Amarin Corporation plc. (NASDAQ:AMRN) 2019 BMO Prescription For Success Healthcare Conference June 25, 2019 11:20 AM ET
Amarin Corporation plc。 （纳斯达克股票代码：[AMRN]）2019年BMO处方成功医疗会议2019年6月25日美国东部时间上午11:20
John Thero - President and CEO
- John Thero - 总裁兼首席执行官
Hello. President and CEO of Amarin, who'll give a presentation for about 15-20 minutes, I think, and then we'll follow-up with some Q&A. John has been at Amarin for almost 10 years, and CEO for the past five years, and I guess the old adage, patience is a virtue, couldn't be more fitting, considering the great results he got in the fall from the long-awaited REDUCE-IT outcomes study for your key product Vascepa, so congrats on that. We look forward to hearing about all that, and thank you so much for being here. So, hand it over to you.
- 你好。 Amarin的总裁兼首席执行官，我想，他会做出约15-20分钟的演讲，然后我们会跟进一些问答。 约翰已经在Amarin工作了将近10年，在过去的五年中担任首席执行官，我猜这句古老的谚语，耐心是一种美德，不可能更合适，考虑到他在秋季从长期获得的巨大成果 期待您的关键产品Vascepa的REDUCE-IT成果研究，所以恭喜。 我们期待听到所有这些，并非常感谢您的光临。 所以，把它交给你。
Thanks, Gary [ph], thanks for the welcome. As an adage I tend to like the one over here, if you follow the data it leads to good things, and particularly when you're working with excellent people, but I am here to talk about Amarin. I will be making forward-looking statements in conjunction with this presentation. Anybody considering investing in the company should review all risk factors and described in our SEC filings before investing. For those of you who have followed us for a while, we'll start with one comment which will be really the only update that I'll be providing here, which is the response to the question that I hear first from most investors today, the question of have we received any word from FDA with respect to a AdCom, and the answer to that is, no. It's been silent at this point in time. They've not told us whether they are considering one, whether they're not considering one, or maybe.
As a reminder, the sNDA that we filed with them was filed on late March, PDUFA date is September 28th, mid-cycle review is the 28th of this month, and while it is not without precedent for companies to be notified by FDA of an AdCom yea or nay before this, there is plenty of examples of companies being notified beyond this point in the review cycle, so Amarin continues to prepare for the potential AdCom. Some people would say, well, why would there be an AdCom. I would say because we're talking about the first therapy in a patient population that's measured in the millions -- potentially tens of millions of patient, and because there are some theses out there at, at least I could hypothetically come up with that the FDA might want to look at like such as emphasizing that the REDUCE-IT result is not a validation of triglyceride lowering, but rather what we studied is a patient population we elevated triglycerides and showed the multifactorial affect of Vascepa lowered cardiovascular risk, which we would agree with.
Or they might want to take on the fact that dietary supplement Omega-3's have repeatedly not worked, and want to emphasize that. The flipside of course is that Vascepa has already been in the market, been prescribed over five million times, and has had results of the study that's under review by the FDA published now into leading journals; the New England Journal of Medicine, and JAC. So we'll find out, in any case we continue to believe that we're in the range where it would be quite reasonable for the FDA to still declare an AdCom, so we are preparing, but the one update here is that we have not heard. The rest of what I will be commenting on in my prepared remarks, for those who've been following us, will not be new. I do look forward to Q&A afterwards.
As an overview, Amarin is working towards addressing a very large unmet medical need in cardiovascular risk. Cardiovascular disease, as you probably know, is an enormous and growing health burden. Current therapy, so the standard of care, whether that be for cholesterol management, blood pressure, diabetes, all are wonderful, but significant cardiovascular risk remains. We have been pioneering, as Gary has talked about, for 10 years a solution to this. Many companies have failed along the way. We, through a robust outcomes study, have shown that our drug, Vascepa, provides a very significant cardiovascular risk reduction beyond existing therapies.
