Greetings. Welcome to the Alkermes plc fourth quarter 2018 financial results conference call. My name is Donna, and I will be your Operator for today's call. At this time, all participants are on a listen-only mode. Later, we will conduct a question and answer session. During the question and answer session, if you have a question, please press star one on your telephone keypad. Please note that this conference is being recorded. I will now turn the call over to Sandra Coombs, Senior Director of Investor Relations. Sandra Coombs, you may begin.
Thanks, Donna. Good morning. Welcome to the Alkermes plc conference call to discuss our financial results and business update for the quarter and year-ended December 31, 2018. With me today are Richard Pops, our CEO, James Robinson, our President and Chief Operating Officer, and James Frates, our Chief Financial Officer. Before we begin, I encourage everyone to go to the investor section of alkermes.com to find our press release and related financial tables, including a reconciliation of the GAAP to non-GAAP financial measures that we'll discuss today.
We believe the non-GAAP financial results, in conjunction with the GAAP results, are useful in understanding the ongoing economics of our business. Our discussions during this conference call will include forward-looking statements. Actual results could differ materially from these forward-looking statements.
Please see slide two of the accompanying presentation and our most recent annual and quarterly reports for important risk factors that could cause our actual results to differ materially from those expressed or implied in the forward-looking statements. We undertake no obligation to update or revise the information provided on this call or in the accompanying presentation as a result of new information or future results or developments. After our prepared remarks, we'll open the call for Q&A. Now I'll turn the call over to Richard Pops for opening remarks.
Thank you, Sandra Coombs. Good morning. I wanted to start with just some brief comments about Alkermes and where we stand as we enter 2019. 2018 was a year of significant progress for us. The financial results we released today reflect our transition from a science and manufacturing-based drug delivery company to a leading CNS-focused organization with our own products and sophisticated commercial operations.
For the first time, we crossed $1 billion in revenues, driven by the growth of our proprietary products, VIVITROL and ARISTADA. We also successfully completed the phase III registration studies for what we expect to be our next major growth driver, ALKS 3831, expanding our presence in schizophrenia. Alkermes has become an important company in the fields of addiction and serious mental illness. The people of this organization are motivated by the opportunity to help this large population of patients.
These are people known to all of us, often neglected by others. This is noble work, it's different than other therapeutic areas. Our medicines are often used in large, resource-constrained systems. A necessary prerequisite for being able to access our medicines, we need to work to improve broken treatment systems around the country. We collaborate with states and the federal government, with policymakers and patient advocates, to improve care and to help patients and their families, we're having an impact.
Our proprietary science has been used in millions of patients now. Hundreds of thousands of patients have been dosed with VIVITROL and ARISTADA alone, with many more expected to come. What's becoming clear to us is that more impact requires more scale and sophistication. Today, we'll talk a bit about our commercial infrastructure and a unique approach to navigating today's evolving and complex treatment systems.
We believe this will serve as a platform for future growth, particularly in the field of schizophrenia. These capabilities provide a unique launching pad for ALKS 3831. Our scientific expertise and our development capabilities have grown, they'll shape our portfolio for the future. The only way to position a company for ongoing success is to have multiple innovative and independent programs sharing a common foundation of scientific excellence. Developing and commercializing medicines in this space is challenging. That also presents opportunity.
We're proud of the multifaceted business that we've built, we're very optimistic about the opportunities ahead to help patients and to create long-term value. Today, James Frates, our CFO, will outline our financial results and guidance for 2019. James Robinson, our President and COO, will provide an overview of the progress we've made since he joined the company almost a year ago. With that, I'll turn it over to James Frates to take you through the financials.
Thank you, Richard Pops. We finished 2018 with a strong financial performance, crossing $1 billion in revenue for the first time in our history, driving growth in our proprietary products, setting the stage for ALKS 3831 to fuel our emerging leadership in schizophrenia. The progress we made during the year to develop our commercial capabilities, pipeline candidates, and discovery efforts provides a solid foundation for long-term growth as we begin 2019.
I'll start with our key financial highlights. For the full year 2018, total revenue grew 21% year-over-year to $1.09 billion, we recorded non-GAAP net income of $97.8 million, both ahead of our expectations. For the fourth quarter, we recorded total revenues of $315.8 million, non-GAAP net income of $54.8 million.
These results were driven by 24% growth of our proprietary product sales year-over-year and the continued strength of our base royalty and manufacturing business, including higher than expected AMPYRA revenues. VIVITROL net sales in the fourth quarter increased 11% year-over-year to $83.8 million, driven by 11% unit growth. On a sequential quarterly basis, net sales increased 5%, driven primarily by underlying unit growth.
Gross-to-net adjustments of 46% during the fourth quarter were flat sequentially and as compared to the fourth quarter of 2017. As in previous years, due to the impact of year-end inventory build to just over three weeks and the reset of commercial plan deductibles. We expect our first quarter 2019 net sales will be down sequentially to approximately $70 million, with the growth resuming in the second quarter.
For the full year of 2018, VIVITROL net sales increased 12% year-over-year to $302.6 million, driven by unit growth of 16%. For 2019, we expect VIVITROL net sales in the range of $330 million-$350 million. We expect to see gross-to-net adjustments of approximately 50% in 2019, slightly higher than the prior year due to shifts in the payer mix.
As always, our guidance for VIVITROL reflects an extrapolation of current growth trends. We'll update you throughout the year if market dynamics evolve. Turning to ARISTADA, which refers to both ARISTADA and ARISTADA INITIO, our fourth quarter was also strong, as net sales increased approximately 72% year-over-year to $48.8 million and grew approximately 35% sequentially. Gross-to-net adjustments for ARISTADA were 43.5% for the quarter.
For the full year 2018, ARISTADA net sales increased 58% year-over-year to $147.7 million, driven by solid volume growth. Looking ahead to 2019, we expect strong growth of approximately 50% for ARISTADA, with net sales in the range of $210 million-$230 million. These expectations include a modest increase in our gross-to-net adjustments to approximately 47.5%, as volumes with certain large Medicaid plans continue to accelerate.
Similar to VIVITROL, we expect Q1 2019 ARISTADA net sales to decrease sequentially to approximately $40 million, thereafter increasing for the remaining three quarters of the year. Over the long term, we believe the addition of ARISTADA INITIO to the product family and our expanded hospital and field commercial teams will drive ARISTADA's market share in the long-acting atypical market, as the overall market continues to grow at double-digit rates year-over-year.
