Mayukh Sukhatme
Analyst · JPMorgan. Your line is open
Yes. Thanks, Matt. Yes – so yes, please turn to Slide 13. So as Matt said, I want to take the opportunity to talk a little bit about one of, I think, what I consider one of the sleeping giants within our portfolio. To the extent that brepocitinib is going to get some notice for investors, I think it’s mostly through the lens of being a pivotal study catalyst for Roivant by the end of this year. And while that is true, we do have the lupus data later this year. I think the lupus story is just a small part of what we’re trying to build with brepocitinib. And so I want to go through that story of fresh here today, the punch line, from my perspective, is don’t sweat on brepocitinib. So put simply, brepocitinib is a unique, highly, highly active dual inhibitor of both TYK2 and JAK1 that has already shown spectacular efficacy in a broad range of auto immune diseases. So as Matt said, we’re reporting here for the first time the sixth consecutive positive Phase II study for brepocitinib this time in Crohn’s disease, which is a study that is being run by Pfizer and [indiscernible] expense. And that adds to the string of positive Phase II studies already reported, now covering as you see here on the slide, psoriasis, alopecia, toric arthritis, ulcerative colitis, hidradenitis to pertiva and nacho disease. And we’ll go through the rest of the material on this slide in greater detail later, but we think that we really have the potential to become the leading oral therapy and loop given the dual inhibition of TYK2 and JAK1 should provide greater efficacy than inhibition of either one alone. That is a large global study that is designed to serve as 1 of 2 registrational studies. And importantly, it is a 52-week study with a 52-week primary endpoint, which is the registrational endpoint that has historically been the most predictive of future studies. Our ongoing single Phase III study in dermatomyositis, which will serve as the basis of an NDA filing shortly asset data, is coming up, to the extent that it now seems a little far off. I think as we round out the year and are sitting in the first half of 2024, it will come into focus as a near-term catalyst ever. And that’s just the beginning for this program. So we think that, that unique dual mechanism and high demonstrated efficacy of brepocitinib really creates the pipeline and a product approach where we can own a series of specialty rheumatology indications, each of which has high unmet need and blockbuster revenue potential for brepocitinib, and we’ll show that in the coming slides. And then finally, we have a long IP runway here with protection to at least 2039. Please turn to Slide 14. So as many of you know, the JAK family consists of 4 IsoPol JAK1, JAK2, JAK3 and TYK2. The JAK family inhibition has proven over the past several years to be an enormously powerful mechanism for treating a wide spectrum of autoimmune disease. While the field has accumulated approval starting in rheumatology and moving on to a [indiscernible] as you see across the top, the underlying biology often remains complex and stubernly irreducible. Soon here is a simplified schematic detailing a number of key cytokines that have been shown to drive pathobiology of autoimmune disease along with the key JAK isoforms responsible for mediating those signaling pathway. While early JAK inhibitors were relatively nonselective more recently in the field has trended towards more specific inhibitors with JAK1 having the broadest applicability and therefore, unsurprisingly, the first to be explored. You can see here in the dark blue band across the middle or JAK1 inhibitors such as RINVOQ and the cytokines that are most directly impacted. Notably, selective JAK1 inhibitors are able as a press signaling of IL-6 and interferon gamma, two important cytokines linked to autoimmunity that are not suppressed to selective inhibition. Now the TYK2 selective inhibitors, such as the TYK2 now coming out of the scene in a particular set of indications. They cover a different set of cytokines, which you can see in the light blue on the right. Key among these are IL-12 and 23. The latter of which drives the differentiation and activation of Th17 cells and downstream IL-17 reduction, a key pathogenic driver of many auto immune diseases. Now both JAK1 and TYK2 approaches are accumulating a track record of meaningful clinical benefit and commercial success across a range of disease. RINVOQ is already approaching $1 billion from net revenue per quarter, and Sotyktu also projected to be a multibillion-dollar product. But in spite of their many successes, both of these medicines also have their limitations. Sotyktu, for instance, failed outright in both ulcerative colitis and crowns, while RINVOQ has produced lackluster Phase II data in both lupus and NHI. We see this at least in part connected to the underlying bio. While some disease may be well treatable by selective JAK1 or TYK2 inhibition loan, many others involve multiple inflammatory pathways and may require intervention across multiple orthogonal [indiscernible] to see maximum effect or maybe even to see a meaningful effect at all. The latter is especially true for heterogeneous highly inflammatory diseases, which have high patient burden for clinically meaningful efficacy to date and limited. So that’s what drove our original high pots at Roivant, that the field in its current state may not be slowly maximizing the power of JAK inhibition that efficacy might