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spk02: Greetings and welcome to X4 Pharmaceuticals' third quarter 2022 conference call. At this time, all participants are in a listen-only mode. A question-answer session will follow the formal presentation. As a reminder, this conference call is being recorded. It is now my pleasure to introduce your host, Dan Perry from Lifesize Advisors. Please begin.
spk03: Thank you, Operator, and good morning, everyone. Presenting on today's call will be X-Force Chief Executive Officer, Dr. Paula Reagan, and Chief Medical Officer, Diego Cadavid. We'll also hear briefly from the company's new Chief Commercial Officer, Mark Baldry, and company board member and incoming Interim Chief Medical Officer, Dr. Murray Stewart. Following prepared remarks, we'll open the call to your questions. We'll be joined by Chief Financial Officer, Adam Mustafa, Chief Scientific Officer, Art Tavares, and Chief Operating Officer Mary DiBiase. As a reminder, on today's call, the company will be making forward-looking statements regarding regulatory and product development plans, as well as research activities. These statements are subject to risks and uncertainties that may cause actual results to differ from those forecasted. A description of these risks can be found in X4's most recent filings with the SEC, including this quarter's 10-Q, which is expected to be filed after market close today. I'd now like to turn the call over to X4's president and CEO, Dr. Paula Reagan. Paula?
spk09: Thanks, Dan, and thank you, everyone, for joining us on the call this morning. As we shared in the press release this morning, and as Dan just mentioned, Diego will be transitioning out of his role as chief medical officer and becoming a senior medical consultant to X4, and our board member, Dr. Murray Stewart, former chief medical officer of GSK and Rhythm Pharmaceuticals, will be joining X4 as interim CMO. At the end of today's call, Murray will say a few words of introduction. As we welcome new team members, we are extremely excited to share the progress that we've been making as we sharpen our focus as a company with a mission to develop therapeutics to treat the broad patient population with chronic neutropenic disorders, including our first potential indication of WHIM syndrome. and where we believe there's a significant need for an oral efficacious therapy with low treatment burden and good tolerability. With no oral therapeutic approved for approximately 50,000 chronic neutropenia patients in the U.S., we believe that Maverick Sephora, if approved, could represent a new opportunity to transform the treatment landscape and create a new standard of care. Today, the focus of the call will be to provide updates on Mavericks IV's progress in our Global Pivotal Phase III Trial in WHIM Syndrome, and to highlight how we are getting appropriately prepared to ramp into commercial launch. Mavericks IV is being studied in an ongoing Phase III for the treatment of WHIM Syndrome, which is a population of people with severe neutropenia, as well as other immune system deficiencies. WHIM syndrome is considered a combined immunodeficiency because patients with WHIM not only have profoundly low neutrophil counts, but also low lymphocyte and monocyte counts, and sometimes low antibody production, which is referred to as hypogamuloglobulinemia. We believe that Mavericks 4 has the potential to favorably impact the combined immunodeficiencies of those with WHIM syndrome and also has the potential to favorably impact a potentially broader population diagnosed with chronic neutropenic disorders. I'd like to take a minute now to review WHIM syndrome and how patients are diagnosed. Next slide, please. As I mentioned, WHIM syndrome is a combined immunodeficiency impacting people from birth. Patients have profoundly low neutrophil counts, as well as abnormally low lymphocyte and monocyte counts. and in many cases, low immunoglobulin levels. The W, H, I, and M of WHIM represent the variable presentation of the disease, which can range from severe wart presentations, the W, and HPV-associated disease to low immunoglobulin levels, the H for hypogamyloglobulinemia, increased susceptibility to frequent infections, the eye, and retention of neutrophils in the bone marrow called myelocathexis, the M, which explains the severe chronic neutropenia. Patients can present with one or more of these disease manifestations in addition to low neutrophils, lymphocytes, and monocytes. In view of this variable and complex clinical phenotype, a range of inputs is utilized by clinicians to diagnose WHIM syndrome. According to leading experts in this field, one of the most reliable ways to begin the journey of diagnosing WHIM is to examine total white blood cell counts, which includes neutrophils, lymphocytes, and monocytes, and look for multiple decreased white blood cell types, referred to as panleukopenia. As a consequence of this panleukopenia, People with WHIM syndrome experience lifelong risk of bacterial, fungal, and viral infections, with particular susceptibility to refractory warts due to infection by human papillomavirus, which can evolve into HPV-related cancers. Infections can be severe, including sepsis. Bone marrow biopsies can be utilized in the diagnostic journey. although it may not always be done due to the pain and potential morbidity associated with this needle-based