Alnylam Pharmaceuticals Inc (ALNY) 2018 Q2 法說會逐字稿

Good day, ladies and gentlemen, and welcome to the Alnylam Pharmaceuticals Q2 2018 Earnings Conference Call. (Operator Instructions) As a reminder, this conference is being recorded.

I would now like to introduce your host for today's conference, Ms. Christine Lindenboom, Vice President of Investor Relations and Corporate Communications. Ms. Lindenboom, you may begin.

Good morning. I'm Christine Lindenboom, Vice President of Investor Relations and Corporate Communications at Alnylam. With me today on the phone are John Maraganore, Chief Executive Officer; Barry Greene, President; Manmeet Soni, Chief Financial Officer; and Yvonne Greenstreet, Executive Vice President and Chief Operating Officer. Akshay Vaishnaw, our President of R&D is unable to join our call this morning.

For those of you participating via conference call, the slides we have made available via webcast can also be accessed by going to the Investor page of our website, www.alnylam.com.

During today's call, as outlined on Slide 2, John will provide some introductory remarks and provide general context; Yvonne will review recent clinical updates; Manmeet will review our financials; and Barry will provide an update on our commercial readiness effort and a brief summary of upcoming milestones before opening the call for your questions.

I would like to remind you that this call will contain remarks concerning Alnylam's future expectations, plans and prospects, which constitute forward-looking statements for the purposes of the safe harbor provision under the Private Securities Litigation Reform Act of 1995. Actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors, including those discussed in our most recently quarterly report on file with the SEC. The press release and related financial tables, including a reconciliation of GAAP to non-GAAP measures that we will discuss today can also be found on the investor page of our website. We believe non-GAAP measures provide useful information to management and investors regarding our financial conditions and results of operation.

In addition, any forward-looking statements represent our views only as of the date of this recording and should not be relied upon as representing our views as of any subsequent date. We specifically disclaim any obligation to update such statements.

With that, I will now turn the call over to John.

Thanks, Christine, and thank you, everyone, for joining the call this morning. The second quarter of 2018 and recent period represent a notable and significant milepost in Alnylam's 16-year journey of advancing RNAi therapeutics as a potential new class of medicines. Indeed, we now had our first recommendation for the approval of ONPATTRO, our trade name for patisiran, with the positive CHMP recommendation in the EU. And by the end of next week, we expect to have our first approval here in the U.S.

Before I turn it over to Yvonne to address our R&D progress, I'd like to make a few introductory remarks. First, as I just noted, we are now at the cusp of bringing our first RNAi therapeutic medicine to patients in the U.S. and Europe. We are also planning for a regulatory submission in Japan in September, in addition to regulatory filings in other countries by year's end. At Alnylam, we couldn't be more excited about this very special moment, since nothing is more important to us than making a difference in the lives of patients around the world.

Secondly, as Barry will highlight shortly, we are building a world-class global team to commercialize ONPATTRO, which we believe has the potential to be a truly meaningful orphan disease medicine. We are launch-ready here in the U.S., and also in Germany, where we expect our first EU launch. In addition, we've been building a highly experienced team in Japan, and we plan to follow in other countries as well, building a global commercialization effort.

Third, we continue to execute on our broader pipeline efforts, especially on our late-stage programs. Notably, we're planning on soon conducting an interim analysis of our ENVISION Phase III trial of givosiran in the acute hepatic porphyrias. If positive, and the safety profile is acceptable, we plan to take these results to the FDA to discuss a possible year-end NDA submission to support an accelerated approval in 2019.

In the meanwhile, enrollment in ENVISION has exceeded our expectations, and we're now on track to have full study results in early 2019, well ahead of schedule. We also scored some notable milestones in other late-stage programs, namely lumasiran and ALN-TTRsc02, related to alignment with regulatory authorities on the design of Phase III studies for each of these programs, each of which will start -- each of these Phase IIIs will start later this year. We believe, all of these important milestones put us on track for the potential to have essentially annual launches from our pipeline in the years to come, assuming favorable results in regulatory approvals and also to meet our Alnylam 2020 objectives of building a multiproduct, global, commercial-stage company with a deep and sustainable clinical pipeline and a robust product engine by the end of 2020, a company profile rarely, if ever, achieved in biotech.

Finally, I want to take this occasion to say that it's been our privilege to serve the hATTR community. We anticipated the imminent approval of ONPATTRO in the U.S. and Europe is the fruit of a decade-long effort, fueled by patients and caregivers, physicians and nurses. And they are truly stellar team across every group here in Alnylam, who've gone above and beyond in this journey to make ONPATTRO a reality for patients.

With that, I'd like to now turn the call over to Yvonne to review our pipeline progress in more detail. Yvonne?

Thanks, John, and good morning, everyone. As John highlighted, it's been a busy quarter and one filled with much excitement and anticipation, as we draw closer to our PDUFA date for patisiran. So let's start with patisiran.

The CHMP's positive recommendation for marketing authorization, a patisiran in Europe, is an important step in validating RNAi as a therapeutic strategy and which is based on the positive results from our APOLLO Phase III study, which was 225 patients, is the largest clinical study of patients with hATTR amyloidosis conducted to date.

