Good day, ladies and gentlemen, and thank you for standing by. Welcome to the Heron Therapeutics Q2 2022 earnings conference. As a reminder, this conference is being recorded. Now I would like to turn the call over to David Szekeres, Executive Vice President, Chief Operating Officer. Please proceed.
Good afternoon, everyone, and thank you for joining us. With me today from Heron are Barry Quart, Chief Executive Officer and Chairman, and John Poyhonen, President and Chief Commercial Officer. For those of you participating via conference call, the slides are made available via webcast and can also be accessed by going to the investor relations page of our website following conclusion of today's call. Before we begin, I would like to remind you that this call will contain forward-looking statements concerning Heron's future expectations, plans, prospects, corporate strategy, and performance, which constitute forward-looking statements for the purposes of the Safe Harbor provision under the Private Securities Litigation Reform Act of 1995. Actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors, including those discussed in our filings with the SEC.
Any forward-looking statements present our views only as of the date of this webcast and should not be relied upon as representing our views as of any subsequent date. We specifically disclaim any obligations to update such statements. Now I'll turn the call over to Barry.
Thank you, David. Welcome, everyone, and thank you for joining us. Q2 has been extremely productive on a number of fronts. John will discuss details regarding our two commercial franchises, both of which showed good growth in Q2 , beating consensus estimates. During Q2 , we continued to prosecute our NDA for HTX-019 for postoperative nausea and vomiting, which has the potential to be many times larger than our CINV business. Interactions with the FDA remain on track for the September 17 PDUFA date. We've also made excellent progress completing enrollment in the four clinical trials with ZYNRELEF planned for inclusion in what we call sNDA number two, designed to further expand the indications for ZYNRELEF. This sNDA is planned for late this year.
Based on our agreement with the FDA, sNDA two should provide the basis for expanding the indication statement to cover essentially all 14 million target procedures. I'll now turn the call over to John.
Thank you, Barry. I'm excited to share our Q2 commercial results. We continue to make significant progress with the ZYNRELEF launch. During my presentation, I'll start with a number of updates on key performance metrics related to this progress. I'll finish with an update on our outstanding Q2 commercial results with our oncology care business. Q2 net sales were $2.5 million, which was a 140% increase over the prior quarter. We currently expect Q3 ZYNRELEF net product sales to increase in the range of 40%-50% over the prior quarter. The level of ZYNRELEF inventory in the distribution channel has been a topic of great interest during the past couple of quarters. We previously described in earnings calls; there was excess initial stocking inventory in the distribution channel.
In order to better understand the inventory level in the distribution channel, we've been reporting the ex-factory reorder rate based on demand unit volume for both SKUs. Ultimately, our goal is to have ex-factory orders at 100% of demand unit volume, meaning the distribution channel is replenishing their inventory for every unit sold to a hospital or ASC. As you can see in the table provided in slide six, we continue to make meaningful progress in burning through the inventory based on increases in ZYNRELEF demand unit sales. Results of the Q3 through August 3 indicate we have reached our goal of stabilizing inventory levels at the distribution centers with channel orders mirroring the demand unit results.
The 400 mg SKU reorder rate is 99% of demand unit volume, and the 200 mg SKU reorder rate is 105%. This should simplify the modeling of future ZYNRELEF net sales at levels consistent with ZYNRELEF demand unit volume. ZYNRELEF demand unit volume grew by 47% in the Q2 over the Q3 . Thus far in Q3, ZYNRELEF demand units are ahead of the same period in Q2, with an expectation of achieving 40%-50% growth in Q3. Next, I'll summarize the ZYNRELEF launch highlights to date by sharing our scorecard of leading indicators. During our first year of launch, we've continued a strong cadence of adding unique new ordering accounts, which have been growing at about 50 accounts per month.
We're also very encouraged by the increases in account reorder rates that have grown from 50% in the first three months of launch to 84% in the first year of launch. We continue to gain formulary approvals for ZYNRELEF in targeted hospitals with a run rate of 30 formulary approvals per month since the beginning of our launch. Importantly, we're also seeing excellent growth with integrated delivery networks, or IDNs, adding ZYNRELEF to formulary. We believe gaining IDN support is a critical component of potential therapeutic interchanges, with our key accounts substituting ZYNRELEF for EXPAREL for indicated procedures in the future. Slide nine benchmarks the number of unique ordering accounts during the first year of launch based on Symphony Health data. We continue to rapidly add new accounts ordering ZYNRELEF, with 602 ordering accounts in the first 12 months of launch.
