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The new drug looked so promising except for that one warning sign.

This story also ran on Fortune. It can be republished for free.

At the American College of Rheumatologys annual meeting in 2008, Duke Universitys Dr. John Sundy proudly announced that pegloticase, a drug hed helped develop, was astoundingly effective at treating severe gout, which affects perhaps 50,000 Americans. In about half of those who had taken it, the drug melted away the crystalline uric acid deposits that encrusted their joints to cause years of pain, immobility, or disfigurement.

But Sundy also disclosed an unsettling detail: In one clinical trial, patients who got the drug were more likely to develop heart problems than those who didnt. The day after Sundys talk, the stock price of Savient Pharmaceuticals, which developed the drug with Duke scientists, plunged 75%.

That danger signal would disappear in later studies, and the FDA approved pegloticase, under the trade name Krystexxa, two years later. But the small biotech company never recovered. In 2013, Savient was sold at auction to Crealta, a private equity venture created for the purpose, for $120 million.

Two years later, a young company now called Horizon Therapeutics bought Crealta and its drug portfolio for $510 million.

Even at that price, it proved a good deal. Krystexxa brought in $716 million in 2022 and was expected to earn $1 billion annually in coming years.

Although Horizon says it now has 20 drugs under development, in its 15 years of existence it has yet to license a product it invented. Yet the company has managed to assemble a war chest of lucrative drugs, in the process writing a playbook for how to build a modern pharmaceutical colossus.

As the White House and both parties in Congress grapple with reining in prescription drug prices, Horizons approach reveals just how difficult this may be.

Horizons strategy has paid off handsomely. Krystexxa was just one of the many shiny objects that attracted Amgen, a pharmaceutical giant. Amgen announced in December that it intends to buy Horizon for $27.8 billion, in the biggest pharmaceutical industry deal announced in 2022.

Horizons CEO, Tim Walbert, who will reportedly get around $135 million when the deal closes, has mastered a particular kind of industry expertise: taking drugs invented and tested by other people, wrapping them expertly in hard-nosed marketing and warm-hued patient relations, raising their prices, and enjoying astounding revenues.

Hes done this with unusual finesse courting patients with concierge-like attention and engaging specialist clinicians with lunches, conferences, and research projects, all while touting his own experience as a patient with a rare inflammatory disease. Walberts company has been particularly adept at ensuring that insurers, rather than patients, bear the costly burdens of his drugs.

A federal prosecutor in 2015 began examining allegations that Horizons patient assistance program had worked with specialty pharmacies to evade insurers efforts to shun Horizons expensive drugs. A separate probe opened in 2019 over alleged kickbacks to pharmacy benefit managers, companies that negotiate to get Horizons drugs covered by insurers. Those investigations appear to be no longer active, Horizon spokesperson Catherine Riedel said. The company this year disclosed a third probe, concerning methods the company allegedly used to get prior authorization of its drugs. Justice officials did not respond to requests for comment on the investigations. Email Sign-Up

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An Injection of Marketing

To help sell its drugs, Horizon blankets specialist physicians with marketing and peer-to-peer appeals. Its payments to physicians for things like consulting, speeches, and meals totaled $8.7 million in 2021, compared with the $10 million it paid them for research, federal records show. By contrast, Seagen, a biotech company of roughly the same size, paid doctors a total of $116 million, with nearly $112 million of that pegged for research. Riedel said Horizons marketing and educational approaches were necessarily unique because of the challenges of treating rare and neglected diseases.

Walbert launched Horizon in 2008 in the Chicago area by combining and refashioning generic drugs into single pills. Duexis, Horizons first drug, is a mixture of generic Motrin and Pepcid. Its Vimovo combines generic Aleve and Nexium. In a 2017 article, a ProPublica reporter described being prescribed Vimovo for a shoulder injury. It cost him nothing, but his insurer was billed $3,252 for pills that together cost about $40 for a months supply in generic form. Horizon sold more than $57 million worth of Vimovo that year.

In 2014 and 2015, respectively, Horizon picked up two relatively new drugs that had no generic versions: the immunosuppressant Actimmune and Ravicti, which treats a rare genetic disorder. Soon Horizon was charging more than $50,000 a month for each, placing Actimmmune fourth and Ravicti second on GoodRxs 2020 list of the most expensive U.S. drugs.

Horizons net sales soared from $20 million in 2012 to $981 million in 2016; Walberts pay package followed suit, topping an astronomical $93.4 million in 2015 in salary and stock. Stock analysts questioned the long-term soundness of a strategy of simply selling old drugs for mind-boggling prices, but Walbert was using the cash to refashion the company as a rare-diseases franchise.

His approach would make Walbert a darling of pharmaceutical investors and his board, which lavished him with over $20 million in compensation each of the past three years. While most biotechs and startups borrow heavily from venture capital to do science and have no idea how to develop and market a drug, Walbert got cash coming in quickly. He did it backwards, said Annabel Samimy, an analyst at Stifel Financial Corp. Horizon built commercial platforms before they got into drug development.

