Good day, and thank you for standing by. Welcome to Madrigal Pharmaceuticals' Fourth Quarter and Full Year 2024 Earnings Conference Call. At this time, all participants are in listen-only mode. After the speakers' presentation, there'll be a question-and-answer session. As a reminder, today's conference call is being recorded. I would now like to introduce Ms. Tina Ventura, Chief Investor Relations Officer. Please go ahead.

Thank you, Marvin. Good morning, everyone, and thank you for joining us to discuss Madrigal's fourth quarter and full year 2024 earnings. We're also sharing this morning new two year data from the active treatment open-label compensated MASH Cirrhosis or F4c arm of the Phase 3 MAESTRO-NAFLD trial. We issued a press release this morning and have a slide deck that accompanies this webcast, which we'll post on the Investor Relations section of our website right after the call. On the call with me today is Bill Sibold, Chief Executive Officer; and Mardi Dier, Chief Financial Officer. They'll provide prepared remarks, and then we'll take your questions. Dr. Michael Charlton, our Head of Clinical Development will join us for the Q&A portion of the call. Dr. Charlton has more than 30 years of experience in MASH as a leading hepatologist, Head of the Mayo Clinic Hepatology Group, and a treating physician. We plan to keep today's call to about 45 minutes. Please note on Slide 2, we will be making certain forward-looking statements today. We refer you to our SEC filings for a discussion of the risks that may cause actual results to differ from the forward-looking statements. And with that, I will now turn the call over to Bill on Slide 3.

Well, thanks, Tina. Good morning, and thanks for joining. Today, I'll provide an update on the significant momentum we're building with the U.S. launch of Rezdiffra. We ended 2024 strong, and we're pleased with how we've started the year in 2025. I'll also share an update on new two year data from an open-label study for F4c patients, as Tina mentioned. The results are very promising and support Rezdiffra's potential to benefit this high risk patient population, if approved. But before we look ahead, I want to take a moment to reflect on 2024, a year of remarkable transformation and achievement for the company. I've been in the industry a long time, and I've launched a lot of successful medicines. I'll be the first to attest to the tremendous amount of work required for any successful launch, let alone a first in disease therapy, and the launch of Rezdiffra is no exception. We worked to meet or exceed our high expectations last year and started to lay the foundation for Rezdiffra to potentially become a blockbuster therapy. I'm incredibly proud of our team's accomplishments highlighted on Slide 4. These are the things that we said that we would do and we did them. We built a world class team to drive the launch of Rezdiffra and support Madrigal's long-term aspirations. Our groundbreaking Rezdiffra Phase 3 trial data were published in the New England Journal of Medicine. On March 14, we achieved the milestone for the MASH field, the landmark approval of Rezdiffra, the first ever treatment approved for this disease. This achievement was further validated by two top tier liver societies in Europe and the U.S., both updating their guidelines to include Rezdiffra as first line therapy for MASH. And, we made significant progress expanding Rezdiffra's reach both geographically and…

Thank you, Bill. Earlier today, we issued a press release detailing our full financial results. I will highlight a few key takeaways for the fourth quarter and full year as noted on Slide 15. Fourth quarter net sales totaled $103.3 million, bringing full year 2024 net sales to $180.1 million, an impressive achievement considering this reflects only nine months of commercialization. We delivered another strong demand quarter with inventory well within the expected two week to four week range. Our gross to net discount increased in line with what we previously discussed. As we said, we expect some variability in gross to net early in the launch. Looking ahead to 2025, as expected, we anticipate an increase in the gross-to-net discount compared to 2024 as is typical at this stage of a specialty medicine launch. Importantly, this is already reflected in our expectations for robust year-over-year net sales growth in 2025. R&D expenses for the fourth quarter and full year of 2024 were $25.6 million and $236.7 million, respectively, compared to $70.6 million and $272.4 million in the prior year periods. R&D expenses decreased by $35.6 million in 2024 due primarily to a reduction in clinical trial accruals and the change in accounting for inventory cost following FDA approval of Rezdiffra, partially offset by an increase in headcount. Looking ahead, we expect a somewhat higher level of R&D spend in 2025 compared to 2024. SG&A expenses for the fourth quarter and full year of 2024 were $141.2 million and $435.1 million, respectively, compared to $46.5 million and $108.1 million in the prior year periods. This year-over-year increase was expected and reflects the rapid scale up of our U.S. commercial operations following Rezdiffra's approval in March 2024. Looking ahead, we expect SG&A expenses to increase in 2025 as we continue to invest in the U.S. launch and our international expansion. Turning to our balance sheet. We ended 2024 with $931.3 million in cash, cash equivalents, restricted cash and marketable securities. With this strong cash position, we are well resourced to support the ongoing launch of Rezdiffra in both the U.S. and our planned launch in Europe. I'll now turn the call back over to Tina.

