Cantor Global Healthcare 2021 Conference

Sep 27, 2021

Hello. Good morning, and welcome to the Cantor Global Healthcare Conference for 2021. My name is Charles Duncan. I'm a managing director and senior biotechnology analyst with the firm's equity research department. This is day one of the Cantor conference. I have to say, boy, what a year it has been since we last hosted our clients in the fall of 2020. It's a pleasure to introduce the next, actually the first presenting speaker for me. This is KalVista Pharmaceuticals. KalVista is an interesting platform-enabled drug developer, and it's a pleasure to introduce the company's CEO, Dr. Andrew Crockett. I also have Mr. Benjamin L. Palleiko, the company's CFO and CDO with me today, and Dr. Christopher M. Yea, the company's Chief Development Officer. Gentlemen, good morning. How are you? Hi, Chad. Thanks for having us today. Good morning. Great to see you. Yeah, as I mentioned, it has been quite a year. A lot of challenges. However, some innovation in biotechnology as well. We've seen the delivery of a COVID vaccine. We've also seen the first approval of potentially a disease-modifying agent in Alzheimer's. I guess for you folks, how's it going for you? How have you kept your staff together and moving forward? Yeah, for us, it's been a very good year at KalVista. We've made some significant progress on our lead products. The company is growing significantly. Despite a lot of the challenges that we've been having with the pandemic and so many related items, at KalVista, we feel very fortunate that we've had a very good year. The year really started off for us with headline data from our phase II study for our lead product, KV-1004, on-demand treatment of HAE attacks, where we showed some really fantastic data coming out of that study and moving forward now with that program to an end of phase II meeting and phase III quickly thereafter. Very good. Great to hear that it was a productive year for you. We will get into that. I wanted to mention that you do have a distributed business model. I know that Chris is probably talking to us from London, as an example, and you in the U.S. How has it worked for you in terms of being able to organize your processes and move forward with regard to productivity? From our perspective at KalVista, we've always kind of had this, if you will, distributed model, where we've got folks in the U.S. and the U.K. Since our inception, we've kind of been set up that way. We've tried to find expertise wherever that is. When the pandemic began, quite frankly, we were kind of already established that way and set up that way. In many ways, the tools that we've had to operate have only improved. Things like Zoom and other elements have only gotten better when more of the world had to operate in this way. I'd say that our models has been benefited by the challenges of others. We've been set up this way for a long time, for us, it wasn't that much of a dynamic change. Very good. I mentioned at the beginning that your company is an interesting platform-enabled drug developer. I'm wondering if you could just take a moment to describe that platform for protease inhibition. Why is that a difficult thing, and why is it differentiated, perhaps, from other platforms that are out there for drug discovery? Sure. I think, as you say, we're focused in development of small molecule protease inhibitors, that field of drug discovery has been a challenge for a long time. Especially when you kind of add the small molecule element to it, from a chemistry perspective, you're always balancing among achieving potency, oral bioavailability, and selectivity with your molecules. That's just a challenge in this field. The good news from our perspective is we've been doing it for a long time. We have chemists at KalVista that have been researching these small molecule protease inhibitors for decades, and that really gives us a competitive advantage. We've worked on a number of different proteases and now through to our work in plasma kallikrein and factor XIIa. With the molecules that we're generating, I think really the fruit is, and the proof is in the pudding with what we're bringing forward. Well, we're going to talk about both targets over the course of this discussion. One more question on the platform? When you think about your approach in terms of medicinal chemistry, but better understanding even the biology of these targets, You mentioned competitive advantage, do you believe that it generates drug candidates that are differentiated and have a profile that is emerging that could be different than past approaches by other companies? Yeah. I think our approach, for example, with the drug candidates we're moving forward in HAE is we want to be able to offer patients oral therapies that are every bit as effective as the injectable therapies that they've become accustomed to, right? As it relates to each specific drug, that is a challenge, right? For example, in the on-demand setting in HAE, to be successful there, you need an oral drug that is absorbed and reaching effective concentrations in minutes. Right? You don't see that very often with oral drug candidates to have that type of rapid absorption to levels to which you can quell an attack where this biological process is kicked off in a significant