提醒一下，我们向他们提交的sNDA是在3月下旬提交的，PDUFA日期是9月28日，周期中期审查是本月28日，虽然公司被FDA通知并非先例AdCom是的，或者在此之前，有很多公司在审核周期之后被通知超过这一点，因此Amarin继续为潜在的AdCom做准备。有些人会说，为什么会有一个AdCom。我想说的是因为我们谈论的是患者人群中的第一次治疗，数百万人 - 可能是数千万患者，并且因为有一些论文在那里，至少我可以假设得出美国食品和药物管理局可能希望看到像强调REDUCE-IT结果不是甘油三酯降低的验证，而是我们研究的是患者群体，我们提高甘油三酯并显示Vascepa的多因素影响降低心血管风险，我们会同意。
As these results have been published we have submitted to the FDA for approval of this expanded indication to build upon the indication that we have in the marketplace place, which is an important but niche indication for treating patients with triglycerides of 500 mgs per deciliter or greater which is more of a pancreatitis rather than a cardiovascular indication. We believe that the opportunity to be first in the market to be -- is an opportunity to address millions if not tens of millions of patients, and is an opportunity to be measured in the billions.
In terms of recent highlights, I've a little bit about the sNDA already; this is under priority review with the FDA. Again, the PDUFA date is September 28th. We, after the results of REDUCE-IT were known we expanded our commercial presence a bit. We will be expanding our commercial presence further upon the expanded label continuing to review what that expansion should be, but envisioning it being in multiple steps of starting with and increasing our sales force in the United States to between 600 and 800 reps. So now we're currently at 400, so that would be up by another 50% or potentially a doubling, and then we would be promptly submitting to OPDP to allow for consumer promotion which in their normal course typically takes about five to six months, but we would be envisioning a substantial DTC commending on a branded basis in the second quarter of next year.
We, based upon the positive results of REDUCE-IT, we have seen significant prescription increases. Greater than 50% of our prescriptions currently are all off-label. Fortunately our managed care coverage is already good. I think it will get better upon label approval, but the approval rate of our prescriptions is at right around 80%. We look forward to continuing to see prescription growth here based upon the label, and then hopefully further upon label expansion in the DTC, so it's multiple points of inflection there, and very pleasing to me is that here, in approximately seven months, since the time when we had these results presented we've already seen a market shift from early months of people trying to understand, and I'm talking about KOLs here because most docs don't yet know Vascepa.
We're looking forward to that broader education, but docs who have studied the REDUCE-IT results early on tried to understand the multifactorial effect. I think they predominantly get it at this point in time, and that the conversations at society meetings has so shifted to not to does it work but rather how do we best implemented this in our practices as therapy sort of the next treatment beyond statins, and I am very happy to be American Diabetes Association here even before the label has been expanded has provided a type A recommendation which is the high evidence recommendation for the use of the active ingredient. Our drug recommends specific drug, but they recommend the use of the active ingredient of the drug for patients who are statin treated and continue to have triglyceride levels of 135 mg/dl or greater. So that transition here even before the label approval to adoption of Vascepa is happening.
由于这些结果已经公布，我们已经向FDA提交了批准这一扩展适应症的建议，以建立我们在市场上的指示，这是治疗甘油三酯500 mg / dl或更高的患者的一个重要但适当的适应症。这更多的是胰腺炎而不是心血管疾病。我们相信，成为市场第一的机会 - 是一个机会，可以解决数百万甚至数千万患者，并且是一个以数十亿计量的机会。
我们期待更广泛的教育，但是早期研究REDUCE-IT结果的文档试图理解多因素效应。我认为他们现在主要得到它，并且社会会议上的谈话已经转变为不会起作用，而是我们如何在我们的实践中最好地实施这种治疗，作为他汀类药物以外的下一种治疗方法，以及我很高兴在这里成为美国糖尿病协会，甚至在标签扩大之前提供了A型推荐，这是使用活性成分的高证据推荐。我们的药物推荐使用特定药物，但他们建议将这种药物的有效成分用于接受他汀类药物治疗的患者，并继续使用135 mg / dl或更高的甘油三酯水平。因此，即使在标签批准采用Vascepa之前，这种转变正在发生。
Background, of course, cardiovascular risk is huge. I think people who have elevated LDL or bad cholesterol should get it managed. If you lower your cholesterol, you are lowering your cardiovascular risk by about 25% to 35%. That's great. Of course, that still leaves 65% to 75% of the risk remaining. Someone dies in the United States every 38 seconds from cardiovascular disease. It's number one cause of death more than all cancers combined.