Barry will discuss the CHMP recommendation from a commercial perspective, but we are very pleased with Summary of Product Characteristics, or SmPC, that includes our important secondary and exploratory endpoint data, including results reflecting exploratory cardiac parameters. In the meanwhile, we continue to work collaboratively with our colleagues at the FDA towards our goal of achieving regulatory action by our PDUFA date, next week. Also during the quarter, in recent period, we published our APOLLO Phase III results in the New England Journal of Medicine, and also reported on additional data analysis from APOLLO. For example, we recently presented data at the Peripheral Nerve Society Annual Meeting, where new analysis from APOLLO demonstrated the patisiran case of patients showed improvements in overall health factors compared to placebo and improvements in neuropathy impairment with patisiran treatment, which were associated with improved ambulatory status.

Additionally, an indirect treatment comparison reports at PNS demonstrates the patisiran's impact on measures of neuropathy and quality of life in the APOLLO study, relative to those measured in the previously conducted randomized study of tafamidis and hATTR amyloidosis patients with Phase I polyneuropathy.

What are the limitations of this approach? And no head-to-head studies have been conducted. This comparison suggest the benefit for patisiran versus tafamidis in Stage I polyneuropathy for patients with hATTR amyloidosis. This benefit was above across all endpoints assessed, and in some cases, reached statistical significance.

Turning now to ALN-TTRsc02, as John mentioned, we are pleased to reach alignment with the FDA on the design of a pivotal Phase III study that TTRsc02 in patients with hATTR amyloidosis. The Phase III pivotal trial will be an open-label study, with co-primary endpoints of mNIS+7 and Norfolk-QOL at 9 months comparing the effects of TTRsc02 in approximately 120 patients with hATTR amyloidosis to results from the placebo arm of the APOLLO Phase III study of patisiran.

In addition, certain cardiac parameters will be included as endpoints. The study will also include a small reference arm of approximately 30 patients receiving patisiran, although no formal comparisons will be conducted between the TTRsc02 and the reference patisiran arm. We are on track to start the Phase III study in late 2018, and plan to start additional Phase III studies of TTRsc02, including in wild-type ATTR amyloidosis in 2019.

Let's move on to givosiran. Our investigational RNAi therapeutic, in development for the treatments of acute hepatic porphyrias. As you recall, we previously announced that we completed enrollment of the cohort of patients in the ENVISION Phase III study that will comprise a planned interim analysis in support of a potential accelerated approval. The interim analysis is based on lowering of urinary ALA levels at 3 months of treatment as a surrogate biomarker that is reasonably likely to predict clinical benefit. We expect to report top line results from the interim analysis around the end of September. If positive, and also the safety results are acceptable, we will then go to the FDA to discuss the interim analysis results to discuss the possible NDA filing at or around year-end to support an accelerated approval.

We also announced today, this enrollment in ENVISION has proceeded well ahead of schedule, and we now anticipate full patient accrual by the end of September. As such, we expect to report top line results on the primary endpoint of annualized attack rate after 6 months of treatment in early 2019.

Let's move on to lumasiran. Our investigational RNAi therapeutic in development for the treatment of primary hyperoxaluria type 1, where we also made great progress. We present a new positive data from the Phase I/II study at the OxalEurope European Hyperoxaluria Consortium. See on Slide 10, in cohorts 1 to 3 of Part B of the Phase I/II study, lumasiran demonstrated a mean maximum reduction in urinary oxalate of 64%. Furthermore, all lumasiran treatment patients experienced a lowering in the urinary oxalate below key threshold level commonly associated with the reduced rate of progression to end-stage renal disease. This clinically meaningful reductions were durable, with lumasiran patients maintaining a mean reduction in urinary oxalate of 63% at day 85. We believe these potent and durable reductions in urinary oxalate support a once-quarterly subcutaneous dose regimen. Additionally, we believe these results continue to support the hypothesis that inhibition of glycolate oxidase has a potential to reduce and possibly normalize level of hepatic oxalate production, thus potentially holding PH1 disease progression. Lumasiran was generally well tolerated in all 20 patients for Phase I/II study. The majority of adverse events were mild to moderate in severity and unrelated to study drug.

Lumasiran has not been associated with any clinically significant adverse laboratory finding, and there were no study discontinuations due to AEs through the data cut-off date. During the quarter, we achieved alignments with the regulatory authorities in the Phase III study design for lumasiran. Importantly, urinary oxalate reduction was expected as the primary endpoint for a full approval. The planned Phase III pivotal study will have approximately 25 patients and the treatment period will be 6 months. We remain on track to start the study in the coming weeks, with results expected in late 2019, supporting a potential NDA filing in early 2020.

We'll be providing a more comprehensive review of our recent lumasiran clinical days for next step as our upcoming RNAi round table on lumasiran on August 15. And I encourage you all to tune in then. In addition, The Medicines Company continues to make great progress with inclisiran for hypercholesterolemia. Medco announced in June that the Independent Data Monitoring Committee for the ongoing ORION Phase III trials conducted its third planned review of safety and efficacy data from the trials and recommended that the trials continue without modification. At the time of review, substantially all patients in the trial had received 2 doses of inclisiran or placebo. Medco has now accumulated more than 1,550 patient-years of safety data, to date, for inclisiran. In the case of fitusiran for hemophilia now transferred to Sanofi, enrollment continues in the ATLAS Phase III program. As noted in our earnings press release this morning, we are shifting our guidance on our Phase II study of cemdisiran in aHUS due to a slower-than-expected enrollment in this ultra-rare patient population.

