Rick Graham
Analyst · from Eva Xia Privitera from Cowen. Your question, please
Thanks, Rhonda. As we've covered in the past, slide 12 illustrates the design of the ongoing Phase 4 PIFR-2 study in patients with severe or very severe COPD and suboptimal peak inspiratory flow rates. Patients are randomized 1:1 to receive either revefenacin via nebulization or tiotropium delivered via dry powder inhaler and the primary endpoint is change from baseline in trough FEV1 at day 85. Enrollment is nearly complete, and we expect to have top line results late in the fourth quarter of the year. We're continuing to work with our partners at Viatris regarding the exact timing of disclosure, but currently intend to disclose results in January of 2024. On slide 13, I'd like to remind our audience briefly of the rationale behind the PIFR-2 study design. Our previously conducted PIFR-1 study published in 2019 included 206 patients, GOLD 2, 3 and 4 status and a peak inspiratory flow of less than 60 liters per minute. GOLD 2 through 4 patients have moderate to very severe COPD and baseline FEV1 of less than 80% of what will be predicted. In PIFR-1 revefenacin treatment did not demonstrate a statistically significant advantage over tiotropium, although there was a numerical trend favoring revefenacin, driven by GOLD 3 and 4 patients with baseline FEV1 of less than 50% are predicted. Importantly, a prespecified analysis of GOLD 3 and 4 patients shown on the right hand figure, demonstrated a clear and clinically relevant treatment benefit of revefenacin over tiotropium. We, therefore, designed the PIFR-2 study in this population of responders. COPD patients with suboptimal peak inspiratory flow and baseline FEV1 values of less than 50% are predicted. As Rhonda covered in her comments, the positive result from PIFR-2 would provide the commercial organization, a catalyst to help drive YUPELRI uptake in a portion of the maintenance COPD market whose symptoms are inadequately controlled despite treatment with handheld LAMA containing regimen. Turning to ampreloxetine. Slide 15 outlines the design of our registrational study, 197, also known as CYPRESS, for the treatment of symptomatic nOH and MSA patients. Based on the strength of the prior Phase 3 study results and alignment with the FDA on the primary endpoint and study design, we believe the CYPRESS study has a high probability of technical and regulatory success. The study consists of a 12-week open-label period, followed by an 8-week double-blind placebo-controlled randomized withdrawal phase. The duration of the open-label and randomized withdrawal periods were optimized based on the results from our prior 170 study. Given strong results from the 170 study, the primary efficacy endpoint in CYPRESS is the change in OHSA composite score. The composite score captures a broad set of symptoms and is expected to reduce variability relative to an individual symptom score such as OHSA number one, an endpoint that has been used in other programs. As announced last quarter, the Phase 3 CYPRESS study is open and actively recruiting patients, and we project enrollment to be completed in the second-half of 2024. I'm proud of the team's accomplishments as they've made good progress in activating multiple clinical trial sites in the U.S. with several are coming online in the near future. We have also made substantial progress with the new centralized EU clinical trial application process and expect to be in a position to activate a large number of EU sites throughout the second-half of this year. As shown on slide 16, we estimate that the addressable patient population for ampreloxetine is between 35,000 and 45,000 individuals in the United States. Despite two approved therapies indicated to treat symptoms of orthostatic hypertension, there remains a significant unmet need, which we believe ampreloxetine could address. First, based on data generated to date, we believe ampreloxetine has the potential to impact multiple symptoms of nOH durably with a favorable safety profile. Neither approved OH therapy has demonstrated broad and durable symptom relief in patients with nOH, including those with MSA. Second, ampreloxetine is dosed as a single 10-milligram tablet administered once daily. This is especially beneficial for MSA patients with dysphagia, which is a frequent and disabling symptom of the disease. Current therapies typically require patients to take multiple tablets several times a day. Third, patients within nOH are also at risk for supine hypertension, a dangerous decrease in blood pressure while lying down. The two FDA-approved therapies that are used for the treatment of orthostatic hypertension have black box warnings in the label, highlighting the risk and recommending both frequent monitoring and management thereof. Relative to the current treatment option, ampreloxetine has the potential to decrease the risk of in hypertension. At night, ampreloxetine remains in the system, resulting from its relatively long half-life. But because the natural norepinephrine levels are reduced during sleep, ampreloxetine does not cause overstimulation and as a result, reduces the risk of hypertension. In fact, in a safety database of more than 800 patients in healthy subjects, no signal for supine hypertension has been observed with ampreloxetine treatment. As we enter a new era in treating MSA symptoms, we believe ampreloxetine offers hope to MSA patients with symptomatic nOH. On slide 17, we summarize how the current treatment landscape translates into opportunity for ampreloxetine owing in parts only two therapies being FDA-approved, coupled with our limited effectiveness as well as safety and tolerability issues, treatment tends to be highly individualized in nOH. Issues such as inconsistent response to therapy and the risk of supine hypertension, complicated medical management and lead to high administrative burden. Depending on their experiences, patients may remain on therapy for only a short duration. Based on our clinical experience with ampreloxetine to-date, we believe that it offers significant potential to improve both the number of symptomatic MSA patients treated with pharmacotherapy for nOH and both compliance and persistence rates amongst those treated. Ampreloxetine appears to be safe and well tolerated, and given its differentiated efficacy and safety profile, we are optimistic that it will yield clinically relevant and durable benefit for patients. I'll now turn the call over to Aziz to review the financials.