Q3 2023 Kiniksa Pharmaceuticals Ltd Earnings Call

Participants

John F. Paolini; Senior VP & Chief Medical Officer; Kiniksa Pharmaceuticals, Ltd.

Mark Ragosa; Senior VP & CFO; Kiniksa Pharmaceuticals, Ltd.

Rachel Frank; Associate Director of IR; Kiniksa Pharmaceuticals, Ltd.

Ross Moat; Senior VP & Chief Commercial Officer; Kiniksa Pharmaceuticals, Ltd.

Sanj K. Patel; CEO & Chairman of the Board; Kiniksa Pharmaceuticals, Ltd.

Anupam Rama; VP and Analyst; JPMorgan Chase & Co, Research Division

David Matthew Nierengarten; MD & Head of Healthcare of Equity Research; Wedbush Securities Inc., Research Division

Liisa Ann Bayko; MD & Fundamental Research Analyst; Evercore ISI Institutional Equities, Research Division

Paul Choi; Equity Analyst; Goldman Sachs Group, Inc., Research Division

Unidentified Analyst

Presentation

Operator

Good day, and thank you for standing by. Welcome to the Kiniksa Pharmaceuticals Third Quarter 2023 Earnings Conference Call. (Operator Instructions) Please be advised that today's conference is being recorded. And I would now like to hand the conference over to your speaker today, Ms. Rachel Frank. Please go ahead.

Rachel Frank

Thank you, operator. Good morning, everyone, and thank you for joining Kiniksa Call to discuss our third quarter 2023 financial results and recent portfolio execution. Press release highlighting these results can be found on our website under the Investors section. As for the agenda, our Chief Executive Officer, Sanj K. Patel, will start with an introduction. Ross Moat, our Chief Commercial Officer, will provide an update on our commercial execution. John Paolini, our Chief Legal Officer, will provide a KPL-404 forum review; and Mark Ragosa, our Chief Financial Officer, who will review our third quarter 2023 financial results. And finally, Sanj will return for closing remarks and to kick off the Q&A session.
Before getting started, please note that we will be making forward-looking statements today that are subject to risks and uncertainties that may cause actual results to differ materially from these statements. Review of such statements and risk factors can be found on this slide as well as under the caption risk factors contained in our SEC filings. These statements speak only as of the date of this presentation, and we undertake no obligation to update such statements, except as required by law. With that, I will turn it over to Sanj.

Sanj K. Patel

Thanks, Rachel. And good morning, everyone. I'm happy to review our third quarter 2023 financial results today. We continued to advance all aspects of our business, including strong revenue growth with ARCALYST and clinical trial execution with KPL-404. On the commercial side, Q3 represented another quarter of growth for ARCALYST with a net product revenue of $64.8 million. We continue to execute commercially, and we have seen strong prescriber adoption and patient enrollments in the third quarter. We also remain encouraged by the high patient satisfaction, payer approval rates and the duration of therapy.
And we're currently tracking towards the high end of our previously issued guidance of $220 million to $230 million for 2023. We're also executing across our clinical development portfolio, and we have now completed enrollment of the third cohort of the Phase II trial of KPL-404, which is our CD40 antagonist program and is focused in rheumatoid arthritis, and we now expect data from cohorts 1 to 3 in the first quarter of 2024. This trial is designed to evaluate the efficacy, dose response, PK and safety of chronic subcu dosing over a duration of 12 weeks.
Dr. John Paolini will cover more details on this program in a moment. Additionally, we continue to pursue collaborative study agreements with mavrilimumab to evaluate its potential in rare cardiovascular diseases. This is a molecule that has the potential to impact a number of diseases. So with that, I'll turn it over to Ross to review our commercial execution of ARCALYST. Ross?