Looking earlier, at our R&D effort, we made a significant step forward in RNAi therapeutics with the announcement of successful delivery of novel siRNA conjugates to central nervous system, or CNS. In initial results from a rat preclinical study presented at the TIDES 2018 Annual Meeting, we demonstrated that a single intrathecal injection of a novel siRNA conjugate resulted in broad distribution across the brain and spinal cord regions. Robust, highly durable and specific silencing of a disease target gene transfer were seen in all key anatomical regions of the brain and spinal cord. The novel siRNA conjugates utilize Alnylam's Enhanced Stabilization Chemistry platform with further modifications to enable broad CNS delivery and efficient uptake in the urinal cells. We believe this is a very exciting achievement for Alnylam that has the potential to expand applications of our technology beyond liver-expressed disease targets. And we plan to complete selection of our first CNS-targeted development candidates by late 2018.

With that, I'll pass the call over to Manmeet to review our second quarter financials. Manmeet?

Thanks, Yvonne, and good morning, everyone. Please refer to our press release issued earlier today for a summary of our financial results for the second quarter of 2018. I would like to take this opportunity to provide a brief overview of 3 key areas: our cash position, our second quarter results and our reaffirmed 2018 financial guidance.

Moving to Slide 15, let me start with our cash balance. We maintained a solid balance sheet ending the second quarter with approximately $1.48 billion in cash, cash equivalents, marketable debt securities and restricted investments, excluding equity securities.

Moving to our financial results for the second quarter, we recognized $29.9 million of collaboration revenue during the second quarter of 2018 as compared to $15.9 million during the second quarter of 2017. Revenues for the second quarter of 2018 included $23.1 million from our alliance with Sanofi Genzyme and $6.8 million from other sources. The amount recognized during the second quarter of 2018 relates primarily to the achievement of a $50 million milestone payment due from Sanofi Genzyme upon dosing of the first patient in the ATLAS Phase III program for fitusiran during the first quarter of 2018 and recognized using the proportional performance method based on the new revenue recognition standard. As a result of our adoption on January 1 of the new revenue recognition standard, we recognized significantly lower revenues during the quarter and 6 months ended June 2018 from our alliance with Sanofi Genzyme. To compare under the previously applicable revenue recognition guidance, we would have recognized $16.3 million higher in collaboration revenue during the second quarter of 2018. For the 6 months ended June 2018, we would have recognized $49.4 million higher in collaboration revenue under the previously applicable revenue guidance.

Moving to expenses. Our GAAP R&D expenses were $137.6 million in the second quarter of 2018 as compared to $90.6 million in the second quarter of 2017. Non-GAAP R&D expenses were $126 million in the second quarter of 2018, as compared to $77.4 million in the second quarter of 2017. The increase in non-GAAP R&D expenses was due primarily to increase manufacturing expenses, related primarily to our late-stage programs and increased compensation and related expenses as a result of an increase in headcount during the period as we expand and advance our development pipeline. To remind, non-GAAP R&D expenses excludes stock-based compensation expense.

Moving on, our GAAP G&A expenses were $84.7 million in the second quarter of 2018 as compared to $45.8 million in the second quarter of 2017. Non-GAAP G&A expenses were $74.1 million in the second quarter of 2018 as compared to $35 million in the second quarter of 2017. The significant increase in non-GAAP G&A expenses was due primarily to an increase in commercial and medical affairs headcount and commercial-related services to support corporate growth and prepare for the potential launch of patisiran in 2018 and potential additional product launches in 2019 and thereafter.

Non-GAAP G&A expenses also exclude stock-based compensation expense. We recorded a $20.6 million gain on litigation settlement based on our agreement with Dicerna Pharmaceuticals, which was announced in April of 2018. We have excluded the impact of the gain on litigation settlement to present non-GAAP measures as we believe this item is a onetime event occurring outside the ordinary course of the company's business.

Turning to losses. The GAAP net loss for the second quarter of 2018 was $163.6 million or $1.63 per share on both a basic and diluted basis as compared to a net loss of $118.4 million or $1.34 per share on both a basic and diluted basis for the second quarter of 2017.

The non-GAAP net loss for the second quarter of 2018 was $161.9 million or $1.61 per share on both a basic and diluted basis as compared to a non-GAAP net loss of $94.4 million or $1.07 per share on both a basic and diluted basis for the second quarter of 2017. Non-GAAP net loss for the second quarter of 2018 excludes both stock-based compensation and onetime gains on litigation settlement, as I mentioned above.

With respect to guidance for 2018, we remain on track to end 2018 with approximately $1 billion in cash, cash equivalents, marketable debt securities, restricted cash and restricted investments, excluding equity securities. We continue to expect that 2018 annual non-GAAP R&D expenses will range between $420 million to $460 million and 2018 annual non-GAAP SG&A expense will range between $280 million to $320 million.

