David Mazzo
Analyst · H.C. Wainwright
Thanks, Doug. I will now touch on the other exciting programs in our pipeline. Among others, our CD34 cell technology has spawned the development of our product candidate for the treatment of critical limb ischemia, CLBS12, which is currently the subject of a registration-eligible clinical study in Japan. CLI is characterized by a severe obstruction of the arteries that significantly reduces blood flow to the lower extremities, principally the feet and legs and represents the end stage of peripheral arterial disease. CLI patients often experience severe rest pain, limited mobility, nonhealing skin ulcers and, if not successfully treated, eventual amputation. Please note that it is a well-documented, but not well-known fact that CLI patients have a higher mortality rate than patients with most cancers. CLBS12 was awarded a SAKIGAKE designation from the Japan Ministry of Health, Labor and Welfare for the treatment of CLI. The SAKIGAKE designation is a regulatory designation akin to an RMAT designation in the United States and affords the recipient prioritized regulatory consultation a dedicated review system to support the development and review process, including the option of a rolling J-NDA submission as well as reduced review time of 6 months for the CLBS12 registration application once filed. CLBS12 is also eligible for early conditional approval and possibly full approval based on the compelling nature of the complete data from our ongoing prospective, randomized, controlled, open-label, multicenter study in CLI patients in Japan. In addition, the European Medicines Agency granted CLBS12 advanced therapy medicinal product or ATMP classification for the treatment of CLI. ATMPs are defined as medical treatments that are based on genes or cells and are intended as long term or permanent therapeutic solutions to acute or chronic human diseases at a genetic, cellular or tissue level. This regulatory achievement sets the stage for us to work closely with European regulators to define the most expeditious development and regulatory plan to registration of CLBS12 in the EU. The ongoing study in Japan comprises subjects divided into 2 cohorts, a 30-subject group with traditional arteriosclerotic CLI and a 7-subject group with Buerger's Disease, a type of CLI often associated with heavy smoking. Those subject to a randomized treatment are dosed with CLBS12 in a single treatment through a series of intramuscular injections in addition to receiving standard of care pharmacotherapy. Subjects randomized to the control arm only receive standard of care with drugs approved in Japan, including antiplatelet agents, anticoagulants and vasodilators, the choice of which is made by the investigators according to the protocol. The study allows for the rescue of subjects in the control arm by indicating the crossover to treatment if their CLI is deemed to be progressing. The primary objective of this study is to show that CLBS12 can prevent the serious consequences of CLI by reverting the patients to a CLI-free condition through improved blood flow in the affected limb. CLI-free status is defined as 2 consecutive monthly visits in which rest pain is absent and previous nonhealing skin ulcers are completely healed as determined by an independent adjudication committee. As previously reported, and as you can review in our corporate presentation on our company website, the responses observed to date in the Buerger's disease cohort are very positive and consistent with the beneficial therapeutic effect and safety profile as reported by previously published clinical trials in Japan and the United States. For patients with Buerger's disease, amputation and even death are likely outcomes and no available pharmacotherapies prevent amputation. However, subjects in the fully enrolled Buerger's disease cohort in our study have achieved a remarkable remission rate of 57%, meaning that 4 of the 7 subjects have now met the primary endpoint and are CLI-free. It is worth repeating that the natural history of Buerger's disease patients is continued disease progression, often leading to amputation. So our data are extraordinarily positive. We are very encouraged by the study results to date and believe that they suggest a positive outcome for the overall trial, recognizing, however, that the final conclusions of the trial will be dependent on all data from all subjects. Enrollment in our trial continues to progress, though like most companies executing clinical trials around the world, we are experiencing a slowing of enrollment that is unpredictable in its rate and duration. However, we are very encouraged by the patient prescreening pipeline that has been identified, and we hope to conclude the trial enrollment rapidly once the coronavirus abates, and physicians are again able to treat non-COVID-19 patients. That said, our current best estimate is that we will complete patient enrollment during the second half of this year. With this delay, the timing of availability of top line data for the full study will likely shift into the first half of 2021, leading to an earliest possible approval in Japan in late 2021 or early 2022. Regarding commercialization, our strategy remains to license a partner CLBS12 in Japan. To that end, our conversations continue with prospective partners, and we continue to seek to consummate a deal in concert with the completion of the study, if not before. Turning now to