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spk09: Ladies and gentlemen, thank you for standing by and welcome to the fourth quarter 2021 financial results and corporate update 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 this session, you only press star one on your telephone. Please be advised that today's conference is being recorded. If you require any further assistance, please press star then zero. I would now like to hand the conference over to your host today, Joshua Higa. Sir, please go ahead.
spk16: Good afternoon, and welcome to the Ultragenyx Pharmaceutical Financial Results and Corporate Update Conference Call for the fourth quarter and full year 2021. We have issued a press release detailing our financial results, which you can find on our website at ultragenyx.com. I am Joshua Higa, Senior Director of Investor Relations. Joining me on this call are Emil Kakas, Chief Executive Officer and President, Camille Bedrosian, Chief Medical Officer, Eric Harris, Chief Commercial Officer, and Marty Deer, Chief Financial Officer. I would like to remind investors that this call will include forward-looking statements within the meaning of the safe harbor provisions of the Private Securities Litigation Reform Act of 1995, including but not limited to the types of statements identified as forward-looking in our annual, quarterly, and periodic reports filed with the SEC, which are all available in the investor section on our website. These forward-looking statements represent our views only as of the time of this call. It involves substantial risks and uncertainties, including many that are beyond our control. Please note that actual results could differ materially from those projected in any forward-looking statement. For a further description of the risks and uncertainties that could cause actual results to differ materially from those expressed in the forward-looking statements, as well as risks related to our business, see our periodic reports filed with the SEC. I'll now turn the call over to Emil.
spk19: Thanks, Josh, and good afternoon, everyone. We've had an exciting start to the year. We concluded a strategic rare disease deal with Regeneron to license global commercial rights outside of the U.S. for both EFKISA and the potential for a second rare disease therapy, Coridizumab. We also released with our partner, Genetics, a clinical update on the ANHRN program showing positive clinical activity and no lower extremity weakness events observed. We finished 2021 in a strong financial position, exceeding expectations of the performance of our commercial products. And finally, we've made good progress with our broad late-stage pipeline, where we've initiated enrollment in three of four pivotal programs that will be ongoing this year. Along the way, and despite the challenges presented by the COVID pandemic, we also successfully completed manufacturing technology transfer to our partner, Daiichi Senkyo. I'll let Eric, Marty, and Camille provide more details on these accomplishments later on this call. I do want to spend a few minutes to discuss the deal with Regeneron on the commercialization of Evkisa for the treatment of homozygous familial hypercholesterolemia, or HOFH, outside of the U.S. The deal also includes our exclusive right to negotiate a separate ex-U.S. agreement for their investigational antibody for fibrodysplasia ossificans progressiva, or FOP. This deal establishes a strategic partnership with a leader in high-quality antibody drug discovery and development. It also enables us to both scale and leverage our global commercial capabilities in commercial medical affairs and regulatory functions. Efkisa is a potent approved product with a novel treatment mechanism that strengthens our portfolio with another commercial stage, traditional biologic that targets the underlying cause of HOFH. This disease occurs when two copies of the familial hypercholesterolemia-causing genes are inherited, one from each parent, resulting in very low or absent LDL receptors on the liver and lead to dangerously high levels of LDL-C. Patients with HFH are at risk for premature atherosclerotic disease and severe cardiac events. Despite all the studies and all the work that's been done in this disease over many years, True homozygous null patients still don't have a great treatment approved, and aparesis to remove lipid from the blood every single week is very difficult to tolerate and very cumbersome. FKESA targets and binds to ANG-PTL3, which is a protein that plays a broad role in cholesterol regulation and atherosclerosis. In patients whose LDL receptors are not present, to direct appropriate liver uptake, EFKES instead enables an alternative pathway by which VLDL are converted into VLDL remnants that are rapidly cleared by the liver through an alternative set of receptors. Taking advantage of this novel mechanism significantly reduces the level of LDL cholesterol in these severe patients despite the lack of working LDL receptors. The clinical value of blocking angPTL3 is supported by data showing that that natural genetic mutations also protect patients from atherosclerotic disease, and treating LDL receptor-deficient mice with an angPTL3 blocker does reduce atherosclerosis. In Regeneron's pivotal clinical program for epikesis, the drug demonstrated significant improvement over standard of care with consistent 49% reduction in LDL-C in a 24-week study in 65 patients with HOFH on top of all existing LDL-lowering treatments. The study also showed that treatment reduced the LDL-C by 72 percent in the most severe patients with less than 2 percent of LDL receptor activity, and that triglycerides were also reduced by 50 percent across study participants. FKESOS also has a good safety profile and has been well-tolerated across all study populations. Evkisa is approved by the FDA and EMA for patients 12 and older. Regeneron is currently marking the treatment as Evkisa in the U.S., and we will lead its launch and commercialization all around other countries and regions, including Europe, Latin America, and Asia. We may also expand our collaboration with Adreneron to include another antibody in Phase II-III development called FOP. That license will include the same commercial rice, excluding the U.S., FOP is an ultra-rare, devastating genetic ectopic bone disease that affects approximately 1,400 patients in these territories. In patients with FOP, abnormal bone formation occurs in soft tissue like muscles, leading to freezing of movement and difficulties in eating, walking, and breathing, and leads to premature death by patients in their 50s. I met my first patient with FOP while training in Los Angeles, and recently presented a keynote at the IFOPA meeting, so I'm familiar with this oral disease. Seeing patients frozen in terrible positions waiting for someone to save them or to freeze completely is not a sight you readily forget. I'll now hand the call over to Eric, who will talk about the commercial team's performance last year and what his teaming is doing to launch FKESA.
