing 28% of total M&A deal value from 2019 to H1 2024, according to Larka. The largest deal, Novo Holding’s US$16.5 million acquisition of Catalent, shows the dramatic increase in interest in metabolic disease. M&A investments in metabolic disease accounted for 19% of total deal value in 2023, versus only 0.3% in 2022.
Oncology: Approvals are too cold!
One in five people will develop cancer in their lifetime, according to the World Health Organization (WHO). There is a 77% expected increase in cases from 2022 to 2050, attributed to changing population demographics and increased exposure to risk factors. In the US, the American Cancer Society projects over 2 million new diagnosed cancer cases in 2025 and over 618,000 deaths, equivalent to 1,700 per day. In countries with real GDP per capita above US$33,000, the US leads in percentage of patients achieving five-year survival, at 65%. The US oncology spend represented 45% of global oncology spending in 2023 and is expected to grow at a CAGR of 11-14% from 2024 to 2028, when it is projected to reach US$180 billion.
Treatment of women’s cancers, prostate cancer and late-stage multiple myeloma advanced in recent years as novel modalities, including antibody-drug conjugates, radiopharmaceuticals, bispecifc antibodies and CAR T-cell therapies, provide better outcomes. The first CAR T approved by the FDA was Novartis’ tisagenlecleucel in 2017 for acute lymphoblastic leukemia, leading to commercial availability of CAR T. Arcellx, a biotech advancing anitocabtagene autoleucel for relapsed or refractory multiple myeloma, is advancing CAR T in partnership with Gilead, with a hopeful 2026 launch. Aileen Fernandes, chief business officer, is excited for the future of the therapy: “At the macro level, academic centers and physicians are excited about CAR-T because they have seen the impact of this therapy in lymphoma and now in multiple myeloma. We are also seeing hospitals investing in CAR-T infrastructure, expanding access and exploring outpatient administration of CAR-T.”
There is a lot of momentum in the space, as evidenced by Roche’s acquisition of Poseida Therapeutics in January to expand Roche’s cell therapy capabilities, particularly in developing CAR-T cell therapies for hematological malignancies. In March, AstraZeneca announced its agreement to acquire EsoBiotec for their in vivo CAR-T.
Despite receiving the most funding dollars, oncology has the third lowest likelihood of all therapy areas of getting approval from Phase I. According to Andrew Feinberg, president and CEO of BostonGene, a biotech using AI-driven analysis of tumor genomics, the tumor microenvironment, and digital twin models to personalize cancer treatment, this will change: “We simulate clinical trials before they begin, modeling patient responses and optimizing drug development strategies. This dramatically increases the probability of technical success (PTS), accelerates trial timelines and reduces costs.”
Immunology: Major indications are too hot!
For the past two decades, immunology was a major growth engine in the biopharmaceutical space, sustaining 12-23% growth each year, which was three to five times that of the industry. Reaching US$166 billion by the end of 2024, immunology was the second largest therapy area by value. While growth continues, IQVIA predicts a slowdown from 15% CAGR over the past five years to 3-5% for the next five. This is due to patent expirations of autoimmune blockbusters, like Humira and Stelara. There is intense competition in major immunology indications like rheumatoid arthritis, psoriasis and ulcerative colitis. There will likely be at least six mechanisms of action and 12 brands for each of these indications, IQVIA found.
Innovators are looking to small immunology indications like lupus, hidradenitis suppurativa and alopecia areata as a hedge against overcrowding. Four first in class therapies were launched in the space in 2024, in indications like prurigo nodularis and WHIM syndrome. Three of 2024’s largest acquisitions further support this trend. In April, Vertex Pharmaceuticals beat four companies to acquire Alpine Immune Sciences for US$4.9 billion. Alpine is testing its flagship drug in patients with lupus and autoimmune cytopenias. Eli Lilly and Biogen also strengthened their immunology portfolios acquiring Morphic Therapeutics and Human Immunology Biosciences, respectively.
Marinomed, an Austrian-based biotech, divested its medical device business to focus on Marinosolv, a drug delivery platform enhancing the solubility of poorly soluble drugs. “Marinosolv has greater long-term commercial potential, particularly in immunology and ophthalmology,” said Andreas Grassauer, the CEO.
Neurology: Target selection is (almost) too hard!
According to the Lancet, one in three people worldwide will experience a neurological disorder during their lifetime. Disability, illness and premature death caused by neurological conditions increased 18% since 1990. Globally, disorders affecting the nervous system are the leading cause of overall disease burden.
The focus on such conditions is well founded, and 2024 saw great advances. The FDA approved four first in class molecules. Within this, Cobenfy was the first new mechanism of action launched for schizophrenia treatment in over 30 years. From IQVIA data, there were 605 neurology trial starts. Alzheimer’s, depression and Parkinson’s are the focus, each seeing more than 200 trials over the past five years. Phase I and II trial starts increased in 2024, with growth elevated by multiple sclerosis, depression, muscular dystrophy and amyotrophic lateral sclerosis.