Thanks, Mardi. Let's move into the Q&A portion of the call. Marvin, please go ahead and provide instructions for the Q&A session.

We will now open the lines for questions. [Operator Instructions] Our first question comes from the line of Thomas Smith of Leerink Partners. Your line is now open.

Hey, guys. Good morning. Thanks for taking the questions and congrats on the strong launch and the new cirrhosis data. I just had a question with respect to the ongoing Rezdiffra launch. Now that we're roughly two-thirds of the way through the quarter, so wondering if you could comment on what you've seen in the first-two months of the year in terms of new patient adds, any change in the cadence of patients starting on drug or anything notable as patients and prescribers kind of work-through their insurance or co-pay adjustments? And then historically, you've given some high level guidance based on the comp group of specialty drug launches, I guess, any color that you could provide as we think about Q1 and maybe 2025 broadly? Thanks so much.

Tom, thanks for the question. Look, as just a couple of points, first of all, 2024 was really an incredible year. When you think about going back 12 months from now, there wasn't a product on the market for MASH. And in a very short period of time, we've really done, I think a remarkable job executing and finishing-off the year with a $103 million quarter is really very impressive. By any measure you look at as we look at metrics all across the blockbuster launches that you referred to, we're tracking extremely well on all fronts. There's no weakness here on any of them. We carried, I would say, the momentum of '24 into '25 of steadily adding patients and prescribers, so that's -- we've seen more of that in the first quarter of '25. We also do have, like everyone else, the Q1 dynamic that is that clearly a phenomenon each year. And teams have been well-prepared and I think we're managing through that extremely well. As I think about what's happening at the prescriber level, each -- I would say there isn't a prescriber yet that has maxed out or even close to maxing out of the patients that exist in their practice or that are being referred into their practice, and each practice is learning. We talk about wiring the system, that's been a lot of hard work and we've done it on a practice-by-practice basis. And as you can see, we continue to add new prescribers and we're now at the 60% penetration into that target group. For each of those as they start prescribing, they're doing their wiring. So, what we're continuing to do is just bring on steadily each day, each week, each month, each quarter, prescribers, have them get ready to be able to handle the volume of their patients, how they work-through the system, et cetera. Now, from a Q1 dynamic perspective, as I said, certainly that's something that we're seeing like anyone else. I think the teams have done a good job getting ready to manage through that. No real other challenges that we've seen with the quarter, it's pretty standard.

Yeah. Maybe I'll just add a little bit, Tom, to answer your question about the analogs. So yeah, we do track very closely with our group of ten specialty launches over the last ten years. It gets a little tricky when you go from a Q4 to Q1. So, we're not giving specific guidance in that percentage for Q1 and may not go -- may not give that guidance going forward, but we're really tracking with these analogs thus far. But I will also say if we just look at consensus, as Bill said, we're very pleased with what we're seeing going into 2025. And a little commentary there that we believe consensus for Q1 2025 will narrow and go up a little bit, as a result of what we've been seeing so far.

Great. Thanks, Tom. Marvin, next question, please.

Thank you. One moment for our next question. Our next question comes from the line of Andrea Newkirk of Goldman Sachs. Your line is now open.

