) --Not even another foot of snow (on top of the foot or so already on the ground) can keep the Biotech Stock Mailbag from making its appointed rounds.

HK Patel writes, "I have been following your articles since 2010 and I have learned a lot from them. My sincere thanks.

Orexigen Therapeutics'


PDUFA date is Jan. 31 for their obesity drug. Adam, could you please comment on the prospects of its FDA approval or rejection?"

I was asked the same question on Twitter this week and my reply (prediction) was that Orexigen receives a complete response letter on Contrave, its obesity drug in waiting.

Now, that's a bit of dodge on my part because a large majority of investors believe Orexigen will receive a complete response letter. Orexigen and the U.S. Food and Drug Administration have had too little time since the

Dec. 7 Contravy advisory panel meeting

to resolve outstanding issues.

The real question is what flavor of complete response letter is coming? I see two varieties possible:

  • The "good" complete response letter is one in which FDA tells Orexigen that Contrave is approvable without the need for new pre-approval clinical studies or new efficacy and safety data. Full approval of Contrave would be granted later in 2011 after the two sides reach agreement on a post-approval trial to assess cardiovascular safety and nailing down a risk management plan.A "good" complete response letter pushes Orexigen's stock price higher.
  • The "bad" complete response letter is one in which FDA tells Orexigen that pre-approval clinical trials and/or efficacy and safety data are required before Contrave can be cleared for marketing. A "bad" complete response letter sends Orexigen's stock lower. How low depends on how much and what type of data FDA requires for approval. If the FDA goes against the wishes of the advisory panel and asks for a pre-approval cardiovascular outcomes study, Orexigen is cooked extra crispy. If the data request can be fulfilled without a new clinical trial and still leaves open the possibility of a 2011 Contrave approval, the stock may only fall a bit or even stay relatively flat.

Obviously, a full approval for Contrave on Jan. 31 is the best possible outcome for the drug and the stock.

My prediction: Drumroll….

Orexigen will receive a "good" complete response letter.

Feel free to ignore my guess since my obesity-stock prognostication track record hasn't been very sharp. The only thing I've been consistently right about is being bearish on

Arena Pharmaceuticals

(ARNA) - Get Report


I polled 20 buysiders for their Contrave predictions: Ten (50%) expect a "bad" complete response letter; six (30%) believe a "good" complete response letter is coming; while a single respondent (5%) said he thought FDA would punt on making a decision altogether, meaning a delay in the approval decision date.

Another three buy-siders (15%) told me that they had no prediction at all. These folks may be the smartest of the group.

Stay tuned for the Contrave approval decision on Jan. 31.

One more Orexigen note: If FDA issues a complete response letter of any flavor, I personally challenge Orexigen management to publicly disclose the letter in full. Do not summarize the contents of the FDA's response in a press release or on a conference call.

Do the right thing, Orexigen CEO Michael Narachi, and let investors read the complete response letter verbatim in the spirit of full transparency and accountability.

You'll be a hero if you do.

Jim Johnson emails, "


(CVM) - Get Report

announced that it started the Phase III clinical trial for Multikine. Is it me or is Cel-Sci the expert in taking old information and/or already-announced information, publishing it to the wires and reeling in new bag holders on small price-per-share jumps? Is this company for real or is this just another PR tactic?"

You're being too harsh on Cel-Sci! I think it's great that the company has taken investors on an around-the-world tour as it issues press releases on each and every country allowing the Multikine phase III study to proceed. Personally, I've used the Mulitkine press releases to help my kids learn geography: Russia, Ukraine, Taiwan, Hungary, Mississipi (a state, not a country, I know), India.

It takes a village to raise a child but a mini-U.N. to conduct a Multikine phase III study.

The important thing missing from all these Cel-Sci press releases is an announcement of the first patient enrolled in the Multikine study. Where are the actual patients eager for treatment with Multikine?

