Nyxoah SA

Good day and thank you for standing by. Welcome to the NICSOA First Quarter 2025 Earnings Conference Call. At this time all participants are in a listen-only mode. After the speaker's presentation, there will be a question and answer session. To ask a question during the session, you will need to press star 1-1 on your telephone. You will then hear an automated message advising your hand is raised. To withdraw your question, please press star 1-1 again. Please be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker today, Pearson Dennis, Investor Relations Associate. Please go ahead.

Thank you. Good morning everyone and I welcome you to our first quarter of 2025 earnings call. Participating from the company today will be Olivier Talman, Chief Executive Officer and John Landry, Chief Financial Officer. During the call, we will discuss our operating activities and review our first quarter 2025 financial results released before U.S. market opening today, after which we will host a question and answer session. The press release can be found on the Investor Relations section of our website. This call is being recorded and will be archived in the events section on the Investor Relations tab of our website. Before we begin, I'd like to remind you that any statements that relate to expectations or predictions of future events, market trends, results or performance are forward-looking statements. All forward-looking statements are based upon our current estimates and various assumptions. These forward-looking statements involve material risks and uncertainties that could cause actual results or events to materially differ from those anticipated or implied by these forward-looking statements. All forward-looking statements are based upon current available information and the company assumes no obligation to update these statements. Accordingly, you should not place undue reliance on these forward-looking statements. For a list and description of these risks and uncertainties associated with our business, please refer to the risk factors section of our Form 20-F filed with the Securities and Exchange Commission on March 20, 2025. With that, I will now turn the call over to Olivier.

Thank you, Pearson. Good day, everyone, and thank you for joining us for our first quarter 2025 earnings call. Before we start, I'd like to welcome Pearson Dennis, who recently joined us as our Investor Relations Associate. I'd like to focus today's discussion on our part to promote the full PMA approval in the United States. As we announced in March, the FDA issued an approvable letter for our GENIUS system, which confirms that our application substantially meets the requirements for marketing in the U.S. Importantly, the FDA accepted our biocompatibility testing, usability studies, clinical data demonstrating safety and effectiveness of the GENIUS system, just to highlight a few components of our submission. Following receipt of the approvable letter, the FDA will approve the application subject to satisfactory completion of manufacturing facilities, methods, and control reviews. In that context, the FDA requested a validation of one specific manufacturing process at the U.S. contract manufacturing site. I am submitted the required documentation to the FDA. FDA reviewed this validation already and has confirmed they have no further questions regarding it. As a final step, the FDA is now conducting an on-site inspection of the U.S. contract manufacturing facility, which we expect to be completed shortly. This site already successfully passed an FDA inspection as part of our PMA process with no deficiencies. We are confident in our ability to complete this final step in the process, and based on this timeline, we continue to expect to receive PMA approval in the second quarter of 2025. In preparation of our U.S. commercial launch, we have built a world-class team in support of our U.S. -to-market strategy. In addition, we have put in place industry-leading talents with a track record in neuromodulation and or obstructive sleep apnea, or OSA, across our sales, marketing, reimbursement, and medical affairs teams in the U.S. Our strategy for penetrating the U.S. market is focused on a two-pronged approach. First, as a smart follower, we will target high-volume hyperlossal nerve stimulation in planting centers where patients and physicians are actively seeking an alternative solution to current therapy. Market research confirms significant demand from patients who are hesitant about receiving a pacemaker platform technology, including an implanted battery, which currently requires a subsequent surgery to replace it. Research also indicates that physicians are eagerly awaiting a compelling alternative to further expand their treatment options. This is consistent with feedback from the 75 U.S. physicians that already have been trained on the genealogy technology, giving their participation in our clinical trials and usability studies, and became familiar with the unique features and patient outcomes. Second, we will develop strong networks with sleep physicians who manage large populations of moderate to severe OSA patients where hyperlossal nerve stimulation is not yet fully embedded as part of their treatment pathway. As a company that prioritizes clinical evidence and patient outcome over simplified marketing messages, we believe in setting realistic patient expectations and partnering with physicians to find the optimal treatment for each patient as part of our mission in pulling patients first. We are ready to launch in the U.S. with 50 commercial team members who are all hired and trained. This team is comprised of sales, marketing, market access professionals who will be supported by focused -to-consumer or DTC initiatives and dedicated reimbursement support. We plan to scale up U.S. commercial teams each quarter post FDA approval, -in-hand with the opening of new and planned accounts. Regarding reimbursement, we are working closely with the American Academy of Auto-Laryngeology and participating in the FDA's Early Pairs feedback program to educate CMS and major commercial pairs on the genealogy system and the clinical impact it can have on their OSA patient population. We have identified an established CPT code that we utilize at launch. The CPT code, to be very precise, is 64568. This CPT code has been recognized by commercial and government pairs for OSA indications and is the same CPT code used for the current FDA-approved AG&S technology. We expect that our pricing will be similar to our OSA patient. We are also working closely with the American Academy of Auto-Laryngeology and Academy of Auto-Laryngeology and marketing to develop a new approach to clinical research.

