Amylyx Pharmaceuticals Inc. Q1 2023 Earnings Call

Speaker 1: Next time might be a nice day.

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Speaker 2: Good afternoon. My name is Debbie, and I will be your conference operator today. At this time, I would like to welcome everyone to the Amalex Pharmaceuticals First Quarter 2023 Earnings Conference Call. All participants will be in listen-only mode.

Speaker 2: After today's presentation, there will be an opportunity to ask questions.

Speaker 2: To ask a question, please press star then 1 on your telephone keypad.

Speaker 2: To withdraw your question, please press star then 2. Please be advised that this call is being recorded at the company's request. I would now like to turn the call over to Lindsay Allen, Head Investor Relations and Communications. Please proceed. Lindsay Allen, Head Investor Relations and Communications

Speaker 3: Good afternoon, and thank you for joining us today to discuss our first quarter 2023 earnings.

Speaker 3: With me on the call are Josh Cohen and Justin Klee, our co-CEOs, Margaret Olinger, our Chief Commercial Officer, and Jim Fradies, our Chief Financial Officer. Before we begin, I would like to remind everyone that any statements we make or information presented on this call are only for subscriptions only.

Speaker 3: that are not historical facts are forward-looking statements that are based on our current beliefs, plans, and expectations and are made pertinent to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995.

Speaker 3: These statements include, but are not limited to, our expectations with results to Rolibrio and Albrioza, statements regarding regulatory developments and the expected timing thereof, our business strategy and outlook, and our expected financial performance.

Speaker 3: by any forward-looking statements as a result of various risks, uncertainties, and other factors, including those set forth in our most recent filings with the SEC, and any other future filings that we may make with the SEC.

Speaker 3: You are cautioned not to place any undue reliance on these forward-looking statements, and Amalex disclaims any obligation to update such statements unless required by law. Now I will turn the call over to Justin.

Speaker 4: Thank you, Lindsay, and good afternoon. As everyone on this call knows, there's an enormous unmet need in ALS and other relentlessly progressives and fatal neurodegenerative diseases.

Speaker 4: It is our mission at Amalex to one day end the suffering caused by these diseases.

Speaker 4: Our treatment Relivio enables us to make meaningful advances toward and continue to investment in our mission. During the first quarter, we generated $71.4 million in net product revenues, reflecting the significant progress we continue to make toward our goal.

Speaker 4: first and only approved treatment for ALS that, in a randomized placebo-controlled trial, both met its pre-specified primary outcome demonstrating a statistically significant benefit in function and showed a benefit on survival in a longer-term post-hoc analysis.

Speaker 4: These data suggests that ALS can in fact be treated. The full approval of Relivrio is an important step toward ALS one day being a manageable disease.

Speaker 4: The ALS community has been waiting for meaningful treatment options since the disease was first characterized over 150 years ago, and we believe that Relivrio will eventually be a foundational therapy for ALS.

Speaker 4: In the first quarter, we saw a continued high level of interest from the ALS community in ReliVriote, broadened insurance coverage, and high levels of engagement with our Amlex care team, also known as ACTS.

Speaker 4: Just two quarters into launch over 10% of the approximately 29,000 people living with ALS in the US are now on Relivrio.

Speaker 4: Even with that success in our first six months, we have more to do. There remain many more thousands of people living with ALS in the US, and at least 200,000 people living with ALS globally.

Speaker 4: We are still in the early stages of our journey, and our team remains hard at work.

Speaker 4: Shifting to our plans internationally, we are diligently preparing to help bring our medicine to all eligible people living with ALS around the world.

Speaker 4: The regulatory review process in Europe remains ongoing, and we continue to expect an opinion from CHMP mid-year and a decision at the earliest in Q3.

Speaker 4: Overall, we believe we have a strong scientific position that is supported broadly by the ALS medical and advocacy community and a capable team who is leading our process.

Speaker 4: We continue to prepare to execute a successful launch in the EU if approved.

Speaker 4: We are proud of our team's progress on advancing our mission, and now I'll turn the call over to Margaret to share a commercial update.