Enormous cost here, and there is no proven therapy. We will be the first assuming that we get approved for this indication, so a huge need and huge opportunity. Identification of risk, LDL and triglycerides have been shown in various studies to be somewhat equal identifiers of risk. Lowering of LDL, bad cholesterol is shown to be directly co-related to lowering risk of -- lowering of triglycerides alone has not had as direct a correlation.
And as we get further into this presentation, you will see that we are using triglycerides as an identifier of risk, but with Vascepa addressing some of the underlying factors. You can see from this chart that risk begins to increase with triglyceride levels well below a 100 mgs/dl and then continues to go up. So, the most definitive way of evaluating the effectiveness of a therapy is through an outcome study.
And we conducted a very robust outcome study called the REDUCE-IT study which results were presented at the American Heart Association in November of last year and published in New England Journal of Medicine for Primary Results in Cardiology Watch called the number one story for 2018 in the cardiovascular area. This is a study where we took patients who were all treated with the current standard of care. So they were on statins, had their LDLs well controlled, baseline of 100 -- excuse me, 75 mg/dl. They were all below 100, and if they were diabetic, they were on diabetic meds. If they were hypertensive, they were on blood pressure meds et cetera. We took those patients, and if they had elevated triglycerides of 135 mg/dl or greater and other cardiovascular risk factors, we enrolled them in a study.
We randomized them on a one for one basis between staying on standard of care therapy plus Vascepa, or staying on standard of care therapy plus placebo, and we evaluated the results over what turned out to be an average of 4.9 years. Saw over 35,000 patients in years of study that was conducted under a special protocol assessment agreement with the FDA, and the results were terrific. So, the primary results were on the first occurrence of events. The primary endpoint was a composite 5-point MACE. So 5-point MACE consisting of heart attack, stroke, cardiovascular death, revascularization things like bypass and stents, or hospitalization for angina, and they have exceeded 25% relative risk reduction versus placebo and a lots of zeros in the P value. For those who like Hard MACE which is stroke, heart attack, and death, it jumps up to 26%, and if go to death which you don't see for most studies. In fact, you don't see in most of the statins study didn't the statistical significance on a SCV death reduction by 20%, statistically significant death, heart attack, down 31%; stroke down 28%.
这里的成本非常高，而且没有经过证实的治疗方法。我们将首先假设我们获得了此指示的批准，因此需要巨大的机会。各种研究表明，风险，低密度脂蛋白和甘油三酯的鉴定在某种程度上是相同的风险标识。降低低密度脂蛋白，坏胆固醇被证明与降低风险直接相关 - 单独降低甘油三酯没有直接相关性。
随着我们进一步深入讨论，您将看到我们使用甘油三酸酯作为风险的标识符，但Vascepa解决了一些潜在因素。从这张图表中可以看出，随着甘油三酯水平远低于100 mgs / dl，风险开始增加，然后继续上升。因此，评估治疗有效性的最明确方法是通过结果研究。
我们进行了一项非常有力的结果研究，称为REDUCE-IT研究，该研究结果于去年11月在美国心脏协会上发表，并发表在新英格兰医学杂志的心脏病学初级结果观察中称为2018年的第一个故事。心血管区。这是一项研究，我们采取了所有接受现有护理标准治疗的患者。所以他们服用他汀类药物，他们的LDL控制良好，基线为100 - 对不起，75 mg / dl。他们都低于100，如果他们是糖尿病患者，他们就是糖尿病患者。如果他们是高血压患者，他们就是血压药等。我们服用这些患者，如果他们的甘油三酯升高135 mg / dl或更高以及其他心血管危险因素，我们将他们纳入研究。
The principal investigator for the study was Dr. Deepak Bhatt, out of Harvard. He has discussed these results as being the most significant breakthrough in preventive cardiovascular care since statin, so 25 years ago. For those who like this graphically see the divide occurred pretty early throughout the one year point and what you like to see is that consistent separation there afterwards number needed to treat 21, but the result continued. So if people had heart attack or stroke or other event and survived those might add another event. So there are second events 32% reduction, third event 31%, 48% beyond that on a relative basis for an overall reduction of 30% but this translates into one fewer major adverse cardiovascular event for every six patients treated over a five year period and for those of you who like it graphically see again divide occurred early and was consistent.
