Let us take up the case of Tecfidera, the new Biogen/Idec drug for multiple sclerosis, known to us chemists as dimethyl fumarate. It joins the (not very long) list of industrial chemicals (the kind that can be purchased in railroad-car sizes) that are also approved pharmaceuticals for human use. The MS area has seen this before, interestingly.

A year’s supply of Tecfidera will set you (or your insurance company) back $54,900. That’s a bit higher than many analysts were anticipating, but that means “a bit higher over $50,000”. The ceiling is about $60,000, which is what Novartis’s Gilenya (fingolomod) goes for, and Biogen wanted to undercut them a bit. So, 55 long ones for a year’s worth of dimethyl fumarate pills – what should one think about that?

Several thoughts come to mind, the first one being (probably) “Fifty thousand dollars for a bunch of dimethyl fumarate? Who’s going to stand for that?” But we have an estimate for the second part of that question – Biogen thinks that quite a few people are going to stand for it, rather than stand for fingolomod. I’m sure they’ve devoted quite a bit of time and effort into thinking about that price, and that it’s their best estimate of maximum profit. How, exactly, do they get away with that? Simple. They get away with it because they were willing to take the compound through clinical trials in MS patients, find out if it’s tolerated and if it’s efficacious, figure out the dosing regimen, and get it approved for this use by the FDA. If you or I had been willing to do that, and had been able to round up the money and resources, then we would also have the ability to charge fifty grand a year for it (or whatever we thought fit, actually).

What, exactly, gave them the idea that dimethyl fumarate might be good for multiple sclerosis? As it turns out, a German physician described its topical use for psoriasis back in 1959, and a formation of the compound as a cream (along with some monoesters) was eventually studied clinically by a small company in Switzerland called Fumapharm. This went on the market in Germany in the early 1990s, but the company did not have either the willingness or desire to extend their idea outside that region. But since dimethyl fumarate appears to work on psoriasis by modulating the immune system somehow, it did occur to someone that it might also be worth looking at in multiple sclerosis. Biogen began developing dimethyl fumarate for that purpose with Fumapharm, and eventually bought them outright in 2006 as things began to look more promising.

In other words, the connection of dimethyl fumarate as a possible therapy for MS had been out there, waiting to be made, since before many of us were born. Generations of drug developers had their chances to see it. Every company in the business had a chance to get interested in Fumapharm back in the late 80s and early 90s. But Biogen did, and in 2013 that move has paid off.

Now we come to two more questions, the first of which is “Should that move be paying off quite so lucratively?” But who gets to decide? Watching people pay fifty grand for a year’s supply of dimethyl fumarate is not, on the face of it, a very appealing sight. At least, I don’t find it so. But on the other hand, cost-of-goods is (for small molecules) generally not a very large part of the expense of a given pill – a rule of thumb is that such expenses should certainly be below 5% of a drug’s selling price, and preferably less than 2%. It’s just that it’s even less in this case, and Biogen also has fewer worries about their supply chain, presumably. The fact this this drug is dimethyl fumarate is a curiosity (and perhaps an irritating one), but that lowers Biogen’s costs by a couple of thousand a year per patient compared to some other small molecule. The rest of the cost of Tecfidera has nothing to do with what the ingredients are – it’s all about what Biogen had to pay to get it on the market, and (most importantly) what the market will bear. If insurance companies believe that paying fifty thousand a year for the drug is a worthwhile expense, the Biogen will agree with them, too.

The second question is divorced from words like “should”, and moves to the practical question of “can”. The topical fumarate drug in Europe apparently had fairly wide “homebrew” use among psoriasis patients in other countries, and one has to wonder just a bit about that happening with Tacfidera. Biogen Idec certainly has method-of-use patents, but not composition-of-matter, so it’s going to be up to them to try to police this. I found the Makena situation more irritating than this one (and the colchicine one, too), because in those cases, the exact drugs for the exact indications had already been on the market. (Dimethyl fumarate was not a drug for MS until Biogen proved it so, by contrast). But KV Pharmaceuticals had to go after people who were compounding the drug, anyway, and I have to wonder if a secondary market in dimethyl fumarate might develop. I don’t know the details of its formulation (and I’m sure that Biogen will make much of it being something that can’t be replicated in a basement), but there will surely be people who try it.