Karyopharm Therapeutics Q3 2023 Earnings Call Transcript

Quartr
Provided by Quartr
November 2, 2023

There are 9 speakers on the call.

Operator

Good morning. My name is Drew, and I will be your conference operator today. At this time, I would like to welcome everyone to the Karyopharm Therapeutics Q3 2023 Financial Results Conference Call. There will be a question and answer session to follow. Please be advised that this call is being recorded at the company's request.

Operator

I would now like to turn the call over to Ilhan Webb, Senior Vice President, Investor Relations.

Speaker 1

Thank you, and thank you all for joining us on today's conference call to discuss Karyopharm's 3rd quarter 2020 3 financial results and recent company progress. We issued a press release this morning detailing our financial results for the Q3 of 2023. This release along with a slide presentation that we will reference during our call today are available on our website. For today's call, as seen on Slide 2, I'm joined by Richard, Reshma, Sohani and Mike, who will provide an update on our results for the Q3 and recent clinical developments. Before we begin our formal comments, I'll remind you that various remarks we'll make today issued forward looking statements, FLS, for purposes of the Safe Harbor provisions under the Private Securities Litigation Reform Act of 1995 as outlined on Slide 3.

Speaker 1

Actual results may differ materially from those indicated by these FLS as a result of various important factors, including those discussed in the Risk Factors section of our most recent Form 10 Q, which is on file with the SEC and in other filings that we may make with the SEC in the future. Any FLS represent our views as of today only. While we may elect to update these FLS at some point in the future, we specifically disclaim any obligation to do so, even if our views change. Therefore, you should not rely on these FLS as representing our views as of any later date. I will now turn this slide over to Richard.

Speaker 1

Please turn to Slide 4.

Speaker 2

Thank you, Elhan. Good morning, everyone, and thank you for joining Karyopharm's Q3 2023 earnings call. Turning to Slide 5. We are strongly positioned for our next stage of growth driven by our focused and rapidly advancing mid and late stage pipeline of innovative, 1st in class, oral, selective inhibitors of nuclear export that target Xp01, as well as a strong commercial organization that continues to positively impact the lives of multiple myeloma patients every day. Our U.

Speaker 2

S. And global commercial presence is on track to deliver $145,000,000 to $160,000,000 of annual total revenues in 2023 and provides us with the capabilities needed to launch in new indications if approved following the outcome of our 3 pivotal Phase 3 clinical trials. We have the opportunity to significantly improve standard of care for patients across these indications and we continue to generate compelling data including impressive durability data observed with selinexor 60 milligrams in combination with ruxolitinib in patients with myelofibrosis as well as substantial progression free survival observed in patients with TP53 wild type endometrial cancer, which Reshma will expand upon shortly. We are committed to deliver on the opportunities ahead of us and believe selinexor could generate approximately $2,000,000,000 of peak annual revenues in the U. S.

Speaker 2

Alone. With a cash runway through late 2025, we have the financial strength to deliver on key data readouts from our 3 Phase 3 studies. We will continue to be disciplined about our expense management focusing our resources on our prioritized late stage pipeline. As we move to Slide 6, presented here is an overview of the timing of the upcoming key data readouts, which we expect in 2024 and 2025. Each of our ongoing Phase 3 clinical trials, if successful, represents an incredibly meaningful growth opportunity for our organization with the potential to deliver roughly $2,000,000,000 in annual peak revenues.

Speaker 2

Our proven and established commercialization and late stage development capabilities are focused on executing with our current label and rapidly progressing these pivotal Phase 3 programs. An approval in just one of these three indications is a transformational opportunity for Karyopharm and the clinical data that Reshma will review today continues to strengthen our confidence in each of these programs. With the potential for pivotal catalysts over the next 2 years and with the cash runway to deliver on each of these top line readouts, we are well positioned for our next stage of growth. Moving to Slide 7, I would now like to turn the call over to Reshma to expand further on our clinical pipeline progress. Reshma?

