Madrigal Pharmaceuticals, Inc. Price & Performance (MDGL)

We're also sharing this morning new two year data from the active treatment open label compensated MASH cirrhosis or F4C arm of the Phase three MaestroNAFLD trial. We issued a press release this morning and have a slide deck that accompanies this webcast which we'll post on the Investor Relations section of our website right after the call. On the call with me today is Bill Civil, Chief Executive Officer and Marty Dear, Chief Financial Officer. They'll provide prepared remarks and then we'll take your questions. Doctor. Michael Charlton, our Head of Clinical Development will join us for the Q and A portion of the call. Doctor. Charlton has more than thirty years of experience in MASH. As a leading hepatologist, the Mayo Clinic hepatology group and a treating physician. We plan to keep today's call to about forty five minutes. Please note on Slide two, we will be making certain forward looking statements today. We refer you to our SEC filings for discussion of the risks that may cause actual results to differ from the forward looking statements. And with that, I will now turn the call over to Bill on Slide three. Well, thanks, Tina. Good morning and thanks for joining.

Today, I'll provide an update on the significant momentum we're building with The U. S. Launch of [indiscernible] We ended 2024 strong and we're pleased with how we've started the year in 2025.

I'll also share an update on new two year data from an open label study for F4C patients as Tina mentioned. The results are very promising and support RESDIFFER's potential to benefit this high risk patient population if approved. But before we look ahead, want to take a moment to reflect on 2024. A year of remarkable transformation and achievement for the company. I've been in the industry a long time and I've launched a lot of successful medicines. I'll be the first to attest to the [indiscernible] in disease therapy. And the launch of ResDipra is no exception. We worked to meet or exceed our high expectations last year and started to lay the foundation for Resdiffra, to potentially become a blockbuster therapy. I'm incredibly proud of our team's accomplishments highlighted on Slide four. These are the things that we said that we would do and we did them. We built a world class team to drive the launch of ResDipra and support Madrigal's long term aspirations. Our groundbreaking RESIDFIR Phase three trial data were published in the New England Journal [indiscernible] On March 14, we achieved a milestone the landmark approval of Rizdifra the first ever treatment approved for this disease.

This achievement was further validated by two top tier liver societies in Europe and The U. S. Both updating their guidelines to include ResDIFFERA as first line therapy for MASH. And we made significant progress expanding ResDifers reach both geographic and clinically submitting ResDIFFER for approval in Europe and completing enrollment in our MaestroNASH outcomes trial. Importantly, these accomplishments are translating into and building a strong foundation for Madrigal's future as the leader in MASH. Let's move to The U. S. ResDIFFER launch update on Slide five. [indiscernible] As we detailed in our earnings release this morning, and first previewed at JPMorgan in January, we generated $103,000,000 in net sales in the fourth quarter of twenty twenty four, reflecting 66% quarter over quarter growth. This was another strong demand quarter with inventory well within our expected two to four week range.

For the full year 2024, we generated a hundred and $80,000,000 in net [indiscernible] A remarkable achievement considering we launched in April and these figures represent just three quarters of performance. Our launch trajectory continues to track in line with some of most successful specialty medicine launches in the past decade. This confirms the urgent need Rizjifra is addressing in the MASH community its excellent product profile, and the exceptional execution of our team. These strong financial results are driven by the key performance indicators critical to any successful drug launch. Patients on therapy, prescribers and access. In the third quarter of twenty twenty four, on our payer metric, we reached a key milestone 180% commercial coverage for Resdiffra. Since then, we've continued to make great progress on the other two launch metrics. First on patients. As noted on Slide six, we ended the fourth quarter with more than 11,800 patients on Resdiffra. Incredible accomplishment in just nine months. Crossing the 10,000 patient threshold is a significant milestone and we continue to steadily add patients at a rate that's consistent with other top tier specialty medicine launches. Importantly, this figure represents patients actively on therapy meaning it accounts for any discontinuations, making it the most rigorous and meaningful metric to track sustained treatment adoption.

