Before we begin, I'd like to remind our audience that today's discussion may include forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, including statements regarding Entera Bio's clinical development programs, development plans, and the potential therapeutic and commercial profile of EB613. These statements are subject to risks and uncertainties that could cause actual results to differ materially. For a full discussion of these risks, we refer you to Entera Bio's filings with the U.S. Securities and Exchange Commission. In addition, today's discussion will include perspectives from participating physicians based on their clinical and research experience. These views are their own and do not constitute medical advice or regulatory guidance. With that, I'll turn it over to Miranda for some opening words.
Thank you, Yehuda, and welcome everyone to this roundtable discussion today where we are looking to put a spotlight on the treatment of osteoporosis, and specifically on the opportunity for our lead clinical candidate, EB613, which is being developed as the first and only anabolic or bone-forming tablet for patients with osteoporosis. For those of you less familiar with Entera, we're a biotechnology company that leverages on a proprietary platform that enables us to develop tablet or pill formats of peptides, and peptides are simply small therapeutic proteins. Our platform and science is focused on large, linear hydrophilic peptides specifically, and we have programs across PTH, GLP-1, glucagon for metabolic and fibrotic diseases, GLP-2 for mucosal diseases of the gastrointestinal tract, such as short bowel syndrome, and we also have a separate long-acting PTH program looking to provide a protein replacement therapy to patients with hypoparathyroidism.
Specifically, all of those pipeline programs are in preclinical development, and we expect to move the long-acting PTH for hypoparathyroidism and potentially the GLP-1 glucagon metabolic program into clinic in potentially 2027. Our mission with EB613 is really to provide potentially millions of women and men an opportunity to adequately protect their bone health. Osteoporosis to date has limitations in terms of the uptake, accessibility, and acceptability of the available anabolics. All three of which require either daily injections or a monthly injection at the clinician's office. Our goal with EB613 is actually to turn that equation on its head and democratize anabolic therapy so that with a simple tablet format with a well-known mechanism of action, we can actually provide an adequate anabolic to millions of patients, to the majority of patients that are eligible for this type of treatment.
Without further ado, we have set this up as a roundtable discussion with Dr. Felicia Cosman and Dr. Steve Goldstein. We're very privileged at Entera to have both of these key opinion leaders as our endocrinology and gynecology gurus. Their perspective is really important in terms of our understanding or gaining understanding of the clinician voice, but more important, and as important in our thesis is really the patient voice. Thank you so much, and I'll turn it over to Yehuda.
I think what we want to do now is move into a discussion around how osteoporosis is managed in practice today, where the key gaps exist, and maybe how the field will evolve over time. I thought maybe we could start by giving our audience some context about the current treatment paradigm. From your perspectives, Dr. Goldstein and Dr. Cosman, across clinical practice, research leadership, do you think there's still a meaningful treatment gap in osteoporosis today? What, in your view, are the primary drivers of such a gap? Maybe we'll start with you, Dr. Goldstein. As a key opinion leader in gynecology, it would be great to hear your thoughts on this.
Well, thank you, and thank you for having me. OB-GYNs, well at least here in the United States, really function as the primary care physician for bone health for our female patients who are going through the menopause transition and have arrived in menopause. We did a survey of a large group of doctors, gynecologists, recently, and I want to share with you some of the findings because they're really eye-opening. 92% were ordering DXA scans, 71% would treat patients to prevent osteoporosis, 82% were familiar with the FRAX model, 64% were treating patients with osteoporosis. When we asked them what drugs they used, more than 90% would utilize alendronate, known as Fosamax. More than 60% used risedronate, Actonel. Slightly more than 50% would use raloxifene, Evista, and slightly more than 50% were using denosumab as well, Prolia. Notice all of these are antiresorptives.
When it came to the anabolic agents, the injectables, only 12% of the gynecologists surveyed were using any injectables, yet 92% of them said they would treat if an oral anabolic agent were available to use. It was interesting that even 50% of those who don't currently treat said that they would consider treating if an oral anabolic were available. Clearly, there's a gap, and the other place that that gap exists is when patients do become severe enough now to need or want an anabolic agent, gynecologists by and large are referring them either to endocrinologists or rheumatologists. That step of having to refer is one more place where they can fall through the cracks, where they often don't end up in that endocrine or rheumatology office, or they have difficulty making the appointment.