way. What we showed with our data from KVD900 is that actually we were able to deliver that. Again, I think the platform, if you will, is the expertise to bring forward differentiated molecules, right? KVD900 is positioned for on-demand. It was designed specifically to address that concern and that market, whereas with KVD824, we're focused on prophylaxis. That's a very different profile that's required. From our perspective, we don't think it's really the right thing to try to, if you will, force one molecule into two very different indications that require different characteristics of molecules. I think the platform, our ability to discover differentiated drugs is really what makes us different. Very cool. Why don't we talk a little bit about the first indications or disease state that you're going after, Andrew Crockett, and we can maybe set the table to talk about some of the specific candidates. With regard to hereditary angioedema or HAE, what do you see as the current, call it unmet need and the market dynamics? It has been evolving, certainly in the last year. Tell us what you think remains to be wanting for patients and prescribers. Yeah, I think, really HAE has gone through a transformation really over the past five to seven years, right? Where patients now have access to a number of very effective drug therapies. Most of those therapies are injectable therapies, right? Still the same, patients have access to those therapies. What we've been saying for quite a long time is that what patients really want is oral therapy, right? They want oral therapy in kind of whatever way they can get it, whether that is on an on-demand basis or whether that's on a prophylactic basis. Patients want that kind of next advance, which is oral therapy. We've had now the first approval of an oral prophylactic agent. I think what kind of sets us apart, as we think about both the on-demand and the prophylactic setting is, a comment I made earlier, which is we're intending to bring forward drugs that don't ask patients to kind of choose between the high levels of efficacy that they experience with their injectable therapies and what they want, which is oral therapy, right? For enabling the type of life and freedom that they want with their disease. What we're looking to do with our drug therapies is not ask patients to make that choice, right? I think we delivered on that, at least in the phase II clinical study with KVD900, where the efficacy profile we saw was every bit as good as what we've seen with injectable therapies. Certainly what we believe will be the type of drug administration that patients really want in the space. Okay. Well, why don't we talk specifically about sebetralstat and perhaps even bring in your colleagues, Chris and Ben. When you think about sebetralstat and the data that you've presented thus far, what gives you confidence that it could be competitive and achieve the target product profile that you mentioned in terms of not having to compromise on efficacy for speed or vice versa? Hi, Charles. Yeah. Let me talk to that. I think the first thing, as Andrew said, is the speed with which sebetralstat absorbed is really impressive. Cmax is typically around about 30 minutes. Perhaps more importantly, that time to reaching an effective concentration, a pharmacodynamically effective concentration, is obviously prior to that. I think we've shown data that's in the region of 10 minutes or so. I think the speed with which it gets there, of course, as an acute setting is incredibly important. You need to stop the attack as soon as possible. The first thing a patient wants to know is the treatment I've taken is starting to work. They say that's the most important thing to them. They recognize there's a period over which the attack resolved, but I want to know that I've taken something that's going to work, and it's going to work quickly. That's the first one. I think the second thing is, as Andy said as well, we get to very high concentrations, and what we've shown is that that completely inhibits plasma kallikrein. There is essentially no plasma kallikrein activity in the plasma from around about 30 minutes or so. It gets there very quickly, and when it gets there, it gets there very effectively pharmacodynamically. I think as well, the other thing around the target is really interesting. Plasma kallikrein, if you will, sits at the middle of the contact system. What we know is that plasma kallikrein produces bradykinin, obviously by cleaving kininogen. That's, if you will, that's the effector of the edema. The contact activation system is actually maintained and amplified by plasma kallikrein. We know that plasma kallikrein is able to cleave prekallikrein to produce more kallikrein. It's also able to cleave Factor XII to factor XIIa, which is right at the top of the pathway. If you will, plasma kallikrein kind of sits in this key position in the middle and amplifies the whole cascade. I think, not only are we stopping the downstream effector, we're stopping the whole pathway from this increasing activation. I think that's really important. I think when you add together that pharmacokinetic profile, the clear pharmacodynamic effect, and the impact within the pathway, it's certainly, if you've shut down plasma kallikrein activity, clearly you've