invasive procedure. Upon microscopic evaluation, the hypermature or hypersegmented neutrophils in the bone marrow are important findings to corroborate the diagnosis of limb syndrome. In fact, the disease was initially called myelocaphexis before there was knowledge about genetic mutations. Genetic testing to look for gain-of-function mutations in the CXCR4 receptor is the conformational assessment most often used. Interestingly, genetic analysis in patients with a clinical diagnosis of WIMP syndrome but without CXCR4 mutations have identified new genetic mutations, including mutations in genes associated with the signaling cascade, such as CXCR2. In fact, in these individuals, Neutrophils share functional alterations of CXCR4-mediated responses despite the lack of CXCR4 mutations. Finally, a family history of WIMP syndrome also supports the ultimate diagnosis in any individual patient due to the autosomal dominant nature of the disease for those with CXCR4 mutations. We continue to support the needs of the medical community to facilitate awareness and earlier and accurate diagnosis of WHIM syndrome via multiple approaches, including knowledge of the variable clinical manifestations, pathologic abnormalities in the bone marrow, genetic mutations, and family history assessments. Importantly, there are no approved treatments specifically for WHIM syndrome. Existing treatments only address individual components of the disease, such as giving high-dose immunoglobulin to treat the low antibody levels or GCSF injections to treat the neutropenia, which is often poorly tolerated for chronic use. We recently completed the randomized placebo-controlled portion of the Phase III study of Mavericks 4 in WIM which is testing for the first time in a registrational study a targeted treatment that specifically addresses the root cause with the potential to improve the full spectrum of problems associated with the disease. I'll now turn it over to Diego to review our Phase III study design and our historical data that supports why we are so excited about our pending pivotal trial results. Diego?
spk05: Thank you, Paula. I'll now briefly review the study design of our four WIM global registrational trial assessing Maborix A4 as a potential treatment of WIM syndrome. As Paula mentioned, the design is a randomized placebo-controlled and double-blinded study. We completed enrollment in Q3 of last year over enrolling the trial with 31 patients from 12 countries. We have now completed the last patient, last visit for the placebo-controlled 52-week period and are diligently working towards database log. The study's inclusion criteria required that all patients enrolled had a confirmed absolute neutrophil count, or ANC, less than or equal to 400 cells per microliter during screening. For the 31 patients enrolled in the trial, the average pretreatment ANC was 220 cells per microliter, an indication of the severity of chronic neutropenia that characterizes WIMP syndrome. Recall that an ANC less than 500 cells per microliter is considered severe neutropenia, indicating that this population was severely neutropenic as they entered the study. Importantly, almost half of the patients enrolled were pediatric between 12 and 17 years of age, which supports the potential for us to receive a Rare Pediatric Disease Priority Review Voucher, or PRV, upon approval of Mavixa IV of significant potential value to the company. At the end of the placebo-controlled portion of the study, all participants were eligible to roll over into the Open Label Extension, or OLE, study. Notably, more than 90% of eligible participants elected to continue on and receive Maborik support treatment in the OLE. We are continuing to collect data from this ongoing portion of the trial. Safety from the trial has been monitored regularly by a data safety monitoring board which has endorsed the continuation of the study without any protocol modifications due to safety or tolerability. As I mentioned, we have now completed last patient last visit in the placebo-controlled portion of the trial. The blinded data are being reviewed by an independent adjudication committee and database log is soon to follow. We continue to expect announcing Phase III top-line data in the fourth quarter of this year. Next slide, please. We have a robust series of metrics to assess the efficacy and safety of Maborixa for in-wing patients in this Phase III trial. The primary endpoint is a metric called TAT-ANC, which is Time Above Threshold, or TAT for short. for absolute neutrophil counts, or ANC. It is an assessment of Maborixafor's potential to raise neutrophil counts above the severe neutropenia threshold over a 24-hour period. Participants in the study were dosed once daily for 52 weeks with either placebo or Maborixafor. The 24-hour TAT-ANC was measured four times during the 52-week treatment period, approximately once every 12 weeks. The study's first key secondary endpoint is time above threshold for absolute lymphocyte counts, or TAT-ALC. Calculations follow the same approach as for TAT-ANC. Assessment of TAD ALC is important for WIM patients who suffer from significant lymphopenia and hypogammaglobulinemia. Recall that lymphocytes are mostly BNT cells and are key for mounting effective immune responses. The graph here presents how time above threshold is calculated. Patients undergo a series of up to 12 blood draws over