Q1 2024 ACADIA Pharmaceuticals Inc Earnings Call
Okay.
Speaker Change: Good day, everyone and thank you for standing by welcome to the Acadia Pharmaceuticals first quarter 2024 financial results and operating overview conference call. At this time all participants are in a listen only mode. After the speaker's presentation, there will be a question and answer session.
Speaker Change: To participate you wouldn't need to press star one one on your telephone you will Danny or a message advising your hand. This race to withdraw the question Press Star one one again please be advised that today's conference is being recorded I would now like to hand, the conference over to I'll kill Danni Senior Vice President.
Kill Danni: Of Investor Relations and corporate Communications. Please proceed.
Kill Danni: Thank you.
Speaker Change: Good afternoon, and thank you for joining us on today's call to discuss the <unk> first quarter 2020 for earnings.
Speaker Change: Joining me on the call today from Acadia are Steve Davis, our Chief Executive Officer, who will provide some opening remarks, followed by Brendan Sheehan, our chief operating officer and head of commercial who will discuss our strong commercial franchises debut of NUPLAZID.
Speaker Change: Also joining us is.
Brendan P. Teehan: Kimberly Man, our senior Vice President of global strategic planning and execution of who will provide an update on our pipeline programs and Mark Schneider, Our Chief Financial Officer will review the financial highlights Steve will then provide some closing thoughts before we open the call up for your questions.
Speaker Change: In addition, <unk> senior Vice President you penetrate rare disease franchise will be available for the Q&A session.
Speaker Change: We are using supplemental slides, which are available on our website to events and presentations section.
Speaker Change: Before proceeding I would like to remind you that during our call today, we will be making several forward looking statements within the meaning of the private Securities Litigation Reform Act of $19 95.
Speaker Change: These forward looking statements, including goals expectations plans prospects growth potential timing of events or future results are based on current information assumptions and expectations that are inherently subject to change and involve several risks and uncertainties that may cause results to differ materially.
Speaker Change: These factors and other risks associated with our business can be found in our filings made with the SEC you are cautioned not to place undue reliance on these forward looking statements, which are made only as of today's date.
Speaker Change: I'll now turn the call over to Steve for opening remarks.
Steve: Thank you al good afternoon, everyone and thank you for joining us.
Steve: Turning to slide five.
Steve: The foundation of the Kt's business is built on our two first in class drugs on the market.
Steve: Our robust pipeline of late stage assets with more behind us and a strong balance sheet that allows us to invest in future growth.
Steve: During the first quarter, our commercial franchises delivered total revenues of $205 $8 million, increasing 74% from the first quarter of 2023, which did not yet include sales to date here.
Steve: NUPLAZID it remains a strong cash flow generating franchise that delivered first quarter sales at one.
Steve: $129 $9 million up 10% from the first quarter of last year as we continued to grow volume and gain share in the Parkinson's disease psychosis sector.
Steve: We look forward to expanding on this growth.
Steve: Sales of debut were $75 $9 million in the first quarter or first time, completing this calendar periods since our April 2023 launch.
Steve: As we'll discuss on this call one year into the launch.
Steve: Approximately one in four diagnosed <unk> patients have initiated therapy with debut.
Steve: The remaining three quarters of diagnosed patients and those not yet diagnosed.
Steve: It represents a very large opportunity to continue to grow this drug and reach families not yet benefiting from the only drug approved to treat ret syndrome.
Steve: Beyond our two commercial franchises, we have a deep and growing pipeline, including our phase III <unk> Willi syndrome program and our seamless phase II phase III program in Alzheimer's disease psychosis.
Steve: Acadia continues to operate from a position of financial strength.
Steve: Revenues from our two commercial franchises enabled us to add $30 million to our cash position in the first quarter, which is traditionally a seasonally weak quarter of the year in our industry.
Steve: As a result, we continue to make in a very strong balance sheet with total cash of $475 million.
Steve: As of March 31.
Steve: Turning to slide six I'll now provide a high level update on debuted at both Brendan and Mark will expand on in their sections.
Steve: We've just completed one year into the launch of debut let me take a moment to recap where we stand today.
Steve: As you know the launch after launch we experienced a surge of patients have initiated therapy quickly in the first several months of debuts availability.
Steve: As I referenced a moment ago, we have a sizeable population to continue building share.
Steve: Out of 5000 diagnosed patients in the U S. As I mentioned approximately one in four of these patients have initiated therapy with debut.
Steve: In addition, we believe that prevalent population of <unk> patients in the U S is between 6000 9000 patients. We expect this debuts on the market longer we will see more and more of the and diagnose patients get diagnosed.
Steve: Importantly, we continue to see real world persistency rates tracked about 10 percentage points above the time base rates of persistency observed in the most relevant populations from our clinical studies.
Steve: We believe that on average the dose patient stake following any period of titration up or down is approximately 75% to 80% of the label dose.
Steve: To date, we've established a very broad prescriber base with over 650 individual riders.
Steve: Brendan will speak to the shift in mix.
Steve: We have observed since launch together with our expectations going forward.
Steve: We've established a broad access to debut with over 80% of lives covered and.
Steve: And conversion metrics that are consistent with industry norms and seasonality.
Brendan P. Teehan: Let me turn to a few of the key dynamics, we see today as we enter our second year on the market.
Steve: In the last year, we've now accumulated a substantial body of real world experience with debut.
Steve: Seeing more and more stories shared on both the medical and caregiver communities regarding the benefits of debut including alertness engagement communication and motor benefits.
Steve: On the dosing of GI management front, while our data indicate the average dose patients take longer term continues to be in the 75% to 80% range. We're.
Steve: We are seeing some variability in the application of strategies for titration of dose adjustments getting to the longer term dose.
Steve: This represents an opportunity where we are focused on supporting dialogue in both the medical and caregiver communities regarding the establishment of consistent application of Gi management strategies and best practices.
Steve: Brendan will speak to both observed benefits of debut in GI management practices in his section.
Steve: During most of the first quarter, we saw a decline in active patients on therapy as we experienced firsthand seasonal dynamics together with an increase in numerical discontinuation primarily associated with the higher rate of new patient starts in the preceding two quarters.
Steve: In other words, there is somewhat of a lag between numerical new patient starts and numerical discontinuation.
Steve: Just to be clear, our overall rate of persistency continues to track well above our clinical trial experience.
Steve: Despite the fluctuation of numerical discontinuation as we see in any given month or quarter.
Steve: Importantly, we now see net patient additions in each of the last six weeks and believe the lag based increase in numerical discontinuation. We observed in the first quarter has peaked and is now largely digested.