shut down all the contact activation, and therefore that should be as effective a treatment as you can get, and it will get there very quickly as well. Very good, Chris. Great overview. Appreciate that. When you think about the data that you've presented, and you consider it relative to designing the next steps in terms of clinical studies, what would you anticipate those clinical studies to be? I understand that you have an end of phase II meeting coming up, so I'm not really talking or asking you about your FDA interactions. Given the results that you've seen, how confident are you in being able to demonstrate that target product profile in a phase III? As you can see, based on that phase II data, Charles, we're very confident. What do we expect the study to be? Our expectation is that essentially the study will be as close to the phase II study, to be frank, as we can make it. We looked at several endpoints. FDA asked us prior to the phase II that we look at several endpoints to educate that discussion that we will have with them, as you say, at our end of phase II meeting. I think the nice thing, the comfortable position we're in, is all of the key endpoints we hit. We hit our primary, which is use of rescue. I think we've said previously, we're not sure that that's something that FDA will necessarily believe in, at least as a primary, but I think it's a very important endpoint nonetheless. The other endpoints that have been used for previous studies, including the VAS scores, including what we call the PGIC, this question, transition question. How do you feel now? Do you feel better or worse than you did? Also, we used this Likert scale outcome, which is a very simple rate your symptoms now from none to very severe. We got very good P values on all of those endpoints. I think, without being too blasé, whilst I like the PGIC outcome, we know from patients that that's meaningful. Actually if you ask a patient, "When you take a treatment, what do you want to happen?" A patient will say, "I want to feel better." They won't say, "I want my symptoms to be this level," or, "I want to be this score on a 10-centimeter line." They'll say, "I want to feel better." I think that's a very meaningful outcome. As I say, we have some flexibility, at least because of the outcomes from the phase II in each of those. I think, in general, the study will look, we would propose very much the same as the study we just completed for the phase II, both in terms of study design, crossover, and also in terms of the endpoints that we'll be looking at. I guess if you had to guess on a sample size, can you give a broad estimate? With regard to timing of being able to articulate that plan forward? Again, I would estimate the study size to be somewhere similar to the phase II. Somewhat dependent, obviously, on our discussions with the agency. I think from an efficacy point of view, again, because we got such good P values, on the assumption that our assumptions going into that end of phase II meeting are correct. I think it will be around about the same study sample size. It's not an atypical sample size in the HAE setting anyway. Right at phase II, phase III level. I think that's a pretty good expectation. We have everything up and ready. We've selected sites already. We're ready to go. We have drug product manufactured. That's all ready to go. As soon as we can reach that, finalize that agreement with FDA on exactly what they require in the phase III program, we can press the button, and we'll be up and running very quickly. As you'll be aware, once we can get a protocol filed in the U.S., you can get on and start initiating sites immediately after that. We should be up and running very quickly. Okay. Very good. We'll look forward to that information, that those press releases here in perhaps in the near term on sebetralstat with regard to acute therapy or on-demand therapy. You have a second candidate that Andy actually mentioned, KVD824, with regard to prophylaxis HAE. As you spoke, there has been another oral agent, a prophylaxis agent, for HAE. I guess I'm wondering if you can go back to the original conversation and say, how do you feel about the market dynamics there and the need for prophylaxis oral agent versus on-demand? Ben, do you want to take that one? Ben? Sure. Hey, Charles. Right. What you're referring to is, as you said, ORLADEYO from BioMarin just have launched. It was approved end of last year and launched earlier this year. It has got a lot of attention in the market space because it's the first oral therapy for HAE that's been approved and launched, as you point out, with prophylaxis. Ostensibly, this seems like an attractive idea, right? Prophylaxis in the U.S., focusing on the U.S. market, we'll set the rest of the world aside, it's about probably 60%, maybe a little more even nowadays, prophylaxis. It looks like they're launching into a very large segment. Clearly the launch to date has actually seems to have gone fairly well. They've obviously got approval and reimbursement in a number of countries. They've shown some reasonably interesting numbers in the first couple of quarters. What they really do is validate the fact that what Andrew Crockett said previously is true, which is there's an overwhelming desire by patients for oral therapies. HAE