Good morning, ladies and gentlemen, welcome to the DiaMedica Therapeutics second quarter 2023 conference call. An audio recording of the webcast will be available shortly after the call today on DiaMedica's website at www.diamedica.com in the Investor Relations section. Before the company proceeds with its remarks, please note that the company will be making forward-looking statements on today's call. These statements are subject to risks and uncertainties that could cause actual results to differ materially from those projected in these statements. More information, including factors that could cause actual results to differ from projected results, appears in the section entitled "Cautionary Statement Note regarding forward-looking statements" in the company's press release issued yesterday and under the heading "Risk Factors" in DiaMedica's most recent annual report on Form 10-K. DiaMedica's SEC filings are available at www.sec.gov and on its website.
Please also note that any comments made on today's call speak only as of today, August 15th, 2023, and may no longer be accurate at the time of any replay or transcript rereading. DiaMedica disclaims any duty to update its forward-looking statements. Following the prepared remarks, we will open the phone lines for questions. I would now like to introduce your host for today's call, Mr. Rick Pauls, DiaMedica's President and Chief Executive Officer. Mr. Pauls, you may begin, sir.
Thank you, Paul. Hello, everyone, and welcome to our second quarter conference call. I am joined this morning by Scott Kellen, our Chief Financial Officer. Before we begin this morning, I want to take a moment to welcome Dr. Richard Kuntz to our board of directors. Dr. Kuntz recently retired from Medtronic, where he was the Chief Medical Officer, Chief Scientific Officer, and a member of the Executive Committee. Prior to that, he served as a Senior Vice President and President of Neuromodulation of Medtronic. Before Medtronic, he was the Founder and Chief Scientific Officer of the Harvard Clinical Research Institute in Boston. He also served as an Associate Professor of Medicine at Harvard Medical School, Chief of the Division of Clinical Biometrics, and as an interventional cardiologist in the Division of Cardiovascular Diseases at the Brigham and Women's Hospital in Boston.
He also served as an advisor to multiple national and regional committees in the National Academy of Medicine and National Institutes of Health. Dr. Kuntz has directed numerous multi-center clinical trials and has authored over 200 original publications. We are grateful to have Rick join our board. His experience complements and broadens the knowledge and skill set of our board. Turning back to our update, the second quarter saw two important milestones for DiaMedica and our shareholders: the FDA's lifting of the clinical hold on our ReMEDy2 stroke trial and the completion of an at-the-market financing, raising gross proceeds of $37,500,000 . Starting with the FDA, on June 21st, we announced that the FDA had fully lifted the clinical hold on our ReMEDy2, Phase 2/3 clinical trial, studying DM199 as a treatment for acute ischemic stroke or AIS.
With this decision, we immediately reengaged with our study support vendors and have selected a new contract research organization with strong current experience in the stroke space. As many of you know, there's a great deal of work involved with preparing for a pivotal registrational clinical trial. I can assure everyone that our entire team is excited and focused on working with our CRO, the supporting vendors, and key advisors for the resumption of the trial. Recall that we have a bit of a leg up as we have approximately a dozen sites already under contract from last year. We are now also evaluating the addition of clinical sites outside of the U.S. to increase our enrollment rate in countries viewed as being able to enroll more quickly than their U.S. counterparts.
Our goal is to deliver a complete and clean clinical data package to the FDA at the conclusion of the ReMEDy2 trial, enabling the FDA to accept and improve DM199. It has been with this objective in mind that we expanded our clinical team over the past year. As of today, all key vendors have been engaged and are actively pursuing preparations for the resumption of patient enrollment. The estimated timeline has not yet been finalized, but based upon discussions with our CRO and multiple others, we are optimistic that enrollment for the interim analysis can be completed before the end of 2024. The final timing will come down to the actual pace of enrollment.
I want to stress that with our recent capital raise, which brought in significantly more capital than anticipated, we are able to pursue expanding the study globally in order to increase the enrollment rate with the intent to ultimately reach both the interim and final analysis more quickly. We expect to be able to provide more clarity on the overall timeline at our Q3 earnings call. On a related note, and as we've previously discussed, we are conducting a Phase 1C open label, single ascending IV dose study of DM199 in healthy volunteers using the same PVC IV bags as in the ReMEDy2 trial. The first part of the study demonstrated the safety of our planned 0.5 microgram per kg IV dose level to be used going forward in the ReMEDy2 trial.