Generating robust sales of what sounded like not very interesting drugs allowed Walbert to start a company on not very much, said Oppenheimer analyst Leland Gershell. All the while, Horizon funded and cultivated the patient advocacy groups that can help lobby for a drug to be approved by the FDA and placed on insurers formularies, the lists of drugs health plans cover for patients.

Capitalizing on His Own Illness?

As Walbert and his spokespeople often point out, Walbert and his youngest son suffer from a rare disease, and Walbert also has an autoimmune disease. Walbert wont name the diseases, but has said hes taken the anti-inflammatory injectable Humira since 2003 the year he led that drugs commercial launch as a vice president at Abbott Laboratories. Humira has become the bestselling drug in history, with about $200 billion in all-time global sales.

In 2014, Walbert moved Horizons headquarters to Ireland, which nearly halved its tax rate. A year later it gained control of Krystexxa, and in 2017 it bought, for $145 million, a failing company that produced Tepezza, a drug for thyroid eye disease, which causes unsightly eye bulging and pain.

Tepezza quickly became a blockbuster, with $3.6 billion in total sales in 2021 and 2022. The company conducted additional clinical research on both Tepezza and Krystexxa, but it also spent heavily promoting these and other drugs to specialists who could prescribe them.

All the while it steadily raised prices. Savient put Krystexxa on the market in 2011 at $2,300 per injection. Horizon charges roughly 10 times as much. Six months of Tepezza treatment can run more than $400,000.

Horizons publicity emphasized the companys sensitivity to patients, and its constant contact with disease advocates.

Our scientists are attuned to the unmet needs of patients, their diagnostic and therapeutic journey, Bill Rees, Horizons vice president for translational sciences, told KFF Health News. Its the marrying of the basic clinical science with a focus on the needs of the patient that differetiates us.

To make sure patients keep using its drugs, clinicians say, Horizon staffers negotiate with insurance carriers, and the company offers drug discounts to lower-income patients while swaddling them with attention from its medical staff.

Horizon has a nurse talk to each and every patient before every appointment, said Dr. Brigid Freyne, who treats around half a dozen patients each year with Krystexxa at her Murrieta, California, rheumatology clinic. The patients who come in here are highly motivated to get their IV. They get the message that its very important and they are fortunate to get the medicine.

None of the manufacturers of her other infusion drugs shower patients with this kind of attention, she said.

While at Abbott, Walbert pioneered direct-to-consumer advertising for specialty drugs like Humira, a trend that aggravated insurers, who anticipated, correctly, that they would soon be shelling out billions for expensive drugs.

Horizons marketing plan for Krystexxa includes direct-to-consumer ads aimed at driving patients to specialists. The drug is designed for recalcitrant gout patients, who often have large lumps on their fingers, feet, and kidneys. Many, though not all, are heavy drinkers of beer or soda sweetened with high-fructose corn syrup, which can increase the buildup of uric acid, the cause of gout, said Dr. Robert McLean of Yale University.

While Krystexxa can help patients with advanced gout, the American College of Rheumatology views it as a drug of last resort, with plenty of cheaper, early intervention alternatives available.

I prescribe it maybe once a year, McLean said. From a cost-effectiveness standpoint, it warrants questioning.

Horizon recently started a publicity campaign addressed to all gout sufferers, urging them to see a rheumatologist or a nephrologist the specialists it has targeted with Krystexxa educational materials before the disease does too much harm.

Horizon would like you to say, Everyone with serious gout should be started on Krystexxa, said Dr. James ODell, a rheumatologist at the University of Nebraska Medical Center. The Horizon pitchmen he deals with are nice guys, but we dont believe thats the best way.

The company defends its marketing practices. We learn what matters most to patient communities and act. This approach has been validated by independent third-party research, said Riedel.

The Federal Trade Commission said in January it was seeking more information on the Amgen-Horizon merger. Sen. Elizabeth Warren (D-Mass.), citing high prices for Horizon and Amgen drugs, urged the agency to nix the deal.

Arthur Allen: ArthurA@kff.org, @ArthurAllen202 Related Topics Health Care Costs Health Industry Pharmaceuticals Drug Costs Prescription Drugs Contact Us Submit a Story Tip

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Entertainment

Russell Brand charged with rape and sexual assault

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Russell Brand charged with rape and sexual assault

Russell Brand has been charged with rape and two counts of sexual assault between 1999 and 2005.

The Metropolitan Police say the 50-year-old comedian, actor and author has also been charged with one count of oral rape and one count of indecent assault.

The charges relate to four women.

He is due to appear at Westminster Magistrates’ Court on Friday 2 May.

Police have said Brand is accused of raping a woman in the Bournemouth area in 1999 and indecently assaulting a woman in the Westminster area of London in 2001.

He is also accused of orally raping and sexually assaulting a woman in Westminster in 2004.

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Ashna Hurynag discusses Russell Brand’s charges

The fourth charge alleges that a woman was sexually assaulted in Westminster between 2004 and 2005.

Police began investigating Brand, from Oxfordshire, in September 2023 after receiving a number of allegations.