a 24-hour timeframe. and levels are measured via standard CBC methods and plotted versus time. Time above threshold is the amount of time in hours that neutrophil or lymphocyte counts are equal to or above certain thresholds. Here, 500 cells per microliter for neutrophils and 1,000 cells per microliter for lymphocytes. Finally, there is a comprehensive list of clinical endpoints, both key secondary and exploratory endpoints to assess the clinical impact of Maborixza 4 over placebo during the first year of treatment. A few of them are listed here, organized by category. One category is patient and physician reported outcomes, or PROs. The second category is related to infections and warts. The third category is response to vaccine. And the fourth category is safety, tolerability, and PK. There are also several pre-specified subgroup analysis. This robust and comprehensive study design reflects the guidance provided by the FDA over a number of consultations, and we will share more specifics on this in a few slides. Next slide, please. As you can see here, the Phase II endpoints closely mirror our Phase III endpoints, and the success of this trial, along with results from the Phase II Open Label Extension Study, have formed the basis of our confidence in Phase III success. The positive Phase II results not only inform the Phase III trial design, but also served as the basis for the power assumptions for the primary and the top secondary endpoint of the Phase III trial. Based on the blinded baseline ANC and ALC of the 31 subjects enrolled and the high retention rate in the study, the primary endpoint of the Phase III trial in Wim's syndrome is power to greater than 95%. In the Phase II study, we saw that all patients responded to Maborixafol treatment with increased neutrophil and lymphocyte counts. Increases in both TAD ANC and TAD ALC upon treatment with the 400 milligram dose, which was the dose selected for the phase three trial, ranged between approximately two and 24 hours. Importantly, these observed increases in TAD ANC and TAD-ALC in the Phase II trial were associated with clinical benefit, including positive patient-reported outcomes, reductions in both the rate of infections and the ward burden, and equally importantly, Maborixafor was well-tolerated throughout the study, including the long-term extension. Recall that these favorable Phase II results resulted in the FDA granting us Breakthrough Therapy Designation, or BTD, for Maverick's effort for the treatment of WIMP syndrome. Also recall that the hurdle for BTD is high and required preliminary clinical evidence from our Phase II study that indicated that the drug may demonstrate substantial improvements on a clinically significant endpoint or endpoints over available therapies. The totality of the Phase II data was shared with the FDA and supported their award of BTD for Maborix A4 in WIN. On this slide, We provide a patient-specific view on the impact of one's daily oral treatment of Mammoryxaforin in a participant in the Phase II study. This study participant was a 24-year-old female with a long history of large refractory warts that had a major negative impact on her quality of life and cancer risk. She also reported frequent sinus infections. In this close-up, You can see the large compound words encasing her nail and part of her thumb. Additional words of even larger sizes were distributed over her hands and feet. A dramatic reduction in the subject's white lesions was evident over time during the Phase II study. These images captured this favorable change. The thumb image on the left shows the worked lesions prior to treatment. The image on the right shows the same thumb after the subject was treated for almost a year with the 400 milligrams once daily dose. We can see that in many areas, the lesions are almost completely resolved. Similar reductions were visibly evident across most of her other lesions as well. This same patient was interviewed after more than three years of treatment. She reported on her experiences as overall reducing her infections and world burden and reported an improvement based on the patient global impression of change or PGIC questionnaire. We have included the PGIC assessment among other patient and physician reported outcomes in our phase three trial. Next slide, please. Since the initiation of our IND for Maborixa foreign-wing syndrome, we have had ongoing interactions with the FDA, and frequent engagement with the agency has continued under breakthrough therapy designation and in the context of an orphan drop designation. Importantly, the FDA has provided clear guidance that has informed our study design endpoints and planned analysis. They have recognized the rarity and heterogeneity of WIMP syndrome and have guided us on our endpoints, including combining assessments of infections and watching to a single composite endpoint to optimize the potential for the trial to show a difference between Maborixifor and placebo on infection-related metrics with the available sample size. X4 has followed all of the guidance provided by the FDA, and we are looking forward to announcing top-line results later this quarter. Once the data are unblinded and analyzed, we plan to share data that will include the primary endpoint, TAD-ANC, and likely the first key secondary endpoint, TAD-ALC, along with the trial safety assessments. I'll now turn it back to Paula.
