Thomas A. McCourt
Analyst · Mizuho USA
Thanks, Michael. Well, it's been a busy and exciting few months as we and our partner, Forest, begin to introduce LINZESS to the U.S. marketplace. While still early and there's an awful lot to do, we're quite encouraged by the launch execution to date, as well as the initial patient and physician response, reinforcing to us the substantial commercial opportunities for LINZESS. Our sales and marketing teams, a fully integrated effort between ourselves and Forest, began promoting LINZESS in mid-December, and we've been encouraged by the success the team has had in their access and communication with both gastroenterologists and primary care physicians, with a particular focus initially on Gastroenterology. What we're hearing from our sales professionals, anecdotally, is that physicians are seeing a lot of suffering, dissatisfied adult IBS-C and chronic constipation patients. And that early experience on LINZESS has been favorable among both physicians, as well as with patients. This feedback is in line with the prescription data, which most of you have seen, signifying a strong initial uptick of LINZESS. The rate of adoption by both gastroenterologists and primary care physician appeared solid. And we're just beginning to engage and educate patients so they can more effectively communicate their symptoms and treatment history to their physicians. We're also pleased with some of the early positive decisions from a number of key national payers. We are actively moving forward to strengthen the clinical profile of LINZESS, and expand its clinical utility through additional approved indications and populations. And we're also looking forward to launch Constella in Europe with our partner, Almirall, expanding our global access to appropriate patients worldwide. As I mentioned earlier, the progress we've made to date is encouraging, but it's still very early in the launch. We and Forest are completely focused on maximizing the opportunity for LINZESS. And it is critical for us to learn as much as we can in these early days and apply these learnings to our continued launch execution. Beginning with our efforts to engage the broad physician base, we've been focused on both gastroenterologist and primary care physicians so they can understand the profile of LINZESS and can better identify all appropriate patients to be treated with LINZESS. Through our partnership with Forest, we have over 1,400 sales professionals who are targeting more than 80,000 physician, with the initial focus on the GI community and early adopting, high-volume primary care physicians, who are likely to establish the trend for future growth. Based on early feedback, physicians are not only seeing a lot of IBS-C and chronic constipation patients in need, they appear to be quite enthusiastic about LINZESS as the new treatment option for their dissatisfied patients, which is consistent with previous market research. One of our key launch objectives is to enable physicians and patients to quickly observe the benefit LINZESS can offer, so we implemented an early experience program. The combined sales effort has just completed distributing over 300,000, 30-day early experience kits to over 30,000 gastroenterologists and high-prescribing primary care physicians. Each of these physicians received 5 kits of all strengths to treat both adults with IBS-C and chronic constipation. The 30-day unit provide patients and physicians with an opportunity to critically evaluate the clinical benefits of LINZESS. We believe there will be a positive experience, and this experience will support continued treatment of LINZESS for these patients and thus, increase physician adoption. Additionally, we continue to provide all physicians with traditional 4-day samples of LINZESS to initiate and evaluate treatment response. Physicians appeared to be eagerly requesting both samples and early experience kits, which we believe is another key indicator of the demand for LINZESS. We are also launching physician peer-to-peer education program that involve trained gastroenterologists to speak to local gastroenterologists and primary care physicians to share patient, disease and LINZESS specific information that can enable these physicians to appropriately use LINZESS. We plan to conduct 10,000 programs over the next 12 months. In the initial months of launch, our sales professionals have focused their efforts on the highest potential influential gastroenterologists and high prescribing primary care physicians, as they are the key drivers of uptick out of the gate. We have been encouraged by the steady growth of adoption with LINZESS among these physicians, which tells us that both gastroenterologists and primary care physicians are now choosing LINZESS for many of their patients. Slide 8 illustrates the rate of adoption by top decile, high-prescribing gastroenterologists and primary care physicians. We predicted that these physicians would drive the initial uptick of LINZESS into the marketplace. And as you can see by this slide, over the first 4 months of launch, over 50% of top decile gastroenterologists and almost 20% of top decile primary care physicians have already prescribed LINZESS. There's also been steady growth in the lower decile physician. However, there are still thousands of physicians in these lower decile to represent a significant future opportunity. We will continue to educate and engage currently prescribing physicians, aiding them to identify all appropriate patients, as well as those physicians who are likely to be future prescribers of LINZESS, particularly in the primary care community. The peer-to-peer programs will enable gastroenterologists to engage and educate the referring primary care physician base on the appropriate use of LINZESS and share their personal experience that they've gained to date with LINZESS. As we've described before, there is currently about 44,000 Americans suffering from IBS-C and chronic constipation. Of those, about 15 million patients are actively seeking