Joseph Belanoff
Analyst · Matt Kaplan with Ladenburg Thalmann. Please proceed with your question
Thank you, Charlie. Our Cushing's syndrome business is built on a solid foundation, a life-saving medication promoted by a commercial team that puts the interest of patients first. Leading endocrinologists increasingly believe that there are considerably more patients with Cushing's syndrome than was once assumed. Korlym is an excellent treatment for patients with Cushing's syndrome and there are many eligible patients who have yet to receive it. We are extremely optimistic about the growth potential of our Cushing's syndrome business and are making substantial investments to improve the screening and treatment of these patients. We are providing 2023 revenue guidance of $430 million to $450 million. In addition to generating substantial cash in 2022, we significantly advanced the clinical development programs of our proprietary selective cortisol modulators, relacorilant, dazucorilant and miricorilant. We expect to make further progress in the next 12 months with the submission of relacorilant's NDA in Cushing's syndrome and enrollment of our confirmatory Phase 3 trial of relacorilant in platinum-resistant ovarian cancer, Phase 2 trial of dazucorilant in ALS, and Phase 2 trial of miricorilant in NASH. Since inception, our research and development efforts have built upon the hypothesis the cortisol modulation can be a powerful therapeutic mechanism in many serious disorders. Our proprietary compounds modulate cortisol's effects by binding to the glucocorticoid receptor, or GR. They do not bind to the progesterone receptor, so it don't cause some of Korlym's, our approved product's, most serious off-target effects. Interestingly, while our compounds modulate cortisol's activity without modulating progesterone's activity, they are not identical. Some cross the blood-brain barrier, others do not. Some perform best in models of solid tumors, others are more potent in models of metabolic disease. Some appear to be tissue-specific, others have more global effects. These diverse qualities allow us to study a wide variety of disorders. Currently, we are conducting programs in ovarian, adrenal and prostate cancer, ALS, NASH and, of course, Cushing's syndrome. We are investigating cortisol modulation's role in other diseases and have additional compounds in clinical and preclinical development. Our Cushing's syndrome business has funded all of these activities and will continue to do so. As most of you know, we are evaluating relacorilant for the treatment of hypercortisolism in two Phase 3 trials: GRACE and GRADIENT. Relacorilant is a selective cortisol modulator. Like Korlym, it achieves its effect by competing with cortisol at the glucocorticoid receptor. Unlike Korlym, it does not bind to the progesterone receptor, PR for short, and so does not cause PR-related side effects, including termination of pregnancy, endometrial thickening and vaginal bleeding. By a different mechanism, relacorilant also does not appear to cause hypokalemia, low potassium, a serious side effect experienced by 44% of patients in Korlym's pivotal trial. Korlym-induced hypokalemia is a leading cause of Korlym discontinuation. Relacorilant's Phase 2 efficacy and safety data were compelling. Patients experienced meaningful improvements in hypertension and glucose control, as well as in a variety of other signs and symptoms of Cushing's syndrome. There were no relacorilant-induced instances of endometrial thickening or vaginal bleeding and no drug-induced hypokalemia. The trial results were published in Frontiers in Endocrinology in July 2021. We are pleased to announce that we believe that we have enough patients and screening in our GRACE trial to complete enrollment in the coming weeks. We expect GRACE to serve as the basis for our NDA submission in Cushing's syndrome, which we plan to submit in the first quarter of 2024. Our second Phase 3 trial in hypercortisolism, GRADIENT, is studying relacorilant's effects in patients whose Cushing's syndrome is caused by an adrenal adenoma or adrenal hyperplasia. Patients with this etiology of Cushing's syndrome often experience a less rapid decline, but their health outcomes are poor. While we do not expect our NDA in Cushing's syndrome to depend on data from GRADIENT, we do expect that its findings will improve the care of these patients. Finally, we plan to initiate a randomized double-blind placebo-controlled Phase 4 study in Korlym this quarter. We have named the study CATALYST. CATALYST will examine the prevalence of hypercortisolism in patients with difficult to control type 2 diabetes and treat the patients determined to have hypercortisolism with Korlym. Planned enrollment is 1,000 patients, which we expect to complete by the end of this year. The most prominent diabetologists in the country helped design and are participating in this study. Our oncology program is testing three anti-cancer mechanisms first postulated by investigators at the University of Chicago and later confirmed by other prominent researchers. One mechanism is increasing apoptosis, the programmed cell death that chemotherapy is meant to induce in solid tumors. Cortisol works against the beneficial effect of chemotherapy by suppressing apoptosis. In our successful controlled Phase 2 trial in women with platinum-resistant ovarian cancer, the addition of a selective cortisol modulator, relacorilant, enhanced the effect of chemotherapy, likely by blending cortisol's anti-apoptotic effect. Relacorilant provided meaningful benefit to many of the women in our study. While these women's disease had progressed on two or more previous lines of treatment, including previous taxanes, relacorilant appeared to resensitize the disease to chemotherapy's beneficial effects in some women. Those who received relacorilant intermittently, the day before, the day of and the day after they received nab-paclitaxel, exhibited a statistically significant improvement in progression-free survival and duration of response compared to the group who received nab-paclitaxel monotherapy. Women in the intermittent relacorilant group also live longer than those in the comparator arm, with a p-value that approached statistical significance. Our analysis to date indicates that 29% of the patients who took intermittent relacorilant were alive two years after study start versus only 14% who took nab-paclitaxel alone. 