Marinus Pharmaceuticals, Inc.

Q1 2021 Earnings Conference Call

5/17/2021

spk14: Greetings and welcome to the Marinus Pharmaceuticals first quarter 2021 business update call. At this time, all participants are in a listen-only mode. A brief question and answer session will follow the former presentation. There will be a question and answer session. To ask a question during the session, you will need to press star 1 on your telephone. As a reminder, this conference is being recorded. And it is now my pleasure to introduce your host, Sasha Kamouni. Vice President, Investor Relations, and Corporate Communications. You may begin, Mr. Mooney.
spk03: Thank you. With me from Marinus are Dr. Scott Rodstein, Chief Executive Officer, Dr. Joe Houlihan, Chief Medical Officer, Christy Schaefer, Chief Commercial Officer, Steve Fansfield, Chief Financial Officer, and Kimberly McCormick, Vice President, Regulatory Affairs. Before we begin, I would like to remind everyone that some of the statements made today are forward-looking statements under the securities laws. These forward-looking statements involve substantial risks and uncertainties that could cause our clinical development programs, future results, performance, or achievements to differ significantly from those expressed or implied by such forward-looking statements. These risks and uncertainties and risks associated with our business are described in the company's report filed with the Securities and Exchange Commission, including forms 10-K, 10-Q, and 8-K. I will now turn the call over to Scott.
spk13: Thank you, Sasha, and welcome to our first quarter 2021 business and financial update. This year is off to a tremendous start. We've continued to make progress across our oral and IV clinical programs, have intensified preparations for a commercial launch, deepened discussions with potential European partners, have made exciting headway in our next-generation formulation research, and have strengthened our management team, scientific advisory board, and board of directors. To support this continued progress, today we announced $125 million credit financing that is being funded by Oaktree Capital Management, a global asset management firm specializing in alternative investment strategies. This financing provides us with access to additional capital to support our research programs and commercialization efforts, as well as extending our cash runway through the end of 2022. The completion of this agreement assists in our ability to monetize the rare pediatric disease priority review voucher we anticipate would be granted with this potential approval of Ganaxolone next year. We believe the financing exemplifies Oaktree's confidence in our NDA submission, our company's ability to deliver on upcoming clinical milestones, while providing capital to support our ongoing and future research and development programs, as well as preparing for our first potential commercial launch. The NDA for the use of Ganaxalone in CDKL5 deficiency disorder, or CDD, is on track for submission by the middle of this year. This is the first step in developing a sustainable oral franchise to address the meaningful opportunities that we envision over the long term. As a reminder, the sufficiency of the Marigold data set to support approval will be determined during the FDA review process. The Marigold study showed strong efficacy and a favorable safety profile, and the open label data from that study continues to display durability that has been noted since Ganaxolin's early preclinical studies. Let me give you a quick update on Europe. The company has had encouraging interactions with the European Medicines Agency surrounding our planned oral Ganaxalone EU submission, and we remain on track to submit a pre-marketing authorization application by the end of the third quarter. We continue to have constructive discussions with potential European commercial partners and hope to have a partner selected over the coming weeks to months. we would expect oral Ganaxalone, if approved, to be commercially available in Europe beginning in the middle of next year. We have been intensifying our commercial planning efforts in front of a potential mid-year 2022 CDD launch in the U.S. This is the first call that you will hear prepared remarks from our Chief Commercial Officer, Christy Schaefer. Christy has been building a fantastic team filled with experts in both the orphan disease space as well as the hospital arena. Our medical science liaisons are working diligently to prepare for their educational efforts with the clinical community. Our message will focus on the mechanism of action of Ganaxalone and its modulation of the extrasynaptic GABA receptor and the unique characteristics and results of that binding. We believe that Ganaxalone will have a differentiated profile based on efficacy, safety, and durability. More to come on our commercial plans from CRISPY. Let me move to our TSC program. We expect to share top-line data from the 23-patient Phase II study with the investment community around the middle of the third quarter. We have completed the study design for our planned Phase III trial of Ganaxalone in tuberous sclerosis complex, or TSC, and an end-of-Phase II meeting with the FDA based on an interim data analysis is expected early in the third quarter. As a result, we are planning for site initiations to begin for the Phase 3 trial in the latter portion of the summer, while the first patient enrolled is anticipated in the fourth quarter of 2021. We are targeting completion of site selection by the end of Q3, and we expect to share our timelines for the Phase 3 study by the end of September. We also plan to meet with EMA early in the fourth quarter to obtain scientific advice on the phase three trial and clinical development program. We plan to submit an orphan drug designation request for the use of Ganaxalone in TSC in both the US and EU later this year. We believe Ganaxalone has the potential to play a critical role in the chronic treatment of refractory epilepsies. To further support our expanded clinical efforts, We announced today that we have strengthened our scientific advisory board with the appointment of several leading experts in clinical neurology and pediatric seizure disorders. Joining our SAB are new members, Dr. Elizabeth Thiel from Massachusetts General Hospital and a professor of neurology at Harvard Medical School, Dr. Ilana Pisana-Knight, pediatric