Good morning. Thanks for taking the question. Maybe I can ask you here on the cirrhosis data that you shared. I was hoping you could speak a little bit more on the clinical meaningfulness of achieving that 6.7 kilopascal reduction. And I know in the context of your three year data for the F2, F3 NASH patient population, we had talked about how a VCTE measure below 10 kilopascals was correlated with fewer liver related outcomes. Just wondering if that same threshold stands for the F4 cirrhotic patient population? And then finally, just how did today's data change how you're thinking about the NASH outcomes trial, if at all, and does that change how you're thinking about the powering of the study? Thanks so much.

Great. Thanks for the question, Andrea. I'll turn it over to Michael in a second. But as we think about how does it change our view on MAESTRO-NASH outcomes, look, we've been confident about that study. This is just another piece of information which gives us, I would say, greater confidence in it. We're doing something here, which is really, again, as we've done with our F2, F3 program, we're pioneering the way. And we believe that we have designed the right trial for MAESTRO-NASH outcomes. This trial that we announced today actually helped us -- helped to inform our thinking on MAESTRO-NASH outcomes. And with the really exciting news that we presented today, as I said, it gives us even more confidence. But maybe, Michael, do you want to answer the first couple of questions that Andrea had?

Yeah. It's a great question. The predictability of decreases in liver stiffness increases with a higher baseline level. So our baseline level was 25 kilopascals, the predictivity really starts to tick-up at around 15 kilopascal. So there are 6.7 kilopascal reduction, start with the starting point to 25 kilopascals. So should be highly predictive of decreased risk of clinical outcomes.

Great. Thanks. Thanks, Andrea. Next question, please, Marvin.

Thank you. One moment for our next question. Our next question comes from the line of Yasmeen Rahimi of Piper Sandler. Your line is now open.

Good morning, team and thank you so much for all the great updates. Is there -- I guess, could you comment on as we go into 2025, if you will be in a position to provide guidance? I think that Mardi, your commentary was very helpful around that the consensus is going to a little increase, tighten a little bit. So just maybe help us understand how you're thinking of -- thinking about moving forward. We understand the dynamics of first quarter. But beyond that, at what point will you feel comfortable to kind of share with us what the 2025 or 2026 guidance would look like, that would be really helpful, and I'll jump back in the queue.

Great. Mardi, let me pass that over to you.

Yeah. Thanks, Yas. Yeah. With respect to guidance, we've been very clear. We're not giving guidance right now. We consider it internally, but that's not something we're providing at this time. We're just too early in the launch. I did provide a little commentary on Q1 2025, and I think the same commentary goes for the full year '25. We like what we're seeing, the momentum going into 2025, we commented on the robust year-over-year growth. So, where consensus sits for 2025, we expect that to narrow as well, and go up a little bit based on what we're seeing.

Good.

Thanks, Yas. Marvin, next question please.

Thank you. One moment for our next question. Our next question comes from the line of Ellie Merle of UBS. Your line is now open.

Hey, guys. Thanks for taking the question. Interesting F4 data. I guess, were those FibroScan benefits seen irrespective of the liver fat content at baseline? And any color on sort of which patients were more or less likely to show these VCTE reductions? And then just in terms of this study, I guess, can we expect any further long-term data cuts from this study like the three-year data? Just curious the timing here since I think the study has been going on for a few years already? Thanks.

Yeah. Thanks, Ellie. Look, so more to come. This is just some really topline look at the data at an upcoming medical meeting. We'll go into a little bit more detail on things. I think there's certainly still a lot left that we can learn from this study, just with the data that we have at two years. Is there anything else, Michael, to comment on? We're not giving out any more than the topline that we've given today.

No, I think the predictivity for these results, the clinical outcomes and with the decline of 25% based on that study of 10,000 patients respectively, that 30% to 40% decrease likelihood of a liver related clinical event. So, that's our main takeaway from these results.

Great. Thanks, Ellie.

Thanks, Ellie. Marvin, next question please.

Thank you. One moment for our next question. Our next question comes from the line of Akash Tewari of Jefferies. Your line is now open.

Hey, this is Amy on for Akash. Thanks so much for taking our question. Starting off, just wanted to get your thoughts on the competitor FGF21 data in cirrhotic NASH and how that could read-across to your F4 outcome study. Also on Part D redesign, I think our preliminary math is getting to a potential full-year net sales impact of around 3% to 5% for Rezdiffra going forward. Just wanted to sense check this number with you. And will you do any additional discounts ahead of the summer launch? Thanks so much.