Yet, we're still in the early days. We have penetrated only a fraction of the market with Resdiffra. Less than four percent of the three hundred and fifteen thousand diagnosed patients with F2F3 MASH. We remain focused on the three hundred and fifteen thousand diagnosed patients which represents a highly attractive specialty market. Looking ahead, the stated efforts of the next entrant are focused on expanding the market to many multiples of three hundred and fifteen thousand. We believe that the strength of Bridge Differs profile positions it for leadership in either scenario creating multiple paths to success for Resdiffra in the years ahead. Our ability to steadily add ResDIFFER patients quarter over quarter is directly tied to increased penetration of our prescriber base. From day one, we've talked about wiring the system. How we have been laying the foundation to support the patient volume we expect in the years ahead. And we're seeing real progress as we've engaged providers driven change in clinical practice and helped build the infrastructure necessary for sustained prescription growth. On Slide seven, the bar graph on the left illustrates this progress. As a reminder, our field team is focused on a total of 14,000 target primarily hepatologists and gastroenterologists, a concentrated effort on the top 6,000 prescribers.

In the fourth quarter, approximately 60% of our top 6,000 targets prescribed risdiffra. Up from 40% in the third quarter. We are steadily adding new prescribers and we are seeing increased depth of prescribing from current writers. Both metrics are tracking exceptionally well with other successful blockbuster launches. As expected, our top target for Just as we've successfully driven adoption among our top target prescribers, we plan to continue shaping clinical practice and expanding access across our full prescriber base as we build Resdifference towards its peak sales potential. We're already making meaningful progress. By year end, approximately 40% of the 14,000 had prescribed Resdiffiroc. Reflecting a strong and growing foundation of support. ResDipra's broad based uptake is being driven by its attractive profile. It's a liver directed therapy that halts or improve liver stiffness. A proxy for liver fibrosis. In ninety one percent of patients out to three years. It's also a once daily well tolerated pill with simple dosing. And with the chronic and serious liver disease like MASH, this favorable profile supports long term adherence with early data continuing to indicate persistency rates comparable to other well tolerated oral therapies. We're also hearing overwhelmingly positive feedback on Resdiffra, from both physicians and patients continue to highlight the benefits of the medicine, including improvements in liver function tests, and lipid levels, reduced fatigue, increased physical activity, And these real world outcomes really matter.

We recently heard from one Res Differ patient diagnosed with MASH. She said, quote, living with MASH felt like having a time bomb in and my life back, end quote. [indiscernible] Our goal is to be the leader in MASH and help patients for many years As noted on Slide nine, our long term strategy builds on the success of RISDIFRA's U. S. Launch. First, we are expanding geographically and remain on track for a mid year regulatory decision for ResDiferin Europe. Assuming a positive outcome, we plan to take a targeted country by country approach to commercialization beginning with Germany in the second half of the year. Beyond Europe, we are also assessing opportunities to bring Rezdiffra to patients in additional attractive geographies. Second, we're advancing risk differ for patients with compensated MASH cirrhosis. Approval in F4C would represent a major step forward for the mass field and for patients significantly expanding the treatment landscape and effectively doubling Resdivros market opportunity. I'll spend some more time on the data we shared this morning in a moment. And third, we are committed to building a strong pipeline beyond resdivirap. In the enviable position of providing a highly meaningful medicine to the MASH community today, we are now focused on building the right pipeline behind it.

We are evaluating assets at different stages of development across multiple mechanisms of action all with the goal of strengthening and extending our leadership position in MASH. Moving to Slide 10, and the unmet need in compensated mast cirrhosis. It's a chronic progressive liver disease characterized by significant liver damage, loss of liver function, liver cancer and death. Substantial portion of compensated MASH cirrhosis patients also suffer from portal hypertension, which often leads to life threatening complications such as hepatic encephalopathy, ascites and variceal bleeding. While patients with F2F3 fibrosis face a ten to seventeen times higher risk of liver related mortality, F4 patients are at a staggering forty two times increased risk. In this very sick F4 patient population, preventing progression to adverse clinical outcomes is the central treatment goal. This is reflected in FDA guidance, which recommends that clinical trials and compensated MASH cirrhosis use outcomes as an endpoint as opposed to biopsy based surrogate endpoints. This guidance along with data from our open label F4C cohort informed the design of our ongoing MAXTRO NASH outcomes trial. We believe that ResDIFFERENCE liver directed mechanism of action should deliver a benefit not only in F2F3 MASH patients, in F4C MASH patients as well.