Moving on to our manufacturing and royalty business. We saw revenues of $526.7 million in 2018 compared to $505.3 million in the prior year, driven by revenues of $312.5 million from RISPERDAL CONSTA, INVEGA SUSTENNA, and INVEGA TRINZA, and higher than expected AMPYRA revenues.
Revenues from AMPYRA and FAMPYRA came in above expectations in the fourth quarter due to the delay in generic market entry for AMPYRA, resulting in total revenues of $107.1 million in 2018. Due to the launch of generic competition in the U.S., we do not expect meaningful revenues related to AMPYRA in 2019. We do expect to continue to receive revenues related to FAMPYRA outside the U.S., resulting in a combined expected range of $25 million-$30 million in 2019.
In addition, in the fourth quarter, manufacturing and royalty revenues included $26.7 million from Alkermes' share of proceeds from the sale of certain royalty streams by Zealand Pharma A/S related to products using Alkermes technology to Royalty Pharma. This was a one-time payment in lieu of future royalty payments. Taking a step back on the royalty and manufacturing business, the cash flows from this platform have enabled the company's self-funded development of our proprietary portfolio of commercial and pipeline medicines.
While the royalty and manufacturing business will become a less prominent element of the company's growth drivers in the future, our expectation is that it will continue to provide an important foundation of financial resources for the next several years. Turning to expenses. Overall, our expenses for 2018 were in line with our expectations.
Our R&D expenses for 2018 were $425.4 million compared to $412.9 million for the prior year, driven by our spend on our pivotal programs for ALKS 3831 and diroximel fumarate, as well as ALKS 5461 and the expansion of the ALKS 4230 program. Our 2018 SG&A expenses of $526.4 million compared to $421.6 million in the prior year, reflecting investments in our commercial organization in support of both ARISTADA and VIVITROL.
Q4 sales and marketing expenses increased, mainly related to the addition of field sales personnel and the expansion of our hospital sales team focused on ARISTADA. Looking ahead, our overall financial expectations for 2019 reflect a number of important dynamics as we position the company for long-term growth. On the top line, we expect total revenues to be in the range of $1.14 billion-$1.19 billion as the growth of VIVITROL and ARISTADA offsets the loss of AMPYRA.
Our guidance also reflects $150 million milestone payment from Biogen related to the anticipated approval of diroximel fumarate in the fourth quarter of 2019. On the operating expense side, R&D revenues are expected to be in the range of $450 million-$480 million. Excuse me, R&D expenses, $450 million-$480 million. This expectation is driven primarily by three areas of investment.
The first relates to activities surrounding our commercial and late-stage assets, including ongoing studies related to ARISTADA, ALKS 3831, and diroximel fumarate that are carryover from 2018, as well as the preparation of the ALKS 3831 NDA submission and lifecycle management initiatives related to ARISTADA and ALKS 3831 that will primarily impact the second half of 2019. The second element of our R&D investment is intensified activity for the clinical development program for ALKS 4230, as we enroll our monotherapy, combination, and subcutaneous studies.
The third element is focused on expanding our internal research and discovery efforts. While these activities are less visible externally, they're generating interesting data and represent an important aspect of our growth strategy. SG&A expenses are expected to be in the range of $590 million-$620 million, which may be higher than previously expected for some of you.
This range is driven by the full year impact of the expansion of the ARISTADA commercial team that took place at the end of 2018, and other important investments in our infrastructure that we believe create a platform for long-term growth. With this infrastructure now in place, we're well-positioned to capture efficiencies as our commercial portfolio grows, particularly as we prepare for the launch of ALKS 3831 in schizophrenia.
Our top-line growth and investments in our business are expected to drive a GAAP net loss in the range of $135 million-$165 million, and a non-GAAP net income in the range of $40 million-$70 million for 2019. We expect that our quarterly results will generate a net loss for the first three quarters of the year, and a return to profitability in the fourth quarter, with the anticipated recognition of the $150 million milestone from Biogen, as well as the increase in our proprietary sales throughout the year.
Turning to our balance sheet, we're well-positioned and ended 2018 with approximately $620 million in cash and total investments, compared to approximately $590 million at the end of 2017. The company's total debt outstanding was approximately $280 million at the end of 2018. Overall, we're pleased with our 2018 results and our healthy financial position as we enter 2019.
Given the growth opportunities for our proprietary products and pipeline candidates, we believe that increased investments in 2019 establishes an important platform to drive long-term revenue growth, pipeline expansion, and profitability. I look forward to updating you as we deliver on our strategy throughout the year. With that, I'll turn the call over to James Robinson for additional updates on Vivitrol and ARISTADA.
Thank you, James Frates, and good morning, everyone. As Richard Pops stated, the progress we've made in the last year has been significant. We have two valuable medicines, Vivitrol and ARISTADA. Following a comprehensive analysis of our commercial plan and capabilities, we implemented a number of important initiatives to drive growth over the long term. One key element you'll hear us talk about in addiction and schizophrenia is continuity of care.
Continuity of care is particularly important to physicians and to patients suffering from serious mental illness and substance use disorder. These patients may receive treatment for their disease in multiple settings of care, where access to the prescribed treatment across settings is often difficult to maintain, yet remains central to their effective treatment. This is just one element of the complex treatment systems which Vivitrol and ARISTADA operate.
We've adapted by assembling a set of capabilities that provides a unique approach to navigate these treatment systems, positioning us well for long-term growth. With that, let me turn to our progress. Starting with Vivitrol, in 2018, net sales increased approximately 12% year-over-year to $302.6 million, driven by underlying unit growth of 16%.
In 2018, we made significant progress in evolving our commercial organization and developing capabilities in order to be best positioned for future growth. Throughout the year, we saw positive activity with federal funding and state policy changes, which we believe will continue to increase access to medications for patients suffering from substance use disorder. Vivitrol sales continue to be concentrated, with the top five states representing 45% of Vivitrol volume overall.
In states like Ohio and Massachusetts, which were the primary drivers of Vivitrol's progress in 2015 and 2016, growth rates have slowed over the last two years. Because of that, we're implementing new strategies and resources to reinvigorate growth. However, we're also seeing broader base growth. In 2018, 28 states demonstrated more than 25% growth year-over-year.