Steve: To recap on debut one year into the launch we've established very healthy share with one in four diagnose patients on therapy.
Steve: Key long term value drivers include a very large opportunity to continue adding share and rates of persistency attract approximately 10 percentage points above our clinical trial experience and are supported by a large prescribing population and broad payer access.
Steve: Let's turn to a snapshot of our current products and pipelines on slide seven.
Steve: NUPLAZID continues to contribute substantial revenues and share growth.
Steve: Furthering our strategic objective of optimizing cash flow in this franchise.
Steve: In addition to our two successful commercial franchises, we have numerous late and early stage pipeline assets representing important opportunities.
Steve: These include ACP 101, and product really syndrome, where we're currently enrolling subjects in our phase III study.
Steve: <unk> is a rare and debilitating genetic disease, where patients have an unrelenting drive to eat called hyperphagia.
Steve: Sadly the severity of this disorder translates into an average lifespan of only 30 years.
Steve: Here are two there are no FDA approved treatments.
Steve: We are currently enrolling our seamless phase III phase III program with <unk> in Alzheimer's disease psychosis patients another disorder, where there are no approved treatments.
Steve: <unk>, our second generation <unk> to a blocker where we.
Steve: We're leveraging our learnings from <unk> answering.
Steve: And behind that we have a rich pipeline of early stage disclosed and undisclosed programs that position us for future growth.
Steve: I'll now turn it over to Brendan to discuss our commercial performance beginning on slide eight.
Brendan: Thank you Steve Please turn to slide eight.
Brendan: Beginning with debut let.
Brendan: Let me start by discussing the three key drivers of long term value for debut and continued growth potential they represent.
Brendan: First with now one out of four diagnosed <unk> patients having received treatment with debut we still have a large remaining patient population in the market that has significantly higher physician and caregiver awareness about the product one year post approval.
Brendan: Launch to date, we've been successful penetrating centers of excellence, where we now have approximately 50% share of patients treated so we have a lot of room to grow to pursue growth to pursue in the segment. In addition, we're also focusing on driving depth of prescribing outside of Coes, where the majority of our patient potential exists.
Brendan: We're already seeing a shift in the source of prescriptions today and expect an increasing share to come from non center of excellence high volume institutions and community practices moving forward.
Brendan: Second a year into launch we now have a foundation of real world evidence, providing us the following levers.
Brendan: Number one is real world benefits, we are describing the real world benefits patients and families are seeing across a wide range of ages as well as severity of disease services, serving as examples of successful treatment with debut.
Brendan: In a moment I will share some quotes from caregivers about the meaningful benefits they are seeing in their patients.
Brendan: Number two is Gi management.
Brendan: We're sharing key learnings from successful Gi management strategies, we've observed a wide range of Gi management approaches and we see an opportunity to further enhance and accelerate the establishment of best practices in the community.
Brendan: Number three is the time to benefit is a key consideration.
Brendan: We know a majority of patients with their doctors guidance are starting treatment by tight trading and of course, when you titrate over a period of several weeks it may take longer to get to a therapeutic dose.
Brendan: It's therefore important to ensure that families and physicians have the rate expectations regarding the time it may take to observe benefits.
Brendan: We have observed that many discontinuation as happened early in a patient's treatment a timeframe that may not have been sufficient to get to a dose that produces benefits or work out an appropriate Gi management regimen.
Brendan: To further support these families are messaging on treatment expectations emphasizes the importance of Hcp's and caregivers working together on setting the appropriate timeline to realize the benefits of debut and determine the appropriate Gi management strategy for each patient.
Brendan: Our third driver is persistency on therapy.
Brendan: We now have data out to the nine month, Mark that demonstrates persistency tracking 10 percentage points above what was observed in the lilac open label extension study for placebo rollover patients.
Brendan: This continues the consistent persistency curves, we've seen from the time of launch.
Brendan: I'd like to take a deeper dive into each of these drivers.
Brendan: First let's discuss market penetration and growth potential one.
Brendan: One year into launch we've started more than 3500 patients on debut in a market with 5000 diagnosed <unk> patients many.
Brendan: Many of these patients come from Coes, where we have approximately 50% patient share, which leaves us ample opportunity for growing in that setting.
Brendan: Our mix is shifting to an even more split of prescriptions with one third of prescriptions coming from centers of excellence one third from non center of excellence high volume institutions, and one third from community practices.
Brendan: Since the level of experience with treating <unk> patients outside the centers of excellence is lower we're delivering enhanced messaging to these prescribers on both clinical benefits to expect from debut as well as Tolerability management strategies.
Brendan: Our second key driver is the real world evidence and the success stories those are created to motivate both HCP and families to initiate debut.
Brendan: Broad prescribing early post launch has led to many debuted treatment success stories across a range of ages and disease Severities were now utilizing these successes to educate prescribers and caregivers on what to expect when starting and staying on debut which will encourage broader adoption.
Brendan: Looking at GI management strategies, we've seen a pretty wide range of approaches.
Brendan: Some physicians and practices, particularly a few of the Coes feel they have this very much dialed in utilizing product labeling and Gi management strategies to achieve success.
Brendan: However, implementation of these strategies and the broader community as variable telling us there is an important opportunity to educate further on these guidelines.
Brendan: While we continue to be very encouraged by the longitudinal rate of persistency, we've been tracking we believe.
Brendan: We believe that in addition to communicating debuts clinical benefits implementation of more consistent best practices in GI management will further support building a sizable base of enduring patients over time.
Brendan: This leads to our next driver persistency, where we've seen a very consistent pattern.
Brendan: At very consistent pattern since launch when comparing the post launch rate of persistency to our clinical trial experience.
Brendan: Let me now share our latest persistency data.
Brendan: With patient cohorts now out to nine months, the real world Persistency rate is 58% compared with 47% seen for placebo rollover patients in lilac at nine months.
Brendan: As we described on our last call approximately 40% of patients that initiated therapy on debut in phase III remain on therapy today.
Brendan: And have been on therapy for more than two five years.
Brendan: This comparison underscores the opportunity we see to build a sizable enduring population on debut.
Brendan: If we continue to track approximately 10 percentage points above our clinical trial experience. We believe the enduring population could be approximately half of patients who initiate therapy.
Brendan: Let me touch on the number of patients we have on therapy as of the week ending may 3rd we have 862 patients active on debut therapy compared with the figures we shared on February 27% to 860.
Brendan: During the during the during most of the first quarter, we saw a decline in active patients on therapy due in part to an increase in numerical discontinuation Steve described earlier.
Brendan: We've now seen net patient additions in each of the last six weeks and we believe the increase in numerical discontinuation that we observed in the first quarter has peaked and is now largely digested.
