Okay, we'll continue with the next session. Good morning, everyone. I'm Paul Choi, and I cover the biotechnology sector here at the firm. It's our pleasure to have BridgeBio here for our next panel, and Neil, CEO, join us for Q&A. What we'll do is let Neil kick it off with a little bit of overview and just kind of what's topical with BridgeBio, and then we'll dive into questions. If you have questions along the way, please raise your hand, and we'll try and get a mic to you if possible. With that, Neil, I'll turn it over to you.
Yeah, thanks, Paul, for having me, and thanks to Sonia, Ben, Lila, and others for having us back. I notice you sat us between our two competitors in ATTR cardiomyopathy, and next year maybe BioMarin and Ascendis. I guess the good news is we're the smallest in any of those groups, so lots of room for growth. Yeah, 2025 is obviously an extraordinarily important year for BridgeBio, really four things that we're focused on. First and foremost is the launch of Acoramidis, which we'll have an opportunity to talk about in the ATTR cardiomyopathy market. That's really an existential thing for us because we need to prove that we can be the best owner of a commercial asset in the context of a competitive space with great scientific and medical data.
If we can do that, the second priority is really to continue to build on that growth aspect with our three phase IIIs and billion + dollar marketplaces reading out late this year, early next year. It's ADH1, LGMD2I, and achondroplasia, so hopefully we can talk about those as well. The third is probably an underestimated piece, but has been an area of focus for us, which is the continued prosecution of expansion indications around our late stage medicines. We can talk about ADH1 as it sort of extends into hypoparathyroidism. I think an obvious one is HypoCon for our achondroplasia franchise, and a smaller one is Fukuyama syndrome for our LGMD2I franchise, but those are amongst the highest ROI opportunities we see in the present portfolio. The fourth is continued management of our BERM profile.
We obviously de-conglomerated last year, spinning out our oncology franchise and spinning out our early stage gondola franchise. Two exciting readouts there later this year, almost 16 assets in the pipeline, but for BridgeBio, we'd like to keep that OpEx - stock-based comp at around $200 million per quarter. And we view ourselves as a very lean operation, less than $20 million to IND, $50 million a year usually on phase IIIs or so. But obviously, the breadth of the work that we do leads to reasonable amounts of spend, and so we really want to manage that carefully. The vast majority of our spend right now is on commercial. I think that's appropriate. So those are kind of the four categories we're focused on. Happy to take it from there in any way.
Okay, great. Thanks for that, Neil. Maybe we'll start with the Attruby launch since it's probably top of mind with investors. Your early metrics look really strong. It's going pretty well. Maybe you can tell for us what's resonated, I guess, in the marketplace so far and with the competitive space continuing to evolve quite rapidly as recently as this past quarter here. Just how you're thinking about the launch trajectory perhaps and the cadence over the remainder of 2025?
Yeah, great question. I think it really starts with the science and the medicine for us, and maybe I'll spend a second on what's been happening because there's so much data in this space. We can't really play games as a small sponsor around contracting or American taxpayers footing the bill for a buy-in bill or something like that. We have to stay laser-focused on what's best for patients at the lowest cost, which our drug is obviously in this space. From the scientific and clinical perspective, it really starts with our three, 42, 50 messaging. As early as three months, you see effect of this product on the salient endpoint, which is cardiovascular hospitalization and all-cause mortality. That's the earliest time point that we've seen in this space as a point estimate.
The 42% relative risk reduction against that same endpoint is again the highest in terms of relative risk reduction that we see at 30 months in this space. The 50% reduction in hospitalization is quite important, suggesting that people can live longer and live better lives. All of that, we believe, is underpinned by the fact that we have the most potent small molecule stabilizer in this space. We believe small molecule stabilizers will be frontline, and we continue to see that in the marketplaces we can talk about. We've shown in four of four preclinical assays that we are the most potent stabilizer. We sort of cheekily put up an email from Jeff Kelly, who invented tafamidis, to one of our founders, suggesting that he also believes acoramidis is the most potent stabilizer.
