Mitchell Steiner
Analyst · Jefferies
Good morning. With me on this morning's call are Dr. Gary Barnette, the Chief Scientific Officer; Michele Greco, the Chief Financial Officer, Chief Administrative Officer; Michael Purvis, Executive Vice President and General Counsel of Corporate Strategy; and Sam Fisch, Executive Director of Investor Relations and Corporate Communications. Thank you for joining our call.
Veru is a late clinical stage biopharmaceutical company focused on developing novel medicines for the treatment of advanced breast cancer and for acute respiratory distress syndrome related to viral lung infections. Our drug development program includes enobosarm as directive antigen receptor agonist for the treatment of second-line hormone receptor-positive HER2-negative metastatic breast cancer and sabizabulin, a microtubular disruptor for the treatment of [indiscernible] COVID-19 and other types of viral-related ARDS. The company also has an FDA-approved commercial product, the FC2 Female Condom, internal condom, put a dual protection against unplanned pregnancy and sexually transmitted infections. The revenue from the sexual health program is being used to partially fund the clinical development of our late-stage therapeutic candidates, which aim to address multibillion-dollar premium market opportunities.
We've had a very busy and productive third quarter fiscal year 2023. This morning, we will provide an update on the clinical development of breast cancer and viral ARDS drug candidates as well as the good progress on the commercialization of our FC2 product. We'll also provide financial highlights for our third quarter fiscal year 2023. Now as regard to our oncology program, the company's oncology drug pipeline is focused on the clinical development of enobosarm for the treatment of metastatic breast cancer. Enobosarm is a different and new class of endocrine therapy for advanced breast cancer. Enobosarm is an oral new chemical entity, selective antigen-receptor agonist that activates the androgen receptor in angio-receptor positive s-receptor positive HER2-negative metastatic breast cancer to suppress tumor growth without the unwanted masculinizing side effects and increases in nematicide typically seen with androgens.
Enobosarm has extensive nonclinical and clinical experience, having been evaluating 25 separate clinical studies in approximately 1,450 subjects dosed, including 3 Phase II clinical studies in advanced breast cancer involving more than 250 patients. In the 2 Phase II clinical studies conducted in women with angio-receptor positive ER-positive HER2-negative metastatic breast cancer, enobosarm demonstrated significant antitumor efficacy in heavily pretreated cohorts that failed estrogen blocking agents, chemotherapy and the CDK4/6 inhibitors, and it was well tolerated with a very favorable safety profile.
The current standard of care for first-line treatment of ER-positive HER2-negative metastatic breast cancer is treatment with a CDK4/6 inhibitor in combination with an estrogen blocking agent once the patient progresses while receiving this combination therapy and if there's no specific genetic mutations are detected, the FDA-approved treatment choices are limited to either another estrogen blocking agent or chemotherapy. As up to 90% of ER-positive HER2-negative metastatic breast cancers also have the antigen receptor, we're developing enobosarm, a selective angio-receptor targeting agent as another with very different hormone therapy for second-line treatment of ER-positive HER2-negative metastatic breast cancer.
In preclinical studies, metastatic breast cancer tissue samples taken from patients who have ER-positive/HER2-negative metastatic breast cancer that has become resistant to CDK4/6 inhibitors and estrogen blocking agents were growing in mice. In these mice, treatment with enobosarm in combination with a CDK4/6 inhibitor suppress the growth of the human metastatic breast cancer greater than a CDK4/6 inhibitor alone. Interestingly, the CDK4/6 inhibitor treatment caused the metastatic breast cancer tissue to make higher amounts of antigen receptor, which may explain the synergy of combining CDK4/6 inhibitor with enobosarm, a selective AR agonists. Further, enobosarm treatment alone was also effective in suppressing the growth of CDK4/6 inhibitor in estrogen-blocking human metastatic breast cancer tumors in mice.