13% of patients who took intermittent relacorilant are alive three years after study start compared to none who took nab-paclitaxel alone. Perhaps even more important, the women who received relacorilant plus nab-paclitaxel experienced no additional side effect burden compared to those who received nab-paclitaxel alone. The results from the study were featured in podium presentations at the 2021 and 2022 European Society for Medical Oncology, ESMO, meetings, and at the 2022 American Society of Clinical Oncology, ASCO, Annual Meeting. ROSELLA, our pivotal Phase 3 trial in platinum-resistant ovarian cancer, is active and enrolling patients. ROSELLA's design closely tracks our Phase 2 study with planned enrollment of 360 women, randomized one-to-one to receive either relacorilant plus nab-paclitaxel or nab-paclitaxel alone. The primary endpoint will be progression-free survival with overall survival a key secondary endpoint. We are conducting the study in collaboration with leading clinicians from the Gynecologic Oncology Group in the United States and the European Network of Gynecological Oncology Trial groups in Europe. Our goal in Phase 3 is simply to replicate our positive Phase 2 results. Leading gynecological oncologists have told this that in their view, relacorilant's potential benefit, improved survival without increased side effect burden, would constitute an important medical advance, and relacorilant plus nab-paclitaxel has the potential to become a new standard of care in women with platinum-resistant ovarian cancer. A second mechanism by which cortisol modulation may prove useful is by blocking an important tumor growth pathway. Cortisol stimulation is a major reason why patients with prostate cancer treated with the widely prescribed androgen receptor antagonist, enzalutamide, eventually experience resurgent disease. Deprived of androgen stimulation, their tumor switch to cortisol activity to stimulate growth. Our hypothesis is that adding a cortisol modulator to androgen deprivation therapy will close this tumor escape route. By midyear, our collaborators at the University of Chicago plan to begin a randomized placebo-controlled Phase 2 trial of relacorilant plus enzalutamide in patients with prostate cancer before these patients have had an initial prostatectomy. A third therapeutic mechanism seeks to treat tumors by enhancing the body's immune response. Cortisol suppresses the immune system, which may blunt the effectiveness of cortisol -- of cancer therapies intended to stimulate the immune system. Our hypothesis is that adding a cortisol modulator to immunotherapies, such as checkpoint inhibitors, may enhance the effectiveness of these therapies. We are conducting a Phase 1b trial of relacorilant plus the PD-1 checkpoint inhibitor, pembrolizumab, Merck's drug KEYTRUDA, in patients with advanced adrenal cancer whose tumors produce excess cortisol. These patients suffer the effects of adrenal cancer and Cushing's syndrome, a usually quickly lethal combination. Pembrolizumab is rarely effective in treating this form of adrenal cancer. Our trial is evaluating whether relacorilant can treat these patients' Cushing's syndrome by reducing excess cortisol and by reversing cortisol-induced immune suppression, allow pembrolizumab to achieve its full cancer killing effect. The primary endpoint of the study is objective response rate, with secondary endpoints including progression-free survival, duration of response and overall survival. ALS, commonly known as Lou Gehrig's disease, is a devastating illness with an urgent need for better treatment. DAZALS, our 198-patient randomized double-blind placebo-controlled Phase 2 trial of dazucorilant in patients with ALS, has begun enrolling patients. Dazucorilant is selective cortisol modulator and has shown great promise in animal models of ALS, improving motor performance and reducing neural inflammation and muscular atrophy. We are conducting this important study in collaboration with TRICALS, the leading ALS academic consortium in Europe. Finally, I'll turn to our program in NASH, a serious liver disorder that affects millions of patients in the United States. Miricorilant, an oral medication, continues to demonstrate great promise as a treatment for NASH. In our prior NASH study, patients who received miricorilant exhibited large rapid reductions in liver fat, but also substantial, albeit transient, elevations of liver enzymes ALT and AST. The improvement in liver fat in these patients was greater and occurred much more rapidly than we had expected and is rarely seen over any period of treatment. Our Phase 1b dose-finding study has identified a range of doses, all substantially lower than our originally-tested doses that appear to cause substantial reductions in liver fat without causing excessive liver irritation. We expect to share results from this study by midyear and plan to start a Phase 2 trial later this year. In conclusion, we are extremely optimistic about the growth potential of our Cushing's syndrome business and are making significant investments to improve the screening and treatment of these patients. In the meantime, the business continues to generate substantial profits even after funding all of our development programs. Our development programs continue to generate evidence validating our long-held belief that cortisol modulation has the potential to treat a wide range of diseases. Reducing cortisol activity is a straightforward and effective way to treat Cushing's syndrome. It is also clear that cortisol modulation can offer substantial benefits for many other serious disorders. Ovarian cancer, ALS and NASH are prime examples, but there will be others. And in addition to relacorilant, dazucorilant and miricorilant, we have many other cortisol modulators in our portfolio with potential -- potentially different and valuable clinical attributes. Corcept continues to advance across multiple fronts. I thank our dedicated creative employees and loyal investors for making this possible. I'll stop here for questions.