Biogen's controversial Alzheimer's drug approval, the billionaire space race, real estate, Bitcoin & more

The episode opens with banter about the camera framing, a 9 AM start that one speaker says is rough on Jacob, and a hosting setup in which one of the besties is joining from an undisclosed location in Europe. The tone is jokey: the remote host pans his camera around an ornate room and the others tease him about paying an architect for a house that is already built.

The remote host says it is 6 in the evening where he is and that he was in London the previous week, where the temperature swung from roughly 24 degrees Celsius one day to 62 and raining the next. He offers this as his own observation of climate change in Europe, and another speaker quips that Europeans take it seriously because they feel it daily. The speakers then note that the show has been off for two weeks, so there is a lot to cover.

The first topic is the FDA's Monday approval of Biogen's Alzheimer's drug, described in the discussion as the first new Alzheimer's treatment in almost two decades. The framing is cautious from the start: it is not a cure and does not reverse the disease, but is meant to mitigate its worsening. The hosts stress how unusual the process was, since members of the FDA's advisory panel quit after the panel voted unanimously against approval because of the drug's modest efficacy. One speaker says three members quit out of roughly ten or eleven, and puts the price at $55,000 (a later speaker says $56,000), with brain scans still required.

The question put to Friedberg is whether the dispute reflects a broader contest over truth, as in journalism and social media, or a different problem in science.

The answer begins with the drug's name, which the transcript renders as "Edu Canomab". Any drug ending in "mab" is a monoclonal antibody, a protein that binds a specific target and flags it for the immune system to clear. The speaker says such biologic drugs have been used for decades to remove specific cells or proteins. He recounts that researchers at the University of Zurich found an antibody in the brains of people with slowly progressive dementia that bound amyloid plaque, which is one theorized mechanism of Alzheimer's progression. He is explicit that amyloid as the driver of the disease is "not proven".

The speaker says the antibody passed to a company the transcript renders as "Neuromune", which licensed it to Biogen, and was engineered into an injectable treatment meant to bind and remove amyloid. In trials across thousands of patients, he says, it did not differ meaningfully from placebo on cognitive scores, so the trial was stopped a few years earlier.

About nine months later, he says, Biogen refiled, pointing out that the group given the highest dose had a 23% decline in progression, which he calls "one way of slicing the data". Some cognitive tests still did not show a benefit, some people pushed back, and, in his words, no one knows for sure how the FDA reached its final decision.

The speaker raises two issues. First, price: he says an antibody therapy costs roughly $5 to make, while the treatment is priced at $56,000, which raises the question of whether a quality-of-life premium of that size is justified. Second, whether a drug with weak efficacy and a favorable slicing of the data should have been approved at all. These figures are his own claims and are not checked in the discussion.

He adds that all payers, whether insurers or the government, ultimately bear the cost, and he says about 15,000,000 people in the United States have Alzheimer's. Patients will want any chance of hope, but he asks whether it is the responsibility of payers to fund hope when the drug may not work. He describes side effects as negligible, so for him the debate centers on cost and upside: whether to approve such drugs and whether pharma companies should be allowed to charge what they want when efficacy is low and manufacturing cost is small.

Chamath, asked for a financial view, says he has taken biotech seriously for about 18 months, prompted by Friedberg. He calls the setup for Alzheimer's "really scary" and says that Black people are 20% more likely to get it and that 60% to 65% of patients are women, so he calls it a disease of minorities and women, which he says makes it an equality issue.

He also claims that every Alzheimer's drug that has gone through the FDA has been rejected and failed, and that two infamous insider-trading episodes involved failed Alzheimer's drugs. One he describes as inside baseball involving a large hedge fund; the other is the case of Martha Stewart, which he ties to speculation on a phase 3 result. He says betting against such drugs was almost the surest money on Wall Street. These are his recollections and are not verified in the conversation.

Chamath, who says he is "super torn", first lays out the negative case: the FDA approved a drug with no clear evidence of clinical benefit, which could give families false hope. A unanimous negative vote also raises the question of why there is an advisory committee of outside experts at all, and approval on limited evidence could set a precedent for other companies.

The positive case is a long-term one. Biogen has said it believes this is a $100,000,000,000 market, and he argues that capitalism will draw young startups into the space, which might eventually lead to a real solution. He offers a bit of trivia: the acting FDA commissioner in 2016, whom he names as Janet Woodcock, approved a different drug for Duchenne muscular dystrophy after a negative panel vote, on the view that safety data showed no harm. He says four years later there were many more companies working on that disease and pouring money into R&D, and suggests she may be running the same playbook here.

Asked whether the economic incentive could drive innovation that benefits patients more than the current drug, Chamath says he thinks so. He sees two positives in the FDA's behavior: accelerating approval timelines, citing the vaccines as the best example, and requiring a well-structured safety study showing that a drug is not harmful.

He then says that approving a $56,000 drug implies a $10,000 copay, which he says shows how broken Medicare Part B is, a topic he says deserves its own discussion. He summarizes the FDA's action as creating a $100,000,000,000 market out of nothing. The copay and market figures are the speaker's own claims.

One speaker presses the question of price: if regulators approve a drug and enable a commercial opportunity, should they also say the company can only charge a set amount, rather than having taxpayers pay whatever is asked. A host also asks why the FDA published no plain-English document explaining how it reached its decision, and why it did not take an interim step such as overruling the vote with stated reasons. He says he looked for such a document and could not find one.