Brendan: I'd like to recap our view of the U S opportunity as we now commence our second year on the market.
Brendan: With over 3500 diagnosed patients who have not yet tried debut and several thousand red patients who have not yet been diagnosed we have an opportunity to continue to substantially grow debut.
Brendan: Our persistency experienced to date indicates we can build a sizable enduring population benefiting from debut.
Brendan: We have a strong foundation to build on including a large prescribing population and broad payer access.
Brendan: Please turn to slide 10 for a discussion of our plans on debut outside the United States.
Brendan: Looking beyond the U S. We are rapidly advancing toward making debut available in additional markets.
Brendan: Our pediatric investigation plan or Pip, which detailed the previously completed clinical trials for debut has been agreed upon with the pediatric committee of the EMA paving the way for an anticipated filing in the first quarter of 2025.
Brendan: In Japan, we now have a formal meeting scheduled with the <unk> later this quarter to discuss our proposed clinical plan.
Brendan: And in Canada, We recently announced that our new drug submission was accepted for filing and granted priority review by health, Canada, potentially leading to an approval in that market around the end of this year.
Brendan: Let's now turn to slide 11.
Brendan: Here you see quotes from caregivers reinforcing some of the observations described above each consistent with the feedback we've been hearing for many months such as caregivers, noting higher levels of engagement improve.
Brendan: Improvement in speech with a broadening vocabulary and improved engagement in conversations.
Brendan: More purposeful use of hands and decreased hand wringing in stereotypic we.
Brendan: We also regularly hear feedback about our loved ones increased cognitive ability or increased alertness with patients now being able to better follow conversations.
Brendan: Caregivers tell US debut these improvements as meaningful enhancements and quality of life for the patients and their care as well as their families.
Brendan: These testimonials all speak to the promise of treatment with debut and underscore exactly why we at Acadia do what we do to support and benefit those with greatest needs.
Brendan: Let's turn to slide 12 for a discussion of our NUPLAZID franchise.
Speaker Change: I'll start by reiterating that our primary financial objective with NUPLAZID is to optimize cash flow and we do that in two ways.
Brendan: First we're continuing to grow <unk> shipments and market share in our eighth year on the market for PDP.
Brendan: The most effective lever to drive growth recently has been the broad educational campaign, we launched last year, bringing attention to a real world evidence studies.
Brendan: These efforts have allowed us to grow new patient starts faster than the market.
Brendan: The second way, we optimize NUPLAZID franchise cash flow is by carefully managing expenses and we will continue to do that throughout 2020 for.
Brendan: These combined efforts have enabled us to generate over $300 million.
Brendan: On a stand alone fully burdened basis.
Brendan: Annual cash flow.
Brendan: Now, let's turn to slide 13 to review our quarterly performance.
Brendan: In the first quarter of 2020 for NUPLAZID delivered $129 9 million and net product sales.
Brendan: As evidenced in the prescription data presented on the slide the Parkinson's disease market remains largely flat with both carbon dopa levodopa <unk> essentially flat versus the prior quarter, while other anti psychotics in NUPLAZID, both increased by 4% and 6% respectively in the first quarter compared with.
Brendan: The fourth quarter of last year.
Brendan: Importantly, NUPLAZID outperformed growth in the PD market in both the office space and long term care channels.
Brendan: We are encouraged by these recent trends and look forward to continuing to grow this franchise.
Brendan: Now I'll turn it Kimberly Manhart senior Vice President of global strategic planning and execution to provide an update on our pipeline programs starting on slide 14.
Kimberly Manhart: Thank you Brendan and addition to our commercial products and a strong pipeline of late stage clinical programs and early stage disclosed and undisclosed programs, providing us with several opportunities to further expand our growth.
Kimberly Manhart: I'll review, our two late stage programs. Please turn to slide 15 to discuss our <unk> 101 program the treatment of hyperphagia in <unk> Willi syndrome RP Ws.
Kimberly Manhart: Let me start with just a brief background on the disease.
Kimberly Manhart: <unk> Willi syndrome is a rare genetic neuro behavior disorder that affects approximately eight to 10000 patients in the U S.
Kimberly Manhart: Finding characteristic of PWM is hyperphagia, which is constantly begins between the ages of three to eight.
Brendan: Hypertension is characterized by unrelenting hunger that often leads to obesity and behavioral challenges such as anxiety and aggression.
Brendan: As you can imagine it is extremely distracting for patients as well as parents and caregivers of patients with dws.
Brendan: To illustrate just how devastating this disorder is the average life expectancy is 30 years, largely due to obesity and the resulting cardiovascular related diseases.
Brendan: Hyperphagia MPW ACH represents a significant unmet need as it currently no therapies approved to treat it.
Brendan: Let's now turn to slide 16, while we describe our clinical program and product Wellington rounds.
Brendan: Late last year, we initiated a phase III study of <unk> hundred one for the treatment of hyperphagia and gws.
Brendan: This study builds on the prior phase III experience and includes $3 two milligram dose that was shown to significantly reduce hyperphagia related behaviors.
Brendan: As you see on this slide the Compass Dws is our phase III global Multicenter randomized double blind 12 week placebo controlled study evaluating efficacy and safety of <unk> 101, and approximately 170 <unk> patients.
Brendan: The primary efficacy endpoint is improvement of hyperphagia as measured by the hyperphagia questionnaire for clinical trials or HTC Tcl also used in the prior phase III study.
Brendan: Those patients to complete this study are eligible to enroll in an open label long term extension study.
Brendan: If data from the Phase III study are positive we plan to submit a new drug application for the treatment of hyperphagia and dws to the FDA.
Brendan: The product will it community has incredibly high level of enthusiasm for this opportunity and interest in our study.
Brendan: We look forward to working with them and with clinical experts as it continue to advance this program.
Brendan: Please turn to slide 17 to review our second late stage clinical program.
Brendan: Q4.
Brendan: Yes.
Brendan: <unk> is our next generation five Ht QA compound that we're developing as a potential treatment for Alzheimer's disease psychosis.
Brendan: Similar to the answer and ACP cure for what's primarily as an inverse agonist at the five Ht receptor.
Brendan: With ACP till four we are seeking to build on our learnings from <unk> and bleed and it's an exciting product opportunity.
Brendan: Our work completed to date includes a comprehensive phase one program that supports our target product profile for ACP Q4, including no sign of Qt prolongation that planned doses in our studies a wide dose range established supporting the potential of our industrial Cleveland to approximately two times the approved.
Brendan: And the dance around 30, 34 milligram dose.
Brendan: Steady state PK achieved in less than half the time of kind of answering suggesting the potential for an earlier onset of activity.