They don't want to have an injectable to start with, even if they do get there. There's a tremendous disconnect here that I think this oral agent would fill that space.
I agree with everything that Steve said, and the proof of this is that we've got about two million fractures occurring every year due to osteoporosis, at least in part, and those fractures have consequences on both quality of life and on mortality. Our ultimate goal is to try to prevent these and to improve both quality of life and longevity.
To jump in and just increase on what Felicia just said, some of the statistics are eye-opening, and I go over this with all of my patients. Do you realize that in the United States, the survival in Stage 1 breast cancer is 99%? Most of my patients are really cognizant of their breast health. They go for their mammograms religiously, annually. They're scared to death of breast cancer. When I tell them that in this country, if a woman fractures a hip, 21% are dead within a year, 25% can end up in a nursing home. Yes, sure, they may be a little bit older, but it's said that a 50-year-old woman who doesn't already have cancer or heart disease has a life expectancy of 91.
Women are living so much longer than they did a generation or two ago that bone health and fracture prevention, in my mind, may be just as important, in fact, if not more important than breast health, especially if you are diligent about your breast imaging, because Stage 1 breast cancer is not the disease it was when some of us were growing up. Fractures are a huge, huge burden, both on financially, morbidity, and even mortality.
What we've done is really try to survey and understand who are the players and who's taking care of osteoporosis, and where do patients seek help. This is such a widely discussed clinical indication. It is synonymous with endocrinology and rheumatology, but it is really being treated at the gynecologist's office, at primary care, as well as at the specialist office. I would dare to say that the vast majority of patients are not being treated at the specialist office, or don't make it there. I think the other thing that we've noticed doing clinician surveys and kind of look at prescription trends is that this is a conservative group, but the prescriptions are quite consistent across each of the key stakeholders, and we kind of see this globally.
We've discussed this with Asian clinicians, and we've discussed this with clinicians across Europe, and the vast majority of women are being treated with bisphosphonates, and this was always the case even when Fosamax was not generic. I think there's something to be said for silent asymptomatic disease, that when a woman understands that she has low bone mineral density and consistent with that, her skeleton is deteriorating, the go-to in a silent disease where she may not have fractured yet but is clearly high risk and should be on anabolic, is to agree to get onto an oral agent. Most likely those women we know statistically stop taking bisphosphonates because of acid reflux and other side effects, and that's something that we're trying to close that gap as well.
I think what we need to talk about is education and empowering women to protect their bone health, but also providing something that they, when looking across to their clinician, may actually accept to take. At least that's our goal at Entera for EB613, to kind of change the conversation so a woman and hopefully a man will be able to protect their bone health and feel comfortable. I think part of our thesis also with EB613 is that we're not looking to reinvent the wheel. We're trying to provide a tablet of a drug that's been approved for 24 years that has a very well-characterized efficacy and safety dataset and also sequence data, and we'll get into that a bit more.
We've all touched on this at this point, anabolic therapies specifically. I think it would be good to give some context on how these are different from antiresorptive treatments and kind of what role they play in managing osteoporosis today. I also think it would kind of be good to understand a little bit about how they're used in clinical practice and maybe where adoption sits, barriers, sequencing, as part of the broader treatment pathway.
Sure. Anabolic treatments actually stimulate the growth of bone tissue in contrast to antiresorptives, which work primarily by slowing bone loss that's associated with bone remodeling, a process that goes on throughout our lives but it's accelerated after menopause. Anabolic medication produces larger and faster increases in bone density, and it can repair the microstructural defects in bone tissue that also contribute to fragility or risk of fracture in patients with osteoporosis. The anabolic agents that we currently have available are very effective. We have to either inject them daily or monthly. The need to inject, to go to a specific center to get this done for one of the medications, romosozumab, or the need to teach patients how to do this on their own every day. These are significant barriers to the use of these medications by many healthcare providers as well as by patients.
That's one of the reasons that we have such a big treatment gap in this group of individuals.
Certainly in clinical medicine, we are seeing a shift in the paradigm. For decades, we have treated people initially with antiresorptives to try to maintain their bone mass, and if they become severe enough, then we switch them to an anabolic. Now that we understand that a significant amount of bone is lost during the perimenopausal transition into menopause, and this is especially true for many women who never peaked their bone mass in their 30s where they should have. The concept of using an anabolic first to build bone back, build bone, and then switching to the antiresorptive to maintain the gain is sort of catching on and I think will only become more and more utilized in the future. There's a total shift here in the thinking and the paradigm, and I just see it increasing as time goes forward.