We're also encouraged by recent policy trends in states like Michigan, where new legislation is being implemented to encourage patient-centered care for those with opioid dependence. This is the first state to fully embrace the provisions of the Comprehensive Addiction and Recovery Act, mandating that opioid treatment programs offer all three FDA-approved forms of medication.
There's also action on the alcohol dependence side, with recent legislation in Michigan that requires courts to order an assessment for alcohol use disorder and possible medication-assisted treatment for people convicted of two or more DUIs. Michigan is just one example of the forward progress we're seeing across the country. We're also encouraged by new trends and initiatives in a number of important states like Pennsylvania, California, Florida, and Kentucky.
These bellwether states, with a variety of policies and funding sources, serve as an important example for other states as they design strategies to ensure that patients in need of treatment are provided with options that best fit their recovery journey and treatment objectives. Looking ahead, our 2019 expectations for Vivitrol are based on a linear extrapolation of current trends.
However, to support the continued and long-term growth of Vivitrol, we've implemented new commercial capabilities to support continuity of care, including the launch of field reimbursement and key account teams, which are designed to improve patient access to treatment. Additionally, in the second half of the year, our ARISTADA sales force will promote Vivitrol in community mental health centers and other adjacent settings of care in which opioid dependence is treated.
Vivitrol is the only treatment indicated for the prevention of relapse to opioid dependence. While Vivitrol operates in a fragmented and idiosyncratic market, where timing and trends are difficult to predict, there's also many reasons to be optimistic about the outlook for Vivitrol and its role in our nation's response to the opioid crisis. Turning to ARISTADA. In 2018, we recorded net sales of $147.7 million, driven by unit growth of 52% year-over-year.
2018 was highlighted by the launch of ARISTADA Initio, part of a new approach to treatment initiation that gives physicians the unique ability to fully dose a patient on day one for up to two months. This is critically important to help support continuity of care for this patient population, when there's often only a span of two or three days to stabilize and initiate a patient on treatment prior to discharge from a hospital or crisis stabilization unit.
On the access and reimbursement side, we've seen the addition of ARISTADA Initio to formularies that parodied ARISTADA, including adoption by the largest PBMs and health plans. Within the hospital setting, we continue to be encouraged by the positive receptivity to ARISTADA Initio, with the addition of both ARISTADA and ARISTADA Initio to GPO and hospital formularies.
We expect that ARISTADA Initio coverage will continue to expand and that awareness will deepen as we expand our reach into more hospitals in 2019. ARISTADA sales grew 58% year-over-year in 2018 and represent a substantial opportunity for Alkermes. In terms of market share, ARISTADA's market share overall for new prescriptions, in terms of months of therapy in the long-acting aripiprazole market, was 29% in December 2018.
As I mentioned in our last earnings call, during the fourth quarter, we expanded our field and hospital-based sales force for ARISTADA by approximately 60 sales reps, based on the opportunities and encouraging trends that we're seeing. Looking ahead, we expect to see approximately 50% growth in ARISTADA in 2019, driven by the uptake of ARISTADA Initio and our expanded commercial presence.
To maximize impact and efficiency, our newly created field reimbursement and key account teams will also support continuity of care for ARISTADA patients and engage with large multi-site providers. Our commercial infrastructure and expertise are unique and highly leverageable assets designed to support additional commercial opportunities, including ALKS 3831. Let's spend a moment on that. We see ALKS 3831 as a major commercial opportunity.
With a planned NDA submission in mid-2019, we'll be using the time we have now to prepare for this potential launch. This begins with the presentation of additional data at spring medical meetings and scientific education initiatives. We'll also initiate appropriate engagement with payers later this year. As we prepare to compete in a largely generic market, we plan to share clinical and pharmacoeconomic data to support ALKS 3831's value proposition and its place in the treatment paradigm for payers.
We believe a significant opportunity exists for medicines like ALKS 3831 that provide robust efficacy with an attractive tolerability profile. Our existing ARISTADA field and hospital teams will be the core of the commercial efforts for ALKS 3831 and as we get closer to launch, we'll evaluate the need for additional reps.
We have significant synergies to leverage, particularly within the treatment settings where our patients are seen. Now, we have substantial work ahead of us, but I'm confident that we have the right resources in place to successfully execute on our commercial strategy and drive growth. With that, I'll turn the call over to Richard Pops.
That was great, thank you. Let's move to what's next, the pipeline. The last few months were highlighted by important developments across the late-stage portfolio. We've reported positive top-line results for the second phase III study of ALKS 3831, an important milestone for the program, which moves us now into NDA preparation. For diroximel fumarate, the registration program culminated in the submission of the new drug application to FDA in December.
I'll make a brief comment on ALKS 5461. As expected, we received a complete response letter from FDA at the end of January. We disagree with the conclusions reached by FDA in its review, but we'll need additional interactions with the agency to know whether there's a reasonable path forward for ALKS 5461. It's not clear to us at this point that there is.
In the meantime, we'll continue to enroll in the ongoing study 217 until we determine where we stand. With that said, let's shift back to ALKS 3831 for schizophrenia. The news here is really encouraging. We designed ALKS 3831 with a specific intention, to capture the robust antipsychotic efficacy of olanzapine, but with a favorable weight profile.
Late last year, we successfully completed the second phase III study in our registration program, called ENLIGHTEN-2. This was the definitive head-to-head study versus olanzapine, and I want to take a moment to share some of the key details. ENLIGHTEN-2 evaluated the differential weight profile of ALKS 3831 versus olanzapine over six months in patients with schizophrenia.
We agreed in advance with FDA on two co-primary endpoints, the difference in the average or mean weight gain between the two groups and the difference in the proportion of patients in each group gaining 10% or more of their baseline body weight. These two endpoints serve different purposes. The mean is a continuous variable that captures all the information across all of the patients in the study, from those who lose a lot of weight to those who gain a lot.
The 10% endpoint is a categorical endpoint focused on the severe weight gainers, which are frequently seen with olanzapine. Taken together, the two endpoints are useful in characterizing the complete weight distribution curves of the two medicines across the entire population of patients in the study.
