Q4 2023 BioCryst Pharmaceuticals Inc Earnings Call
Participants
John Bluth; Chief Communications Officer; BioCryst Pharmaceuticals Inc
Jon Stonehouse; President, Chief Executive Officer, Director; BioCryst Pharmaceuticals Inc
Ryan Arnold; Chief Medical Officer; BioCryst Pharmaceuticals Inc
Charles Gayer; Chief Commercial Officer; BioCryst Pharmaceuticals Inc
Anthony Doyle; Chief Financial Officer; BioCryst Pharmaceuticals Inc
Tazeen Ahmad; Analyst; BofA Global Research
Brian Abrahams; Analyst; RBC Capital Markets
Jessica Fye; Analyst; JPMorgan
Liisa Bayko; Analyst; EVERCORE ISI
Stacy Ku; Analyst; TD Cowen
Serge Belanger; Analyst; Needham & Company Inc.
Gena Wang; Analyst; Barclays
François Brisebois; Analyst; Oppenheimer & Co., Inc.
Maury Raycroft; Analyst; Jefferies
Presentation
Operator
Good day and welcome to the BioCryst fourth-quarter 2023 earnings conference call. (Operator Instructions) Please note, this event is being recorded. I would now like to turn the conference over to John Bluth at BioCryst. Please go ahead.
John Bluth
Thank you very much. Good morning, and welcome to BioCryst fourth-quarter and yearend 2023 corporate update and financial results conference call. Today's press release and accompanying slides are available on our website. Participating with me today are CEO, Jon Stonehouse; CFO, Anthony Doyle; Chief Commercial Officer, Charlie Gayer; Chief Medical Officer, Dr. Ryan Arnold. Following our remarks we'll answer your questions.
Before we begin, please note that today's conference call will contain forward-looking statements, including the statements regarding future results unaudited and forward-looking financial information as well as the company's future performance and or achievements. These statements are subject to known and unknown risks and uncertainties which may cause our actual results, performance, or achievements to be materially different from any future results or performance expressed or implied in this presentation. You should not place undue reliance on these forward-looking statements. For additional information, including a detailed discussion of risk factors, please refer to the company's documents filed with the Securities and Exchange Commission, which can be accessed on our website.
In addition, today's conference call includes non-GAAP pro forma financial measures. For reconciliation of these non-GAAP measures against the most directly comparable GAAP financial measure, please refer to the earnings press release posted in the Press Releases section of our Investor Relations website at biocryst.com. Now I'd like to turn the call over to Jon Stonehouse.
Jon Stonehouse
Thanks, John. 2023 was another impressive year for ORLADEYO, starting with generating $326 million in revenue in just the third year of launch. We continue to make great progress toward our goal of global peak revenue of $1 billion.
Let me explain why. Late last year, we laid out a set of assumptions that would lead us to $800 million in peak sales in the US. The first assumption was to exit last year with a base of approximately 1,050 patients on therapy. We actually exited the year with a base of over 1,100 patients on therapy. Second, we added over 300 net new patients, well above the average of 200 per year we need. Third, we improve the percentage of paid therapy in the commercially insured part of the business from 7% to 79%. And fourth, we made a modest net annual price increase in the US. In all four of these assumptions Charlie (technical difficulty) executed such that we met or exceeded each of these goals. That's great execution and real progress towards our goal.
Today, we'll focus our prepared remarks on ORLADEYO in the financials. We'll start with Ryan, who will cover the data presented at Quad AI this past weekend and how many patients ORLADEYO are seeing excellent control of their HAE, along with the convenience of once daily dosing. With that, I'll pass it over to Ryan.
Ryan Arnold
Thanks, Jon. I've had the privilege during my career to work on several therapies that helped change the lives of patients who live with chronic life-altering diseases. An important lesson I've learned is that long-term data and particularly evidenced from real-world experience, especially in rare disease, are critical to understanding how a treatment can address unmet needs and change the lives of different patient populations.