We're conducting a Phase III clinical ENABLAR-2 study, with enobosarm monotherapy or in combination of abemaciclib, which is a CDK4/6 inhibitor versus nestin-blocking agent, which is the active control as a second-line treatment for AR+/ER+/HER2- medicine breast cancer. On March 30, 2023, the company met with the FDA to gain further agreement on our Phase III clinical trial design and program. The Phase III study has been amended to accommodate the FDA's latest recommendations to support the registration of enobosarm as a second-line treatment for patients with AR+/ER+/HER2- metastatic breast cancer to tumor progression while receiving a CDK4/6 inhibitor plus an estrogen blocking agent, in other words, first line.
The Phase III ENABLAR-2 study has 2 stages. In Stage 1 of the Phase III study, the objectives are to optimize the dose of enobosarm in the combination with abemaciclib and to assess the efficacy of enobosarm as a monotherapy. In the clinical trial design of Stage 1, we will enroll 160 patients into 5 treatment arms of 32 patients each. The arms are as follows: estrogen blocking agent, which is the active control, abemaciclib enobosarm 9-milligram combination therapy, abemaciclib plus enobosarm 3-milligram combination therapy, bemaciclib plus enobosarm 1 milligram combination therapy and enobosarm 9-milligram monotherapy. Primary endpoint for the Stage 1 is an objective tumor response rates also referred to as ORR. We are currently producing clinical supply of 1 milligram or 3-milligram enobosarm capsules for the additional dose optimization arms, which is expected to be available early next quarter.
The Stage 1 initial run-in enrolled 3 patients to assess the safety and pharmacokinetics of abemaciclib plus enobosarm 9-milligram combination. In this run-in portion, there were no drug-drug interactions between abemaciclib and enobosarm and were no new safety findings. Further, the early preliminary clinical results show 2 partial responses, 1 stable disease in the first 3 patients based on local assessments, and all patients are or were on study for over 9 months. By way of reference, the objective tumor response rates are about 4% for the estrogen blocking agent alone in similar patients as reported in the scientific literature.
In Stage 2 of the Phase III study, we plan to enroll approximately 200 subjects in a multicenter open-label randomized 1:1 active control clinical study to evaluate the efficacy and safety of enobosarm with and without abemaciclib therapy depending on the outcome of the stage First is an alternative antigen blocking agent in subjects with AR+/HER2- breast cancer, we've progressed while receiving a CDK4/6 inhibitor plus an estrogen blocking agent, again, the first line. The primary endpoint for the Stage 2 of the Phase III study is progression-free survival.
Our current plan is to have the Phase III stage 1 clinical results by late 2024 or early 2025. If enobosarm monotherapy of abemaciclib plus enobosarm combination therapy compared to an estrogen blocking agent, which is the active control, demonstrates significant improvement in ORR, which is considered as a surrogate endpoint for clinical benefit, then the company plans to meet with the FDA to consider an accelerated approval regulatory pathway based on the clinical data from the stage 1 portion of the Phase III study, whereas the Stage II portion of the Phase III clinical study will serve as the confirmatory study with progression-free survival as the primary endpoint. In January 2022, Veru entered into a clinical trial collaboration and supply agreement to which Eli Lilly supplies abemaciclib with the ENABLAR-2 Phase III clinical trial.
Now let's turn to our viral ARDS infectious disease program. The company is developing sabizabulin 9 milligrams, which is both a host targeted antiviral and broad anti-inflammatory properties as a two-pronged approach to the treatment of hospitalized patients with viral lung infections and high risk for ARDS in death. The company has completed a positive Phase II and a positive Phase III COVID-19 clinical studies that have demonstrated that sabizabulin treatment resulted in significant mortality benefit in hospitalized moderate to severe patients with COVID-19 viral lung infection in high-risk ARDS. As viruses that cause lung infections and ARDS do so in a similar way, the company believes that sabizabulin has the potential to be a treatment for all types of viral-induced lung infections, not only SARS-CoV-2, but also influenza A or B, respiratory syncytial virus, also known as RSV and other viruses in hospitalized patients on oxygen with high-risk ARDS.