With that, I will now turn the call over to Barry. Barry?

Thank you, Manmeet, and good morning, everyone. With CHMP's positive opinion for patisiran in hand and the PDUFA date just over a week away, our commercial capabilities are in place to deliver the first-ever RNAi therapeutic to patients upon approval. As you saw last week, the CHMP recommended that patisiran be indicated for the treatment of hereditary ATTR amyloidosis in adult patients with Stage I or Stage II polyneuropathy in the EU. In its recommendation, CHMP recognized that patisiran treats the disease with positive effects on both the neuropathy manifestations of the disease and on quality of life, as well as affirming the positive impact on cardiac parameters. Importantly, the recommended Summary of Product Characteristics, or SmPC, includes all of the secondary and key exploratory endpoint data from APOLLO, including the exploratory cardiac endpoint results. The SmPC has recommended, includes substantial efficacy and safety data from APOLLO that we believe will both provide health care providers with robust data, upon which they can make prescribing decisions for their patients and will provide payers with substantive data to make reimbursement decisions based on the value patisiran delivers to patients. We continue to engage multiple health technology assessment bodies in countries across Europe, and reimbursement will be negotiated on a country-by-country basis. We expect reimbursement will be granted in accordance with the label.

Pending the full EC approval of our MAA, our first launch market within the EU is planned to be Germany. Other countries will launch there after following negotiations with relevant health authorities. In the U.S., we remain in a launch-ready state pending FDA approval. Our U.S. field team is on board and we are in a position to get patisiran to patients as soon as possible, once the drug is approved.

We remain focused on raising awareness and improving patient identification. With 3 companies planned to actively engage and educating on this disease, we feel confident that we can make significant inroads on awareness, and importantly, in shortening the diagnostic process.

As you're aware, Alnylam has been working to improve diagnosis through a number of initiatives. For example, Alnylam Act, which is a third-party genetic testing service in the U.S. and Canada that is free to patients. As of July 31, Alnylam Act has enabled testing for approximately 6,700 individuals, who may carry gene mutations associated with hereditary ATTR amyloidosis. With 460 patients identified as having pathogenic TTR mutations. We are also pleased to have an active expanded access program in the U.S. and Europe, providing early access to patisiran in response to request from treating physicians for eligible patients. As we announced in our press release, we've now fulfilled physician requests for more than 200 patients who're being treated with patisiran in the U.S. and certain European countries. But we believe that this is indicative of the unmet need in hATTR amyloidosis and a measure of the increased disease awareness among health care professionals and patient families.

A global rollout also continues. We continue to plan to file a Japanese NDA for ONPATTRO with the PMDA in mid-2018, representing expansion into a very important market. Accordingly, in June, we were pleased to announce the appointment of Masako Nakamura as our Head of Asia. In this role, Masako who joins Alnylam with over 25 years of rare disease and orphan drug biotech experience, will be responsible for the strategic direction and execution of Alnylam's operations in the Asia region with initial focus on Japan. This will include building capabilities and sequencing the potential commercial launches in Asia of patisiran in 2019 and givosiran and lumasiran thereafter.

As we discussed, the biggest challenge for hATTR amyloidosis is disease awareness and finding patients. Therefore, we believe we're having ourselves and others actively working to raise disease awareness, shorten the patient journey and improve patient diagnosis, will result in expansion of the overall market and the way that should ultimately increase the number of patients diagnosed. We see the hATTR amyloidosis disease setting as one that will benefit substantially more from market growth versus just market share. Similar to what we've seen before in other market settings like multiple sclerosis and hereditary angioedema. We believe this is a transformative time for patients with hATTR amyloidosis. We are incredibly excited, as we plan for the first-ever commercial launch of an RNAi therapeutic, and we are on track with our launch readiness.

We believe all of this work puts us inside of our Alnylam 2020 goal in becoming multiproduct, global, commercial-stage company with a deep and sustainable pipeline by the end of 2020.

Let me now turn to a brief update on upcoming milestones. In mid-2018, which we define as Q2 to Q3, we intend to achieve FDA approval and launch ONPATTRO in the United States. We intend to gain regulatory approval for ONPATTRO from the European Commission, followed by launches in certain European markets shortly thereafter. As I mentioned, we plan to file a Japanese NDA for ONPATTRO with the PMDA. And as highlighted earlier on the call, we intend to report top line interim analysis from the ENVISION Phase III trial of givosiran in support of potential accelerated approval through the data justify. And we intend to initiate lumasiran to Phase III study.

In late 2018, which we define as Q3 and Q4, we intend to file for regulatory approval ONPATTRO in additional global markets; file an NDA for givosiran with the FDA, again, assuming positive results with acceptable safety from the interim analysis of ENVISION and pending FDA review; initiate the Phase III study of ALN-TTRsc02 and hATTR amyloidosis; we intend to file an IND or CTA, including ALN-AAT02 in development for the treatment of alpha-1 antitrypsin deficiency associated liver disease and ALN-HBV02 in development in partnership with Vir for the treatment of chronic hepatitis B virus infection. As also mentioned, we plan to complete the selection of our first CNS target development candidate. And finally, we'll also be presenting new data on patisiran and lumasiran at medical meetings in the back half of the year.

