Trevi Therapeutics Inc (TRVI) 2021 Q4 法說會逐字稿

Good afternoon, and welcome to the Trevi Therapeutics Q4 and Year-end 2021 Earnings Conference Call. (Operator Instructions) Please note, this event is being recorded.

Various remarks that management makes during this call about the company's future expectations, plans and prospects constitute forward-looking statements for purposes of the safe harbor provisions 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 the Risk Factors section of the company's most recent annual report on Form 10-K, which the company filed with the SEC this afternoon.

In addition, any forward-looking statements represent the company's views only as of today and should not be relied upon as representing the company's views of any subsequent date. While the company may elect to update these forward-looking statements at some point in the future, the company specifically disclaims any obligation to do so even if its views change.

I would now like to turn the conference over to Jennifer Good, Trevi's President and CEO. Please go ahead.

Good afternoon, and welcome to our fourth quarter 2021 and year-end earnings call and business update. Joining me today on this call are Lisa Delfini, Trevi's Chief Financial Officer; and Dr. Bill Forbes, Trevi's Chief Development Officer. Lisa and I have some prepared remarks then the 3 of us will be available for questions at the end.

It has been an exciting few months at Trevi, and I'm happy to share the progress we've made on advancing the development of both of our programs. We recently announced that our Phase II CANAL trial in chronic cough and IPF showed a statistically significant reduction in cough during an interim analysis that allowed us to stop the trial early. This news has gained a lot of external interest and allows us to accelerate our plans.

Also, we completed enrollment as of January 31, 2022, in our Phase IIb/III PRISM trial in chronic pruritus and PN. These are important milestones in our clinical development for our lead programs and allow us to shift our focus on preparing for the next stages in development.

Our most advanced program in clinical development is in severe chronic pruritus in prurigo nodularis, or PN, which is a serious and debilitating disease characterized by papules and nodules on the skin as well as incessant and severe itching. Haduvio is being studied in PN in our PRISM trial, which is a 14-week Phase IIb/III trial. We expect to report top line data in the second quarter of this year. We believe PN, due to the refractory nature of the disease, is neurologically mediated and potentially aligns well with the neuronal mechanism of our mixed agonist antagonist drug. With no approved therapies in this indication, we remain the lead oral therapy in development.

Let me give you an update on our open-label extension study for PN. The percentage of subjects continuing into the open-label extension remains high at approximately 93%. This will provide not only long-term safety data, but also important efficacy data around skin healing and quality of life for these subjects. We believe that by reducing itch, an effective therapy has the potential to disrupt the itch-scratch cycle, leading to skin healing and resulting in disease modifications over time. We see a significant market opportunity and estimate the global prevalence of PN is approximately 730,000 patients with 300,000 patients in the U.S. and 430,000 in the rest of the world. Most of these patients have already tried and failed topical treatments, and we believe they will be eligible for an oral therapy like Haduvio before turning to biologics.

Turning now to our other clinical program, which is in chronic cough and idiopathic pulmonary fibrosis, or IPF. This has been a very exciting couple of weeks for this program. We were happy to report a positive result from a prespecified interim analysis, allowing us to end enrollment early, save money and accelerate into the next phase of development. In this interim analysis, Haduvio showed a 77% reduction from baseline at day 22 in daytime cough frequency as measured by an objective cough monitor, demonstrating a 52% difference from placebo. The p-value on this analysis of 26 subjects with p less than 0.0001 and conditional power was 100%. These results were consistent regardless of baseline cough frequency, antifibrotic use, and we saw no impact from the treatment period in this crossover design.

Patient-reported outcomes followed the same trend as the objective cough monitor and demonstrated a rapid response to treatment as early as the first week. Haduvio is the lead therapy in development and the only one to have shown positive results on the reduction of cough in this patient population. Haduvio was well tolerated in the study with only one SAE that was not deemed to be treatment related, and the adverse events were consistent with what we have seen in Haduvio trials and other indications.

We announced this week that the last patient was randomized in this study and expect approximately 40 subjects in total that will be evaluated. With the strength of the p-value reported, we would expect to see similar results in the final data set, and we plan to announce top line data on the full set of subjects in the third quarter of this year. We will look to present the full results at a medical meeting in the fall.

Bill and his team are also in parallel planning the next clinical study which we intend to design as an adequate and well-controlled trial as well as preparing for discussions with regulatory authorities. This data set is exciting and is initial validation of our hypothesis of the mechanism of Haduvio in treating cough. And as a team, we are determining our path forward, not only in this indication, but also other chronic cough indications. Chronic cough and IPF is an indication in a much larger opportunity for chronic cough, both in other interstitial lung diseases as well as the growing opportunity in refractory chronic cough. This global chronic cough market is estimated to be approximately $10 billion.

To give you more background on IPF, it is a progressive and severe condition in which there is scarring of the lung tissues. One of the leading debilitating symptoms of this disease is chronic coughing, which affects up to 85% of these patients and for which there are no approved therapies. In the U.S., we estimate that there are approximately 130,000 patients with IPF and an equal amount in Europe. Due to the high 5-year mortality associated with IPF, prescribers and patients are not only looking to slow the progression of the disease but also improve the patient's quality of life.