spk06: Thank you, Emil, and good afternoon, everyone. I'll start my section discussing the commercialization team's performance in 2021, despite the impact of the Omicron variant. For Chris Vita, within the North American territory, we continue to see steady underlying demand from both the pediatric and adult markets. In the fourth quarter, we added over 50 unique prescribers in the US alone. The split of pediatric and adult patients remains approximately 50-50. while the total number of patients on therapy continues to increase. We expect this split will continue shifting towards a greater portion of adults on CRISPR as the teams are increasingly finding doctors who have adult patients with XLH or TIO in the community setting. The compliance rates remain high. In fact, four years into this launch, we continue to hear stories from patients about how much better they feel once they begin receiving therapy. Outside of North America, demand for Chris Feeder continues to gain momentum. In 2021, product revenue grew 107% to $21.4 million. While there might be variability in the ordering patterns that cause some quarter-to-quarter fluctuations in revenue, it's clear there is strong underlying demand for Chris Feeder. This is a direct result of all the work the teams have been doing to educate providers, find patients, and work with regulatory and reimbursement authorities. For 2022, we expect presbyter revenue in ultragenics territories to be between $250 and $260 million. The midpoint of this range represents 32% year-over-year growth, an impressive metric four years into a rare disease launch. Turning now to De Jovi and starting with the U.S. launch metrics. In the fourth quarter 2021, we added approximately 40 start forms, bringing the total since launch to approximately 350 start forms. As of the end of the fourth quarter, this has led to approximately 280 patients on reimbursed therapy. Approximately 160 unique healthcare providers have written a prescription for De Jovi with many of them writing prescriptions for multiple patients outside of the U S use of the Joby continues through our name patient and early access programs in Europe. The Joby growth is driven by significant increases in name patient requests in France and Italy. We are continuing to work with regional authorities as we look to expand access for all patients who could benefit from the Joby late last year, the Brazilian National Health Surveillance Agency, approved DiGiovi for the treatment of both pediatric and adult patients with LCFAOD. The final step is to get full reimbursement approval from Brazil's Ministry of Finance, a process we have begun working through for the last few months. I should note, this will be the last quarter that we provide specific launch metrics for DiGiovi. We believe The 2022 guidance range of $55 to $65 million is a better representation of the confidence we have and our ability to continue finding patients and getting them on reimbursed therapy. Now, shifting gears to the opportunity we have with Epikiza, which is approved for the treatment of HOFH, an inborn error of metabolism like most of our portfolio. These patients are typically seen by cardiovascular and lipid specialists. HOFH is also a fairly well-developed market with established diagnosis protocols, knowledgeable physicians, and a relatively high estimated rate of identified patients. Across the Ultragenyx territories, we estimate there to be between 3,000 and 5,000 patients with HOFH. This program will help further establish us as a truly global commercial organization. Initially, commercialization efforts will focus on Europe, where we estimate there to be approximately 1,600 patients. As we modestly build on the current infrastructure that is supporting Mepsevi and DiGiovi, we will also work to submit dossiers and begin reimbursement discussions. This team will also be in place to respond to requests for named patient access, which could begin in 2022, given the strong interest we have seen from the KOL community. In Latin America and Canada, our commercial and medical affairs infrastructure is already well established and ready to add FKESA to their portfolios. We have in place today the field teams and patient and prescriber support services needed to successfully launch FKESA with very little build-out required. The addition of FKESA to our portfolio also sets the stage for our long-term commercial efforts as we expand into the APAC region. This is a new geography for Ultragenyx, where we recently established a Japanese entity and have hired a general manager. While FKESA will help Ultragenyx to advance along its mission of being a truly global rare disease company, we should note that each of these regions are unique and have complex pricing and reimbursement processes. We have begun these efforts, but as you all know, it can take some time to work through these processes and see revenue from our new therapy. Key opinion leader feedback on the program is very supportive. and the strong clinical data speak for themselves as a significant leap forward for patients with HOFH. My colleagues and I look forward to offering FKESA as a new and compelling treatment option for patients. In closing, I would like to reiterate just how proud I am of the team's efforts in 2021, and as I look forward to 2022, we will continue to build on that momentum. With that, I'll turn the call over to Marty to share the financial results.
spk14: Great. Thanks, Eric. We issued a press release earlier today that included a financial update, which I'll briefly summarize. Company revenue for the 12 months ended December 31st, 2021, totaled $350.4 million. CRISPEDA revenue in Ultragenyx territories grew to $192.6 million, including $171.2 million from the North America profit share territory and net product sales of 21.4 million in other regions. Total royalty revenue related to the sales of CRISPEDA in the European territory was 18.2 million. DeJolvi revenue for the year was 39.6 million. As Eric mentioned, the ongoing strength of the launch is reflected in our 2022 guidance for DeJolvi, which represents approximately 50% growth at the midpoint of the guidance range. Net SEVI for 2021 was $16 million. As we have previously stated, we expect these revenues may modestly increase over time. 2021 revenues also included $85 million related to the tech transfer as part of our strategic manufacturing partnership with IG Sankeo around our PCL and HEC 293 gene therapy technologies. In the fourth quarter, 2021, the technology transfer activities were substantially completed, And total revenue recognized under this license agreement through December 31st, 2021 is $174.2 million. Our total operating expenses for the year were $733.1 million, which includes research and development expenses of $497.2 million, SG&A expenses of $220 million, and cost of sales of $16 million. I should note this also includes a one-time expense of $50 million related to the upfront payment for the Moreo license and collaboration agreement regarding citrusimab for OI. We continue to expect our R&D spend to somewhat increase in 2022 as we support three pivotal gene therapy clinical studies, the UX143 Phase 2-3 clinical study in OI, the Angelman Phase 1-2 study, and the Phase 1-2 study for our most advanced mRNA program, UX053 in GSD3, and a number of other preclinical activities as we get ready to advance the next programs into the clinic. We also expect SG&A to modestly increase in 2022 as we continue to support the expansion and launches of our existing commercial products and the launch of Epikiza. For the year ended December 31st, 2021, net loss was $454 million or $6.70 per share. The net loss includes a $42.1 million decrease in the fair value of equity investments. Net cash used in operations for the 12 months ended December 31st, 2021 was $338.7 million compared to $132.2 million for the same period in 2020. Net cash used in the 12-month period ended December 31st, 2021, included the $50 million upfront payment for the closing of the Murillo agreement. This compared to the net cash used in the same period of 2020 that included approximately $155 million of operating cash received from Daiichi Senkyo related to the collaboration and license agreement. We ended the year with approximately $1 billion in cash, cash equivalents, and marketable securities. This puts us in a strong position to achieve critical milestones and expand our commercial presence over the next few years. Now I'll turn the call over to Camille to touch on some of our clinical programs.
spk12: Thank you, Marty, and I too wish everyone a good afternoon. In my section, I will briefly provide status updates on our six clinical stage programs before turning back the call to Emil. Starting with the three gene therapy programs, DTX401 for the treatment of glycogen storage disease type 1A or GSD1A is currently dosing patients in the randomized placebo-controlled phase 3 study. DTX301 for the treatment of ornithine transcarbamylase or OTC deficiency is in the final stages of study startup. We anticipate the first patients will enter the four to eight-week baseline screening period in the first half of 2022. after which they will be dosed in the Phase III randomized placebo-controlled study. UX701 for the treatment of Wilson disease is currently enrolling patients in a seamless Phase I-II-III randomized placebo-controlled study. Outside of gene therapy, UX143 or citruzumab, an anti-scorostin antibody, will begin enrollment in the first half of 2022 in the seamless Phase II-III study for pediatric and young adult patients with osteogenesis imperfecta. GTX102, the ASO in development with our collaborator genetics for patients with Angelman syndrome, continues to enroll and dose patients under the amended Phase 1-2 protocols in the UK, Canada, and the US, with no reported lower extremity weakness. Cohorts 4 and 5 in the UK and Canada, following DSMB support, have expanded, adding in additional A patients to this protocol. The initial assessments have shown early signs of clinical activity. We look forward to providing an update on this program in mid-2022. UX053, our first mRNA for the treatment of glycogen storage disease type 3, is currently dosing patients in the single ascending dose arm of the Phase I-II study. Preliminary data from that arm, as well as initiation of the repeat dosing phase of the study, are anticipated in the second half of this year. With this update, I will now turn back the call to Emil. Thank you.