Speaker 2: Thank you, Justin. As we enter the seventh month since our U.S. launch, we remain focused on three key priorities.

Speaker 2: The first is our effort to drive awareness and education about Relirial among people living with ALF and clinicians.

Speaker 2: This includes educating that ReliRIO is the first approved drug for adults with ALF to demonstrate a statistically significant benefit and function in a clinical trial, as well as a benefit on survival in a longer term post-hoc analysis.

Speaker 2: Our efforts to drive awareness are yielding strong results. We are seeing continued interest and demand for ReliRio. As of March 31st, there were roughly 3,000 people on ReliRio in the U.S., more than double the number of people on ReliRio at the start of the quarter. We are seeing continued interest and demand for ReliRio.

Speaker 2: We are pleased that this many people have gained access to our important treatment. I think it's worth spending a minute to provide some additional context on the strength of our launch. While we knew there was pent-up demand, the fourth quarter and first quarter were still well ahead of our expectations. The rate of net patients' ads has begun to moderate as expected.

Speaker 2: However, we still see significant demand from people living with ALF and physicians alike. Importantly, we still have plenty of room for growth, both at the top ALF centers and a broader neurology community.

Speaker 2: Now, let me run through a few metrics that show our progress, but also the growth opportunities ahead of us. By the end of the first quarter, approximately 65% of the top 500 US for Scribers and approximately 95% of the KALF centers had prescribed more alibrio to at least one person's sense launch.

Speaker 2: Prescribing remains fairly concentrated with roughly 80 prescribers, mostly at major ALF centers, representing approximately half of all Relibrial Prescriptions during the hallway, through the central corridors, just clean from Clinical faith and Medical RecFather.

Speaker 2: While we are encouraged with these data points, we see an opportunity for broader and deeper uptake of KALF centers and the opportunity to continue to penetrate the group of top prescribers.

Speaker 2: Additionally, we believe we have a large, untapped opportunity for additional growth outside of this group of top prescribers as we expand our outreach and education efforts more broadly. Our second priority is engaging with payers to work towards our goal of ensuring that every eligible person who can benefit from Relivrio has access as quickly and efficiently as possible. Thank you.

Speaker 2: At the end of the first quarter, US insurers representing approximately 50% of covered lives have published formal coverage policies.

Speaker 2: including many of the key national and regional plans. The vast majority of these insurers provide broad access to Frauen transfer, especially because of even though the

Speaker 2: For people living with ALS who go through the medical exception process, we are pleased that approximately 80% of prior authorization requests have been approved on the first admission.

Speaker 2: We continue to see a wide range of people living with ALF in terms of time-sense initial diagnosis, interested in and gaining access to ReliREO. How team remains engaged with insurers across the country.

Speaker 2: And we continue to anticipate most plans will formalize their policies during the first half of this year.

Speaker 2: Our third priority is ensuring eligible people living with ALS have positive interactions through their treatment journey with Relivrio and ALS clinics have positive interactions with Amilux.

Speaker 2: This includes facilitating an organized, clear process to get people prescribed relireo access to the therapy as quickly as possible, and optimizing people's experience accessing relireo as best we can. Our team is working expeditiously to get people living with ALF who have been prescribed relireo on therapy.

Speaker 2: In the first quarter, on average, it took about 30 days between receiving an enrollment form and the real being shipped.

Speaker 2: down from a little more than 45 days in the fourth quarter. And we expect to make additional progress on this metric in the second quarter with the benefit of more insurers having formal coverage decisions.

Speaker 2: In the limited cases where access has been granted, through an insurer, our interim access program and our patient assistance program are available for eligible patients.

Speaker 2: In the first quarter, roughly 10% of people taking relief rail were part of these programs.

Speaker 2: We are pleased with the progress we've made so far on our goal to ensure that every eligible person living with ALF has access to Reliria, which we see as a potential foundational therapy and neurodegenerative disease.

Speaker 2: Our launch is off to a strong start, and it is our hope that eventually, or Lario will become the most commonly used ALS medication.

Speaker 2: While we are clearly focused on the launch of Relireo in the U.S., we also have a large opportunity internationally.