In addition to the formal study endpoints, we also wanted to show that ALKS 3831's weight gain profile was flat after an initial period of time. In contrast to olanzapine, which we know has an ascending profile for a long period of time. We've seen this clearly in phase II, and we wanted to see if that profile would be replicated in phase III. The study was a success.
We hit both of the co-primary endpoints with a high degree of statistical significance and consistent with our previous experience, the weight profile ALKS 3831 became flat. We believe that this shift in the entire weight distribution profile has profound implications for patients who will be prescribed this medicine. 73% of the patients on ALKS 3831 did not gain clinically significant amounts of weight.
Compared to ALKS 3831, patients on olanzapine experienced 57% higher mean weight gain and also had twice the risk of gaining more than 7% of their body weight, a threshold that's commonly considered to be clinically meaningful. These data just represent the top-line results of the study. We're planning data presentations at spring medical meetings to provide a more comprehensive overview of the profile of ALKS 3831.
The presentations will focus on the pivotal data, but will also include data from a long-term extension study, in addition to elaborating the metabolic profile of ALKS 3831. With the completion of the ENLIGHTEN pivotal program, we'll request a meeting with FDA to review the key regulatory requirements for ALKS 3831, including antipsychotic efficacy, weight, safety, metabolic profile, and we plan to submit the NDA in mid 2019.
We believe that ALKS 3831 has the potential to play an important role in the treatment paradigm for schizophrenia. The field would benefit from a new medicine with the proven efficacy of olanzapine, coupled with a comparatively favorable weight profile. From a commercial standpoint, it's the ideal next move for us. ALKS 3831 builds on our experience and infrastructure for ARISTADA and positions Alkermes with two important new offerings in schizophrenia: one, a long-acting injectable, and the other, an oral.
I'll talk next about diroximel fumarate or BIIB098, our novel oral fumarate being developed in collaboration with Biogen for relapsing forms of multiple sclerosis. In December, we submitted the NDA, positioning Biogen for a potential commercial launch in early 2020. Biogen recently announced they intend to commercialize diroximel fumarate under the brand name VUMERITY, which has been conditionally accepted by FDA.
Diroximel fumarate is intended to provide a differentiated gastrointestinal tolerability profile. In addition to the required clinical elements of the registration package, we're expecting data from EVOLVE-MS-2, which is an elective head-to-head GI tolerability study versus TECFIDERA, and we'll get those results in mid-2019. I'll finish with a brief update on ALKS 4230, our novel immuno-oncology candidate. We're now in a position where the critical studies are progressing in three different domains.
The first is monotherapy. Our hypothesis is that if we achieve or surpass the immunostimulatory cell expansion seen with high-dose IL-2, there is a potential for monotherapy efficacy of ALKS 4230 in tumor types where IL-2 has shown efficacy. We're continuing through dose escalation, and once we've identified the optimal dose, we'll expand to the next stage, evaluating ALKS 4230 as monotherapy in patients with renal cell carcinoma or melanoma.
The second domain is the evaluation of ALKS in combination with the checkpoint inhibitor pembrolizumab. Last fall, we accelerated our plan to initiate a combination study, and that study is well underway, now enrolling patients with a variety of tumor types. The third is the subcutaneous dosing phase I study, which we expect to initiate in the next few weeks.
Now that we're getting a sense of the pharmacodynamic profile of ALKS 4230 via the IV route, this study will evaluate simpler and less frequent dosing regimens that can provide similar immunostimulatory effects with greater flexibility for patients. 2019 will be an important year for the ALKS 4230 program, with expanded clinical activity and the potential to generate initial indications of ALKS 4230's antitumor activity in a range of tumor types.
With our late-stage assets now in the final stages of pivotal development and a number of studies for ALKS 4230 now enrolling, expanding our pipeline will also be an important focus for us in 2019. While less visible externally, for the past few years, we've invested in our internal research and discovery efforts, building our teams and running programs in the areas of pain, addiction, and expanding our capabilities in biologics and oncology.
We'll discuss some of these programs when it's appropriate, and we'll look forward to sharing more about these efforts as they mature. In addition to our internal efforts, we'll also continue to evaluate external opportunities that may be a complementary fit for our commercial or our development capabilities. I'll end there. The high-profile regulatory activity and pivotal data readouts that characterize 2018 clarify the next phase of growth of the company.
2019 presents different opportunities for value creation and has the potential to be equally transformative with the growth of our proprietary products, the planned NDA submission for ALKS 3831, the regulatory review of the NDA for diroximel fumarate, and the increasing momentum surrounding our ALKS 4230 immuno-oncology program. This is an unusual company doing important work, potentially affecting the lives of millions of patients. We'll look forward to updating you on our progress throughout the year. With that, I'll turn it back to Sandra Coombs to run the questions.
All right. Thanks, Richard Pops. Donna will now open the call for Q&A, please.
Thank you. The floor is now open for questions. If you would like to ask a question, please press star one on your telephone keypad at this time. A confirmation tone will indicate your line is in the question queue. You may press star two if you would like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. Once again, that is star one to register questions at this time. Our first question is coming from Cory Kasimov of JP Morgan. Please go ahead.
Hey, good morning, guys. Thanks for taking my questions. I have two of them for you. First one is on ARISTADA. With regards to the head-to-head phase IIIb study against INVEGA SUSTENNA, I'm wondering what kind of difference in placebo-adjusted response rates would be considered clinically meaningful. I guess in the end, I'm wondering what makes this study a win for ARISTADA. I have one follow-up on ALKS 3831.
Hey, Cory Kasimov. It's Richard Pops. I'll start. I'll ask James Robinson perhaps for his point of view. The study is actually achieving a number of different objectives. We got ARISTADA INITIO approved on PK data rather than clinical data. It's actually the first clinical trial that's demonstrating this distinctive offering that we have in the marketplace, which is ARISTADA INITIO plus two-month ARISTADA. The study is actually showing its primary statistical analysis is individual treatment arms change from baseline.
Patients come into the study with a certain PANSS baseline. They'll get INITIO plus two months. We'll measure their antipsychotic efficacy at time points beyond that. In parallel, we're enrolling a matched group of patients into the market-leading arm, which is INVEGA SUSTENNA. Allow us to provide simultaneous indications of efficacy of what we think are the two most important and leading long-acting injectable antipsychotics.