Thank you, Olivier. We recorded revenue of 1.1 million euro in the first quarter of 2025 compared to 1.2 million euro in the first quarter of 2024. The slight -over-year revenue decrease was primarily due to temporary softness in the international AG&S market. We also launched our Genio 2.1 patient software upgrade commercially via a phased approach which resulted in certain Genio sites deferring their purchase until the upgrade of patient software was available to them. We expect these factors will normalize in the upcoming quarters. Total operating loss for the first quarter of 2025 was 20.6 million euro versus 12.2 million euro in the first quarter of 2024, driven by investments in the U.S. commercial organization in preparation for FDA approval and subsequent commercial launch. Our cash position was 63 million euro at March 31, 2025 compared to 85.6 million euro at the end of 2024. With that, I'd now like to hand the call back to Olivier to discuss thoughts for the remainder of 2025. Olivier?

Thank you, John. What sets Nixo apart in the OSA treatment landscape is our patient's first approach and unique therapy which mitigate the limitation of implantable pacemaker technologies. We have designed the Genio system with patient comfort and convenience as priorities. No implanted battery, bilateral stimulation for consistent therapy regardless of patient sleep position, and the single incision procedure. All supported by strong clinical data demonstrating the safety and effectiveness. Importantly, we are the only company with clinical data in positional OSA and supine sleep time. The U.S. represents not just our largest market opportunity, but also a chance to meaningfully change the standard of care for millions struggling with moderate to severe OSA. With our commercial team in place, our reimbursement pathway established, we are positioned at the starting line of what we believe will be a significant growth trajectory once we have FDA approval. The enthusiasm we have seen from the clinical community during our trials reflect what we have known all along. Patients and physicians are looking for meaningful innovation in OSA treatment options. Our approach addresses specific limitations that have affected patient adoption and treatment outcomes with existing therapies. As we stand on the verge of FDA approval, we have never been more confident in XOAS future and our ability to deliver value to patients, physicians, and shareholders alike. With that, I would now like to open the line for questions and answers.

As a reminder to ask a question, please press star 1-1 on your telephone and wait for your name to be announced. To withdraw your question, please press star 1-1 again. Please stand by while we compile the Q&A roster. Our first question comes from the line of John Block from Stiefel.

Thanks guys, good morning. Olivia, can you talk about what needs to get done at this U.S. inspection versus the initial one that took place, you know, call it earlier in the FDA process?

Yes, hello John, thank you for the question. So to be very precise, we were informed by FDA to do a validation of a specific manufacturing process at the contract manufacturer in the U.S. You start by doing this administrative and also show protocols and how you validate certain processes that have been done, submitted, and accepted by FDA. So that part is off the table. As part of the regulatory process, a site visit to confirm that this validation is standard practice after the first step of the validation and that is ongoing as we speak.

Okay, I think I got that just one follow-up to my first question for clarification. When you say the physical site inspection is ongoing, you know, has that, again, it's a physical site inspection. So has that occurred? Have they been out to the site? Is there a date for the site inspection? I'm just trying to get as granular as possible while still being sort of respectful to process if you would.