I think most importantly, we see it in the serum TTR data, which is clinically relevant to a lot of folks looking at patients with ATTR cardiomyopathy. What's exciting really recently is two categories of data. The first is allowing us to connect the dots between ever better stabilization and outcomes. I can remember talking to you even years ago when we were Eidos about, well, how much more risk reduction does an additional 5% stabilization really buy you? We just released a seminal paper in JAC. It's starting to get quite a bit of excitement. Matt Moore was the lead author on it, tying serum TTR levels and elevation in serum TTR to decreasing probability of mortality. What's really profound are really two things in that.
One is when we look at our database, there is no better predictor of downstream mortality other than eGFR characterization at baseline than change in serum TTR levels at day 28. That's remarkable. It's not NT-proBNP. It's not some quality of life thing. It's not even hospitalization. It is change in the day 28 serum TTR level. That's one. Second, what is remarkable about our finding is that every mg/dL increase in serum TTR leads to approximately a 5% decrease in probability of mortality. If you think about it, the average wild-type patient in our trial might have 23, 24 mg/dL at baseline, and they're going up to 33, 34, 9-10 or so change. Really profound decreases in probability of mortality associated with acoramidis.
I'd say the second important point there is, recall, when folks were dropped in on tafamidis but then moved on to our open label extension, we were able to see what kind of elevation they would get in serum TTR levels, and it was a little over three. A little bit over a 15% reduction in probability associated with mortality at a p-value less than 0.002. Really remarkable outcomes. I think as people learn more about that, they're going to get more and more excited about the benefits of an ever more potent stabilizer. One last thing is, as in any commercial setting, it's important to start thinking about patients not as some monoculture, but rather different pockets of patients and where can acoramidis be the best drug because it's not going to be the best drug for all patients.
The first thing we started looking at was AFib or the cardiac arrhythmic population. It's almost half of the population with ATTR cardiomyopathy. Here what you can see from the clinical data is that small molecule stabilizers, but not knockdowns for some strange reason, at least as far as we can see from the AE tables, have an impact. What we were able to publish just recently is a 43% reduction in cardiovascular hospitalization in that AFib population associated with treatment with Atrubby. That's important. That's one subpopulation. Finally, another subpopulation is the sickest of patients, those variant patients. What we've shown is a 59% risk reduction in ACM and CVH, which I think is the most profound relative risk reduction in the space, again, and the only statistically significant relative risk reduction.
We're going to use that data to go out to the clinical community and educate them on, hey, do you have a patient with AFib, the V122I patient population, which has been dramatically underserved? How do we continue to push there and those types of things? That is really the science of medicine. That is what underpins our launch.
Maybe just as a quick follow-up, are those subpopulations you can eventually pursue on label, whether it's AFib or the variant or any plans to do that?
No plans right now to expand medical education.
Yeah, medical education?
Yeah, just mostly by medical education and publishing. Yeah.
Okay, great. You talked a little bit about different patient populations, but I was just curious, as you think about how the marketplace is evolving here and just what is easiest for a community physician versus an academic or heart failure center specialist physician to sort of appreciate, and how has that mix of prescribers perhaps changed over time? Do you see the market eventually getting to a general cardiologist community or just maybe just how you think about the strengths and weaknesses of your product and your franchise in each of those settings?
Yeah, great question. I'd say at the broadest level, the market continues to go across all of those segments. I mean, I give you some example. You heard Albert up here talking about his franchise, but we've seen incredible growth in our franchise continue even with new market entrants. The growth in May was similar to the growth that we had in April and similar to the growth that we had in March. That to me suggests an ever-growing community of cardiologists that are prescribing. Certainly, we see that in our data. It also suggests, obviously, an ever-broadening awareness and so that we're finding patients. Look, we haven't seen physicians that only use one product or another, by and large. I mean, there's a few outliers.