With all of that, let me turn it over to Christine. Christine?

Thanks, Barry. And before I open the line for questions, I'd like to quickly note that given the timing of this call and pending regulatory actions for patisiran in the U.S. and EU, we will not be able to discuss U.S. regulatory interactions, potential label communications or scenarios or anticipated pricing. We look forward to providing those updates in appropriate time in the near future. Operator, we'll now open the call for questions (Operator Instructions)

(Operator Instructions) Our first question comes from Gena Wang with Barclays.

I will just ask Phase III trial design for TTRsc02 and the lumasiran, just -- TTRsc02, just wondering, how would you come up with the 9 months? And also, the 2 primary endpoints, is there any hierarchy to hit one -- to show meaningful reduction in one versus the other or you have to show both? And then, for the lumasiran Phase III trial design, just wondering if there is any percentage of reduction like the requirement for urinary oxalate reduction?

Those are great questions, Gena. Yvonne, do you want to handle them both?

Yes, happy to. So we were pleased to get alignment with the FDA around study design for TTRsc02, particularly the agreements around essentially a single-arm open-label study being able to read across to the placebo arm and APOLLO. We have 2 primary endpoints ahead, mNIS+7 and Norfolk-QOL. And in 9 months, we see it as a reasonable time frame, which is to assess the impact of TTRsc02 on these endpoints.

And then the question on lumasiran?

Could you remind me the question on lumasiran?

Yes, the question is what the level of -- do we have an absolute requirement for lumasiran?

No. I mean, essentially what we need to do, so significant varying of ALA with givosiran compared to placebo is something that we feel is well within our reach, given the impressive data that we generated so far in the Phase I/II study.

Right, and the question was on lumasiran with -- so just we did have Celgene for the reduction in urinary oxalate...

Oxalate, yes. We've done a terrific job kind of aligning around biomarkers for the (inaudible) I had givosiran, but John is correct, (inaudible) lumasiran is used, answer question around urinary oxalate lowering.

Good. Did that answer your question, Gena?

Yes.

Our next question comes from Terence Flynn with Goldman Sachs.

Maybe just ahead of the tafamidis data that we're all focused on later this month, maybe just remind us what you guys will be looking for with respect to the data. And then in terms of the next steps for TTRsc02 on the wild-type side, when might you be in a position to share your thoughts there? And is there an effect size where you might not elect to conduct a superiority trial there, just as we think about framing the data?

Yes. Thanks, Terence. Well, let me take it, and then maybe Barry and Yvonne can chime in as well. These are things, that's on my mind. One is, is the effect seen in wild-type only? Or is there also an effect in hereditary ATTR? I mean, biochemically, there is a reason to believe that a stabilizer can shift the equilibrium for wild-type protein to be non-amyloidogenic better than it could shift the equilibrium for a mutant protein. And so that's going to be very interesting to look at, how strong of an effect is there in the hereditary setting versus the wild-type. So that's sort of first and foremost on my mind, because if tafamidis doesn't show a strong effect in hereditary, then I think, obviously, that enhances our competitive position in that setting. The second thing I'm going to look for personally is whether the 20-milligram dose is the same as the 80-milligram dose or is 80-milligram is different, and the reason that's of interest, Terence, is, if 20 and 80 are the same, then tafamidis really is no different than what we saw before, at least, in the neuropathy studies. And so therefore, organic corroborates its potential that maybe the effects are being driven in the wild-type setting by a more favorable role of a stabilizer in that context. And then finally, obviously, whatever the treatment effect is, is at the 50% level, that I think people are expecting, or is it a more modest level in the 25% type of range, but those are the 3 things that are on my mind. I don't know, Barry and Yvonne, If you guys have different views of things that you're looking for?

Yes. Those are all the right views of the data. I guess, in addition, and it's not clear how much of this we're even going to learn when the detail data are presented. If you think about this from a patient perspective, and I reflect on APOLLO, again, in a heredity setting, patients are progressing and their disease is debilitating. What they want is for the disease progression to stop or for many of the manifestations of these to reverse, which is what we saw on APOLLO. The majority of patients had stable or reversal of many disease manifestations. That's what the patients want. Will we see that in the overall tafamidis dataset or the patients just continue to progress but at a slower rate? And Terence, you asked -- also asked about effect size in terms of showing superiority. I think we'll have to see the data, analyze, what -- when they launch and to understand whether kind of a stand-alone wild-type trial or head-to-head makes more sense at that time. It's soon -- early right now to predict.

Good. I think, clearly, we have some thoughts about how to progress, but I think we need to wait to see the full dataset on the track, so we can finalize the design of the study.

Yes. I mean, I think the other -- only other thing I would just add is, the sort of the timing for separation of a fact between drug and placebo will be of interest as well in the study.

Our next question comes from Ritu Baral with Cowen.

My first question is a follow-up to Terence's, and how you are thinking about the competitive landscape, assuming that tafamidis will come into the market in 2019, not to mention, (inaudible), I mean, is -- are you hearing anything about doctors potentially warehousing milder patients, mutant patients for an oral compound? Or what is your messaging around that? And I got a follow-up.

Okay. Barry, do you want to handle it?