It also demonstrated that this dose level achieved our targeted KLK1 blood concentration level, a level that we believe is the desired therapeutic range, similar to our prior phase I stroke trial and the reported drug levels of the human urine-derived KLK1 protein, widely used in China under the product name Kailikang. We were able to report today that we also completed a fourth cohort in the phase I C study, consisting of three hypertensive patients on ACE inhibitors. These patients received the 0.5 microgram per kg dose using the updated methods plan for the ReMEDy2 trial. We are pleased to see that all participants received the full IV dose, and there were no instances of hypotension or large drops in blood pressure.
We believe that the additional clinical data from these combined results will provide further assurance to current and potential physician investigators that the correct IV dose level has been identified, patients, including ACE patients, may be safely enrolled in the ReMEDy2 trial. Turning to our second milestone, we also significantly strengthened our balance sheet during the past quarter. In June, we completed an offering of straight common shares, no warrant coverage, priced at the market. Gross proceeds from the offering were $37,500,000 , net proceeds were $36.100,000 , bringing our cash balance to over $60,000,000 at the end of the quarter. The financing was led by existing investors, who contributed a significant portion of this capital raise and who remain enthusiastic about DM199 and its potential to offer a compelling new treatment option for stroke patients.
We also had excellent participation from our management team and board, who collectively invested $700,000. We are grateful to our investors who have put us in a position where we believe we can now drive our destiny. We believe that we now have the sufficient capital enabling us to complete the interim analysis with a remaining cash runway of approximately one year. We focus on the interim analysis as it has the potential to signal a beneficial impact of DM199 to stroke patients, a patient set that has not seen a significant therapeutic development in over 25 years since the approval of tPA. Before I turn the call over to Scott, I also want to call your attention to a new video and slide in our corporate deck that had created, which further illustrates the DM199 mechanism of action as it applies to stroke patients.
Specifically, DM199's role in increasing collateral circulation. The key updated mechanism message is that in response to ischemic conditions caused by a stroke, the bradykinin B2 receptors expressed on endothelial cells in the arteries of the brain are highly upregulated locally in the ischemic penumbra. This increase may be by as much as 40-fold higher based upon testing in animal models. By augmenting with DM199, we believe a significantly greater number of the upregulated bradykinin B2 receptors may be activated, causing the beneficial focal vasodilation in the affected area of the brain, the ischemic penumbra, to increase blood flow and oxygen. We believe this improved collateral circulation will salvage brain tissue in the penumbra and lead to improved patient outcomes. This video can be found on our website at www.diamedica.com, and scrolling down to the front page to the section titled Advancing Patient Care with Innovative Treatments.
I would like to now turn the call to Scott Kellen to review the financial highlights.
Thanks, Rick. Good morning, everyone. As Rick mentioned, we strengthened our balance sheet considerably in June with the completion of a $37,500,000 private placement with accredited investors. Net proceeds from the transaction were approximately $36,100,000 . Also, when David Wambeke joined us as our Chief Business Officer in April, he invested $750,000. As a result, our June 30, 2023, total cash, cash equivalents, and marketable securities increased to $60,600,000 - $60,600,000 , up from $33,500,000 at the end of 2022. Our cash usage was $10,100,000 for the six months ended June 30, 2023, compared to $6,400,000 in the prior year period.
The increase in our cash usage was due primarily to a combination of factors, including the completion of the in-use study and the phase IC studies, ongoing manufacturing development work, our expanded management and clinical team to support the ReMEDy2 trial, and our lawsuit with PRA. We believe that our current capital will support the clinical development of DM199 and our operations into 2026. Our research and development expenses increased to $2,500,000 for the three months ended June 30, 2023, up from $2 ,000,000 in the prior year period. R&D expenses increased to $6,200,000 for the six months ended June 30, 2023, compared to $3,900,000 for the six months ended June 30, 2022.
The increase for the 6-month comparison was due primarily to costs incurred for the in-use study, performed to address the recently lifted clinical hold on our ReMEDy2 trial, and costs incurred for the phase IC study, determining the DM199 blood concentration levels achieved with the new IV dose of DM199. Also contributing to the increase were increased manufacturing and process development costs, costs incurred to finalize the clinical data and perform the related analyses for the REDOX trial, and increased personnel costs associated with expanding our clinical team. These increases were partially offset by decreased costs incurred for the ReMEDy2 trial, which until late June, had been on clinical hold. Our general and administrative expenses were $2,200,000 for the 3 months ended June 30, 2023, up from $1.,400,000 for the 3 months ended June 30, 2022.