be getting left on the table in certain indications with highly specific TYK2 or JAK1 inhibitors. So in our search for the right molecule to prove out this hypothesis, we unsurprisingly ended up partnering with Pfizer, probably the company with the longest history and deepest experience with JAKs in the industry. In brepocitinib, we found a highly active, safe and well-characterized molecule with a novel mechanism perfectly suited for what we are looking to do. Simultaneous inhibition of both TYK2 and JAK1, which we can uniquely accomplish with brepocitinib creates 2 distinct opportunities to deliver differentiated efficacy. For diseases driven largely by Type 1 interferon signaling that is to say interferon alpha and beta, a dual hit on both sides of the heterodimer shown in the bottom in page, second from the right and schematic on the slide. May allow for greater suppression and thus potentially greater efficacy as compared to hitting TYK2 or JAK1 alone. And second, diseases with broad cytokine involvement that include, for instance, to IL-6 and B-cell pathways on 1 hand, and IL-12/23 and the IL-17 access on the other may actually be treatable with brepocitinib in a way that would not be possible to either JAK1 or TYK2 inhibition. So that’s the core hypothesis stated in the bottom line. Brepocitinib will deliver best-in-class efficacy in indications mediated by the TYK2 JAK1 diver and in diseases requiring broad cytokine coverage. Please turn to Slide 15. So what concretely drove our excitement of brepocitinib? So to start, when we looked at a series of standard cytokine inhibition assays, we saw exactly what we hope to see. So shown here are the results of studies run internally at 5. The left battle looks at type 1 interferon signaling, a key driver across multiple autoimmune diseases and one where both TYK2 and JAK1 inhibition would be expected to have an effect. That’s exactly what you see experimentally with NICE inhibition by the leading pure JAK1 inhibitor and NICE inhibition by the leading 2 inhibitor. And then importantly, Pfizer’s experimental data showed that brepocitinib is able to suppress type 1 interferon signaling as well as or potentially even better than either RINVOQ or Sotyktu. This is exactly what would have been predicted in the prior slide. We are benefiting from the double hit and thus achieving a greater inhibition of type 1 or brand signal. On the right, we show 2 other critical cytokine drivers. So on the top right, we see Type 2 interferon, interferon gamma, which is mediated by JAK1 but not by TYK2. So the pattern of inhibition is again, what you’d expect. You see that RINVOQ and brepocitinib, which both inhibit JAK 1 have a relatively higher degree of inhibition of interferon gamma compared to a selective TYK2 specific inhibitor Sotyktu. And then on the bottom right, you see the opposite performance from the single isoform drugs on a cytokine inhibition assay for IL-12 and 23, both of which are TYK2 and not JAK1 median. Here you see a nice inhibition by the Sotyktu, the TYK2 inhibitor, while the action of RINVOQ is much more modest. Again, that’s exactly what we’d expect based on the schematic we showed in the prior slide. And again, we see that brepocitinib is a very, very unique TYK2 mediated cytokine outperforming to TYK2 in this asset. The conclusions here, let’s at the bottom. On the left, you can see the brepocitinib should achieve greater type 1 interference suppression and as possible by targeting either TYK2 or JAK1 alone by virtue of the dual hit. And on the right, brepocitinib can reach sufitulate in a single molecule for cytokine suppression profile of both the leading TYK2 agent and the leading JAK1. Please turn to Slide 16. That cytokine vision experimental data has translated well into a string of Phase II data readouts to date. As you can see, oral brepocitinib has demonstrated an extremely consistent pattern of meaningful clinical efficacy in every single indication tested. Efficacy results for alopecia, caricarthritis, ulcerative colitis, psoriasis and HS were all statistically significant and consistent with as good or better than any other small molecule inhibitor. The HS data, which I’ll cover later, was a relatively recent readout that occurred subsequent to our taking over the drug from Pfizer. We’re also excited to be reporting today the induction results of a large global Phase II Crohn study run by Pfizer. So I’ll provide some additional details in the following slide. Finally, we have another major benefit in the clinical package for brepocitinib. We know what we have on safety as well. So we know that stacking both TYK2 inhibition and JAK1 inhibition does not apparently lead to a safety profile that undercuts the efficacy advantages that we hope to show. Our extensive safety database now consists of over 1,400 patients exposed across 20 different Phase I and Phase II clinical studies for up to 64 weeks. And what we’ve seen is a well-characterized safety profile in line with approved JAK family inhibitors. Please turn to Slide 17. So we’re pleased to report today the top line results from the induction portion of a Phase II study with repository Crohn’s disease. This is 151 patient global Phase II study. The primary endpoint was the SES CD50 and the key secondary endpoint was the clinical remission rate at week 12, defined as a proportion of patients who achieved a CDAI of less than 150 both endpoints were highly initially significant. We think that actually the true efficacy might have been