This represents an increase of 33% from the 451 level in the first nine months of launch. In addition, ZYNRELEF, the 84 accounts reordering during the first year represents the greatest reorder percentage of all four products benchmarked in this analysis. We believe this growing reorder rate is an excellent indication of the strong real-world experience that surgeons are having with their patients. While the initial ZYNRELEF results are strong, aggressive expansion and product usage in ordering accounts is a key priority in 2022. New formulary approvals represent our new business pipeline. This slide highlights the continued rapid progress that ZYNRELEF is making with formulary approvals. At the end of April, we reported 319 formulary approvals.
This number has continued to grow at about 30 new formulary approvals per month since the launch to 384 total approvals through the end of July. In those accounts actually making P&T decisions, over 90% of hospital P&T committees continue to add ZYNRELEF to formulary. Importantly, an estimated 68% of our formulary approvals are for unrestricted usage of ZYNRELEF. Those accounts with restricted usage typically limit the procedures for their internal trial evaluations of the product. Many institutions cut back on P&T meetings over the summer to account for vacation schedules. The remainder of the year will remain busy with over 80 additional P&T committees scheduled to review ZYNRELEF before the end of the year. New formulary approvals help us establish a critical pipeline for new ZYNRELEF business and remain a key priority for the commercial team.
Next, I wanted to provide an update on a key top-down strategy of targeting integrated delivery networks, or IDNs, to create new system-wide opportunities for therapeutic interchange from EXPAREL to ZYNRELEF for indicated procedures. Thus far, 57 IDNs have added ZYNRELEF to their formularies, with 33% of the approvals for unrestricted use. In addition, these 57 IDNs account for over 1 million annual ZYNRELEF indicated procedures, representing a potential ZYNRELEF net sales opportunity of $200 million annually if we converted all indicated procedures. Of course, no company ever gets 100% share, but the potential with our existing indicated procedures creates a strong opportunity for meaningful ZYNRELEF sales growth. In addition, our IDN formulary expansion now covers $135 million of annual EXPAREL sales. We also have 15 IDNs at various stages of evaluating switching from EXPAREL to ZYNRELEF for indicated procedures.
Now let's drill down on the 15 IDNs that are interested in potential therapeutic interchange. With ZYNRELEF's existing expanded label indication, it's not surprising that IDNs are looking to save $ millions for a product with demonstrated superior clinical results to the standard of care bupivacaine. We're excited to be partnering with both pharmacy and physicians to drive their internal evaluations with ZYNRELEF. Of the 15 IDNs who are interested, 11 have already initiated their internal trials with ZYNRELEF. Initial feedback on their trials continues to be very positive across a variety of surgical procedures. While moving a large IDN certainly takes some time, the first IDN to make their therapeutic interchange decision was positive at the end of the Q2 , and they are now switching to ZYNRELEF. This quarter, we're introducing a new metric to help evaluate the impact we're making with IDNs.
Let's start by focusing on the 15 IDNs evaluating therapeutic interchange. During the H1 of 2022, ZYNRELEF demand units grew by 290% compared to the H2 of 2021. Clearly, our expanded label indication is fueling this growth. Additional new metrics to measure is branded market share. This is simply ZYNRELEF units divided by the total number of EXPAREL units plus ZYNRELEF units. Overall, in the 57 IDNs with formulary approval, we have demonstrated solid branded market share growth. It's important to keep in mind adding new IDNs actually lowers our share since we're just beginning to get new ZYNRELEF business in these accounts.
For example, last quarter, we reported 46 IDNs with formulary approvals, which has now grown to 57 IDNs. Finally, we have also provided ZYNRELEF's branded unit market share for the top 5 IDN share accounts out of the 15 IDNs evaluating therapeutic interchange from EXPAREL to ZYNRELEF. As this table demonstrates, our branded market share can grow very quickly with a high of 41% for Q2. The CMS approval of passthrough status for separate reimbursement of ZYNRELEF for Medicare patients in the hospital outpatient setting of care is a game changer for us. As a reminder, ZYNRELEF is the only local anesthetic separately reimbursed in the hospital outpatient setting for the next three years. This important approval builds on our existing reimbursement strengths already in place. CMS separate reimbursement for ZYNRELEF in the ASC setting of care effective January 1, 2022 .