It has been a busy few months in both of our studies, but we still have a data-rich few months ahead of us. In the second quarter, we will complete the double-blind portion of our pruritus trial in PN and report top line data. We will also complete the dosing in the remaining subjects in our cough trial in IPF and report out the data on the full set of subjects in the third quarter. In parallel, we are actively preparing for the next stage of development for both of these indications as well as planning for indication expansion in both chronic pruritus and chronic cough.

One final comment before I turn it over to Lisa to review the financial results. We will be hosting a KOL call on Wednesday, March 30, from 8 to 9 a.m. Eastern Time. On that call, Bill will review the interim results as well as provide additional new analyses. And importantly, we will be joined by Dr. Lisa Lancaster, who is a Professor of Medicine at Vanderbilt University School in the School of Medicine. Dr. Lancaster is also the Medical Director of the Interstitial Lung Disease Program at Vanderbilt University Medical Center and a medical adviser for the pulmonary rehabilitation program at Vanderbilt. She has deep experience with patients with interstitial lung disease, including idiopathic pulmonary fibrosis and will be helpful in describing the disease and suffering of these patients. We invite you to join us on that call. We will be issuing a press release in the next week with information on how to register.

That is all I have on the business update. I will now ask Lisa to review our financial results, and then we will open it up for questions.

Thank you, Jennifer, and good afternoon, everyone. As I always need to remind you, the full financial results for the 3 and 12 months ended December 31, 2021, can be found in our press release issued ahead of this call and our 10-K, which was filed with the SEC just a few minutes ago.

During the fourth quarter, we raised $14.8 million in financing, which enabled us to end the year with a cash balance of $36.8 million. As Jennifer noted, we were able to end enrollment in our CANAL trial early, which provided cost savings that will help us accelerate the planning for the next clinical trial for chronic cough and IPS.

For the fourth quarter of 2021, we reported a net loss of $8.5 million compared to a net loss of $9.5 million for the same quarter of 2020. R&D expenses were $6.2 million during the fourth quarter of 2021 compared to $6.6 million in the same period of 2020, primarily due to decreased purchases of clinical trial supplies, partially offset by increased activity in our CANAL trial as well as an increase in personnel-related expenses due to increased headcount. G&A expenses were $2.1 million during the fourth quarter of 2021 compared to $2.6 million in the same period of 2020, primarily due to decreased market research costs.

This concludes our prepared remarks, and I will now turn the call back to the operator for Q&A.

(Operator Instructions) Our first question is from Annabel Samimy with Stifel.

So I had a couple. The first was on the CANAL program. So I'm curious to know what you expect the development path to be from this point forward. And I asked because there are a couple of other chronic cough studies going on in the P2X3 space. And I know it's not specifically related to IPF, but I'm just curious to know if you believe that there's broad activity or applicability for your program. Is there the same broad applicability of those P2X3 inhibitors to move into IPF? So I'm just curious to know how the landscape plays out.

Thanks, Annabel. I'll answer that, although, Bill, jump in if you want to add anything. Yes. So we have always believed that our mechanism could work broadly in cough. I mean, as you and I have discussed it, opioids have been known to work in cough for a long time. IPF cough, I think, is considered a very severe and serious form of cough. As a matter of fact, some of the P2X3s have been studied in IPF cough, Dupixent, and actually failed there.

So we feel that the fact that we work there is a good sign. We are considering both refractory chronic cough and other interstitial lung disease cough as we move forward. I think once we read out all our trial data, we'll probably step back and think of the best way to build out the company. But I do feel that the mechanism is -- could be broadly applicable to cough.

Yes.

Okay. Sorry, go ahead.

Bill has a more informed perspective. He wants to add anything to my comments.

No, not necessarily to that, but just kind of getting to CANAL and kind of next steps. I think you started there, Annabel. One of the things that we're obviously anxious to do is complete this study and report out the top line results. At the same time, we're going to be moving things forward on the regulatory front.

And we're also starting up discussions with ILD centers around the United States. So we anticipate the next study will be in both the U.K. and the U.S. So obviously, we're anxious to get in with the FDA and talk to them about next steps and what we need to do. I anticipate that, that meeting with the FDA will take place in Q3, and then we'll try to get things up and running soon thereafter.

Okay. And I guess the reason I asked is you've got $36.8 million in cash, and these are relatively large markets that could potentially be very costly to develop some, trying to think about how you might fund this program going forward, especially in light of some -- well, P2X3s have shown some failure in IPF, but there's others that have shown success in chronic cough and perhaps have a better profile than the ones that have failed. So I'm just a little curious to the extent to which you might have to invest in this to position yourself in a very, very, very large market, potentially.

Yes. So Annabel, you're right. I mean there's a lot of indications here, which could get very expensive. I should just comment that IPF cough and PN will be our priority of the data, assuming they are both successful. Those are both serious unmet patient needs, and we're committed to sort of finishing what we start. Where we move into part of the consideration will be the cost of the programs, the overall pricing the unmet need, all those kinds of things. And we'll have to do that mindfully. I mean we're definitely mindful of where our stock sits in the market cap. So I think there's opportunity to do that. It's something we'll revisit.