spk19: Thank you, Camille. Before we close out, I'll provide a quick reminder of the key upcoming milestones for the company. For GTX 1 and 2 in Angman, we'll provide an update in mid-2022 on cohorts 4 and 5 in the Canada and UK arm of the study, as well as available safety and efficacy data from the patients treated in the U.S. For our gene therapy pipeline, we'll continue enrolling the three late-stage clinical programs, and we'll look to provide longer-term durability data from the Phase I-II studies for GSD1A and OTC at major conferences. For UX143 and osteogenesis imperfecta, we'll begin dosing in the pivotal Phase II-III study in pediatrics in the first half of the year. In the second half of the year, we expect to provide an update on the dose strategy we have selected for the Phase III portion and initiate a supportive study in children under five years old. For US 053, in the second half of the year, we expect to share single dose data from the first part of the Phase I-II study and to initiate the repeat dosing stage. In 2021, we made meaningful steps in building a strong financial position, bolstering our commercial portfolio, advancing our clinical programs, and completing the tech transfer of our gene therapy manufacturing technology ahead of schedule. In 2022, we look forward to building on this and sharing updates with you. With that, let's move on to your questions. Operator, please provide the Q&A instructions.
spk09: Thank you. If you have a question at this time, please press star, then 1 on your touchtone telephone. If your question has been answered or you wish to remove yourself from the queue, please press the pound key. We ask that you please limit yourself to one question or one follow-up. Our first question comes from the line of with Citigroup. Your line is open. Please go ahead.
spk02: Great, thank you very much for taking the question. I just had a question with respect to your planning for the pivotal trial for Angelman's. Presumably, you're going to do a randomized placebo-controlled trial, and so my question is, assuming you see a mean CGIIS increase in line with the two and a half that you've observed so far in the phase one, two, how are you thinking about the separation from placebo, given the natural history on Angelman's, where clinicians have actually observed slow gains in function over time. For instance, there's a 2020 publication in the Journal of Autism and Developmental Disorders that makes this point quite nicely. Thank you.
spk19: Thank you, Egal. I think one thing about ANGEMEN is though there may be some small gains over time, the gains are pretty modest compared to the kind of change observed in the trial. So I have no question if we can achieve the efficacy we've seen before in our Phase III that we'll be able to distinguish that from placebo. I'm really no concern at all. The CGI as a tool is one approach to measuring the disease, but it is a more subjective approach depending on the opinion of the investigator. We also are certainly going to use underlying instruments that we used before, such as Bayley's and others, that are specific measures of particular function, which we will be studying in our Phase II study currently with genetics, which will allow us to understand the magnitude effect and understand the separation. And I have no doubt, given the effect we've seen before, that we can design a study that will have appropriate endpoints and capture what was, in our view, a very profound effect on development in this disease. Right now, we need to optimize our dosing, which we're working on, and we'll figure out the magnitude of these effects and come up with a design for the study. But whether it's CGI dependent or whether it's based on Other endpoints, I would say we still have some time to figure that out. But I think your question or concern raised, and we certainly will look carefully at assuring we're powering and observing a change that's meaningful.
spk02: Okay, thank you. That's super helpful. And then just to follow up on another topic regarding the Regeneron deal, obviously this was very interesting. As you usually see, the smaller company licensed to the larger firm to commercialize an asset, but obviously the reverse happened here. So the question is, could we see more transactions following what happened with Avkeza, or was this more of a one-off situation that presented itself with Regeneron? Thanks.
spk19: Yes, well, I think we just are a big company in how we act and behave, so that's what's going on here. No, but Regeneron is a great company, but they haven't built a global commercial capability, especially in the rare space. They were appreciative of what we had, and and felt the best thing for their product, and they really cared about these patients and wanted them to get good care, and they said, we want you guys to handle this product because they have confidence in our ability to take care of business and do it well. So if there's anything, it's our reputation for taking care of people correctly that draws us together. It is a two-product deal. Look, we're pretty full of busy and pipeline right now, so right now we're not expecting to do many deals on other commercial deals, but in our view, we want to be selective. We want to pick products that we want to work on that we're proud of, that we think really change care and are important in order to get us to take our precious people's time and put them on an effort. And the Kesa, we think, will be a change in standard of care. And we think Gorizumab has the potential to be life-changing for FOP. So we're excited about both of those. And right now, we'll stick to just keeping those going, and we won't think about what else could be. We'll wait and see if it comes.
spk07: Okay. Appreciate it. Thank you.
spk09: Thank you. And our next question comes from the line of Gina Wang with Barclays. Your line is open. Please go ahead.
spk15: Thank you for taking my questions. I also have one question regarding Enderman. So, Emil, in the early January update, you said the sign of improvement in terms of CGI score. So did you continue to see that trend? If you can be a little bit more quantified regarding the score improvement. In the past you mentioned like two score improvement in two out of five domains. Did that meet that criteria? And then second part is mid this year, can you lay out specifically what kind of data are we expecting to see from the 12 patients, like, for example, the first two patients from each cohort, the loading dose, after initial loading dose, what additional data we could see, and also for the remaining eight patients, what we could see. And will you have a definitive answer by mid-this year that you will know which dose to move forward for a pivotal study?
