This article describes the status of Xyrem as a prescription drug. To learn about the chemical and its biological mode of action, see the article on gamma-hydroxybutyric acid.
Xyrem is a trade name for gamma-hydroxybutyric acid or GHB, an endogenous neurochemical involved in regulating metabolism, especially regarding sleep or hibernation. In medical contexts GHB is often called sodium oxybate, which is an alternate term for the sodium salt of the chemical.
GHB has a long history as a sleep aid, nutritional supplement, and recreational drug. In the 1980s research studies indicated that it was helpful as a treatment for narcolepsy, and in 2002 the company Orphan Medical was approved by the U.S. Food and Drug Administration (FDA) to market GHB as a treatment for narcolepsy with cataplexy. Jazz Pharmaceuticals, which acquired Orphan Medical in 2005, is currently conducting Phase III clinical trials to evaluate sodium oxybate for the treatment of fibromyalgia as well, based on clinical trials showing that it reduces pain and disability associated with the disease. Xyrem is currently marketed in the United States by Jazz Pharmaceuticals. There are also ongoing tests to see if Xyrem could prove helpful with other medical conditions, such as Parkinson's, Chronic Fatigue Syndrome (ME), and Schizophrenia..
Xyrem is an orphan drug, meaning that the U.S. government recognizes it as worth developing even though the condition it treats is relatively rare. Orphan Medical received special incentives from the U.S. government for bringing it to market, in order to help them recoup the costs of testing. In this case Orphan Medical did not have any development expenses, since GHB is inexpensive to synthesize and was already recognized as a potential narcolepsy treatment. They did, however, need to gather extensive information demonstrating that the drug was safe, as well as showing low potential for addiction or tolerance when used under a doctor's supervision. They are also required to operate a distribution program that tightly controls who can receive Xyrem and under what circumstances. This process entails sending the package through FedEx Priority Overnight with direct signature required at a base cost of about $50 for a standard delivery compared to the average monthly cost of about $1.7k for treatment. Xyrem is distributed directly from the manufacturer and cannot be accessed by licensed pharmacists. It is therefore more tightly controlled than other drugs on Schedule III, and even some on Schedule II. This of course means that the manufacturer enjoys a larger share of the profits being that there are no middle men "adding value" to the pharmacoeconomic chain.
Xyrem is also the only drug to be on two drug schedules at once under U.S. law: GHB is on schedule I, meaning that it is considered a highly dangerous and addictive drug with no medical uses, but GHB marketed as Xyrem and prescribed for specific conditions is on schedule III, which includes many drugs considered safe when used properly. This is unusual because the schedule system is built around the assumption that a drug's risks are due to the chemical itself, without reference to the user or the circumstances of its use. However, the government cites pragmatic reasons for the distinction: recreational drugs are often of unknown origin, may contain contaminants, and are difficult to take at a precise dose, while the same substance in prescription form is easier to use as intended. The involvement of a doctor also helps reduce the risk of dependency or of recreational, rather than medical use. This is similar to the justification for offering Marinol under schedule III, while marijuana is schedule I, but it differs in that pharmaceutical THC (referred to as Marinol or dronabinol) is a pure version of one of the many active chemicals in marijuana, whereas GHB and Xyrem are chemically identical. The law is inconsistent in this regard, as other drugs such as amphetamine and fentanyl fall under a single schedule, regardless of whether they are in pharmaceutical form or have been illicitly synthesized for recreational use.
In 2007, the makers of Xyrem, Orphan Medical, which is now part of Jazz Pharmaceuticals, pleaded guilty to a felony charge of marketing Xyrem for unapproved uses. These off-label uses included treatments for conditions such as fatigue, pain, and psychiatric disorders.
The lawsuit claimed that the manufacturers:
For example, one physician had made well over $100,000 in just one year for giving such speeches. The doctor, Peter Gleason, admitted to giving speeches and seminars without following "evidence-based guidelines". It was said that he once claimed "table salt is more dangerous" than Xyrem.
Although GHB can be synthesized easily from inexpensive chemicals, the price for Xyrem is high, and many insurance plans do not cover it. Some insurance plans will cover it on a case-by-case basis, if the patient submits an appeal for coverage. The basis for the appeals would be that this is the only FDA-approved drug in its class that treats this condition. Jazz Pharmaceuticals does not publish a price, but one insurance company reports it at ~$1300/month. The cost varies depending on the dose. The average dose currently costs about $1,700 a month, but this can be significantly higher if a larger dose is required. In the UK the BNF list is priced £360.00 per 180ml (500 mg/mL) (Nov 08) . In the U.S., private insurance can cut the cost to the consumer to just the deductible, but many insurance companies say they do not cover the drug because they classify it as experimental. An appeals process can be successful to get Xyrem covered.
For potential reasons for the high cost, see the discussion of Xyrem's orphan status, above. Jazz Pharmaceuticals operates an assistance program, to make the drug available at a slightly reduced cost for certain individuals. The program is administered by the National Organization for Rare Disorders (NORD).
Like most newly-approved drugs, Xyrem is produced by only one manufacturer, whom in this case is also the only approved retailer. Thus, the price is not likely to drop due to competitive pressure. The price steadily increased from 2007 to 2009. At the beginning of 2007, a monthly dose cost roughly $900–$1,000. As of January 2009, that same dose cost just under $1,500, having increased by more than $400 in the year 2008 alone. As of May 15, 2009, the standard monthly supply of Xyrem cost $2,000. The patents Jazz holds on Xyrem will not expire until 2020.
Xyrem is available by prescription only through a restricted distribution program, called the "Xyrem Success Program". This restricted program was implemented due to safety concerns associated with the use of Xyrem.
The program involves many risk management components, such as:
The program includes a single centralized pharmacy with a toll-free number.
Initial dosages are set by the prescribing physician. Each bottle of Xyrem is shipped with a graduated syringe (measured in grams) and two dosing cups. Each night, the patient self-mixes two doses with 60ml of water, Crystal Light, or sugar-free Kool-Aid.The first dose is taken at bedtime, and the second is taken 2.5 to 4 hours later.