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The comedian has denied the accusations and said he has “never engaged in non-consensual activity”.

He added in a video on X: “Of course, I am now going to have the opportunity to defend these charges in court, and I’m incredibly grateful for that.”

Metropolitan Police Detective Superintendent Andy Furphy, who is leading the investigation, said: “The women who have made reports continue to receive support from specially trained officers.

“The Met’s investigation remains open and detectives ask anyone who has been affected by this case, or anyone who has any information, to come forward and speak with police.”

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Sports

O’s Henderson off IL; will make ’25 debut vs. KC

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O's Henderson off IL; will make '25 debut vs. KC

Baltimore Orioles All-Star shortstop Gunnar Henderson was activated from the 10-day injured list and will make his season debut Friday night against the Kansas City Royals.

Henderson has been sidelined with a right intercostal strain and missed the first seven games of the big league campaign.

The 23-year-old Henderson will lead off and play shortstop against the host Royals.

Henderson was injured during a spring training game Feb. 27. He was fourth in American League MVP voting last season when he batted .281 and racked up career bests of 37 homers and 92 RBIs.

Henderson completed a five-game rehab stint at Triple-A Norfolk on Wednesday. He batted .263 (5-for-19) with two homers and four RBIs and played four games at shortstop and one as the designated hitter. He did commit three errors.

“I think everybody’s looking forward to having Gunnar back on the team,” Baltimore manager Brandon Hyde said Thursday. “The rehab went really, really well. I talked to him a couple days ago, he feels great swinging the bat. The timing came, especially the last few days. He just had to get out there and get some reps defensively and get some games in, and it all went well.”

Baltimore optioned outfielder Dylan Carlson to Triple-A Norfolk to open up a roster spot. The 26-year-old was 0-for-4 with a run and RBI in two games this season.

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Politics

‘Will the PM side with parents or tech bros?’: Labour peer demands action on children’s smartphone safety

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'Will the PM side with parents or tech bros?': Labour peer demands action on children's smartphone safety

Sir Keir Starmer needs to choose between parents who want stronger action to tackle harmful content on children’s phones, or the “tech bros” who are resisting changes to their platforms, Baroness Harriet Harman has said.

Speaking to Beth Rigby on Sky News’ Electoral Dysfunction podcast, the Labour peer noted that the prime minister met with the creators of hit Netflix drama Adolescence to discuss safety on social media, but she questioned if he is going to take action to “stop the tech companies allowing this sort of stuff” on their platforms where children can access it.

Sir Keir hosted a roundtable on Monday with Adolescence co-writer Jack Thorne and producer Jo Johnson to discuss issues raised in the series, which centres on a 13-year-old boy arrested for the murder of a young girl, and the rise of incel culture.

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The aim was to discuss how to prevent young boys being dragged into a “whirlpool of hatred and misogyny”, and the prime minister said the four-part series raises questions about how to keep young people safe from technology.

Sir Keir has backed calls for the four-part drama to be shown in all schools across the country, but Baroness Harman questioned what is going to be achieved by having young people simply watch the show.

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Sir Keir Starmer held a roundtable with the creators of the Adolescence TV drama.

“Two questions were raised [for me],” she said. ” Firstly – after they’ve watched it, what is going to be the discussion afterwards?

More on Electoral Dysfunction

“And secondly, is he going to act to stop the tech companies allowing this sort of stuff to go online into smartphones without protection of children?

“Because if the tech companies wanted to do this, they could actually protect children. They can do everything they want with their tech.”

She acknowledged there are “very big public policy challenges” in this area, but added of the prime minister: “Is he going to side with parents who are terrified and want this content off their children’s phones, or is he going to accept the tech bros’ resistance to having to make changes?”

Harriet Harman said the government should impose time limits on inquiries
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Baroness Harriet Harman

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Can parliament keep up?

The Labour peer backed the Conservative Party’s call for a ban on smartphones in schools to be mandated from Westminster, saying it would “enable all schools not to have a discussion with their parents or to battle it out, but just to say, this is the ruling” from central government, which Ofsted would then enforce.

“I’m sensitive to the idea that we shouldn’t constantly be telling schools what to do,” she continued. “And they’ve got a lot of common sense and a lot of professional experience, and they should have as much autonomy as possible.

“But perhaps it’s easier for them if it’s done top down.”

Baroness Harman also questioned the speed with which parliament is actually able to legislate to deal with the very rapid development of new technologies, and posits that it could “change its processes to be able to legislate in real time”.

She suggested that a “powerful select committee” of MPs could be established to do that, because “otherwise we talk about it, and then we’re not able to legislate for 10 years – by which time that problem has really set in, and we’ve got a whole load more problems”.

On the podcast, the trio also discussed the 10% tariffs imposed on the UK by Donald Trump and the government’s efforts to strike a trade deal with the US to mitigate the impact of the levy.

The government has refused to rule out scrapping the Digital Services Tax, a 2% levy on tech giants’ revenues in the UK, as part of the negotiations with the Trump administration – a move Baroness Harman said would be “very heartbreaking”.

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