Ross Moat

Thank you, Sanj. I'm delighted to share further details on our third quarter commercial performance and the underlying drivers of our continued strong revenue growth. In Q3, the net revenue of ARCALYST grew to $64.8 million. This represents approximately 94% year-on-year growth and just over $10 million growth quarter-on-quarter. That has been the case since launch, the vast majority of growth this quarter came from increased demand due to a higher number of patients on therapy as a result of increased new patient enrollments and strong compliance and persistence.
Additionally, the Q3 revenue benefited from a slight increase in inventory within the contracted range of our recently restructured specialty pharmacy network. The underlying driver of the continued increase in ARCALYST demand is our focus on a dual strategy of broadening the prescriber base as well as deepening the experience within existing prescribers. This strategy has resulted in more than 1,450 individual prescribers since launch, and off that higher base, 24% have now prescribed for 2 or more recurrent pericarditis patients. Our payer approval rate continues to be greater than 90% of all completed cases.
Patient compliance remains above 85% and the duration of therapy currently sitting at a total of around 20 months on average may continue to evolve as more patients get towards the longer durations of therapy. Moving to Slide 8. We're making good progress in continuing to build the market and change the treatment paradigm to establish artist as the standard of care in recurrent pericarditis. Through our experience launched to date, we've outlined several core priorities to drive our future growth. Firstly, we need to drive a proactive mindset for the identification and treatment of recurrent pericarditis patients.
In a Harris poll survey, 96% of patients reported that they were incorrectly diagnosed with other conditions prior to their recurrent pericarditis diagnosis. In fact, they had an average of 2.7 diagnosis before the recurrent pericarditis diagnosis. This highlights the substantial room for improvement that's possible by advancing education on the disease. Additionally, once a diagnosis is reached we need to evolve physicians' mindset to be more proactive in treating earlier and preventing future flares as well as increasing patient education on their disease and treatment options so they can advocate for themselves.
Secondly, we're focused on closing the knowledge gap by increasing the awareness of ARCALYST. We know that when ARCALYST is prescribed, both physicians and patients have a very positive experience. However, to continue growing the prescribing base, we need to increase knowledge within the broad cardiology and rheumatology audience. Based on a recent survey of 200 physicians, around 95% of the respondents were generally aware of ARCALYST. However, only half were very knowledgeable which we interpret as having the critical information you would need in order to make a prescribing decision such as who it's for, how it works and what the clinical data look like.
So again, we have a lot of opportunity ahead. The good news is that the percentage of physicians who consider themselves very knowledgeable has been growing. And more importantly, of the physicians who were seen by Kiniksa representative in the last 3 months, three quarters consider themselves very knowledgeable, which speaks to the impact of our sales force. Additionally, we're starting to evolve the treatment paradigm for recurrent pericarditis. While there are currently no consensus guidelines in the U.S., recent publications coming from thought leaders are introducing treatment algorithms that recommend interleukin-1 alpha and beta antagonism ahead of corticosteroids after a patient fails NCEs and colchicine.
When you look at the current prescribing patterns, around 1/3 of health care professionals report they're prescribing ARCALYST ahead of corticosteroids which suggests great progress so far since launch, but still a substantial opportunity for future growth. Also encouraging is that physicians overwhelmingly report that they intend to increase their future prescribing of ARCALYST, while 58% say that they intend to decrease their utilization of corticosteroids which is exactly aligned to our positioning of ARCALYST. Based on the progress we've made to date, we believe there is significantly more opportunity to penetrate the recurrent pericarditis market and we're excited to help even more patients who are suffering from this debilitating disease.
Overall, we're delighted with our progress over the last quarter, growing both our net revenue and the profitability from our collaboration. Based on our current trajectory and accounting for the headwinds of Q4 industry dynamics, and an expected level setting of inventory, we are currently tracking to the high end of the previously stated guidance range of $220 million to $230 million. With that, I'll hand over to John to discuss KPL-404. John?

John F. Paolini

Thanks, Ross. The aim of the Phase II trial of KPL-404 rheumatoid arthritis shown here is to evaluate the efficacy, dose response, pharmacokinetics and safety of chronic subcutaneous dosing over a duration of 12 weeks. As Sanj mentioned, we've completed enrollment in cohorts 1, 2 and 3 of the study. Subsequently, we initiated an additional or a fourth cohort of the study whereas Cohort 3 enrolled approximately 75 patients randomized in a 1:1:1 ratio to the 5-milligram per kilo subcutaneous dose level administered weekly versus biweekly versus placebo. This new fourth cohort will enroll approximately 40 patients randomized in a 3:2 ratio to a fixed subcutaneous KPL-404 dose administered monthly versus placebo.
Specifically, participants in the active arm will receive a 600-milligram loading dose on day 1 followed by 400 milligrams subcutaneously every 4 weeks for 12 weeks. We decided to initiate Cohort 4 in order to provide a more comprehensive picture of the KPL-404 PK/PD dose relationship. This additional cohort of patients is predicted to reach a trough exposure level, which is complementary to the trough exposure levels already being tested in the other arms of the proof-of-concept portion of the trial. The primary endpoint remains the same as Cohort 3, which was changed from baseline in DAS28-CRP at week 12.
While this study is designed to test the efficacy of different subcutaneous dosing regimens versus placebo, we are also going to be looking at the raw horsepower of the mechanism relative to the competitive landscape. We expect data from cohorts 1, 2 and 3 in the first quarter of 2024 and data from Cohort 4 in the second quarter of 2024. I will now turn it over to Mark to cover our financials. Mark?