spk19: Very good. So, thank you, Gina. For Angelman, what we said was, and we'll just reiterate, is that we had improvements in clinical activity. That is, their CGI scores for the domains were improving. But in the lower-dose cohort, we had said that they hadn't achieved plus two in more than two domains. Therefore, the patients escalated to the next dose level. In cohort five, the older patients, that DMC has met and also allowed the expansion to the cohort five, the additional four patients in that cohort. And those patients also escalated That is, they were seeing improvements, but not two domains, two plus. So we're at the beginning of the titration. We wanted to get in the clinic, get started. We're seeing activity. We're not seeing any lower extremity issues right now. So we're encouraged. They'll continue to dose and titrate as we move forward with those 12 patients. So that's kind of where we're at. We haven't put out specific scores, but we said if they had two domains of two plus, they wouldn't titrate further. That would be considered getting to the level of efficacy we saw before. So we're encouraged, but we're continuing to move forward with dosing and titration. Now, what kind of data will we see? We're talking about mid-year. That data would be, expectation would be that we would see data from the first cohort four and cohort five that had gotten their doses and evaluated at day 128, which includes now a whole series of endpoints, not just CGI's and domains, but it would include the Bailey's expressive and language scores, violence scores, sleep evaluations, and as well as the behavior evaluation. So we would have a number of endpoints that would be supporting. Those endpoints would come from both patients or families, the investigator, or a psychologist. So there's three different types of evaluators. So we think we can look at the synchrony between different evaluators and how they're looking at these with different endpoints. We hope this will be a robust assessment of how the drug's doing. So with regard to where we are, the point of this program is to kind of get dosing and titrate dose until we see sufficient efficacy that we would separate from placebo in a trial and be a substantial clinical benefit to patients. And we'll see at that point, we look at that data, if we've achieved that level If we are close to it or at that level, we expect that we would expand the cohort and actually add more patients beginning at the new dose level that we had established and move forward. Now, you asked how are we going to know when we got to the dose. I'm guessing by mid-year we'll have a sense for the dose, but it could be that the expansion cohort will help identify or verify that higher level. The idea is to try to tune up the efficacy and manage within what we consider a safe dosing range. That would allow us to see results later in the year regarding that dose. And it could be that we deal with a young dose and an older dose, or it could be something else we do. But the idea is we're going to learn about how to dose and get an idea of what the optimal dose range is. But we're really encouraged so far that we're not seeing anything at all with the risk of a lower extremity event. And so we're encouraged we're seeing activity, and we think we just need to work deeper in the therapeutic range as we move forward. So we're excited about potential with Angelman.
spk15: Great. Thank you very much.
spk09: Thank you. And our next question comes from the line of Tazeen Ahmed with Bank of America. Your line is open. Please go ahead.
spk13: Hey, guys. Thank you for taking my questions. Just one point of clarification for Angelman's, Emil. Can you just remind us about whether or not you will be able to re-dose those original five patients that you had on drugs. You know, if you don't know yet, is that going to be part of the discussion with the agency? You know, what would you need if it's not been decided yet to get them comfortable with re-dosing? And then secondly, for Ephesa, can you talk about where, you know, in a little bit more detail, the synergies are between the products that you currently market? and what you would need to build out to market HOFH. Thanks.
spk19: Very good. Thanks, Tazeen. So for Angelman, we're obviously very interested in redosing those original five. So are those families, because they had seen so much, and to have that pulled away has, of course, been tough for them. And so they're anxiously waiting. Our belief is we need two things in order to go back to the agency. We want to collect data from the XUS program that's ongoing right now to help look at the dose and administration method, to help verify it, and just to show that we can dose safely. The second thing is we are doing some evaluations on immunological response and other things, which will show that there is no immunological issues at all, which I think was part of the original concern on redosing. With those two elements in hand, we'd expect to go to the agencies in this year, middle of this year, and would seek a plan to redose those patients and get them back on treatment. And we'd hope with that also to eventually get essentially the world program, the U.S.-ex-U.S. programs aligned in terms of dosing and administration. So we think we want to have some of the data from these next set of patients as well as this additional evaluation of those fives in order to get to the next step on redosing. So on Evkisa, rare disease launches have some very common elements. certainly a detailed medical kind of knowledge-based thing, but there is the reimbursement and country management piece, which is very common. And rare disease products like this always, in Europe particularly, have key centers that are the key opinion leaders, run centers, or centers of excellence are defined by the government. And therefore, it really is a very easy orphan model to go out and, with a small number of field people, manage a limited number of centers. We're very comfortable that the basic inner workings of supply, medical affairs, as well as reimbursement are things that we can use, and we'll have a very limited number of growth in people that would go to those centers. The thing that will also happen is that KISA will enable us to go to more countries in Europe, which will expand our footprint a bit, which will allow us to gain revenue from more countries than we currently are. And so I think that's where the we will actually gain benefit from FKESA, which will set us up for the rest of the other programs we have with the work we will do. So we're comfortable that we can leverage. There will be some growth, but we think we'll get a lot of benefit from the team we have who can move on to working FKESA. Remember, FKESA and HOFH, it's still a lipid metabolism disorder. And while there may be sometimes different doctors involved, it is fundamentally a genetic metabolism disorder, and our team's well capable of doing it. The other thing I'll point out is because it's such a common, really well-known disease area, it's not as hard as some rare disease areas, right? Everyone knows about LDL. Everyone knows about diagnosis of this disease. It's not like a mysterious disease, which might be more challenging. Here, the patients are known. They already go to places. The challenge is just find them, get them on drug, and if they're at the major centers, it won't take a lot of people, and we'll be fishing in how we set up and commercialize FKESA.
spk13: Okay, thank you.
spk09: Thank you, and our next question comes from the line of Corey Kazimoff with J.P. Morgan. Your line is open. Please go ahead.
spk03: Hey, good afternoon, guys. Thanks for taking my question. Two for me as well. I guess first, just to follow up on the FKESA topic, Can you just talk a little bit more about the anticipated cadence of countries coming online here? Do Canada and LATAM potentially contribute in 22? Or should we think about these as more of a 2023? And then to change up from Angelman, can you talk about what we might learn from the phase two dosing update for citruzumab or UX 143 in the second half of this year? Do we get like a full-on safety and efficacy update around the various doses, or is it just more like the dose you chose and the plan for phase three? Thank you.