Speaker 3

Thank you, Richard. Turning to Slide 8, we have a very promising late stage pipeline with pivotal data readouts over the next 2 years. I will focus on our 3 Phase 3 trials where our confidence only grows given the positively evolving and clinical data that support each indication. Each of these trials could position selinexor to substantially change the treatment paradigms in each of these populations, if approved. Turning our attention first to myelofibrosis on Slide 10, Treatment of JAK naive myelofibrosis patients remains an area of high unmet need with more than 20,000 myelofibrosis patients in the U.

Speaker 3

S. Alone. Ruxolitinib remains the standard of care for the majority of JAK naive patients. However, there is an opportunity to improve benefit given that The efficacy with ruxolitinib is limited with less than 50% of patients achieving an SCR35 and TSS 50. We are evaluating the potential for selinexor in combination with ruxolitinib to provide benefit across all of the hallmarks of the disease, including spleen reduction, symptom improvement, disease modification and stabilization, if not improvement of cytopenias.

Speaker 3

On Slide 11, you see that Xp01 inhibition is a fundamental mechanism in myelofibrosis, given that it targets both JAK and non JAK pathways. Underscoring Selinexor's additive or potentially synergistic activity when dosed in combination. Non JAK mechanisms include inhibition of NF kappa beta, induction of cell cycle arrest and p53 driven cell death. Together Xpl1 inhibition increases malignant cell death, decreases malignant cell proliferation and reduces inflammation. We presented updated Phase 1 data at the ASCO and EHA conferences in June 2023, which can be seen on Slide 12.

Speaker 3

These data show meaningful SVR35 and TSS 50 improvement with 60 milligram selinexor including a 79% SVR35 Amongst the evaluable patients, 100 percent achieved in SVR35 at any time. Today at the NPN Congress, data are being presented, including SVR response and TSS-fifty durability amongst 11 out of 14 patients who achieved a 35% or greater spleen volume reduction at week 24 and the 7 out of 12 patients who achieved a TSS 50 at the same time point. We are very encouraged by these data given the impressive durability seen on Slide 13 for both of these endpoints. As of August 1, 2023, none of the week 24 SVR35 responders dosed at selinexor 60 milligrams had observed radiographic progressions. Note that the longest patient has been followed for 78 weeks and the median duration of follow-up as of the data cutoff is 32 weeks.

Speaker 3

Similarly, none of the week 24 TSS 50 responders had observed symptom progressions with the longest follow-up of 64 weeks and a median duration of 51 weeks. While I acknowledge the apparent limitations in cross trial comparisons, contrast these data to ruxolitinib alone in which only Approximately 70% of responses were ongoing at 78 weeks. Data for ruxolitinib PSS 50 durability data beyond week 24 have not been provided. These data add to the substantial benefit observed with week 24 SVR and TSS 50 and highlight the substantial benefit that may be observed with this novel combination compared to ruxolitinib alone. Together these data illustrate the rapid deep and now durable spleen and symptom improvement achieved with selinexor in combination with bruxolitinib and further demonstrate the potential for this combination to change treatment paradigms for JAK naive myelofibrosis patients.

Speaker 3

This profile in conjunction with the subgroup analysis shown on Slide 14, which depict SVR35 and TSS50 responses Despite treatment with suboptimal doses of bruxolitinib, which is suggestive of potential monotherapy activity, underscores our confidence in the ongoing Phase 3 study. As seen on Slide 15, our Phase 3 study is evaluating the combination of selinexor 60 milligrams with ruxolitinib versus ruxolitinib alone in 306 JAK naive myelofibrosis patients. This important trial in addition to the Phase 2 selinexor monotherapy trial that we are planning in treatment naive myelofibrosis patients with moderate thrombocytopenia Cytopenia has the potential to entrench selinexor as a foundational therapy in approximately 90% of all treatment naive myelofibrosis patients. As we turn to Slide 17, endometrial cancer is a key focus in our pipeline given high unmet need and the substantial benefit observed in patients whose tumors are p53 wild type. Advanced and recurrent endometrial cancer is the most common form of gynecologic cancer in the United States with the current treatment landscape being driven by molecular classifications.