Okay. The follow-up on ALKS 3831 is I'm curious if you've discussed the results from this program with regulators outside of the U.S. and kind of what the strategy is there and how you ultimately view that market relative to the U.S.
Well, I'll answer the question a little bit more broadly because we're beginning to share the results with some of the study investigators and key opinion leaders. We're really encouraged by the feedback we're getting. As this data set matures, remember in December, we simply gave you the top-line analysis of the primary analysis. It's a rich data set.
I think you're going to be impressed when you see the full data set presented in the meetings in April and May. OUS, we're going to go seek scientific advice because I think now that we have a much better sense of what the drug's true profile is, we think we have a chance to differentiate this drug, even with strict regulators and payment systems, OUS, based on its favorable weight metabolic profile and its profile. We'll go seek scientific advice and then make a decision about Europe.
Okay. Thanks for taking the questions.
Thank you. Our next question is coming from Jason Gerberry of Bank of America. Please go ahead.
Hi, good morning, everyone. This is Qi on for Jason Gerberry . Thanks for taking our questions. Two, if I may. First on VIVITROL, thanks for providing comment on how you think about fiscal 2019 guidance. On your comment that the expectation for 2019 is a linear extrapolation of current trends, can you maybe provide a little bit more colors on the growth drivers for VIVITROL as we look into 2019 and your expectation for the federal grant proceeds to work their way through treatment system in a manner that may accelerate uptick?
Just a follow-up on that, does the guidance factor in any negative impact from some of the competitive dynamics in the buprenorphine segment, either on net pricing or volume? Thank you.
Sure, Qi. Thanks for the questions. I'll start with that, then maybe James Robinson can provide some color as well. I think as we've done for the past few years with VIVITROL, we've taken the most recent quarter and projected that forward for growth rates. That's what we've done for 2019. I think the key part about the VIVITROL market, of course, is it really is a state-by-state market with each of the reimbursement systems, each of the ecosystems and states being very different.
James Robinson touched on the broader growth that we're seeing. In years past, we've talked about 50% of our sales coming from the top five states. That's moved down into the 45% range, and as I think we continue to broaden the growth of VIVITROL, we see that as a very positive trend for us.
Again, having nearly half the sales come from five states gives us what we see as a lot of upside moving forward. In terms of the competition, we certainly have taken into account what we see as the evolving landscape on buprenorphine. Since VIVITROL is such a different approach to treatment, we believe very firmly, and have talked about it for a long time, patients need to have all three options available for treatment shared with them.
The different choices that patients are going to make we think will favor VIVITROL in the long run because with our very low market share right now, when patients are given active and fully educated choices, we see many more patients looking to lead a non-narcotic life. Therefore, that choice would be VIVITROL.
I think what I would add is more to the question you raised on funding and the catalyst of funding for VIVITROL. Clearly, the federal government continues to provide federal grants to the states. We're going to continue to partner as appropriate with the states in terms of educating what those grants are available for and supporting the states as they look to be able to potentially build treatment systems that
Include all three medications and also have examples of where VIVITROL has provided a value for patients within that particular state. Our continued partnership with at the state level is going to be very important. As I've said in the past, we're going to continue to drive growth where we've had success, and we're going to expand from there. Continue to grow in some of the inpatient settings of care that we've been successful in and then expand further out in outpatient. The goal for VIVITROL in 2019 is continued pull-through. It's pull-through of federal funding at the state level.
It's pull-through of our new commercial infrastructure to ensure that we're fully collaborating across the settings of care as necessary, that we're looking to support the continued rollout of new models that we are learning at each state and make sure that those models are well understood throughout the country.
Thank you. Our next question is coming from Chris Shibutani of Cowen. Please go ahead. Chris Shibutani , make sure your phone's not on mute.
I'm sorry. It was on mute. Can I follow up on the Vivitrol question, particularly for the guidance for 2019? The assumed range lower end implies about 9% growth, which is a little bit of slowing versus this year, and up to 16%, which would be kind of maintained for a little bit of acceleration. Can you talk to what the components of that range are from a bigger picture? Is it this question of duration that you've talked about in the past? Is it patient numbers? Is it mix in terms of the inpatient or Medicaid populations? What are the components of that range?
Chris Shibutani, it's James Robinson. Thanks for the question. I think that the components contain all that range. We guided to a little bit of an increase, a three or four-point increase in gross to net next year. We continue to see some of our largest growth in Medicaid expansion states. That mix of business more toward Medicaid versus commercial will continue in that dynamic.
We do our models on a state-by-state basis, really looking at patient expansion. It's mainly focused on an increased number of patients, therefore an increased number of vials used. If we can make inroads in terms of length of therapy or duration of therapy, that'll obviously help us enhance that growth. Again, you're right to point out the ends of the guidance, if you look at the midpoint, which is a midpoint for a reason, it's right around the growth that we saw in 2018.
It strikes me that when we think about the bigger picture scenario about using medication-assisted treatment, that's always been a bit of a puzzle in terms of why we're not seeing more penetration or growth, broadly speaking, whether it's Vivitrol or other forms of treatment. You talk about having a strategy commercially that really embraces patients being able to have access to all forms.
Is there a point of view that you have about why Alkermes wouldn't perhaps expand your portfolio treatment options? Why the focus singularly on Vivitrol as opposed to the other options to address medication-assisted treatment of addiction, opioid addiction specifically? Thanks.
Hey, Chris Shibutani. It's Richard Pops. How are you? It's a good question. The MAT big picture question, I think, is at the core of it. It's interesting the way that James Frates and James Robinson described the way we structure our guidance and our communications with you all is really based on a conservative estimate of where we are exiting the year in a complex, fragmented market with some ups and some downs and states coming in and some states coming out.
Against the backdrop of increased federal funding moving into the system and a progressively worsening opioid epidemic. We also have to provide at all times for that surge capacity for when certain things flip over. For example, in 2016, we grew at a nonlinear rate driven by two states, by Ohio and Massachusetts alone. We see that potential happening in the future as well.
We just can't model it. We don't know whether it happens in 2019 or 2020, but there's no question that there's more and more impetus for the use of MAT. Within the MAT, the place that's becoming very clear that Alkermes and Vivitrol are most comfortable is in that post-detox patient. There are literally millions of people, three million people or so in the U.S., undergo detox each year.
