So, yes, we’re going to get it.
Operator: Thank you. Your next question comes from Douglas Tsao from H.C. Wainwright. Please go ahead.
Douglas Tsao: Hi, good afternoon and thanks for taking the questions. Maybe as a starting point, I’m just curious — with the CAH readout on the interim look that we’ll get, I’m just curious, sort of, is there an operational decision that you make from getting that versus the full readout? I mean, is it sort of similar to carcinoid syndrome where it sort of really helps you jumpstart, thinking about the Phase III study, or are there potential changes that you would make to the CAH study itself that — sort of mid-course adjustments that would help you sort of better understand, how the molecules behave?
Scott Struthers: Yes, Doug, it’s like all the core endocrinology studies, including the Phase I we did with Paltusotine, where in the earliest cohorts of our SAD study, we knew the drug was working and we knew the pharmacology that was coming out by these changes in hormonal biomarkers. And as this CAH study progresses and we begin to get that type of information, it’s an open-label study. So, we’re looking at it all the time and we’re getting all this information to guide our Phase 3 design. But until we start to, and still — until we disclose it, we can’t be talking about it publicly, either with our investors, or with a broader group of physicians outside of our investigators and our advisory boards. So, we want to be able to talk to a broader community about how we advance this program forward. And that’s — and it’s been moving well. So that’s why we decided that — our current estimate is we’ll be able to start talking about it next quarter.
Douglas Tsao: And then just a quick follow-up on the TSH antagonist, I’m just curious, what are you looking at, I guess, in a preclinical setting to determine or select your molecule? I’m just curious what sort of you are most focused on in terms of lead candidate selection ahead of obviously going into the clinic and seeing the sort of the impact on thyroid levels, et cetera?
Scott Struthers: Yes, so it’s very much like our other programs. In finding the right molecule, you’re trying to optimize 20, 30 different characteristics. And we’ve had molecules for a long time that were potent at the receptor and able to normalize hormone levels in a mouse bottle. But we’re really working on all those other little, polishing to make a good molecule to make sure it’s highly orally absorbed, doesn’t have drug interactions, has good toxicology profile. But if you’re interested in efficacy, I’ll point you towards our corporate deck where there’s a slide towards the back, where we give mice an antibody just like the humans have that cause activation of their TSH receptor. Their thyroid hormone levels go up remarkably.
And then we start treating them with one of our oral candidates. And those hormone levels go back to normal. So, we’ll do that same type of study in patients with Graves’ disease. So I think it’s quite relevant as an efficacy model. But like I said, in many of our programs, it’s not about the efficacy, it’s about finding the great drug that also has the great efficacy.
Operator: Thank you. Your next question comes from Jon Wolleben from Citizens JMP. Please go ahead.
Jon Wolleben: Hey, thanks for taking the question. Two from me. Just wondering if you could give some context about how you think the opportunity for Paltusotine changes in acromegaly if you just have a maintenance label versus a maintenance and treatment label? And then seems like a lot of excitement 4894 and CAH in Cushing’s has been a difficult indication and the dynamics are changing there. Are you still thinking about moving forward in Cushing’s as well, or is 4894 going to be focused on CAH moving forward? Thanks.
Scott Struthers: Well, let me address 4894 and then I’ll hand it over to Jim to think about the commercial opportunity — talk about the commercial opportunity. 4894 addresses the ACTH receptor, which is the heart of the body’s — or the center of the body’s endocrine response to stressors. And when things go wrong in that pathway, bad things happen. So in Cushing’s disease with excess glucocorticoids or in CAH patients with excess glucocorticoids, you’re adding too much adiposity, you’re increasing blood pressure, you’re damaging bone. It’s a problem. So, we were out front in CAH. We have an exciting ongoing study with the NIH in Cushing’s disease, and we’re continuing to work on that. And we’re thinking about what else we might do down the road with an ACTH antagonist.
This is something nobody else in the world has ever evaluated in humans. And we’re going to learn a lot about the pathway in these studies. So Jim, maybe you want to comment on indications and expectations for Paltusotine and acromegaly.
Jim Hassard: Sure. And I think the question was specifically kind of maintenance versus naive. I mean, from an addressable patient population standpoint, the majority of the patients are currently on treatment. So in any given year, we estimate maybe 500 new patients, or naive patients enter the marketplace. So that gives you approximately 10,000 patients that are maintenance patients. And that’s the importance of the PATHFNDR-1 data already in hand, is that group of approximately 10,000 patients. However, don’t want to minimize the value of PATHFNDR-2, because, again, PATHFNDR-2 gives us the broadest possible label to really address patients across the continuum. It’s differentiated from several products that are in the marketplace.