epileptologist in the pediatric epilepsy section at the Cleveland Clinic, and Dr. Nicola Specchio, head of the epilepsy unit in the Department of Neuroscience at Bambino Gesu Children's Hospital, Rome, Italy. I'd like to shift gears and move to the IV program. Our Phase III clinical trial of IV Ganaxalone for the treatment of refractory status epilepticus, or RSE, the RAISE trial, continues to advance. I know that many of you have been tracking both the rate of new COVID infections and hospitalizations in the U.S., and we are thankful that the numbers continue to significantly move in the right direction. COVID hospitalizations are below 40,000 U.S. patients for the first time in almost a year and showing continued progress, which is encouraging news. Despite these challenging hospitalization numbers, interest in the study over the past several months has continued to be robust. Our clinical operations team has done a tremendous job to open sites in major academic centers in the middle of this pandemic. We continue to open sites and evaluate enrollment accordingly. We are happy to report that currently total patient per site numbers are tracking in line with our expectations thanks to the diligent interactions from our clinical development team, including Dr. Henry DeCavage and Dr. Maja Gasior. It is still early in the study. However, at this time, we are reiterating top line data readout for the RAISE trial in the first half of 2022, despite the persistent COVID headwinds that have affected site activations for the past six months. More than half the trial sites are expected to be open by the end of the second quarter, with the vast majority open by the third quarter. Planning also continues for a separate European RSC trial recently named the RAISE-II trial to begin in the first half of 2022. A meeting was recently held with the EMA where we engaged in a very constructive dialogue and that Joe will describe in further detail. Our European strategic discussions encompass both the oral and IV franchises, and we believe a partner would bolster our ability to execute on a second appropriately powered IV registrational trial. Our hope is that we will have a partner in place to help fortify our execution effort, specifically around site selection and medical education. We currently believe that the RAISE-II trial would not only serve as a pivotal registrational trial for European approval, but has the potential to have an important clinical implications for the global market. More to come from Joe. As we continue to build the team and strengthen the organization, this will be the first Business Update conference call for a newly appointed CFO, Steve Fanstiel. Steve has been a major contributor in the completion of the credit financing, and his amazing effort and strong leadership skills could not have come at a better time for the organization. Steve has only been with us a few weeks, but the entire leadership team is thrilled with his ability to jump right in and contribute in a meaningful way. Finally, we are pleased to welcome Dr. Sarah Nocture to our board of directors. Sarah brings tremendous experience and success in managing global regulatory and drug development and has been involved in the approval of several novel drugs for rare diseases. Sarah is currently serving as an Alnylam Pharmaceuticals Chief Diversity, Equity, and Inclusion Officer. We plan on tapping into our expertise as we continue to build our corporate culture and drive to achieve our core values at Marinus, commitment, innovation, and community. I would now like to turn the call over to Christy Schaefer. Christy joined us as our first Chief Commercial Officer six months ago. I am pleased to have her provide more on her early thoughts as we plan for our first potential commercial launch.
spk05: Thanks Scott, and thank you everyone for joining our call today. As Scott mentioned, we are fully engaged in developing our commercial launch strategy and plans. The commercial team continues to broaden its capabilities by solidifying the internal and external strategic plan. During Q1, Marin has finalized the senior leadership construct by welcoming its market access, sales and marketing, operations, and commercial supply chain leaders, who are in turn developing the operational and tactical plans. Our most recent addition to the team is Lisa Lejuan as Vice President of Sales, who joins us from Alexion. We will continue to grow the commercial team commensurate with planning for a mid-2021 NDA submission of Ganaxalone in the treatment of epileptic seizures associated with CDKL5 deficiency disorder and a mid-year 2022 launch, if approved. Our strategy is consistent with basic principles of orphan disease launches. First, We plan to keep the organization lean with 16 to 20 account managers and four payer representatives, one specializing on Medicaid. Our sales and marketing efforts will be focused on top treaters and high influencers as most of the commercial opportunity is concentrated in a limited number of facilities. We have completed several core pieces of market research that have informed the assumptions and conclusions underlying our go-to-market strategy. We have now finalized several key critical elements in our process, such as the patient journey, account segmentation, deployment strategy, and market size and structure. This work has given us the foundation upon which to build our branding, messaging, print, and digital platforms. we are in the final stages of selecting our external marketing agency, an important decision to be made collaboratively amongst the Marinus cross-functional team with an emphasis on a cohesive and targeted messaging platform design that will prioritize the unmet needs of our CDD patient population. From a pricing perspective, we want to ensure our value proposition is reflected. As part of those efforts, We are generating health economics and outcomes research to bolster our value proposition. This includes managing the reimbursement and payer landscape to ensure timely access and assuring we can mitigate any potential complicating restrictions. Additionally, we continue to monitor the competitive landscape and engage market access experts across the US and Europe. We are confident that these efforts will characterize true value for our patients living with CDD, their families, and for the physicians that treat them. I'd like to turn the call now back to Scott.