Brendan: ACP to workforce profile could represent a significant improvement over their already strong product profile for Ken the downtrend.
Brendan: Please turn to slide 18.
Brendan: Our seamless phase II phase III program for <unk> for which we are aligned on what the FDA built on our clinical experience with <unk> and is now underway.
Brendan: Our plan includes a phase II study with over 300 patients, which is designed to work seamlessly into Q3 studies.
Brendan: This phase III study is ongoing and is designed and sized in such a way that is successful it could be considered an adequate and well controlled registrational trial.
Brendan: Once the full study allocation of patients for phase two is complete we will analyze and report phase II results by which time the two phase III studies will already be underway.
Brendan: We are pleased to be advancing both of these promising late stage clinical assets and look forward to providing future updates and now I'll turn it over to Mark for a financial update beginning on slide 19.
Mark: Thank you claim related let's review, our quarterly financial performance on Slide 20.
Mark: In the first quarter, we recorded $205 8 million in total revenue up 74% from the first quarter of last year.
Mark: W. Net product sales were $75 9 million in the first quarter, which was a sequential decline of 13%.
Mark: As compared to the fourth quarter of 2023.
Mark: The sequential quarterly change was comprised of a 10% reduction in bottles sold and a 3% reduction in net price due to higher gross to net.
Mark: In terms of the reduction in bottles sold on our last call. We described the seasonal dynamics that were affecting our business in the first quarter, including fewer rent clinic days and ret patient visits as well as reductions in refills in conversion rates due to the beginning of the year insurance reauthorization and re enrollment.
Speaker Change: Yes in.
Mark: In addition for a period of time numerical discontinuation outpaced new patient starts the dynamics of which were described earlier by Steve and Brian.
Mark: As we are now back to a period of net patient adds in the first quarter seasonal dynamics are behind US. We are confident in our ability to grow debut sales on a quarter by quarter basis through the remainder of the year.
Mark: NUPLAZID net product sales were $129 9 million in Q1 up 10% versus the prior year's first quarter.
Mark: <unk> net for NUPLAZID was 33, 1% in Q1.
Mark: Our NUPLAZID franchise achieved 4% demand growth year over year, driven by increases in new patient starts in both segments.
Mark: Sell in growth increased by 6% benefiting from the impact of a larger from a larger reduction in channel inventory in the first quarter of last year as compared to the level of in channel inventory reduction we experienced in the first quarter of this year.
Mark: R&D expenses decreased to $59 7 million in the first quarter of 2024 from $69 1 million in the first quarter of 2023.
Mark: The decrease was mainly due to the <unk> commercial supply build in Q1 2023 that was accounted for as R&D expense.
Mark: Those expenditures took place prior to the FDA approval of debut.
Mark: We had a similar level of clinical spend year over year.
Mark: SG&A expenses increased to $108 million in the first quarter of 2024 from $101 2 million in Q1 2023.
Mark: The increase was primarily driven by annualized <unk> of debut expenses as well as foundational investments to commercialize <unk> outside the U S.
Mark: We ended the quarter with a cash balance of $475 million, which increased by $31 $6 million from our 2023 year end balance of $438 9 million.
Mark: Turning to slide 21, you can see that we are reiterating our guidance ranges for 2024.
Mark: And now I'll turn the call over to Steve for closing remarks. Thanks.
Steve: Thanks, Mark Let's now please turn to slide 22.
Steve: Looking to this year and beyond we are focused on penetrating the significant opportunity that remains in front of us for debut in the United States.
Steve: Together with NUPLAZID, we expect.
Steve: Our commercial franchises to drive strong growth. We're excited to bring debuted to markets outside of the U S and are making strong progress already this year.
Steve: We look forward to further enrolling our two late stage programs, including our phase III program for <unk> Willi syndrome, and our seamless phase III phase III program in Alzheimer's disease psychosis.
Steve: We're pleased to have these terrific opportunities ahead of us while at the same time being in a position to generate.
Steve: Sustainable and growing cash flow from operations to fund future growth.
Speaker Change: With that I'll turn the call over to our operator for Q&A operator. Thank you. So much NSS reminder, press star one one to get into queue and wait for your name to be announced we ask that you. Please keep your questions to one please standby, while we compile the Q&A roster.
Speaker Change: Our first question is from Tess Romero with JP Morgan. Please proceed.
Tessa Thomas Romero: Hi, good afternoon guys.
Tessa Thomas Romero: Thanks for taking our question.
Tessa Thomas Romero: On the business development front curious you've previously talked a lot about an interest in rare disease and neuro just curious how would you characterize your appetite today here can you speak to the amount of capital you would ideally allocate the BD activities and the amount of rescue would be willing to take on.
Tessa Thomas Romero: In terms of stage and then quick follow up just on <unk> you talked about net patient adds in each of the last six weeks. We just wanted to confirm with the correct interpretation B that you expect this to continue such that you are comfortable to reiterate the guide today. Thanks guys.
Speaker Change: Got it thanks for that yes.
Speaker Change: I'll take the BD.
Speaker Change: Question, then I'll ask Mark to comment on your <unk> question.
Speaker Change: In terms of BD.
Mark: Nothing has changed and it continues to be a very important part of our strategy.
Speaker Change: We are.
Mark: It's always a little bit difficult to predict the timing of transactions.
Mark: A lot of things have to come together obviously.
Mark: But we continue to be very active on the BD front and looking at what I would characterize as some really interesting opportunities.
Mark: It is also <unk>.
Mark: A little bit difficult to.
Mark: Project exactly how much capital.
Mark: Would allocate to.
Mark: Individual deal or deals.
Mark: Because it's really.
Mark: And in fact dependent.
Mark: But what I would say is we do see a what I would characterize as a very interesting opportunity set.
Mark: And.
Mark: And we will execute on deals that we think are additive.
Mark: <unk> add value to our to our base.
Mark: I think that was it on BD Mark do you want to take the debut guidance question.
Mark: On guidance. Thanks for the question. Your interpretation is correct. We do expect to have net patient adds continue in a positive direction going forward and that supports through really a reiteration of our guidance range.
Mark C. Schneyer: Yes, I just wanted to confirm did you have a third question on DVS.
Speaker Change: <unk> excuse me I think I captured all but want to make sure.
Speaker Change: Yeah. Thanks, Steve Thanks, Mark just kind of stage of asset on the BD side that you'd be contemplating.
Speaker Change: How early would you go versus something more late stage.
Speaker Change: Yes. Thanks I appreciate the question.
Speaker Change: You will also vary.
Mark C. Schneyer: Opportunity dependent.