Speaker 2: Interest in Albrilloza remains high in Canada, and we continue to negotiate public insurance coverage consistent with the expected public timelines for coverage. In addition, a few weeks ago, we appointed Massago Nakamura to lead our efforts in Asia Pacific and Latin America as we pursue additional opportunities to bring AMX 35 to as many people with ALS globally as possible. She brings 30 years of commercial, general management, and operational leadership experience in the biopharmaceutical industry with a strong track record of introducing rare disease therapies.

Speaker 2: worldwide across multiple therapeutic areas. We are very pleased that she decided to join our team to further explore opportunities for AMX 35 access around the world. I will now turn the call over to Josh to provide an important update on our R&D pipeline. Thanks, Margaret.

Speaker 5: We are very pleased with how quickly we are bringing our important new treatment to people with ALS. Our top focus, day to day, remains the success of our commercial launches.

Speaker 5: These efforts enable the continued investment needed to bring more liberal to more people living with ALS worldwide.

Speaker 5: They also enable the research and development needed to advance our pipeline in support of our mission.

Speaker 5: We have positive randomized clinical trial data and ALS, encouraging biomarker data from the randomized phase 2 Pegasus study in Alzheimer's disease, and a wealth of preclinical models demonstrating the effects of AMX35 in reducing neuronal death. To prioritize which diseases to focus on, we look at the following criteria. Clear, unmet need, strong scientific rationale, existing and robust understanding of the natural history of disease, biomarkers to track treatment effects, adjacencies and synergies with ALS, potential to move directly into a phase 3 pivotal study.

Speaker 5: and interest and support from KOLs. We are excited to announce today our plans to initiate a global pivotal phase 3 study of AMX35 in progressive super nuclear policy, or PSP, a disease which meets all of these criteria.

Speaker 5: For those of you who may not be familiar with PSP, it is a rare, progressive, and fatal neurodegenerative disorder that affects body movements, walking it, and balance, speech and swallowing an eye movement.

Speaker 5: It is typically fatal within just five to eight years. The estimated prevalence is five to seven in 100,000 people worldwide.

Speaker 5: translating to between roughly 15 to 20,000 people in the United States.

Speaker 5: There are currently no disease-modifying treatments for PSP. In addition to PSP meeting her criteria for a significant unmet need with a well-characterized natural history, there is also a strong scientific rationale for the potential use of AMX 35 in treating PSP.

Speaker 5: PSP is both a disease of rapid and significant neurodegeneration, and its pathology is characterized by significant tau protein deposition in affected regions of the brain. In the Pegasus Alzheimer's study of AMX-35, AMX-35 treatment demonstrated a statistically significant lowering of both phosphotel 181 and total tau.

Speaker 5: in the CSF of people living with Alzheimer's disease. AMX-35 is an oral, well-tolerated FDA-approved medication for ALS that has been shown pre-clinically to protect neurons against the generation and clinically to lower TOW, the Hallmark protein of PSP.

Speaker 5: This has led to significant and strong support from key opinion leaders in PSP and we are excited to work with them to test AMX35 in a phase 3 study which I will now outline.

Speaker 5: In designing and planning the study, we have collaborated with key global academic leaders, people living with PSP and advocacy groups working in this field. With an open IND in hand, we plan to enroll approximately 600 people in a randomized placebo controlled study.

Speaker 5: making this likely the largest PSP trial to date. We expect to have the study up and running by the end of this year.

Speaker 5: We are hopeful that we can provide a new treatment option, especially since there are currently no disease modifying treatments available for this devastating disease. But we prepare to launch our Pivotal Phase III study. We also remain hard at work in Wilferum Syndrome.

Speaker 5: Earlier this year, we announced Helios, a Phase II trial studying AMX-35 in Wolfram Syndrome. This study is now enrolling participants.

Speaker 5: Importantly, we are also investing in new ALS research to continue to transform how the disease is treated. We believe that it is going to take a combination approach targeting multiple cellular pathways implicated in disease pathogenesis to make ALS more and more manageable and ultimately to find a cure. For this reason, we are investigating other therapies with different or potentially complementary pathways to treat ALS and other neurodegenerative diseases.