We plan to meet with the FDA in September to expand the patient population of the agreed-upon Phase III confirmatory COVID-19 study into a Phase III study to treat hospitalized adult patients who have any kind of viral lung infection who are on oxygen support and at risk for ARDS. The way to think of it is COVID-19 represents one of many respiratory viruses that cause lung infections, pneumonia, that may progress the ARDS in death for which we've already conducted a successful Phase III study, demonstrating a mortality benefit with sabizabulin treatment. The Phase III was a double-blind randomized placebo-controlled study in 204 hospitalized moderate to severe COVID-19 patients and high risk for ARDS. The primary endpoint was a proportion of patients that died by day 60. And based on the planned interim analysis of the first 150 patients randomized the independent data monitoring committee unanimously recommended that the study be stopped for clear evidence of clinical benefit, and they identified no safety concerns.
In the interim analysis, treatment with sabizabulin 9 milligrams once daily resulted in the clinically meaningful and statistically significant 55.2% relative reduction in deaths compared to placebo. On May 10, 2022, the company had a pre-emergency use authorization EUA meeting with the FDA to discuss the submission of an EUA application for sabizabulin COVID-19 treatment. On June 7, 2022, at the request of the FDA, the company submitted a request for FDA emergency use authorization for sabizabulin adult hospitalized moderate to severe COVID-19 patients in high-risk to ARDS in death. On February 28, 2023, FDA notified the company that had declined to grant the company's request for emergency use authorization. In communicating its decision, the FDA stated that despite the FDA declining to issue an EUA for sabizabulin at this time, the FDA remains committed to working with the company in the development of sabizabulin.
Separately, at the FDA's Advisory Committee meeting, the FDA's statistical efficacy summary of our Phase III clinical study was presented in their Slide 88 of the FDA's presentation and was as follows: The study met the statistical criterion for stopping at the interim analysis. Data in all 204 subjects completing the study indicated treatment benefit for all-cause mortality at day 60. Results robust to missing data assumptions. Exploratory analysis indicate minimal impact of baseline imbalances and timing of enrollment with duration of standard of care, and it was a positive numerical trend consistent across subgroups defined by age, baseline WHO category, region and standard of care use at baseline.
On April 27, 2023, the company met with the FDA and reached agreement on the design of the Phase III confirmatory COVID-19 clinical trial to evaluate sabizabulin treatment of hospitalized moderate to severe COVID-19 patients who had risk for ARDS and the path forward to submit a new EUA application and/or an NDA. The FDA agreed to a confirmatory Phase III randomized 1-to-1 multicenter efficacy and safety study as sabizabulin 9 milligrams oral daily dose plus standard of care versus placebo plus standard of care in 408 hospitalized adult patients with moderate to severe SARS-CoV-2 infection with high-risk ARDS. The indication, in other words, the patient population for sabizabulin will also be expanded to include all hospitalized moderate to severe COVID-19 patients. In other words, WH04, which is passive low oxygen, WHO54 high flow oxygen with WHO6 mechanical ventilation without a requirement for a comorbidity. The primary efficacy endpoint will be all-cause mortality at day 60. Secondary endpoints include days in the hospital, days in the ICU, days in a mechanical ventilation and the proportion of patients alive without respiratory failure and an exploratory endpoint, which will be the presence of long COVID-19 symptoms at day 180.
In order to get a potentially efficacious drug to patients in an efficient time frame, 2 planned interim efficacy analysis will be conducted. The first planned interim analysis is expected to occur when 204 patients, which is 50% of the population has completed the day 60 primary efficacy endpoint. And the second planned interim analysis is expected to occur when 290 patients that 71% of the patient population have completed the day 60 primary efficacy end point. Either the interim efficacy analysis meet the statistical significance criteria, the trial could be stopped for efficacy. Should the prespecified primary efficacy endpoint analysis demonstrated statistically significant effect on all cause mortality favoring sabizabulin, the company may consider a new request for an EUA or a submission of an NDA as a company would potentially have 2 adequate and well-controlled trials to review. As the program has fast track designation, a rolling NDA submission is a possibility for subizibulin.