Therefore, as shown on Slide 11, we included a separate open label active treatment arm of patients with compensated mass cirrhosis in our Maestro NAPLD-one trial to begin evaluating RISDIFFERENCE safety and efficacy in F4C. As a reminder, MAINSTRA NAPL-one was a double blind randomized placebo controlled Phase three safety trial to support regulatory approval.

We previously presented positive one year data from the F4C cohort of this trial and are highlighting new two year VCTE data 101 patients on Slide 12. VCT or Vibration Controlled Transient elastography. Is a widely used non invasive test conducted with a FibroScan that measures liver stiffness as a proxy for fibrosis. It's also a strong predictor of clinical outcomes. Two year results show that patients achieved a mean 6.7 kPa or kilopascal reduction in liver stiffness at two years, which represents the largest mean KPA reduction reported in an F4C MASH patient population to date. While this was a single arm open label trial, this reduction was highly Physicians use the Baveno rule of five kPA to stratify risk of liver related events in patients with MASH So a 6.7 reduction suggests that many patients are moving into a lower risk category. Fifty one percent of patients achieved a twenty five percent or greater decrease in liver stiffness as measured by VCTE. This level of reduction in liver stiffness has been associated with reduced progression to end stage liver disease moving patients further away from the risks of cirrhosis and its complications. And Resdiffra's safety profile was consistent with other Res clinical trials with a low rate of discontinuations due to adverse events.

We look forward to sharing more details from this two year cohort at a future medical meeting.

These data add to the growing body of evidence supporting ResDIFFERA's potential benefit in this high risk patient population and support continued confidence in our fully enrolled cirrhosis outcomes trial. As noted on Slide 13, MaestroNASH outcomes is a large Phase three double blind placebo controlled trial evaluating progression to liver decompensation of in eight forty five patients with compensated MASH cirrhosis. Expect to announce data from this trial in 2027. So looking ahead to the opportunity in F4C, and assuming today's results translate to MaestroNASH outcomes and ResDIFRA obtained regulatory approval. We believe Resdiffra is and will be the leading therapy in F2 to F4C period.

Before I hand it over to Marty, let me briefly summarize our progress on Slide 14. 2024 was a transformational year for Madrigal. We secured FDA approval for Resdiffra and are executing on a highly successful launch.

We see significant runway for growth with less than 4% of The U. S. Target market penetrated and an attractive real world profile, Res Differ is well positioned for continued strong momentum in 2025 and beyond. We are preparing for global expansion We see a significant opportunity in F4C. And believe we will be first to market. And we continue to build for the future as we actively explore opportunities to expand our pipeline. With that, I'll turn it over to Marty.

Thank you, Bill.

Earlier today, we issued a press release detailing our full financial results. Will highlight a few key takeaways for the fourth quarter and full year as noted on Slide 15. Fourth quarter net sales totaled $103,300,000 bringing full year 2024 net sales to $180,100,000 an impressive achievement considering this reflects only nine months of commercialization. We delivered another strong demand quarter with inventory well within the expected two to four week range. Our gross to net discount increased in line with what we previously discussed As we said, we expect some variability in gross to net early in the launch. Looking ahead to 2025, as expected, we anticipate an increase in the gross to net discount compared to 2024 as is typical at this stage of the special of a specialty medicine launch. Importantly, this is already reflected in our expectations for robust year over year net sales growth in 2025. R and D expenses for the fourth quarter and full year of 2024 were $25,600,000 and $236,700,000 respectively. Compared to $70,600,000 and $272,400,000 in the prior year periods. R and D expenses decreased by $35,600,000 in 2024 due primarily to a reduction in clinical trial accruals and the change in accounting for inventory cost [indiscernible] FDA approval of risdiaphragm, partially offset by an increase in headcount.