Speaker 3

As a result, in MMR deficient patients who represent approximately 20% of all advanced recurrent endometrial cancer patients, The new FDA approved standard is dastarlimab in combination with chemotherapy followed by dastarlimab maintenance. For MMR proficient patients, which represent the remaining 80% of advanced recurrent endometrial cancer. Checkpoint inhibitors are not approved. As such, the primary treatment option is chemotherapy followed by watch and wait. Importantly, wild type p53 is found in a majority of all advanced recurrent endometrial cancer.

Speaker 3

As seen on Slide 18, taken together, Patients whose tumors are both MMR proficient and p53 wild type represent 40% to 55% of all advanced for recurrent endometrial cancer patients. In the substantial population, the benefit observed with selinexor is considerable as seen on Slide 19. Given that a 68% decrease in the risk of disease progression or death corresponding to a hazard ratio of 0.32 and the median progression free survival that has not been reached was observed in this exploratory subgroup of patients from the SANDRA trial as of March 30, 2023 data cutoff. The progression free survival results observed in those patients who are p53 wild type And are also noteworthy with a median PFS for selinexor of 13.1 months and hazard ratio of 0.45. Further strengthening our rationale in p53 wild type endometrial cancer are the preclinical data that were recently presented at the AACR NCI EORTC International Conference on Molecular Targets in Cancer Therapeutics in October.

Speaker 3

These data from endometrial cancer models have further confirmed the biology by demonstrating significantly better potency in p53 wild type models as compared to p53 mutant models further validating the design of the ongoing Phase 3 study as shown on Slide 20. The EZ-forty two pivotal Phase 3 study is evaluating selinexor as a maintenance therapy in patients with TP53 wild type advanced trail cancer. The study will enroll approximately 220 women whose tumors are TP53 wild type. Ultimately, this trial will enable the development of a companion diagnostic and we anticipate the approval of a companion diagnostic would occur at the same time as Selinexor, if approved. The study is a collaboration between Karyopharm and Engot, the European Network for Gynecological Oncological Trial Group and GOG, the gynecology oncology group.

Speaker 3

NGOT and GOG include the top opinion leaders in gynecology oncology. Their participation in the ongoing Phase 3 study further underscore score, the strength of the data observed in the p53 wild type subgroups and the potential selinexor may have in providing a new standard of care to p53 wild type endometrial cancer patients. Together, we are making strong progress and have been intensely focused on activating sites and enrolling patients. We are now expecting top line results in the first half of twenty twenty five with the slight timing shift related to country specific regulatory delays in a few European countries. As seen on Slide 22, we are expanding our multiple myeloma franchise with the ongoing Phase 3 trial that is evaluating selinexor for at the low dose of 40 milligrams in combination with the well established backbone therapy of pomalidomide and dexamethasone.

Speaker 3

SPD, an all oral combination and evaluated after an anti CD38 antibody has the potential to benefit a significant number of patients across the multiple myeloma treatment journey. As seen on Slide 23, The Phase 3 trial is enrolling patients with relapsed refractory multiple myeloma who have received an anti CD38 antibody as their most recent therapy. Patients are randomized 1 to 1 to the oral regimen of selinexor, pomalidomide and dexamethasone or elotuzumab, pomalidomide and dexamethasone. Dazone. The primary endpoint is progression free survival.

Speaker 3

The potential approval of this combination could lead to the only all oral potentially T cell sparing regimen for patients with relapsedrefractory multiple myeloma, which is gaining increased importance given the incorporation of T cell therapies in the multiple myeloma treatment landscape. As seen on Slide 24, we are evaluating the effect of selinexor on the immune environment through preclinical, translational and real world data as well as clinical trials. We recently announced a collaboration with BMS that will evaluate selinexor in combination with mesigtimide, a novel cell mod or cerablon E3 ubiquitin ligase modulator in triple class exposed multiple myeloma patients. This combination has the potential to reverse T cell resistance and builds upon the multiple selinexor combinations that have already demonstrated clinical benefit in multiple myeloma. In summary, we have near term late stage opportunities supported by compelling data in our rapidly advancing pipeline that will potentially benefit multiple cancer patient populations of high unmet need building on our approved indications.