Now sabizabulin does have activity against influenza. So on April 4, 2023, the company announced results from a preclinical study of sabizabulin, demonstrating robust anti-inflammatory activity with improved outcomes in the H1N1 influenza induced pulmonary inflammation mouse ARDS model, and this was conducted by a team of researchers at LabCorp early development laboratories in the United Kingdom. Sabizabulin treatment resulted in a statistically significant decrease in the total number of inflammatory cells and a reduction in key cytokines and chemokines in lung fluid. Clinically sabizabulin treatment resulted in a reduction in severity of lung inflammation by histopathology and a dose-dependent improvement in lung function.
As for our case, we're expanding the indication to all types of viral margin infections in ARDS, well, viruses cause up to 1/3 of community-acquired pneumonia and viral infections can trigger the immune system to release an overwhelming amount of inflammatory proteins known as a cytokine storm. Cytokine storm causes tissue damage in lungs that lead to ARDS and patients who develop ARDS have a high mortality rate. As ARDS results in the overexaggerated immune inflammatory response by patients to the virus infection rather than by direct injury from the virus itself, and antiviral agent alone may not be effective. Sabizabulin is a host targeted antiviral and broad-spectrum anti-inflammatory agent has the potential to address the virus infection and the inflammation caused by the cytokine storm that causes ARDS, multi-organ failure and death.
Now we're in the middle of the summer surge for COVID-19 and another one is expected in the fall and the winter. In the current endemic phase, COVID-19 infection is estimated to be the fourth leading cause of death in the United States in 2023. ARDS remains a frequent serious complication of severe COVID-19 infection. It has been reported that up to 33% of hospitalized patients, COVID-19 have ARDS, and 75% to 92% of patients admitted to the intensive care unit with COVID-19 have ARDS. The mortality rate of COVID-19-associated ARDS is 45%. And among the patients who died from COVID-19, there's a 90% incidence of ARDS. As the COVID-19 endemic continues, there's also need to remain vigilant and focused on preparedness for the next wave of infections involving new viral strains.
COVID-19 will be a problem for the foreseeable future, and there's a need for effective therapies, especially for these hospitalized patients with moderate to severe COVID-19 infection in highways for ARDS. Further, the influenza burden estimates according to the Center for Disease Control and Prevention in the United States was up to 630,000 hospitalizations and up to 55,000 deaths in the past 9 months. RSV was responsible for 177,000 hospitalizations and 14,000 deaths among 65 years and older adults in the United States. Interestingly, the pathogenesis and the mortality rates for hospitalized influenza and RSV adult patients who have viral lung infections and who develop ARDS are similar to the COVID-19-associated ARDS. Patients with viral lung infections who are on oxygen support and who are at risk with ARDS represents a high unmet need and a potentially large market opportunity with very limited treatment options. Viral-induced pneumonia and lung infection is the leading cause of hospitalization in the U.S. according to the American Thoracic Society.
So although we have reached agreement with the FDA for the design of the Phase III confirmatory COVID-19 clinical trial, we believe that given the changing COVID-19 landscape, the need for an agent like sabizabulin and that has the potential to provide a mortality benefit in all types of viral lung infections that could lead to ARDS in death and viral lung infections in ARDS is a serious unmet medical need. The company now plans to meet with the FDA again to reach agreement on the design of the proposed expanded Phase III confirmatory study, evaluating sabizabulin 9 milligrams for the treatment of hospitalized adult patients who have viral lung infection on oxygen, who are at high risk for ARDS and death regardless of the type of virus and to confirm that a completed -- that the completed positive Phase III COVID study that we've already done and the proposed Phase III for all viral ARDS study together, we'll be sufficient to submit an NDA for the broader indication for the treatment of all hospitalized adult patients with viral lung infections on oxygen support and high risk of ARDS.