Speaker 5: This includes an anti-sense oligonucleotide called AMX114 that our internal R&D team has developed. I am the enabling studies of AMX114 are underway and progressing well.

Speaker 5: We continue to expect to build our pipeline both through internal and external sources.

Speaker 5: Before turning the call over to Jim, I wanted to share that Phoenix, our Phase 3 study of AMX 35 and People with ALS, continues to progress as planned.

Speaker 5: In February , we announced that the study was fully enrolled with 664 participants. Reminder that there will be no interim data readout and we expect data on the primary outcome and several secondary outcomes in mid-2024.

Speaker 5: Overall survival data will take another year or more to mature and therefore won't be available until at least mid-2025.

Speaker 5: I will now turn the call over to Jim to review our financial results for the first quarter. Thanks, Josh. We're encouraged by the strong interest in demand. We continue to see from the ALF's community, from a financial point of view, our businesses strong.

Speaker 6: Inventory levels at the quarter end were as expected, with approximately two weeks of inventory in the channel at specialty pharmacies. Costs of cells were $5.3 million for the quarter, and in the range of our expectation as sales volume grows. And for modeling purposes, keep in mind that roughly 10% of the people on Religrio are receiving it for free to either our interim access program or patient assistance program. Research and development expenses were $24.2 million for the quarter, compared to $21.5 million for the same period in 2022. These costs were primarily driven by our Phase 3 Phoenix Study.

Speaker 6: and added personnel as we support our programs. Starting in the second quarter, we expect R&D expenses will increase as we incurse meaningful expenses to initiate our Phase III Pivotal Study in PSP. You should expect R&D expenses to increase this year.

Speaker 6: Delling General Administrative Expenses, or SGNA, were $44 million for the quarter, compared to $26.3 million for the same period in 2022. We're investing in SGNA to support our strong commercial launch and expect our spend to settle in around $45 million for the remainder of the year. Overall we're very pleased with our results this quarter, including achieving $1.6 million of net income, just two quarters into our launch.

Speaker 6: I want to pause a moment on our overall financial results. With the strong demand for Relivio driving near-term profitability ahead of our expectations, we want to reiterate our long-term financial goals.

Speaker 6: Driving top-line revenues, delivery of become standard to care, growing profitability for our investors, and investing in a pipeline that has the potential to provide much needed treatments for neurodegenerative disease.

Speaker 6: We're well positioned to build a profitable, financially strong organization for the long term.

Speaker 6: We ended the quarter with cash and short-term investment with $345.7 million and zero debt.

Speaker 6: So we're currently in a position to fund the programs we discussed today without the need to raise additional capital.

Speaker 6: Finally, just a word on guidance. Last quarter we gave some specific guidance on how the first quarter was going as we reported in mid-March.

Speaker 6: Since we're still early in the quarter, it's premature to provide a specific range of revenue guidance for the second quarter or for the full year at this time. The road ahead over the next few quarters is fairly simple. Execute on the launch and execute on our technical and pipeline development programs.

Speaker 6: I'm excited about the progress that we've made and most importantly our ability to have a positive impact on the lives of so many people living with ALS.

Speaker 6: With that, I'll turn the call over to Justin for some closing remarks.

Speaker 4: We covered a lot of exciting news. Our commercial ramp in the US and Canada is proceeding very well, and we will know more on Europe later this year. We are expanding our clinical pipeline into PSP, a market that is likely as large as ALS, with a product that has already been shown to have a favorable safety profile in another disease, and that has a demonstrated effect on relevant biomarkers. And we achieved our first quarter of profitability in just the second quarter of our commercial launch in the US. We remain committed to our goal to help additional people with ALS and other relentlessly progressive neurodegenerative diseases.

Speaker 4: gain access to new therapies. Now we'd be happy to take your questions. Operator, please open the call up to Q&A.

Speaker 2: We will now begin the question and answer session. To ask a question, you may press star then one on your telephone keypad. If you are using a speaker phone, please pick up your handset before pressing the keys.