Well, Amy, thank you. That's a lot of questions to get through. Let me see if we can -- if we can talk through. First of all, as we launched the product, from a gross-to-net perspective, we have been extremely, extremely diligent about gross-to-net. We weren't contracting as we launched the product. And when we launched the product, we don't -- you don't think about launch in a quarter or two or four. You think about kind of the years ahead. And we thought about gross to net anticipating that there will be additional competition in the marketplace in time, additional indications hopefully for us, etc. So, we take an extremely disciplined approach here. Now, we will react to market dynamics as any company does. You always have a dynamic in Q1, which we've talked about. As it relates to working with the payers and so forth, there's a constant dynamic there. So, we'll continue to react to the market as these dynamics continue to shift. I think your other question was on Part D, I mean, look, Mardi, I think covered it a little bit in some of the opening remarks, but Mardi do you want to make any comments?

Yeah. I'll just say specifically about the Part D with -- how it impacts gross to net. Remember, Medicare patients are about a-third of our business. And Part D, we've always said that there will be some impact going into 2025 with the redesign, that's absolutely true. But we also had -- in 2024, we were paying Medicare rebates really. So the impact is a little more incremental in 2025 versus a significant step-up. So, I think the good news with our gross to net, particularly in 2025 is everything is going as expected, right? So, we see a little bit of increase, and our co-pay assist is as expected and included in our expectations for net revenue for the year.

Yeah. I mean our excitement and belief in this product and just also where you think about where we are, we're at the very beginning stages, all of this is taken into account to our enthusiasm. And then maybe on the first question that you had, Ellie, look, we're not going to comment on competitive data. But what we do believe is, we're very confident in our data. We think that the release of this, this morning gives us further confidence, as I said, in MAESTRO-NASH outcomes. The 6.7 kilopascal reduction, that really is meaningful. Michael and team, everyone's really excited and people that we've spoken to in the community as well. That's a number that really gets people's attention and we think that translates into a real meaningful effect for patients. And as we said, ours is an outcome study. We have followed FDA guidance and believe that we've designed the right study for approval.

Great. Thanks, Amy. Next question, Marvin.

Thank you. One moment for our next question. Our next question comes from the line of Liisa Bayko of Evercore ISI. Your line is now open.

Hi. Thanks for taking the question. Just two quick ones from me. First, the kilopascal change and the changes you talked about today, could you put that in context of any change in sort of F4 to F3 changes in fibrosis score? And then also just wanted to touch upon semaglutide coming to market in NASH and NASH story and how you think about your positioning there in particular with respecting to the pricing differential and how you might handle that? Thank you.

Yeah. Thank you for the questions, Liisa. You know, maybe I'll start off, and then I'll pass it over to Michael with your first question. But as it relates to sema, I think, look, we've been really clear. First of all, we're at the very beginning of this market evolution, right, less than 4% penetration. So, we've got many years of growth ahead. You then look at the profile of our product, we've got a great profile. As I look towards the future, I don't see any product with the profile that actually is as good as ours. Sema, assuming they come to the market, we're planning for that. We would assume that it's kind of maybe as early as late Q3, beginning of Q4. And that's a very different profile of product. Remember, the problem we're trying to solve here, you've got patients that are one to two steps away from cirrhosis. And what they can't afford is time. And by that I mean, you know, if you're waiting months to dose titrate and then have a high discontinuation rate, now you have to be on a drug for it to work. And the one thing that we do know is that with our liver directed therapy, it's easy to take, it works fast, and the results that we're seeing in the real world are extremely promising. So, what we believe is that actually assuming sema does get approved, it's actually going to drive additional market growth, which is something that ultimately as the leader in the space we're going to benefit from. But a kind of final point, this is a specialty market that can support multiple products being in it. It then comes down to things like profile, which we have a great profile, order of entry, we're first and have built this market. So, we feel extremely, extremely confident in our ability to grow through any of the potential competitive entrants. So maybe, Michael, why don't I turn it over to you for the first part of the question?