spk19: Okay, very good. So on EFKISA, there is a sequence that usually people work through in country by country, and I probably wouldn't go through that at this moment. But obviously in Germany you can launch more quickly, but other countries like France and Italy have a process we have to work through, and we're going to work through the filings and timing of these things to manage the the pricing process to get through it and to try to achieve consistent pricing across the region. So I won't go through it right now, but 2022 will be spent primarily filing reimbursement and beginning the process of getting reimbursement in these countries. And ultimately, Germany at some point is the one country you can launch sooner. And of course, that would be something we would do in our plan. With regard to Canada and LATAM, this is This still requires filing and approval, so it's obviously not going to be a big revenue generator in this year. And Canada, LATAM is also right now also launching Joljolvi. And in LATAM, Crispita is still in the beginnings of its growth. So they have plenty to do there, but FKESA will fall in after that. But this year will be more about driving Europe. Again, we'll get the filings in for the rest of the Western world for FKESA. Now, for... The next one, was it both UX143 and Angerman? Was it both or just UX143? So, 143... Yeah, 143. Yeah, okay. I kept hearing Angerman all the time. Maybe I'm kind of dreaming it now. So, UX143, look, it's a pretty simple story. They already proved that 20 microkilo works quite well, right? We know that already. We're now going to young kids, so we're going to test a higher dose and that dose and kind of compare. And the purpose is really fine-tuning the dose. It's not like we don't know. We know the dose is probably 20. The question is, do you need to go higher than the little kids? That's all. And so what we're going to do is try to figure out is maybe the five-year-old needs to be on 40 and the old ones are on 20, you know, and maybe somewhere in between. So we're going to kind of look for how do we assess drug distribution, pharmacodynamic effect at different ages and doses and just create a dosing algorithm. I think of it less as the dose as a dosing algorithm to how to optimize for age. And based on P1P, which in our hands showed, at least in the hands of the study, excuse me, showed a really good correlation. So that's kind of what we're expecting. We'd put out a significant amount of data to say, here's what we're doing in our dosing algorithm. We'll talk at high level about dosing We probably would not provide great detailed data because it's the middle of a blinded study, and so we'll have some restrictions on how much detail we can provide. But it should be enough to say, drugs working, we figured out how we're going to dose, and that we're heading to phase three. And I think that would be an important update for the program. Okay. That's very helpful. Thank you.
spk09: Thank you. And our next question comes from the line of Chris Raymond with Piper Sandler. Your line is open. Please go ahead.
spk20: Yep, thanks. I've also got a couple of non-angelman's questions, if that's okay. Maybe just the first one, you know, speaking of the Regeneron deal, I think you've highlighted, Emil, before, you know, the second drug in that, you know, potentially second drug is garotosumab. You know, just Regeneron, I guess, ran into some issues when they were developing some fatal SAEs at the end of, I guess it was 2020, right? And they kind of went silent on it. But just to get into this, it's not clear, I guess, that these deaths were treatment-related. But there still seems to be a safety signal. Maybe just curious to maybe expand on what you see with that molecule, Emil, in terms of the path forward. And then just maybe a follow-up on Corey's question on citrusumab. I think I've heard you say in the past, you've framed this as maybe an opportunity that when you compare it to XLH, that the demand might even be greater for treatment. Can you just, you know, high level, maybe expand on that a little bit in terms of the market opportunity that you see, and just kind of thinking about that as setting up as a big catalyst in the next year, or end of this year, I guess.
spk19: Sure. So I agree to that, but obviously I need to defer to Regeneron and details of their program. But what I can say is we evaluated, and the death they had in their study, some very advanced patients who have scores that were very advanced, And we look at all that. Our conclusion is the drug is not the cause of those, that they are just very sick people with advanced disease, and that is why we're comfortable with what is going on. The drug may have events. We are not going to talk through them all, but what I can say to you is its effect on disease is so profound, disease so horrible, that we feel confident it's a drug that should get approved. And right now, Regeneron is doing their work on developing the development strategy, and I would refer to them on that development strategy. But we're confident there's a good product in there from our look at things. For truzumab, the OI patient population that can be treated is both type 1s as well as type 3s and type 4s. Now, if you look at the types, type 1s have fractures, and there can be a variable degree. Some people have occasional fractures. Some have you know, more than occasional, more significant, so some fraction of those patients are really having more issues. Type 3s and type 4s are physically more devastated patients, and their bodies are disintegrating. Okay, those patients are far more advanced and impaired than, let's say, a child with XLH, right? These kids end up in wheelchairs, significantly impaired kids, right? They are devastated, not just crooked legs. We're talking about bent bodies, right? So, There's no doubt that type 3 and 4 are horrible, and even with bisphosphonates, whatever's being done with them now is nowhere close to adequate treatment. So we think there's a very high need in the OI population, and we've been looking the last few years for something better. And what we've been impressed with is that among anabolic agents, antisclerostin is very potent and has a biology sufficient to basically normalize the strength of the bones in models, and the drug in their study showed dramatic improvement in bone density in the lumbar spine, which is one of the places that Type 3 and 4 patients disintegrate. Their spines essentially collapse and disintegrate. This drug had 8 to 10 percent bone marrow density improvement in just one year, which is more than double any other anabolic agent in the lumbar spine. We think that the potency in improving lumbar spine, for example, for young patients would be profound, and the strength then achieved could change their future from one of constantly broken bones and declining function to one of stabilized and improved growth and function. So we believe, given that severity and unmet need, they'll be a big driver. But on top of that, when you talk to KOLs, especially the larger KOLs, they generally have 50 to 100% more OI patients than XLH patients in their clinic. And so the 60,000 prevalence of population for OIs could be higher than that. We think there's about 50,000 XLH in that same population, but it could very well be there's more OI than XLH by a significant amount. That's why if you add that on with a high minute need, we think it's a population needing our help, needing a new drug, and we're in good position to get there with this one.
spk20: Great. Thank you very much.
spk09: Thank you. And our next question comes from the line of yarn Werber with Cowan. Your line is open. Please go ahead.
spk08: Hi, this is Brendan on for your own. Thanks for taking the questions guys. Uh, just one quick one on Chris Vita. Um, understand the rest of the world in person can be a bit choppy, but obviously it was a pretty impressive quarter recorder jump in North America. Um, just want to see maybe what drove that in Q4 and how we should think about it in context, uh, maybe, and maybe moving forward this year. Um, and then just a quick one on the GST three readout in the second half. Um, what kind of data could we maybe be expecting from how many patients are you expecting by then? I wasn't sure if you said we'd get repeat dosing data or if it'll just be the sad patients. Thanks very much.
spk19: All right. Uh, thank you, uh, Bren. I'll let, uh, Eric handle the Chris Vita quarter on quarter, uh, number question. And then Camille can handle GSD three patient briefly. Thank you.
spk06: Yeah. Yeah. The, the, um, we had a strong fourth quarter, um, You know, it surged following summer long, which was driven by the Delta virus, where there was a lot of lower activity in the mid-year with patient volumes going into offices. So we saw a surge at the latter part of the year as we rebounded coming out of that Delta variant.
spk12: Wow. Great. Thanks for the question about UX053, our GSD3 program. Yes, we will have data on our open-label single ascending dose portion of the study in the second half of 2022, approximately 8 to 10 patients of data. As the name suggests, the doses will be escalated by cohort by cohort. And so we'll have information first and foremost on the safety as well as some additional pharmacodynamic and initial clinical activity data from that portion of the study. The repeat dosing portion of the study will be blinded, randomized and blinded, so we won't have data until that portion has been completed. But we'll certainly give you an update on where that portion stands in the second half of the year as well.
spk08: Okay, great. Thank you.
spk09: Thank you. And our next question comes from the line of Maureen Raycroft with Jefferies. Your line is open. Please go ahead.