care, and about 10 million patients are actively seeking care, treated and not fully satisfied. These patients are likely looking for new treatments and are in their doctor's office on an average of 3 to 4x a year complaining of their symptoms. These 10 million adult patients consume over 30 million laxative units annually, whether a prescription laxative or an OTC laxative, representing a $6 billion opportunity for LINZESS. And keep in mind, there's an additional 15 million individuals who are self-treating and not satisfied, or they have stopped seeking care out of frustration. So all of these patients are also strong candidates for LINZESS. Not surprising, as you can see on Slide 10, the majority of LINZESS growth is coming from adult patients, who are either new patients seeking care, who are previously self-treated with OTC laxative, or are actively managed by their physicians and treated with OTC laxative. We're also seeing approximately 26% of patients being converted to LINZESS from other prescription treatment, primarily prescription laxative, and about 14% of patients having LINZESS added to other additional prescription therapies. These initial data are very encouraging because it shows that we are already seeking -- we're already seeing significant growth in the size of the prescription market, driven by either new patients seeking care or a conversion of OTCs to LINZESS. All this has been driving steady prescription growth over the past few months. As of the week ending April 12, almost 70,000 prescriptions for LINZESS were filled. And the volume of both weekly new prescriptions, illustrated in the graph by the dotted green line, and total prescriptions illustrated by blue line, have seen steady growth. There is also steady growth in the number of prescription refills, depicted by the solid green line. We'll be watching the data carefully over the next several months to understand patient persistence and annual days of therapy. Moving on to our patient education efforts. Ironwood and Forest are focused on educating patients to more effectively communicate their symptoms and treatment history to their physicians. These patients are high users of the Internet, seeking help and information online. So we've just began to launch a robust digital platform to connect with patients, and the early experience has been very strong. Approximately 1 million potential LINZESS patients have engaged and responded to an e-mail, an e-mail marketing campaign educating them on LINZESS. And hundreds of thousands have visited the LINZESS website after engagement in a banner advertisement. Importantly, there appears to be a high willingness on the part of physicians to prescribe LINZESS, as 80% to 90% of physicians report they will honor a patient request for a prescription. And we're encouraged to hear the feedback from physicians that patients are already beginning to request for LINZESS by name. In previous calls, we have identified the importance of payer access and reimbursement as the potential driver, or more likely, a barrier for primary care launches. It's been our objective to combine the strong clinical profile of LINZESS with the pricing contracting strategy that maximizes payer acceptance and ensures broad access to LINZESS for appropriate patients. Negotiation with payers are well underway. Initially, the majority of managed care payers are providing LINZESS a Tier-3 coverage, with either limited or no restrictions. We've already heard from a number of payers, in fact, with over 80 national and regional plans choosing to place LINZESS on formulary. To date, approximately 75% of patients and commercial insurance can access LINZESS with no restriction. Meaning, that they can fill their prescription without having to obtain a prior authorization or try in previous therapies. In addition, approximately 50% of patients with commercial insurance covered by national formulary to have access to LINZESS at Tier 2 co-pay, which is typically about $30 a month. Some of the payers who have already made formulary decision, include a few of the large -- including a few of the largest Pharmacy Benefit Management groups or PBM, such as ESI and Medco, as well as Catamaran. It's important to keep in mind that these PBMs put LINZESS on Tier 2 in an unrestricted status on the national formularies, which provide guidance to regional payers, who ultimately determine what formulary tier to place LINZESS. We are also thrilled to learn that Kaiser recently adopted LINZESS under Tier 2 unrestricted coverage. We and Forest will continue to work with payers as we seek to obtain broad Tier 2 coverage over time. For those patients not in Tier 2 coverage, we have implemented a LINZESS instant savings plan, an automated co-pay assistance program in early February, allowing commercial patients to fill their LINZESS prescriptions at a co-pay as low as $30 out-of-the-pocket, similar to a Tier 2 co-pay. This program includes a network of approximately 41,000 pharmacies, making it available to more than 90% of commercial patients. It is not only convenient and beneficial for patients, but also helpful for physicians as they have become increasingly more sensitive to the costs of prescription to their patients. We will continue to work towards ensuring broad access and reimbursement for LINZESS to reduce the financial burden on patients. We and Forest have made a lot of progress in executing the LINZESS commercial strategy over the past several months. We have considerable work to do to continue to accelerate the growth in the marketplace. Early adoption by physicians is encouraging, but we will continue to focus on expanding the prescriber base more broadly. We also will continue to work to improve communications between physicians and patients, educating physicians to identify the unmet medical needs of patients, and educating and enabling patients to more effectively communicate those needs. We will continue to work closely with payers to secure broad Tier 2 access with little to no restriction to patients. And