PIavix, one of the world's best selling drugs in 2010, appears to have a limited future. Its patent was due to expire soon and recently new data had been discovered which indicated that a small subset of the population would be at risk for stroke, heart attack or even death if they took PIavix. As a result the FDA had added a black box warning-the agency's most severe--to Plavix's label in 2010. In addition, it had been discovered that the common combination of Plavix and Prilosec, an over-the-counter drug, could adversely affect patients. Finally, Plavix faced new competition from two new drugs with different mechanisms of action. This case reviews the recent history of Plavix in greater detail to encourage a discussion of the following questions: How might the current manufacturers of Plavix handle these emerging threats to their leading blockbuster? How might Plavix's potential competitors utilize Plavix's mixed history to their advantage? How should genotyping be integrated into the clinical care of patients in the light of emerging knowledge?

Scientific advances have begun to give doctors the power to customize therapy for individuals. However, adoption of this approach has progressed slowly and unevenly because the trial-and-error treatment model still governs how the health care system develops, regulates, pays for, and delivers therapies. Aspinall, the president of Genzyme Genetics, and Hamermesh, chair of a Harvard Business School initiative to improve leadership in health care organizations, discuss the barriers to personalized medicine and suggest ways to overcome them. The blockbuster model for developing drugs, the authors point out, is still what most major pharmaceutical companies follow, even though its days are numbered. What the industry must embrace in its place is a business model based on a larger portfolio of targeted--and therefore more effective and profitable--treatments, not a limited palette of one-size-fits-all drugs. The current regulatory environment overemphasizes large-scale clinical trials of broad-based therapies. Instead, the focus should be on enrolling subpopulations, based on diagnostic testing, in trials of targeted drug treatments and on monitoring and assessing effectiveness after drugs are approved. A dysfunctional payment system complicates matters by rewarding providers for performance of procedures rather than for accurate diagnosis and effective prevention. Aspinall and Hamermesh call for coordinating regulation and reimbursement so that incentives are provided for the right outcomes. Finally, the authors urge changing physicians' habits through education about genomics, diagnostic testing, and targeted therapies. They say that medical schools and physician organizations must become committed advocates of personalized medicine so that patients and the medical industry can get all the benefits it offers.