Yeah. It's a great question. The literature supports that when compared to baseline, a change in liver stiffness, a reduction in liver stiffness of 5 kilopascals or 25% in a comparable population, compensated cirrhosis is highly predictive for a reduction in fibrosis of one stage or more. So, that's how we would look at these stages. We had about over 50% of our patients achieved that 25% reduction threshold.

Great. Thanks.

Thank you, Liisa. Marvin, next question please.

Thank you. One moment for our next question. Our next question comes from the line of David Lebowitz of Citi. Your line is now open.

Thank you very much for taking my question. On the emergence of GLP-1s, once they actually get approved and they can officially get reimbursed for MASH, how do you think that impacts usage vis-a-vis Rezdiffra in terms of combination, do you think it makes it an easier discussion with payers or do you think it makes it a harder discussion?

Well, thanks, David. Look, looking at the data now and we've reported this before that about 25% of Rezdiffra patients are already on a GLP-1. And when you look at who's already been exposed, it's about 50%. So, they're already there being used for the comorbidities. And look, as a company, you know, we are supportive of GLP-1s being used in comorbidities that can benefit patients such as obesity. So, they're already there, that's the thing and they've been there for 14 years. Now, we know that at the lower doses, they clearly haven't had an impact on NASH because we're still seeing high diagnosis rates and so forth. So that -- they haven't -- they can only solve it at the highest doses. And we know that, that takes time and that there are challenges with tolerability. So, we really as we think about the GLP-1s coming in, it's going to be a market expansion focus that they're going to have, and we believe that given their profile and our profile, those patients are going to ultimately, the majority of them anyways are going to end up on Rezdiffra anyways, because they're going to still need to treat the problem that they're having, which is now a really severe liver disease, right? This is not a mild disease. We hear from patients all the time their stories of family members that have died as a result, and how grateful they are to have an opportunity to avoid that. So, we just -- we -- and we are fully planning on GLP-1s being here. We expect that with our profile, we continue to be the product of choice in the space. And as it relates to, I think you alluded to from a kind of an even payer dynamic perspective, hey, we -- with our profile and with the benefit that we've shown to preventing downstream costs, we think that we have an attractive profile. We've had extremely productive conversations with payers, and we believe that will remain the case with or without the introduction of GLP-1s.

Thank you very much.

Okay. Thanks, David. Marvin, next question please.

Thank you. One moment for our next question. Our next question comes from the line of Andy Chen of Wolfe Research. Your line is now open.

Hey. Thank you for taking the question and congrats on the new data. I'm just curious if you can talk about the Europe launch in the second half. So I believe the European regulators, they may be less receptive to your U.S. pricing. Can you talk about the unique challenges and opportunities there? Have you crafted a strategy to win there in that geography? Just curious if you could share some color there. Thank you.

Yeah. Thanks, Andy. I mean, look, I mean, remember, as we think about Europe, it's not Europe overall, it's going to be a country-by-country review and we will be extremely disciplined and we have an objective of within two to three years to be positive contribution in any country that we launch in. Obviously, a key piece of that is going to be the pricing. We think from an EPI perspective, there are patients there, the unmet need is there, and that tends to Europe overall kind of approximate U.S. patient numbers. Now, it's on a -- the regulators aren't obviously involved in the pricing discussion as you go country-by-country, talk to HTAs, etc., one of the things that I have found in previous launches is that if you have an innovative product that provides value, that there is a recognition of that value in Europe. Clearly, we will be having discussions with each of the countries and be making our argument as to the value of the product. Fortunately, we have really great data and we think that we will ultimately be able to support favorable pricing within Europe. However, as I said, we will be making decisions on a country-by-country basis, and we will pursue the countries where we believe the value of Rezdiffra is recognized.

Good. Thanks, Andy. Marvin, next question please.

Thank you. One moment for our next question. Our next question comes from the line of Ritu Baral of TD Cowen. Your line is now open.