This is an exciting time for ORLADEYO because after three, four years on the market, we are seeing a very consistent picture emerged from the building evidence. The real-world experience and the long-term clinical data are telling a very consistent story on how ORLADEYO can provide meaningful benefits to a variety of HAE patients. We recently published the final analysis of data from the open label long-term extension portion of the APeX-2 study of berotralstat. The patients who started on blinded berotralstat 150 milligrams and completed a full two years of the study, had an average reduction of 90.8% in HAE attacks compared to their baseline rates. But most don't measure their tax and percentages. What's most meaningful to people living with HAE, is that they get the chance to live a normal life by minimizing their attack burden and experience meaningful improvements in their everyday quality of life, all while avoiding the unnecessary potential burdens of treatment.
ORLADEYO treated patients in this long-term study reported rapid and sustained improvements from baseline of 3.3 attacks per month to 0.3 attacks per month after two years with a median attack rate of zero at month 24. These patients also reported meaningful long-term improvements in quality of life, treatment satisfaction, and an overall safety profile that is very reassuring for people living with this lifelong disease. That kind of change in a sustained low rate of attacks with just one pill once a day is transformative for many patients. These long-term data from our clinical program tone important part of the story, which is being consistently reinforced by our expanding base of real-world evidence.
This past weekend at the Quad AI meeting in Washington, DC, we presented five posters showing strong real with evidence with ORLADEYO in a variety of patients with HAE. What patients are experiencing in the real world is consistent with the two-year clinical data. Patients with type 1 or 2 HAE are reporting long-term median attack rates of around half an attack per month after switching from other prophylactic therapies. By their own account, these patients are having fewer attacks on ORLADEYO than on their prior therapies. Patients report rapid and sustained reduction in attacks or maintaining attack-free status regardless of whether their baseline monthly attack rate was very high or very low prior to starting on ORLADEYO.
These data on attacks regardless of baseline attack rate, are consistent with evidence we have presented from our clinical trials. Patients diagnosed by their physicians as having HAE with normal C1-inhibitor levels, also are reporting rapid and sustained reductions in attacks on ORLADEYO. And we are seeing similar outside of the United States, particularly in countries like France where patients can be followed in comprehensive programs with the active involvement of healthcare providers.
This real-world evidence demonstrating the long-term safety and effectiveness of ORLADEYO is exciting. Our team has been hearing the stories of ORLADEYO oil a day over the past three years. And these data further illustrate why there's such a favorable treatment option for people living with HAE. What is even more exciting is that the data we presented at Quad AI are just the start. We will continue to generate more real evidence with ORLADEYO over the coming years. And we look forward to showing again and again how this treatment can help change the lives of patients and families impacted by HAE. I'll now turn it over to Charlie to describe how this emerging evidence is translating to our commercial efforts.
Charles Gayer
Thanks, Ryan. As John noted earlier, we recently described how consistent net patient growth of 200 per year for the next several years puts us on track for $800 million in sales in the United States. Entering our fourth year on the market, we are very much on track because we added 321 ORLADEYO patients in the US in 2023. The real-world evidence that Ryan described helps explain this growth.
Patients would like convenience, there's no doubt about that. But what they demand is efficacy control of their attacks. The real-world data with ORLADEYO clearly demonstrate that patients can have both, efficacy and convenience. No trade-offs. Our teams have done a very good job of launching ORLADEYO, but in the end, patient experience will dictate how far we go.
Ryan shared that after switching to ORLADEYO from other prophylaxis therapies, patients experienced a median rate of about half an attack per months. What that means for patients is that many or most months are attack-free, and attacks that need to be treated are often less severe. Half an attack per month is also an important benchmark.
We do market research with large samples of HAE patients, and we've reported previously at a medical congress that half an attack per month matches the level of attack control reported by patients taking injectable prophylaxis therapies in the real world. This low and consistent rate of attacks on ORLADEYO meets patients' expectations because they know from experience that perfect control is unlikely with any product. For many patients to be able to get that level of control with an oral once daily therapy is transforming how they live with HAE.