Separate reimbursement outside of the surgical bundle payment for ZYNRELEF, with more than 123 million covered lives in ASC, and in some cases, it's also reimbursed separately in the hospital outpatient setting. A key component of our pricing strategy is even without separate reimbursement, our lower acquisition cost benefits customers across all settings of care where the drug may be paid for under the surgical bundle payment. ZYNRELEF's value proposition continues to be a critical driver of new business and expansion in the market. Switching to ZYNRELEF provides a cost savings of 25%-32% based on wholesale acquisition cost, and a savings of 42%-48% based on our 340B price offering compared to EXPAREL. This provides a huge financial incentive for customers to switch to ZYNRELEF.
From a reimbursement perspective, using ZYNRELEF is profitable with Medicare patients in the hospital outpatient setting and ASC setting of care. In these challenging financial times, 340B accounts can experience financial benefit of over $429 per patient by using ZYNRELEF rather than EXPAREL. Based on these economic benefits, it's not surprising that large IDNs are now conducting therapeutic interchange evaluations. Our key priorities for ZYNRELEF in 2022 remain the same from a commercial perspective. Our top priority is to leverage the new label indications for faster growth. This will be accomplished by expanding existing surgeon usage into new procedures. Our second priority is increase usage within ordering accounts by increasing the number of surgeons routinely using ZYNRELEF.
Many accounts initially evaluated ZYNRELEF with only two or three surgeons based on the excellent outcomes with their patients who are actively using their experience to support expanded usage of ZYNRELEF with their colleagues. Our third priority is to continue to gain formulary approvals in new targeted IDNs and hospitals. Increased access in our pipeline is a key opportunity for growth and therapeutic interchange. Finally, we continue to maximize our separate reimbursement outside of the surgical bundle payment for ZYNRELEF. In summary, we've already made strong progress with a number of leading indicators, which gives us confidence that 2022 will be a year of significant growth for ZYNRELEF. Now I'd like to shift gears and review the Q2 results for our oncology care franchise.
During the Q2 , our oncology care team did an outstanding job of growing our CINV portfolio net sales by 12% over the prior year. This growth was driven by 11% increase of CINVANTI and an 18% increase in SUSTOL over the prior quarter. Overall, CINVANTI unit demand units increased by nearly 11% compared to the prior quarter, with a strong 11% increase in the hospital setting of care, which was our third highest demand unit in a quarter ever in the hospital segment. CINVANTI demand units also remain strong in the clinic setting of care with a 10% increase over the prior quarter. We have a number of ongoing discussions to bring former CINVANTI customers back following the end of the generic fosaprepitant arbitrage period. The outlook for our CINV products remains positive based on continued improving reimbursement tailwinds over the past year.
As shown in the table below on slide 21, both CINVANTI and SUSTOL are much more favorable, in a much more favorable reimbursement position versus the competition than the same time last year, with generic fosaprepitant down to $27 and IV Emend down to $458 based on ASP + 4% reimbursement. In addition, the elimination of separate reimbursement for generic fosaprepitant in the hospital outpatient segment effective January 1 , 2022 , made the CINVANTI value proposition much more attractive this year. Our full year 2022 CINV net sales guidance has been increased to a range of $93 million-$95 million, representing an 11%-14% increase over the prior year.
In addition, we expect demand units in the H2 of 2022 to be higher compared to the prior year, which will be partially offset by lower net sales for both products. Finally, the new CMS guidelines published in July indicated that effective January 1, 2023, that reimbursement for 340B accounts will increase to ASP + 6% compared to the current rate of ASP - 22.5%. With the greatest portion of our CINVANTI hospital demand unit sales in 340B accounts, we believe this new opportunity will help us increase unit sales in the Q4 and in 2023. That completes my prepared remarks, and I'll now turn the call back over to Barry.
Thank you, John. In June, we announced a restructuring which included a 34% reduction in head count by year-end. Between the restructuring, improvements in gross margin from the move to large scale manufacturing and other cost-cutting measures, we expect to achieve reductions of over $50 million in annual operating expenses in 2023. These reductions in burn, coupled with the private placement financing announced this morning, are projected to provide a cash runway through 2024 and to allow us to become cash flow positive in 2024. As of June 30, 2022, Heron had cash equivalents and short-term investments of $83.5 million. Adjusting for net proceeds of $75.2 million from our August 2022 private placement, Heron had cash equivalents and short-term investments of $158.7 million. Q2 burn was $28.4 million.