Yes, so definitely. So the site inspection is actively taking place as we speak. Normal process of a site inspection is that it can last up to five days. We don't know. It's all in the hands of the inspector that is visiting or contract manufacturer. After this, he will finish his report. He will submit the report to FDA, to the PMA review committee, and then at that point, they can issue us an approval. And that's also why we stay confident that we will obtain the approval by the end of QoR 2.

Okay, very helpful. And then just for the second question, to shift gears, you know, as we think about the market launch and the commercialization, can you talk about the company's strategy, you know, to have sort of outreach to the ENT where I'm guessing, you know, if you get it on the label, the no contraindication on CCC might mean a lot versus the outreach to the sleep doc where, again, I'm hypothesizing, but the supine data might resonate a little bit more because obviously the sleep is the one with the ongoing management of that patient. So, you know, two very different variables when we think about differentiation on the label that's possible. Can you talk about the outreach on one versus the other and how the company will tackle that? Thank you.

Yes, okay. I will try because you're asking several questions at the same point. So let's talk with the clinical aspect. As I mentioned, I always genuinely designed to with the patient focus and centric in mind. So that is one aspect of this. And therefore, we are extremely proud that we were able to demonstrate this in robust clinical data showing the differentiation compared to what competition is offering today. Very concrete, we are the only company that can offer clinical data in showing effectiveness in supine sleep position and also helping patients that are suffering from positional OSA. That's one clear differentiation point when it comes to our patient centric focus. So that's one aspect. Now linking this to the label because that was the second part of your aspect. Of course, in our label submission to FDA, we are highlighting this. And I cannot jump to conclusions yet because we haven't seen the published label from FDA because that goes hand in hand with an approval. But it is clear that the discussions and the way we position the Medoc case was clearly well perceived by FDA. So yes, we do expect that FDA will also build this in our labeling. So as you know, we already have CCC on label in our international markets. We are seeing great results in the markets where we are commercially available on CCC patients. We are conducting a specific study in the US called ACCESS treating those CCC patients. And also here, we do think it will make sense that over time, we will add the CCC label in the US. And to start with, CCC would be reflected as a contraindication in the label that will be issued in going forward. But again, we will have to wait upon our approval to have the final confirmation of all this.

Understood. Thanks for the call, guys.

Thank you. One moment for our next question. Our next question comes from the line of Adam Meader from Piper Sandler.

Hi. Good morning, Olivier and John. Thank you for taking the questions. The first one for me, just on FDA approval process, great to hear you reiterate the Q2 FDA approval expectation and to hear that the final site inspection is ongoing. My question is, I'm wondering if there's any kind of statutory response time from FDA associated with this process? And really, I'm just trying to kind of better understand what's informing the confidence that the US approval is going to come either later this month or next, and then add a follow-up or two. Thanks.

Yeah, nice hearing you, Adam. So first of all, let me repeat the final steps. So there is currently an inspection that is taking place. Once the inspection is finished, then there will be a final report completed and submitted to the FDA PMA review committee. And at that point, FDA has all the information needed to also issue an approval. As I keep repeating about the previous timeline, before the end of Q2, we are feeling confident that we will obtain the FDA approval. I'm just highlighting again the steps that we are facing that we are going through as we speak.

Okay. Okay. Understood. You know, and then for the next question, I just wanted to see if there was an update around timing for the Dream Journal publication, just any visibility into when that could be published?

Definitely. So we submitted the publication to the Living Industry Journal. Also, here there is a clear review process. We have passed the first acceptance barrier that they like to refer to. So now we are in the second level of review. We got some questions already from the reviewers that we are answering and addressing. So if you add all these up, I do think that before summer starts, we should be able to have a publication out.

Okay. Fantastic. And just one more from me, if that's okay, and then I'll hop back into queue. For John, you know, just wanted to ask about the pace of OPEC spending going forward, you know, any qualitative or quantitative color that you're going to share as we think about the next couple of quarters as you guys get ready to launch this in the U.S. would be helpful. Thank you.