spk05: Hi. Congrats on the progress, and thanks for taking my questions. I was going to ask one on Angelman. Wondering what the cadence of enrollment could look like in the United States. How many patients do you plan on enrolling in the U.S. at two MIGs, and will you have ability to adapt dosing or expand the study in the U.S. during the four-month time frame? I guess, could there be a U.S. dosing update before your mid-year data update.
spk19: Yeah, very good. The patients are essentially, I think they're essentially enrolled. So we're enrolled, the four patients that were planned for 2MIG. So that's already there. And then we're letting them go and get started. It was an agreement with FDA just to get started. I think our plan was to take enough data from our XEUS to come back to the agency and look through what we can do to update the U.S. program. I would expect that somewhere toward the middle of the year. I don't know that by the update we would have changed the FDA protocol for the U.S. yet, but we're planning to try to get as much data from the current set of patients so that we go back to the agency with a very crisp single package and get their agreement. So once we have the other safety information and that, we'd hope to go back and align the U.S. protocol with the ex-U.S. We'd have to deal with patients who are on 2-MIG. By that point, they would probably have their doses completed, but we would probably expect to enroll them as participants in the cohort of the expanded protocol that we're doing. So we can't tell you exactly, but we're going to try to get to that certainly mid-year.
spk05: Got it. That's helpful. And then I just had a quick question on the FOP option with Regeneron. I guess for FKESA, I'm wondering if there are near-term obligations with launches that may factor into negotiations related to the exclusive FOP option.
spk19: Well, the two things are not really tied to each other. There are certainly, in our agreement on FKESA, we'll have a aspects of performance that we need to execute on, and that's all agreed to. But the option doesn't depend on those. It just is what our requirement is. The option will depend on, at a point in time, it will provide information that they have and what the development plan is, and we'll have the ability to opt in and then start to share some of the development costs for a greatest map. But the two things are not related to each other at this point.
spk05: Got it. Okay, thanks for taking my questions.
spk09: Thank you. And our next question comes from the line Adigan Ha with Stiefels. Your line is open. Please go ahead.
spk21: Great. Good afternoon. Thanks for taking our questions. I'll also stay away from Angelman tonight. One, just on FKESA, it seems to be more commercially driven, but I was wondering, Emil, if I could get your take on ANG-PTL3 targeting gene editing approach and whether or not you consider that before you went with FKESA. And then secondly, on citruzumab, I guess, can you remind us, in terms of how you're thinking powering-wise, that you're going after fracture versus the bone density that was measured in the asteroid study? Thank you.
spk19: Okay. Okay. So, in the commercial side, there's obviously other ways to knock out angPTL3, but the antibodies in hand is very safe, works well, and gene-netting knockout strategies have just submitted the very first few patients, which is very exciting, but to me is going to take years to get through. The goal people have in trying to do this is certainly not treating HSH and gene editing. But right now we're watching the gene editing field. We're a company that likes to take advantage of platforms, but not have to develop them ourselves. So in our view, what we needed was not another early stage program to experiment with, but a product that we could sell that worked. And down the road, If your point is, well, could something replace this Evkisa for AngPTL3? Maybe. But is it really in the next few years? Or is it 10 years? How long? Could be a while. And honestly, very few people are going to spend all the money on gene editing to treat that few number. So if they're trying to do the bigger market at some point, maybe that will happen. But right now, we feel comfortable with the program we can sell now that works, works well. It's pretty convenient. It doesn't have any unknown genetic issues that are yet to be figured out, and so we're comfortable there's a good place for it in our portfolio at this point in time. But we're watching gene editing just like all of you, and they'll have ups and then downs. For UX143... FOMO real density by the FDA is generally not considered sufficiently clinical in their mind. There have been situations where it didn't correlate well, although I think with anabolic agents it correlates better with outcomes. So their requirement was to have clinically observed fractures to be the primary endpoint. What we know from the data in ASTERoID is that there were trends to fracture improvement. The study was not very big and didn't have enough time. But our view of it was that the bone mineral density improvements and the trend and fractures that we're seeing in the higher-dose patients would be clinically important, and we feel comfortable that will work. Second thing, remember that asteroid study was adults. Adult bones don't respond like kid bones, and that's why, remember, with XLH, we got out of adults and went to peds. And peds are what drive the powerful efficacy story. Same thing is going to be true for UX143. Kids' bones respond much greater, much faster, and will remodel faster and build bone faster. And so I'm very confident that in that group that we can improve fractures even more readily than you would in adults. So that's why we're pretty comfortable. That was true, by the way, in kids. Everything we did in kids worked faster and more powerful. In fact, people said it should take two years to see bone changes, remember, in XLH. But in kids... We actually got 80% of the benefit in nine months only, right? That was unexpected to some. But as a pediatrician, I like kids because they get better. That's why I went into pediatric medicine originally as opposed to us pediatric guys. All right. Thanks very much. Good.
spk09: Thank you. And our next question comes from the line of Sylvain Richter with Goldman Sachs. Your line is open. Please go ahead.
spk11: Hey, thanks for taking our question. This is Elizabeth on for Salveen. For your 2022 CRISFIDA guidance, I was wondering if you could comment on the breakdown you expect may come from North America versus the other rest of world geographies.
spk19: Well, generally we don't make that breakdown for the sole purpose of allowing Eric the room to do what he has to do to get the sales there. But Eric, I don't know if you want to comment. I don't think we've made the breakdown in the past.
spk14: I'll comment just a bit. And then just from the numbers, you can jump in. Yep. So, I mean, we put in the press release that the North American territories were $171 million last year and other product sales, although we didn't break that down, but it's mostly Chris Vita coming from Latin America was about $21 million. So that gives you the magnitude of difference within that guidance. So we continue to see very strong growth of CRISPR in Latin America, but generally the biggest growth and the largest numbers clearly come from North America. Eric, I don't know if you want to add anything more.
spk06: Exactly what I was going to say.
spk14: Sorry. First that.
spk19: So Elizabeth, there's your answer.
spk11: Thank you. Great.
spk09: Thank you. And our next question comes from the line of Joseph Swartz with SVB Securities. Your light is open. Please go ahead.
spk18: Hi. Thanks very much. At the FAST conference, I guess I'll preface this by saying my first question is on Angelman and my second is not. But at the FAST conference late last year, Dr. Dindo emphasized the value of preclinical models for Angelman. And so I was wondering if, particularly the PIG model, and I was wondering if you've studied GTX 102 in the PIG model, and if so, what did you see with respect to the therapeutic index and dose response of GTX 102, and is any of that of value and working out to be in line with what you're observing in patients now?