The results were consistent male, female, diabetic, non-diabetic, secondary and primary prevention. Just to put the number needed to treat into perspective and we're not competing with cholesterol management drugs but our number needed to treat at 21. If you look at Lipitor or Atorvastatin you know, there's 45. You look at Repatha PCSK9 there is 67 again, no head to head studies here, but this is an important result and again that those numbers are all against first occurrence of events we go for first and recurrent events down to one in six, not seen that anywhere else.
An interesting finding of the result and again sort of speaks to the fact that Vascepa is addressing underlying factors to triglycerides is that while all the patients in the study had elevated triglycerides, the reduction was relatively consistent across triglyceride levels whether the triglycerides were 135 to 150 or 150 and above, we had seen the Japanese study the same active ingredient that you had at 19% relative risk reduction slightly lower risk patient population with only a 6% change in triglycerides. We had a pretty good idea coming into the study that this was about more than just triglyceride reduction and for those who want to go on our Web site, we have a couple of dozen publications on mechanism of action that deal with effects on inflammation to endothelial cell function to plaque formation, plaque regression, oxidation, anti-platelet et cetera sort of multifactorial effect.
The safety profile of Vascepa is pretty well-established that the drug has been prescribed over five million times and in the REDUCE-IT study with 35,000 patient years of study. The overall event rate between the Vascepa arm of the study and the placebo arm of the study was similar. There were no events of serious adverse, no serious adverse events greater than 2% greater than placebo. Keep digging you have to show something in the New England Journal of Medicine had us keep digging and we did report a few events that they considered to be low but to sort of round out the picture but overall a safety profile that's placebo like.
Just to put into perspective, the accomplishment that we're showing here again statins, lower cardiovascular risk by about 25% to 35% before going generic that was an over $20 billion market in the U.S. alone over $30 billion. Globally many people have tried to show cardiovascular risk reduction beyond statins CETP inhibitors particularly niacin firebreaks all which have failed in studies saying CDL lowering drugs that we don't compete with them but you know, is that a PCSK9 that sixth and 15%, the Qantas study an interesting study on inflammation drug probably would never really be used for this purpose to its cost and safety profile but 15% Omega-3 mixtures whether that be Lovaza has a prescription therapy which completed two outcome studies last year failed them both or the dietary supplements have been shown not to work probably in part due to the LDL increasing effect of DHA which is included in those products, but the science goes beyond that.
The only success is sort of beyond the LDL lowering here has been with pure EPA both in the Japanese study and then very significantly in this robust study that I'm talking about reduced it with 25% risk reduction. So we think we're going to be able to help millions of patients with these results and the active ingredient is unique, it isn't ripe in nature but it's been declared a new chemical entity by FDA. It is a fragile molecule. Isolating it and keeping it stable is not a trivial exercise. We've put a lot of science into being able to do that. Its smaller size allows it get into the endothelial cell in a way that other Omega-3s and other agents haven't been shown to be able to do, which then improves endothelial cell function, endothelial cell signaling, which seems to have a downstream effect of lower inflammation and plaque formation, et cetera.
Conversely, something like DHA, which is a little bit longer, has a more difficult time getting into the endothelial cells and tends to be disruptive, doesn't have the reduction in inflation, doesn't have the -- in fact, ends up resulting in LDL going up, and I'll save time for Q&A here by not going into mechanism of action in more detail, but somebody who is interested in the multifactorial affect please look at our Web site, we have dozens of publications on these. This slide really lists the eight key steps in the formation of Atherosclerosis and EPA are their active ingredient. Eicosapentaenoic acid is the only molecule that's been shown to have a positive affect on all of these eight key factors.
Our primary focus today is the U.S. market. We have increased our sales presence modestly to start, this year. As I described earlier, we intend to increase it further, both in terms of the reach that we will have to docs, but also the frequency with which we're calling on physicians then to be complimented by DTC. The feedback we're hearing from physicians is very positive. Managed care coverage is already very good, and we look forward that to that expanding further upon our label approval expansion. We have been building our supply chain and staying out ahead of this, we came into this year with the guidance on revenues in which guidance was based upon assumed standard review of 10 months, rather than a priority review of revenues of $350 million, we came in with capacity to support about a billion dollars in revenue. So, from a supply perspective we're looking forward to expanding that and working with our suppliers to do so.