While burn will increase in Q3 due to the restructuring, Q4 burn minus one-time expenses is projected to be approximately $21 million, with significant further reductions going into 2023. I'd like to take a minute to review a few of the key accomplishments and catalysts for the company. As we have discussed in Q2 , ZYNRELEF demand units increased by 47% compared to Q1 . Our contract manufacturer has successfully validated large scale manufacturing for ZYNRELEF, and we've completed enrollment in the clinical studies needed to submit sNDA two to further expand the indications for ZYNRELEF. One area where we did not meet our goal was to complete a business development deal in Q2 . Unfortunately, the timing of business development deals are difficult to predict, but we are still laser-focused on getting one or more such deals done this year.
For each major territory, we have at least one regional company and at least one multinational in active discussions. For the oncology care franchise, we saw good growth in sales resulting in our raising full year 2022 guidance to $93 million-$95 million. As John mentioned, we are very excited by the recent change in CMS reimbursement for 340B hospitals, which we believe makes CINVANTI an extremely attractive opportunity for these hospitals to generate additional revenue. Slides 24 and 25 contain important safety information for ZYNRELEF. These slides will be available on our website. With that, we're ready for questions. Operator?
At this time, I would like to remind everyone in order to ask a question, press star then the number one on your telephone keypad. We'll pause for just a moment to compile the Q&A roster. Your first question comes from the line of Brandon Folkes with Cantor Fitzgerald. Your line is open.
Hi. Thanks for taking my questions and congratulations on all the progress. Now maybe just two from me. Can you just talk about some of the moving pieces that will drive cash flow positivity by 2024 as we model that? And then secondly, when you look at the 15 IDNs evaluating switching at $42 million of EXPAREL business, what is the hurdle they're using to evaluate the product? Is it just surgeon and patient experience? And then should they decide to switch, how quickly does that revenue take to shift? Is it a gradual switch, or is it something that sort of as of a certain date they will switch all their business? Thank you.
Thanks, Brandon. You know, I'll have John answer the second question first 'cause it certainly leads into the answer to the first question.
Good morning, Brandon. Regarding your question on the 15 IDNs, generally, there is an evaluation period that will be set based on specific surgical procedures. What we see frequently is they'll start it off in a lower extremity arthroplasty like TKA or total hip replacement rather. In addition, they'll look at generally something in a small to medium abdominal surgery like bariatric surgery. What they're really looking at is key parameters. They'll look at pain reduction over three days. They'll look at the impact on opioid usage, and importantly, they'll also look at time to discharge.
Those are generally there may be individual differences amongst each of the IDNs, but those are what are most typically reviewed. With respect to time to change, you know, each of these systems is a bit different and some move more rapidly than others. I think you can see from the report that we provided today on slide number 13, where actually, you know, there's one IDN number one that didn't have any market share in the Q3 or Q4 of last year but went up to 14% then 41% in the Q2 . They can move pretty quickly once they start making that type of commitment. But you know, it's certainly a situation where we would never expect to get 100% of the EXPAREL business.
I think that would be, you know, fairly rare, but we do believe that we can get a very significant portion of it. Hopefully that answered your question.
Thanks, John. Yeah, going back to the moving parts associated with becoming cash flow positive. You know, obviously it is, you know, partly associated with decreasing burn. As mentioned, we did a restructuring in June, reducing the organization by approximately 34%, and taking significant costs out of our base burn. We're always continuing to look at ways to be more efficient in that regard. Also, an important contributor here is increasing margin. As we've discussed previously, Heron has invested a significant amount of money in moving to large scale manufacturing for CINVANTI as well as for ZYNRELEF. We have accomplished that now for ZYNRELEF, and we are almost to the end of that process for CINVANTI.
Our anticipation is that we will start being able to sell product from large scale manufacturing of CINVANTI in the Q4 . That improves our margin substantially. Obviously, that just drops to the bottom line with increasing sales of units. Also, you know, over the course of the next two years, we anticipate launching HTX-019 as we bring that product to market. That has a very exciting opportunity in terms of going after approximately 500,000 units of oral aprepitant that's currently being used for PONV. An IV push product like HTX-019 is certainly set to take a significant portion of that oral market and then expand beyond that.