Good morning, guys. Thanks for taking the question. Just following up on that, Bill. Can you talk a little more to the health technology assessment algorithms that you are preparing to face? What parts of the dataset that you've generated so far drive value that the national plans have either in writing or in meetings indicated they're willing to pay for? And then just a quick follow-up on the safety of the F4 open label dataset that you presented today. Just given even with compensated patients they're more fragile KOL focus has been on things like hypoglycemia and liver events. Can you give us the outlines of safety?

Yeah. So first of all, with discussions in Europe with the HTAs, I mean, look, as you know, there's a very formal process that you go through in each of the countries. You prepare your value dossier, and we're at various stages of that depending on the country. But again, a lot of this -- a lot of the evaluation looks at are you offsetting downstream costs, et cetera. I mean, I take you back to our ICER analysis, which showed it -- Rezdiffra to be a very cost effective therapy. So again, they use slightly different tools in each country, but we will be a part of that process. And we feel that the merit -- the severity of the disease and the merits of the product really do stand on their own. And we're looking forward to, I think, productive discussions that we'll have with each of those entities. Maybe Michael, do you want to comment briefly on the second question?

Yes. It's an important question. So, the same study, of course, included patients in other arms that had the lower degrees of fibrosis. And the AE, the type and frequency was comparable between patients with F4c and non-cirrhotic disease. It's a good question.

Good. Thanks, Ritu. Next question, please, Marvin.

Thank you. One moment for our next question. Our next question comes from the line of Prakhar Agrawal of Cantor Fitzgerald. Your line is now open.

Hi. Good morning, and thank you so much for taking my questions. So maybe Bill, you had previously talked about GI docs being a little bit slower to adopt. But maybe if you can talk about the latest trends there, what you're seeing in terms of the GIs versus hepatologists for Rezdiffra? Thank you.

Great. Thanks for the question. Look, the -- we're predominantly focused on hepatologists and gastroenterologists. If you just look at the numbers of those specialists, there's less than 1,000 hepatologists. So when we start talking about targeting 14,000 prescribers, you know, the overwhelming majority are gastroenterologists. So, on the backs of the gastroenterologists, we've really seen this really strong performance to date. So, when we talked about them coming on a little bit slower, it was a little bit more of the time that it takes to kind of wire their practice. They -- it's not a disease that they had been treating. So they had to hire staff in some cases if they wanted access to NITs and wanted their own NIT internally. So that -- it's just those mechanics to create the pathway within their practice, but they -- when they come on, they come on. And by that, I mean the gastroenterologists, I've been extremely, extremely happy with the way that they have adopted the product. And as I said, just based upon the numbers, they are really the driving force of the performance that we have seen and will likely see in the future. Clearly, the hepatologists are, I would say, and remain further ahead in most cases just because the liver is what they are most familiar with, they're more familiar with the disease, and their practices are probably initially a little better suited. But I'm really happy with what we've seen. We've seen some of the big super groups come on, and we've seen them go from, I would call more or less dabbling to full on NASH treatment and literally treating hundreds and hundreds of patients with many more to come. So, we're feeling that the evolution of the prescriber base is in a really great place. And I would say that the breadth of prescription that we're seeing in this launch is a true standout, and something which is a great prognosticator for future uptake of the product. You need prescribers, you need patients, and we have both of those.

Okay. Thanks, Prakhar. Marvin, it looks like we've got time for one more question, please.

Thank you. One moment for our next question. Our next question comes from the line of Catherine Okoukoni of Citizens. Your line is now open.

Hi. This is Catherine on for John. I just have a quick question about dose adjustment in the open-label -- two year open-label expansion. Did all patients stay at the 80 milligram dose? And also just as far as patient retention goes, how many patients -- how many Cirrhosis started the study and how many continued through the two year time point? Thank you.

Okay. Great. Michael, maybe I'll turn this one over to you for those specifics.

122 patients entered the second year of the open-label extension and these data are from 101 that had a second VCTE.

Thank you. And then general stay on dose?

Yes, everyone at 80 yes.

Everyone had 80. Great. Thanks, Catherine. And thank you all for your time and interest today. This now concludes our call. A replay of this webcast will be available on our website in approximately 2 hours. So, thanks for joining.

Ladies and gentlemen, thank you for your participation in today's conference. You may now disconnect. Have a wonderful day.