Well, we know that a history of fracture is the dominant predictor of more fracture risk, and all patients who've had a fracture need to be evaluated for osteoporosis and almost always need to be treated. In patients who haven't yet had a fracture, the bone density, expressed as a T-score, is the dominant predictor of future fracture risk. For these patients diagnosed either way, high or very high-risk patients, we prefer to use the more potent therapies, such as anabolic treatments, rather than just antiresorptive therapies that prevent further deterioration.
Right. I think that kind of brings us perfectly to talk a little bit about EB613. Given that based on everything you've said, the effective therapies, they essentially exist, but they're not widely enough used, where do you see the opportunity for something like EB613? In other words, how would an oral anabolic be different in terms of access and usability? Where could that also fit into the patient treatment paradigm that we talked about? Maybe we'll start off with you for this one, Dr. Cosman.
Well, we've always known that the best approach to treat osteoporosis is to try to repair the underlying bone defects. This is best done using anabolic therapy. This concept, though, has been very difficult to implement with the availability only of anabolic agents. An oral anabolic, EB613, would make it so much easier for doctors to prescribe anabolic therapy and for patients to take bone building therapy. We think this could have a big impact on the treatment gap in osteoporosis.
Yehuda
Right
I would just repeat what I said in the beginning. These statistics speak for themselves. 12% only of gynecologists are using any injectables, and all the anabolics right now are injectable. 92% said if they had an oral agent, they would utilize it. That's a huge jump, and it also would negate the necessity right now that exists for a referral to a specialist in endocrinology or rheumatology to get that anabolic, which the majority of patients, even if they were willing to accept an injectable, and many are not, fall through the cracks, have difficulty making that appointment. It's just one more barrier that creates that much more of the gap.
The recent feasibility study that we conducted with over 400 potential investigators across 22 countries, which included endocrinologists and gynecologists and other specialists, rheumatologists, something that really resonates with them is the fact that they know Forteo and they know what teriparatide is. They've had decades of experience or worked on clinical studies with Forteo. The conversation and credibility of them having a woman across the table and explaining kind of the safety and efficacy is very different from, for example, explaining the potential safety profile of a novel drug. Who's been at the forefront of those clinical studies of anabolics is Felicia, and the whole sequencing story is how do you turn the table around and get younger women to protect their bones and empower their bone health when in a silent, asymptomatic disease where they don't feel their bones degrading?
You're asking them to, at the age of 53 or 55 or 56, without having sustained a fracture, but certainly is a candidate for an anabolic drug, take a daily injection or come in for in-office visits every month. What's been your experience with that?
Well, I think the concept of treatment sequencing with an anabolic-first approach is one that's evolved over the last two decades, in part because we see how much more effective the anabolic agents are when you give them as initial therapy. The idea is to try to diagnose a woman with osteoporosis and then fix the osteoporosis, try to get her out of the osteoporosis range, achieving a BMD level that is associated with minimal or modest risk of future fracture, and building up the bone structure in addition to the mass, and then sequencing her to a treatment that will help maintain that. There are a variety of different options that can be utilized. This approach can help prevent so many of the fractures that are otherwise occurring because we're not being proactive about treating patients when they're diagnosed with osteoporosis.
I think now is the perfect time to maybe talk a little bit about EB613's data. Dr. Cosman, from a clinical standpoint, when you look at EB613's phase II data, how do you see it in the context of what you would expect from therapies in this class?
Well, our phase II data show several really important things. First, EB613 stimulates bone formation, so it's anabolic. That's really the definition of anabolic. At the same time, it suppresses bone breakdown. It illustrates a dual mechanism of action at the tissue level. The bone density increments that we've seen at six months in the phase II study are comparable to the BMD increments that we see with injectable PTH at both hip and spine sites. We know how effective this early BMD change is at improving bone strength and reducing fracture risk quickly.
Now, zooming out a little, how do you look at the broader pipeline in osteoporosis evolving? For example, what are the other approaches that you're both watching, and how would something like EB613 be positioned in that landscape? Maybe for this one, we'll start with you, Dr. Goldstein. Kind of looking at the broader pipeline, what are your views on that?