We recently conducted an anonymous market research project with a sizable cohort of patients who have experience with ORLADEYO and asked them as part of an exercise to write a letter to ORLADEYO describing that experience. Themes such as, you gave me confidence, you changed my life, and I feel like a normal person again, were common. The strong evidence from patients also continues to shape prescriber expectations and give them confidence. Our large quarterly surveys of allergists in 2023, showed they consistently expected to grow the proportion of their HAE patients treated with ORLADEYO by about 30% over the next 12 months.
As we noted in our press release today, the number of patients on paid therapy or our long-term free product program also grew by 30% in 2023, tracking with physician predictions. Currently about 50% of patients on ORLADEYO has switched from other prophylaxes. But the allergists in our 2023 surveys expect about two thirds of ORLADEYO growth over the next year to come from switches from injectable prophylaxis.
By the end of 2023 ORLADEYO have been prescribed over 2,500 times in the United States. That means that at least 5,000 diagnosed and treated patients have not yet tried ORLADEYO. Over 1,000 US healthcare providers have now prescribed ORLADEYO, including over 200 new prescribers in 2023. But clearly, there's an opportunity for HAE treaters to (technical difficulty) -- for many more of their patients, just as our market research predicts.
We have way more opportunity in front of us than behind us. And the growing body of evidence about how ORLADEYO is changing patients' lives is going to help us get there. I'll pass it to Anthony to describe our financial performance.
Anthony Doyle
Thanks, Charlie. So it was great to see such a strong Q4 and full year 2023 for ORLADEYO. Not just the revenue performance, but the continued underlying strength in net new patient adds, giving us confidence of achieving between $380 million (technical difficulty) $400 million in global ORLADEYO revenue this year on our path to peak sales of $1 billion. You can find our detailed fourth quarter financials in today's earnings press release and I call your attention to a few items.
Total revenue for the quarter came in at $93.4 million, $90.9 of which came from ORLADEYO and ORLADEYO net sales for full year 2023 at $326 million, an increase of $74 million or 30% year over year. Of the $90.9 million of global ORLADEYO revenue, $79.4 million came from US sales, with the remaining $11.5 million or 12.7% coming from ex-US. On a full-year basis, US ORLADEYO sales contributed $288.4 million of the $326 million global total, with the remaining $37.6 million or 11.5% coming from ex-US.
Operating expenses, not including non-cash stock comp for the quarter were approximately $119.6 million, included in this are significant one-time expenses. These include about $5.4 million attributable to the R&D reorganization, including costs related to the reduction in force and the postponement of the expansion of the Discovery Center in Birmingham, Alabama. The $5 million upfront payment we made to Clearside related to our partnership as well as around $7 million in CMC, another trial costs related to our partnership decision for BCX-10013, all of which explain the increase in OpEx from Q3 of 2023.
Operating expenses, not including non-cash stock comp for the full year came in at $379.5 million, which when excluding the $5.4 million of restructuring one-time adjustments I mentioned, landed within our guidance range. We expect that quarterly expenses in 2024 will normalize in the low to mid $90 million range, taking us in line with our full year 2024 guidance of between $365 million and $375 million, and essentially flat to 2023.
Cash at the end of the year was up $390.8 million and net cash utilization for the quarter was $8.4 million. In January, we provided guidance on our near-term timeline to achieve profitability. For 2024, we expect that revenue will exceed OpEx, not including non-cash stock comp, and this will result in us generating an operating profit this year. Additionally, with revenue exceeding $350 million, it puts us into tier whereby the incremental revenue will be more profitable as the blended royalty rate is reduced.
In the second half of 2025, we expect to be approaching net income and cash flow positivity on a quarterly basis. And then in 2026, we expected to achieve net income and cash flow positivity on a full-year basis, achieving independence from the capital markets. While we also continue to invest in further expanding our global reach for ORLADEYO and expanding our label with the pediatric indication, while also further advancing our exciting early-stage pipeline, puts the company in a very strong position moving forward.
Operator we'll now open up for Q&A.
Question and Answer Session
Operator
(Operator Instructions) Tazeen Ahmad, Bank of America.