Mark Ragosa

Thanks, John. Our detailed third quarter 2023 financial results can be found in the press release we issued earlier today. There are a few items I'd like to call your attention to this morning. First, total revenue in the third quarter was $67 million, including ARCALYST net product revenue of $64.8 million, representing 94% year-over-year growth and $2.2 million of collaboration revenue from the Genentech license agreement for vixarelimab; second, strong ARCALYST net product revenue in the third quarter drove ARCALYST collaborating operating profit to $34.6 million representing more than 275% year-over-year growth and leading to collaboration expenses of $17.3 million.
Third, higher cost of goods sold and collaboration expenses both of which were driven by our revenue growth as well as advancement of the KPL-404 Phase II trial in rheumatoid arthritis and investment related to ARCALYST commercialization contributed to year-over-year operating expense growth for the period. Lastly, in the third quarter, we received a $15 million development milestone from Genentech that was disclosed and recognized as revenue in the second quarter of this year. This led to net cash flow of $16 million for the third quarter and an ending cash balance of $201 million.
We continue to expect these reserves as well as strong ARCALYST commercial execution to fund our current operating plan into at least 2027. And with that, I'll turn the call back to Sanj for closing remarks.

Sanj K. Patel

Thanks, Mark. As you've heard today, and as demonstrated by our consistent execution, we are a well-capitalized and highly growth-orientated company. We're focused on maximizing the commercial opportunity with ARCALYST as well as providing data from cohorts 1, 2 and 3 of the Phase II clinical trial of KPL-404 in rheumatoid arthritis in the first quarter of 2024. In addition to the potential in RA, we believe KPL-404 could be a best-in-class therapy across a number of autoimmune indications.
Given the company's cash reserves of $201 million, strong ARCALYST commercial execution and our financial discipline, we have a cash runway into at least 2027. Ultimately, we continue to be focused on helping patients in need, creating massive value and making a generational impact, and we believe we are strategically positioned to do exactly that. I do want to thank you all for your time today, and I'll now hand it back to the operator for questions.

Question and Answer Session

Operator

(Operator Instructions) Our first question will come from Anupam Rama of JPMorgan.

Anupam Rama

Congrats on all the progress. I'm wondering maybe what are you seeing on the pull-through from the sales force expansion for ARCALYST? And how are you kind of quantifying the return on investment there?

Sanj K. Patel

Good to hear your voice. Ross, do you want to start and I can go and jump in?

Ross Moat

Yes. I mean, thanks, Anupam, for the question. I think I'll just start with saying you can see from the last couple of quarters worth of revenue performance, where we've had a pretty robust growth. I think a large part of that is down to the sales force expansion that we did towards the end of last year. And we said by the time that team were in place and trained, and we changed the territories around and had handovers we saw a jump up in activity in the early part -- late stages of last year in the early parts of this year and then an increase in patient enrollments associated with that higher activity.
And then really from the Q2 sales where we saw a growth of more than $11 million in the most recent earnings and growth of over $10 million. We're starting to see some of the fruition of that hard work out there in the field. And I think it just speaks to the potential that's out there, but also the spread of recurrent pericarditis patients, the importance of getting out broadly to the cardiologists of rheumatologists.

Operator

Our next question will come from the line of Paul Choi of Goldman Sachs.

Paul Choi

My first question is for John with regards to the addition of the cohort 4 to the KPL-404 study. The loading dose and the 2 other doses are higher than you're generally testing with the other weekly or every other weekly cohorts. So can you maybe just characterize for us, is there a view that you need to increase exposure here? Or given the monthly dosing schedule, is it more of a test to see if we can improve on convenience relative to the other cohorts?
My second question is for Ross just with regard to his comments on misdiagnosis and the lack of treatment guidelines. Can you maybe just update us on what the status is of potentially getting either a consensus ACC or AHA guideline inclusion and just kind of what the timing and gating factors are for that.