Speaker Change: I would say, we as an industry. We worked through several years there were the biggest challenges that we and other companies had doing deals we are honestly the capital markets because youre things.
Speaker Change: Capital is readily available and that just made it more challenging or more expensive too.
Speaker Change: <unk>.
Mark C. Schneyer: New partnerships or acquisitions.
Speaker Change: Yes, it's a little bit different environment today, and I am seeing.
Mark C. Schneyer: Much more fertile environment for dealmaking.
Mark C. Schneyer: And so having said that.
Mark C. Schneyer: No.
Mark C. Schneyer: Historically, because it was very challenging and very robust capital markets, we and other companies did a lot of early tended to.
Mark C. Schneyer: Produce more debt environment produces more early stage deals I guess the way itself.
Mark C. Schneyer: We have an appetite for early and late stage deals I think are the sweet spot of our capabilities translates to more of a focus on.
Mark C. Schneyer: Pre commercial assets, although we do from time to time look at.
Mark C. Schneyer: Products that are already commercialized and so I would say there are no Greg.
Mark C. Schneyer: We're agnostic more or less to the stage of development of asset we have a strong balance sheet. We have strong capabilities, we certainly would love to do.
Mark C. Schneyer: More late stage assets.
Mark C. Schneyer: Debut and ACP 101 in product related to examples of deals that we've done at the late stage and we'd certainly be eager to do more of it really is more a function of.
Mark C. Schneyer: The kinds of opportunities that exist in the market.
Mark C. Schneyer: Thank you. Thank you.
Speaker Change: One moment for our next question please.
Mark C. Schneyer: And it comes from the line of Lee to borrow with TD Cowen. Please proceed.
Lee: Hi, guys. Thanks for taking the question, let me apologize for any background noise.
Lee: Can you guys talk about.
Lee: If you have this number and the performance of <unk>.
Lee: This is fahad.
Speaker Change: Got it.
Speaker Change: Any time.
Lee: Given the.
Lee: Long term.
Lee: Does that mean.
Speaker Change: Thank you.
Lee: Plenty of market share.
Lee: First one of diagnosed patients have a tendency to start thinking and Ken.
Lee: Can you speak a little to what you know about we start rates.
Lee: How do I manage this plan.
Ken: Thank you.
Ken: <unk> I'm not sure we understood. The full question, but I think Brent didn't think see caught it also going to let him answer I think I did read you and thanks for thanks for both portions of the question.
Ken: The first is the percentage of of.
Brent: Patient diagnosed patients that are on debut is as Steve pointed out a quarter of patients. So 25 actually a little north of 25% of patients are on debut.
Brent: That would.
Brent: I would discuss in terms of diagnosed patients forgiven or on debut we.
Lee: Have initiated therapy and have initiated therapy W. We have prescriptions, obviously for more as you know we work them through the payer access process.
Lee: So we would expect that we will as we have said with conversion rates continued to convert those procured prescriptions. We have on hand, as we continue to get additional prescriptions in your second question was around restart rates.
Lee: We do see restarts of patients and that happens for a variety of reasons in some cases, a patient and family may have gone too.
Lee: A prescriber that is not necessarily a ret expert, but as close by they may have started on the full dose and may not have had the best of experiences. That's one group that tends to come back as they've heard a bit more about titration as a potential strategy for starting so we see that.
Lee: We also see patients that have gone through significant medical procedures and honestly take a break.
Lee: And then come back to therapy that often happens and as we've discussed because of our family access manager team. We are very we stay very close in proximity to each of these families offering support whether they have decided to initiate debut for in some cases that they have decided at least to take a temporary.
Lee: Pause or to discontinue to just keep them up to date on what we're seeing and opportunities to to restart.
Speaker Change: Got it.
Speaker Change: The first question.
Speaker Change: Thank you.
Speaker Change: For my part.
Speaker Change: Is the 25% the number im sorry, the proportion of patients that have.
Speaker Change: Thank you Scott.
Scott: So there are a number.
Scott: Of diagnosed patients.
Scott: At one point sorry, the bundle.
Scott: So it may not have remains key to lump sum consultants.
Speaker Change: Thank you yes. Thanks, thanks for the clarification. It is the former 25% of patients is it 5000 diagnosed patients or as Bernie said slightly more than 25%.
Scott: <unk> therapy on debuts we do obviously have some of those it just continued but 25% have started therapy.
Scott: Okay.
Speaker Change: Thank you one moment for our next question. Please.
Speaker Change: And as a reminder, we ask that you. Please keep your questions to one.
Speaker Change: Our next question is from Gregory <unk> with RBC capital markets. Please proceed.
Gregory: Yes, Hey, Steve and team good afternoon, congrats on the progress. Thanks, Thanks for taking my questions.
Gregory: Just wondering when it comes to that the new patient starts my question just really around the rate of that certainly appreciate the discontinuation of the ball that you commented on kind of picking those up.
Gregory: The totals I'm just curious.
Gregory: To what extent do you think there'll be some degree of predictability or maybe some stability on anticipating a more stable rate of historic especially as you think about broadening beyond the centers of excellence. Thanks, So much.
Speaker Change: Yes. Thanks, so much for the question Greg Brendan Yes. Thanks for the question Greg. So in terms of new patient starts as we described in the first quarter. It was slow in January but did begin to pick up in February March and April as we discussed in our guidance range, we do anticipate continuing.
Speaker Change: An upward increase in new patient starts the two factors I would say that <unk>.
Scott: Factor in most notably for us will be new patient starts and net patient. So as as we've also described we've seen.
Scott: A decline in numerical discontinuation, which we think is logical based on the bolus of patients that started and now a more consistent rate of patient adds week over week.
Speaker Change #100: Thank you one moment for our next question. Please.
Scott: And it comes from Amit <unk> with Needham <unk> Company. Please proceed.
Amit: Hi, Thanks for taking my question.
Amit: You mentioned in your remarks that.
Amit: Going forward you can expect a significant portion of the growth to come from.
Amit: Non high volume sorry, non CBOE high volume centers as part of a community centers.
Amit: Which often tend to be more spread.
Amit: Spread out how are you thinking about.
Amit: Sort of the commercial effort in.
Scott: Integrating in reaching these physicians.
Scott: So that they can start patients on therapy appropriately.
Scott: Thanks to a titration schedule that flex and enables patients to stay on drug longer.
Scott: Thanks, So much for the question on me Brendan you want to take that yeah sure. Thanks for the question.
Brendan: And maybe from my prepared comments I would I would say that obviously in the early days, we had a substantial number of patients come from centers of excellence, but we already had.
Brendan P. Teehan: A good number of patients that were coming from those high volume institution, non coes and from the community and what I think we've seen as a very logical migration of where prescriptions are coming from.