Sure. Yes, Adam, good to hear from you. From an FDA timeline perspective, obviously we've taken steps to defer costs and the investments until our FDA approval is achieved and received. So we've taken steps in terms of deferring commercial-related investments that naturally go hand in hand with revenue. And we also have a number of other levers we've pulled in the P&L to extend our cash runway as well into the second quarter of 2026.

Okay. John, any finer point around how we should think about R&D and SG&A going forward? I guess the genesis of the question was it came in a little bit more heavy-handed than we were modeling. So just trying to kind of wondering if you can kind of orient us into a zip code for spend going forward. Thanks.

Sure. Absolutely. From an R&D perspective, I'd expect, you know, the full year to be probably in line with where we were from a 2024 perspective. And then from a sales and marketing perspective, SG&A perspective overall, I would expect that to be, a little bit more than double what we had incurred in 2024. And then when you look at it for the full year, we'll be, from a timing perspective, you know, the first couple quarters are probably going to be a little bit heavier than the back quarters of the year.

That's really good, Tyler. Appreciate it. Thank you. You're welcome,

Adam. Thank you. One moment for our next question. Our next question comes from the line of Ross Osborne from Cantor Fitzgerald.

Hey guys, thanks for taking our questions. Starting off, we'd be curious to hear how the commercial launch of Neo in Dubai is progressing and how you're thinking about the allocation of resources given Middle East is obviously a large and underserved market, but focus is likely on the US in the near term.

Yeah. So thank you, Ross, for the question. So yes, it's great that with Genio, we are the first AG&S company that is implanted in the Middle East. Dubai was the first hospital. In Dubai, we had the first hospital where we had two successful implants to start with. We are opening a second hospital in Dubai, and then we are also looking at Kuwait and Saudi Arabia to go further. Yes, I do think great milestones entering the Middle East and offering also there, AG&S is a solution for the patients. First implants taking place, training and education put in place, and we are educating some very specific sites spread over the Middle East where we will be first implanting in quarter two, quarter three, and then beyond.

Great. And then apologies if I miss this. Any update on the access study in terms of where we can get the implants?

No, absolutely no problem. But on access, as communicated, we keep making great progress in enrolling patients. So we were always talking about stopping the enrollment by summer, so that timeline hasn't changed. And once we have this, the next step will be 12-month data. Once we have those data, submit it as a PMA supplement, and then negotiating further or discussing further with FDA on how this can expand or label in the future. So we are always looking at adding CCC patients.

Great. Thanks for taking our questions.

Thank you. One moment for our next question. Our next question comes from the line of Suraj Khalia from Oppenheimer and Company.

Good morning, Olivier. John? Hey, Olivier. So thank you for providing a lot of details. You've consistently said that the initial target for GENIO would be 75 physicians have been trained, the 300 or so top HGNS sites. My specific question, Olivier, is as we understand it, there are like 10 or so units, HGNS units, already on the shelves for these top sites. How do you envision, would you all also, I shouldn't say mandate, but require some of the sites to have a certain minimum unit upfront purchases? How are you going to, do you think existing inventory would be an issue as you roll out into existing sites, the top sites?

Yeah, most of us, nice hearing you, and thank you all for the commercial question, if I can refer to this like this. So first of all, I would like to highlight that over 100,000 patients have received HGNS treatment. And why do I want to start with this in the US? It's just indicating that when you look at high volume sites, that 10 implants are having an inventory of 10 products, it will be easily absorbed in a couple of weeks. So I don't see an issue of having current inventory of competition because that's the only company out there who would be an hindering factor also in launching HGNS going forward. So that's the first answer. The second answer to the question is that when working with the 75 surgeons and also with the hospitals, it's also clear that we will have to make sure that we part the fact committees, that when passing this, we also start planning all our time and also scheduling real-time patients. And once we are doing this, we will make sure that we have products available at the hospital to treat those patients. But it will not be a strategy where we are loading shelves even before we identify patients. I think the healthiest best to start is also you identify patients, you have your audit and you make sure you have your products available, including some backups in case there would be a need for more than one product. Got it. I apologize for the background.