As we've discussed in previous forums, but aprepitant has been demonstrated to be certainly one of the most effective molecules for PONV. With a convenient, easy to use, easy to administer product like HTX-019, we believe that this will become an extremely important component of prophylaxis for PONV. Can we go on to the next question?
Your next question comes from the line of Josh Schimmer with Evercore. Your line is open.
Great. Thanks for taking the questions. I have a few, if I may, but maybe we can start with the ZYNRELEF launch is about 80% below where EXPAREL was at this point in time. Maybe you can clearly indicate why you think that's the case and whether any specific measures or changes to strategy have been put in place to address that.
Yeah. Thanks, Josh. Good question. You know, as you know, the first two quarters of launch were significantly hampered by the very restricted label. We, you know, unfortunately, misread the market in terms of surgeons' willingness to use the product beyond the limited label. Although market research had indicated that the label would not be an impediment to launching the product, it turned out to be a significant impediment, in fact. The first two quarters, obviously, the launch was much slower than anticipated.
Obviously, there's the impact of COVID, particularly in terms of the Omicron surge, early this year, right at the time we were launching the expanded label, and the broadening of covered procedures from around 2 million to over 7 million. I think we've now started to hit our stride in terms of moving the product into obviously new institutions, starting to see the movement of IDNs to start switching versus EXPAREL based on both the clinical data that we have, showing superiority of ZYNRELEF to bupivacaine, as well as the economics associated with ZYNRELEF. Absolutely it has been much slower launch than we would have projected.
A lot of factors involved, but I think that we're now starting to turn the corner on many of the issues that have hampered us. As noted, we anticipate submitting the sNDA two to further expand the indication statement near the end of the year. With the approval of that sometime next year, we'll finally be in a position to go after the entire market. I think we'll start to see between now and then continued good growth.
Got it. I mean, given how obvious the narrow label was, why do you think your market research missed something as obvious as that factor turned out to be?
Well, you know, I'll let John give some color on this. You know, the surgeons that we interviewed for the market research, which was a large number, indicated that they were comfortable with use of a local anesthetic. They understood, you know, the pros and cons of using local anesthetics, and the fact that the label specified three specific procedures wasn't going to be an impediment. One factor that we didn't take into account early on was that we were actually reinforcing the limited aspect of the label, because we would not permit our sales reps to stay in the OR if the surgeon was using the product in an off-label.
We really reinforced the concept that the product needed to be only used in those three indicated procedures. John, I don't know if you have anything else to add.
No, I think that you summarized it very well, Barry. The one thing I would add just based on Josh's initial question, and if you know you really look at just the past two quarters, which is how we're evaluating the launch because of the very limited label that we had at launch. During the first two quarters of launch, EXPAREL sold just over 19,000 units, and we sold, you know, if you start at January first, over 21,000. So, you know, we think we're tracking much more favorably even with the first expansion of the label, and we think that'll continue to expand as we get sNDA two approved.
Got it. Have another couple of questions. One is on the formulary approvals. I think based on what you've indicated in the past, looks like there's still maybe 700 formularies left to go. Where are you in terms of your initial expectations for formulary adoption, and what progress do you expect to make for the large number of remaining formularies where you've not been yet approved?
Yeah, that's a great question, Josh. The first thing I would mention is that the way that we evaluate an IDN formulary approval is even if an IDN has 10 or 15 hospital accounts, in some of those IDNs, it only takes the system level approval to get it, and you may get the entire number of hospitals within that IDN with just one single approval. We're probably undercounting it a bit. You know, certainly we're getting a great success rate that we're seeing in accounts that are evaluating ZYNRELEF with over 90% approval rating. We would like to see it go faster. I think if you look at the number of ordering accounts that we have, I think we're on track where we thought we would be as far as ordering accounts.
We just need to increase our usage at those accounts. As I talked about in my comments, you know, that's really based on getting surgeons to use ZYNRELEF in additional surgical procedures based on our new label indication. It's also getting more surgeons within the existing accounts. You know, we believe that, you know, of the 600 accounts that we have or have tried ZYNRELEF and 84% already ordering, we've got a very good base of business. We just need to increase usage at those accounts right now, and we'll continue to expand the formulary approvals as we go forward.
What percent of the addressable market do you have formulary coverage for now or a clear line of sight to coverage by end of year?