相反，像DHA这样的东西，有点长，进入内皮细胞更困难，往往是破坏性的，没有减少通货膨胀，没有 - 事实上，最终导致LDL上升，我将通过更详细地讨论行动机制来节省问答时间，但是对于多因素影响感兴趣的人请查看我们的网站，我们有很多关于这些的出版物。这张幻灯片确实列出了动脉粥样硬化形成的八个关键步骤，EPA是其活性成分。二十碳五烯酸是唯一被证明对所有这八个关键因素产生积极影响的分子。
We've got now over 200 patents globally most with expiries in 2030, and internationally, we have a partner in Canada that has priority review there. We have some approvals in the Middle East that started, and other applications there, a trial going on with a partner in China where we're positioned to be first to market, and we're considering various pathways in Europe with an aim towards having a submission to EMA sometime around the end of this year, and just a sort of a near closing caption, so if we think about cholesterol management 25 years ago you're moving from resins and other therapies which weren't particularly convenient and weren't entirely proven without outcomes data to statin therapy. We think that the opportunity is similar here for risk management beyond LDL, and we're moving away from therapies that have been used for millions of patients but that haven't been proven successful, to now finally having a drug where there is a successful preventative result, and we've priced the drug affordably, like statins are with the hope that this can be a mass use to help millions of patients. Financially, we ended last quarter with about $211 million in cash. We do have a little bit of a royalty remaining, but no traditional debt, and we've got some loss carry forwards that are substantial, about $800 million, that I look forward to working through.
And with that I conclude my prepared comments, and I'll sit down and see what questions I might --
Yes, excellent. Thanks for that overview. John, that was great.
是的，非常好。 感谢您的概述。 约翰，那很棒。
So my first question is do you have a sense from FDA if you're going to have an advisory panel yet or not?
Zero words so far.
I'm joking. You only said that for about five minutes.
I spoke for a while. I thought maybe that was last of the music.
I was awake in the beginning. No, the real question is --
我一开始很清醒。 不，真正的问题是 -
I will by the way, just for the audience, comment that because we get this question almost daily. If we find out something definitive on that topic from the FDA we will let -- we will publicly state it, but until we have something definitive, you know.
顺便说一下，我会为观众发表评论，因为我们几乎每天都会收到这个问题。 如果我们从FDA那里找到关于该主题的确定性内容，我们会公开说明 - 但是在我们确定了一些确定的内容之前，你知道。
Okay. The question is more around what is the likelihood that you do get the expanded indication? And like just looking at other analogues for other cardiovascular drugs or even drugs in other categories where they have outcomes studies, the kind of data that you have, is there precedent that makes you pretty confident that it's just a question of when and not if?
好的。 问题在于您获得扩展指示的可能性有多大？ 就像只看其他心血管药物的其他类似物，甚至是他们有结果研究的其他类别的药物，你拥有的那种数据，是否有先例让你相信它只是一个什么时候的问题？
So this trial was conducted under a special protocol assessment agreement with the FDA. They -- we along the way because we had a long trial reaffirm that SPA with them, and the results have now been presented in multiple scientific congresses, and published in two leading journals. We were taken over the coals with the reviewers at those various journals, I think we're in very good stead, but there's always the unknown, but we've got a high degree of confidence in the likely approval of this sNDA.
因此，该试验是在与FDA的特殊方案评估协议下进行的。 他们 - 我们一路走来，因为我们进行了长时间的试验，重申SPA与他们一起，结果现已在多个科学大会上发表，并在两个主要期刊上发表。 我们在各种期刊上与审稿人一起接管了煤炭，我认为我们处于非常好的状态，但总有一些未知，但我们对这个sNDA的可能获得批准有很高的信心。
Okay. And you highlighted the prescription trends have accelerated very nicely, so it's being used off label. Physicians obviously are grabbing on to the data and a lot more comfortable with the benefits of Vascepa, but so even if you don't get the expanded label how much does that really matter? Obviously it helped, and then you could promote it more aggressively, but within the physician community it seems like it's out there.