So Olivier, if I could send a couple of two-part questions your way quickly. So the regions where your sales force has been hired, how would you, any additional color you can give us there? And the second question, the second part of the question, Olivier, as you're rolling out Genio commercially, what do you expect to do in terms of DTC? How are you expecting to be different than Inspire? Thank you for taking my questions.

Yes, definitely. So Suraj, we have been planning very carefully and studying the US market. It starts with heat maps. They are called like where are the high volume sites. We have access to this. Based on this, we also combined with the Suraj that already are experienced with our product and we did some further market research. So we mapped out to the entire AG&S market in the US using heat mapping and then we start building and hiring our sales force accordingly. So that's the answer to the first part of the question. The second one on DTC, how are we different? We are different that we will not have super low commercials. I'm trying to say something maybe a little bit funny, but we will not have this huge DTC outreach as known today by AG&S competitor. We will work very focused. We will work around sleep sites where they can also through DTC specifically address and provide patients access to know what would be the best technology available to treat their OSA. Once we have identified these patients and those patients came forward with them, of course, we will further invest in a very focused manner to drive these patients to the EMT solution where then they can further discuss and end up with a genuine.

Got

it.

Thank you.

Thank you. One moment for our next question. Our next question comes from the line of David Ray Scott from Baird.

Oh, great. Thanks for taking the questions. Olivia, I wanted to ask on Genio 2.1. I think you called out that in Europe with the rollout there of the software update, there was some delays in its plans. So when you think about, I guess the first part of the question is going to be curious on Genio 2.2 or kind of just future software upgrades as you come to the US, but when you think about the rollout in the US and the potential for there to be future maybe updates here, I guess, how do you smooth out that kind of transition and so that you don't have delays or patient warehousing at all on the implants when new system updates are ultimately rolled out in the next few years?

Thank you for this question, David. It's a very important one. I will start and John will definitely step in on the second part of this question of rollout and how do we further scale up. But as I mentioned in the beginning, it is so important for Nixola to offer patient-centric solutions. And the Genio 2.1 software upgrade is a clear example in how our therapy is different compared to a pacemaker platform technology. Now, concrete, the software upgrade provides the opportunity for a patient to gradually increase stimulation, which will result in an improvement of patient comfort. So it gives the patient the comfort and it gives the physician the option to gradually ramp up stimulation, enabling him also to treat patients that might be sensitive previously when treated with stimulation that now all of a sudden become eligible. So that is one aspect of the upgrade. The second one is also providing the patient with autonomy to increase or decrease stimulation settings within predefined boundaries set by the physician. Now, once you start providing a patient with that autonomy, it also increases the compliance of technology. Patients feel they are in control and they can find their optimal comfort. So combining those two upgrades in one software upgrade is really contributing to our mission in having a patient-centered solution. Now, how do you roll this out? I will hand it over to John because I know he's working very closely with our manufacturing team on this and maybe you can provide some more color, John. Excellent. Thank you, Olivier.

Yes, so to your point, David, we had a few orders that we didn't ship out this past quarter because we wanted the customers and the customers wanted to have the upgraded activation chips for their customers. Had we shipped those, we would have seen low double-digit growth in the first quarter of 2025 versus first quarter of 2024. What we're looking to do in the US, we'll have our Genio 2.1 available for all these customers. So as we enter the market, we won't have a switch from the Genio 2.0 to the 2.1. So we'll be ready to roll from that perspective as we enter into the US market.

Okay, thanks. And then on the reimbursement front, you've been consistent on the code you're going to go after. I'm curious what you're doing maybe on the back end to ensure that when the rollout happens that you definitively will be able to map to that or use that code. And if the case implants are maybe a little bit tougher than you anticipate, do you expect to have a built-out back end reimbursement team to really help streamline pushing these patients through and getting coverage when you also rollout in the US? Thank you.

Yeah, thanks for the question, David. Yeah, so short answer. We have a team, a market access team that's dedicated to helping us work through that process. They have a lot of experience, specifically in the neuromodulation space. So as we work through the rollout, we have very specific materials that we're utilizing to help our sales force and then our market access teams navigate and work through the pre-authorization process for these particular patients as they make their way into the facility. So again, we have a strong team in place that's growing and will be well prepared to help with that process as we enter new accounts in the US.