The FDA has granted a meeting with Veru in September of 2023. We will provide an update on the viral lung infection ARDS program after we meet with FDA and have appropriate clarity on this proposed study. Now if we reach agreement with the FDA, we will not pursue the Phase III confirmatory COVID-19-only study or the influenza A or B only study. Now the clinical precedent that informs us of our -- that informed us for this potential change in the regulatory and clinical strategy was actually set by AstraZeneca. AstraZeneca has begun enrolling a Phase III efficacy and safety of tozorakimab in hospitalized patients receiving standard of care for all types of viral lung infections requiring supplemental oxygen. And it's listed in clinicaltrials.gov NCT0562-4450.
The primary endpoint is the proportion of patients that die progress to invasive mechanical ventilation by day 30. And tozorakimab is an anti-inflammatory anti-IL-33 antibody that inhibits the IL family of cytokines. Now interestingly, in hospitalized COVID-19 patients on supplemental oxygen, similar anti-inflammatory antibody treatments had an absolute reduction in mortality of less than 5%. So [indiscernible], which is an IL-1 antibody had a less than 4.4% absolute reduction, and tozorakimab, an IL-6 antibody had less than 4.2% absolute reduction in mortality. In our Phase III COVID-19 study, which included patients on mechanical ventilation, treatment with sabizabulin a dual antiviral and broad anti-inflammatory agent resulted in a 20% absolute reduction in mortality.
Now in April, we submitted a requested FDA to reevaluate FDA's declination of our EUA for sabizabulin through FDA's formal dispute resolution process. The FDA denied our request for entry into the process, FJ stated that they're committed to working with us on sabizabulin. They have recommended we continue with our current clinical plan and to reach out to the FDA as often as needed under the Fast Track designation that support sabizabulin's development. Interestingly, in another development, the influenza and emerging infectious disease division of the Biomedical Advanced Research and Development Authority of the United States Department of Health and Human Resources, BARDA, is planning a large multicenter clinical trial in hospitalized adult patients with ARDS. BARDA states, "This clinical trial will evaluate the safety and efficacy of novel threat agnostic and host-directed therapeutics that can address ARDS caused by known and unknown health security threats such as pandemic influenza, COVID-19, other emerging infectious diseases and chemical, biological, radiological and nuclear incidence."
Veru was selected as one of the finalists and present us to visible to BARDA as a novel threat agnostic and host-directed therapeutic agent with broad anti-inflammatory and anti-inflammatory activities in hospitalized adult patients at high risk ARDS. The ARDS Therapeutics pitch event was called Just Breathe, was conducted at the end of July of 2023. We expect to be notified of the decision in early Q4 2023. BARDA plans to select up to 3 therapeutic candidates representing different mechanisms of action versus placebo for participation in the planned BARDA-sponsored ARDS clinical study, which would consist of 200 subjects per arm.
As you know, we're pursuing smallpox and the ebolavirus, other viral infections that may also lead to our ARDS in depth imposing a global public health wet society includes small pox and ebolavirus. A single outbreak involving any one of these viruses would be an immediate global emergency with limited existing options for treatment. On April 11, 2023, Veru announced positive results in preclinical in vitro study conducted by a team of researchers led by Dr. Brian Ward, Associate Professor of Microbiology and Immunology University of Rochester in New York. The preclinical study evaluated the effects of sabizabulin against the prototypical poxvirus called vaccinia virus, which demonstrates sabizabulin prevented both the release the poxvirus from infected cells and the spread of the poxvirus to healthy cells.
Sabizabulin as a host-directed antiviral and broad anti-inflammatory agent may be useful as a novel treatment not only against smallpox and other pox viruses, but also may reduce the hyperreactive immune response triggered by poxvirus that's responsible for severe pneumonia, ARDS, multi-organ failure and death. The company has a scheduled pre-IND meeting with FDA this month to discuss the animal rule regulatory requirements for assessing the efficacy of sabizabulin for smallpox virus. As you know, clinical human efficacy trials of drugs for preventing or treating smallpox virus is not feasible and you can't challenge studies, those challenge studies, we actually try to give smallpox to healthy subjects because that's unethical. Therefore, drugs with these indications are generally developed and approved and the regulatory pathway commonly referred to as the animal rule. The FDA may grant marketing approval based on adequate and well-controlled animal efficacy studies when the results of those studies establish the drug is reasonably likely to produce clinical benefit in humans.