好的。 并且你强调处方趋势已经非常好地加速，所以它被用于标签之外。 医生显然正在抓住数据，并且对Vascepa的好处更加舒服，但即使你没有得到扩展标签，这真的有多重要？ 显然它有所帮助，然后你可以更积极地推广它，但在医生社区内，它似乎就在那里。
Physicians are beginning to learn about it, and as they are learning about it beginning to use it more. There's about 660,000 docs who prescribe statins, we're calling on a little over 50,000 of them. We look forward to being able to expand our promotion on call on more of them. The hypothetical of our not getting approved and what that would mean, I really can't go down that rabbit hole because I cant think of the reason why we wouldn't be approved, and not knowing what that reason is I'd have a hard time saying what the impact would be where -- we are planning for success, and we think that we're well positioned for that.
医生们开始了解它，并且正在学习它开始更多地使用它。 大约有660,000名医生开了他汀类药物，我们要求他们服用超过50,000名。 我们期待能够在更多的电话会议上扩大我们的促销活动。 假设我们没有得到批准，这意味着什么，我真的不能说那个兔子洞，因为我无法想到我们不会被批准的原因，也不知道我的原因是什么 很难说影响会在哪里 - 我们正在计划成功，我们认为我们已经做好了准备。
Okay. And then you touched briefly on the patents that you have on the product, but maybe just spend another minute or so, just how comfortable you are? I forget if there are ANDA filers already on a product and you're in the middle of litigation. So just give us an update there, and is there actually any potential lifecycle extension beyond the REDUCE-IT data, which I'm sure you could try and file for patents around that I would imagine, but is there anything else in terms of the ingredient itself or things that you're working on to try and extend the lifecycle of the franchise even further?
好的。 然后你简要介绍了你对产品的专利，但也许只花了一分钟左右，你有多舒服？ 我忘了如果产品上已经有ANDA申报者而你正处于诉讼中。 那么请在那里给我们一个更新，实际上除了REDUCE-IT数据之外还有任何潜在的生命周期扩展，我相信你可以尝试为我想象的专利申请，但是还有什么其他方面的 成分本身或你正在努力尝试延长特许经营生命周期的东西？
So regarding patents, the majority of our patents go to 2030, and some potentially beyond. Regarding the tail-end of your question about lifecycle management, we've got plenty of time to think about that. In terms of the here and now, there are ANDA filers, ironically sort of insulting if there wouldn't be ANDA filers around a good drug. There were four; Apotex sort of removed themselves from the process relatively early. Teva settled. They could come into the market with a generic in the second-half of 2029, so a little over 10 years from now. There are two remaining ANDA filers, Dr. Reddy's and Hikma. Claims, construction, the Markman hearings are done. We did very well in those, more recently procedurally. The court has allowed us to introduce the results of the REDUCE-IT study, which we think supports the uniqueness of Vascepa.
There is a court data scheduled for opening hearings on January 13th, if it goes to court then we likely would have a judgment coming out of that two to three months later. We've asserted 14 of our Orange Book list of patents, each have multiple claims and we intend to defend those vigorously.
Okay. By the way, if there are any questions in the audience just raise your hand, we'll get a mic over to you. Or we have an app. You could always put it through the app. Okay, I will keep going. So, you also briefly touched on the manufacturing and the capacity, and you're working towards a billion. So, how much of a natural barrier is that, like how difficult is the manufacturing process see of you to get from where you are to the $1 billion, and then potentially to get to the next level in order to really satisfy the market?
好的。 顺便说一句，如果观众有任何问题只需举手，我们就会给你一个麦克风。 或者我们有一个应用程序。 你可以随时通过应用程序。 好的，我会坚持下去。 所以，你还简要地谈到了制造业和产能，你正努力达到十亿。 那么，一个天然的障碍是多少，比如制造过程看到你从10亿美元到10亿美元的难度，然后为了真正满足市场需要更上一层楼？
So learning -- and our manufacturing process is complex. So we've got a very fragile molecule and isolating it and keeping it stable, and we are very proud that we've got a proven four-year shelf life is important, right? So if somebody thinks about sort of normal fish oil, you open it and you then smell it, the odor you know, get a little bit of fishy taste, that's rotting basically, but it's oxidation and you tend to take a product from antioxidant or pro-oxidant which we don't think is necessarily helpful. Being able to isolate this unique molecule in a way that doesn't damage it and then being able to keep it stable over an extended period of time is tricky. You can think about a drug like Lovaza, which is easy to manufacture. They left in 16% of other stuff. Either they didn't know that that other stuff was not necessarily helpful or I think more likely it was just too difficult to remove.