spk13: Thank you, Christy. Two additional comments from me before I turn the call over to Joe. Joe will walk you through the updates to the CDD data, and Kim will discuss our regulatory activities, but I am confident that we have been diligent with our preparations of the NDA and in our interactions to date with the U.S. and EU regulatory authorities. Timing is on track for both our FDA and EU submissions, which are our top priority. The final data analysis does not affect the statistical and clinical conclusions of the study as reflected in our May 2021 corporate deck. Finally, we continue to progress our oral reformulation and pro drug endeavors and evaluate other opportunities for Ganaxolone in additional refractory epilepsy indications. We still expect to move at least one of these formulations into the clinic in the first half of 2022. As we announced this afternoon, we are planning on initiating a phase two trial in Lennox-Gastaut syndrome, or LGS, in the middle of 2022, and if all proceeds as planned, with a potential new formulation. Given the overlap in seizure types and etiologies with other disorders, organaxalone has shown meaningful potential specifically CDD, as well as early encouraging data in the TSC patient population, we believe the future investment is warranted. We understand that the LGS market is highly competitive and would look to enter the market with the best chance of a differentiated clinical profile. With that, I would now like to turn the call over to our Chief Medical Officer, Joe Houlihan.
spk11: Joe? Thank you, Scott, and welcome, everyone, to our business update call. Let me get right into it. I'll start with our program in refractory status epilepticus, or RSE. In the RAISE RSE trial, even with COVID-19 delays, we're still expecting to have more than half the sites open by the middle of the year, with the vast majority of sites open by the end of the third quarter. We're encouraged to see that sites are screening appropriate patients, and we're pleased with the rate of enrollment to date. Our experience with screening reinforces our conviction that we have the right study design, and we've thought very carefully about response rates in the control arm. Let me explain that a bit. The protocol requires that patients have failed two second line AEDs. We've asked sites to prescreen potential study candidates after they failed the first second line AED so they can be enrolled quickly after failing another. We believe that requiring failure of two second-line AEDs will lessen the response to standard of care. In fact, some patients have actually responded to the second of those AEDs. If we'd enrolled those patients in the trial, it's likely they would have been placebo responders. So we believe that requiring failure of two second-line AEDs is the correct strategy for defining the population in this study. We're continuing plans for an RSE pivotal registration trial in Europe, which we have named the RAISE-2 trial, targeted for launch in the first half of 2022. We had a very productive dialogue with the European Medicines Agency and reached agreement on major features of the study design and endpoints. Since one of our goals is establishing leadership in the treatment of status epilepticus, we were pleased to hear that our approach to studying RSE could influence the next version of EMA treatment guidelines for epilepsy. The U.S. and European studies have similar enrollment criteria in study designs, but there are some key differences. Both studies are double-blind, placebo-controlled trials, and in both, patients must have failed initial treatment with a benzobazepine, such as lorazepam and midazolam, However, in the U.S. trial, as I mentioned, patients must then fail at least two second-line IV AEDs. But in the European study, they will need to have failed only one. The reason for this is that, unlike in the U.S. study, in RAISE2, IV Ganaxolone or placebo is started at the same time as the second standard of care AED. We're aware that treating earlier in the course of RSE could allow a better response to standard of care, thereby producing a higher placebo response. However, we've anticipated that possibility and have incorporated other features into the study design intended to maintain the placebo response at a low rate. The U.S. trial has two co-primary endpoints, one assessing early response and the other prevention and progression to IV anesthesia within 36 hours, looking at durability of response. Since physicians don't use IV anesthesia for the treatment of status nearly as much in Europe as in the U.S., we modified the durability endpoint for the European trial to be any escalation of care, whether an IV anesthetic or another AED to treat status. Importantly, instead of co-primary endpoints as in the U.S., EU regulators preferred that we use a combined endpoint, i.e. a responder analysis. A responder is defined as having cessation of status within 30 minutes and no escalation of care within 36 hours. The differences in design and study endpoints mean that these trials are now complementary to each other, further increasing the chance for success of the overall program and having the potential to broaden the efficacy claim for iViganaxalone and RSC. Next, I'd like to give you an update on our trial in established status epilepticus, or ESE. ESE is earlier in the treatment continuum of status epilepticus than RSC, and is defined as status that continues following failure of benzodiazepines. The ESE study will enroll patients from emergency departments with convulsive rather than nonconvulsive status. We plan to initiate the study in early 2022 after we've completed the process of exception from informed consent and gained alignment with the FDA. It's important to note that patients who qualify for the ESE trial have a type of status distinct from those who would enter the RAISE trial. who will have predominantly nonconvulsive status epilepticus. So, we can consider the same sites for our established status trial without compromising enrollment in the RAISE study. In the ESE study, enaxalone is intended to act as an adjuvant to standard of care, which will be the initial second-line IV AED. The ESET study in established status epilepticus showed that response rates to the standard of care AEDs is less than 50% within the first hour. We believe that Ganaxolone has the potential to reduce the time to