Looking ahead, we expect a somewhat higher level of R and D spend in 2025 compared to 2024. SG and A expenses for the fourth quarter and full year of 2024 were $141,200,000 and $435,100,000 respectively compared to $46,500,000 and $108,100,000 in the prior year period. This year over year increase was expected and reflects the rapid scale up of our U. S. Commercial operations following Riziphera's approval in March 2024. Looking ahead, we expect SG and A expenses to increase in 2025 as we continue to invest in The U. S. Launch and our international expansion. Turning to our balance sheet, we ended 2024 with $931,300,000 in cash, cash equivalents, restricted cash and marketable securities. With a strong cash position, we are well resourced to support the ongoing launch of Ruzifra in both The U. S. And our planned launch in Europe. I'll now turn the call back over to Tina. Thanks, Marty.

Let's move into the Q and A portion of the call. Marvin, please go ahead and provide instructions for the Q and A session.

We will now open the lines for questions. To open your line, Our first question comes from the line of Thomas Smith of the Ring Partners. Your line is now open. Hey guys, good morning.

Thanks for taking the questions and congrats on the strong launch.

And the new cirrhosis data.

Just had a question with respect to the ongoing risk different launch. Now that we're roughly two thirds of the way through the quarter, wondering if you could comment on what you've seen in the first two months of the year terms of new patient adds. Any change in the cadence of patients starting on drug or anything notable as patients and prescribers kind of work through their insurance or copay adjustments? And then historically, you've given some high level guidance based on the comp group of specialty drug launches, I guess any color that you could provide as we think about Q1 and maybe 2025 broadly? Thanks so much. Tom, thanks for the question. Look, as just a couple of points firstly, 2024 was really an incredible year. When you think about going back twelve months from now, there wasn't a product on the market. For MASH. And in a very short period of time, we've really done, I think, a remarkable job executing and finishing off the year with $103,000,000 quarter is really really very impressive. By any measure you look at as we look at metrics all across the blockbuster launches that you referred to. We're tracking extremely well on all fronts.

There's no weakness here. On any of them. We carried, I would say, the momentum of '24 into '25 of steadily adding patients and prescribers. So that's we've seen more of that in the first quarter of twenty twenty five. We also do have like everyone else the Q1 dynamic that is clearly a phenomenon each year. And teams have been well prepared and I think we're managing through that extremely well.

As I think about what's happening at the prescriber level, each I would say there isn't a prescriber yet. That has maxed out or even close to maxing out the patients that exist in their practice or that are being referred into their practice. And each practice is learning. We talk about wiring the system That's been a lot of hard work and we've done it on a practice by practice basis. And as you can see, we continue to add new prescribers and we're now at the 60% penetration into that target group. For each of those as they start prescribing, they're doing their wiring. So what we're continuing to do is just bring on [indiscernible] each day, each week, each month, each quarter prescribers have them get ready to be able to handle the volume of their patients how they work through the system, etcetera. Now from a Q1 dynamic perspective, as I said, certainly that's something that we're seeing like anyone else. I think the team has done a good job getting ready to manage through that. No real other challenges that we've seen with the quarter, it's pretty standard.

Yes. Maybe I'll just add a little bit, Tom, to answer your question about the analogs. So yes, we do track very closely with our group of 10 specialty launches over the last ten years. It gets a little tricky when you go from a Q4 to Q1, so we're not giving specific for Q1 and may not go may not give that guidance going forward, but we're really tracking with these analogs thus far. But I will also say, if we just look at consensus as Bill said, we're very pleased with what we're seeing going into 2025. And a little commentary there that we believe consensus for Q1 twenty twenty five will narrow and go up a little bit.

As a result of what we've been seeing so far. Great. Thanks, Tom. Marvin, next question please.