I think that the call point has been growing outside of the COEs, but within COEs, certainly we have a lot of Attruby scripts. Within the quote-unquote community or high-volume heart failure practices, there is quite a bit of prescribing. It has not gotten to what you might call the general cardiologist as much yet, but just as a reminder, there are 10,000 of these high-volume heart failure practices out there. I think the opportunity is ripe in all of those settings for Attruby. We have not seen one where we are not meaningfully selling, especially in that front line. Obviously, with the entrance of knockdowns, we are going to lose some switch patients. How has the brand continued to grow so aggressively? I think a large part is that we are taking increasing share in the front line.
Okay, great. You launched with a very unique patient access program, including patients who are in your clinical trial getting free drug for lifetime as well as other different patient access schemes. You have also said on your first commercial stage earnings call that utilization of these programs was somewhat lower than expected. Has this held true in this quarter? Just maybe how do you think about use of patient access programs on the forward here?
Yeah, thus far, it's been lower than we expected from the get-go. I think we do have a lot of new-to-market edits. I mean, from an access perspective, a new drug is always going to be the most disadvantaged, and certainly we're going to be the most disadvantaged when we started as compared to brands that have either been on in polyneuropathy or on in the marketplace for years. I expect that that'll dramatically improve over time. I do expect some of the very generous access programs that we put in place to be used, especially as we push more and more into the variant population, which has traditionally been underserved. Again, our hope being that anyone who needs Attruby can get Attruby as expeditiously as possible.
Okay, great. Maybe just as a follow-up to that, you've talked about Medicare access in your last update being at parity versus tafamidis. Maybe just what other insurance coverage or commercial coverage progress have you made this quarter? And just sort of where are we in terms of market to market in terms of insurance coverage?
Yeah, I mean, I think a lot of those numbers are driven by the fact that Pfizer's franchise was mostly all formulary as well. The new-to-market edits were obviously unique to us. We continue to make progress with locking in contracts with the major five insurers as associated with Medicare. That is going to be a utilization game over time. I think it is important for us to continue to communicate that we do have all the scientific benefits at the lowest cost. As we communicate that both to folks in the US and in Europe, where the launch has been extraordinarily strong, I think in part because of that and in part because of hospitalization reduction, we will continue to have a privileged access situation.
Okay, great. I want to ask and switch to a topic maybe that probably comes up with you a lot as well, and which comes up a lot in our conversations, which is just sort of the intellectual property landscape with regard to stabilizers here. Given that specifically tafamidis and acoramidis have similar mechanisms of action, I guess what is your latest thought on the Pfizer IP and just sort of how you see that potentially evolving over the next few years? What steps are you thinking about as a management team for BridgeBio should a generic tafamidis enter either at the end of this decade or at some point in the 2030s?
Yeah, so I won't comment on Pfizer's IP position. I think people know our position on it, but Albert is sticking to the talk track, and I think they will continue to do so consistent with what they've done with other brands. I think the mechanism of action being similar, yeah, you're right, they're a small molecule stabilizer, but one is highly much more potent than the other and has a different mechanism of binding. Generally, I think its outperformance as compared to tafamidis in terms of its potency is going to be the anchor point as to how we get around any generic sort of entry in the future. I mean, look, we got real-world evidence from Moore and Mosry suggesting discrepancy survival rates over time. We're going to continue to do switching studies in and around serum TTR and some other key biomarkers.
I think as people get more and more evidence that Attruby is the right drug for some of their patients, it's not going to be as challenged by a generic entry. I'd also say this. I mean, I think we're basically generic as compared to Amvutra. I mean, there's a $500,000 drug on the marketplace right now, and it's being prescribed just as well too. Any generic that would come into the space would have the same patient copay as we do or as Vyndaqel would, and that's about $2,000, whereas they would lack patient access programs, they would lack obviously the ongoing research, et cetera, et cetera. I think that the dynamic of a generic entry here is a little bit different as well. You don't see that many physicians reaching for a Vyndaqel 20 right now.
It is just, I think, broadly being better and better described that ever more stabilization is going to be better for patients. It is kind of how we think about it. I do not think genericization, whenever it occurs, I think it is a little later than maybe my colleagues do that were on this stage before. Whenever it occurs, I do not think it is really going to meaningfully affect Attruby if we do our work correctly.