Well, Felicia already alluded to the fact that it's sometimes difficult to get women who are early in the menopausal transition to take any medication for a silent disease. What has, in my practice, been the motivating factor has been a T-score on their DXA scan that scares them. Whether that's not even yet osteoporotic, if they've got a FRAX number that's scary, these patients sort of wake up and want to do something about it. The ability to build bone with an anabolic agent that also has some antiresorptive properties like EB613 would be much more acceptable to most of my patients in that younger, previously silent group who are now becoming much more attuned to bone and bone health. The National Osteoporosis Foundation, 43-year-old support group, four years ago changed its name to BHOF, Bone Health & Osteoporosis Foundation.
I think that the public awareness of bone health being a huge issue as the population ages is just taking off geometrically and will do so more and more as we go forward.
Great. Dr. Cosman, I know you already touched on this a little bit earlier, but is there anything you want to add before we move on?
Yeah. I wanted to say that there are some new osteoporosis medications that are currently in development, and I'm very excited about these. Some of these products are going to target the very highest risk patients with recent major fractures or multiple fractures or extremely low BMD. There's a huge need for these additional therapies to come out. Our hope for EB613 is different. With EB613, we want to approach, as Steve has said, and I've said, and Miranda, this broader category of patients who have osteoporosis but are not yet that severe. Maybe they've had a minor fracture or more remote fracture, T-scores that are in the osteoporosis range but not terribly low, including younger patients that are often not offered anabolic therapy.
We'd like to offer EB613 to this much broader group of patients as an easy, quick fix to rapidly improve BMD, restore structure, and reduce fracture risk, and improve associated quality of life.
I think now maybe it's a good chance to look a little bit ahead and talk a little bit about EB613 and what you think it would need to demonstrate in order to gain acceptance among all these clinicians and patients.
Well, I think that the acceptance of EB613 is going to be pretty easy because this is something that many physicians are used to prescribing and patients are taking, and it doesn't require as much bureaucracy, and cost, and effort to get patients on a single daily pill versus an injectable therapy. It's going to bypass a lot of the resistance that we've seen with the current agents that are out there. We know that all anabolic therapies need to be followed by use of an antiresorptive drug. If you take an anabolic agent by itself and then you don't do anything afterwards, you're going to end up losing the gains that you achieved on that medication. We're always talking about a treatment sequence, and I think we have a number of different antiresorptive therapies that would be appropriate after a course of EB613.
The idea is to use EB613 upfront for these patients with new diagnoses of osteoporosis to rapidly repair and reduce risk, and then to maintain the benefits that we achieve with EB613.
Right. Dr. Goldstein, now turning back to you. Can you talk a little bit about the perspective of gynecologists on what EB613 would need to show?
I couldn't agree more with what Felicia just said. The paradigm until now, and still among almost all of the gynecologists that I lecture to, has been to start with antiresorptives in an attempt to stave off further bone loss. If patients get severe enough, they refer, and then they're put on an anabolic. It totally makes absolute sense that those patients with low bone mass who are at risk should build bone back with an anabolic and then maintain the gain, as I said very early in this session, with an antiresorptive. In terms of accessibility, the fact that it's oral can be administered by that same healthcare provider who's made the diagnosis, who has a relationship with the patient, who's not a super specialist and doesn't require a referral and going somewhere else on a different day. From access, that's access with a capital A.
That's very helpful. I think we've highlighted really well the challenges in the current treatment landscape and the potential opportunity for an oral anabolic like EB613 now. I think this is a good point to maybe turn it back to Miranda to give us some closing words.
Yeah. Thank you so much, Yehuda. Thank you so much, Felicia and Steve. I think you know our journey that we hope to kind of move forward into this phase III program imminently is to try to address this white space. I think we've now designed this phase III to answer a few questions, which include, how does EB613 do as a monotherapy, right, for up to 24 months or 12 months, and how does it perform when used in sequence as it should be with an anti-resorptive drug? I think our goal with this program hasn't wavered all these years, which is to try to ease patients and help provide a viable anabolic in a format that they might actually agree to take to protect their bone health and deter fractures and hopefully not get to a place where these comorbidities and potential mortality exist.
Anyway, thank you so much for your time today. Hopefully, this can be a series of round tables that we have on different topics at Entera, and thank you so much, Yehuda, for moderating this discussion. Thank you.
Thanks, Miranda, and thank you again to both of our panelists for a very thoughtful and insightful discussion. We appreciate everyone who took the time to join us today. A recording of this event will be available shortly after the event concludes. Thank you very much.