Thank you. One moment for next question. Our next question comes from the line of Andrea Newkirk of Goldman Sachs. Your line is now open.

Good morning. Thanks for taking the question.

I can ask you here on the cirrhosis data that you shared. I was hoping you could speak a little bit more on the clinical meaningfulness of achieving that 6.7 kilopascal reduction And I know in the context of your three year data for the F2F3 NASH patient population, we had talked about how a VCTE measure below 10 kilopascals was correlated with fewer liver related outcomes. Just wondering if that same threshold stands for the F4 cirrhotic patient population And then finally, just how did today's data change how you're thinking about the NASH outcomes trial? If at all? And that change how you're thinking about the powering of the study? Thanks so much.

Great. Thanks for the question, Andrew. I'll turn it over to Michael in a second. But as we think about how does it change our view on MaestroNASH outcomes, look, we've been confident about that study. This is just another piece of information, which gives us, I would say, greater really, again, as we've done with our F2F3 program, we're pioneering the way And we believe that we have designed the right trial for MaestroNASHO outcomes. This trial that we announced today actually helped us help to inform our thinking on MaestroNASH outcomes. And with the really exciting news that we presented today, As I said, it gives us even more confidence. But maybe Michael, do you want to answer the first couple of questions that Andrea had? Yes, it's a great question. The predictivity of decreases in liver stiffness increases with a higher baseline level.

So our baseline level was 25 kilopascals The predictivity really starts to tick up at around 15 kilopascals.

So there are 6.7 kilopascals reduction start with the starting point to 25 kilopascals should be highly predictive of decreased risk of clinical outcomes.

Great. [indiscernible] Thanks, Andrea. Next question please, Martin.

Our next question comes from the line of Yasmeen Rahimi of Piper Sandler. Your line is now open.

Good morning team. And thank you so much for all the great updates.

Is there, I guess, could you comment on as we go into 2025, if you'll be in a position to provide guidance I think that Marty, your commentary was very helpful around that the consensus is going to a little increase, tighten a little bit. So just maybe help us understand how you're thinking of thinking about moving forward. We understand the dynamics of first quarter. But beyond that, at what point will you feel comfortable to kind of share with us what the 2025 or 2026 guidance would look like? That would be really helpful and I'll jump back in the queue.

Great. Marty, let me pass that over to you.

Yes. Thanks, Yas. Yes, with respect to guidance, we've been very clear. We're not giving guidance right now. We consider it internally but that's not something we're providing at this time. We're just too early in the launch.

I did provide a little commentary on Q1 twenty twenty five. And I think the same commentary goes for the full year 2025. We like what we're seeing, the momentum, going into 2025. We commented on the robust year over year growth. So where consensus sits for 2025, we expect that to narrow as well and go up a little bit based on what we're seeing. Thanks, Yaz. Marvin, next question please.

Thank you. One moment for our next question. Our next question from the line of Eli Merl of UBS. Your line is now open.

Hey guys, thanks for taking the question. Interest seen irrespective of the liver fat content at baseline And any color on sort of which patients were more or less likely to show these VCTE reductions? And then just in terms of the study, I guess, can we expect any further long term data cuts from this study like the three year data? Just curious, the timing here since I think the study has been going on for a few years already? [indiscernible] Thanks, Ely. Look, so more to come. This is just some really top line look at the data at upcoming medical meeting We'll go into a little bit more detail on things. I think there's certainly still a lot left that we can learn from this study. Just with the data that we have at two years. Is there anything else, Michael, to comment on? We're not giving out any more than the top line that we've given today. No, I think the essentially end of predictivity for these results, the clinical outcomes and with the the decline of twenty five percent based on that study of ten thousand patients perspective, you expect a thirty percent to forty percent decrease likelihood of a liver related clinical event.

So that's our main takeaway from these results.

Great. Thanks, Ellie. Thanks, Ellie.

Thank you. One moment for next question. Our next question comes from the line of Akash Tewari of Jefferies. Your line is now open.