Okay, great. Maybe switching gears to the pipeline and thinking about your commercial programs as well as your clinical stage programs. Over time, I'm sure you're probably thinking about international markets as well too. Given that some of your competitors' revenues are significantly ex-U.S., for instance, in the achondroplasia space, about three-quarters of BioMarin's Voxzogo revenues come from ex-U.S. markets. How are you thinking about potential most favorite nation exposure in terms of pricing for your partner drugs such as acoramidis, ex-U.S., or future commercialized drugs that are ex-U.S. as well?
Yeah, so I'd say it's too early to tell precisely what impact MFN is going to have on any sponsor. My crystal ball is as foggy as anyone else's. We have been in touch with folks within the administration, and a lot would have to go wrong for MFN to meaningfully affect us. It'd have to go to Part D, it'd have to be applied to orphan products, it'd have to be applied to biotech firms. Just as a reminder, net pricing is not all that different for orphan products between the U.S. and EU, especially where there's no standard of care established like you do see in cardiomyopathy, achondroplasia, and the like. I think MFN for our category of drugs is going to be a little less meaningful for all of those reasons, but we'll have to wait and find out.
Okay. Maybe now turning to the pipeline, and let's talk about the Calibrate study for encaleret and ADH1. Can you maybe just give us a status on how that program is enrolling and just sort of what the latest thought on timing for top-line results could be here? And then subsequent to that, how quickly would you turn around an NDA filing for that?
Yeah, great question. Yeah, we continue to guide to late this year for the readout of that trial. It's fully enrolled. Actually, already 90% of people have the open label extension. We're closing in here on the final pieces of the trial. Very, very low dropout rates. I think encaleret is turning out to be a magical little medicine for a wide variety of reasons. Look, we're prepared to turn around the NDA. We did it pretty fast for acoramidis. I think we can do it even faster for encaleret. That's the challenge to the team. We've been doing things like batch data collecting, all of the different site quality inspections, et cetera, et cetera, to make it even faster this time around. I expect priority review for this drug as well.
Hopefully commercial launch not too far out with respect to ADH1.
Okay, great. Maybe just briefly on the ADH1 market, how is that sort of recognized and/or diagnosed in the endocrinology community and just how familiar are physicians with it versus, let's say, HPT, hypopara, and just sort of how does it fit in the sort of population and treatment landscape currently?
Yeah, good question. I mean, I think we've commented on the few thousand patients that are already identified with ADH1. There is an ICD-10 code that you can look at that I think under strips the number of patients that we see in academic medical centers. One thing that's interesting is if you look at the non-surgical hypopara community, which, it's about 20%-25% ADH1 or otherwise patients that haven't been identified with calcium sensing receptor gain of function mutations, but we find that that is about a quarter of the population, similar to HFpEF having a certain percent that is ATTR cardiomyopathy. A vast majority of those patients are seen in the community, and we know what the practices are.
A big part of what we're doing today in terms of medical education and a big part of the commercial launch will be going out to those practices and talking to those physicians about, "Hey, look, if you think that ADH1 might be afoot here, there are genetic tests that you can quickly determine whether or not encaleret will be the right drug for you." That will be a big part of the push.
Great. Earlier, you touched on lifecycle management, and you're already obviously thinking about that for encaleret in terms of expansion to hypoparathyroidism. Excuse me. This is a market that I think has captured investors' attention quite a bit given the recent success of ascendis. You said there's also some high amount of unmet medical need there. How do you think about what need will be out there for you post a potential hypoparathyroidism clinical program and approval for encaleret?
Yeah, look, I think the approved product obviously does remarkable things for patients. It makes sense if you do not have PTH to put PTH back. It is important to remember what PTH is doing in the normal human body, which is it has a diurnal regulation going from 10-60 or so over the course of the day. What the medicine today is doing is it comes in with effectively a uniform PTH concentration. That is why you see people step up in dose over time. Ultimately, they get to the point where about 20% of patients cannot continue to dose up for bone resorption issues and others that you are well familiar with. There is at least 20% of the community that is not well served by the current drug. I have never seen one drug serve everyone, so that is not a knock on that drug.