Speaker 2: To withdraw your question, please press star then 2. At this time, we will pause momentarily to assemble our roster. The first question comes from Charlie Young with Bank of America. Please go ahead. Great. Thanks for taking that question. This is Charlie Young for Jeff Mitchum.

Speaker 7: So I have two questions please. The first one is, you mentioned that the rate of the pace has to moderate some quite a little expectation going to perhaps a second quarter. And you just provide more authority on that. And my second question, you know, just can you provide a little more details regarding the

Speaker 2: and more importantly, our ability to bring a new treatment option and hope to the ALS community, especially given that this is the first product to demonstrate in a clinical trial a statistically significant benefit in both function and survival. So maybe if I could just reiterate a few key points, we ended the quarter with roughly 3000 patients. Again, double what we started with at the beginning of the quarter and that's about 10% of the 29,000 patients living with ALS. So, you know, not surprisingly, our net patient ads can't double forever. So in Q2, we are expecting the number will be lower than what we delivered in Q4 and Q1. You know, I think more importantly, we continue to see significant interest in demand for delivery of both from patients and HCP.

Speaker 2: and we have a tremendous opportunity for us to grow, you know, both in death and death at all the KALS centers as well as the broader neurology community. And then the second question was on payers and, you know, again, we're very pleased with progress. We're making with payers with 50%.

Speaker 2: of the covered lives to date having a published policy, and we expect that to only get better over the first half of the year.

Speaker 2: date having a published policy, and we expect that to only get better over the first half of the year.

Speaker 2: The next question is from Michael Defuer with Evercore. Please go ahead. Hi guys. Congrats on the quarter and thanks so much for taking the time to watch.

Speaker 8: making my question. A few for me, the first question I have is a follow-up to the previous one. Now that more commercial pairs have come on board and given the fact that you said that the rate of net patient ads is beginning to moderate.

Speaker 8: Could you perhaps provide any updated views on how big the initial bolts of patients could be and how long it could last before you achieve a steady state trajectory of new starts? That's my first question. And the second one is regarding the phase 3 Phoenix trial. You mentioned that the OS data is going to take at least a year more to read out and that it's a critical endpoint. So if you if we assume conditional approval in the U based on set.

Speaker 2: Great, thank you. This is Margaret again. Thanks for your question. Regarding the bolus, it's really too early to tell when the bolus will finish. But what I can say is that we know in Q4 and in Q1, we did see that high level of demand due to the kinds of demand that we had. And they were quite frankly even ahead of our expectations. So we have to see the rate in new patients.

Speaker 2: rare disease. So some accounts are highly penetrated and some accounts have a great deal of room ahead of us to penetrate. And we really have just started to get out into the broader neurology community. So again, we see tremendous growth ahead of us to, you know, serve all the remaining patients that are depending on us. Yeah, and Hi Mike, this is Justin. Thanks for the question. So, you know, first just sort of.

Speaker 4: you know baseline for everyone so we continue to expect an opinion from the CHM team mid-year and decision at the earliest in the third quarter and in the meantime you know our team is preparing for approval and launch so

Speaker 4: In terms of the Phoenix trial and how that could affect the conditional approval. So, you know, the way that the EMA, so first, you know, we won't know if it's a conditional approval or full approval until, you know, until we get the final decision, but in terms, but our expectation is on the conditional marketing authorization.

Speaker 4: So, the way that that works is that you get approval, but with the condition that you do a follow-on study, and in this case our expectation would be that it would be the Phoenix trial. And then you have to renew that every single year until you meet the condition. So, then the question is, will we...

Speaker 4: it's the best data anyone's seen in ALS. So I think either is a very positive situation, but ultimately it's up to the CHMP and EMA.

Speaker 2: Thank you. The next question is from Corinne Jenkins with Goldman Sachs. Please go ahead.

Speaker 9: Good afternoon, everyone. Maybe a couple from us. I guess one, with more than 3,000 patients now in drug from the 1300, even understanding that there could be some moderation, how long are you thinking it will take you from here to get to the 10,000 patients you had stated as a target for being stable on therapy at steady state?

Speaker 9: phase two or otherwise and help us understand the relevant clinical endpoints for that indication.