understated on the SES-CD50 in the study as there ended up being a slight imbalance in baseline severity between the arms which made it harder to achieve that endpoint for the drug arm. That imbalance would not have an impact on the secondary end point since the way that, that endpoint is calculated only takes into account patients to start with a baseline CDAI of greater than or equal to 220. The point line here is that this is a trial that I’m sure it wasn’t on any investor’s radar and yet has delivered really strong efficacy. In fact, that 33.5% placebo-adjusted delta on clinical remission, which is used as a co-primary endpoint in registrational studies and is particularly important for prescribers is, in fact, the highest seen in the late-stage study from any drug oral or biologic to date. Please turn to Slide 18. So we find ourselves in an enviable position. So we have a highly efficacious molecule that has strong biologic and clinical translation in a variety of large market indications. There are lots of things that we could do with brepocitinib, but our vision with brepocitinib from the start was to really focus on those indications where we could deliver a step function improvement in outcomes for patients, generating maximum impact for patients and maximum return for our investors. To that end, we ask ourselves what are the disease indications where the unique properties of brepocitinib really shine. For us, that came down to a few simple considerations laid out on the left side of the slide. So in the light blue and moving clockwise, the first where is inhibition of both TYK2 and JAK1 required for maximal efficacy. Here we look for biologic rationale for dual TYK2 JAK1 inhibition and corresponding clinical validation. Second, in dark flu, which indications have extremely high morbidity and mortality, creating a need for novel therapies that provide a meaningful efficacy benefit. And third, in pink because the indication has few available treatments, including no approved oral therapies. And finally, of course, we need to be confident that we could run an efficient experiment, minimizing development and regulatory risk. Put those together, and we think that there’s an opportunity for brepocitinib to become a leading treatment option in a series of large and uncoded markets. The next two slides will go into more detail on the [indiscernible]. But remember, that’s just the beginning. Please turn to Slide 19. Dermatomyositis is a large orphan indication with a very similar profile to indications like PAH and cystic fibrosis where oral small molecules have become $1 billion plus products. Over the past 30 years, dermatomyositis has become much better understood and characterized in the medical community, an increasing disease awareness and diagnosis has led to higher incidents and proven estimates over time. We’ve done our own analysis with claims data from 2016 to 2020 and estimate that the U.S. adult pavilion sits at 37,000 patients, consistent with recently file estimates as well. So we’re looking at a patient population that is already clearly in the large orphan category. This is not an ultrarare indication. And as awareness and diagnosis of the disease continues to increase we expect the number of patients to grow over time. For an autoimmune disease of acting this many patients, dermatomyositis presents a strikingly high disease burden. There is high mortality with some estimates of up to 40% at 5 years. The characteristic skin rash is shown on the right, cover large percentages of the body and lead to significant pain in addition to disfigurement. The vast majority of patients also suffer from proximal muscle weakness, which can severely impact daily living activity. Many patients end up meeting walkers or wheelchairs. Finally, a meaningful proportion of patients suffer from intertial lung disease. In sum, this is a high mortality, highly inflammatory disease which covers multiple organ systems and will evolve into a large commercial market. On top of that, there have been no NCEs approved in the past 60 years, and there are no oral therapies in industry-sponsored late-stage development. Steroids, ISTs and IVIGs have been used in for many years, with the latter recently gaining formal approval. But again, there is not a single modern drug approved for the indication and the current treatment options present high safety and convenience burdens in addition to limited benefit. IVIG, for instance, requires multi-hour infusions for 3 or more days every month and is associated with side effects, including quite a high rate of thrombotic events. So we really CDM as one of the major unmet needs in all of autoimmune disease and an opportunity for a modern targeted therapy, particularly in Oral one to enter the market and rapidly become a blockbuster products. And while a number of companies are exploring small proof-of-concept studies, there are very few drugs in late-stage development and no oral therapies in Phase III, other than brepocitinib. So looking ahead to a product launch of brepo in this market in just 3 years, we think this has the potential to become a material commercial driver for Roivant as we think about the overall sales across our pipeline over the next 5-plus years. Please turn to Slide 20. We also see this as an indication where the case success for Bret is very high. With no modern medicines approved for DM, the physicians often experiment with various different therapies to add on to corticosterone, as a result, to