If you take a look at the percentage initially, we were targeting based on the reps that we had in the field, what looked to be about 65% of the overall market. Right now, I would say that you know based on the formulary coverage that we've got we've probably got somewhere around a 1/3 of that. We've probably got you know let's say 20%-25% of the opportunity, Josh. By the end of the year, you know we would hope to push that over 30%.
That sounds like still a fairly long way to go.
Well, it's certainly, you know, as far as getting everything opened up, but if you take a look at the number of ordering accounts and the type of business that we can generate from those ordering accounts, you know, we think that there'll be significant growth as we move forward. You know, hospitals tend to move slowly and, you know, certainly this is no different than any other hospital launch. I think the hospitals that are using ZYNRELEF are getting great results in it, and that's been demonstrated by the growth that we've seen in units quarter-over-quarter as well as the reorder rate from the hospitals.
Got it. Last question and thank you for indulging so many. As we think about the HTX-019 PONV opportunity, maybe you can help frame that for us relative to SUSTOL and CINVANTI and ZYNRELEF. You know, what market dynamics and features might make this launch more CINVANTI-like than SUSTOL-like or ZYNRELEF-like?
John, you wanna take that?
Sure. It's a great question, and from our perspective, we think that it will be much more CINVANTI-like, really because if you look at it, number one, ZYNRELEF is a high touch product from a selling procedure where we have to be in to in-service the surgeon as well as the support staff on how to prep the product and then how to use it. Everyone in the operating room knows how to use a 30-second IV push.
We just had an advisory board last weekend and talked to orthopedic surgeons about HTX-019, and there was a very high interest because what they're really focused on is how do we move patients out of the PACU quicker and get them to discharge with so much of the surgical procedures moving to outpatient. Really, HTX-019 is the perfect drug to do that because it's got the best clinical profile as far as reducing vomiting and emesis of any product on the marketplace.
You know, from our perspective, we think that we've got the right pricing strategy to come out to gain rapid access in the marketplace as well as rapid uptake since the in-service perspective will be much, much easier than what we've seen with ZYNRELEF.
Great. Thanks very much.
Certainly.
Your next question comes from the line of Boris Peaker with Cowen. Your line is open.
Great. Thanks for taking my question. This is Nick on for Boris. I just have a few questions. The first is, for the IDNs that are evaluating the therapeutic interchange, around how long will those individual trials take? I know that you mentioned that they could be in like a couple of different surgeries. Do you know like how long, how many patients, for example, they would need and how many surgeries they would need in each indication? Also, on top of that, could the hospital or an IDN decide to only have therapeutic interchange for one surgery, for example, or would it have to be a total therapeutic interchange?
John, you wanna take that?
Sure. Really they're all over the board on the length of time. Nick, as you've suggested, it really depends on the number of surgical procedures that they'll be evaluating. Generally there'll be a bony model and a soft tissue in accounts that are looking at it, and it depends on the number of accounts or hospitals within an IDN that may be conducting it. As far as the size, you know, we've seen accounts looking at, you know, several hundred to make their decision. We've seen some that are, you know, more in the 50 of each range. It really depends on an account by account basis.
It's tough to predict, but what I can say is that, you know, during the Q2 we had the first IDN that, you know, really started their evaluation, I would say probably in March. By the end of the Q2 they had made their decision, and it was positive for ZYNRELEF. They are actually looking to switch ZYNRELEF for indicated procedures. If you go through that type of process, I think most accounts will look to use ZYNRELEF more broadly than a single surgical procedure. Really that's why the expanded label is so important in helping us drive the strategy.
Great. Thank you. Just a follow-up on that. What would it take for the rest of the IDNs that currently are not actually evaluating therapeutic interchange, but what would it take for them to start evaluating that? Is that something that you would have to do on your end, or is it more so just takes time for them?
Based on the feedback that we're hearing, some of them just wanna get a bit more experience with ZYNRELEF before they look at moving that aggressively. I think the other thing that I would point out is if you look at some of the accounts in that 57 IDNs, we already have 100% market share based on branded products because either they never used EXPAREL or had already quit using it because of, you know, the overpromising they made on duration of therapy. You know, I think really it has everything to do with experience and getting good feedback from surgeons and their patients to expand that to a much broader label or a much broader group rather of IDNs considering that.
Great. Thank you very much.
Certainly.
Your next question comes from the line of Serge Belanger with Needham & Company. Your line is open.