response and increase the durability of effect of standard of care IV AEDs. Our goal in the study is to find a safe and well-tolerated dose of Ganaxolone. The study design proposed in the FDA involves the initiation of Ganaxolone at the same time as the first AED following benzodiazepine failure. The trial utilizes a novel sequential design to assess the safety and efficacy of several doses and infusion durations of Ganaxolone, with the optimal dose regimen progressing to a double-blind phase two study versus placebo. Now I'd like to give you a quick update on our oral Ganaxalone programs. In PCDH-19-related epilepsy, we still plan to submit the results from our Phase II study for presentation at an upcoming scientific meeting and for publication in the medical journal. We recognize that this condition is a difficult one to study due to the intermittent and variable nature of seizure activity. Importantly, we'll continue to offer Ganaxalone to any patient who participated in the study and wishes to continue treatment. And in CVD, as Scott mentioned, we're on track for a mid-year FDA submission and for filing with the EMA in the third quarter. We also plan to submit a series of abstracts for the upcoming AES meeting in December, including the one-year open-label extension data from the Marigold study. With data on 48 patients who reached one year of open-label treatment, we're seeing percent reductions from baseline during open-label months 11 and 12 of 46.5% in patients who are on ganexolone and double-blind. Those who had been on placebo and transitioned to open-label ganexolone achieved a percent reduction of 53.8%. We continue to work with several centers across the U.S. who have shown interest in the CDD Expanded Access Program, and we are committed to making Ginexone available to patients prior to a potential U.S. approval. We recently discovered that the top-line data that we previously presented included duplicate seizure diary entries resulting from a data transfer error. This affected less than 2% of the over 73,000 total diary entries though there were some small differences between the top-line seizure reduction data and the validated data set for regulatory submission. The final statistical analysis of the primary endpoint showed that the percent change in major motor seizures in the Ginexilon group was 30.7%, and for placebo it was 6.9%, with a p-value of 0.0036. The previously reported top-line data analysis showed a reduction of 32.2% for gonaxolone and 4% for placebo, with a p-value of 0.002. These changes do not affect the statistical or clinical conclusions of the study, and there were no changes in key secondary endpoints, safety data, or other study outcomes. With regard to TSC, We're planning an end of phase two meeting with the FDA early in the third quarter and with the EMA in the fourth quarter. We're also anticipating a second meeting with the FDA to receive scientific advice on our IMD submission. We expect to initiate our phase three TSC study with the first patient enrolled in the fourth quarter of this year. The study will enroll 160 patients who failed at least two prior AEDs. We anticipate that study participants will be taking a range of concomitant medications. And unlike the Epidiolex study, our trial will allow enrollment of patients taking the mTOR inhibitor of Finitor or Everolimus, which is used for treatment of seizures and also for TSC associated tumors. And we expect that roughly 50% of patients will enter the study taking or having failed Epidiolex. We're also exploring new indications this year, including Lennox-Gastaut syndrome. Our current thinking is that this would complement our work in other pediatric epilepsies, as we've had several patients in our CDD and TSC studies who carried the diagnosis of LGS. Unlike a genetic epilepsy diagnosis, LGS represents a clinical syndrome that can have a number of different underlying etiologies. We'll share more of our thinking about a clinical trial sometime later this year. As always, in closing, I would like to thank the patients, families, medical professionals, and advocacy groups who've been so supportive of our efforts. Now I'd like to turn the call over to Kim for a regulatory review.
spk05: Thanks, Joe. Since we've been receiving an uptick of regulatory questions from the investment community, we wanted to discuss our interactions and communications with the FDA and EMA. A pre-NDA CMC meeting was held with the FDA in August of 2020 for the Marigold study. During the meeting, the FDA provided very constructive feedback and overall agreement on the format and content of the CMC section of the NDA was achieved. Subsequently, in January, we had a Type A meeting with the FDA to review our proposal that one Phase III study would be adequate to support our MDA submission for CBD. Prior to the meeting, at the FDA's request, in addition to the details of the Marigold study, we provided information on legacy epilepsy studies conducted by the company that have failed to show efficacy, most notably a Phase III study of focal seizures in adults. We reviewed key aspects of that study and the miracle trial. In particular, differences in dosing and PK that we believe explain the discrepancy in study outcomes and support the efficacy that Ganaxon demonstrated in the Phase III CVD trial. Following review of the data and information we provided, the FDA agreed that the miracle study would be adequate to support our NDA filings and that the adequacy of the data for NDA approval would be determined by the review of the NDA during the process. We completed a pre-NDA meeting with the FDA at the end of the first quarter. The FDA has been very engaged and responsive and provided constructive feedback in the pre-NDA meeting on what information they wanted to see in the NDA and in what format. Rapid response teams are being set up to quickly respond to any potential requests from the FDA. We believe that the final data analysis for the Marigold study fully supports this submission, and we remain on track with our U.S. and E.U. regulatory filings. It's worth noting that we had a successful pre-MAA meeting with EMA in March 2021, where overall agreement was achieved on the format and content of the MAA. a meeting with the rapporteur and co-rapporteur to discuss the MAA is planned for the end of May. Now, I would like to turn the call over to Steve for review of our financials.