spk09: Thank you, Diego. We believe Maverick X4 is well positioned to make history by being the first treatment specifically developed for the treatment of WHIM syndrome. Based on our discussions with the agency, we expect our label to be focused on those age 12 and older diagnosed with WHIM syndrome. It has been an ongoing commitment of X4 to support education, awareness, and ultimately the diagnosis of WHIM syndrome in the medical and patient communities. As previously described, the diagnosis of WHIM requires a clinical assessment consistent with one or more of the various phenotypes of the WHINM in the setting of combined immunodeficiency. That is, neutropenia, lymphopenia, monocytopenia, and or hypogammular globulinemia. And can potentially include bone marrow examinations as well as genetic testing assessments and family history information. We've been investing in a breadth of activities to support the clinical and patient community as outlined here, and I'd like to highlight a few more recent efforts. We've begun collaborating with a bone marrow pathology expert with the potential to establish a myelocathexis center of excellence. In the future, we envision such a center could be a place where physicians can send bone marrow samples for a second opinion to be analyzed by those experienced with myelocathexis to aid in a potential diagnosis of WHIM syndrome. Additionally, we have hired a patient education liaison, a medically trained professional who can compliantly engage directly with patients and their families to support the potential for genetic testing amongst individuals or kindred members within the same family. And finally, we are excited to support the International Patient Organization for Primary Immunodeficiencies, or IPAPI, in establishing a global registry for people with WHIM syndrome. By bringing together those working across a breadth of existing immunodeficiencies, including a patient foundation, patient community representatives, experts in WHIM syndrome, and academic centers in the U.S. and abroad, We believe this registry has the potential to be a great resource for the WHIM patient community, their physicians, and for drug development companies such as X4 to learn even more about the disease. Next slide, please. I hope you can now see why we are so excited for the unblinding of our phase three trial results. Assuming a successful phase three, we are already gearing up for an NDA submission in the early part of the second half of 2023, and if approved, preparing for the U.S. launch of Mavericks 4 in the first half of 2024. EMA filing is expected to follow our U.S. filing by about 12 months, and if approved, we expect commercial launch would be initially focused in the top five to seven European markets with others to follow. We may consider partners to support the launch of Maverick X4 in territories outside of the US and these key European countries. We will update you at a future point when we have clarity into any potential partnerships. Next slide, please. As Dan mentioned earlier, we are joined on this morning's call by Mark Baldry, our new Chief Commercial Officer. Today is actually Mark's first day at X4 and we couldn't be more pleased to welcome him. As a quick background, Mark comes to us with more than 30 years of experience in global life science commercial strategy and operations, having launched multiple orphan and rare disease therapeutics. He's particularly skilled in building and coordinating global teams, and equally importantly, is as passionate as we are about innovating for patients in need. We consider ourselves very fortunate to have someone with Mark's background joining us at this critical time in our corporate evolution and are looking forward to getting Mark up to speed on our Mavericks 4 program and continuing to advance our commercial readiness as we approach the unblinding of our Phase 3 4WIM trial. Welcome, Mark, to your first day at X4.
spk00: Thank you, Paula. I'm really pleased to be here, and I'm looking forward to digging in. This is such an exciting time at X4, and as you've just outlined, a great opportunity for me to help support free commercial efforts and hopefully the commercial launch of Maverick SIFOR and its first indication. I've spent much of my career focused on launching innovative therapeutics that were able to transform the lives of patients around the world who are living with rare diseases. And I've joined X4 because I can clearly see the potential of Maverick SIFOR to not only become the first therapy for people with WIM syndrome, but also to become a new standard of care for those with chronic neutropenic disorders who face considerable challenges with currently available therapies. So I'm really looking forward to working with you and the whole X4 team.