lastly, we are working to strengthen the profile of LINZESS in its indicated population, as well as expanding the clinical utility of LINZESS to other approved populations and indications. It's important to keep in mind that we're just in the initial stages of building our linaclotide franchise over the long-term. As we expect, the patent protection to last through 2026, with patent term extension. There are a number of critical success factors to understand the leverage throughout the stages of life cycle management and in order to optimize the growth of success. We have previously talked about Prilosec and Zelnorm as reasonable, but not perfect analogs. These products had varying levels of success, but provide good insights around building the market-leading brand in the GI category. As we examine the growth accelerators, to no one's surprise, it starts with physician adoption. And the willingness to continue to prescribe the drug for broader patients, followed by physician's ability to identify this worldwide range of patients and appropriate patients. Patient adherence or the desire on the part of physician to stay on treatment is critical, as it can greatly accelerate growth over time. And the ability to attract patients to the product is a critical market builder, particularly in highly symptomatic diseases. Finally, leveraging the opportunity to build upon the key benefits of the drug and expanding utility to other approved indications or patient populations is the last critical element to accelerate our growth. The brand introduction phase tend to last the first 12 to 18 months of the product life cycle. To be successful in the introduction phase, the product must have a compelling clinical profile to grab the attention of the physician, who then needs to effectively be educated on the appropriate use of the product. Ideally, there exists an easily identified patient population with a clear unmet need that the patient can effectively serve. Creating urgency on the part of the physician to initially choose the product and gain a product positive early experience. The positive early experience is likely to lead to broader use in the appropriate patient population over time. Initial access and reimbursement to the brand should be a minimal barrier to physicians and patients to use the product. This has become a more important obstacle, as we've seen access to be more problematic than we saw with Prilosec and Zelnorm. Currently, we are making very strong progress on all fronts. As we move forward, it's critical to understand that while product education and promotion are important to introduce the product to customers, real world experience rules. To maintain an accelerated growth, the product must clearly demonstrate the benefit and value that will, in turn, bolster physician confidence, leading to broader use for their appropriate patients. And patients need to experience and recognize benefit to them, to continue taking the product. This will be particularly powerful in a highly symptomatic disorders such as GERD, IBS-C and chronic constipation, as observed with Prilosec for GERD patients, which benefited greatly from strong patient adherence. Strong demand will help to improve and maintain good payer access and reimbursement. And an effective product in a highly symptomatic disorder, such as IBS and chronic constipation, can attract new patients into the physician's office, who will request effective therapy and even the specific brand, building the category over time. We will continue to strengthen LINZESS' profile by leveraging existing and new data that will be generated from additional studies to further document improvement in additional abdominal symptoms and to better understand the potential tolerability and safety questions. There also appears to be a significant opportunity to manage co-morbid disorders with fixed combination products. Over 20 million adult patients who suffer from GERD, also suffer from either IBS-C or chronic constipation. Patients suffering from this co-morbid conditions appear to suffer from more frequent abdominal pain, constipation and heartburn symptoms, than patients suffering from individual disorders. A fixed combination of LINZESS, combined with the PPI, may provide these patients with an effective and more convenient treatment option to manage their symptoms. Our quest is to build a category leader and dramatically grow the category. To achieve a market leadership position, a product must be viewed as the leader for a specific disorder and become synonymous with goals of therapy, which establishes, builds and leads the category. Ideally, the product enhancement of science in terms of the understanding of the clinical benefit, but also its pharmacology deepens the understanding of the underlying pathology, paving the way the future of therapies. There are number of large commercial opportunities to expand this clinical utility for LINZESS. We are currently evaluating other indications including opioid-induced constipation, other forms of IBS, such as IBS mix or even non-constipating IBS. And finally, functional dyspepsia. We are also working with the FDA to determine whether to pursue clinical development in pediatric population. If we are successful on our efforts, these additional indications could serve millions and millions of additional patients. This greater understanding of the disease, expansion of the clinical utility and follow-up therapies enables the product line and this product to define and raise the standard of care beyond the reach of potential competitors that might emerge over time. We all recognize this is an ambitious goal, but we are optimistic that LINZESS can meet this goal, given the large number of patients suffering from frequent and bothersome symptoms, and who are actively looking for relief, combined with a strong clinical profile that can relieve many of their symptoms and satisfy their needs. I will now turn it over to Mark, who will provide a brief update on the progress with our GC-C franchise. Mark?