Speaker 3

With that, please turn to Slide 25, and I will now hand it over to Solania for a review of our commercial performance for this quarter.

Speaker 4

Thank you, Reshma, and good morning, everyone. On Slide 26, I am pleased to present the progress we have made in our 3rd quarter performance as we delivered sequential growth in net product revenues over 3 consecutive quarters in 2023 in an increasingly competitive landscape and amidst high utilization of free drug through our patient assistance program. Exovio delivered $30,200,000 in net sales in Q3 and when compared to Q3 of last year, Net sales was adversely impacted by higher utilization of our patient assistance program due to the impact from myeloma foundation closures as we have previously discussed. In the Q3, 2 of the 4 main multiple myeloma foundations were open and continue to remain open. As a result, new patients entering PAP have largely normalized, although we saw the refill impact of patients already in PAP earlier in the year.

Speaker 4

Total PAP utilization contributed to 9% of total demand in Q3 2023 versus 4% in Q3 2022. As we mentioned before, in 2024, due to the IRA related changes in the design of Medicare Part D, which will eliminate the patient burden of the 5% beneficiary coinsurance requirement. We expect significantly less need for Medicare Part D patients to utilize PAP for co pay assistance. Additionally, net revenue was impacted by 2 points higher year over year gross to net in the 3rd quarter, driven by increased Medicaid rebates and 340B discounts. Total demand year over year declined 3% when compared to Q3 of last year, which was our strongest quarter thus far.

Speaker 4

Total demand growth year over year for Q3 was negatively impacted by increased competition in the late lines in the academic setting. In the earlier lines, we continue to make strong progress. In Q3 2023, XPOVIO new patient share mix was greater than 60% in the second to fourth line, which represents approximately 20% growth year over year. This shift in mix of patients continues to drive higher refill use as early aligned patients tend to stay on therapy longer. Furthermore, our opportunity in the earlier lines is enhanced by the elevation of EXPOVIO in the NCCN guidelines to a Category 1 and now preferred regimen in the lenalidomide refractory patient population in relapsed or refractory multiple myeloma.

Speaker 4

This is meaningful in guiding treatment choices for physicians, particularly in the community and for patients progressing from regimens like the DARZALEX, omidexamethasone combination. In addition, new subgroup data was presented at the European Hematological Association from our Phase 3 BOSTON study, which showed that patients that are PI naive or not previously exposed to a proteasome inhibitor and that are treated with XVD showed an approximately tripling of PFS of 29.5 months versus the control arm, VD of 9.7 months with a hazard ratio of 0.29. Patients are increasingly treated with PI free regimens like the DARZALEX, Revlimid, dexamethasone combination in the frontline, which constitutes up to about 10% of frontline patients with this segment growing over time. As multiple myeloma patients are living longer with the emergence of new classes of therapy, EXPOVIO represents opportunity for these patients to be treated with an effective and novel class of therapy earlier in their treatment journey and allow for potential sequencing in the future with other classes of therapies. Our commercialization team is laser focused on sharing our new data, sideline updates and leveraging the experience of our broad base of physicians that have used XPOVIO to drive further use and in earlier lines, all amidst an intensifying competitive landscape in the late lines.

Speaker 4

We reaffirm our U. S. Exfoliov net revenue guidance of $110,000,000 to $125,000,000 in 2023. Let's now turn to Slide 27 to review how we are distinctly positioning XPOVIO in the community and academic settings in an evolving landscape. In the community setting, while we do see competitive pressures in the late line with some larger accounts, The majority of physicians in the community tend to treat early aligned patients and are looking for agents that are effective, manageable and convenient.