G&A expenses were $4,100,000 for the 6 months ended June 30, 2023, this was up from $3,000,000 for the 6 months ended June 30, 2022. The increase for the 6-month comparison was primarily due to increased legal fees incurred in connection with our lawsuit against PRA Netherlands and increased personnel costs associated with expanding our management team. Increased professional service fees and non-cash share-based compensation also contributed to this increase. Before I turn you back over to Rick, let me also provide a brief update on our ongoing lawsuit against PRA Netherlands. As many of you will recall, in December of 2022, the Netherlands Court, at our request, seized our study records from PRA.
In April 2023, following a March 2023 hearing, the Netherlands Court issued a ruling affirming our ownership of the study data and, importantly, stating that PRA had no legal basis for withholding the study data. PRA appealed this decision in June. While this appeal may take 9-12 months to resolve, it is not holding up our main damages lawsuit. This hearing is currently scheduled for December seventh of this year, and we look forward to presenting our case against PRA and providing our analysis of the damages caused by PRA's actions. It's also interesting to note that the same 3-judge panel that oversaw the hearing on our ownership of the study data is scheduled to oversee the hearing for the main lawsuit. For more information regarding the background to this lawsuit, please see our SEC filings.
Now, let me turn the call back over to Rick.
Thanks, Scott. With that, we would like to open the call for questions. Paul, if you could please open the line for questions.
If you would like to ask a question, please press star one on your telephone keypad now. You'll be placed into the queue in the order received. Please be prepared to ask your question when prompted. Once again, if you have a question, please press star one on your phone now. Our first question comes from Thomas Flaten from Lake Street Capital Markets. Your line is open.
Hey, good morning. Oh, thank you. Good morning, guys. Appreciate you taking the questions. Hey, Rick, with respect to the patients that were enrolled in the study prior to the clinical hold, I don't know if you've told us how many there were, but will they be kept in the efficacy analysis set, or will they be censored out?
Yeah, Thomas. We haven't disclosed that number, but they, we do plan to have those included in the analysis.
Got it. Then, for the interim analysis, given the change to the endpoint, is the number of patients still the same for the interim analysis?
Yeah, we're still planning for 144 patients for the interim analysis.
Got it. Got it. Are you, you're still shooting for a total of 75 sites, is that right?
The current plan is currently being revised, kind of live as we move ahead. Currently, we're working towards 40 sites in the U.S., 10 sites in Australia, and then, as I mentioned on the prepared remarks, with the additional capital that came in, we're also looking at going further ex-U.S. We're looking at Canada and Europe. There's some work right now just making, seeing what it's going to take in terms of timelines to add. I think it's important for us if we can expand internationally to increase the enrollment rate for the trial.
Excellent. Appreciate you taking the questions. Thank you.
Thanks, Thomas.
Our next question comes from Alex Nowak of Craig-Hallum Capital Group. Your line is open. One moment. We seem to have lost him from the queue. I apologize for the technical difficulty. For those that were in the queue, if you could please press star one again. All right, Mr. Nowak, your line is open.
Okay, hopefully, you can hear me this time. I'm not sure what you could hear, what you couldn't hear, Rick. You know, just with regards to the getting the clinical hold listed and searching for the new CRO, what were some of the new requirements that you had this time when searching for a CRO compared to when ReMEDy2 was initially started? It sounds like maybe some more international exposure was a new requirement, but anything in addition?
Alex, so that, you know, we're in a different environment today, so we're, you know, a year plus now past, you know, COVID. It was important for us to take the learnings we had previously, and then we were looking for a, a global CRO that could really help us with expanding outside of the U.S. as well, but also importantly, having a CRO that could that has recent experience with stroke trials. That, that was an important piece. The CRO we've selected has, you know, extensive experience with a number of more recent trials, better understanding, I'd say, of a good understanding of sites that could ideally be strong enrollers for this trial.
Okay, understood. Then maybe expand on the expected international uptake of DM199 in the clinical study versus domestic uptake. Why would international necessarily go faster? Just from your conversations, what are you thinking there?