Under SAMHSA guidelines, post-detoxification initiation on long-acting naltrexone is indicated. Detox without long-acting naltrexone is not medically indicated. That's a place where we're not competing against Suboxone or methadone. It's for a different patient who has different treatment objectives.
To your final part of your question is, we're interested in some of these other new addiction treatments as well because obviously they would fit into our commercial infrastructure, and I think that we have the unique perspective on the injectable side of the market as well as the non-agonist part of the market. We like the features of some of the long-acting buprenorphines because they address the principal national liability of buprenorphine, which is its potential for diversion in the community. We don't have any immediate plans to move in that direction, but we're always looking to see what new things are arising.
Great. Thanks very much.
We'll take the next question please, Donna. Thank you. Our next question is coming from Umer Raffat of Evercore ISI. Please go ahead.
Hi guys. Thanks for taking my questions. I had a few. Maybe I'll just go one at a time. Perhaps first, Richard Pops, could we see Alkermes do something a bit more aggressive on the M&A side? I guess what I'm really trying to get at is maybe if you could give us color on. Do you have a top-line number in mind when you think about capital deployment or a certain type of asset? I'm just trying to get a sense for the ultimate target. Do you have an EPS number or a certain profitability target in mind as you think about these acquisitions you're looking at? I had a couple of follow-ups.
I'd say that the two major areas of our acquisition hunting have been, historically, complementary R&D development capabilities in therapeutic areas where we have competitive advantage or expertise. That's historically been psychiatry and addiction and anything that has adjacencies to those. The new component that you're hearing us say is that the commercial platform that we've been building by necessity and by opportunity with now VIVITROL and ARISTADA is distinctive. It's unique.
It's calling on providers in complex treatment systems, where you need a lot of additional capabilities in order to service and even enter the market. Now for the first time, we're also looking at adjacencies that leverage the commercial platform rather than the scientific platform. I'd say if I had to pick a financial metric that we're most motivated by at this moment, it's top-line revenue growth with high-quality products. We're not really interested in bulk for its own sake. We want to continue the pedigree that we're building in the community of having very differentiated, high value-added medicines.
Got it. On that commercial platform, perhaps turning to James Frates for my second one, and I did have an R&D one after that. James Frates, here's my long-winded question. In 2016, the commercial performance was very good. VIVITROL grew 45%, ARISTADA put up $50 million in the first full year of launch. It all happened on a GAAP SG&A of $374 million, which was already up from $300 million in 2015. The guidance on GAAP SG&A this year is $600 million. Maybe just in broad strokes, and I understand the therapeutic area focus is still the same as 2016. My question is, what explains the 63% GAAP SG&A increase versus 2016 levels as per 2019 guidance?
Well, Umer Raffat, I'll start. Afternoon. I think the key here is building out in a competitive space, both in schizophrenia and in addiction, building out a fully capable sales organization. As we've grown, I think to continue to show that long-term GAAP growth that Richard Pops talked about that we're looking for on the top line, making sure that we have the right infrastructure in place, again, to match the competitive nature in the antipsychotic market, but also to make sure that we have those field reimbursement managers and key account managers in VIVITROL, as James Robinson mentioned before.
Yes, we absolutely have been investing in SG&A, but I think we're going to see that long-term growth accelerate as we really match the market with the opportunity that we have. Again, these have the opportunity to show that long linear growth again in both ARISTADA and VIVITROL, I believe.
Got it. Then the last one was maybe just to clarify EVOLVE-MS-2's primary endpoint a little better. It's my understanding that the trial's comparing the number of days with a GI event. I guess my question really is what exactly has to happen either on the criteria or the cutoff on the IGISIS scale that makes a certain day qualify as a GI AE day or not?
Umer Raffat, it's Richard Pops. I wish I knew the answer to it, but I don't. We'll get back to you on that.
No worries. Thank you very much.
You're welcome.
Thank you very much.
On the question, I just want to say one more thing on the thing that James Frates answered. I think in 2016, we were underpowered on the commercial side, and I think it would've been a mistake. We enjoyed incredible growth in VIVITROL, as I mentioned, because Massachusetts and Ohio turned on big time.
If we had sat back and just relied on that happening and continuing year after year, we would've been sorely disappointed because those were anomalies. What we learned is that what does it take to try to replicate that across states around the country on the addiction side, and that's what we built to be able to provide for that as we have more of a 50 state strategy. On ARISTADA, we were just getting going.
It's a competitive marketplace, and we think we have the most competitive product, but we're the most recent one to market, and we're going up against J&J with INVEGA SUSTENNA and another competitor in the ARISTADA space. I think particularly when James Robinson got here, we looked around and said, "Okay, instead of just competing, how do we compete to win?" I think that we're sizing ourselves now, and that's what you're hearing in our messaging is that we really feel like we're positioning ourselves to win now. We can take the next question now.
Thank you. Our next question is coming from Paul Matteis of Stifel. Please go ahead.
Hey, thanks. This is Nate on for Paul Matteis . Maybe just going back to Umer Raffat's first question. As you're thinking about the pursuit of top-line revenue growth, how are you prioritizing BD to achieve that? Then are you seeing any attractive opportunities out there?
I don't think I'm going to give you a whole lot of specificity here, Nate. I think the concentric circles of prioritization are ones that you could predict. I mean, ones that sit squarely in our addiction and psychiatry field force and national accounts capability, pricing, reimbursement, all that. Those obviously make a lot of sense. There are adjacencies that aren't immediately self-evident
I'd say the other area of emerging interest is oncology, because ALKS 4230 is really quite interesting in terms of the number of potential combinations, and the ALKS 4230 aspect of the combinations can actually provide the IP differentiation. We're actually being pretty expansive in what we're looking at now.
Great. Thanks.
You're welcome.
Thank you. Our next question is coming from Biren Amin of Jefferies. Please go ahead.
Yeah. Hi, guys. Thanks for taking my questions. Maybe on ALKS 3831, have you had the pre-NDA meeting with FDA, and are there any key takeaways that you can share with us from that meeting?
No, we'll request that meeting in the next few weeks, and we expect to have that meeting later in the year.
Okay. Richard Pops, on the 2019 guide for ARISTADA, it kind of suggests 7%-17% growth when you annualize Q4 and what you reported in Q4. Given ARISTADA grew in Q4, 35% quarter-over-quarter, why shouldn't that carry through? I guess another question on ARISTADA growth in 2018, do you think share came from new patients, or was it switches from other therapies that drove that? Thanks.