Speaker 4

We believe exovio as a novel class that is an effective, manageable, easily combinable and a convenient oral therapy fits the needs of the community well. Furthermore, the NCCN has recently updated their guidelines to recommend switching classes The therapy that patients have not been exposed to previously versus recycling the anti CD38 class, which occurs frequently in the community. This update, combined with the elevation of exovio in the NCCN guidelines, highlights the importance of changing the mechanism of action with a novel class like XPOVIO. A highly compelling new PI naive subgroup data further strengthens our positioning in the community in the second to fourth line. In the academic setting where we're seeing the impact of competition from new approvals, including T cell therapies, We continue to build the body of evidence to demonstrate how XPOVIO may be used as an optimal therapy with a novel mechanism of action pre or post T cell therapies.

Speaker 4

Also the opportunity to launch STD when approved at the lower dose of 40 milligrams that lead to the only all oral and potentially T cells bearing regimen. In Q4, we remain focused on entrenching exovio in the community, which represents about 60% of our business and driving earlier line growth. While we expect further intensification of the competitive landscape in the later lines. In the mid to long term, we believe The potential approval of SPD and further data generation around the T cell fitness space with novel combinations could unlock further benefit for myeloma patients with XPOVIO. Furthermore, Karyopharm has a tremendous opportunity for growth across multiple indications in the future, and we look forward to leveraging our strong commercialization team and capabilities and our deep relationships in the community and centers of excellence for these launches.

Speaker 4

Please advance now to Slide 28, and I'll turn the call over to Mike.

Speaker 2

Thank you, Suhania. During 2023, we have further reduced our cost structure to focus resources on our pivotal Phase 3 trials. And in August, we reduced our workforce by approximately 20%, including contractors. These steps further strengthen our financial position to invest in our 3 ongoing Phase 3 studies with top line data readouts expected within our cash runway. Now on Slide 29, I will focus on the quarter's financial highlights.

Speaker 2

Total revenue for the Q3 of 2023 was $36,000,000 compared to $36,100,000 for the Q3 of 2022. Net product revenue from U. S. Commercial sales of XPOVIO for the Q3 of 2023 was $30,200,000 compared to $32,000,000 for the Q3 of 2022. As Suhanyu discussed, net product revenue continued to be adversely affected by more patients using our patient assistant program as well as higher growth to net discounts.

Speaker 2

Growth to net discounts were 20% in the Q3 of 2023 as compared to 18% in the Q3 of 2022. Turning to costs. With our continued focus on cost management, We are pleased to be delivering a combined 12% year over year reduction in our R and D and SG and A expenses for the 9 months ended September 30, 2023. R and D expenses for the Q3 of 2023 were $35,600,000 compared to $31,400,000 for the Q3 of 2022. We expect Q4 2023 R and D expenses to be relatively consistent to the Q3 as we continue to invest in our 3 ongoing Phase 3 studies with each representing a large addressable market with unmet patient needs.

Speaker 2

We have reduced SG and A expenses in the Q3 of 2023 by 12% at $30,800,000 compared to $34,600,000 for the Q3 of 2022. Cash, cash equivalents, restricted cash and investments as of September 30, 2023 totaled $209,200,000 compared to $279,700,000 as of December 31, 2022. Based on our current operating plans, we are reaffirming revenue guidance for full year of 2023 as follows. Total revenue is expected to be in the range of $145,000,000 to 160,000,000 XPOVIO net U. S.

Speaker 2

Product revenue is expected to be in the range of $110,000,000 to $125,000,000 We are also reaffirming our expense guidance for the full year of 2023 as follows. Non GAAP R and D and SG and A expenses, which exclude stock based compensation expense, is expected to be in the range of 240 to $255,000,000 And importantly, coming to our cash guidance, our existing cash, cash equivalents and investments as well as the revenue we expect to generate from our XPOVIO product sales and other license revenues will be sufficient to fund our planned operations through late 2025, excluding maturity of our convertible bonds in October 2025. I'll now turn to Slide 30 and some final thoughts from Richard. Thank you, Mike. Turning to Slide 31.