Now I'd like to turn to our commercial business. The company sells FC2 in both the U.S. commercial sector and in the public health sector in the United States and globally. As the only FDA-approved female internal condom in the United States, FC2 is a well-established and serious business. We have sold over 750 million female condoms worldwide. And since 2017, FC2 has generated over $213 million of net revenue. We have and we plan to continue to invest the profits from the FC2 business to help fund the clinical development of our drug candidates in enobosarm and sabizabulin. Telehealth channel has become an important commercial strategy in the United States for access to birth control products, especially for our product, FC2, is a non-hormonal and latex-free option to prevent pregnancy and transmission of sexually transmitted infections.
In the recent survey of 6,000 respondents conducted by the Kaiser Family Foundation, 82% of the respondents said that the COVID-19 pandemic was not the reason they first access birth control online, which supports our strategy to provide contraceptive access using the telehealth portal. In the same survey, almost 5% of women reported getting the FC2 female continent was actually the #3 most prescribed contraceptive behind pills and emergency contraception. As a point of reference, we believe this is good news about the potential commercial opportunity for FC2 in the United States contraceptive market. If 5% market share shown in the survey is able to be extrapolated to the estimated $8.3 billion contraceptive market in 2022, with projections to grow at a compound annual rate -- growth rate of approximately 5.1%, there is potentially agree a $400 million market opportunity for FC2.
Accordingly, to have more direct control over promotion and distribution to maximize U.S. prescription sales of FC2, the company made a decision last year to launch its own independent FC2 dedicated direct-to-patient telehealth telecontraceptive portal. The company continues to invest in and grows its direct-to-patient telemedicine portal as well as adding new telehealth and Internet fulfillment pharmacy partners so we can provide coverage in all 50 states in the United States. Having taken the time to refine our marketing, drive operational improvements and enhance the patient experience during the initial launch phase, they are increasing new prescriptions being written and filled through our FC2 telehealth portal. During the third quarter of fiscal year 2023, we saw our new prescriptions grow over 115%, providing prescriptions to approximately 4,400 patients. We believe these results support our strategy and demonstrate high demand for FC2. We plan to continue to grow and deepen our investment in a profitable way by further expanding our presence both in social media channels and online search.
Now in the U.S. public sector, in the U.S. public sector, the company has seen a 115% increase in volume there the third quarter fiscal year 2023 versus third quarter fiscal year 2022. The growth is attributable to key U.S. public sector partnerships, including the company's recent announcement in April 2023 that has entered into a purchasing agreement with Afaxys Group Services, the #1 provider of oral and emergency contraceptives in the U.S. clinics. In the global public health sector outside the U.S., the company markets FC2 to entities, including ministries of health, government health agencies, UN agencies, not-for-profit agencies and commercial partners. We are currently supplying a large multiyear South African tender for female condoms, which is expected to continue until 2025, and we have seen sales grow in the current year as the current tender is launched. We also expect a former Brazil tender process to commence later this year.
Based on our experience to date, we expect revenue from our U.S. FC2 prescription business will demonstrate robust growth, both from our dedicated FC2 telehealth portal and from the addition of new telehealth and other commercial distribution partnerships. Furthermore, we intend to continue to leverage partnerships with entities in the U.S. public sector, such as state departments of health, 501(c)3 organizations that generated strong unit sales growth we have seen in fiscal 2023 from this channel.
Now the company had another FDA-approved product called Entadfi, which is a product for a new treatment for BPH that was approved by the FDA in December 2021. Product report the company's sexual health program. On April 19, 2023, the company ended to an asset purchase agreement with Bluewater Vaccines to sell substantially all of the assets related to Entadfi. Transaction closed April 19, 2023 and the purchase price for the transaction was $20 million plus $80 million in future sales milestones. I will now turn the call over to Michele Greco, CFO and COO, to discuss the financial highlights. Michele?