I Cannot Remember the Names of Biologics. Should I Retire?

— The old days of drug nomenclature were simpler

A computer rendering of the release of monoclonal antibodies
Nair is a cardiologist.

From oncology to rheumatology, therapy with monoclonal antibodies have rapidly changed the face of modern medicine. Frankly, I am dead scared of them, not because of their cost or their side effects, but because of their complex, tongue-twister names. Give me a short coffee break after hearing a new name and I am certain to forget it, or at best mispronounce it in a way that would sound funny to my younger colleagues.

I have heard passing mention of abciximab and bevacizumab in academic meetings, but routine community practice never forced me to learn the names of biologics, let alone prescribe them.

"Your professional days are over," joked my ob/gyn colleague, as she shared an editorial that recently got published in the New England Journal of Medicine, entitled "Silencing Angiotensinogen in Hypertension." The authors talked about an encouraging new drug, called zilebesiran, a single injection that reduced blood pressure apparently with no discernable side effects. It sounded very promising, but by evening, as I was trying to impress my son -- a medical student -- I just could not remember the name.

"It starts with Z, and ends with ran, maybe," I told him.

"I think you should stop practicing medicine and play Scrabble with me," commented my son.

These two very important unsolicited opinions made me start thinking seriously about my practicing of medicine. I started reading about monoclonal antibodies.

Don't get me wrong, at 60 years old I have fair cognitive function for my age. I keep myself updated regularly on evidence-based medicine. I agree that I can't remember names of clinical trials, or the names of 31 flavors of Baskin-Robbins ice cream as before, but surely, I don't qualify for dementia.

My professor used to tell me to prescribe only one particular brand of digitalis because "that's the only brand that's effective." Coming from a plant source, it is not just the chemical formula that counts, but its bioavailability and dissolution depends on how it is manufactured.

He died before he was proven wrong.

The new synthetic drugs coming out of automated manufacturing lines are more like silicon chips or paper cups: all created equal, maintaining the same quality. Today, it is not easy to find a leaky Starbucks cup or an ineffective pantoprazole tablet from a reputed manufacturer. Along with their similarity in quality, they also retained a plethora of nice sing-song names.

As we transited from synthetic designer drugs to biologics, drug nomenclature took a quantum jump. Cute names like prasu (prasugrel) to tica (ticagrelor) and lina (linagliptin) were replaced with tongue-twister biologics. Names like rituximab, trastuzumab, adalimumab, and canakinumab sound to me like an alien language spoken through an airline PA system. Names ranging from alemtuzumab and alirocumab, to basiliximab and bevacizumab, all the way to zolbetuximab, leave me frustrated. I give up.

So, I decided to take a deep dive. I called my pharmacology friend.

"Can you tell me about how monoclonals are named?"

"Easy-peasy and logical," he started explaining. "The suffix, the surname is -mab, just means monoclonal antibody. The middle name is called infix. Depending on the site of action, it could be cardiovascular (ci), bone (so), tumor (tu), followed by the source from which it is obtained -- human (u), mouse (o), chimeric (xi), humanized (zu). The prefix is the choice of the inventor. So tu-xi-zu-mab," he said.

I was already feeling dizzy.

Then he continued on: "After 2022, they decided to simplify it. A suffix of -tug, -bart, -mig, or -ment, is preferred depending on the pattern of epitope recognition."

"Thanks," I said, and quickly hung up.

I didn't have the courage to ask him what exactly an epitope is. All I knew was that my time as a physician is reaching its expiry date.

Tiny Nair, MD, DM, is the head of the Department of Cardiology at PRS Hospital in Trivandrum, Kerala in India.