Yes. So if we're talking about the hereditary setting, given the disease awareness that's been going on, you have that setting both neurologist and cardiologist. It's not practiced for either of those to work to try to warehouse patients for future. And obviously, people are trying to get their patients, if applicable, into the extended access programs. And we're seeing, as I mentioned, that uptick. On the wild-type setting, other than the generic NSAID diflunisal, there is nothing available for these patients. So I wouldn't say, they're warehousing. I mean, they certainly are waiting for drugs to be available that are potentially more effective to treat their patients.

I mean, clearly for diseases like hATTR amyloidosis, I think physicians will be keen to treat their patients as soon as they possibly can when they see those drugs become available, rather than keep patients waiting for a medicine that may or may not come to market downstream.

Did that answer your question, Ritu?

Yes. And just a follow-up there. Actually, you mentioned the whole neurologist, cardiologist thing. We've done a series of calls with doctors recently, and one interesting thing we noticed was, a cardiologist, FAC specialist, were complaining about the level of awareness of TTR amongst the community neurologists whereas they say that the awareness in the community cardiologists is quite good. And we didn't know if that was just specialty competitiveness or that's something that you're seeing and how might the Alnylam attract results that you said the 6,700 tests, 460 diagnosis, how does that feed into the specialist split and awareness?

Yes, Barry?

Yes, so what your KOLs observed is also what we're observing. And if you think about cardiology community, they've been dealing with amyloidosis for some amount of time, starting with AL amyloidosis driven by something like multiple myeloma, with a treatment chemotherapy and see positive results. So they've been aware of amyloidosis for some amount of time. TTR is a newer phenomenon in the cardiology community, but the receptors were on for amyloidosis in general, and at least, the large practices, they understand how to look for amyloidosis. Some of them may not be able to differentiate the cause the amyloidosis but they knew to look. The neurology setting was not necessarily looking for this disease. So things like Alnylam Act and disease awareness in these congresses are really important tools to raise awareness in both communities as we go forward. And clearly, once we have a label and can promote, then awareness, particularly in neurology community, will go up exponentially.

So can we assume that, that is a particular focus post-launch neurologist awareness versus cardiologist awareness?

I wouldn't say versus, I'd say awareness across the whole medical community is a big focus of ours. These patients are also at gastroenterology offices. So wherever the patient hits new journey, our goal is to not have 7 or 8 specialists be seen before patient get diagnosed over 4 years, but have a patient be diagnosed much earlier.

Yes, this is one of the reasons why we've been very interested in the growth of specialized amyloidosis centers of excellence, where you have the full range of clinicians available with those diagnosed patients and also to treatment.

Our next question comes from Vincent Chen with Bernstein.

An early quarter on TTRsc02 study you are announcing today. What dose you are moving forward in that study? Is this a 25-milligram q 3 month dose that was previously highlighted in your poster ISA or higher dose is being tested?

Yes. 25 milligrams q 3 monthly is the planned dose going forward, Vincent.

And what was the rationale for the selection of a dose? How do you think about the trade-off between greater knockdown and potentially some increase in the efficacy from there versus the risk of side effects as you push TTR down to lower and lower level?

Well, this, as we feel based on modeling, we feel that -- well, not feel, but we have data that shows convincingly the 25 milligrams achieves a patisiran-like TTR knockdown effect. So we should be saying 80% to 90% type of TTR knockdown, and we now know, from a safety perspective, that over 4 years, at this point, knockdown of TTR at that type of level is well tolerated in patients. So we think that's the right level of TTR knockdown to achieve, and we can replicate that faithfully with the 25 milligram q 3 monthly dose regimen.

I guess, well, that's certainly a very -- well, is there any point where the data you've shown so far shows good safety and efficacy? I guess, the question I wonder about is, if you -- I guess, there are a few doses that you have sort of previously shown in the Phase I that get to even deeper and deeper level. Is it -- was there any consideration to sort of exploring further levels of knockdown just to see if you could sort out eke out even greater efficacy than what you've seen so far?

Well, I mean, we certainly explore that internally. We think that the best approach from a regulatory science perspective is, however, to have a comparable level of TTR knockdown. In the future, we can always explore going up in dose, but having from a regulatory framework perspective, the 25-milligram dose is the right approach. And the FDA has agreed with that.

Our next question comes from Madhu Kumar with B. Riley.

So the first one is kind of how do you think about the relative product lifecycles for ONPATTRO versus TTRsc02 and hATTR?

Yes. I mean, let me start, and then maybe Barry and Yvonne can chime in as well. I mean, we obviously -- with ONPATTRO, we have a terrific medicine that is going to make a big difference in the lives of patients with hereditary ATTR amyloidosis. We believe that all patients within that disease setting can benefit from ONPATTRO and that's what we've demonstrated with the APOLLO Phase III study. With TTRsc02, the initial Phase III study that we just outlined today is going to make TTRsc02 available for the same patient population that currently ONPATTRO is going to serve. And that will provide patients with a choice between using patisiran or ONPATTRO or having to set 2 options. And we suspect that many patients will continue taking ONPATTRO because this work well for them. They don't -- they're not bothered by infusions, and they continue to take ONPATTRO, but other patients, particularly new patients that get diagnosed, will likely go on to the subcutaneous option given once a quarter, a very favorable type of convenience profile for them. And then, of course, when we think about other settings in ATTR amyloidosis like the wild-type setting and even the presymptomatic genetic carrier setting, which is of great interest to us. We believe that TTRsc02 is going to be the goal for a molecule and when we're making our Phase III in late-stage investments behind that molecule. So Barry or Yvonne, anything to add? Did I cover?