Neurological conditions only have a 5.9% chance of FDA approval from phase I and average 11.1 years development, according to BIO analysis. Neurological disease treatments come with challenges such as understanding the underlying pathophysiology of a disease, which in many cases is multifactorial. The genetic aetiology of many CNS disorders is ambiguous, leading to difficulty in target selection.
If the challenge of target selection is surmounted, drug delivery becomes the next obstacle. The blood brain barrier (BBB)— a protective, selective and semi-permeable membrane between the blood and the interstitium of the brain—blocks 95% of small molecules and nearly all biologics. At Aphios, a biotech company focusing on CNS disorders, the lipid-based composition of nanoparticles hurdles this barrier. “For active transport we enhance delivery by attaching ligands, such as sugar moieties, to the nanoparticle surface. There are many receptors for sugar at the blood-brain barrier, so these ligands help transport the nanoparticle material across the BBB,” explained Trevor Castor, the founder, president and CEO.
Camden Cutright, president US at Micropore—a company building more efficient processes to formulate injectable drug products—elaborated on the benefits: “Lipid nanoparticles protect RNA payload from the body’s natural immunity defenses, increasingly they are also being tuned to facilitate targeted delivery.”
Metabolic Disease: Goldilocks conditions
One in eight people globally live with obesity, a figure that has doubled since 1990. The percentage of children with obesity has quadrupled over the same period. In 1997, the WHO declared obesity a global epidemic. Since then, it has only gotten worse. A recent study from CU Boulder estimates one in six deaths in the US are related to excess weight or obesity. Obesity goes hand in hand with noncommunicable diseases such as cardiovascular diseases, diabetes, cancers, neurological disorders, chronic respiratory diseases and NASH. In 2019, higher-than-optimal BMI caused 5 million deaths, according to the WHO.
Unsurprisingly, all bets were on the metabolic space in 2024. The largest acquisition, Novo Holding’s takeover of Catalent, added momentum. There was a 77% increase in obesity trial starts in 2024 compared to 2023, and a nearly five-fold increase over the past five years, found IQVIA. Morgan Stanley Research predicts the global market for obesity to reach US$105 billion in 2030, and as high as US$144 billion for 2050. Eli Lilly is the world’s most valuable pharmaceutical company, in part because of its glucagon-like peptide-1 agonist (GLP-1), Mounjaro/Zepbound. McKinsey identified drugs for obesity and related conditions as one of eighteen future arenas—along with semiconductors and AI— that could reshape the global economy and generate US$29 trillion to US$48 trillion in revenues by 2040. “The metabolic disease space is entering its golden era,” summarized Liping Liu, founder, CEO and chairwoman at HighTide Therapeutics.
42% of the obesity pipeline are GLP-1s. These come with a slurry of side effects like muscle loss, osteopenia and reduced effectiveness over time. Over 60% of GLP-1 users stopped within a year due to side effects, tolerability issues, or reaching their target weight, found a UK government report. Hightide’s berberine ursodeoxycholate (HTD1801) has potential to be creamer for the GLP-1 coffee, said Liu: “GLP-1 side effects often stem from high doses. Combining HTD1801 with a lower GLP-1RAs dose enhances weight loss while preserving muscle mass.”
HTD1801 is also being tested in type II diabetes phase 3 and MASH phase 2b trials. The FDA approved the first MASH drug in 2024, an area with high unmet need.
Prevention: The ‘just right’ treatment
There is an epilogue page to the story. A study in an American Cancer Society Journal found an estimated 44% of all cancer deaths in US adults were attributable to modifiable risk factors— like cigarette smoking, second-hand smoke, excess body weight, alcohol use, poor diet, physical inactivity, UV exposure, and certain infections. In a word: preventable.
The WHO’s obesity factsheet states: “Overweight and obesity, as well as their related noncommunicable diseases, are largely preventable and manageable.”
The Lancet revealed that 84% of stroke disability-adjusted life years (DALYs) could be prevented through reduced exposure to identified risk factors. Reducing high fasting plasma glucose could reduce the burden of Alzheimer’s disease and other dementias by 14%.
Research in a peer reviewed journal suggests environmental factors, such as pollutants, medications, toxins and viral infections, and lifestyle factors including diet, sleep deprivation, stress and lack of physical activity all contribute to the rise in autoimmune diseases.
Antinuclear antibodies (biomarkers of autoimmunity) increased 30% since 1988 and obesity by 50% since 1990. Our genes have not changed; our environment has. A study in Nature Reviews Drug Discovery found global pharmaceutical R&D expenditures is US$276 billion annually. If even half of that money was directed towards lessening known risk factors, we would live in a healthier world.
Article header image courtesy of GSK