Cel-Sci plans to enroll 880 patients in the phase III study -- an ambitious enrollment goal, for a drug with a paucity of phase II data. The Multikine data that do exist shouldn't inspire much confidence at all in the drug's efficacy. I wrote about the

multiple problems and shortcomings of the Multikine

phase II study last year,

in two parts


If you're interested in following what will likely be the very slow progress of the Multikine phase III study, I'd watch for the number of U.S. hospitals open to enrollment. Right now, that list stands at one -- North Mississippi Health Services of Tupelo, Miss., according to A diminutive roster of U.S. enrolling sites is a red flag -- indicative of underwhelming interest in Multikine amongst U.S. doctors.

Cel-Sci plans to seek approval of the drug here and the FDA will want to see a significant amount of data from U.S. patients.

That's assuming the study is positive, which I believe is unlikely. Data from centers in Eastern Europe or other less-developed parts of the world isn't always reliable and can lead to problems.

As enrollment in the Multikine study drags on for the next few years, I'd also watch out for any changes made to the study design or efforts to lower the number of patients enrolled. Stuff like that can be tracked easily at

Sticking with the obesity drug theme, Mark M. emails a question regarding


(VVUS) - Get Report


"I appreciate your balanced and unemotional reporting of Qnexa and other weight-loss drugs as they attempt to gain FDA approval. Other than your articles, there seems to be a significant amount of bias in most of the reporting on weight-loss drug developments, maybe a reflection of positions held. In the case of Qnexa, I do not really understand how the FDA can question the safety of low-dose topiramate when they have already approved its use in other higher dose applications. Perhaps you can address this issue in a future article."

It's a great question. The thing to keep in mind is that the risk-benefit of any drug depends largely on the disease being treated and the patient population who will take the drug.

Let's start with an easy example. Cancer drugs, generally, cause significant side effects. That makes sense because a lot of chemotherapy drugs, for instance, are basically poison designed to kill tumor cells. Healthy cells are often collateral damage, too. Doctors, patients and the FDA are okay with the high toxicity of cancer drugs because they're used to treat patients with cancer, a fatal disease that is usually (not always) worse than whatever toxicity or side effects the treatment may cause.

If chemotherapy drugs were used to treat a less serious and non-fatal disease like psoriasis, the risk-benefit trade off would be unacceptable to everyone. Psoriasis can be a nasty disease, but patients aren't going to die from it. Moreover, psoriasis is a chronic disease, meaning patients require long-term treatment. If they stop taking whatever drug they're using to keep the psoriasis at bay, the disease will return. Again, chemo drugs would never be acceptable to treat psoriasis even if the efficacy was fantastic because the cumulative toxicity of long-term exposure would likely kill patients.

With that understanding, let's examine Qnexa, which as most obesity drug stock watchers know, combines two currently marketed medicines -- topiramate and phentermine -- into a single, weight-loss pill. Topiramate is an anticonvulsant. At higher doses than what's in Qnexa, topiramate is used to treat epileptic seizures and prevent migraine headaches.

After a recent meeting with FDA,

Vivus disclosed that regulators are interested in seeing more safety data that could better define the incidence of birth defects

, particularly cleft lips, in the babies born from women treated with topiramate. FDA's request for new safety data could delay Vivus' efforts to resubmit Qnexa for approval again after last fall's rejection.

Epilepsy and to a lesser extent migraine headaches are serious, acute conditions that affect a relatively smaller number of patients. Obesity is a chronic and non-fatal disease (at least directly) that affects millions of people, if not tens of millions of people. An obesity drug, if approved, could be very widely used. Women, most of childbearing age, will be particularly interested in obesity drugs.

That's the most likely reason for FDA's interest and concern about the topiramate component of Qnexa, even at lower doses. A teeny tiny risk of birth defects tied to topiramate use in a small number of epilepsy patients is acceptable; but the risk could become very much magnified if millions of obese women who may become pregnant start taking Qnexa.

Mike J. asks, "Follow you regularly, I appreciate your work. Did the

Ariad Pharmaceuticals


move surprise you? I was thinking ponatinib would be more the future driver of this stock."

Ariad shares 34% to $7.32 intraday on Jan. 28 following the release of positive results from the phase III study of ridaforolimus ('rida) in sarcoma. The stock has since settled back to around $6.76 as I write this column Thursday. Aria was a $2 stock in early 2010.