Second is a daily injection, and we have a daily oral, once daily oral. Look, we've been on this stage talking a lot about efficacy and safety, and that's what's going to drive everything. Being in the commercial marketplace, you can see little changes in convenience can change compliance rates and the enthusiasm for patients to be on it. For many patients with a 30% injection site reaction level, they'd rather take a once daily oral. The final thing is I always come back to efficacy. What you want to do for this condition is you want to normalize serum and urine calcium. I'm really pleased today to say our 10th patient from our small clinical study in HP came in. We have an 80% responder rate on both serum and urine calcium.
That point estimate, albeit small ends, is by far and away the highest that we've seen in the space. You get a single daily oral, incredibly safe. Yes, it's an orthogonal mechanism to PTH, but in a PTH-independent way, it's able to rectify the thing that's gone wrong for these patients. We think that will be quite attractive for many of the patients in the HP community.
Great. Maybe just as a follow-up to that, one of the key things that patients look for in the HP community is reduction of pill burden. A fair number of them are large amounts of calcium and calcitriol and so forth and vitamin Ds. Just how do you think about that metric and that sort of convenience down the road being a factor in shaping preference shares in the marketplace?
Yeah, we'll have to see how that 125-dihydroxy alpha vitamin D regimen, how we change that over time will be certainly something we're looking at in phase III, not something we've measured to date. Certain serum calcium obviously would, that's an obvious thing that we would get around and that would go down. You don't take standard of care in the context of encaleret, even in the ADH1 trial.
Okay, great. Maybe are there any other aspects of lifecycle management for encaleret that you would potentially want to call out at this point, or is it just something you're still keeping close to the vest here?
No, I think those two are the main ones. I think ADH1 being the salient marketplace and HP being the follow-on. There are a lot of other conditions that are associated with gain of function and calcium sensing receptor.
Okay, great. I want to turn maybe to ribitol, which I think is a program that's maybe a little under loved among investors here. Just first, people are obviously following other dystrophies very closely like DMD in the marketplace here, but maybe just sort of what is the opportunity maybe to start here with limb girdle and just how are patients identified?
Yeah, this is a well-diagnosed community. I'm already 7,000 patients between the US and EU. You can see that from how fast our clinical trial enrolled. You can see that from the wide variety of now three natural history studies that have been done in the space. It's a big market, bigger than exondys 1, I would say, but not as big as DMD broadly, obviously. The opportunity there is to be first and best in class. I think we haven't seen an agent yet really move the needle for this otherwise devastating condition, and that's what we hope to do with a readout here later this year.
In terms of the metrics in LGMD2I, I guess, what are the key ones that you would highlight for us? I think in the DMD space, people are familiar with dystrophin or micro-dystrophin production, time to walk and/or North Star assessments. Just sort of how do treaters in the LGMD2I space think about what they want to see in terms of patient outcomes?
Yep, very similar, excepting this is a different path of mechanism. You could substitute dystrophin expression, if you will, for glycosylation of the alpha dystroglycan complex. Here what we have agreed with the FDA and what the clinical community agrees with as well is that any rise in ADG glycosylation would be meaningful to patients, 5%-10% on an absolute basis, is able to create something remarkable in the mouse model. You can see that in the natural history as well, going from homozygous to heterozygous patients. That is really the aim, the core aim over this 12-month study. Obviously, we have a confirmatory trial that is going out to look at North Star and some of those associated endpoints. I do not imagine that those will change meaningfully in 12 months. You can see that from the natural history. We will be looking at everything.
We'll be looking at ambulation, to your point. We'll be looking at lung function. Our hope is that we're able to, similar to our phase II, show some improvements that are discrepant with natural history there, in addition to profound biochemical improvements, both on ADH as well as CK. Hopefully all of that lines up in the same way it did in our phase II.