spk07: Thank you, Kim. I am pleased to be able to share our financial results. For the first quarter of 2021, we recognized $1.8 million in federal contract revenue related to the BARDA contract. This contract was signed in September 2020 there are no revenues associated with this from the first quarter of the prior year. As a reminder, our base BARDA contract extends approximately through the third quarter of 2022 and is expected to provide a total of $21 million of non-dilutive funding over this time. The potential exists to extend the BARDA contract further based on success-based milestones with potential total funding of up to $51 million. Research and development expenses increased to 18.6 million for the three months ended March 31st, 2021, as compared to 15 million for the same period in the prior year. The change versus the prior year was due primarily to costs associated with increased clinical activity, including startup of the RSC phase three trial and increased resourcing primarily within our clinical and CMC teams. General and administrative expenses increased to $10.4 million for the three months ended March 31, 2021, compared to $3.9 million for the same period in the prior year. The primary drivers of the change over the prior year were increased support for scale-up of the company's operations, as well as preparation for commercialization. The company reported a net loss of $27.1 million for the three months ended March 31, 2021, compared to $18.7 million in the same period a year ago. These totals include non-cash stock-based compensation expense of $5 million and $1.9 million in Q1 2021 and 2020, respectively. The first quarter of 2021 included $2.1 million of stock-based compensation related to a severance agreement with our prior CFO. Cash used in operating activities increased to $16.2 million for the three months ended March 31, 2021, compared to $14 million for the same period a year ago. As of March 31, 2021, we had cash and cash equivalents of $123.5 million. This balance, combined with the net upfront proceeds of the Oak Creek Credit Agreement, will enable us to fund the company's current scale of operating expenses and capital expenditures through the second quarter of 2022. As a result of the credit facility, our focus on executing a European partnership, and our plans to monetize the priority review voucher associated with an anticipated CDD approval, we look to accelerate several key investments within the business, including the TSC and RAISE II Phase III trials, activities to support European approval, and additional formulation work related to Canucks Loans. As a result of this, we estimate operational expenses of between $113 and $118 million for the fiscal year 2021. This total includes approximately $16 million of stock-based compensation. Offsetting these expenses, we estimate barter revenues of between $9 and $12 million for the fiscal year 2021. In addition to the first quarter financial results, I would like to provide additional details of the credit facility with Oak Tree Capital signed on May 11th, 2021. Under this agreement, we have the ability to access up to 125 million of credit financing subject to certain conditions to be taken down in tranches upon successful completion of certain milestones. We have already received the initial 15 million upfront payment in connection with our signing. Two additional tranches of $30 million each occur based on progression of the CDD indication with one funded at FDA acceptance of the NDA filing and a second funded upon FDA approval. The remaining $50 million will be available at our discretion upon successfully achieving certain clinical, financial, and commercial milestones. Importantly, this facility provides the potential to extend our cash runway significantly based on just the CDD indication alone and does not encumber our ability to monetize the potential priority review voucher. With that, let me say I'm excited to be a part of Marinus and work alongside such a talented and top-notch group of experts. My first few weeks at Marinus have been incredibly productive, and I am excited to see this company become a commercial leader in rare epilepsies. Now, turning the call back to Scott, who will provide concluding remarks.
spk13: Thanks, Steve, and once again, welcome aboard. Before concluding our prepared remarks, I want to thank the entire Marinus team who has been responsible for the significant progress we have made and continue to strive to bring ingenuity and solutions to challenges. Our headcount has hit a milestone of close to 100 employees, and I could not be more enthusiastic about the next stages in the company's history. Operator, can you now open the call to questions?
spk14: As a reminder, to ask a question, you would need to press star 1 on your telephone. To withdraw your question, press the pound or hash key. We also ask that you limit yourself to one question only to allow everyone in queue to ask a question. Please stand by while we compile the Q&A roster. And your first question comes from the line of Joe Tomei with Cohen & Company.
spk09: Hi there, good morning, and thank you for taking my question. Maybe just one on the RAISE-2 study design. Is there any consideration for which specific AEDs can be used in conjunction with Ganaxalone, and is there any worry that there could be drug-drug interactions or any exacerbations of potential AEs when you do do the combination of Ganaxalone and other AED? Thanks.
spk11: Thanks for your question. No, there's no limitation on the other AEDs. It's the investigator's choice. The number of available AEDs, it isn't that many. But we do expect we'll get randomizational balance out, what drugs are used and that that reflects standard of care. In terms of drug interactions, no. There is potential interaction with CYP3A4 enzyme-inducing drugs. But we, in an oral epilepsy study, we didn't see any effect, any difference in efficacy based on the use of the other drugs. And the dose of danaxilone used in the trial was high enough. We wouldn't expect to see any interaction, especially with acute use. I don't think that would be a factor at all.