Biren Amin, hey, it's James Frates. I'll start. I think the growth rate trends, I think we did mention, of course, that we expect to see that decrease in growth in the first quarter, that decrease in overall revenues in the first quarter. We've seen it historically each year as the plans reset and a little bit of that year-end inventory washes through the system.
I think if you take into account that first quarter cyclicality that we see or seasonality that we see, excuse me, the growth rates make more sense from a linear perspective. We're looking at roughly 50% growth year-over-year, not just the fourth quarter. The fourth quarter typically tends to be quite strong in both of our products. From an expected growth perspective, I'll let James Robinson comment.
Yeah. We saw growth in both, in new patient starts as well as patients switching from another long-acting injectable. It's not surprising. Obviously, this patient type will cycle through medications, a lot of medications. We see it generally from both.
I guess with the 60 reps that you've expanded the ARISTADA sales force with, how many new prescribers are you targeting with those new sales reps? Where do you expect that they would have the greatest impact? Is it going to be on new patients or on switches?
It's going to be, first of all, in the hospital, we added an additional 10 representatives to augment our current hospital team. That is really about starts, since 30% of all starts for long-acting injectables happen in the hospitals. It's an opportunity for us to broaden our reach within the hospitals, both on a breadth and then on a depth perspective, to make sure we have good coverage of the crisis stabilization units within those hospitals. We predominantly see that as the new starts.
With the 50 new reps, it was a combination of white space in terms of filling white space. That's an opportunity for us to be in particular geographies that we historically had not been in. That's going to be new starts. In some cases, where we have the highly concentrated metropolitan areas, it's about really augmenting our reach and frequency. It's going to be a blend of new starts as well as it's going to be a blend of refills as well.
We'll take the next question, please.
Thank you. Our next question is coming from Brandon Folkes of Cantor Fitzgerald. Please go ahead.
Hi, thanks for taking my question. I was wondering, could you give some additional color around the VIVITROL detox and induction strategy data we may see later this year? How incremental could this be to the sales effort around VIVITROL? Thank you.
I'll start here. Without question, that's an opportunity for us in 2019. We have resources available now for our field team to answer the questions that providers have on how to appropriately detox a patient. That's generally been the number one question on provider's minds. When we would sit with a prospective provider that was interested in treating patients with VIVITROL, the questions they would normally ask was, "How would I go about providing or detoxing the patient?"
Now we have the data to be able to explain how that's typically done. That's one of the key components for us in 2019 is being able to explain that. When we explain this about how do we support that office fully, and that goes back to the discussion we had about the field reimbursement team. Much of what you see in this patient population is a lack of support or lack of continuity of care. It's not only getting a patient initiated on therapy, but how do you help them stay on therapy? That's a big opportunity for us in 2019.
Great. Thank you very much. Maybe just one follow-up. How do you view VIVITROL's growth within alcohol dependence?
Today, it represents roughly 30%-32% of our overall sales. It's been fairly stable. I do think we're continuing to evaluate every segment of the market to ensure that we're maximizing all of the opportunities, whether it's an opioid use disorder or whether it's an alcohol use disorder.
Okay. Thank you very much.
Thank you. Our next question is coming from Marc Goodman of SVB Leerink. Please go ahead.
Morning. Two questions. First, on ALKS 3831, now that you've had a lot of payer discussions, I was wondering if you could just remind us how you're thinking of positioning this product. Are you thinking that this is going to be for naive patients? Is this going to be for Zyprexa patients who switch? Is there anything more that you've learned about that positioning strategy?
Second question is on ALKS 5461. Can you just help us with the two scenarios here with respect to the numbers? Like, you're running the study 217. Can you give us an idea of how much you're spending on that in the guidance this year, such that if we get a press release soon that ALKS 5461 and the whole program has been shut down, how much expenses can we take out of the model? Vice versa, if you decide that there is an opportunity to push forward with ALKS 5461, should we be assuming that there would be an increase in R&D spending? Can you give us a sense of what that would be for this year? Thank you.
I'll handle ALKS 3831 upfront. We have yet to engage payers fully. We have just begun to do ad boards with payers at this point. We'll have much more detailed information on the payer side within upcoming months. Once we have that detailed information, we'll then build our go-to-market strategy for the payers.
We'll be engaging the payers probably in the summertime this year. Part of that, though, in terms of answering your question, the key in my mind is not only in terms of establishing the clinical benefit of ALKS 3831, but also the pharmacoeconomic benefit of ALKS 3831. When you look at the number of patients that drop off therapy from a burden of illness perspective, that's a huge burden of illness in terms of overall medical costs related with treating these patients.
If there's a benefit with patients staying on ALKS 3831, that's a quantifiable benefit and a value proposition to the payer. In addition to that, as we release and discuss more data, we'll also look at other elements of the ALKS 3831 clinical profile that will allow us to do more on the pharmacoeconomic modeling perspective. Our expectation is we'll have a well-balanced value proposition, both with a strong pharmacoeconomic value proposition as well as a clinical value proposition. In terms of your other question, in terms of new and switch patients, it would be both.
Marc Goodman, on ALKS 5461, we've got approximately $15 million earmarked for that study through the course of 2019. I think, depending on the timing and obviously the advice we get and whether it's in each of the scenarios you talked about, that would be the range. We're planning for that study in our guidance to continue through the course of the year at this stage. We'll know more after we meet with the agency, as Richard Pops talked about.
All right. Thanks, Marc Goodman. We'll take the next question, please.
Our next question is coming from Danielle Brill of Piper Sandler . Please go ahead.
Hey, guys. Good morning. Thanks for the questions. Two quick ones from me. First, I'm just wondering which medical meetings you're considering for presentation of the ALKS 3831 data. Can you provide an update on the VIVITROL IPR and potential implications if this patent is invalidated?
Hey, Danielle Brill, it's Richard Pops. We're looking at three different meetings for the ALKS 3831 data. One is called SIRS, that's in Orlando, that's in April. There's APA in May, and there's the ASCP in late May. Somewhere in that mix, we'll be able to give that more expanded presentation. Oh, the IPR. The IPR is expected to be resolved by next November, I believe. I think just last week, we submitted the.