When we were talking about Encaleret earlier and ADH1, it's clearly a biomarker-driven disease where you focus on calcium. Here, in terms of dystrophies, I think the agency has expressed a view that, or at least that seems to be evolving in real time, that they're amenable to surrogate endpoints like biomarkers or dystrophin and so forth, similar here for limb-girdle. You also talked about functional outcomes down the road and confirmatory trial. Maybe just at a high level, Neil, as you've sort of watched the agency's commentary here on surrogate endpoints as well as confirmatory trials, how does your ribitol program, I guess, line up with this potentially?
Yeah, we've been very impressed to date with our discussions with the agency. They haven't really meaningfully changed from the last group in and around what people call surrogate endpoints. Especially when it's a causal piece of the condition, serum calcium and urine calcium obviously being the core drivers effectively of ADH1. That's not really an accelerated approval. That's a full approval. In the case of LGMD2I, it's what you can measure. It's a devastating condition, and we know it to be on the causal pathway. I think there's a lot of enthusiasm for those types of conditions. We're seeing it with Canavan disease. We're seeing it with LGMD2I. Obviously, there's no need to talk about it with our achondroplastic franchise. Yeah, no, continued enthusiasm there. My hope is that sponsors continue to do the right thing and running confirmatory trials like we are.
It all comes together for patients in a really nice way.
Great. Maybe just to close it out on limb-girdle, you've talked about the 7,000 patients that have been identified in sort of the major geographies here. As you think about it, what does that translate to in terms of a potential market opportunity?
Yeah, we think it's well over a billion dollars. Obviously, the pricing in this space, you can look at the comps, is fairly reasonable. That is how we think about the primary indication. The secondary that I talked about, Fukuyama, is mostly most of the patients are in Japan. We will have to see what the price point is there and just how big that marketplace is. It stands to reason that the molecule should work in that condition, which is an upstream mutation in the same FKRP associated signaling pathway.
Okay, great. Maybe turning to achondroplasia and your infrared program, that's also a data set that could come potentially end of this year, maybe early next year. The marketplace continues to be very attractive given the commercial success of BioMarin's Voxzogo. Obviously, you first have to complete your pivotal trial here. Just maybe to start, what will you share in terms of top-line metrics either at year-end or early next year? Just maybe help us contextualize how you think about infrared potentially performing versus some of the commercial or clinical stage agents out there?
Yeah, good question. I mean, I think we'll share everything that we've been traditionally sharing, baseline characteristics, responder rate, obviously change from baseline in HV, which is the primary endpoint, absolute AHV proportionality, all of those things that you can expect us to have a fulsome data report upon top line. How does it compare to the CMPs? I've been outspoken on this. I think it's obviously a much more efficacious agent to start targeting the well-described condition at its source. I think it has its benefits. Obviously, it did in terms of the phase II with higher point estimates on change from baseline, but more importantly, I think the impact on proportionality and others. Obviously, it's a once daily oral. Again, I just I'm seeing the impact of convenience across the board.
I think it's, I don't think we need to even post a better point estimate in the phase III. I think we will, by the way, but I don't think we need to to get a majority market share here. Why? Because the totality of the evidence suggests that this is a better product, more efficacious product, a safer product, and then ultimately one that is much more convenient for the patient, for the community that we're serving here.
Do you plan to present the data at a medical meeting prior to your NDA filing, or is that just something you'll do in parallel at some point?
I'd imagine that we would do that. I don't know exactly what the medical meeting timeline would be. Yeah, the New England Journal paper and a medical meeting would be the way to go if it's successful.
Great. Maybe just touching on something you said a minute ago, which is just oral administration in the pediatric community, pediatric patient population, I guess. Can you maybe just share with us what your survey work shows versus the injectables, whether it's a daily or a weekly here?
Yeah, because I mean, just going back to my prior point too, people do understand that, so for instance, our trial goes all the way down to three years of age, right? You're taking a hit on the point estimate on change from baseline in AHV. The younger you go, all the rest of the trials that have been generated for approval are five and up. This kind of like just like what is the point estimate? What is this? What is that? I think it's going to be less important to clinicians than the totality of the evidence and the convenience. I think with an oral, especially in sachet form for young patients going all the way down to three, our survey work suggests that you take a majority share.