spk09: As are we, Mark. Thanks. Next slide, please. As you would expect, preparing the product, the market, and the company for commercialization to ensure Mavericks 4 treatment reaches patients with WHIM syndrome is well underway in anticipation of the Phase 3 data and leading up to a planned 2024 launch, if approved. Here, I want to share some additional ongoing activities and near-term planning and highlight several spokes to building the commercial wheel and getting it rolling. I've already mentioned the team of people we have in place out in the field, PDLs and PELs, and in the home office. In this pre-commercial phase and under Mark Baldry's leadership, we intend to right-fill the commercial team as we enter into the next phase of preparation. These customer-facing people are actively engaged with healthcare professionals, patients, and patient communities to raise awareness of WHIM, educate on recognizing and diagnosing the disease, and communicating the potential of Maverick Sephora through medical channels. We have also conducted primary payer research with U.S. and European payers to understand the issues and opportunities to gain market access. We've begun to identify the capabilities we need to build and define the full spectrum of healthcare value that Mavericks 4 may demonstrate and ensure access for patients. On the manufacturing front, registration batches have been completed. The key requirements, core components, and partnerships are well underway to ensure a stable and efficient commercial supply chain and specialty distribution network. And lastly, from a marketing standpoint, we have secured conditional approval of a brand name with the FDA, an exciting step for Maverick before. Additionally, we have conducted early healthcare professional market research, focused on targeting the physicians most likely to have a WHIM or a potential WHIM patient, introduced tools available to the patient and HCPs on disease awareness, and are developing full branding. Next slide, please. As we move towards an anticipated approval in WHIM, we would like to highlight that our time and commitment to launching in WHIM will be leveraged towards improving our potential future success in developing Mavericks for indications that may treat the broader chronic utropenia community. The same physicians that treat WHIM syndrome also treat those patients with chronic utropenic disorders. The same patient foundations that support WHIM patients also support those with chronic neutropenic disorders. In fact, we've already seen these synergies benefit patients and physicians. For example, our free genetic testing program called Path Forward has enabled physicians to diagnose new patients across the full range of chronic neutropenic disorders, including WIMP syndrome and other congenital neutropenias. Additionally, we see the synergy as potentially translating into support for the additional enrollment in our amended Phase 1B2 and anticipated CN Phase 3 trials, and of course, further expanding our network of medical experts that diagnose, manage, and care for these patients. Finally, we expect highly leveraged distribution channels for drug supply and payer interactions to support market access to optimize our future sales for the WIMS indication, if approved, and our bottom line. Next slide, please. We believe that Maverick Sephora has a bright future ahead. If approved for the WHIM indication, we intend to continue to develop Maverick Sephora in additional indications where we believe it has the potential to become the only oral treatment approved for an array of chronic neutropenia disorders. As presented over the last few years in the context of various clinical trials, we've seen dramatic and sustained increases in neutrophil counts, with all patients responding to Maverick Sephora including across all of the CN disorders we've studied thus far. As a result, we plan to study whether Mavericks 4 has the potential to treat up to 50,000 patients currently diagnosed with idiopathic, congenital, and cyclic neutropenia in the U.S. And we are on the cusp of a potentially positive Phase II trial that could support a U.S. launch in 2024. a launch that could not only begin to generate meaningful revenue for X4, but could also set the company up to maximize success in chronic neutropenia disorders beyond WHIM syndrome. In closing, you can see that we expect a steady cadence of milestones ahead of us, starting with our potentially transformative WHIM Phase 3 data later this quarter, followed by additional expected CN data and potential initial clarity on the regulatory path forward for Mavericks IV and CN in the first half of 2023. Assuming positive Phase III results in WHIM, our NDA filing for Mavericks IV is on track for early in the second half of 2023, and we're aiming to be Phase III ready to move forward with advancing a CN registration trial following the expected filing of our NDA in WHIM. As I mentioned at the beginning of this call, we believe Maverick X4 is poised to change the treatment landscape in chronic neutropenia starting with WHIM and expanding into idiopathic, cyclic, and congenital neutropenia. And X4 is ready for this transformation. We are ready to go. And one last thing before we conclude. We'd like to officially welcome Dr. Murray Stewart as our interim CMO. He has a wealth of experience in the development and launch of rare disease therapeutics from his previous CMO roles at GlaxoSmithKline and Rhythm Pharmaceuticals. And he has helped guide multiple successful NDA filings throughout his career. We are fortunate to have him join us during this exciting time for X4. Murray is on the call with us today. Murray, would you like to say a few words?
spk07: Thanks, Paula. I'm really pleased that I'm able to support X4 at this time. I look forward to working with the whole X4 team as we're poised to unblind the Phase 3 data and advance as quickly as possible to an NDA submission. Having been part of the X4 story for several years now, I'm really excited to help the company bring an important new treatment option to patients.