Patent owner response
What's called the patent owner response, which you should take a look at. We feel very strongly about our IP position on this IPR. You've heard me say many times before, there's more than patents that protect us in our commercial position with VIVITROL. VIVITROL is extremely difficult to make. It requires large-scale, consistent manufacturing. We think that we should prevail in this IPR.
To the extent that we don't, it's incumbent upon whoever comes into the market then to try to manufacture VIVITROL at scale. If they can't make an AB substitutable product, then they have an NDA or a 505(b)(2) type submission, and that requires new clinical information, and we expect them to come compete. As I've always said, many people have the ability to come in and create a long-acting naltrexone product.
There are drug delivery technologies that exist, naltrexone is off patent. No one's done it for a couple of reasons. It's hard, and the market is incredibly difficult, as we've shown. As we build this commercial capacity and this policy capacity and this presence in the communities and the states and the federal government, we think that's a really important competitive advantage for VIVITROL as well. First principles, we think the IP is strong, and we expect to win.
All right. Next question, please.
Thank you, Danielle Brill. Our next question is coming from Vamil Divan of Credit Suisse. Please go ahead.
Hi. Thanks for taking my question. Just a couple following up on some of the earlier questions as well. One, there was a discussion around expenses and the growth from 2016 to 2019. I'm just wondering, the expense assumption that you guys have in your guys was a little bit more than we thought for this year.
I don't want to get too far ahead of ourselves, but just as you look at our models kind of looking out further, do you think the Street is doing a proper job of modeling expenses over, say, 2020, 2021? Or is there going to be a lot more investment that we're maybe not factoring in right now? Second, kind of following up on the ALKS 3831 discussions, I appreciate your comments on the payer side.
Just maybe as you see the profile more from a clinical perspective, is there sort of a sweet spot that you're seeing in terms of the patient types where you think ALKS 3831 would be best positioned as a frontline therapy? Obviously, it's a pretty diverse market of patients in schizophrenia. Just trying to get a sense of where you see maybe the best clinical impact and/or pharmacoeconomic impact could come from. Thanks.
Yeah. Hi, Vamil Divan. It's James Robinson. Just on the long-term modeling, we typically don't guide, obviously, beyond 2019, we're going to stick to that practice right now. There is a lot of disparity of models over time, obviously a lot of people don't include certain revenues, a lot of people have very varied level of expenses. I would say that this investment we're making now, we feel very comfortable with
We're right-sized now going into 2019 on the ARISTADA and VIVITROL sides. It actually gives us a really nice platform on the health system side, on the hospital side, and on the key account manager side for the potential growth and synergy with ALKS 3831. I think you'll see a lot of synergies with the opportunity in ALKS 3831 in schizophrenia, along with ARISTADA. Maybe I'll leave it to that, and we'll guide more closely as we go closer to those years.
I'll just add on ALKS 3831. If you look at the segments in terms of how olanzapine historically had been used, the appreciation for olanzapine was this ability to rapidly control a patient's symptoms. This rapid treatment was really a key element of the value proposition of olanzapine. Those patients that were well-controlled on it, there was this belief that it was the best medicine for treating patients that were suffering from schizophrenia.
Obviously, the side effect, the weight gain was the issue in terms of why it was not used more widely over time. I would see it not only for patients that need to be controlled quickly, but also for patients that are well-controlled over the long term, especially now that we're able to attenuate weight with ALKS 3831 or weight gain with ALKS 3831. I see it being used in all patients, candidly.
There's obviously a segmentation approach we'll be taking given the fact we also have patients who would benefit from a long-acting injectable. We'll clearly have the patient segmentation worked out. We'll be able to clearly articulate the patient segmentation and really be able to draw a very clear and compelling picture as to where ALKS 3831 would fit in, as well as where ARISTADA would fit in terms of treating patients suffering from schizophrenia.
Thank you. Our next question is coming from Terence Flynn of Goldman Sachs. Please go ahead.
Hi, this is Holly on for Terence Flynn. Thanks for taking the question. Just another one on your 2019 SG&A guidance. Can you provide any additional details on your assumptions regarding your build for ALKS 3831? Thanks.
Sure. At this point in 2019, there's no commercial field investment for ALKS 3831 inside of our guidance. There is a portion of dollars in that for education and the beginnings of the marketing work. You could also almost feel that it's actually very similar to what we were spending on ALKS 5461 last year. There's not a lot of growth in that area, and mainly the growth is coming from that field organization that we started to build in Q4, and obviously, that'll be annualized into next year. No investment in the field organization for ALKS 3831 beyond what we're using for ARISTADA and VIVITROL in 2019.
Great. We have time for one more question.
Thank you. Our last question today is coming from Akash Tewari of Wolfe Research. Please go ahead.
Hey, thanks for taking my questions. In the event that TECFIDERA goes off patent earlier than expected, can you talk to us about the opportunity ALKS 8700 has in switching existing TECFIDERA patients onto the next-gen version? In the literature, it seems like most of the GI events, when they do occur, happen within the first month of treatment initiation. There also seems to be a disconnect between what we hear in a real-world setting about how many GI discontinuations happen and what's in the clinical data. As you look at your head-to-head data, what type of treatment discontinuation rate are you looking at?
Hey, Akash Tewari, it's Richard Pops. Obviously, the most important people to answer this question is Biogen because they're in charge of the commercial launch and conduct entirely. We file the NDA, we pass the baton to their commercial expertise. The real world, call it that, in the large open label safety study we're running is quite remarkable. That's where we're seeing GI discontinuation rates below 1%. I agree with you, the real world discontinuation rates that you hear from TECFIDERA are substantially higher than what you see in the clinical trial information that would have been the summary basis of the approval of TECFIDERA.
I think that we feel like we have a differentiated drug, when patients are put on the drug, that difference is, as you said because the GI discomfort is often experienced immediately within the first weeks of treatment, that's where we're going to separate very early in the real world when VUMERITY is launched. I really would encourage you to go to Biogen for the specifics of their plan.
All right, everybody. That concludes the Alkermes Q4 call for today. Thanks everyone for dialing in. If you have any follow-up questions, please don't hesitate to reach out to us at the company.
Ladies and gentlemen, thank you for your participation. This concludes today's conference. You may disconnect your lines at this time, and have a wonderful day.