Speaker 2

As we have discussed today, we are rapidly advancing our pipeline, concentrating our investments in 3 Phase 3 programs that are expected to read out through 2024 2025 as we work to create near and long term value for all our stakeholders. We are well prepared for the next stage of growth as we continue to expand on our foundation in multiple myeloma with our proven commercialization and late stage development capabilities. I would like to thank our teams who continue to execute in a disciplined manner and who strive each day for patients with high unmet needs. Thank you again for joining us today. And I would now like to ask the operator to open the call up to the Q and A portion of today's call.

Speaker 2

Operator?

Operator

We will now begin the question and answer session. On your telephone keypad. To assemble our roster. The first question comes from Peter Lawson with Barclays. Please go ahead.

Speaker 5

Hi, good morning. This is Shay on for Peter. Thanks for taking our question. Congratulations on the new MF data announced today. Maybe They'll contextualize for us as we think about getting that top line data from Phase 3 in 2025, maybe what the more appropriate bar is to be looking at rather than Just JAK inhibitor monotherapy.

Speaker 5

And then secondly, just a quick add on question. For eltonexor and MDS, I believe we're Potentially going to get an update on development plans here. Is that still on track for something we could learn about more in this quarter? Is it something we should be thinking to stay prioritized for Karyopharm at this point. Thank you.

Speaker 2

Thanks, Shay for your question. I'll turn to Reshma for that. Reshma?

Speaker 3

Yes. Thank you, Shay. A lot of excitement around the new MF data that we are presenting today at the NPN Congress in New York. It only builds upon the Aggressive efficacy that we see with the combination of selinexor and ruxolitinib in this JAK naive patient population. As you mentioned, we've already presented data at week 24 for both SVR as well as TSS 50, 79% SVR rate, as well as a 58% TSS 50 rate.

Speaker 3

What Patients and physicians really want to know is that how long are those SVR and TSS data or response is going to last. And that's the durability data that we're presenting today.

Speaker 4

And what you see is

Speaker 3

a very impressive durability for both of these endpoints. In fact, as of the data cutoff of August 1, none of the patients experienced a radiographic progression for either SVR or TSF50. So again, just builds upon the body of evidence that really suggests that this combination could be a game changer for patients who are JAK naive And we'll continue to evaluate this as part of our Phase 3 study. Right now, the focus is Very much on SVR TSS 50 at week 24. But as we mentioned, we'll continue to look at durability as well as multiple other efficacy endpoints that are relevant to this patient population.

Speaker 3

In regards to your question about the appropriate comparator, it still remains ruxolitinib. So ruxolitinib is the standard of care for patients who are JAK naive myelofibrosis who have platelet counts above of 100. So the study design is appropriate, and evaluates again the efficacy With this combination relative to the current standard of care. In terms of your question about eltenexor, great question, Very enthusiastic about those data as well, specifically observed from the Phase 1, Phase 2 study. We have been evaluating elkinesor in Very hard to treat patient population, specifically relapsed refractory higher risk MDS patients.

Speaker 3

Overall survival is Very poor in this patient population around 4 to 6 months. And as we've disclosed previously, the Survival that we've seen as part of both the Phase 1 and Phase 2 are very encouraging, right? 9 to 10 month median overall survival. We are in the process of optimizing our next steps in this program and look forward to updating everybody

Operator

Was there a follow-up, ma'am?

Speaker 5

That's it. Thanks so much.

Operator

Thank you. The next question comes from Maury Raycroft with Jefferies. Please go ahead.

Speaker 6

Hi, good morning. Congrats on the progress and thanks for taking my questions. I was going to ask one on endometrial. So for selinexor as maintenance endometrial. When do you think you could show the initial overall survival data from the SIENDO Phase 3 study?