spk09: Thank you, Murray. And with that, why don't we now open the call up for your questions? Operator?
spk02: Thank you. We will now begin the question and answer session. To join the question queue, you may press star then one on your telephone keypad. You will hear a tone acknowledging your request. If you're using a speakerphone, please pick up your handset before pressing any key. To withdraw your question, Please press star, then two. We will pause for a moment as callers join the queue. The first question is from Stephen Wiley with Stifel. Please go ahead.
spk01: Yeah, good morning. Thanks for taking the questions, and I appreciate the update and the overview ahead of data. I know that it was mentioned, I guess, the average ANC count of patients pretreatment. Do you happen to know also what proportion of patients pretreatment were severely lymphopenic as well in terms of what the average ALC was?
spk09: Hi, good morning, Steve. It's Paula. Thank you so much for the excellent question. I think my understanding is they are quite severely lymphopenic as well. The actual number, I think, is escaping us at this moment, but I believe we published in an abstract back in April some of the details. So, we're happy to take that offline with you and make sure you get that information. Okay.
spk01: No, that's fine. I can dig that up. And then, have you been able to see just the blinded infection rate that's been observed in the trial to date? Just curious as to whether or not that's information that you're privy to, and I guess whether or not that's kind of tracking to expectations.
spk09: Yeah, so we are able to look at overall blinded safety-related events, which of course infections are one of them. I'll refer to Diego to provide any more context on that.
spk05: Yeah, this is something that the team has monitored, as Paula said, and yeah, we have seen infection events. Of course, we're completely blinded. We have a very rigorous process of central adjudication, and they are actually working now to finish that, and that will poise the trial to help us You know, it's one of the metrics of clinical benefit that we are tracking, obviously, among several others. But yes, I think we've seen a good number of infections that we believe is consistent with what we expect now that the pandemic impact has been somehow mitigated.
spk01: Okay, that's helpful. And then, just lastly, maybe a little bit of a bigger picture question, but I know that you're kind of now talking about the addressable patient opportunity as being, I guess, in the 50,000 range. Um, I know that you had previously indicated or estimated that the proportion of patients, I think in the U S who were on chronic GCSF was, was maybe somewhere in the 2,500 range. Um, How do you think about the disconnect between those two numbers? How do you close that gap in chronic neutropenia specifically? And then how does that 50,000 number factor into your thoughts around this initial Maverick Sephora price set?
spk09: Yeah, so a couple things, Steve. Thank you for highlighting that disconnect. So the 2,500 number that we threw out previously was really based on registry data, so of course it doesn't really capture the average utility out in what I would call the commercial setting, number one, and it's very difficult. So GCSF is used intermittently in many patients, so how you define chronic, semi-chronic is another challenge for us as we consider the number of patients on G. Then also to highlight, only about half of them can tolerate it based on our patient surveys. Of course, we don't even know what we're not capturing underneath that approach as well. So I hear you on the disconnect. I'm actually not worried about the overall market size for folks with chronic neutropenia. It's a massively underserved market with a treatment that is incredibly painful to take on a daily basis. So we think there's certainly a lot of opportunity to further uncover these patients who really need something new.
spk01: And then just how that factors into diagnosis. how you're currently thinking about a pricing decision on Maverick support, with the understanding that you're still a ways away from having to make that decision?
spk09: Yeah, I mean, I think we've done enough price sensitivities even around WIM to appreciate that even numbers in the tens of thousands are relatively consistent with ultra orphan pricing around WIM. I mean, there's examples of this in the field already with the Vertex CF molecules. certainly getting, you know, into the tens of thousands of patients that they serve and commanding the price points of that particular treatment. So, I don't think there's really a, you know, sort of a deep consideration that we need to make as we think about the broader chronic utropenia markets.
spk01: Very helpful. Congrats on the progress. Thanks.
spk09: Thanks, Steve.
spk02: The next question is from Eva Previtero with Cohen. Please go ahead.
spk10: Hi. Thanks for taking our questions and congrats on all the progress. Can you remind us of the powering assumptions for the 4WIN trial? Are there any updated assumptions given the high enrollment numbers?
spk04: Yeah. Good morning, Eva.
