Promising no fuss and no muss, medical super glue was supposed to quickly overtake old-fashioned sutures as doctors' first choice in closing simple cuts and incisions.
But a funny thing happened on the wonder glue's path to glory: Doctors kept right on sewing.
Shares of Raleigh, N.C.-based Closure Medical Corp. tumbled 36% in one day last month when the maker of the first medical version of the glue said that its exclusive distributor, Johnson & Johnson, was scaling back orders of Dermabond, the trade name for the adhesive.
Since the Food and Drug Administration approved the glue last August, demand for the product has been somewhat underwhelming.
"We stock it, and we use it on select cases," says Michael Weinstock, M.D., chairman of emergency medicine administration at Lehigh Valley Hospital in Allentown, Pa. "I'm neither ecstatic nor displeased with it."
That ho-hum reaction, based on slow orders so far, wasn't exactly what the companies had hoped for. They expect the setback to be temporary, though, as most physicians' natural reluctance to change fades with training and experience.
Dermabond does have its limits: It can't be used on knees, elbows or other joints where it would crack, and it's no match for deep cuts. Plus, doctors have to learn how to smear rather than stitch, a conversion that takes practice.
For other cuts, however, the case for the glue is strong.
Fast and effective, Dermabond eliminates the need for local anesthetic and, in many cases, for a follow-up visit, because no stitches have to be removed.
So far Dermabond has been touted mostly for use in the emergency room. New Brunswick, N.J.-based Johnson & Johnson says 83% of hospitals stock the product, which costs $25 per use.
Johnson & Johnson made "something of a miscalculation of the rate at which physicians would feel comfortable with it," says Susan Odenthal, a spokeswoman for the company's Ethicon division.
What went wrong?
"(Johnson & Johnson) confused breadth with depth," says Robin Young, an analyst with Stephens, an investment bank in Little Rock, Ark. "They got wide market penetration and awareness, but it didn't go deep." Young recently surveyed approximately 1,000 emergency room physicians about Dermabond and got responses from 403 of them. More than four of five doctors already used the glue, and 83% of them expected to continue to use it at the same or higher levels (See box).
Doctors, though grateful for a new option, seem unwilling to abandon their old standbys.
"I've taken a middle-of-the-road approach," explains Jim Holliman, M.D., who works in the emergency room at Penn State Geisinger-Milton S. Hershey (Pa.) Medical Center. He uses sutures for wounds under tension and special tape, a cheaper suture substitute than glue, for simple cuts on a flat surface, such as a forearm.
Around the eyes or at the hairline, though, the glue is terrific, he says. And because it's fast and painless, glue is a godsend when dealing with squirmy kids.
Johnson & Johnson remains upbeat about the prospects for Dermabond.
"In a way this is a company that pretty much wrote the book on skin closure, and we look at this as the next step," Odenthal says.
Hershey's Holliman, too, is optimistic about adhesives, saying that eventually they could replace sutures in up to 90% of cases.
A combination of new products, expected over the next few years and doctors' growing familiarity with the technology mean that glues and related sealants will probably stick around.
Closure Medical was one of the first companies through the FDA gates with a general medical glue, but the field is filling in fast. Baxter International, Deerfield, Ill., also makes a special blood-stopping adhesive for surgery called Tisseel. It costs about $330 per use and was approved last year. Other companies with new wound-closing technologies on the horizon include Cohesion Technologies, Palo Alto, Calif.; CryoLife, Kennesaw, Ga.; Focal, Lexington, Mass.; and Fusion Medical Technologies, Mountain View, Calif.
All told, U.S. sales in the category could approach $400 million next year and exceed $800 million during 2002, according to estimates by Stephens' Young. Later this week he will host an investment conference in New York on the outlook for companies that make glues and sealants.
The interest in glues is white-hot because nobody, especially Johnson & Johnson, wants to be left behind in what could be a fundamental shift in clinical practice.
Three years ago the company's Ethicon division paid Closure $3.5 million for an eight-year, exclusive license to sell Dermabond and prepaid $2 million against future orders and toward research and development.
Sutures, used for centuries to close wounds, finally gave ground to staples starting in the 1960s. In a now legendary screw-up, Johnson & Johnson, the leading suturemaker then and now, rejected a proposal by entrepreneur Leon Hirsch to commercialize the staplers he was developing.
Hirsch, undaunted and determined to prove he was right, formed U.S. Surgical Corp., Norwalk, Conn., which pioneered the now established surgical stapling niche. Last year, Tyco International bought U.S. Surgical for $3.3 billion.