is, in some ways, a very well-served market. It's kind of remarkable to think that 20 years ago, there were really no effective modern therapies, and now you have. Yeah A whole group of these. The key issue, of course, remains that they're all either injected or infused, and that becomes a huge liability for patients. Again, this is a lifelong disease. You're talking about people doing this for 70 something years. Even if it's a couple injections a month, that's highly undesirable for patients to go through in the long term. Because it's familial, we also have to think about the fact their children are having to deal with this as well in many cases. The point on ORLADEYO is it's come out as an orally delivered therapy, and the initial demand, we think, reflects the fact that, again, patients overwhelmingly want to have another option that's better. It's not just about convenience. It's the fact that this actually improves their quality of life by allowing them to have a shelf-stable tablet as opposed to having to deal with all the challenges that come with storage of antibodies and proteins, and again, to have something that can treat their disease for the long time in a more attractive manner. The problem for ORLADEYO has been really the efficacy results and the safety profile. TAKHZYRO, HAEGARDA, these other prophylaxis therapies are probably in the range of 80-plus % reduction in attack rates. The safety profile is pretty good. You have injection site reactions. You have the standard injection items. Generally, they're pretty well-tolerated. ORLADEYO, at the high doses, in some of the early studies, showed very high rates of attack rate reduction, probably comparable to those. The problem is the side effect profile made the drug essentially intolerable for large segments of patients. What they had to do was lower the dose. Lowering the dose reduced the efficacy. At the end of the day, what they ended up with was a drug that has about half the efficacy of TAKHZYRO, about a 44% attack rate reduction in the phase III study, and a side effect profile that's still challenging. A lot of patients experience abdominal discomfort with this, and it has made patients getting on and staying on therapy a challenge. Our view on ORLADEYO is, again, in some way, it shows that the demand is actually there and that the market opportunity is strong. It also, however, we think over time, is going to show the corollary to that, which we've always said, which is patients aren't really going to settle for a lot lower efficacy. There's a lot of folks getting on it now. I think the challenge or the interesting point is going to be toward the end of this year or early next year to see how many of them stick around. It's probably unusual, at least in my experience, to have drugs perform twice as well in the real world as they do in clinical studies. I think that's where we'll see how ORLADEYO does. Good point on that one, Ben. Probably problem not solved yet with that particular oral agent in prophylaxis, and it may actually increase demand or risk with regard to acute therapy as well. I guess I'm wondering from your perspective or Chris or Andy's, your perspective on your agent, your candidate KVD824, what is it in the early data that you've seen with KVD824 that gives you confidence in terms of the pharmacokinetic and pharmacodynamic parameters that can actually solve the problem for not only acute with KVD900, but also for prophylaxis with KVD824? Yeah. To talk specifically just to the prophylaxis, again, we've shared some pharmacokinetic, and I think more importantly, pharmacodynamic data. What we know for ORLADEYO is in the earlier phase II trials, it looked as if it was as effective as the injectables. Certainly, notwithstanding the GI side effects that they found in the phase II at the higher dose levels for peripheral attacks, it was very effective. It was as effective as lanadelumab. I think that validates the fact that an orally delivered plasma kallikrein inhibitor will be as effective as an injectable. Again, there's no reason to think it wouldn't be. I think that's really important. It was those GI side effects, though, obviously, that meant they had to reduce the doses going into the phase III, and they've reduced them far enough to at least alleviate the majority of those side effects, those adverse events. Of course, not surprisingly, then you lose exposure, you don't inhibit the plasma kallikrein enough, and therefore, you end up with some breakthrough attacks and significant numbers in that phase III study. I think that what it says to us, as long as we can deliver enough of the drug, i.e., it's got to be tolerable that we can deliver the concentrations required, and we have the pharmacokinetics to support that, then we should see efficacy. I think it's fair to say HAE is really challenging from the point of view of the amount of drug you have to deliver. You do need significant concentrations to suppress the contact system enough all of the time. There's 2 ways you can do that. One is you can have a very long half-life drug, and that's ORLADEYO, which has got something like a 3-day half-life, which clearly brings other issues forward in clinical development. I have to say, we've lowered the bar a bit and said, "Well, in the first instance, let's