spk19: Yes, well, Dr. Dindo, of course, at Texas A&M would We talked about animal models being the kind of the ag school it is. And the pig was more recently developed. So we don't actually have the genetic GCS1 data in the pig. They were developing the pig. They got it done now. But now we're in the clinic. So we haven't gone back to the pig with GCS1. So I couldn't really answer those details. I think the pig is interesting because it acts like Angerman patients, humans. It has It doesn't have a stranger anxiety. It will come up to strangers. Most pigs are reluctant to come up to strangers. So there's these subtle behavioral patterns which are retained, which are interesting. But we haven't done the work yet. But I do think it could be helpful in other work in terms of developing additional improvements to the molecule or other types of approaches. But the truth is that fundamentally pig or whatever or monkey is You've got to deal with human patients to figure out what's happening. And so the biomarker story could also be maybe developed in the pig. But honestly, by the time we figure out a biomarker is validated, we'll have already completed the clinical program. So the truth is that right now, our history and future is dependent on what we do in the clinical program. And the models will help us expand the options we have for the future, but I don't think are going to find the path forward in the clinic.
spk18: Okay. And then, given your seamless Wilson disease study, we'll have a couple decision or data points. I was wondering if you can give us a sense of when we might hear something first about the effect and the dose that will be taken into the pivotal portion of the study.
spk19: Sure. We will have an interim assessment of the program, but because it's a blinded program, we won't be able to disclose all the data we have, but our expectation, now the study didn't start, it's just starting now, so the timeline to get that interim is not going to be this year now because of where we are in time, but our expectation is to be able to know what the dosing response looks like, that the drug is working, that there is an impact on the markers of importance, and that we're, you know, choosing a dose and proceeding. So that's the kind of level of granularity probably would provide. And we'll have to be careful about it because we just don't want to have anything that damages the objectivity of the phase three study. But it should be enough to tell you, the drug, here's the dose, and we're proceeding to phase three.
spk21: OK, great. Thank you.
spk09: Thank you. And our next question comes from the line of June Lee with Truist Securities. Your line is open. Please go ahead.
spk04: Hey, thanks for taking our questions. For the Angelman data by mid-year, is your goal to have all Canada and UK patients on 14 milligram dose before you top line the data? Do you have sufficient time to get all those patients to 14 milligrams or do you have the ability to skip a few doses between the starting dose and the maximum 14 milligram dose? And what is your definition of mid-year?
spk19: Very interesting. We'll start with the last one. Mid-year is Q2 or Q3. It's broad enough to really be annoying to all of you, so that's why we pick it that way. But the truth is, we have to get through a number of steps and get the study executed. The study has a protocol where they escalate after two doses, and then they can escalate every three months during the maintenance phase further. However, getting to 14 will take a number of months if we're to get there. So your question is, could we just jump doses and not a normal clinical protocol to jump doses. So we are going to look at the data we have as we get to mid-year, and our expectation, instead of jumping doses, June, is to see where we're at and initiate an expansion cohort, right, which would allow us to start dosing at a higher level now, a dose level, let's say, that's cleared by the data so far, but start at that dose level and now load with four doses at that higher level. So again, what you're getting at, June, By doing that, it will allow us to jump efficacy a little further if we're not at where we want to be by the time we're at mid-year, and that will allow us to jump the dose a bit higher and continue ahead. We have to work through this safety window and establish that therapeutic window. I think what we've seen so far, there is a therapeutic window. We just need to figure out how much it will take to get the dose that gives us the kind of efficacy we think would be meaningful for patients. rather than jumping, those patients will continue, we'll add an expansion core, which will jump up another level, and then titrate from there, and that will hopefully give us that dose, this dose, somewhere between all that information, we'd expect to have clarity later in the year by what we're gonna run in phase three.
spk04: Got it, and then quickly, are there any more planned meetings for the Data Safety Monitoring Board, or is there no pre-specified?
spk19: Yeah, the two pre-specified were related to the further enrollment or expansion of the enrollment. Those will happen. But they will meet on a regular rhythm, cadence, because they need to continuously evaluate safety that's ongoing. Of course, if a low extremity event happened, they would be notified immediately and have an ad hoc meeting. But there is a regular cadence that they are going to be doing. But there's no special triggers yet except a safety event And otherwise, it's a regular cadence of meeting as the data goes forward. Thank you.
spk09: Thank you. And our next question comes from the line of Jeff Hung with Morgan Stanley. Your line is open. Please go ahead.
spk07: Thanks for taking the question. For FTSA, what considerations beyond the indication were there for the partnerships such as, you know, you mentioned geographic expansion to APAC and further into Europe. And then how important is the potential for the expansions?
spk19: So with regard to considerations, I think the importance for Regeneron was that we commercialize in all the territories, that we support patients in all the countries that are in the trials as well, because there are some patients down in South Africa and other places. So we are going to support, of course, any patient in any country. And there's a requirement that we certainly commercialize in a broad array of countries and with that we'll be working on. Because Asia is an area we wanted to go into, this FKESA provides us the tool to actually go and have Japanese patient data in the program. And the Japanese KOL involved was very, very positive on the study and very willing to help us get it approved in Japan quickly. So we have a package that's already potentially filed in Japan that should get us going in Japan earlier. So that will be part of our immediate expansion of the filing process. So beyond that, I don't think this is worth going into more detail. With regard to the taking the option, it's really about us looking at where the development program is going and understanding the current data set they have. And at that point, which is set by time, we'll sit down and have a discussion with them about going forward. And at this point, I think it's a drug that's doing something very profound and important for these patients. And I would say that that effect is so profound that most patients would, I would think, would want to get treated with it. So we're highly encouraged. We would expect to move forward at this point in time.
spk07: And then as a follow-up to the question on Latin America, what are the key factors for further growth in Latin America this year?
spk19: Well, Latin America has always, the story has always been, we have a great team, by the way. We have, like, some of the best people in Latin America on that team. that have done this well for a lot of rare disease programs. The challenge has always been the politics in COVID with regard to reimbursement. In Brazil, I think one of the important pieces that we've gotten through the reverse process now, setting the final step. So once that happens, then there'll be a set agreed price and there will be the ability to expand in Brazil further. In other countries, we're certainly working on filings and working on name patient sales and we'll begin adding where we can, working through the reimbursement. But we are seeing traction now in growth in Latin America. I don't know if there's anything else, Eric, you might want to add to the Latin America growth story at this point.
spk06: No, I think just as similar as we did in North America, and particularly in the U.S., with growth, we continue to expand to find more patients as we reached out further into the community setting. Something similar will occur in Brazil, especially as we attain full reimbursement and we can go into full commercialization promotional activities.
spk19: Yeah, I think that's going to be important. Thanks, Eric.