Yeah, as we're looking at enrollment rates of past trials. What we did see, in particular in Europe, that the enrollment rates per site per month was a fair bit higher than what's been seen for U.S. trials. Part of that may be associated with, socialized healthcare. Based upon this, we think it'd be as important if we seriously can look at, at ex-U.S. expansion.
Okay, understood. do you need a, a specific number of patients in the U.S. versus OUS to meet that statistical analysis plan, or is that kind of getting baked in with the, you know, 40 sites U.S. and then, you know, a remainder amount OUS?
There, there's not. The, the, the context here also is the timelines to get sites set up in Europe, will be longer than, than they are in the U.S. In particular, for the interim analysis, we, we still think it, it's going to be driven by, by the U.S. sites, and then the, you know, other, ex-U.S. sites will be supplementary.
Okay, understood. Just a two-part question to, to end it out here is, you know, at, at first, I think the ReMEDy2 patients with ACE inhibitors would have been excluded, but will this be reversed based on the phase IC's findings in that fourth cohort? The second part of the question is, any other protocol changes to be aware of?
Yeah. If a patient was previously on an ACE inhibitor, there will be a 24-hour washout, so that the drug will effectively be out of the system. This is something actually is quite similar with the human urinary form of the protein in China. There's also a 24-hour washout. So all the patients will be included in the study. Just for context, again, in our phase II trial for stroke, we had about 10 patients that were previously on ACE inhibitor. Of the 46 total patients on drug, there were no instances of hypotensive events. Then we made a couple other protocol changes, learnings, I call it, from the hold.
Particular, we're gonna be starting off with a 15-minute slow infusion, so if there are signs of, you know, large drops in blood pressure, then the dosing will be over 3 hours instead of the prescribed 1 hour. So we think the, the, the hypotensive events are really the result of overwhelming the system very rapidly when the dosing first starts. So that's gonna be, again, an important aspect of it. We ran the phase IC trial, and in particular, the, the ACE cohort, that we just recently completed.
I think just to giving us, and also importantly, to give the clinical site some comfort here, that we, we feel that we've addressed the, the dosing, and, and matching the dosing to what we had previously had in our phase II trial, which was comparable to the, the drug exposure level with the human urinary form of the protein in China today.
Okay, makes sense. Well, appreciate the update and congrats on getting the clinical hold lifted.
Thanks, Alex.
Our next question comes from Francois Brisebois from Oppenheimer & Co. Your line is open.
Hi, this is Dan on for Frank. Thanks for taking my questions. In relation to the interim analysis, is the plan still to end the study if you see great efficacy in around the 140 patients? Any changes there?
Yeah. Similar to what we've discussed in the past. At the interim analysis, there's really three scenarios. The first is that, we'll, we'll stop the study for futility. If we're not seeing a positive drug effect, we'll stop the study for overwhelming efficacy, and that's based upon hitting a p-value of less than approximately 0.0072. Alternatively, we will continue this, this study, and we'll do a resampling size, where the total size will be somewhere between 240 and 728.
Great, thanks. That makes sense. Just a quick one. Regarding the phase IC data in hypertensive patients, had any of the dozen sites from before requested to see additional data in patients, or was this more of a proactive move as you target new sites?
Yeah, this was completely proactive. You know, first off, the FDA did not ask us to run this trial, so we did that proactively, and then none of the sites had asked. When we talked to sites, and we're talking about the hypotensive events, this, this is something that's manageable. By stopping the infusion, the blood pressure, in the three patients that we had that were the three serious adverse events, the blood pressure returned back to normal within minutes. This was just another, basically in the proactive way of providing additional comfort, in case in the future, any new sites that we talk to have any concerns about large drops in blood pressure.
Keeping in context here is that, you know, these neurologists, many of them every day are dealing with treating patients with tPA, and realizing that 5%-6% of patients on tPA, it causes a severe brain hemorrhage. We think that the drop in blood pressure is manageable, but we just want to make sure we're comfortable and also for the sites as well with the dosing.
Okay. Thanks for taking my questions.
Thank you, Dan.
Seeing no further questions in queue, I'll turn the call back over to our host for closing comments.
All right. Again, we'd like to thank everyone for joining us this morning and for your continued support. Our goal is to bring this important treatment to stroke patients as quickly as possible. We appreciate your interest in DiaMedica and your continued support. With that, this concludes our call today. Thank you.
The meeting has now concluded. Thank you for joining. Have a pleasant day.