Speaker 2: I'll take the first question and then I'll turn it over to Josh and Justin and probably Jim as well. So just, you know, we have not provided a timeline on how long it will take us to achieve the 10,000 patients. Our goal of getting to the 10,000 patients really reflects our vision that Relivio will become the most commonly used ALS medication, so basically standard of care. And we feel that that's very achievable given it is the first product to demonstrate a benefit on those.

Speaker 6: as long as we can go revenue faster than we grow expenses.

Speaker 6: will be able to maintain that profitability. I think importantly for us, longer term, it just really highlights the opportunity we have in this business and how unique the ALS market is. And ultimately, I think we have to recognize it's the need of the patients that's driving this launch and the fact of the matter of the data that we have with for liver.

Speaker 6: That's also another thing that differentiates us from a lot of other companies out there. We don't need to continue to go back to the market to fund our business because of how well the launch is going and the interest that we're seeing in the community. But then also we're going to invest in our pipeline because there's a real need in neurodegenerative diseases. And I think we can do all three, which is what makes me so excited to be here at Amalex at this time.

Speaker 5: Thanks Jim. And so talking about PSP, so I think the first thing I should share is over the last several years we've gone through a process internally to try to select those indications that are highest priority for the company. And I outlined some of the things that we look at for that. But most importantly, PSP met all of the criteria that we were looking at for an indication to prioritize as a company.

Speaker 5: progressive super nuclear palsy and so I think that's part of what's driving our excitement as well as the excitement we're hearing from the KOLs and the community about this indication and just as an add to there's also some preclinical data that that's also supporting in and making us excited here but I think it's that constellation of factors that makes us really excited to go into this PSP study.

Speaker 2: Great. Thanks all. The next question is from Nina, but the trip to GAR with city. Please go ahead.

Speaker 2: Thanks for taking my question and congrats on the update. Just in terms of trying to figure out this bolus, can you talk a little bit about what you are seeing in terms of StartForms versus NetAds? I am just curious if you can talk about the trend you are seeing there.

Speaker 2: then give us any color on duration of therapy so far or you know any dropouts that you're seeing that'd be great thanks. Yeah so we're not providing any guidance on the number of patients for the quarter again I'll just go back to you know we think our net patient adds you know they can't double forever.

Speaker 2: So we'll be lowering Q2 than we've been able to deliver in Q4, Q1 because we believe that, you know, that was the initial pent-up demand. Again, we don't know, you know, when that bolus will be over so it's hard for us to really give any guidance on that. In terms of duration of treatment, it's really too early in the launch to give that. I mean the first patients who started on therapy...

Speaker 2: We're basically at the end of October , beginning of November , so they really haven't been on therapy long enough for us to give any clarification there. In terms of discontinuation rates, that's sort of similar as well. People just haven't been on therapy long enough.

Speaker 2: I can tell you that the general trends that we're seeing are kind of in line with what we saw with Centaur. Nothing is out of line there and just as a reminder with Centaur we've seen roughly about a 25% discontinuation rate at six months. So again patients haven't really been on therapy for six months yet. So

Speaker 2: We're going to continue to monitor that very closely. Got it. That's helpful. Thank you. You're welcome. The next question is from... Let's go. Michigan state fermented fuels highcroft fertilizer resource finance irrelevant banana

Speaker 2: monitor that very closely. Got it. That's helpful. Thank you. You're welcome. The next question is from... Let's go....

Speaker 10: Mark Goodman, you're on the podium right now.

Speaker 11: Oh hey, sorry I couldn't hear. Can you talk about the mechanism for 114 and then second, just the data support the Wolfram study and the reason the rationale for moving there. Thanks.

Speaker 5: Sure. So first on 114. So 114 is an antisense oligonucleotide targeting Calpain II. So there's a pathway called valerian degeneration that's been around since the 1850s, which is the pathway whereby a neuron will destroy its own axon in response to injury or stress.