Hey, this is Amy on for Akash. Thanks so much for taking our question. Starting off, just wanted to get your thoughts on the competitor 21 data in cirrhotic NASH and how that could read across to your F4 outcome study.

Also on Part D redesign, I think our preliminary math is getting to a potential full year net sales impact of around 3% to 5% for Resdiffra going forward. Just wanted to sense check this number with you and will you do any additional semi launch? Thanks so much.

Well, Amy, thank you. That's a lot of questions to get through. Let me see if we can talk through. First of all, as we launched the product from a gross to net perspective, we have been extremely, extremely diligent about gross to net. We weren't contracting as we launched the product. And when we launched the product, we don't you don't think about launch in a quarter or two or four, you think about kind of the years ahead. And we thought about gross to net anticipating that there will be additional competition in the marketplace in time, additional indications hopefully for us etcetera. So we take an extremely disciplined approach here. Now we will react to market dynamics as any company does. You always have a dynamic in Q1, which we've talked about. As it relates to working with the payers and so forth.

There's a constant dynamic there. So we'll continue to react to the market as these dynamics continue to shift. I think your other question was on Part B. I mean, look, Marty, I think covered it a little bit in some of the opening remarks. But Marty, do you want to make any comments Yes. I'll just say specifically about the Part D with how it impacts gross to net. Remember Medicare patients are about a third of our business. And Part D, we've always said there will be some impact going into 2025 with the redesign.

That's absolutely true. But we also had in 2024, we were paying Medicare rebates. Really. So the impact is a little more incremental in 2025. Versus a significant step up. So I think the good news our gross to net, particularly in 2025, is everything's [indiscernible] Going as expected, right? So we had to see a little bit of increase in our copay assist. As expected and included in our our expectations for net revenue for the year.

Yes.

I mean our excitement and belief in this product and just also where you think about where we are, we're at the very beginning stages. All of this is taken into account. Through our enthusiasm. And then maybe, on the first question that you had, Ellie, look, we're not going to comment on competitive data. But what we do believe is we're very confident in our data. We think that the release of this this morning gives us further confidence as I said in MaestroNASH outcomes the 6.7 kilopascale reduction, that really is meaningful Michael and team, everyone's really excited and people that we've spoken to in the community as well. That's a number that really gets people's attention and we think that translates into a real meaningful effect for patients. And as we said, ours is an outcome study We have followed FDA guidance and believe that we've designed the right study for approval. Great. Thanks, Amy. Next question, Marvin?

Thank you. One moment for our next question. Our next question comes from the line of Lisa Beyko of Evercore ISI. Your line is now open. Hi. Thanks for taking the question. Just two quick ones for me. First, the kilopascale change and the changes you talked about today, [indiscernible] you put that in context of any change in sort of F4 to F3 changes in fibrosis score.

And then also just wanted to touch upon semaglutide coming to market in NASH and NASH, sorry, and how you think about your positioning there, in particular with respect to the the pricing differential and how you might handle that? Thank you. Yes. Thank you for the questions, Lisa.

Maybe I'll start off and then I'll pass it over to Michael with your first question. But as it relates to Seema, I think, look, we've been really clear. First of all, at the very beginning of this market evolution, right, less than 4% penetration. So we've got many years of growth ahead. You then look at the profile of our product we've got a great profile. As I look towards the future, I don't see any product with a profile that actually is as good as ours. Sema assuming they come to the market, we're planning for that. We would assume that kind of maybe as early as late Q3 beginning in Q4. That's a very different profile of product. Remember, the problem we're trying to solve here you've got patients that are one to two steps away from cirrhosis. And what they can't afford is time. And by that I mean if you're waiting months to dose titrate, and then have a high discontinuation rate, Now you have to be on a drug for it to work. And the one thing that we do know is that with our liver directed therapy, it's easy to take, it works fast and the results that we're seeing in the real world are extremely promising.