spk14: And your next question comes from the line of Alethea Young with Kantor Fitzgerald.
spk04: Hi. Thanks for taking my question and congrats on the progress. This is Nina on for Alethea. Thank you.
spk13: Thank you.
spk04: For the full TOC readout, what additional data will we see and how do you think about what is comparable data versus competitors? Thanks.
spk13: Joe, why don't you take it? Yeah. I don't have to do anything today. I'm going to let everyone else do all the work today.
spk11: So, yeah, I think this phase two study focuses on kind of key efficacy and safety data. So there'll be some other ways to look at the seizure data, obviously the usual safety data. And then one of the things we're interested in with this study is, you know, how, if we see any differences with different drug combinations, particularly, you know, so Epidiolex or Finitor, and also seizure types. The seizure types in this disorder are different in some ways than those we see in CBD. So those are the main things we're looking at. In the Phase 3 study, we'll have a range of patient-reported outcomes and other assessments, but we're focusing on the key data from the Phase 2.
spk14: And your next question comes from the line of June Lee with Truist Securities.
spk01: Hi. Thanks for taking our questions and for the update. For the loan from Oak Tree, what are the interest terms with each draw? And are there any callback provisions if the outcome doesn't meet certain expectations? And is there any flexibility with Oak Tree for further funding for additional educations?
spk13: Before I turn over to Steve for the details, let me just hit on the big picture. June, and thanks for the question. First of all, we're thrilled to do this deal with the Oak Tree team. They've been great. They've been a fantastic partner. And I'll have Steve walk you through the specifics of this deal, but I think we believe that this is a partnership that could expand in many different forms over time. and I think they've taken a lot of time to be quite thoughtful in this deal. So happy to have them as a partner. But, Steve, why don't you walk through all the details of the deal for June?
spk07: Yeah, hi, June. Yeah, certainly happy to walk you through. So I think we've mentioned it's up to $125 million of financing, obviously tranche. The first 75 we can take relative to the CDD indication alone. The remaining 50 is driven by clinical, financial, as well as commercial targets. um the the interest rate on it is 11 and a half percent um it's interest only for the first three years um and then it it um uh you know is it full maturity after five years um there is a um there is a a ticking fee that starts 120 days after funding of the 30 million tranche from the cd filing acceptance uh that that first uh 30 million tranche of funding um I think it's worth noting there's a couple things worth calling out. We can still monetize the PRD. We still have the ability to do a U.S.-based synthetic royalty, and we are able to do a European partnership. So those are kind of a number of the key things. In terms of expanding further, I think that's something we can discuss further as we go along, and, you know, we look at this as a relationship, a long-term relationship with Oaktree.
spk14: And your next question comes from the line of Mark Goodman with SVB Leary.
spk02: Yeah. Joe, can you talk about LGS a little bit? What proof of concept data you have that made you want to pursue this indication? Thanks.
spk11: Yeah. So we did have, you know, LGS is a diagnosis. It's not a specific genetic diagnosis. It's multiple etiologies. So we had some patients in the CBD study that also carried a diagnosis of LGS. And so we We started to analyze that data, but without giving too many specifics, I think it gives us confidence in an LGS study. Not a large number of patients, but it heads in the right direction. And so we've had a previous study done. in multiple seizure types, developmental and epileptic encephalopathies. And there was a small number of LGS patients in that, but that study really didn't capture the data in a way that we, you know, could use it to see whether there's a proof of concept. The other thing that gives me confidence about LGS is the seizure types are largely similar to CDD. And so I'd expect to see the same efficacy in other etiologies as we did in CBD. And if we pursue it, it would likely be with a reformulation. It's going to give us some better and more even exposure to the drug. So I think that's a plus too.
spk13: And Joe and Mark, I'll add one additional comment. Mark, we've updated our slide deck, and we've now included in that slide deck the PK analysis that Joe and Alex have performed on at least the FAIL-3 focal onset study. And I think we're seeing clear differences in PK levels in studies that were previously performed by the company. We think that is just a function of dose titration analysis. over the course of a month, three times a day dosing. And I think when we look back at the LGS study, you're seeing a consistent signal or inconsistent signal in terms of PK, which we think is very different than what we've seen in the CDD study. Thanks for the question, Mark.
spk14: And your next question comes from the line of Douglas Sal with HC Wainwright.
spk08: Hi, good morning. Thanks for taking the question. It's just I'm just curious, in terms of the RAISE-II trial, I know you mentioned the opportunity to potentially sort of expand the utilization. Have you engaged with the FDA, or do you plan to engage with the U.S. FDA about whether that would meet standards to have inclusion in terms of the label and sort of potentially sort of move up the treatment paradigm?
spk13: MR. Go ahead, Joe. You want to start?
spk11: No, maybe I could turn this one over to Kim for the regulatory piece of it.