spk05: As we said during the call, we use the change in the TAT ANC observed in the context of the phase two trial for powering the phase three trial. So based on the increase in the TAT ANC that we observed in phase two, of course there was a range, but we took that into consideration and concluded that to have at least 90% power, we needed around 18 patients minimum. As you heard, we ended up enrolling 31. We have excellent retention. So that's why we said earlier that right now we believe our power on the primary endpoint is greater than 95%. And the same goes for the top secondary endpoint. As Paula said, it's really important to show that we are impacting not only neutrophils, but also lymphocytes, because that goes to the core of this disease.
spk10: Great, thanks. And what's the latest estimate on the prevalence of WIM based on all the research you've done? Are there any updates on new genetic variants or anything?
spk09: Yeah, no, I mean, we continue to feel very comfortable with guiding to 1,000 or higher with WIM syndrome. It's actually fascinating some of the publications that will be coming out or have come out around additional genes even beyond CXCR4, such as CXCR2. So we think we're just at the very beginning. Our physicians are incredibly excited about, you know, potentially supporting their approach to diagnosis, of which obviously genetics is a component, and we'll keep you updated as we refine that any further.
spk10: Great. Thank you.
spk02: The next question is from Mayank Mamthani with B. Reilly Securities. Please go ahead.
spk06: Good morning, team. Thanks for taking our questions and look forward to working with you, Murray and Stuart. So just maybe first question, as I was comparing between the baseline characteristics for phase two and phase three, you know, beyond having now a pediatric cohort, which you didn't have, could you just give us a little bit more color on the clinical presentation of the patients that you have here in phase three versus the phase two. And just remind us what presentation was required for all patients that baseline. And also, if you excluded any prior exposure to paroxypro, and if you permitted any ongoing treatment for GCSF in the study, if you could remind that, that would be great.
spk09: I'm sorry. I'm just going to repeat your question back to you. I hope I got this right. I think your fundamental question sounds like what's different or similar or different between your patient populations between phase two and phase three since we've included pediatrics in there. So Diego can highlight that. And then I think the second element of that was around GTSF use and how was it addressed in the phase three. So, you know, Diego, I'll turn it over to you for those two stage step questions.
spk05: Yes. Good morning, Mayank. So regarding the first question, so Phase II and Phase III populations are actually quite similar in the sense that they're all required to have WIMP syndrome. All of them actually had a CXCR4 mutation. The pretreatment ANC counts actually were almost identical. The main difference is that we opened up Phase III to pediatric, 12 to 17, while Phase II was only adults. You asked what type of clinical phenotype. As Paula mentioned earlier, WIN comes in different ways. So, we did not restrict by whether they have the W or all four letters. They had to be clinically diagnosed with WIN, genetically confirmed, and they had to have severe neutropenia, which they all had. So, we feel that phase three pretty much follows phase two. You also asked about GCSF. GCSF is used mostly intermittently. It's not well tolerated. So we only allow the use of GCSF as rescue therapy in WIM phase three. And it's something that really the doctors don't like much. So essentially, we have mostly a Maborixapol versus placebo trial, randomized, fully blinded, very high quality that we're very proud of.
spk09: And just, Diego, you might want to comment on the approach that we took to make sure we weren't confounding neutrophil counts with TAD ANC and GCSF use.
spk05: Yes. If somebody received GCSF as rescue therapy, we postponed the timing of the TAD ANC assessment to avoid the confounding.
spk06: Got it. And maybe just to clarify, any prior exposure to paroxyphor? And also thinking, because there was one patient on your phase two, which had an early rash, you know, he had prior exposure to paroxyphor. So, did you exclude that also?
spk05: We did not enroll anyone in phase three who had been previously exposed to mammolyxaphone. And in terms of rashes or Dermatology safety signals, we really have not seen much of that. I mean, we're blinded, but based on blinded assessment, we have not seen much. Nor did we exclude anybody for that basis as well.
spk06: Correct. Sorry, I did not mean Mavericks, of course, the other CXN for the injectable. And then my follow-up on the steps forward after the top line data, could you just lay out, you know, between the December top line data and then the early filing of, excuse me, the NDA filing and early second half, what are sort of the activities that you'd undertake on the VIM side and then If there is any overlap, you also talked to the regulators about chronic neutropenia indication with multi-dose durability data becoming available there. Could you just kind of help connect the dots there, how the interactions would progress on these two fronts?