John F. Paolini

Sure. Paul, and thanks so much for your question. So with regard to Cohort 4, yes, the approach was to provide a more comprehensive picture of the PK/PD relationship. But to be clear, the weekly and biweekly KPL-404 dose levels actually provide plasma concentrations that are higher. So actually, the 400-milligram Q4-week dose sits in between the 2-milligram per kilo subcu dose and the 5-milligram per kilo subcu dose, thinking remembering that 5 milligrams per kilo is roughly 350 to 400 milligrams absolute depending on the weight of the patient. And so this actually provides us an opportunity to test not only that intermediate trough plasma concentration but also, to your point, to test the different dosing interval of giving it every month, which is, as you mentioned, more convenient.
And so that's basically the approach and the 600-milligram loading dose allows us to get to that trough plasma concentration quickly. And then, yes, the 400 milligrams every 4 weeks allows for the attainment of that trough plasma concentration, which is in between the other 3. Okay. And then, Ross, did you want to start with the other part of the question?

Ross Moat

Yes. Thank you. Thanks, Paul. So maybe I'll start with your misdiagnosis question I have back on to John for the treatment guidelines part. So I think for the misdiagnosis, obviously, we shared some information on how commonplace that could be among this patient population. And I think that really speaks to the need for education and awareness. I think we're taking good strides in but have so much more to do. We're seeing substantial increases around the awareness of the current pericarditis. And I guess previously, there were no targeted therapies approved for the current pericarditis. So now we're in a different place.
I think we're starting to see the ramp-up of education and awareness. And hopefully, we'll see improvements to the time that it takes for patients to get a correct diagnosis. So we're focused across both our field team from a sales perspective, our medical affairs efforts out in the field, boosting education to physicians direct-to-consumer awareness around doing things directly to patients so they can help to advocate for themselves as well as just in the digital forum around webinars and speaker programs and various other ways that we can get messages out there very effectively across the populations as well.
So we're seeing some good improvements to that, but certainly have a lot more work to do.

John F. Paolini

And then with regard to guidelines, maybe to point out that the last time guidelines were made was in 2015, and that was in the European theater. So the European Society of Cardiology put those guidelines out. And of course, that predates really almost any of the work in the IL-1 space.
And so in that treatment paradigm, patients progress after NSAIDs and colchicine through corticosteroids. And then it's only in patients that are resistant to corticosteroids that an antagonism is used. So therefore, the real evolution in the field came with the data from Rhapsody demonstrating not only the resolution of the acute pericarditis flare but also the prevention of subsequent flares while on therapy in 2 populations of patients, not only those who had been on corticosteroids, which is according to the old paradigm but also about half of the patients in the study had failed NSAIDs and colchicine and had not yet progressed to corticosteroids.
And so the similarity of the data in those 2 populations actually then provides an opportunity to advance the treatment paradigm into the space of using IL-1 antagonism in advance of corticosteroids. And so that is, in fact, what has been picked up in the literature by American thought leaders and showing kind of that sequence of how to best manage the disease. And so we see that as a very encouraging sign for patients to achieve resolution of their acute flares and prevention of subsequent flares on therapy.

Operator

(Operator Instructions) Our next question will come from David Nierengarten of Wedbush Securities.

David Matthew Nierengarten

I have two. Just on the patient stops and restarts again, with a little bit with another quarter worth of data, do you have any idea on the patients who discontinued therapy and don't return if there are less severe or earlier stage in their disease. I'm just curious to get kind of a handle on the distribution of time on therapy. I know it seems like you have a tail there with a stable percentage on longer-term therapy bacterias on the nature of those patients. And then the second question was on 404 if we could expect a discussion of any additional indications beyond RA when you release the data in Q1.

Ross Moat

Okay. Thanks, David. So this is Ross. Happy to answer the part around the restart patient stops and I guess just generally about what we're seeing around patient duration on therapy as well as a reminder that we really educate physicians that the duration of therapy should be linked to the natural history of the disease, which is 3 years as a median from a natural history and still 1/3 of the patients suffer from the disease 5 years out from their initial index episode as well.
So of course, the length of treatment should depend upon how long they've suffered from recurrent pericarditis at the time of diagnosis and treatment. And what we're seeing in the real-world setting is that the initial average time for treatment is around 14 months. The median is 12%. The restart rate is around 45% of all those patients who have cease therapy the first time around and come back on to therapy, most of which within 8-week time period. And we're seeing a total average duration of around 20 months in total across all the patient populations.
So your part of the question around the nature of the patients, I think it's fair to say that there's no real commonality in terms of patient demographics that we can pick out at this moment in time around those that are more likely to stop or stay on for longer and so on. It really just comes down to how long they've suffered from the disease at the time of diagnosis and what their expected natural history is how long they're going to need treatment for with ARCALYST knowing that, of course, there's always a safety net there that if they do stop and they stop too early and there's still underlying auto information present or the patient suffer again, they can go back on to treatment. But obviously, we want to avoid that happening through robust proper treatment duration of ARCALYST in the first place.