Hi, good morning. Couple questions on ZYNRELEF and then a couple on the upcoming PONV PDUFA. First on ZYNRELEF, I guess for John. You talked about unit demand increasing to just short of 13,000 units in the Q2 . Can you maybe break that down between the ASC and hospital segments?
I'm wondering if at this point, you're displacing EXPAREL or really taking over some of the generic bupivacaine share. Then I guess secondly, you also discussed expectations that ZYNRELEF sales would be up 40%-50% quarter-over-quarter in the Q3 . Just maybe talk about the assumptions and maybe what you've seen so far in the first five, six weeks of the Q3 . Thanks.
Okay. The first question on where is the business coming from. If you look at it right now, it's been about 65% coming from hospitals, 35% from ASCs. That would be from an ordering account perspective. If you convert that into units, it's about 80% hospital, 20% ASCs. I think that was your first question, where's the business coming from? It's really coming from both EXPAREL and bupivacaine. As I mentioned in my last response, there were certainly some accounts that had never used EXPAREL or had stopped using it, where we've got a 100% share of the branded product there.
What we're especially excited about is we continue to see good traction against the bupivacaine and the generic cocktails based on the superior clinical results. We've got a couple of accounts that have been doing very extensive evaluations of this with several hundred patients that they've been doing all on their own, and they'll be looking to publish in the H2 of the year, which we think will be a great benefit for us as we go forward. Finally, on the 40%-50% growth, you know, there has been some softness in the overall elective surgery market during 2022. Certainly we continue to see good growth as we enter Q3 with ZYNRELEF and just put together back-to-back, you know, our two strongest weeks ever.
You know, looking forward to continuing that throughout the Q3 and the remainder of the year.
Okay. On the upcoming PONV product PDUFA, I don't know if you've mentioned this in the past, but did the NDA review require a site inspection, and has that inspection taken place? Secondly, what kind of additional marketing spend should we expect with this launch? Just thinking of how that could impact OpEx progression in 2023.
Yeah. Thanks, Serge. So, this product, which is a smaller vial of CINVANTI, which as you know, we've made and sold over 2 million vials of CINVANTI to date, did not require an inspection. We are in the, you know, the very end stage here of the review cycle. There's no indication that that situation will change. The manufacturer for HTX-019 is also a manufacturer for CINVANTI. So I think there's a very significant track record of that manufacturer being able to make the product certainly a larger vial size of it.
You know, in terms of sales expenses and expansion, really excellent question because it leads to a point that we should have highlighted when the question was asked previously, and that is, one of the great things about HTX-019 is it utilizes our resources that are already focused in the acute care setting. We don't anticipate significant additional investment is necessary because we already have the reps out, you know, in the field. They're already talking to surgeons and anesthesiologists, exactly the target audience for HTX-019. It's a perfect segue for them to add this into the bag, as they say, without the significant additional cost and without the need for, you know, any substantial increases in personnel.
Very economical, and really an exciting product when one looks at the published data on how effective the molecule can be for PONV. As John mentioned, in today's world, the biggest issue is getting patients out the door because there's not sufficient staff for patients to be kept in the PACU. We're seeing, you know, surgeries not being scheduled into the afternoon as they might otherwise be because there's concern about not having staff for recovery. If you can use an easy-to-use, safe product that helps you get patients out the door in the ASC setting, for example, we think this is gonna be extremely attractive.
Just one more, I guess. Is this a product that's gonna require kind of the same approval process via P&T formularies for adoption?
Yeah, certainly as a hospital product, it would still need to go to formulary committee, you know, in the hospital setting. Again, however, the molecule itself is very well known. It's simply you know a more convenient approach towards administration of a product that's already being used in over 500,000 oral pills for PONV. You know, we're certainly gonna press very hard to get that acceptance from P&T committees as quickly as possible in terms of the launch. It probably has the most similarities to CINVANTI in that regard as well, which certainly required formulary approval. You know, if you remember back when we launched that product, that process went relatively smoothly.
You know, obviously we took a large portion of the Emend market within the first two years of launch.
Thanks for taking the questions.
Yeah, certainly.
There are no further questions at this time. I will now turn the call back over to Barry for closing remarks.
Thank you. Thanks everyone for joining us on the call today. We're really pleased with the progress this quarter, and we look forward to keeping you updated.
Ladies and gentlemen, that concludes today's conference call. Thank you for your participation. You may now disconnect.