spk09: So it sounds, Mayank, I think you're trying to kind of piece together the various kind of evolutions of WHIM and CNM regulatory, so we'll try to lay those out clearly. So the Phase III data will come in Q4. You know, on average, it takes about six months to file an NDA, give or take, so that's where we're putting it in the early part of second half of 2023. We're in excellent shape there in terms of just moving it forward and, of course, working with the agency as closely as needed. The important thing around chronic neutropenia, of course, is the amended protocol has been completed. We're moving forward with, you know, operationalizing that, which always takes a couple months at these sites. So we think we'll have some early data in the extension study around durability in CN. Of course, the WHIM Phase III will have a lot of durability data given its one-year dosing course. So that totality of data will be useful as we go in to approach the FDA regarding a chronic neutropenia registration trial. So the timing isn't, you know, finely tuned, but we believe when plus the end data plus regulatory conversations should be happening in the first half of next year to prepare us to Then, of course, file the NDA and WIM, and shortly thereafter, complete that registration clarity and kickoff advancing a CN Phase III trial subsequent to the NDA.
spk06: Great. Thanks for taking your questions, and it's been great working with you, Diego. All the best for your next adventure.
spk01: Thank you, Maya.
spk02: The next question is from Trevor Alvarez with Oppenheimer. Please go ahead.
spk04: Hey, good morning. Just wanted to ask a question on Waldenstroms. Any updates here on potential partnerships that might be developing? Thanks. No updates for this morning.
spk07: We'll come back and update as we make progress. We continue to focus on upcoming WIM data and the excitement around cryotropinia.
spk10: Anything else?
spk02: The next question is from RK with HC Wainwright. Please go ahead.
spk08: Thank you. Good morning, Paula, Adam. And most of my questions have been asked, but I just want to have an idea of what sort of data would be presented at the top line announcement. um this quarter and um and what else needs to get done um you know in terms of analysis between now and your filing in the sense trying to figure out if there will be additional updates before you file the bla
spk09: Sure. Thanks, RK. So, you know, as you can appreciate, top line is typically the primary endpoint plus safety. However, we're adding our first key secondary endpoint in there to specifically highlight the, you know, unique approach of Mavericks before the targeted therapy for all the combined immunodeficiency effects of Lyme syndrome. So we're looking forward to sharing a little bit more than usual. In terms of the totality of the data of the entire trial, of course, that's incredibly important to preserve for publication rights. So we do think that we'll be having an update at a relevant medical conference or via a publication, and we'll try to provide more guidance when we have clarity on that. And then, of course, I'll be rolling into our NDA submission early in the second half of next year.
spk08: Thanks for that, Paula. And then, you know, as you stated in late summer that you're focusing on the chronic neutropenia diseases at this point. When would be the next update on the chronic neutropenia study itself? And do you think we'll get additional clarity after we get through the 4WIM study or, you know, will there be any updates on those studies?
spk09: Yeah, so we plan for additional data updates on the CN trial in the first half of next year. Again, I'll try to provide clarity under what format or possibility medical conference, It's an exciting trial to be moving forward quickly with, and as we generate some interesting data under that, we'll take a cut and share it. Most importantly, I think for us, we really want to work with the agency. So it's really about the totality of data to support our regulatory conversations. We're all very bullish on moving this forward as quickly as we can to a CN registration trial. So stay tuned, and we'll look forward to providing those updates in the first half of next year.
spk08: Thank you very much, Paula, and I know it's an exciting quarter, so good luck with everything.
spk09: Thank you. It is very exciting.
spk02: This concludes the question and answer session. I would like to turn the conference back over to Paula Regan for any closing remarks.
spk09: Well, thank you so much for joining today. I did want to make one additional comment since it's now past 9 a.m., As you probably know, ASH 2022 abstracts were just published, and we're very happy to announce that our abstract on our Phase 1b chronic neutropenia study has been accepted for an oral presentation at this year's meeting. In addition, we've had several additional abstracts accepted for poster presentation, and these include two on chronic neutropenia, one on U.S. prevalence, and then the other on the voice of the patient. and one additional on the morphology of myelocathexis and WIMP syndrome. So a very productive ash for us. We look forward to seeing some of you in New Orleans in December. And with that, we're concluded, and I hope everyone has a wonderful day. Thank you.
spk02: This concludes today's conference call. You may disconnect your lines. Thank you for participating, and have a pleasant day.
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