Mike is correct in that a lot of investors are looking past 'rida and focusing more on ponatinib. 'Rida's clinical development and most of the drug's economics are controlled by


(MRK) - Get Report

. The Mtor inhibitor class of cancer drugs to which 'rida belongs is competitive and the 'rida data in sarcoma -- while meeting the primary endpoint with statistical significance -- are not without concerns.

A three-week improvement in median progression-free survival favoring 'rida compared to placebo looks rather anemic even though the relative reduction in the risk of progression was a more robust 28%. Data is forthcoming on a potential survival benefit, if any, from the study, which while not necessarily required for approval, certainly can't hurt.

Sarcoma is a $200 million to $300 million opportunity for 'rida, give or take, of which Ariad receives a double-digit royalty from Merck. 'Rida is a nice base for Ariad's valuation but the drug is largely baked into valuation already.

Ponatinib is more exciting because Ariad owns 100% of the rights. The drug is designed specifically to overcome the genetic mutations that confer resistance to current drugs used to treat chronic myelogenous leukemia. Data presented to date have been strong, positioning ponatinib as a potential best-in-class drug and a strong competitor to


(NVS) - Get Report

Tasigna and

Bristol-Myer Squibb's

(BMY) - Get Report


A phase III study of ponatinib in second- or third-line CML is underway with enrollment expected to complete by the end of the year. Data from the study could be ready in the middle of 2012 and if positive, Ariad could be in a position to seek ponatinib's approval by the end of 2012.

If there's a snag to the Ariad story right now it's probably a lack of near-term catalysts to get ADHD-addled biotech investors excited about owning the stock RIGHT NOW. Merck is supposed to seek approval for 'rida in sarcoma sometime this year but the company hasn't been more specific. Meantime, the phase III study of ponatinib is more of a mid-2012 event.

Dan O. emails, "Hello Adam, I am a long-time member of RealMoney Silver and without doubt your insights are my most treasured reading. I have long followed

Avanir Pharmaceuticals


and would appreciate any updates you might share. One would suspect that something is askew at Avanir headquarters? Why would a stock with such promise act so sickly when it looks to have such potential."

Avanir is supposed to launch Neudexta in February as a treatment for pseudobulbar affect (PBA). Until the launch occurs and script data starts flowing, investors will probably be sitting on the sidelines. That's a fairly well-worn script in biotech investing these days. Drug gets approved, stock pops, then sells off on concerns about commercialization. Stock recovers and does well if drug sells well (Alexion Pharmaceuticals) or remains underwater if drug performs poorly (Vanda Pharmaceuticals.)

Avanir's stock price fell fairly sharply from the peak hit right after Neudexta's approval last October but the stock has started to come back lately as the launch date nears.

Pat. W. asks, "Adam, I have been following

Discovery Labs


for many years and I thinking it's time to invest in Surfaxin getting a favorable review. My concern is buying before a possible reverse stock split and/or continued dilution of the stock, but I like your optimistic view of Surfaxin. What price per share range would you give Discovery if Surfaxin gets approval? Thanks."

I was feeling more snarky than usual Thursday morning, so in response to Discovery's announcement of yet another conference call scheduled to explain the 4,672nd delay in the Surfaxin resubmission process, I tweeted this:

"Memo to $DSCO CEO Tom Amick: STFU! No conf calls. No PRs. Not until you get Surfaxin approved. No one cares until then -- 2015? 2020?"

And I mean it. Amick really need to shut his mouth and just get the job done. Enough explanations, enough excuses. Talk to investors after Surfaxin is approved. Until then, his words are useless.

As for investing in Discovery, haven't you been hurt enough already? Revisit the stock when Surfaxin is approved, if ever.

--Written by Adam Feuerstein in Boston.

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Adam Feuerstein writes regularly for In keeping with TSC's editorial policy, he doesn't own or short individual stocks, although he owns stock in He also doesn't invest in hedge funds or other private investment partnerships. Feuerstein appreciates your feedback;

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