What we believe is that actually assuming CEMA does get approved, it's actually going to drive additional market growth, which is something that ultimately as the leader in the space we're going to benefit from. But a kind of final point, this is a specialty market that can support multiple products being in it. It then comes down to things like profile, which we have a great profile, order of entry, we're first and have built this market So we feel extremely, extremely confident in our ability to grow through any of the potential competitive entrants. So maybe Michael why don't I turn it over to you for the first part of the question?

It's a great question.

The literature supports that when compared to baseline, a change in liver stiffness, a reduction in liver stiffness of five kilopascals or 25% in a comparable population compensated cirrhosis is highly predictive for a reduction in fibrosis of one stage or more so. That's how we would look at these stages. We had about over fifty percent of our patients achieved twenty five percent reduction threshold. Great. Got you. Thanks. Thank you, Beth.

Marvin, next question please.

Thank you. One moment for our next question. Our next question comes from the line of David Laboyce of Citi. Your line is now open. Thank you very much for taking my question.

On the emergence of GLP-one's once they actually get approved and they can officially get reimbursed MASH. How do you think that impacts usage vis a vis resdiffra in terms of combination? Do you think it makes it easier discussion with payers? Or do you think it makes it a broader discussion?

Thanks, David. Look, looking at the data now, we've reported this before, that about twenty five percent of RASDIFFER patients are already on a GLP-one. And when you look at who's already been exposed, it's about fifty percent. So they're already there being used for the comorbidities. And look, as a company, We are supportive of GLP-1s being used in comorbidities that can benefit patients such as obesity. So they're already there. That's the thing and they've been there for fourteen years. Now we know that at the lower doses, they clearly haven't had an impact on NASH because we're still seeing high diagnosis rates and so forth. So that they haven't they can only solve it at the highest doses. And we know that that takes time and that there are challenges with tolerability. So we really as we think about the GLP-1s coming in, It's going to be a market expansion focus that they're going to have. And we believe that given their profile and our profile, those patients are going to ultimately the majority of them anyways are going to end up on a Red Differ anyways. Because they're going to still need to treat the problem that they're having, which is now a really severe liver disease.

Right? This is not a mild disease. We hear from patients all the time, their stories of family members that have died as a result. And how grateful they are to have an opportunity to avoid that. So So we just we are fully planning on GLP-one being here. We expect that with our profile, we continue to be the product of choice in the space. And as it relates to, I think you alluded to from a kind of an even payer dynamic perspective, [indiscernible] we with our profile and with the benefit that we've shown to preventing downstream costs we think that we have an attractive profile. We've had extremely productive conversations with payers and we believe that will remain the case with or without the introduction of GLP ones.

Thank you very much.

Marvin, next question please.

Thank you. One moment for our next question.

Our next question comes from the line of Andy Chen of Wolfe Research. Your line is now open. Just curious if you can talk about the Europe launch in the second half. So I believe the European regulators, they may be less receptive to your U. S. Pricing. Can you talk about the unique challenges and opportunities there? Have you crafted a strategy to win there? In that geography? Just curious if you could share some color there. Thank you. Yes. Thanks, Andy. I mean, look, I mean, remember as we think about Europe, it's not Europe overall. It's going to be a country by country review. And we will be extremely disciplined and we have an objective of within two to three years to be positive contribution in any country that we launch in. Obviously, a key piece of that is going to be pricing. We think from an Epi perspective, there are patients there. The unmet need is there. And that tends to as a Europe overall kind of approximate U. S. Patient numbers. Now, it's on a the regulators aren't obviously involved in the pricing discussion. As you go country by country, talk to HTAs, etcetera, One of the things that I have found in previous launches is that if you have an innovative product that provides value, that there is a recognition of that value in Europe.

Clearly, we will be having discussions with each of the countries. And be making our argument as to the value of the product. Fortunately, we have really great data and we think that we will ultimately be able to support favorable pricing within Europe. However, as I said, we will be making decisions on a country by country basis. And we will pursue the countries where we believe the value of RISDIFFER is recognized.

Marvin, next question please.

Thank you. One moment for our next question. Our next question comes from the line of Ritu Barah of TD Cowen. Your line is now open.

Good morning, guys. Thanks for taking the question.