So it will be an important readout for us as we move forward. And I think we hope to glean more than just an indication from PATHFNDR-2. We hope that there’s some important data that will differentiate Paltusotine from the injectable somatostatin receptor ligands additionally.
Scott Struthers: And if I can just add to that a little bit, as amazing as the data was from PATHFNDR-1, it was all about maintaining a level of control in patients who were controlled. In PATHFNDR-2, we’re starting with patients who are sick and demonstrating, if all goes well, that Paltusotine can help them lower their IGF levels, lower their symptoms, make them feel better. And there’s something visceral about being able to communicate an improvement in a disease condition rather than just a maintenance in the disease condition. And so, we’re very excited to see how this plays out next month.
Operator: Thank you. Your next question comes from Yuchen Ding from Jefferies. Please go ahead.
Yuchen Ding: Hi, good afternoon. Thanks for taking our question. We have two for CAH, if I may. So number one, just around A4 reductions at week 12. There’s actually surprisingly not a lot of data out at week-12, and most are for weeks two to four. So I’m curious to hear what level of percentage A4 reduction do you think will be competitive at week-two, given we already have some of the data out there from others, but those are from earlier time points? And then question two is around a CRF1 competitor who will obviously have some Phase IIb data in March. How do you frame that update given you will report data soon after in Q2? And maybe if I can be a little bit more specific, can you comment on how we should think about percentage A4 change versus the absolute magnitude of A4 change and which should people focus on?
Scott Struthers: Yes. Let’s see how the best way to answer that is. First off, in our study, we’re measuring time courses of A4 and other adrenal markers throughout the treatment period. So, they’ll be comparator time points at different places. One of the other really innovative things that Alan’s doing in that study, and we’d like to make our studies as informative as possible, is we have an option for patients to enroll in what we call the circadian arm where we measure A4 and other markers throughout the day because as you know, those fluctuate. And so understanding the timing of measurements in the day, not just in the weeks, is also important. And I think — but I’ve been around this endocrine systems since the earliest days of my career, and CRF is a very exciting molecule that has some wonderfully interesting biologies.
But at the pituitary, it is only a portion of the signal that goes into the corticotroph cells that make ACTH. And we now have an estimate from the recent data on crinecerfont that by blocking that signal, you can reduce 45% of the A4 output by the adrenal. So that says there’s another 65% of signal going into the pituitary from probably vasopressin or some other things. However, mechanistically at the adrenal, there’s only one way that ACTH can act, and that’s through its receptor, which is called MC2, melanocortin receptor 2. And that’s what we’re blocking. So I would expect an ACTH antagonist to have a much more — if you can fully block the receptor, to have a much larger effect on adrenal A4 output. And we’ll know what that effect is in the coming months.
So super excited to see that. And I think the community is as well. We’ve known about ACTH and Cushing’s disease since 1910. But nobody’s ever had an antagonist in that receptor before. So it’s a very exciting advancement in the field.
Operator: Thank you. Your next question comes from Leland Gershell from Oppenheimer. Please go ahead.
Leland Gershell: Thanks and my congratulations on all the accomplishments that have been made. Just curious, Scott, as we look forward to the annual meeting of the Endocrine Society not too long from now, I want to know if you might be able to give us indication of any updates, perhaps on some of the earlier pipeline programs that you’re moving forward, or just look forward to? Thank you.
Scott Struthers: Yes, thanks. That’s an annual pilgrimage of endocrinologists from around the world to get together and talk about the latest in endocrinology. And I’ve been going since the 1980s. I love that meeting. We will be sending, as usual, a large contingent. We’re submitting many abstracts. I frankly don’t know the final list of abstracts, but that’ll be coming out as we see the acceptances. And I think you can look for a strong presence from — us there in Boston this June.
Leland Gershell: And then just a question, just to clarify on 04894 between Cushing’s and CAH, these two — your press release had mentioned the CAH readout would be next quarter. I think you had indicated previously that we may see Cushing’s data in Q2, but that wasn’t mentioned. So is Cushing’s reveal going to be perhaps moved to Q3? Or I’m just wondering if you might have any indication there?
Scott Struthers: No, I think we just didn’t do a diff between the two discussions and maybe didn’t spend enough time talking about Cushing’s. So let’s see how it plays out. I think there’s a chance we’ll hear about both. But 4894 is certainly something of great interest on many fronts. But don’t interpret any subtlety in the way we phrase things as any loss of interest in Cushing’s disease.
Operator: Thank you. That’s all the time we have for questions today. So I will turn it back to Scott for closing remarks.
Scott Struthers: Thank you, everybody, for joining us today. We appreciate your attention, your support, and look forward to talking to you more in the future. Thank you.
Operator: Ladies and gentlemen, this concludes your conference call for today. We thank you for participating and ask you to please disconnect your lines.