Tazeen Ahmad
Hi, guys. Good morning, thanks for taking my questions. Can you give us a little bit of color regarding the patients that you're able to add last year that came as you said higher than what you anticipated. Was there a particular profile of patients that was added that you weren't expecting? And in general, do you have a sense of what level of baseline attacks patients have when they are switching in particular to your drug from another drug? And then I have a follow-up. Thanks.
Charles Gayer
Sure. Tazeen, there wasn't really a profile that we weren't expecting. Since the beginning of launch, we've been getting patients from all different profiles as Ryan laid out with some of the data. (technical difficulty) -- sorry, some of the datas that we've presented this weekend at Quad AI, regardless of baseline attack rate, regardless of background therapy, patients do really well on ORLADEYO and -- sorry, I can't. Do you want to take the rest of that Ryan?
Ryan Arnold
Yeah. Is there any phenotype? I think what she's asking is, is there a baseline attack rate? Is there any phenotype that we're seeing, any particular group that's going into switching to ORLADEYO.
And I'll call your attention to slide 6 and slide 8 in our deck, both of these speak to the background our baseline attack rates. And what you'll see here is despite varying attack rate speed, high or low, patients do very well in ORLADEYO.
Slide 8 specifically calls out a baseline attack rate of 1.33 at baseline for those with HAE type 1 or type 2. And again, those patients did very well, achieving an attack rate of 0.50 at day 540. So they had a rapid and sustained reduction in their attack rates. So basically, a variety of patients can benefit from ORLADEYO regardless of what their baseline attack rate is.
Jon Stonehouse
Yeah, so Tazeen, you really can't predict it. So the goal is to get everybody to try it and see if it works for them.
Tazeen Ahmad
Yeah, I just want to ask about whether in real life, you are seeing something different relative to what you would see in clinical trials. (inaudible) And then maybe, just as a follow up, how are you thinking about discontinuation rates on a go-forward basis? How have they been trending? Any changes from the time that you launched? Thanks.
Jon Stonehouse
So Charlie's (multiple speakers) --
Charles Gayer
I think I can talk again. It's my asthma attack. The discontinuation has been really steady in 2023 and the last few years. So still when a patient starts ORLADEYO, we get 60% of those patients to 12 months and then very few discontinuations after that.
And I think relating to your earlier questions too, we see the same retention rate regardless of patients' background. So regardless of their attack rate, regardless on whether they're switching from prophylaxis or coming in from acute only, they're all staying on it at about that same rate, 60% a year.
Tazeen Ahmad
Okay, thank you.
Operator
Brian Abrahams, RBC Capital Markets.
Brian Abrahams
Hey, good morning, guys. Thanks for taking my question. Congrats on the continued progress. I'm curious if you could talk a little bit about your sales and marketing strategy this year relative to last year. Do you expect continued pull through from some of the team territory changes that were implemented in 2023? In 2024, what do you expect to be the focus of the additional SG&A investment for this year? And are there any changes to your commercial approach or strategy with an expected even greater proportion of the opportunity now coming from the switchers versus those patients who are on on-demand only?
Jon Stonehouse
Charlie, you want to take that?
Charles Gayer
Yeah. Hey, Brian. So one of the reasons I do think we did so well last year is we did make those adjustments to the teams in the beginning of 2023. By the end of last year, the additional sales folks, the additional patient services market access that we added, everyone was active and really comfortable in their roles and working well together. And I think that is a big part of our performance.
And then going forward to your question about any changes in the kind of data that again, that Ryan presented, I think, is really critical. And we're very focused on getting patients and physicians comfortable with the switching from an injectable prophylaxis to ORLADEYO is opportunity for patients to really benefit. And I think we're seeing that our customers are starting to understand that. So we'll focus on that messaging.
Jon Stonehouse
And Brian --
Brian Abrahams
Got it.
Jon Stonehouse
I'd add. One thing I'd add, Brian, is that Charlie mentioned, was this increasing competition. And one of the things is that we're seeing at Quad AI and other place, we had a standing room only session at Quad AI and the confidence in the docs is really high. You compare that to a year ago where people were still kind of on the fence. And it's only because they've had experienced and they're seeing it work extremely well in patients. So that will have an effect on that will be really positive for ORLADEYO and for patients.