Just following up on that Bill, can you talk a little more to the health technology assessment algorithms that you are preparing to face, what What parts of the dataset that you've generated so far drive value that the national plans have, either in writing in meetings indicated they're willing to pay for? And then just a quick follow-up on the safety of the F4 open label data set that you presented today, just given even with compensated patients, they're more fragile, KOL focus has been on Things like hypoglycemia and liver events, can you give us the outlines of safety?

Yes. So first of all, with discussions in Europe with the HDAs. I mean, look, as you know, there's very formal process that you go through in each of the countries. You prepare your value dossier and we're at various stages of that depending on the country. But again, a lot of this a lot of the evaluation look at are you offsetting downstream costs etcetera. I mean, I take you back to our ISR analysis, which showed Red Zipper to be a very cost effective therapy. So again, they use slightly different tools in each country. But we will be a part of that process. And we feel that the merit that the severity of the disease And the merits of the product really do stand on their own. And we're looking forward to, I think, productive discussions that we'll have with each of those entities. Maybe Michael, do you want to comment briefly on the second question? Yes, it's an important question. So the same study, of course, included patients in other arms that had lower degrees of fibrosis And the AE type and frequency was comparable between patients with FOC and non cirrhotic diseases. It's a good question.

Thanks, Ritu. Next question please, Marvin.

Our next question comes from the line of Praful Agrawal of Cantor Fitzgerald. Your line is now open.

Hi, good morning and thank you so much for taking my questions. So maybe Bill, you had previously talked about GI docs being a little bit slower to adopt.

But maybe if you can talk about the latest trends there, what you're seeing in terms of the GIs versus hepatologists for AstraZeneca?

Thank you. Great.

Thanks for the question. Look, we're predominantly focused on hepatologists and gastroenterologists. If you just look at the numbers of those specialists, there's less than 1,000 hepatologists So when we start talking about targeting 14,000 prescribers, the overwhelming majority are gastroenterologists. So on the backs of the gastroenterologists, we've really seen this really strong performance to date. So when we talked about them coming on a little bit slower, it was a little bit more of the time that it takes to kind of wire their practice. They it's not a disease that they had been treating. So they had to hire staff in some cases if they wanted access to NITs and wanted to have their own NIT internally. So that it's just those mechanics to create the pathway within their practice. But they when they come on, they come on. And by that, I mean, the gastroenterologists I've been extremely, extremely happy with the way that they have adopted the product. And as I said, just based upon the numbers, they are really the driving [indiscernible] Of the performance that we have seen in we'll likely see in the future. Clearly, the hepatologists are, I would say, and remain further ahead in most cases just because the liver is what they are most familiar with.

They're more familiar with the disease. And their practices are probably initially a little better suited. But I'm really happy with what we've seen. We've seen some of the big super groups come on and we've seen them go from I would call, more or less dabbling to full on NASH treatment and literally treating hundreds and hundreds of patients. Many more to come. So we're feeling that the evolution of the prescriber base is in a really great place. And I would say that the breadth of prescription that we're seeing in this launch is a true standout. And something which is a great prognosticator for future uptake of the product. You need prescribers you need patients and we have both of those.

Marvin, it looks like we've got time for one more question, please.

Our next question comes from the line of Catherine O'cony of Citizens. Your line is now open.

Hi.

This is Catherine on for John.

I just have a quick question about dose adjustment in the open label two year open label extension. Well, did all patients stay at the eighty milligram dose And also just as far as patient retention dose, how many patients how many cirrhotic started the study and how many continued through the two year time point? Thank you. [indiscernible] Michael, maybe I'll turn this one over to you for those specifically. We have one hundred and twenty two patients entered the second year of of the open label extension and these data are from one hundred and one that had second BCT. [indiscernible] Thanks, Catherine. And thank you all for your time and interest today. This now concludes our call. A replay of this webcast will be available on our website in approximately two hours. Thanks for joining.

Ladies and gentlemen, thank you for your participation in today's conference. You may now disconnect. Have a wonderful day.