go for a twice-daily." That means we don't have to give such big doses to maintain that 24-hour coverage. Certainly, the phase I data that we have to date shows that with the 2 doses that we're moving forward to or the 3 dose levels at twice a day into the phase II study, we get very good suppression of plasma kallikrein. I think you'll have seen our graphs. We show, in fact, for the vast majority of the 24 hours, we suppress plasma kallikrein probably more strongly than lanadelumab does. I think from a pharmacodynamic point of view, that says we have good suppression, should be efficacious. In terms of tolerability, we've delivered those doses now for up to 14 days, and we've had no signs of any concern around tolerability. If you contrast that to ORLADEYO, even the first-in-human single dose studies, they were seeing these GI side effects. Right. I think if we were to be seeing these, we'd be seeing them within 14 days of repeat dosing. I think I'm very confident that we have the concentrations and suppression of plasma kallikrein enough to get efficacy. To date, as I say, the tolerability profile looks very encouraging. Now, one potential pushback I could imagine from the competitive side is that it's a twice-a-day compound. I guess I'm wondering, as you've thought about the future market dynamic, perhaps Ben or Andy can speak to this, are you concerned about compliance with a twice-a-day compound? Could that limit efficacy or really the perspective of efficacy in the market? That's a good question. It's something we thought really carefully about as we were bringing A 204 forward. Chris kind of alluded to this decision of this long half-life and potential knock-on safety effects with some of that profile versus having patients dose twice a day. I think the research that we did came back overwhelmingly in support of that efficacy is the key driver here. That patients, more than anything, want an efficacious oral therapy. Obviously, that needs to be well-tolerated. We need to be able to deliver doses and a therapy that's going to be very effective and well-tolerated. A 204 in the phase I studies have shown that. In terms of compliance, I think sometimes when we look at this compliance on a macro level with twice-daily dose drugs, we mix in some other indications that don't have the type of acute impact of missing a dose, if you will, like HAE does. We've talked about before migraine. When you know you've got that type of situation coming on, I think it's much different than, say, someone that has high cholesterol and taking medication daily for that. Right. I think these patients understand the potential consequence for missing doses. I think that tends to drive compliance pretty well. That isn't something that's keeping us awake at night. Yeah. This is a highly symptomatic disease and, yeah, patients can learn if they miss one, that that's not a good thing. Correct? Absolutely. Yeah. Charles Duncan, don't forget, though, this also highlights the potential of the portfolio. Yeah. Which is KVD824 plus 900 together. We're going to have the opportunity for patients to take this twice-daily, but if they have a breakthrough attack, if somehow for some reason they miss a dose, whatever, 900 would be available as well. Realize your compliance point goes to the opportunity presented by the fact that we actually are the only company with oral therapies to hit both sides of the market. Well, you're the only company that can deliver an oral therapy that actually has very rapid activity, and so that will give some comfort to the market. In the last few minutes that we have to speak, I wanted to come back around to the concept of the platform that I was discussing with Andrew Crockett earlier. The factor XIIa candidate is really intriguing, and I guess I'm wondering, when you think about that and think about where it sits relative to kallikrein that Christopher M. Yea was mentioning, could you actually see an improvement if you're able to move forward with XIIa, or is it just a totally differentiated approach in terms of treating HAE? As Chris described, we think that plasma kallikrein obviously is the key mediator of the disease that we've seen so far. Obviously, we have very effective therapies where plasma kallikrein is the target, both ours and others. We think factor XIIa represents kind of another opportunity in HAE. As Ben's describing our platform and our desire to hit all points. We've seen some data from a factor XIIa antibody that was really effective. It sits at the top of the cascade. It makes sense to also look to intervene there. Who knows? Some patients may experience benefits there better than with plasma kallikrein. I think that remains to be seen. We're moving forward with our molecule. We've actually had some great progress over the past few months in expanding our factor XIIa program to have molecules that are orally available, selective, and very potent. We're excited to add that to the next clinical investigation that we do in HAE. Very good. Well, we're just about out of time. I hope that in a year we'll be together talking at the Cantor Healthcare Conference for 2022, and we'll look forward to your progress then. Thank you very much for sharing the KalVista story with us this morning. Gentlemen, hope you have a great day. Thank you.