spk09: Thank you. And our next question comes from the line of Lisa Baco with Evercore ISI. Your line is open. Please go ahead.
spk10: Hi. Yeah, just one quick financial question. And most of my questions have been answered, but maybe just one quick one on Angelman. So can you just Guide us, give us some, you know, parameters to think about for spend this year. I was just looking at your R&D number. It's up a bit. Is that, you know, a good run rate to think about? Or maybe you can just walk us through the shape for the year, especially of R&D things.
spk19: Sure. Obviously, there is some increase in spend, as Marty's put out. Marty kind of described it a little more. There have been some one-time items, too, in the mix. So, Marty, why don't you give some sense of that?
spk14: Yeah, we highlighted the $50 million upfront for the Maria collaboration that's in there. But, you know, right now with our development pipeline and late-stage programs and our work in gene therapy, et cetera, we do think we'll have some growth in R&D going into 2022, mostly on the R&D line. I would say SMA, other than the focus on FISA as we build out the reimbursement in multiple countries in Europe, will stay pretty much the same, but we would expect continued growth in our next year for sure.
spk10: Okay, thanks. And then just on to Angelman's, are there any, like, biomarkers or things like that that you're looking at to help guide you and, you know, that would be sort of indicative of or, you know, kind of telling with respect to, you know, the other metrics you're looking at?
spk19: Sure. First of all, the soluble biomarkers like UB3A, we presented it fast. In fact, what people thought were UB3A in spinal fluid was probably blood contamination because there is UB3A in blood cells. And so it turned out that trace amounts UB3 found in the spinal fluid may very well be due to leak, a little bit of blood in the tap, which means that they're probably detecting UB3A in the spinal fluid is not going to be a kind of biomarker. What I'd redirect, Lisa, is to look at the neurophysiology, and that's the Delta Power EEGs. The EEG is now not dependent on patients' thinking or whatever they're doing. It's looking at neurologic function. And what we showed, and there was an updated FAST that you guys should look at, more detailed data on the EEGs of the patients in the trial looking at epileptiform and Delta Power showing changes in neurophysiology in those patients that were meaningful. So, I think it shows you that this is not just a subjective view of the patient that's better. There is neurophysiological evidence, and I would look at that neurophysiology as being probably the best biomarker-type information that would tell you that something fundamental is happening, and these very abnormal brains are starting to respond differently to stimuli than they did before.
spk09: Okay, thank you. Thank you. And our next question comes from the line of Joel Beattie with Baird. Your line is open. Please go ahead.
spk17: Hi. Thanks for taking the question. The first one is outside of the U.S. After approval, how fast could the ramp up in sales be compared to what might otherwise be typical for rare disease drugs? And then the second question is for Wilson's disease in the stage one part of the trial, how much potential is there at that time? to learn about any efficacy on neural endpoints.
spk19: Okay, so the first question on outside the US was about FKISA or something else?
spk17: Yes, FKISA.
spk19: So it's a little hard for us to guide for sales outside yet. I mean, I think this year is going to be about reimbursement in Europe, getting it set and going. And the other countries are going to be somewhat behind them, so I wouldn't be able to tell you much about how the growth is going to be. But I would expect that an ex-U.S. launch is going to take a couple years of filings and approvals and reimbursement work to get dramatically going. But this year is all about Europe, and that's what the team will be focusing on. With regard to Wilson... There are some neurocognitive Wilson scales that are in the program. However, remember, a lot of the patients may not have abnormalities at the beginning. So you were talking about the people that do have score abnormalities. Trying to determine their difference would be hard to do on dosing. So we're going to focus the dosing on the biomarkers of copper control. And there's really good data to say that copper control in its various forms should give us the right answer on dosing. And basically, I would say to you that if all things equal, if the highest dose gives us the highest ceruloplasm levels, which it likely would, and assuming that it's safe, the same safety as the E13 dose, then I would think the highest dose is going to end up most likely to be the dose. And so there shouldn't be that much mystery because we're pretty clear that in this range that the dose that, you know, in the low E13 range, that 2E13 should be better than 1E13, and we would expect, assuming safety is excellent, that that would end up becoming the dose. But because it's a new treatment first in man, we have to work through the process, right? And that's why there's three doses. It could very well be once you get enough copper, detoxification occurring, that going higher doesn't necessarily get you more detoxifying, which we'll see. But the ceruloplasm part of the story is about copper distribution. And we know from the animals that's a little harder to achieve. And therefore, I personally want to focus on the fact we are actually restoring some level of copper distribution, which to me would be the real reason why you do gene therapy, that you're not just getting rid of toxic copper, you're actually restoring copper homeostasis. And that would be the real benefit of gene therapy over everything else.
spk04: Great. Thank you.
spk09: Thank you. And our next question comes online of Laura Schickel with Woodbush. Your line is open. Please go ahead.
spk01: Good afternoon. Thanks for fitting me in. I just have one on Angelman. Assuming the best case scenario and you're advancing towards pivotal studies, I'm wondering if you could talk about kind of on the execution side, what would be a feasible number of recruitment sites in the US? Thanks.
spk19: That's a very interesting clunk off question. Laura. That's a question we've talked about a lot, frankly, because the usual tendency is to run with huge numbers of sites, but I would say most great studies run with a smaller number of really good sites, and that would be our focus. There are a lot of angioma patients and a lot of centers that have a lot of patients. If the drug data from our Phase II study are as promising as we hope they will be, then I think the ability to enroll a study will be there. And we just need sites who can manage intrathecal administration and the support services required for that to be able to treat patients in a fairly large study. But we haven't set a number. But I'm assuming the trial is going to be more than 100 patients just based on the size of the population, probably less than 200. but somewhere in there, and therefore it's going to be an international study, not just U.S. And our hope would be that it would be only a six-month study where we look at loading and show the difference of a clinical effect over a loading period. So I can't tell you the exact number on a number of sites. I don't think I'd venture that guess at this moment in time. But if there's any issue or question you're asking about, like are there going to be competition for patients and sites, Well, there are other programs in Angelman, and I think there could be competition for patients. But I also point out there's a lot of Angelman patients, right? So we think there will be enough patients to get our studies enrolled, even in the context of other programs ongoing. But more important with now is showing what our drug can do and that it's safe in Phase 2. Then everything else will come if that is successful.
spk01: Very helpful, Emil. Thanks.
spk09: Thank you, and this does conclude today's question and answer session, and I would like to turn the conference back over to Joshua Higa for any further remarks.
spk16: Thank you. This concludes today's call. If there are any additional questions, please contact us by phone or at ir.ultragenics.com. Thanks for joining us today.
spk09: This concludes today's conference call. Thank you for participating. You may now disconnect.
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