Speaker 5: that have shown that CalPain 2 inhibition can be effective in several animal models of ALS. And then finally, there's a lot of evidence out there linking CalPain 2 to different ALS biomarkers, including TDP-43. And then turning to Wolfram. So Wolfram, as we shared in the last conference call, is a space we've done at least four years of preclinical work together with Washington University and Dr. Fumihiko Yorano there. And probably those experiments studied both cellular models of the disease, as well as an animal model of the disease. Much of that data is published in the Journal of Clinical Investigation Insight. But probably what we saw was some degree of rescue of the phenotype.

Speaker 5: both in the cellular models as well as in the animal model. So I think that was the data that got us really excited to go forward there.

Speaker 5: in the cellular models as well as in the animal model. So I think that was the day that got us really excited to go forward there. Thanks.

Speaker 4: The next question is from Greg Suvannovic with Mizzou Securities. Please go ahead. Hey, good afternoon. Thanks for taking my questions and congratulations on the quarterly results. I've got two questions if I could.

Speaker 12: whether what percent is in monotherapy versus some combination setting versus a potential triple combination. Any thoughts there would be great. And then on the pipeline, I just had a question on the new phase 3 PSP study and maybe the twofold question. then first...

Speaker 12: you know, in light that, you know, there have been attempts in PSP in the past, you know, one was with an anti-tau antibody, is it really just the movement on markers that gives you confidence that it'll be able to work in PSP? Is there some other element?

Speaker 2: Yes, I'll take your first question. I would say that regarding the, you know, use of whether or not it's monotherapy or combination therapy, it's really a broad mix from single use of Relibrio to combination therapy with all three available products. And we're really seeing the utilization in a very broad patient population. So we continue to see patients that have been diagnosed with this disease for many years get prescribed this drug, as well as newly diagnosed patients. And we define newly diagnosed patients as patients who have been diagnosed in the last six months. I would say that, you know, from an ease of access perspective, some physicians may start first with Riluzole, and then they'll switch to or add Riluzole, and Relibrio too really is all.

Speaker 2: just because again it could take, you know, it was taking up to 30 days last quarter or the in Q1 for a patient to get access to the drug from the time to enrollment on average. Again, again, we expect that to continue to improve as more policies come on board. Yeah, and Greg, thanks for the question on on on PSE adjustment and

Speaker 4: or another neurogeneralative disease. And then in terms of the rationale for PSP, preclinically we've shown that AMX 35 protects against neurodegeneration, PSP is a rapidly progressive neurodegeneralative disease.

Speaker 4: And then clinically, we showed the very significant reductions in tau in our Alzheimer's study. And while, yes, there have been antibodies against tau that were unsuccessful in PSP, PSP is still a tauopathy. That's the canonical protein associated with it. In terms of the study design, we're not going to get into that today.

Speaker 4: really all of the above that makes us and probably more importantly the key opinion leaders so excited about the study in PSP. So we'll continue to share more on that, but we're really excited about starting that study. Thank you.

Speaker 13: The last question comes from Ananda Ghosh with HC Wainwright. Please go ahead. Hi guys, congrats on the quarter. I have two questions on PSP. The first one is, how similar is PSP with ALS concerning the downstream degeneration pathway? And the second is, we never got to hear about the mechanism with which MX 035 impacts the tau in your phase two trial, which is Centaur. Is there any insights? Yeah, so maybe first on PSP and ALS and their degenerative pathways.

Speaker 5: So, you know, I think for both these diseases, there's still a lot of research into exactly all of the ideology and pathology. I think our view and the literature, there's a lot of literature on this as well, is that both diseases see significant cell deaths related to endopause of reticulum and mitochondrial related pathways. And now, there's an incredible etcclework.

Speaker 5: which is what we developed AMX35 to target. And then in terms of the pathways whereby AMX35, you know, may affect tau. So I think there's a lot of literature on the link between tau and endoplasmic reticulum stress. And so that's something that we've focused on there. But this change in tau, we've seen both in preclinical models, including ones that are published, as well as in our phase two Alzheimer's randomized placebo-controlled study.

Speaker 4: likely as large as ALS. And with a product, as we said, that's already been shown to be safe and well tolerated in a neurodegenerative disease, as well as show quite significant reductions in tau. And maybe one other thing we only talked on briefly, but we achieved our first.