investigator-initiated studies in an extensive body of case report. There is meaningful clinical validation for JAK1 inhibition in DM. This aligns with the pathobiology of the disease which is driven in large part by type 1 and type 2 interferon signal. Given no other JAK1 inhibitors are approved or an industry-sponsored development for DM, even if REPO just matched this level of efficacy that was set us up well for clear commercial success but there’s also reason to believe that the addition of TYK2 inhibition can further add to the benefit that brepocitinib will provide, both to enhance potency of type 1 interferon suppression. As well as through suppression of IL-12 and 23, which are also involved in pathobiology. Please turn to Slide 21. Given the high unmet need in our high competence poor success, we took the bold step of moving directly into a Phase III program that involves a single registrational study. Our expectation is that this study, if successful, would support an NDA filing for brepocitinib in DM. The single Phase III study is already well underway, tracking to complete enrollment in 2024 with data and a potential NDA filing in 2025. This time line has us clearly positioned to be the first oral to market by potentially several years and likely also ahead of a few biologics and later stage development. One idiosyncratic consequence of our decision to move directly into Phase III, is it means that our next catalyst in DM won’t be coming until 2025. But that catalyst could be a major inflection point for Roivant a business. with a potential $1 billion-plus product line immediately to fall. And given this launch would be in an orphan indication with a specialized prescriber base, we would expect the revenue ramp to be significantly steeper than for a volume product like VTAMA. So as you think about modeling P&L over the next 5 years and beyond, we think this is a major first additional value that investors right now may be underappreciated. Please turn to Slide 22. DM is the first of many orphan indications where we see a similar opportunity for brepocitinib not talk about a few more of those in a bit. But first, I want to talk to the other indication where we have an ongoing pivotal study where we do have a major catalyst coming up later this year, and that’s lupus. So lupus is a disease that everyone does well in that and is one that’s gotten an increasing amount of attention from industry in recent years. Hundreds of thousands of patients suffer from lupus in the U.S., many with serious and defeating disease. Only two therapies have approved – been approved in the past 20 years, both injectables and as a sign of how desperate the field is for occupancy, Enlist is doing greater than $1.4 billion in U.S. revenue despite very modest efficacy at between 9% to 14% placebo-adjusted SRI-4 and SEFNELO, which launched recently is projected to be a $1 billion-plus product despite mixed Phase III data. One study didn’t show fiscal consistence while the other showed about 18% placebo-adjusted SRI 4. Please turn to Slide 23. The limited options reflect an unfortunate reality everyone no Well, lupus is simply a very challenging disease to treat. It’s highly heterogeneous with multiple interconnected inflammatory pathways, acting on T cells, B cells and interferon signaling and multiple impacted organ systems. To date, most attempts to treat me this involve a molecule acting predominantly across 1 of these 3 acts. Enlist, for example, deplete B cells, while Senal suppresses interferon signal. Both have generated meaningful but ultimately somewhat modest efficacy. And of course, there’s a long history of sale attempts at individual cytokine inhibition, indicating bitocytokine suppression diseases as well. Through JUUL, TYK2 and JAK1 inhibition, brepocitinib is distinctively optimized to address all 3 axis simultaneously. TYK2 modulate T selected IL-12 and the IL-17 A17-axis to IL-23. The JAK1 arm migrates B-cell activity to IL-6, IL-7 and IL-21 and both are enforced together to maximum suppress pathogenic type in or Ceron signal. Please turn to Slide 24. Over the past 18 months, we’ve had readouts from 3 JAK inhibitors in lupus, including Phase III data from illumin, a JAK1, 2 inhibitor Phase II data from LINGO, the JAK inhibitor and Phase II data from Sotyktu TYK2 inhibitor. These data provide clinical evidence for the therapeutic relevance of each of JAK1 and TYK2, respectively. In lupus and as such, increased our confidence in brepocitinib’s positive effect. At the same time, none of these molecules have demonstrated particularly some selling benefit with the high water mark so far being Sotyktu to if you blooded across and roughly the mid-teens placebo-adjusted. This is what we might expect, given that unlike brepocitinib, none of these molecules directly targets all 3 inflammatory actives and lupus. So we are cautiously optimistic that through dual 62 and JAK1 inhibition brepocitinib can deliver greater efficacy benefit than we’ve seen from these other oral therapies and become the leading oral therapy for patients and physicians. Please turn to Slide 25. We continue to expect top line results from our ongoing study of brepocitinib in lupus in the fourth quarter of this year. As we’ve stated in previous earnings calls, this is a large global study using the registrational 52 we primary endpoint and as such, it is designed to serve as 1 of the 2 registrational cities. In the event of a positive outcome, we would expect to rapidly initiate a second confirmatory