Our view is this is a important drug and we shouldn't have 16% of other stuff in there. That volume in the body is important relative to our active ingredient. So, we want our drug to be all of this active ingredient. While many -- rather there is a limited number of companies in the world who can manufacture it, and some of those have failed as we have tried to work with them including some large industrial concerns. The companies that we have been working with are suppliers and now have been working with them multiple years have figured it out, and learning how to do it to begin with is tricky. Replicating it once you have figured it out seems to be relatively straightforward. So, we are using a model of having multiple suppliers competing with one another. We are pleased that they are each looking to find ways to continue to improve on the cost side of things although this is never going to be a cheap product to manufacture.
Our margins right now are around 76%, but also they are also trying to impress us with their ability to expand supply with the belief that if they are able to have more supply that we will commit to be purchasing greater percentages of them as we grow, and we are pleased to be working with such great suppliers.
所以学习 - 和我们的制造过程是复杂的。所以我们有一个非常脆弱的分子并隔离它并保持稳定，我们非常自豪我们已经证明了四年的保质期很重要，对吗？因此，如果有人想到正常的鱼油，你打开它，然后你闻到它，你知道的气味，得到一点鱼腥味，基本上腐烂，但它是氧化，你倾向于从抗氧化剂或我们认为不能帮助的促氧化剂。能够以不损害它的方式分离这种独特的分子，然后能够在长时间内保持稳定是很棘手的。您可以考虑像Lovaza这样易于制造的药物。他们留下了16％的其他东西。要么他们不知道其他东西不一定有用，或者我认为更难以删除。
我们认为这是一种重要的药物，我们不应该有16％的其他东西。相对于我们的活性成分，体内的体积是重要的。因此，我们希望我们的药物都是这种活性成分。虽然很多 - 而且世界上有限数量的公司可以制造它，其中一些公司已经失败了，因为我们试图与它们合作，包括一些大的工业问题。我们一直与之合作的公司是供应商，现在已与他们合作多年已经弄明白，并且学习如何开始这样做是非常棘手的。一旦你弄明白它就复制它似乎相对简单。因此，我们使用的模型是让多个供应商相互竞争。我们很高兴他们每个人都希望找到继续改进成本方面的方法，尽管这绝不是一个廉价的制造产品。
Okay, great. On the commercial side, so you recently increased the sale force to 400 reps, and you are considering taking that up to 600 - 800. So how many -- so I think the target physician audience could be 50,000, right, or north of that, but how many of these incremental physicians are primary care? And how important is that segment for the overall use of the product going forward?
好，太棒了。 在商业方面，所以你最近将销售力量增加到400次，而你正在考虑将其提高到600 - 800.那么有多少 - 所以我认为目标医生的观众可能是50,000，正确或北部 ，但这些增量医生中有多少是初级保健？ 这个细分市场对整个产品的使用有多重要？
So, what we are doing right now is continue to do analysis. We are seeing that with the doctors that we are calling on, which is today about 50,000 or little over 50,000, about 80% of those are primary care. About 12% of those are cardiologist. About 7% of those are endocrinologist, and then there is a rounding in there for other disciplines. Those who tend to the more data drive particularly the cardiologists and endocrinologists have shown the greatest percentage growth, but many of the GPs are showing growth as well. With our existing sales force, we are actually getting to see some of the no-see docs much more than what we were expecting. The overall balance is such that with our current staffing that many doctors have been to sort of our target of blocks me seven times to roughly the third quarter of this year.
So we are seeing growth for that is terrific, but we do think we need to have greater frequency of calls on our existing targets, and there are many additional targets out there that we are addressing. Some of those will be addressed through education -- medical education programs. Some of them addressed through digital means but we do think calling on additional docs. So we are seeing that there are trends. Urban docs tend to prescribe or change practice behaviors faster than suburban docs; group practice docs faster than single practitioners.
Younger docs tend to change faster than older docs, but there is exceptions to all these. We are trying to take all that data and figure out the best path is going forward, but the consistent feedback we are getting is that these results are robust and regularly hearing from docs that they want to use Vascepa on many of their patients. Some of them are doing it already. Others are looking for the label to be expanded before acting more aggressively.