Speaker 6

And then also separately, how is the export Phase 3, in the TP53 wild type patients enrolling? And do you have a sense of how many patients are getting anti PD-one therapy with chemo upfront? If you can provide any perspective on that? Yes.

Speaker 3

Great question, Maury. So as you know, so we continue to

Speaker 4

follow overall survival. We are very excited. We are going

Speaker 3

to be presenting overall survival data for the first time from the SIENDO trial, specifically from the p53 wild type subgroup later this year. So more to come in the next couple of months. Obviously, a key endpoint In addition to the progression free survival, so more to come over there. In terms of the question around The PD-one inhibitors in combination with chemotherapy. So there is a new standard as I mentioned on the call.

Speaker 3

It is dastarlimab in Combination with chemotherapy followed by dastarlimab maintenance. Keep in mind that the approval is only for patients who are MMR deficient. So they represent the minority of patients at only 20%. The remaining patients Who are PMMR or proficient in their MMR as well as TP53 do not have a new standard of care, Continues to remain chemotherapy followed by watch and wait.

Speaker 6

Got it. That's helpful. And any other perspective into enrollment and how that's going? And then Also wanted to ask a separate question on multiple myeloma commercial. You said there were approximately 20% There was 20% year over year growth in second line to 4th line new starts.

Speaker 6

Can you give us some color on how refill rates have evolved, specifically in these early line patients versus when you were just in the later line setting.

Speaker 2

Yes. Maybe I'll turn to Reshma just to follow-up on the trial question and then Sohanya on the progress in multiple myeloma. Reshma?

Speaker 3

Yes. Thank you. So enrollment is going well. There's a lot and largely that's due just from the enthusiasm around these data. And I think that was highlighted most recently at ESMO, a couple of weeks ago in Spain.

Speaker 3

A lot of enthusiasm largely because the benefit that we are demonstrating is again in this high net need patient population that doesn't have any standard of care. That is translating to activation insights and enrollment onto our clinical trials. We in fact have 70 plus sites that are already active and enrolling patients onto the study. So, the study is going it's proceeding quite nicely. Sonya?

Speaker 4

And I can address the question around the 20% year over year growth. So when you look at our mix of EXPOVIO new starts, Over 60% of that is in the second to fourth line, which represents in Q3 year over year a 20% growth. Now the shift into earlier lines, as you pointed out, is a huge growth driver for us, primarily because of the benefit of duration that we see. Now as we think about duration of therapy data, as we've discussed previously, The data can be choppy, takes time to mature, but as we triangulate multiple data sources, we are seeing a nice upward trend in our duration of therapy and refills. And this is largely driven by this increasing patients on the earlier lines and also better management of patients on the lower dose and supportive care.

Speaker 6

Got it. That's helpful. Thanks for taking my questions.

Speaker 2

Thanks, Corey.

Operator

The next question comes from Colleen Cusi with Baird. Please go ahead.

Speaker 7

Great. Thanks. Good morning and thanks for taking our questions. First one on multiple myeloma. With the elevation of the NCCN guideline recommendation for XBD to category 1, you help us understand how much of a tailwind that could be through the end of the year?

Speaker 7

And then I have a follow-up.

Speaker 4

Yes. Thanks, Colleen. So Yes. So as we think about the evolving competitive landscape in multiple myeloma, exovio has become Established as a foundational mechanism. Now this elevation from of exovio from category 1, which used to be other recommended regimens To now Category 1 and preferred regimens is meaningful, particularly in the community setting, where it's a large driver of treatment decisions.

Speaker 4

So notably, the NCCN guidelines made 2 updates that were Favorable for XPOVIO as I mentioned. 1 was recommending class switching against supports a novel class of therapy like XPOVIO as well as the elevation of Expovio Belcade dex into the category 1 and preferred status. In terms of impact, we are not going to see an impact overnight. However, with multiple myeloma, it is an area that is Highly promotionally sensitive and we see steady growth over time. So we are excited that our Steel team is now able to actively promote this update today and moving forward.