And maybe I just to elaborate on this one, it's always nice to be second, meaning that there was a lot of heavy lifting done by competition. There is a quote, the 64568, that is a well established and recognized code by payers, both government and commercial payers, for the specific OEC indication where we also are positioned so yes, we do feel confident that this barrier or this order is also successfully taken and will result in a quick revenue generation. Thank you.

Thank you. One moment for our next question. Our next question comes from the line of Michael Pollard from Wolf Research.

Hey, good morning. I want to follow up on the CCC discussion and make sure I hear this clearly. It sounds like this initial FDA approval will not, it sounds like it will have the CCC contraindication and the FDA is not willing to not have that with your prelim access data and so we need to follow access through to completion to remove the contraindication. Is that, am I hearing the message correct? Is that the

Let me be very precise on this, Mark. So you know that there is off-label, there is on-label, but there are also steps in between and you, to be very, very precise. We don't expect to have the CCC as on-label for the simple reason that in the DREAM study we did not implanted CCC patients. So that's, I think, I hope this is very clear. Second thing is when we look at the CCC worry that is ongoing in the US in access, but also the previous CCC worry and experience that we are having, there is no indication that GINU is not working for CCC patients and therefore there is also not one reason that would point in the direction that CCC should be a contraindication. So what we do expect is, we expect that in our label we do not have it on-label, but we also expect that we will not have it as a contraindication, but simply as an off-label indication that is up to the physician's decision whether they would offer this to their patients, yes or no. I hope this is answering your question. Thank you.

And so related, as you launch this, will you be an advocate for the DICE procedure ahead of a GINU implant? How are you thinking about that given this labeling expectation for CCC?

First of all, it's clear that we will never promote anything that is not on-label or that is off-label and we will never do this. And if you then take it to the next board, how can a physician be certain that a patient is not having CCC? Yes, they will have to do the DICE. That is currently still the most traditional and accepted measurement to exclude CCC. I also know and we also know that there is some work being done by others, also in, for example, measuring the pharyngeal width. The moment that that would become accepted by payers to exclude CCC patients, it's clear that we will also adapt to this. But with our current data of DREAM, it is also obvious that we will have to exclude CCC and that we will not actively promote this when launching the product.

Thank you, L'Orier. Thank

you, Mike.

Thank you. One moment for our next question. Our final question comes from the line of Laura Rova from DGroove Petercam.

Thank you for taking my question. First of all, I would like to come back on a previous question because you mentioned, John, other levers to extend the cash rendering to Q2. So could you elaborate on this? And then a second one on the temporary softness in the AGMS market. Could you provide also a bit more information on this and also your expectations going forward? Thank you.

Sure. So I'll start with the last piece, the temporary softness in the market. We also saw our competitor in the first quarter also posted a big single digits decline in the international market. We saw some softness there, seasonality. We expect it to be temporary in nature and to recover over the course of the year. With regard to some of the other discretionary spending, when we build our P&L, we obviously have a number of fixed expenses, but we also have variable expenses. When we look at the variable expenses, they're discretionary in nature, whether they're projects or other commercial related items related to launch specifically. We've elected to defer to be more in line, obviously, with the FDA approval timeline, as well as to extend some of the other projects that are ongoing that are not essential to either FDA approval status or immediate launch. We'll be deferring those to a later date to extend that cash runway. So those are some of the nature of the items that we're deferring to extend the runway out.

Okay. Thank you.

Thank you. At this time, I would now like to turn the conference back over to Olivier Talman, Chief Executive Officer for closing remarks.

So first of all, I would like to thank everyone for attending the call. And as we stand on the verge of FDA approval, we have never been more confident in NixoA's future and our ability to deliver value to the patient's positions and also share over. So thank you again for your time today and your continued support of NixoA. And we are really looking forward to updating your progress in the coming weeks slash months on FDA to be very precise. Thank you all for joining.

This concludes today's conference call. Thank you for participating. You may now disconnect.