Two new injectable technologies that may potentially fill the gap in treatment options for patients with arthritic joints were highlighted in a session at the 2016 International Cartilage Repair Society (ICRS) in Sorrento, Italy.

With few options available for treating OA pain, joint fluid injections have become a standard part of the treatment regimen for patients with painful arthritic knees. Even though it is not possible to predict which knee pain sufferers will respond to viscosupplementation therapy, commonly administered as a series of injections of hyaluronic acid, most patients seeking treatment will at least give it a “try” as an alternative to non-steroidal anti-inflammatory drugs (NSAIDs) and before resorting to joint replacement.

BioMedGPS estimates that nearly 2 million Americans will receive hyaluronic acid injections for knee OA this year resulting in a market valued at nearly $B in 2016. Robust growth is projected over the next 5 years as high-priced single injection products take hold; new companies enter the market —some with differentiated products used earlier in the treatment continuum; and longer-lasting combination products make their way through the FDA. By 2021, the market is projected to reach  over $1.2B in revenues, according to the recently published 2016  SmartTRAK US Joint Fluid Market Overview.

Shifts In Shares

Sanofi remained the market leader in the US Joint Fluid market but experienced a loss of share in 2014, according to SmartTRAK Financial Dashboard. The big winner was DePuy Synthes whose strategy of promoting MONOVISC without cannibalizing ORTHOVISC, led to strong gains in both the single and 3-injection segments.  Next in line in terms of overall share is Ferring followed by Bioventus; Fidia; and Zimmer Biomet.

Strong Uptake of Single Injection Products

New entrants in the single injection space with unique "J' codes, specifically J&J's DePuy Synthes Mitek division with MONOVISC and Zimmer Biomet which worked out its distribution challenges with Gel-One, propelled overall market expansion in 2015. With 75% of Synvisc sales attributed to Synvisc One, Sanofi, still controls the single injection segment with 71.4% share but lost ground to DePuy Synthes and Zimmer Biomet which posted solid gains in MONOVISC and Gel-One sales. DePuy Synthes' MONOVISC overtook Zimmer Biomet's Gel-One as the No. 2 player in this segment.

Competition Heats Up in 3-Injection Market

Still the largest US Joint Fluid segment is the 3-injection market accounting for 45% of total 2016 US revenues. With the launch of newly approved 3-injection products later this year, competition is expected to heat up as well-entrenched players, such as DePuy Synthes, Ferring and Sanofi, fight to maintain share.

In the competitive 3-injection arena, DePuy Synthes' experienced the greatest YoY increase; followed by Ferring and Sanofi according to SmartTRAK Financial Dashboard. Revenues in the 3-injection segment increased 3.8% in 2015.

With Bioventus, which struck a distribution deal with IBSA for GELSYN-3, and Seikagku with joining the 3-injection playing field with Visco-3 now distributed via Zimmer Biomet, the question that arises is how differentiated are these products? Also, not known is what happens if one of these newcomers decides to go “generic” particularly if there is little differentiation among products. What is certain is that the 3-injection market will expand at the demise of 5-injection products, now that both Fidia and Bioventus, the sole competitors, shift focus to the 2- and 3-injection segments. Even with the entry of OrthogenRx with GENVISC 850, a 5-injection product, BioMedGPS forecasts the 5-injection segment will decline in both procedures and dollars going forward. This shift along with increased competition will result in healthy growth in the 3-injection segment.

Emerging 2-Injection Segment

With recent PMA approval of Hymovis, a 2-injection viscoelastic gel, Fidia is poised to gain share in this unique segment of the market. Launched in March in 2016 via their US sales organization, Hymovis will boost Fidia's presence in the overall Joint Fluid market with a differentiated offering offsetting flat and/or declining sales of Hyalgan, its 5-injection product. Fidia is banking on Hymovis taking share from all segments of the joint fluid market. Effective April 1st, Hymovis was granted a "C" code by CMS allowing pass through status. The product will be reimbursed at ASP plus 6% for CY2016. Hymovis lists at $880 for a 2-syringe pack and will be sold at $932/pack to pharmacies and ASC's.

New Differentiated Injectables

There are 12 approved Joint Fluid products currently approved on the US market for knee OA and this does not include "Human Tissue” products (PRP, amniotic fluid or adipose tissue) also being injected into osteoarthritic joints to a largely self-pay patient population. While largely untested, these products are under increased scrutiny by the FDA since they may not fulfill the “homologous use” criteria put forth in regulatory guidelines. Companies such as MiMedx and Liventa have clinical studies in progress evaluating injections of amniotic fluid for OA.

In the US, Joint Fluid products are approved for use in the knee joint, however, Anika with partner DePuy Synthes commenced an IDE trial evaluating MONOVISC for hip OA potentially expanding the overall market.

Also, on the horizon are longer-acting combination products in various phases of Phase III trials expected to appear on the US market in the next 5 years. Among the companies with products in clinicals include: Carbylan with Hydros, a dual mode viscosupplement which houses a long-acting steroid inside hydrogel beads; Flexion with an intra-articular sustained release steroid for moderate to severe OA pain; and Anika with CINGAL, a single injection hyaluronic acid plus steroid product that could potentially be used in patients with mild-to-moderate OA.

Anika announced plans for selling CINGAL via its own sales network rather than via partner DePuy Synthes and have hired ex-Sanofi executives to lead its commercialization efforts.

However, establishing a distribution network to market a joint fluid product is complex as overtook Zimmer Biomet, the largest orthopedic company, found out when it ran into challenges with Gel-One . Today, most suppliers have direct sales forces focused almost exclusively on selling joint fluid products complemented by large wholesale distributors and specialty pharmacies. While several new entrants, Anika, Seikagku, OrthogenRx are setting up contract sales organizations to promote their products, tapping into specialty pharmacies and securing unique "J" codes for reimbursement takes time which may end up being the major differentiator among products.

Trend #1: Consolidation on a Large Scale Done, Mostly Tuck-In Acquisitions Going Forward

Now that the Zimmer Biomet merger is a done deal, the number of major players in the arthroscopy/sports medicine market has dwindled to a mere five. Consolidation has already hit this market with Smith & Nephew’s (S&N) $1.6B acquisition of Arthrocare in 2014 and CONMED’s partnership with MTF’s Sports Medicine subsidiary in 2012. Interestingly enough, Medtronic inherited a line of soft tissue fixation devices from their recent purchase of Covidien, however, it is not certain what the Company will do, if anything, with these products. As a result of these recent take-outs, exhibitors on the floor of the American Association of Sports Medicine (AOSSM) meeting in Orlando in July were noticeably fewer with the usual suspects, Arthrex, S&N, Zimmer Biomet, and Stryker, only getting larger. M&A going forward will likely result in smaller deals such as Stryker’s 2013 acquisition of hip arthroscopy developer, Pivot Medical, as companies look to fill gaps in their product portfolio.