I know, Lisa, you may want to add something about cash runway, planning.

Yes. So our cash gets us through the data readouts in both of the clinical trials and then the time to start preparing for the next clinical trial. And we will -- we know we need to raise money for the next clinical trial. We will be considering that. We know we've added value to the company as a result of these cost results, and we'll be considering that as we get through the results and the end of the year.

Okay. Okay. And then from just really quickly on size-type profile. I know that from a -- I guess, from the mechanism there was the nausea and vomiting that you had initially tried to address in terms of titrating patients of getting to the right level. Did you find that the patients in the CANAL study had -- just as much issue with that titration period and nausea and vomiting would it be something that could exacerbate that population, given that their condition already puts them kind of in a vulnerable state as far as nausea and vomiting? I'm just curious to know how you balance the potential early-stage side effects with the actual condition itself.

Yes. Just a couple of comments. I mean, obviously, this patient population does an awful lot of coughing. And so vomiting is actually an issue with this patient population. You can imagine if you're coughing up to 90 times per hour, that you might get into some of that. But we've reported that from a blinded perspective, we had 5 AEs that dropped from this study. We don't know what treatment arm they were in when they dropped, but 1 was anorexia, 1 depression, 1 nausea, vomiting, 1 insomnia, fatigue and 1 agitation anxiety, dyspnea.

I think overall, we've been very happy with the tolerability that we've seen in this study. We dose titrated up as we do in the PRISM study. So as I said, I think overall, we're happy with what we see. The other thing is with the antifibrotics, there's a lot of GI side effects with the fibrotic also. And we know that just short of 50% of the population was on antifibrotics in this study. So with that, we understand that there's already a side effect profile from one of the leading therapies in the area.

The next question is from Serge Belanger with Needham & Company.

A couple of questions for me. The first one, a follow-up to just the previous question here. Did you use the same dose and titration protocol in the CANAL trial as you're using in the PRISM study?

It was altered a little bit in the CANAL study. We did 27 to 54 milligrams in the CANAL study and then continue to dose escalate up to 108 and then to 162. We obviously end at the same dosage, 162 BID.

And Bill, you might want to mention why we did that. You were trying to get some dose response data, right? It really wasn't to do with tolerability.

Yes. No, that's an important point. We -- originally, when the study was designed, we got VitaloJAK recordings at weeks -- at baseline and then weeks 1, 2 and 3. So when the study was designed, we tried to get some dose response at each of those, trying to get to the 54, the 108 and then the 162 at the VitaloJAK recording. So that's why it was altered a little bit. Unfortunately, we had to drop the VitaloJAK recordings at weeks 1 and 2 because of COVID, and we couldn't have the inpatient visits that we wanted to. But we did maintain the VitaloJAKs at baseline in week 3. So hopefully, that answers your question, Serge.

Yes. And secondly, just thinking about the timing of the PRISM trial readout as we get closer only a few weeks into the second quarter here. I think in the past, you've talked about around 4-month period between the last patient enrollment potential readout. Is that a right way to think about it?

Yes. I think you should look at it at the end of Q2 is when our readout will come.

(Operator Instructions) The next question is from Nathan Weinstein with Aegis Capital.

Congrats on the progress, including particularly the strong interim analysis from CANAL. Actually, my first question just on Haduvio for severe pruritus patients with PN. I think you mentioned during the prepared remarks the potential to be utilized in the protocol prior to biologics. Could you share a little bit more about that in terms of what that might mean either compare or contrast to that class or what the ramifications could be for share capture?

Yes, it's a good question. I mean biologics are obviously important. They're not for everyone. I think there's an opportunity from a payor perspective, depending on where we choose to price the product to maybe become step-through therapy. I also think orals are generally more just easier for patients, generally a preferred method. So we are thinking about that aggressively, how it's good for the patient. And from a payor perspective, there's probably less expensive than the biologics.

Okay. Great. Fair enough. And then maybe just one follow-up for me. Obviously, you've mentioned that IPF cough and PN, those are the focus, but you have a pretty deep pipeline that could be some attractive indications outside the lead. What's on the table? Could partnering be a strategy? Or can you just speak to what you might pursue there strategically?

Yes. So we have been in partnering discussions, really getting people ready for the data over the past years. And I would say our focus in partnering is around geographic territories. So clearly, Asia, Japan and China and sort of related territories and also Europe. We're a small U.S.-based company. And I think we feel we can do well here, and I think comfortable developing in Europe. But certainly finding a partner in Asia to help advance the drug and a marketing partner in Europe are things that would be advantageous here for the company and the asset. So that's the focus of our conversations.

I'm not showing any further questions. So this concludes our question-and-answer session. I would like to turn the conference back over to Jennifer Good for any closing remarks.

We would like to thank everybody for participating in today's call. I'd also like to thank the Trevi team, our study investigators and all of the subjects who have participated in our clinical trials. Thank you.

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.