Brian Abrahams
Got it, thanks, Jon. And maybe just a quick follow-up. It sounds like you've got some visibility to getting to the goal of a paid rate of 85% by the end of the decade. Where do you think you can get the paid rate this year relative to 2023? What's embedded in your guidance and how much potential upside could there be versus your guidance if things go better than expected on that front? And I'll hop back in the queue, thanks.
Charles Gayer
Brian, what we've said before is that 85% number, we are very confident we'll get there, but it's going to take us a few years. And so we announced this morning in the press release that we ended last year at a rate of 71.5%. So we'll make some incremental improvements to that. But don't expect any major changes. We're not going to jump straight to 85%. We'll get there probably more in the 2026, 2027 timeframe.
Brian Abrahams
Got it. Thanks, Charlie, thanks again.
Operator
Jessica Fye, PMorgan.
Jessica Fye
Hey, guys, good morning. Thanks for taking my questions. Can you just talk about the extent to which your near and long-term top-line expectations for ORLADEYO reflects the introduction of less frequently dosed injectables and other orals. Thank you.
Charles Gayer
Hi, Jess. We take into account all the introductions of new products, including new injectables and possibly in the future, new orals. And what Jinky Rosselli and I described at the last earnings call is that the patients, once they're on therapy and doing well are tend to be really sticky on that therapy. And when patients are doing as well as they are on ORLADEYO, we don't see them moving to other therapies.
The other key part of it is that we have a very differentiated product in a once daily oral, and that's something that patients and healthcare providers really want. And so a new injectable therapy offers some incremental benefits, but it is not highly differentiated the way ORLADEYO is.
Jon Stonehouse
Yeah, I think Jess, flip the question around and ask, why would they go on to another product? What's the incremental benefit? And I think what Charlie presented today and what Ryan presented, is patients aren't sacrificing efficacy for convenience. This drug works spectacularly well in certain patient, and it's a once-a-day drug.
So what incremental benefit is going to cause them to switch? And we've seen where getting switches, you'd have to have some incremental benefit. So the question is, it can't be efficacy, right? Because if you're controlled on our drugs, then you can't do any better.
Jessica Fye
Thank you.
Jon Stonehouse
You're welcome.
Operator
Liisa Bayko, Evercore ISI.
Liisa Bayko
Hi, just a follow up on that. I mean you do have a half an attack rate per month, right? Which is one in every two months which is six per year after switching from other prophylax. So would that not be, like those types of patients would they not be interested in maybe trying something else? That would just be my like one question, but I actually have other questions beyond that.
Jon Stonehouse
Ryan, do you want to tackle that one? I mean, the bottom line is nobody does better than that. That's kind of the standard. Every drug has breakthrough attacks. And in that number is a mixture of people that aren't having attacks and some that are. But Ryan, I don't know if there's anything else to add.
Ryan Arnold
Yeah. As Jon alluded to, you've seen similar attack control with other injectable therapies. And we view this not as a trade off, but a trade up. Because again, patients don't want just attack control, they want the added convenience as the quality-of-life improvements. And again, we've reported all of that both in our clinical studies as well as in the real-world evidence.
So, half an attack per month is doing very well. And again, that doesn't include attack severity, which for some they've shared these are very manageable. So again, this is a very notable improvement and looks very similar to injectables in terms of attack rate control.
Jon Stonehouse
Yeah, so Liisa, don't get confused by the numbers of attack rate reduction in a pivotal study because the confidence intervals from those studies it overlap. They all work is the bottom line. And they're not perfect, they all have some breakthrough attacks.
Liisa Bayko
Okay, and have you done any convenience analysis, like market research on these sort of like very long acting agents? Because it seems like at some point you might flip a balance between taking an oral pill and frequent injections. I realize there's some people don't like injection too, but is there any elasticity there in a way?
Jon Stonehouse
Yeah, no, that's a really good question because we're super paranoid. And one of the things I asked Jinky is, what's the tipping point on frequency of injectable dosing that would make it as attractive as a once daily oral? Found it yet. I mean, we run that research, we haven't found it yet and so. --
Liisa Bayko
Okay.