registrational study. I do want to emphasize that while we’re cautiously optimistic that brepocitinib can deliver data that will position it as the leading oral therapy in lupus, our confidence in the project success here is not as high as in dermatomyositis. We feel rock solid that we are hitting the pathways that matter, but we, as an industry, have had mixed success in proving out efficacy and regulatory end points such as SRI Lupus is just a challenging indication in that respect. And it was not the core bet that we underwrote when we in-licensed refract. That bed rather is the opportunity in dermatomyositis in the string of other large orpediations potentially fall and given the 6 successful Phase III placebo-controlled studies we had to date, our enthusiasm about brepocitinib in these other indications will remain irrespective of our results in lupus. Please turn to Slide 26. Turning now to these other indications. I just want to highlight 2 in addition to dermatomyositis where we have a rapid potential path to market with launches that could follow closely behind DM. A couple to highlight here are noninfectious guidance or NIU NHS. Please turn to Slide 27. NIU, like dermatomyositis is a large orphan indication with a very high disease burden with approximately 30,000 cases of legal blindness attributable to NIE each year. Unlike DM, there is one approved targeted therapy, HUMIRA which has generated over $0.5 billion per year in sales despite limited efficacy and almost no indication specific promotions. The development stages competitive landscape in IU is even more wide open than in DM with no ongoing Phase III studies at this time for any oral or biologic an efficacious oral therapy could easily match HUMIRA’s peak sales in this indication and with sufficiently compelling data, we could potentially do significantly more. Please turn to Slide 28. As with CM, we also have clinical validation of JAK1 inhibition and NIU. Before filgotinib development was discontinued in the U.S., it has generated Phase II data in NIU suggesting JAK1 inhibition may be more efficacious than TNF alpha suppression by HUMIRA. However, the extent and robustness of clinical validation of JAK1 inhibition in NIU is not quite as great as in DM. And so in this indication, rather than moving straight to Phase III, we are conducting a quick proof of concept to. This study also ensues dose ranging that would make a potential pivotal study even more efficient. We’re excited to report that this study is now fully enrolled with top line data expected in the first quarter of 2024. Please turn to Slide 29. HS follows a similar pattern to DM and NIU, a highly debilitating disease with a large orphan prevalence increasing over time through increased diagnosis and awareness. Here too, HUMIRA is the only approved targeted therapy with indication-specific sales of approximately $3 billion per year, again, despite limited efficacy and limited indications to stick promotion. Please turn to Slide 30. Unlike DM and NIU, HS does have other oral therapies in later-stage development, specifically 2 JAK1 inhibitors. As you can see on this slide, the pace recently generated by brepocitinib is great and placebo-adjusted benefit than that seen from either of these molecules. Brepocitinib benefit observed in Phase II also surpasses the 42% growth and 16% placebo-adjusted benefit in its Samira Phase III program. Notably, brepocitinib benefit was robust. It caused both TNF naive and TNF refractory patients and was generated despite the study being heavily impacted by COVID-related discontinuation. In fact, the placebo-adjusted benefit among completers was actually 27%, suggesting an opportunity to potentially demonstrate even greater benefit in Phase III than Phase II. This is further supported by HS pathobiology, which involves not only JAK1 mediated inflammatory pathways, but also the clinically validated IL-23 17 axis which is suppressed by TYK2 inhibition, but not JAK1 inhibition. Please turn to Slide 31. So I hope I’ve been able to convey in some small part, how excited we are about the potential for brepocitinib. It’s a highly active molecule with a unique mechanism of action and long patent life that sets us up to potentially create the leading oral specialty autoimmune franchise in the pharmaceutical industry. Here on this slide, you see how this pipeline and a product will build in the coming years. The successful lupus readout later this year clearly tees up a multibillion-dollar commercial opportunity in business alone. But even without lupus, we have a rapid derisk path to $1 billion-plus commercial launch in DM with full enrollment of our pivotal study coming next year, data in 2025 and a potential product launch in 2026. And then there’s a rapid pipeline of other large orphan indications to follow, each with blockbuster potential, a pivotal program in HS and NIU or both could be initiated in 2024. And we have other large orphan indications to follow with potential proof-of-concept studies planned for 2024. With that, I’d like to thank Ben Zimmer and the rest of the private team for all their work on brepocitinib so far and of course, to our colleagues at Pfizer for both partnering with us on this program, and of course, for all their work in discovering the compound and generating this really rich data set. And I’d also like to thank all the investigators, site personnel and importantly to patients who participate in these trials as well. And with that, I’ll turn it back over to Matt.