You covered it.

No, I think you've covered it very nicely.

And Madhu, does that answer your question?

Yes, great. And then kind of a more factual question. What fraction of patients in the APOLLO will be label extension trial had come up to the study -- in terms of, like, finished the trial?

They finish the trial when they hit 5 years of treatment, and we don't have anybody at 5 years yet, so we will start -- I think this year we'll have our first 5-year veteran, coming off the study and going onto, obviously, commercial drug.

And for the sc02 Phase III, how many -- is there any sense of how much of a headwind that could create for the ONPATTRO launch? Particularly, do any patients have been treated in U.S., Europe or Japan to support approval in those geographies?

Yes. Let me, maybe, Yvonne to comment as well, but let me just say the following, which is, we were very mindful of that dynamic. They're going to be many countries around the world, where even with an approval, we won't have reimbursement in place. And of course, we will be enrolling some U.S. patients as well, we do need to do that. But we don't believe it will meaningfully impact patisiran or ONPATTRO's launch at this point. Yvonne, anything else to add?

No, that's correct. We'll be very thoughtful about site selection here to make sure we minimize the issue that you highlighted, Madhu. And we feel very confident that we'll be able to both enroll patients into TTRsc02 study as well as deliver on the opportunity for ONPATTRO.

Our next question comes from Anupam Rama with JPMorgan.

Maybe I could ask a question on givosiran with a potential launch here in maybe 2019 time frame, one of the questions we get is, how large of an opportunity could this be, and I think there is a range of estimates out there. Maybe you could help us understand some of your prelaunch activities, what we should be thinking about, is there a patient queue that's building and factors that will -- that might impact a long-term sort of launch curve?

Yes. That's a great question. It is like -- just like hATTR amyloidosis. It is an underdiagnosed disease, and so a lot of our efforts are around improving medical education and patient diagnosis. One of the things that we've done is extended our Alnylam Act program to the porphyria setting. And I think it was last week or the week before, we presented in our RNAi round table about 100 or so samples that we've tested somewhere in the range of 15-or-so have come back positive for the mutations. So that's a pretty encouraging hit rate better than we frankly expected from that program so far, and we'll see how that continues going forward. So we do believe it is underdiagnosed. We obviously will be spending a lot of time. We're currently doing it to improve medical education. Of course, we do believe that in the system right now, there are a few thousand patients in the U.S. and Europe. We do believe that the uptake for givosiran in those diagnosed patients will be quite rapid given the extreme burden of that disease and if everything plays out in ENVISION that we've seen in the earlier studies with very high degree of therapeutic impact that givosiran shows. But there will be growth thereafter based on the improved medical education. Barry, anything to add?

Yes, so those are all very important points. And let me emphasize that porphyria will remain an ultra-rare disease, we believe, and our key is within an ultra-rare, frankly, to find everybody. In addition to what John mentioned, we've been working with the porphyria network to strengthen the next set of physicians that are coming up and looking for the disease, younger kind of more aggressive types that are going out into the community to educate, and we've seen good uptake with that. Alnylam Act is a good proof point, and ENVISION quicker than we thought is another proof point that being out there raising disease awareness is helping. And just to give you the background fact, we presented these already, so the average patient journey here is over 13 years with the average patient seeing over 3, for example, gastroenterologists. So we can shorten that journey to months not years and get the first physician interface with doing appropriate diagnosis, which is not that difficult. We see great uptick, whether it's double, triple or quadruple the numbers, it's too early to say right now, but as John mentioned, we know about few 1,000 patients already.

Our next question comes from Alan Carr with Needham & Company.

One around the TTR program or sc02, I assume the EMA is on board too. Yvonne mentioned the FDA. And what are your latest thoughts on design for some of the other registration trials for sc02? I suppose it's all depending on the tafamidis data, but I wonder if you can give us a sense on that. And then the follow-up is touch a little bit more about your plans with CNS effort.

Yes. Those are great questions, Alan. Let me start with sc02, the regulatory interactions in Europe are ongoing. So there is nothing to report there, at this point in time. But we do expect that we'll have similar success in Europe. I mean, we've had past dialogues with the European authorities on this whole field. So we feel that we'll reach alignment there as well. Regarding future trials on TTRsc02, we do need to see the past data that's coming up on the 27th of this month, and we really look forward to it. And for all that reasons I commented before, it's wild-type only, hereditary versus hereditary is 20 milligrams the same as 80 milligrams, all of these different factors I brought up before, that will influence our thinking on a wild-type study for TTRsc02. Right now, as I said here today, I think we have to assume that will be a randomized study comparing both drugs to each other because that is the right thing to do and that's the relevant study that physicians will want to see. And that's certainly how sitting here today, we're thinking about it. Other studies will also begin in 2019 for TTRsc02. It's -- we haven't finalized our 2019 plan yet, but we do believe that the other studies such as the presymptomatic carrier study can also start at that point in time. Regarding CNS, really excited about those data, we'll have more data and OTS in October from that effort. It is really a game-changer from a scientific perspective. And just like we opened up delivery to liver many years ago -- not many years ago, but some years ago, opening up delivery now in the CNS is going to really only expand the number of opportunities we have with RNAi therapeutics. And our goal is to have our first development candidate by the end of the year and then to have our first CTA filing in late '19 or early '20 with that program. And what's you're going to see thereafter, Alan, is a steady flow -- I mean, a continued flow of progress targeting liver expressed disease targets because there are many, many more things to do there. But a continued flow thereafter of balanced programs in the CNS and also in liver targeted opportunities. So I think I've answered your question.