所以我们看到增长非常好，但我们确实认为我们需要对现有目标进行更频繁的调用，并且我们正在解决许多其他目标。其中一些将通过教育 - 医学教育计划来解决。其中一些通过数字方式解决，但我们确实认为需要额外的文档。所以我们看到有趋势。城市文档倾向于比郊区文档更快地规定或改变实践行为;小组练习文档比单个练习者更快。
Okay. And how much additional work needs to be done on the payer side? It sounds like it's been going through in most cases even if it's for off-label use, but do you need to get this expanded indication before I don't know, the gates really open up in terms of reimbursement? Or the way you described it, it sounds like really isn't that much pushback, and maybe just throw in there the price on a relative basis and how payers are thinking about that in the context of the whole pharmaco-economic analysis with this outcome study?
好的。 还有多少工作需要在付款方面完成？ 在大多数情况下，即使是在标签外使用，这听起来似乎已经过去了，但是在我不知道之前，你是否需要获得这个扩展的指示，这些大门在报销方面是否真的开放了？ 或者你描述它的方式，听起来真的不是那么多的推迟，也许只是在相关的基础上投入价格以及付款人如何在整个药物经济分析的背景下考虑这个结果 研究？
So, we have been competing for six years against generic products, and our approval rate and coverage is pretty good, but there are opportunities for improvement. So, today greater than 50% of our prescriptions are off-label. The approval rate overall for our drug with managed care is just slightly below 80%, which is neck in neck with generics and of level that most drugs we are very pleased with.
In terms of coverage and Medicare Part D, we have got over 90% adult lives in the United States covered predominantly on tier 2 unrestricted and over 80% of commercial lives covered predominantly on tier 2 unrestricted, but within that, you have some holdouts and there are some managed care plans that just by their policies won't provide coverage until you have a label. So there is opportunity to improve there.
Many physicians are still very new to Vascepa, and where the drug is new to them, they will assume that coverage doesn't exist even if it does exist, and of course, if they have 10 patients and one doesn't get coverage, they remember the one that doesn't. So, I think -- I am on Vascepa. I have been taking it for six years now. Unfortunately off-label and my insurance company has never pushback on myself or my physician. I am happy to be taking it. Many payers are that way, but there are some that where coverage could improve, and we are looking forward to that happening.
许多医生对Vascepa来说仍然是一个新手，并且药物对他们来说是新的，他们会认为即使它确实存在也不存在，当然，如果他们有10名患者且其中一名没有得到报道，他们记得没有的那个。所以，我想 - 我在Vascepa。我已经服用了六年了。不幸的是，不合格的我和我的保险公司从未对自己或我的医生施压。我很高兴接受它。许多付款人都是这样，但也有一些付款人可以改善，我们期待着这种情况发生。
Okay. And just in terms of net pricing and I don't know there is a change at all given all the robustness of the data and the value prop that you could bring to the payers?
There will likely be at least one if not two pharmaco-economic analyses presented this year. If those economic analysis are consistent with and some people argue whether they are always consistent or not, but if they are consistent with the methodologies that have used say for PCSK9s, where I price is about a fifth of where the PCSK9s were when those analysis were done and our number we didn't treat is considerable lower as we talk. Those analyses should turn out favorable.
That being said, our current pricing is similar to where statins were you to adjust for inflation. Like this is more like where Atorvastatin would be. A little bit lower than where Crestor or Rosuvastatin was, and we think by doing that, we are positioned for mass use as an affordable product, and this is much of a high volume opportunity than it is pricing opportunity.
今年可能会有至少一项（如果不是两项）药物经济学分析。 如果这些经济分析是一致的，并且有些人认为它们是否始终是一致的，但是如果它们与PCSK9使用的方法一致，那么我的价格大约是PCSK9的五分之一。 在我们谈话时，我们没有对待的数量相当低。 那些分析应该是有利的。
话虽如此，我们目前的定价与他汀类药物的通胀调整相似。 像这样更像阿托伐他汀。 比Crestor或Rosuvastatin低一点，我们认为，通过这样做，我们可以作为一种经济实惠的产品进行大规模使用，这是一个很大的机会，而不是定价机会。
Okay. Excellent. We will end on that note. Thank you so much for being here, John. We all appreciate it, and thanks everyone for coming. Enjoy the rest of the conference.
好的。 优秀。 我们将以此说明结束。 非常感谢你在这里，约翰。 我们都很感激，并感谢大家的到来。 享受会议的其余部分。
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