CLBS16, our promising CD34 product candidate for the treatment of coronary microvascular dysfunction. Like all of our CD34+ cell therapy product candidates, CLBS16 uses a proprietary and patented formulation of CD34+ cells, specifically designed for an injection at/or near the site of ischemic insult, which, in the case of CMD, is an infusion into a coronary artery. CLBS16 is the subject of the recently completed ESCaPE-CMD trial, a 20-patient proof-of-concept clinical trial evaluating CLBS16 as a treatment for coronary microvascular dysfunction, a disease involving damage to the tiny arterial blood vessels, the micro circulation in the heart with no discernible large vessel blockages. Despite the absence of large vessel disease, CMD patients have an equally poor prognosis related to major adverse cardiac events and death as do patients who have identifiable large vessel blockages. But because obvious large artery blockages aren't seen, CMD is often underdiagnosed, misdiagnosed and/or untreated. It also should be noted that CMD is more frequently encountered in females, making this an important emerging women's health issue. CLBS16 is designed to address and reverse the underlying pathology of CMD by employing the CD34 cells' innate ability to increase microcirculation and thereby improve symptoms and hopefully improve the long-term outcomes in patients with coronary microvascular dysfunction. In November 2019, at the American Heart Association scientific sessions, we reported the data for those patients, 17 of 20, who at the time, had completed their 6-month follow-up visit in our ESCaPE-CMD study. The data showed highly statistically significant improvement in coronary flow reserve correlating with symptom relief for patients with CMD after a single administration of CLBS16. The results of the ESCaPE-CMD trial are not only important for defining the next development step for CLBS16, but they provide the first direct quantitative evidence in humans corroborating the mechanism of action of CD34+ cells, something which is supportive of all of our programs. These initial results were outstanding, and we look forward to reporting complete study data and conclusions next Thursday, May 14, at the SCAI 2020 Scientific Session's virtual conference. We expect to advance the CLBS16 program to its next clinical development step, a Phase IIb study, in the fall of 2020 with actual timings being driven by the impact of the COVID-19 pandemic on clinical trial initiation and execution. Moving on to our Phase III-ready CD34+ cell therapy product candidate in the United States, CLBS14. CLBS14 is being developed to address no-option refractory disabling angina or NORDA by stimulating the growth of a new microvasculature in an oxygen-deprived heart in those patients who have had large vessel disease treated with all available therapies, but still have debilitating angina likely due to microvasculature deficiency. Our confidence in this program is based on a series of published Phase I, II and III study results that indicate a consistency of therapeutic effect of CD34+ cells to increase exercise tolerance, improve heart function and decrease long-term mortality associated with the condition. As mentioned on our last quarterly call, we finalized with FDA the protocol design for a confirmatory Phase III trial to support the registration of CLBS14 for NORDA in the U.S. Due to the projected cost of the study, however, we have deferred its initiation in the United States pending confidence that we have acquired sufficient capital to fund the study to completion. Among the possible sources of capital are nondilutive grants and/or partnerships, both of which we are pursuing vigorously. And finally, I will simply reiterate our excitement for our CD34+ cell therapy program, CLBS119. As Doug just mentioned, we believe that CLBS119 could offer a potential treatment to repair severely damaged lungs in patients who have recovered from COVID-19, but continue to suffer debilitating lung effects. I'm especially proud of the progress our team has made in contributing to addressing the medical challenges presented by COVID-19. In short order, we have identified an unmet medical need; formulated a potential therapy to address that need based on sound science and biology; prepared, filed and achieved FDA agreement on an IND and proof-of-concept protocol; and initiated activities to make ready manufacturing to support the study. Enthusiasm for our trial in the medical community is high, and we look forward to enrolling our first patients as soon as possible and eventually sharing the results with you. So in closing, we are very pleased with the corporate and development achievements made in the first quarter. It is especially noteworthy that during these uncertain financial times, we have almost doubled our cash reserves, mostly from a nondilutive source and have initiated a clinical program directly relevant to the medical challenges presented by the COVID-19 pandemic. We expect to build on this momentum as we continue to advance our clinical development pipeline and strive to achieve a number of important development milestones throughout the balance of the year. More than ever, our experienced, dedicated and passionate team remains committed to the advancement of our programs as we work to bring innovative treatment options to patients in need and restore human health. And with that overview, operator, we're ready to take questions.