Aine Miller
Analyst · Liisa Bayko from Evercore ISI
Thanks, Rhonda. I'll begin on Slide 13 with a quick recap of our approach to CYPRESS. As many of you know, we met with the FDA in June 2022 and aligned with the agency around conducting a small randomized withdrawal study in MSA patients in order to confirm the durable benefits we saw in study 170, amidst the FDA's requirement for a full approval. Randomized withdrawal designs are well-established methods for demonstrating durable efficacy without exposing patients to undue time on placebo and are often used when the endpoint is a patient-reported outcome as is the case with the OHSA consolidates score. We knew that identifying the right sites in order to recruit the right patients would be crucial to CYPRESS potential success for a rare and clinically complex disease like MSA, we're making the differential diagnosis and addressing patient needs can be challenging, identifying experts and training study personnel is about most important. We, therefore, are prioritizing working with academic institutions and MSA centers of excellence to deliver a high-quality result. These sites are best equipped not only to identify the most appropriate patients for the study but also to manage their experience in a way that positions CYPRESS for success. We also made a strategic decision to manage the CYPRESS study ourselves, given our substantial experience working with this autonomy specialist, advocacy groups and other members of the broader MSA community. In doing so, we have strengthened relationships with decision-makers deepened our understanding of the unmet need and informed our go-to-market model with direct insights regarding how best to reach the patients and caregivers. While we have encountered longer time lines to site activations, as I'll cover shortly, we remain confident that our decision positions us for a high-quality study outcome and a differentiated message to support strong market access should CYPRESS read out as we hope and anticipate. Next, on Slide 14, I'd like to walk through the updated timing for achieving important milestones in the CYPRESS study and some of the factors that have led us to adjust the date at which we now expect to enroll the last patient into the open-label portion of the study to mid-2025. As we first reported in our Q1 2023 earnings call, CYPRESS recruitment officially opened at the end of March 2023 with the first patient enrolled in June of last year. While we opened a number of centers early on, we encountered difficulty ramping flight activations, primarily due to longer-than-anticipated contract completion time line at the larger academic centers for which we anticipate a significant contribution to patient recruitment. We also knew that we would work -- we'll be working with a new centralized EU clinical trial application process which allowed for a substantial number of countries to secure regulatory and ethics approval in parallel for which demanded a greater investment in time and resources approach. As highlighted on the left-hand side of this slide, these factors impacted our ability to achieve a significant number of planned site activations. We have been responding real-time to the evolving site activation and enrollment dynamics of the study. And while these measures have been positive, we are no longer confident that they are sufficient to return us to our original enrollment forecast, which is why we are updating our projections today. In recent one, however, with over 80% of our planned sites now activated, we are experiencing strong enrollment metrics. The majority of activated sites subscreen patients, many have already enrolled patients and our monthly cadence of patients enrolled into CYPRESS is robust. We also have a small number of remaining academic centers that will activate in the coming months which are liquated in areas of high numbers with MSA referrals. Overall, where we had previously expected to enroll the last patient into the open-label portion of the study in the second half of this year, we now believe that this milestone will likely occur in mid-2025. We believe we'll be in a position to report top line data approximately six months after having enrolled the last patient into the open-label portion of the study. Finally turning to Slide 15. I'll add a few comments on the importance of the CYPRESS study design. Beginning with the primary endpoint, we designed empowered CYPRESS to demonstrate a durable clinically important benefit with high probability. In doing so, we held many of the design elements constant from Study 170, where we achieved a clinically meaningful 1.6 point benefit on the OHSA composite score in MSA patients. We also sized CYPRESS appropriately. As a reminder, we achieved nominal significance on the OHSA composite with only 38 evaluable patients in Study 170 and are planning to enroll enough patients in CYPRESS to evaluate approximately 60 patients using the same composite four as our primary endpoint. In order to do so, we need to account for both study design and factors that will impact the number of patients completing all 20 weeks of the study. These include both the enrichment criteria in the 12-week open-label period, which are typical of randomized withdrawal design and consistent with Study 170 and potential discontinuations given the severity of the disease. Our firm plan is to enroll just over 100 patients into the open-label portion of fibers, but the actual number will be driven by our ongoing study experience. Our updated forecast also accounts to the need to ensure we have sufficient patients progressing to the randomized withdrawal portion of the study. Overall, we believe we have designed a study that will support full approval by the FDA and differentiate Ampreloxetine from pharmacological treatments currently offered to MSA patients suffering from symptomatic nOH, if successful. First, CYPRESS should highlight the broad symptom benefits of Ampreloxetine in MSA. Clinical experts developed the OHSA composite as a measure of global symptom burden, capturing the most frequent, debilitating aspects of organ hypoperfusion across the broader patient population. At last year's American Autonomic Society Conference, we presented data supporting a 1 point change on the OHSA composite of clinically meaningful location, which is something that the currently approved therapies have not demonstrated. By comparison, our MSA data from Study 170 supports Ampreloxetine's potential to deliver such a benefit and CYPRESS is designed to provide confirmation. Second, the CYPRESS study is designed to demonstrate Ampreloxetine's ability to deliver durable clinical bet. We believe this is supported by its mechanism of action, selectivity for norepinephrine at 10 milligrams attractive tolerability profile and convenient once-daily dosing. Third, along with the results from Study 170, a positive CYPRESS outcome would position Ampreloxetine to be the first therapy with a full approval specifically indicated for nOH patients with MSA. Taken collectively, we believe these attributes would make a strong case for Ampreloxetine differentiated efficacy when contrasted to the clinical track record and real-world experience of commonly used therapies in this underserved patient population. Unfortunately, none of the drugs currently available for nOH work well in MSA with 65 remaining symptomatic despite treatment. So there is an urgent need for an effective treatment that can help these patients, and we believe that overlain is specifically tailored to address nOH in patients with MSA. At this point, I'd like to turn the call over to Aziz to cover our financial results. Aziz?