Jon Stonehouse
But we'll keep looking.
Ryan Arnold
Sorry to interrupt. I would just add, I think people underestimate the fear of injections that patients experience. And while it can be convenient for some, I think that fear and fatigue of injections can be underestimated. So when we hear that continuously from our physicians and from patients as well. So they are seeking convenience as well as that aspect of having a normal life and carrying around a once-a-day oral feels very normal for a lot of patients.
Liisa Bayko
Okay, great. And then just a quick question for me. Can you kind of go through the math of like how many patients you've treated so far? How many patients, like HAE patients are out there? And how many more need to try ORLADEYO? Given the kind of like stickiness of the product, like maybe whatever half the patients or so end up like sticking to it long term. Think of kind of go through from here to get to that $800 million US number.
Jon Stonehouse
So start with the 7,500 onward and afterwards.
Charles Gayer
Yeah, Liisa, near the end of my remarks today, I pointed out that there are at least 5,000 patients who have not yet tried ORLADEYO. That's based on our previous estimates that they're about 7,500 diagnosed and treated patients. We've had 2,500 prescriptions to date. So there's at least another 1,000 patients. And with what we're hearing from physicians and patients, we expect a lot more trials in that 5,000. So plenty of room to grow.
Liisa Bayko
Okay. And like as you think about what you need to get to that $800 million number, is it half of those that need to try it or what is the amount?
Charles Gayer
That's probably a pretty good estimate. What we need to get is to about 2000 patients who are sticky at peak, and we are more than halfway there at this point.
Liisa Bayko
Great. Thank you so much, guys.
Operator
Stacy Ku, TD Cowen.
Stacy Ku
Thanks for taking our questions. So first question is around kind of potential implications with the change in the Medicare Part D redesign with IRA. So could there be any potential impact to patient volumes with the decrease in the next out of pocket spend? And what would be the timing of something like this? So that's one.
And then just a a follow-up to some of the questions that have been asked. Can you just further characterize your commentary around the clinicians that are prescribing in more academic, more community? Is it really still just that 50% split now? Thanks so much.
Charles Gayer
Thanks, Stacy. So on the IRA, particularly next year, when the max out of pocket shifts to $2,000, we think that will be an advantage for patients in terms of affordability. And then very important is that next year, that $2000 can be paid over the course of the year in the 12 month increments. And so we think that'll increase affordability and likely increase the rate for ORLADEYO. I don't think it will really change the volume of patients treated. It's just going to affect the rate.
And then as far as clinicians, we see a great mix. Again, we see the academic physicians as well as a lot of community physicians. As I said, over 1,000 healthcare providers have prescribed so far. And that is really distributed very evenly across the deciles of our healthcare provider potential index, and it's been very consistent that way every quarter. So we're getting both academic and community.
Stacy Ku
Understood. And just a follow-up, does that mean that you think as the rate is improved for the IRA changes, do you think that you'll be able to switch more patients over to paid? Is that a fair kind of thinking about it?
Charles Gayer
Yes we do, next year in 2025 and beyond.
Stacy Ku
Okay, wonderful. Thank you.
Operator
Serge Belanger, Needham & Co.
Serge Belanger
Hi, good morning. Thanks for taking my questions. The first one for Charlie, just give a little color on the 1Q seasonality this year. Is it similar to prior years? And then second question, I guess for Jon and maybe the rest of the team. I think you've all been consistent, but do you expect competition from an oral prophylactic by the end of the decade? Just curious your thoughts on an oral on-demand treatments and what impact that could have for the market. Thanks.
Charles Gayer
Hey, Serge, I'll start with that. For 1Q, yes, we expect similar seasonality with the first quarter revenue being down versus Q4. This, we had a really strong Q4, so we actually think that percentage reduction could be a little bit more this year. So I think 7% or 8% drop from Q4 and probably mid 80s in revenue for Q1.
Jon Stonehouse
And with regard to oral competition, specifically on-demand therapy. We certainly can't argue that orals are important, and if you have an oral alternative for a breakthrough attack, we think that's great. And so having that as a choice for patients, we think is just another benefit. And an all-oral option would be fantastic, right, prophy, and when you have a breakthrough attack, take an oral on demand.