Anything beyond -- I mean, is it -- so primarily liver, you'll be -- bring some effort in CNS, but any other target organs in mind? Or is that -- just those 2?

Yes. We've got a few more things. We've got a few more things cooking.

And I think it's important to (inaudible) to do in the liver?

Yes. We don't find ourselves at that loss for things to investment.

Our next question comes from Maury Raycroft with Jefferies.

John, you provided some perspective on expectations for tafamidis and what you'll be looking for there. Can you talk on the inotersen CHMP letter? And also the EU label and any thoughts on how those position that program?

Yes. I mean, obviously, those are probably questions that are best asked to our friends over at Akcea and Ionis, but from our perspective, just focusing on the facts, our indication statements are different in our SmPC's. We have, as you know, an indication for the treatment of hereditary ATTR amyloidosis in patients with Stage 1 or Stage 2 polyneuropathy. Their indication statement is for the treatment of polyneuropathy in Stage I or Stage II, hATTR patients. So what is the treatment of the disease, mainly hATTR amyloidosis, which is one of our indication statement is the other is the treatment of neuropathy, which is what their statement says. Of course, our SmPC includes cardiac data. There they don't have any cardiac data that hits statistical significance as we know from the New England Journal paper. So there are important differences between the labels that we think are meaningful and which is leave it at that at this point in time. We'll see how that plays out in the U.S. in the coming week or so for our side and then a few weeks later for them and will just go from there.

Great. And maybe if I can ask a quick one on lumasiran. So I think there is some data we're expecting in second half from Dicerna. It's a different enzyme in the axillary pathway. They are targeting both. Will their data have any readthrough to your program?

I don't think so. I mean, obviously, they are targeting LDHA. We've done preclinical work with mid-LDHA. We -- it's obviously a target that we think can be operative to lower oxalate level. So I will expect that they should see that. We believe that goal is a better enzyme to target, mostly from concerns, which you've seen preclinically around elevating liver pyruvate levels, which may not be the right thing to do. So we'll start to see how the data come up from a safety and efficacy perspective for them versus what we've shown already, which is very encouraging efficacy, near, essentially, normalization of urinary oxalate with a very acceptable and favorable safety profile.

Our next question comes from Konstantinos Aprilakis with JMP Securities.

So just a quick one on sc02. You discussed long-term preventive study in patients that carry TTR mutations were asymptomatic. Can you give us some idea of the potential cost of such a trial and your efforts to gauge how interested patients might be in being treated before they manifest symptoms?

Yes. Konstantinos, since it's -- we're stating betting the design, we think it's a really important setting, we do know that there is quite a bit of interest from the KOL community, and while we haven't really gotten to the patient community yet with the program, I'm sure the basic concept of preventing even a smidgen of disease before -- by treating beforehand, I think just makes complete sense medically. Yvonne, anything else to add to that?

No, I think it's really sort of too early for the details around cost and size.

Yes. I mean, maybe, it could be a long study, Konstantinos. I mean, it may require a period of time, but there are enrichment strategies that we're actively exploring that might shorten that time. So we just -- but it is clearly the right way to think about treating these patients longer term.

And we do have time for one final question from Chris Marai with Nomura Instinet.

Appreciate the update on sc02 and the Phase III study design. I know that looks like it's going to focus mostly on the mNIS+7, looks like that sort of patients there. And so wondering if you could comment on the potential for data in patients with cardiac disease. Looks like -- 9-month study, it looks like, and so -- are you adequately powered to show some of that -- the potential benefits in cardiac though it -- that you observed them in APOLLO?

Yes. Thanks, Chris. Well, we are including cardiac endpoints in the study. And in APOLLO, at 9 months, we were able to show statistically significant differences between drug and placebo on cardiac parameters. So we do expect to be able to show those differences in the TTRsc02 Phase III, absolutely.

Ladies and gentlemen, thank you for participating in today's question-and-answer session. I would now like to turn the call back over to management for any closing remarks.

Right. Well, thanks, everyone, for joining us today. We look forward to updating you on our continued progress in the coming week. We might have another call relatively soon as you guys can imagine. And we're very excited, and I'll be at the cusp of bringing RNAi therapeutics to patients around the world. So thanks everybody, and have a great day. Bye-bye.

Ladies and gentlemen, thank you for participating in today's conference. This does conclude the program. And you may all disconnect, and have a wonderful day.