Again, even if your point estimates are roughly similar to the 1.5 placebo adjusted that you see from the other drugs, I think that it will be higher. I think you will see impacts on other parts of the disease pathology that you do not see targeting downstream with the CMP.
Okay, great. Maybe one more on infrared, which is I think a question you probably get as well, which is just thinking about the regulatory framework for your potential filing and as well as potentially completion of the BioMarin confirmatory trial and just what timelines there might look like and just sort of what your interaction on the agency has been with that regard?
Yeah, unchanged again. We had BTD, which obviously was, I thought, quite compelling because they were able to look at the totality of other evidence and suggested this is a breakthrough. We've heard nothing from the agency that we wouldn't be able to get approval based on the trial design that we have now.
Okay, great. In our last few minutes, I want to talk maybe a little bit more about what happens or what BridgeBio looks like over the coming years. You have three phase III programs that are going to finish this year and potentially could translate to commercial stage starting next year. You have talked a little bit about lifecycle management for these assets as well, as well as managing cash burn on the forward here. Just, I guess, how much do you think about the shape of the company over the next few years looking like as you moderate your late stage program and transition more towards back to your historical development program and some clinical stage programs, just, and the transition to profitability? Can you maybe comment a little bit on that?
Yeah, I mean, we're in serious growth mode right now. Our hope is that these phase IIIs reading out later this year provide us with that growth engine. We sort of couple demonstrated excellence with the true B. Hopefully that continues with these new growth modes. I think that should continue to be the engine of growth for some time for BridgeBio. I don't anticipate a whole lot of early stage research ongoing, especially with the deconglomeratization that we did last year. We'll obviously have a lot of ideas internally should we need to re-energize that growth engine. Right now, the focus really is continued execution, continue to try to capture the value for some of these programs that we think are a bit underrepresented amongst investors.
Hopefully with strong launches against LGMD2I, ADH1, and in the achondroplastic setting, we could be off to the races here in the next couple of years.
If I'm hearing you correctly, obviously you'll potentially have multiple product launches starting next year, maybe 2027. Just as you think about the expansion in your sales force, when does that process sort of start? Should we think about baking that as sort of an ongoing growth investment for the next couple of years?
Yeah, that's why I sort of referenced that 200 per quarter. Actually modeling it out over the next 36 months, I think that's going to be fairly accurate with some error bar around it. Why is that? Because I think R&D expense will moderate as we get through some of these phase IIIs. That will be then paired with increased commercial expense. I should say the commercial expense associated with ATTR cardiomyopathy is vastly different than even that associated with achondroplasia. And ADH1 and LGMD2I, we're the only game in town. So that's a very, very different type of launch. You can look at, I think we use the Ultragenyx KKC launch as a good comp. There are others that the expense can be far lower. We have a shared infrastructure now around market access, medical affairs, LDN, hub management, patient access.
All of those things can be applied across brands. It will just be what's bespoke to each opportunity will be a very small marketing team, a pretty small sales team for those remaining of the indications, and MSL Force, obviously.
Okay, great. You've obviously partnered out acoramidis with Bayer in Germany and Alexion AstraZeneca in Japan. Are you thinking about those other three properties, just agents, excuse me, doing those by yourselves given how you've characterized them, both in the US and abroad?
I think we can do them abroad. I think obviously there's some shared overlap in call point between ADH1 and achondroplasia. I think we're building out rest of world actually for Attruby. We've seen that maybe it's not maybe as complicated or expensive as we gave it credit for. First, lots of companies have spent way too much to get it up. We certainly weren't in the position to raise the capital to do so for the Attruby launch at relatively reasonable cost, but that might be different for ADH1 and achondroplasia. We'd like to maintain the opportunity to do it. If a better owner comes along at a price that's higher than NPV, we would also look at that too.
Okay, great. We're at time here. So thank you very much, Neil.
Thank you. Appreciate it.