Serge Belanger
Thanks.
Jon Stonehouse
You're welcome.
Operator
(Operator Instructions) Gena Wang, Barclays.
Gena Wang
Thank you for taking my questions. I just have one regarding the data report. I think if we look at the slide 6, 7, 8, when we look at number of patients more than two thirds of patients. I mean the beginning of a patient number and the end of the patient numbers; it was about one-third of patient continue and to the end of data report. So any color you could give regarding the other two third of the patient?
Jon Stonehouse
Maybe I'll let you start Ryan.
Ryan Arnold
Yeah. Thanks for the question. These are patients that are reporting, self-reporting their attack rates. And because this is real-world data, there's always limitations in terms of how that is recorded. In some months patients may not share what their attack rates are. But that doesn't mean they've necessarily come off therapy. And all of these patients have, that you've seen in these slides, have completed 540 days of therapy. We're still waiting for some few to complete that same timeframe to include them in the analysis.
Jon Stonehouse
Yeah, keeping somebody in a study for two years is challenging, certainly. And remember, some patients don't do well in our drug. We've got about a 60% retention. And so it's not uncommon to see people not succeed, and you see that in some of these results.
Charles Gayer
Just to underline what Ryan said, just to make sure it's really clear. In this real-world evidence, we measure patients based on the length of time that they're in therapy and some of them just haven't had the opportunity to reach 540 days because they started at a later time point. So it's a dynamic sample. Off course some patients do drop out, but this represents how well patients when they're doing well in ORLADEYO, they're doing really well and sticking on therapy.
Jon Stonehouse
That's the point, Gena, is that the patients that do well, do really well in this drug.
Gena Wang
Okay, great. Thank you.
Operator
François Brisebois. Oppenheimer.
François Brisebois
Hi, thanks for taking the question. I was just wondering in terms of the discontinuation rate, so what leads to this discontinuation rate? Is it that for those patients that just aren't doing well, is there other any other reason out there? And if they do discontinue, what do they usually end up doing?
Charles Gayer
Thanks, François. The discontinuation rate, there are two main reasons for discontinuation and these won't be surprising. The number one reason is perceived lack of efficacy. So as we've said no drug is perfect and no one HAE therapy is for everybody. And so that's the number one reason reported. The number two reason is adverse events, specifically gastrointestinal, which is not surprising given the product label in our clinical trial experience.
What we do know is that some patients give up too early. And so part of our messaging is for physicians and others to set expectations that you can have a breakthrough attack, you might have GI events. The GI events tend to go away after a few weeks of therapy for most patients. And so it's important that patients don't give up too early. We actually see in 2023 about 10% of the patients starting ORLADEYO were actually restarts. They're people who gave up in the past and came back because they knew that they have given up to early.
Jon Stonehouse
And François, John can send you the slide. But one of the slides we've had in previous decks, shows the pattern of discontinuations over two years, and it's flat. And so I think now we have a pretty good idea of what that pattern is. And if we've got you for out to a year, we've got you.
François Brisebois
Understood. And then can you just help me understand a little bit the US versus ex-US dynamics in terms of the growth and your assumptions and expectations? Are there challenges maybe ex-US, that aren't happening in the US? Just any color there would be helpful. Thank you.
Anthony Doyle
Sure. Ex-US first of all, one's with the biggest challenge or the biggest time factor is getting market access in an ex-US market. And so that always takes longer. And we have countries that rolling on all the time. So a number of countries in Europe for example, like Germany, UK, and France. We got market access a few years ago. But we're just now getting market access in others like Spain and Italy. And so that's one factor. Pricing is a lot lower. Ex-US, so it takes four to five ex-US patients to add up to one US patient. So our strategy is very much a volume strategy outside the US.
And then finally, what we're seeing in the real world in these countries where we have market access and we've launched, is the same consistent pattern of patient adds. Depending on the market, the HAE market dynamics, sometimes that's patients switching from other prophys, sometimes is growing the prophylaxis market with a with a drug like ORLADEYO.