Brendan: Well over 50% coming from Coes and the earliest of days now more like a third coming from Coes and two thirds coming from the others from there.
Brendan: We have a base of experience in those two latter segments.
Brendan: What we're really focused on are the real world benefits that have been seen for debut because I think the tangible conversations that take place with caregivers are more around what I'm going to see in my patient what am I going to see in my loved one. So we've created vignettes that look at patients over the age of 20 teenage.
Brendan: <unk> as well as pre teens in two to five year olds to give a much clearer perspective on what the treatment opportunity looks like and the benefits that they can expect to see in debut and then I think embedded in the question was a question about our ability to get to these patients wherever they are we have a great footprint.
Brendan: To cover.
Brendan: All of the Rep Treaters and we also have claims data that helps us more deliberately track down those physicians that would be the point person either at a high volume institution or the community.
Brendan: For us to engage in those conversations.
Speaker Change: Thank you one moment for our next question.
Yadkin: And it comes from Yadkin, So now with Guggenheim. Please proceed.
Speaker Change: Okay.
Yadkin: Hey, guys. Thank you for taking my question could you clarify what the growth what is gross to net right now.
Yadkin: And then since you have reached 50% penetration in CRE is could you just comment on the level of penetration that you could reach and non series over time, and where you can push the Crs.
Speaker Change: At $50. Thank you.
Speaker Change: Alright. Thanks, so much for the question Mark you want to take that first question Brendan and I presume you mean the question on gross of that is related to debut.
Speaker Change: Yes.
Brendan P. Teehan: Yes, okay.
Brendan: So I think for us as we talked about on the last call, where we're tracking towards 20% for the year and we don't expect that to fluctuate on a quarter by quarter basis. So we're not.
Brendan: To disclose it as we go along and I would just say maybe qualitatively in the first quarter were just slightly below that target.
Speaker Change: And for the second part of your question.
Speaker Change: I think in two parts for <unk> with 50% patient penetration I think we have tremendous momentum in these core areas of where these patients are treated.
Speaker Change: We will continue to work through that that population.
Speaker Change: I think that as you get further and further up the curve obviously the engagement of those families with coes.
Speaker Change: A critical factor for how far we will get.
Speaker Change: For penetration there, but we do see that in high volume institutions and in the community some.
Speaker Change: Some of these conversations are easier for us to engage in in terms of our ability to get face to face with those physicians to talk about the benefits that they see for debut and then it's really a function of working very closely with them to make sure that they can get to their families.
Speaker Change: Alert them that a therapy is available and get them get them in for treatment in terms of penetration I think we expect to have similar rates of I think we expect to see rising rates of.
Speaker Change: Penetration of high volume institutions more.
Speaker Change: More closely replicating what we see in Coes and then in the community.
Speaker Change: Really depends on kind of the physician level of engagement that we're seeing in the proximity of the last kind of discussions they've had with their with their reputations, but we're encouraged by what we're seeing early on.
Speaker Change #101: Thank you one moment for our next question. Please.
Speaker Change: And he is from David Wong with Citigroup. Please proceed.
David Wong: Hi, there thanks for taking the question.
David Wong: I just wanted to ask about whether you had any insight on whether persistency differs between coes.
David Wong: The non <unk> community segment, and if you could possibly tie that back to their Gi management strategies.
Speaker Change #102: How are our docks managing it and the non Coa segment and how much room is there to improve.
Speaker Change: Thanks, So much for the question Brendan you want to take that yeah sure David Thanks, Thanks for the question.
Speaker Change #103: At the top of.
David: At the top of I'll say that there are not wide disparities in persistency rates between coes and non coes.
Brendan: What I think we see is more the proximity to patient and the work done on a Gi management strategy. So that there is a clear discussion upfront with the families about the treatment journey and the options that are available to make sure. They manage that so the more experience a physician gets the more <unk>.
David: Consistent I think their approach to Gi management becomes the better persistence. It yet so I think it's more a function of that than it is whether youre in a coa or not.
Speaker Change #104: Thank you.
Speaker Change: One moment for our next question.
Speaker Change: Okay.
Speaker Change: And he is from the line of Joel Beatty with Baird. Please proceed.
Joel Lawrence Beatty: Hi, Thanks for taking the question.
Joel Lawrence Beatty: Net numerical discontinuation in the first six weeks of the year. So could you characterize those a little bit more such as what was the cause and was it driven more by lower patient starts during that time, our higher than usual discontinuation.
Speaker Change: Alright. Thanks, so much for the question Joel Brendan you want to take that.
Brendan P. Teehan: Yes, Joel Thanks. Thanks for the question numerical discontinuation were largely what we would expect which is why we reiterated the point around the consistency of our persistency curves.
Brendan: We do think season from a seasonal perspective, there were some patients that started perhaps in the fourth quarter that discontinued early it may not have been great timing for them to have started debut around the holidays. For example that may have contributed from a seasonal perspective.
Brendan: Slightly higher numerical discontinuation than anticipated.
Brendan: Thanks.
Speaker Change #105: Thank you.
Speaker Change: For our next question.
Jeff Hung: And he is from the line of Jeffrey hung with Morgan Stanley. Please proceed.
Jeff Hung: Hi, Good afternoon. This is Katherine on for Josh. Thank you so much for taking our question just another one on the centers of excellence from US now that we're a year into launch have you observed coes, increasing the number of Red clinic days from the once monthly you mentioned last quarter to a more frequent basis and do you have an updated average number here.
Speaker Change: Yes. Thanks, Thanks for the question Katherine Brendan.
Brendan P. Teehan: Thanks for the question in most cases I would say that coes are maintaining the process that they have had to.
Brendan P. Teehan: To engage families. There are a handful of centers that have increased Coa increased.
Brendan: Increased rent clinic days there are a couple that have specific debut clinic days as well.
Brendan: But generally I would say, it's it's been consistent with how they've seen patients over time.
Speaker Change: Okay. Thank you.
Speaker Change: Thank you one moment for our next question. Please.
Speaker Change: Sure.
Jeff Hung: And he is from the line of Charles Duncan with Cantor. Please proceed.
Jeff Hung: Hi, This is Julian on for Charles Thank you for taking our questions.
Julian: I just wanted to ask I think at the last update you said that the age range was.
Julian: Comparable or spread thrilling for D var.
Julian: When do you say about the key drivers for demand such as payables benefit and establishing GI management strategies does it depend per each range.
Speaker Change: Thanks, so much for the question Brandon.
Brandon: Yes sure. Thanks, so much for the question Elaine I would say that we're still seeing largely what we expected in terms of the existing prevalent population for <unk>, meaning that we're getting.