Speaker 4

And we believe this strengthens our position in the community and in the earlier lines.

Speaker 3

That's helpful. Thank you.

Speaker 7

And then for endometrial, given the evolution of the treatment landscape with dostarlimab and DMMR and you're really encouraging results in PMMR, Have you pre specified any sort of analysis in this PMMR P53 wild type patient population for the ongoing Phase 3 study?

Speaker 3

Yes. It's a great question, Colleen. So similar to SIENDO in which we had endpoints Looking specifically at the DMMR versus PMMR, we'll continue to do that in our ongoing Phase 3 as well. It's not a stratification factor. We assume that the vast majority of patients are going to be MMR proficient, given the fact that they represent 80% That will ensure balance likely, but again, we will be looking specifically at the efficacy across these 2 MMR subgroups.

Speaker 7

Great. Thanks for taking our questions.

Operator

The next question comes from Eric Joseph of JPMorgan. Please go ahead.

Speaker 8

Hi, there. Thanks for taking your question. This is Billy on for Eric. Quick one Just on the combination with the MS stroke, the megaglutamide. Just a little bit of thoughts on what the rationale there is in terms The combination with Selinexo.

Speaker 3

Yes, absolutely great question. We're really, really excited about this novel combination. Just to give you a little bit of insight, right? This combination was pushed by some of our key KOLs coming out of Dana Farber Cancer Institute, Paul Richardson. He just thought that this builds upon the number of combinations that selinexor has already shown Remarkable efficacy in patients with multiple myeloma.

Speaker 3

The other aspect that is intriguing to him, but also BMS and of course It's the fact that both of these drugs XP01 inhibition with selinexor as well as this novel cell mod in Nazigtimide has individually and potentially in combination shown that it can reverse T cell resistance. And this concept of T cell resistance is of course becoming more and more important for multiple myeloma treaters given the fact that they Are now introducing T cell therapies into the multiple myeloma arsenal. This novel combination potentially gives them A really important tool to help with sequencing of these therapies for their multiple myeloma patients.

Speaker 8

That's helpful. Thank you. And then just one if you don't mind quickly on the patient assistance program and how Kind of you see the impact of these foundation closures going forwards and then kind of So a Medicare Part D design might be affecting this in 2024?

Speaker 4

Yes. Thank you for the question. I can take that. So in terms of PAP, as we know, we saw an Pre utilization of PAP, a free drug, this year due to foundation closures. Now year to date, through Q3, The impact of PAP has been roughly $5,000,000 to $6,000,000 which includes about $1,000,000 to $2,000,000 PAP impact in Q3.

Speaker 4

Now in Q3, there were 2 of the foundations that were open and we as a result saw new patient starts In PAP normalized, but the refill impact remained. Now in Q4, these 2 of the 4 foundations Remain open to date, and we anticipate the path impact being very similar in Q4 as it was in Q3, assuming the foundation dynamic does not change. Now as we move forward into 2024, We are encouraged by the IRA related change to the design of the Medicare Part D, which eliminates The patient burden of the 5% beneficiary coinsurance requirement and we expect therefore Significantly less need for these patients to utilize, our patient assistance program for co pay assistance.

Speaker 8

Great. Thanks for taking my questions.

Operator

This concludes our question and answer session. I would like to turn the conference back over to Richard Paulson for any closing remarks.

Speaker 2

Thank you, operator, and thank you everyone for joining us today. As we mentioned, we are well prepared for the next stage of growth as we continue to expand on our foundation of multiple myeloma with our proven commercialization of late stage development capabilities and as we continue to rapidly advance our pipeline, concentrating investments in our 3 Phase 3 programs that are expected to read out through 2024 and 2025 as we work to create near and long term value for all stakeholders. Thank you for joining and have a wonderful day.

Operator

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

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Earnings Conference Call
Karyopharm Therapeutics Q3 2023
00:00 / 00:00