spk05: Sure. Thanks, Joe. I can take that. So we have not yet discussed the RAISE-II study with the FDA. The current plan is to once we have the data from that study, we will then discuss the FDA how and what our potential options are for spending the label at that time.
spk13: Yeah. And let me just give a little more color. I think we understood, I think we have to step back and say, hey, we knew we would require a different regulatory path with the European agency. I think we've gotten to a very good place with the European regulatory agency. And given that study design, we do believe it is so complementary to what we're doing in the U.S. that it would be logical for us to have that interaction with the agency. We'd love to have sites in the study in the U.S. as well. I think from a timing perspective, we would only initiate those sites in the U.S. when the RAISE trial itself was significantly enrolled that we wouldn't see it as a conflict. So we think it's a pretty logical discussion for us to have, and certainly we'd love to have their buy-in from where we are today. But I think as we all know, any time we do additional studies, it's always going to be a discussion of or a filing with the agency in terms of a potential label expansion. So thanks for the question.
spk14: And your next question comes from the line of Jay Olson with Abenomer.
spk10: Oh, hey, guys, congrats on the progress, and thanks for taking our questions. We're curious about CDD. Can you talk about any feedback you've gotten from paired discussions or other prelaunch activities? And do you think the 50% seizure frequency reduction for CDD that you saw in the first 12 months of the OLE could improve beyond 12 months, or is that a plateau effect? And then I had a follow-up question, if I could.
spk13: Chris, do you want to jump right in and take that? Oh, go ahead. Oh, I'm sorry, Joe.
spk11: I was going to have Christy start on the commercial side. No, please. Please, yeah.
spk05: Heather, Jay, good morning. So, from a payer perspective, we've done a significant amount of research just understanding the marketplace, how they view CDD, and the expectations that they have. We have finalized that research, and we're moving into phase of just the internal discussions of that research and how we move into a more strategic plan. I will say, though, because this will be the first and only, payer discussions have been very, very, very positive. So we're increasingly more secure in our value proposition in this patient population. I will also say that based on the market research that we've done with payers and physicians, there is an incredible appetite for a new medication for these patients that is over that 25% reduction standpoint. So that lower threshold certainly supports our communication. So from a clinical perspective, I'll certainly turn it over to Joe.
spk11: Yeah. So in terms of the long-term follow-up, yeah, there is a potential right now for Patients are still moving through, and I think we need to see more patients with the longer-term follow-up to see what happens. I think at a minimum, they'll maintain the efficacy. But there is an opportunity, especially some patients could potentially become seizure-free, or we could see a change in the overall median. But I think there's a possibility we could continue to see improvements
spk13: Operator, why don't we go to the next question?
spk14: Yes, thanks. Sorry. No problem. And your next question comes from the line of Brian Scorny with Baird.
spk12: Hey, good morning, everyone. Thank you for taking the questions, and thanks for all the color and transparency on the call. I guess when it comes to the CDD indication, I was wondering if you could just kind of walk us through what the kind of gating factors here are for the NDA submission. And can you just review, are both the CDD and PSC Pathways under the Division of Neurology II. And last, for TSC, you said the upcoming FDA meeting will be based on an interim analysis. I guess it's an open-label study, so maybe you can talk a little bit about what you've learned from the studies so far, if anything, to kind of give the confidence into moving into Phase III. And if you sort of already have an idea of the interim analysis, we'll be discussing in that meeting. Thanks.
spk13: Thanks, Brian. Kim, do you want to kick off on where we are with the NDA filing and your thoughts about the TSC meeting? And then if Joe wants to add anything, he can hop in after you.
spk05: Sure. So in regards to the NDA submission, we're actively in the process of preparing the NDA submission for filing as targeted by the end of June. So there's a lot of work ongoing at this time and a lot of preparations, but we're still on track. of everything delivered and submitted by the end of the month. In regards to the TSC study, we are planning to use the data cut from the open-label study to submit a request to the FDA for an End of Phase II meeting in July, and hopefully having that meeting in the August-September timeframe to support the initiation of our Phase III study. I will also be discussing the study with the European agency as well, in parallel with the slightly staggered timeframe for those discussions.
spk11: Yeah, and I could comment on the TFC in terms of what we're looking for. I mean, I think the most recent benchmark would be Epidiolex, and so obviously we'd like to see magnitude of effect similar to that. It is an open-label single-arm study, so in terms of predicting the placebo response, we'd have to use historical control. But really, it's the magnitude and the direction of the effect that And we're seeing, you know, in the interim look, we're seeing things heading in the right direction. And we'll present the full data set, I think, later this summer. We should have that.
spk14: And your next question comes from the line of Michael Higgins with Leidenberg Thalmann.
spk11: Thank you. Good morning, guys. Congrats on the continued execution. Certainly a lot going on these days. We look forward to seeing the continued progress Question for you, coming out of Europe, we've discussed for some time now about the differences in the protocols between U.S. and European ED departments. And I think that's driving the difference in design of the RAISE-2 study over there, but also poses some challenge because of the placebo response, which you mentioned.