Julian: The age range and the respective weights that we would expect to see in terms of our patient mix if anything in the first part of 2024, we've seen slightly older and heavier patients that have been started on debut in terms of the patient mix, which might lead to.
Julian: To somewhat of an increase in average dose as a function of that.
Speaker Change: Thank you.
Speaker Change: Thank you.
Speaker Change: For our next question please.
Speaker Change: And is from the line of Jason Butler with citizens JMP.
Jason Nicholas Butler: Good afternoon, Joseph for Jason Thanks for taking our questions. How do you think about the potential role of gene therapies for <unk> syndrome, and how <unk> be used alongside as Derek.
Jason Nicholas Butler: Understand.
Speaker Change: Eric.
Speaker Change: Early in development, but just curious about your thoughts thank you.
Joseph: Yes. Thanks, so much for the question I'll start by saying, we hope to debut as the first of multiple drugs approved to treat this.
Joseph: Highly debilitating disorder.
Joseph: As it relates to gene therapy.
Speaker Change: I think that.
Speaker Change: We know that gene therapy can be very challenging we've even seen some of the challenges played out just in the last week with gene therapy generally speaking.
Speaker Change: Can read it's a little bit more a little bit of an additional hurdle here because.
Speaker Change: With rat, there's kind of a goldilocks level.
Speaker Change: Our of expression that you when operate within because if you have too much expression you get the same symptoms you give it to them.
Speaker Change: And so.
Speaker Change: A couple of companies that.
Speaker Change: Very.
Speaker Change: The early stages of testing on gene therapy, and I think there's just a lot more to come.
Speaker Change: It won't be rapid.
Speaker Change: Nothing is in this industry. It takes some time, but we're certainly hopeful that there will be again that data will be the first of many therapies for this population, having said that as we think about additional drugs, becoming available including gene therapy.
Speaker Change: We don't see any reason that that debut couldnt be.
Speaker Change: Couldnt be prescribed alongside other drugs as well and so these patients are so highly symptomatic.
Speaker Change: If you had another therapy June gene therapy, or otherwise they reduced symptoms by 50.
Speaker Change: 50% or even 75% they would still be highly highly symptomatic and in need of therapy and so we envision debut operating in a world where if there are other therapies down the road.
Speaker Change: We believe that.
Speaker Change: It would be very compatible with those therapies have the potential to.
Speaker Change: <unk> additive benefit.
Speaker Change #106: Very helpful. Thank you.
Speaker Change: Thank you one moment for our next question. Please.
Speaker Change: And he's from Ash Verma with UBS. Please proceed.
Ashwani Verma: Hi, Thanks, Thanks for taking my question I had two so I.
Ashwani Verma: I know in prior instances you have soft guided with sands or subsequent quarters. At this time, Michael I think you just look at that sequential growth is there any reason for that if anything you sound very content laundry volumes in this curious what's sort of driving that demand dynamic and then secondly, I wanted to ask about your cost structure I would like to have you.
Ashwani Verma: Consider revisiting that.
Ashwani Verma: Compared to last year. This year, we've seen NUPLAZID negative symptoms start working out favorably and persistent key coming in below I'm guessing that you would have ordinarily assume.
Speaker Change: Does that make you rethink where your cost structure is.
Speaker Change: Thanks Mark.
Speaker Change: Thanks, so much Ashley the questions Mark I'll, let you take both of them.
Mark Schneider: Yes sure sure on the on the guidance as we transition to annual guidance, you're no longer to give the kind of one coat forward one quarter forward guidance.
Mark Schneider: The unique thing about the first quarter of this year is that we were expecting a sequential down quarter. So we thought it was just helpful in giving the full financial expectations for the year to give the first quarter guidance for this year as well as annual guidance, we don't expect to see sequential declines going forward. So.
Mark Schneider: We're going to keep the annual guidance just like we do for NUPLAZID on the.
Speaker Change: Our cost structure. Thanks for the question as Chief Financial Officer of course, I look at the cost structure every day.
Speaker Change: And but I think as we look at what's the right cost structure for the business and the investments that we're making there is no change there yes, yes, we had.
Mark Schneider: Unfortunately, our negative symptoms of schizophrenia.
Mark Schneider: File was not positive, but we hadn't made investments in commercial investments and negative symptoms of schizophrenia before that readout. So there really is nothing to unwind our business is expanding we're making investments for ex U S.
Mark Schneider: Sure for debut that didn't exist last year. So that's kind of a new leg to the business that requires investment and we're still investing.
Mark Schneider: Appropriately for growth and debut in the U S. So all of that together leads us to supporting the investments that we're making.
Mark Schneider: But as we've done.
Mark Schneider: Over the last couple of years in NUPLAZID right. We've we've looked at that franchise of making efficiencies and we look to make the right investments.
Mark Schneider: Additional investments a reduction investments across our entire cost structure on an ongoing basis.
Mark Schneider: Yes.
Speaker Change: Thank you.
Speaker Change: One moment for our next question please.
Speaker Change: And it comes from the line of Marc Goodman with Leerink.
Marc Harold Goodman: Yes. My question is around the product really trial and I'm hearing a glitch.
Marc Harold Goodman: Slip one up.
Marc Harold Goodman: Uptake has been hindering enrollment and just your general thoughts around.
Speaker Change: How <unk> will play into potentially not.
Speaker Change: Needing as much therapy.
Speaker Change: Potter Williams and the eating disorder.
Speaker Change: And then secondly can you just give us a sense of how many patients are on NUPLAZID. These days, we haven't talked about it yet.
Speaker Change: Thanks benchmark for the question I'll take the first one so proud of Willy.
Speaker Change: We've seen no impact at all.
Speaker Change: Good one.
Speaker Change #107: Utilization in fact.
Speaker Change #107: As Kimberly mentioned that we have a very enthusiastic patient population a medical community and enrollment is moving very well.
Speaker Change: We're enrolling ahead of plan. So so we haven't seen any impact of flip one or anything else honestly.
Speaker Change: Yes.
Speaker Change #108: And I'm sorry, the second question Brendan do you want to take that on NUPLAZID, Yes sure. Thanks for the question Mark.
Brendan P. Teehan: We're continuing to see increases in patients on therapy on a quarterly basis.
Speaker Change: Between.
Brendan P. Teehan: Between the community and LTC and long term and long term care, obviously, we have great visibility into the community.
Brendan P. Teehan: So we've added patients in the first quarter over the fourth quarter.
Brendan P. Teehan: Two the order on the order of about 8500 in total patients and then in LTC. That's obviously more like a quarter of our business, but you know that prescriptions are often split between patients. So we don't have absolute visibility into the number in long term care.