Sanj K. Patel

David, this is Sanj. Thanks for your question with regards to the cohort from the KPL-404 study in RA. We're definitely looking forward to those data from cohorts 1, 2 and 3 in the first quarter, as you mentioned. As I mentioned earlier, we're definitely excited about the potential of KPL-404 for both RA, but also do believe there is a potential to show hopefully some differentiated effects and some strong efficacy, hopefully across a number of autoimmune indications. At this point, we've not disclosed what those would be, but certainly washes space. We're looking forward to some hopefully exciting developments in the future, data dependent.

Operator

Our next question will come from Geoff Meacham of Bank of America.
This is John Joy for Geoff.

Unidentified Analyst

I guess I have 2 quick questions. One is, how are you guys thinking about sort of total prescriber TAM and payer like TAM, do you think there's still headroom to grow? Or are you starting to kind of see that flatten out a bit? And second, just as you continue to grow, how are you thinking about capital structure?

Ross Moat

Maybe I'll just take the first part, John. Thanks for the question, and then I'll hand over to Mark or Sanj for the second bit. And really around the prescriber growth and space just bear in mind that we still see that there's a huge opportunity ahead. We announced at the turn of the year that we reached around 5% penetration when we looked at how many patients were on therapy at the end of 2022. And while we haven't updated that figure as of yet, that speaks to the opportunity that's still there and the fact that patients are reasonably widely dispersed around the U.S., and we're seeing the good growth in both the number of individual prescribers as well as repeat prescribers.
I think all to speak to the opportunity that stand out there. I feel that we're still relatively embryonic in our launch with a pretty exciting opportunity ahead to reach many, many more recurrent pericarditis patients who are suffering.

Mark Ragosa

Yes. I guess to your question regarding our thinking on capital, I mean, we think we're very well capitalized. As I mentioned, $201 million in reserves at the end of the third quarter. At the end of the day, our runway, which we guided to having cash in at least 2027 the ultimate time line depends upon the success of our current and future investments and sort of any future investments that are spawned from the original investment. So we feel very confident in our runway in our cash reserve base of $201 million at the end of the quarter.

Operator

Our next question will come from Liisa Bayko of Evercore ISI.

Liisa Ann Bayko

Can you maybe quantitate a little bit more the amount of inventory changes that you're seeing and how that's contributing to kind of I guess, what seems like a flat quarter-over-quarter into the fourth quarter, but I know this is offset by some inventory changes. So if you could quantify that would be helpful.

Ross Moat

Yes, that's right. In some of that is, this is Ross. So maybe I'll go through that in a little way. I mean we continue to see robust performance across all the key drivers of the commercialization. And as I said, we believe we've still got a huge potential ahead. But when we look at the growth that we had in Q4 and thinking forward to the end of the year, to be very clear, we expect continued growth in Q4 despite a couple of expected headwinds and those being firstly, related to some pressure on our gross to net in Q4. And that's driven from a couple of things.
Firstly, from end-of-year accounting for insurance resets and increases the co-pay systems. So they're really kind of industry-wide items in specialty medicine, but as well as changes that we've had to our specialty pharmacy network, which may drive a slightly higher gross to net in Q4. And secondly, we're expecting inventory to level out in Q4 following some of the favorability we had in that regard under the prior quarter so we expect some additional pressure to the magnitude of the Q4 revenue growth, but certainly still expecting revenue growth in Q4.
And as we said, they are tracked into the high end of the guidance we provided.

Liisa Ann Bayko

Great. Can you just quantitate the inventory change a little bit more, like what amount are we talking about? And then also what we're closing that in the third quarter?

Ross Moat

Yes. So we haven't really quantified the inventory amount, but what we have said is that the majority -- the vast majority of the growth comes down to having a higher number of patients on therapy has really been the key driver of all of our quarters worth of growth since the time of launch. So that's the vast majority.
And then to a smaller level, there's a little bit of inventory dynamic there, as we've mentioned. Gross to net year-to-date is 9.9% and that's versus 9% in 2022. So there's always some quarterly fluctuations, but that's where we are at 9.9% so far this year.

Operator

I am seeing no further questions in the queue. I would now like to turn the conference back to Sanj Patel for closing remarks.

Sanj K. Patel

Thank you very much for the questions and joining the call today. We clearly have an exciting time ahead of us and very much looking forward to providing additional updates in the future. So until then, thanks very much.

Operator

This concludes today's conference call. Thank you all for participating. You may now disconnect, and have a pleasant day.