At peak, we expect ex-US to equal about $200 million of the $1 billion in sales. And what we see so far gives us confidence that we'll get there.
Jon Stonehouse
And if Tech Syros and Analog here right time that the US starts to flatten out, the ex-US continues to grow. So you have overall growth of the brands still. So that's what we're expecting right now.
François Brisebois
Understood. Thank you very much.
Jon Stonehouse
You're welcome.
Operator
Maury Raycroft, Jefferies.
Maury Raycroft
Hi, good morning and thanks for taking my questions. I just wanted to ask a clarifying question on the seasonality of this quarter. Is that for the same reason as in first quarter '23, where there were budget issues with external charities, which increased the number of patients on free drug program? Or what are you seeing this year so far?
Charles Gayer
Sure, Maury. That's one of the situations the Medicare issue. We've got a little bit of insight into that. What I'd say is, it's not solved yet. It doesn't seem to be worse than line, but it's not solved. We think next year, as I said earlier, with the IRA rolling in fully, we have expectations that budget issue will be more solved in 2025.
The main reason for the dip in Q1 is the broader percentage of patients getting reauthorizations. And when that happens, we have to drop many patients back to temporarily to free product. And then also in the first quarters, it's the highest hit to gross to net because in the commercial market we're helping pickup patient co-pays. And the majority of that happens in the first quarter.
Jon Stonehouse
And you'll see a corresponding nice pop in the second quarter when we get those people back to paid.
Maury Raycroft
Got it, make sense. And one other quick question. What proportion of the 321 new patients are on short term quick start? And how long on average does it take to convert these patients to long term paid patients?
Charles Gayer
The 321 was the net growth across the whole year. So what we did say is that we ended the year with a 1,000 -- sorry, 1,104 patients on either paid therapy or long-term free product. There was also a sizable chunk of patients on short term quick start new patients coming in. And it usually takes us, we get the product out very quickly. For most patients, we get them to either paid or from free product within about a month.
Maury Raycroft
Got it. Okay. Thanks for taking my questions.
Jon Stonehouse
You're welcome.
Operator
[John Wolleben, Citizen].
Hi, this is [Katherine] on for John. We just have a question about how you're thinking about profitability versus your earlier pipeline kind of prioritizing those not just a question about the data coming. It's the coming in midyear for the PNH trial. Thanks.
Anthony Doyle
Yes. I think we've been very clear about our path to profitability. Very excited to get to the point where we are independent of capital markets. We've been seeing over the past years, that convergence of the lines between revenue and OpEx. We continue to see it this year and beyond. So being able to generate an operating profit this year, getting towards both cash positivity in EPS at the end of next year is an achievement in 2026. I think it puts us in a great spot. We do that at the same time as continuing to invest in that early phase pipeline.
So the two things coexist, and actually the opportunity to be able to invest in whatever we can do to move as fast as we can in those periods. Because that early phase pipeline that we generated in or that we announced in November is in fact, early-phase, puts us in spot where the expenditure within the next kind of three years is not as meaningful as it would be when you get them to pivotal trials. So I think the companies in a great spot and if there's anything we can do to accelerate. We absolutely will.
Jon Stonehouse
And there's nothing to update on 10013, nothing's change on the timeline.
Thank you.
Anthony Doyle
You're welcome.
Operator
This concludes our question-and-answer session. I would like to turn the conference back over to Jon Stonehouse for any closing remarks.
Jon Stonehouse
Thank you. So one of the things that we're hearing from investors is they have so many things coming at them and it's hard to keep up with the opportunities to invest in.
And if you're in that camp, a question you may want to stop and ask yourself is, how many companies do I have in my portfolio that have a growing product. Have a discovery engine that created the growing product. Have a pipeline that came from the discovery engine, that's going to create another growing product or more. And has an accelerated path to profitability, where we're probably going to be cash-flow positive or near that in the second half of next year.
And if the answer to that is none or too few and you want to diversify your portfolio, reach out to us. We're happy to get you up to speed on our company and answer any questions you may have. So have a great day and thanks for your interest in BioCryst.
Operator
The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.