Brendan P. Teehan: Okay.
Speaker Change: Thank you.
Speaker Change: One moment for our next question please.
Speaker Change: And he's from some months CRU Kearney with Canaccord Genuity. Please proceed.
CRU Kearney: Good afternoon. Thanks for taking my question on debuted discontinuation is been a sweet spot in terms of months on drug discontinuation center clustered and if a patient remains on drug after that they tend to do so more easily passed that point.
CRU Kearney: Most discontinuation as confirmed by clinical visits or are the patients that have gone greater than 60 days without visa.
Speaker Change #109: Yeah. Thanks, Mike I'll answer the first part Brendan I'll ask you to answer the second part in terms of the split on discontinuation.
Brendan P. Teehan: Yes, so what we do see we touched on this on the call. So let me just expand it a little bit.
Brendan P. Teehan: We do see more discontinuation in the first.
Brendan P. Teehan: Two fills of drug so it has a disproportionate number of discontinuation. So now some of that you would expect we see this pretty routinely with drugs that have subjective endpoints, we see it all the time in neuropsychiatry, we have a steeper level of discontinuation in the first two to three months. So we do see some of that we do.
Brendan P. Teehan: Do feel however, though as we as we parse through that data that given the level of titration that we're seeing across the brand and just recognizing that it takes longer to get to therapeutic levels.
Brendan P. Teehan: We do think that.
Brendan P. Teehan: Some patients are discontinued prematurely before they have an opportunity to see those benefits and there is an opportunity for us there to improve on that and it's a high area of focus for us to down as Brendan discussed on the call.
Brendan P. Teehan: Particularly around educating caregivers and <unk>.
Brendan P. Teehan: Medical professionals around their expectations around time, setting the right expectations about time to get the benefits.
Brendan P. Teehan: And in managing to that as a very important area of focus for us.
Speaker Change: Do you want to take the other question, yes. So.
Speaker Change: Steve Obviously did a great job of kind of articulating, where we are with with when discontinuation take place and its probably intuitive, but the further out we get and fills the flatter the curve gets right. There are fewer and fewer patients that are discontinuing when you get beyond 4% and five fills with debut.
Speaker Change: And I think we're encouraged by that.
Speaker Change: Two levels number one is obviously our fans are very close with these families. We have weekly conversations with them. So we have good confidence that once they get through the early part of that patient journey and Tolerability Gi management strategies, we do a nice job of keeping them on therapy, and we also know from talking to <unk>.
Speaker Change: Enters of excellence, how often theyre seeing these patients.
Speaker Change: Many many of the physicians want to see their patients regularly after they start the.
Speaker Change: The vast majority of them I think want to see patients at month, three time period, partially because thats the length of the clinical trial, partially because some some payers are asking for that information at that point and then I think they make.
Speaker Change: Judgment calls on how well the patient is doing how often they want to see them after that but with persistency rates now out to nine months and what we're seeing I think we feel confident in what we're seeing in terms of patients being able to start and stay on therapy. After they get through the early part of the treatment journey.
Speaker Change: Thank you I think I'll, just add one thing to that.
Speaker Change #110: I think the question was also do we are more discontinuation has happened.
Speaker Change: Because they are confirmed versus going over 60 days and I think you asked it in the context of is it a clinical decision I think for us with the connectivity we have with our fans we do find that for the data we receive.
Speaker Change: The majority of discontinuation or confirmed discontinuation and it's the minority of discontinuation stat.
Speaker Change: Deemed discontinued for greater than 60 days, many of which of those then subsequently become confirmed.
Speaker Change: When when when <unk> spoken to the caregiver.
Speaker Change: Thanks for that clarification Mark.
Speaker Change #111: And we have.
Speaker Change: One moment for one more question one moment please.
Lee: And he comes from the line of Lee.
Lee: <unk> with Mizuho. Please proceed.
Lee: Hey, guys, thanks for including.
Lee: Yes, just some question on NUPLAZID.
Lee: So you indicated.
Speaker Change: Real World evidence has sort of grown new start I'm just wondering like.
Mizuho: Is it what exactly is it is there anything thats kind of like that's change in practice, our Ah patients.
Lee: I don't know less scared to come back.
Lee: Judy.
Lee: <unk>.
Lee: The physician's office or is there anything fundamentally.
Lee: And a physician to offers in the long term care that perhaps increasing the number of patients and secondly would you consider perhaps increasing your investment to drive further growth. Thanks.
Speaker Change: Thanks, So much for the question Brendan you want to take the first question for sure.
Brendan P. Teehan: So I think there are a couple of dynamics.
Speaker Change: If youll recall carbon open levodopa scripts in the peak of the pandemic it even towards the end were declining overtime and declining would suggest fewer Parkinson's disease patients overall.
Speaker Change: Even today, we'd say that's flat so I wouldn't call that a rebound by any stretch the imagination I would call that stability, but I think also easing.
Lee: Safety measures that have patients returning to clinics and hospitals are certainly giving us more shots on goal for NUPLAZID as the choice for PDP I think that combined with real world evidence has given us a very compelling story on why we should be the first and best choice.
Lee: And that's given us an opportunity to grow share and what we've seen in long term care I think has been pretty logical in terms of resident accounts in long term care facilities. They obviously plummeted.
Lee: During during the pandemic towards the latter part they have increased.
Lee: They have continued to increase but NUPLAZID performance has outpaced both the resident counts and Aps and <unk>.
Lee: Space.
Speaker Change: I'll take the second part of that.
Speaker Change: As Brendan mentioned, when we look at metrics.
Speaker Change: <unk> will leave the dopa it looks like the overall PCB market is relatively steady or flat, but.
Speaker Change: But we are seeing growth.
Speaker Change: With NUPLAZID there.
Speaker Change: And I think that's the Genesis of your question So would we consider.
Speaker Change: Increasing our investment and I think the answer is we do monitor that too.
Lee: Day to day week to week basis.
Lee: We look for opportunities we're constantly assessing is this the right level of investment given the opportunity and as we've said before if there if we feel like there's opportunities to produce an appropriate ROI, we may make those investments, but at this juncture. That's just a key element of our overall objective.
Lee: Optimizing cash flow.
Speaker Change #112: Thank you and with that I will conclude our Q&A session and pass it back to Steve Davis for final comments.
Stephen R. Davis: Thank you operator, and thanks again, everyone for joining us today, and we look forward to updating you on our progress next quarter.
Stephen R. Davis: And with that we thank you all for participating and you may now disconnect.
Stephen R. Davis: Okay.
Lee: [music].