spk13: Can you help us a little bit in understanding what your expected efficacy rates would be for the two different regions, RAISE versus RAISE-2? Thank you.
spk11: Sure. Yeah, it's a bit complicated. I think the endpoints are different. As I mentioned, you know, in the EU, they tend not to use IV anesthesia nearly as much. It's the standard of practice, really, neurologists and ICUs by the time it gets to that stage of status. And so the second part of the endpoint is any escalation of care rather than escalation to IV anesthesia. That's one accommodation we've made to that. And actually, the endpoint itself is different. In the U.S., it's two co-primary endpoints. They each have to hit on their own. In the EU, it's a combined endpoint, responder analysis. So a given patient has to have an early response as well as a durable response. And I think that because they have to have the early response in particular, that the power of the study has actually increased because of that. And also I think escalation of care I think can actually obviously will show superiority there to standard of care alone. And so the overall magnitude of the effect is the same in the U.S. We're expecting to see a 30 percent delta between Ginexalone and placebo, but for different reasons. The parameters for that are different, and that's reflected in the sample size. Initially, we were going to do a combined study with the U.S., pool the data, But with this complementary rather than identical design, the study is being done on its own, but we can achieve the same power with a much smaller number of patients. The planned sample in Europe is 70 patients. And so, again, that's a reflection of the increased power with the responder endpoint. Very helpful. Appreciate it. Thanks, guys. No, thank you for the questions.
spk14: And your next question comes from the line of Andrew Hussar with Jefferies.
spk00: Hi, good morning, and thanks for all the progress. So my question is on CDD. Should we expect an adcom panel once you file? What do precedents suggest in rare epilepsies? And just wanted to confirm, you know, investors should assume a 12-month standard review once you submit. Thanks.
spk13: Thanks for the question, Andrew. I'm going to turn it over to Kim. We all heard typing in the background. We thought it was us. I guess it was Michael who was keeping us all a little bit on our toes. Thanks, Andrew. Kim, why don't you take the question?
spk05: Sure. Thanks, Scott. So the FDA will actually determine if there is a need for an adcom as part of any typical NDA planning. We are actually preparing for a potential adcom, and so we hear confirmations from the FDA whether or not we will or won't. So at this point in time, we are preparing as if we are going to have one until we hear otherwise from the agency. In regards to the filing duration, as this is an orphan and a rare disease, we will be requesting priority review as part of the NDA's commission. I am very confident that we'll be able to obtain that priority review for this very high medical need. Therefore, getting the reduced review time of the six months versus the typical standard 10-month filing. So we do anticipate when you consider the 60-day filability timeframe plus the six-month review that we're targeting to have approval by the end of first quarter of next year. Does that answer your question?
spk14: And your next question comes from the line of Jason Butler with JMP Securities.
spk12: Hi, thanks for taking the question and congrats on the progress. Just one on the formulation work you're doing. Can you just give us your kind of thoughts on target profile for the first formulation in terms of bioavailability and PK dynamics and how you're thinking about prioritizing the indications that you could move into with the different formulations? Thanks.
spk13: Thanks, Jason. Appreciate it. This is Scott. I'll take it. So we recognize the formulation program will be a multi-step approach. And I think it starts with the basics, that we understand the current bioavailability and the variability of the current formulation is significant. And so what we want to do as a first step is replicate TID dosing and really give patients, physicians, the ability to all obtain TID a therapeutic blood level, and potentially allow physicians to titrate that blood level. And so right now, our three programs, as we mentioned in prepared remarks, any three could go into the clinic next week, are all about better bioavailability, but really replicating that TID dosing paradigm. After that, we will work very aggressively on a drug delivery technology platform to stretch dosing from either TID to BID or even TID to QD. But I think more importantly, from a drug delivery standpoint, the formulation standpoint, we want to minimize Cmax and make sure we have stable Cmins. And I think we now know very clearly from Marigold that we don't want our Cmins to go below 75 nanograms per ml. And I think we can ultimately create a formulation which is better tolerated, gives physicians flexibility on dose titration, ultimately will be incrementally easier for patients and family members to administer to patients. But I think quite obviously the BID or QD formulation is much more importantly about having good control of C-max and C-min. So that's how we're thinking about it, and we're excited about the progress we've made to date. And we're going to try to move very quickly, but we also have a long-term vision for the franchise, which we're thinking about quite a bit. So with that, operator, we're going to make that the last question. It's coming upon 930. We want to thank everyone for dialing in. Certainly it was great to have you all. We know there was a lot in the press release to digest, so we'll be available for follow-up calls. And, you know, I just want to thank the team again. They've just done a great job of helping us out. move the ball forward. Thrilled to have the Oak Tree team on board and having Steve, Christy on this call with Joe, Kim, myself, Sasha, and we didn't even hear from Alex today. You know, I just am thrilled about where our team is today and us moving forward as an organization. So thanks, everyone, and we'll talk to you soon. Operator? And this concludes today's conference call.
spk14: Thank you for your participation. You may now disconnect.
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