Bristol-Myers Squibb Company (NYSE:BMY) Guggenheim Securities Inaugural Healthcare Innovation Conference November 11, 2024 10:00 AM ET

Company Participants

Samit Hirawat - EVP, Chief Medical Officer, Global Drug Development
Robert Plenge - EVP, Chief Research Officer

Conference Call Participants

Seamus Fernandez - Guggenheim

Seamus Fernandez

Okay. So, in the interest of staying on time here, really pleased to have Bristol Myers Squibb joining us. To my immediate right is, Samit Hirawat. He is the Chief Medical Officer and Head of Global Drug Development at Bristol Myers, and Robert Plenge, who is the Chief Research Officer at Bristol Myers as well.

We are actually going to be running a bit longer than the 25 minutes that is posted up there. We're actually going for the full 50 minutes, so just so everybody knows, as on the calendar and on the schedule. So maybe, Samit, just to start big picture rather than diving right into some competitive data, let's start with, you know, kind of six months ago. You know, we saw Bristol stock at $40 a share. Sentiment was uniquely cautious. And, while the threat of generics is unchanged, shares are now trading at $55. From your position in R&D, obviously, what's changed?

Question-and-Answer Session

A - Samit Hirawat

I think those shares might be a little bit different right now.

Seamus Fernandez

Yeah. Maybe might be different.

Samit Hirawat

Keep it to that. But, look, a lot has changed since, and I'll start maybe at the end of last year. Our company profile changed, began to emerge very differently. As we thought about, strengthening our portfolio and how we take care of what was in front of us, we knew that there are LOEs that are coming through. Also, there was no clarity in terms of the IRA, as to how things will land, and now we have that clarity. So those are just the top-line. But I think mostly what has changed now is emergence of our pipeline, which is much stronger, much deeper, much broader.

We added Mirati. We added Karuna. We added, RayzeBio from a portfolio perspective, all in the oncology space in the intent -- with the intent that we needed to move beyond immune-oncology, which was the base for our overall oncology portfolio. We added a ADC through collaboration in China, bringing that into it. So with modality wise, we broadened ourselves, and went deeper into small molecules, antibodies, ADC, and then adding a radioligand therapy.

In a similar way, we went through the portfolio prioritization and looked at opportunities where we don't need to play because the efficacy was not reading out in the right way, or safety was not there, or when we thought about, where we're going in terms of being first-in-class that was not meeting the vision that we had set for ourselves. So we took out some of those molecules from the pipeline. But very importantly, once we added, Karuna into our portfolio, we needed to get that approval. And that approval actually just happened, in September. So that was a very, very important medicine that we wanted to add.

As we defined our resurgence into Neuropsych, remember 20 years ago, we had ABILIFY, and now we have COBENFY for schizophrenia. And that's just the beginning of it. We have six other indications that are to follow after that. We also changed our ways of working a little bit in term -- we had done some work the year before and then last year, as well looking at our, R&D ways of working in terms of timelines, et cetera. And we certainly were not the best. And so we went deep into it and reviewed our ways of working from all the way from developing our concept to our execution of clinical trials and then taking them into submission and approval mode.

And so we have begun to change that narrative. Two years ago, remember at R&D day, was it last year, where we presented that we are -- we'll be looking at our productivity from an [Indegene] (ph) perspective, at least 10 INDs, bringing into the, into the framework, as well as looking at a median of 6.5 years from IND approval to -- approval for first indications, as well as, increasing the positive outcomes from our IND to 20% where the industry average is 10% to 11% right now. And we are on that trend. We are working towards that. And as we think about 2025 and 2026 from R&D perspective, these are the years of data generation and certainly data and execution. And then 2026, of course, about 10 to 12 or 15 studies that we'll read out as Phase 3 studies.

So overall picture as we think about the future, we'll we know that what we have in front of us from a legacy portfolio going down, but we also know a very young, first-in-class portfolio that is continuing to emerge now, growth portfolio contributing more than 50% to our revenues. And by the end of the year -- end of the decade, we also look forward to emerging in accelerated fashion now.

Seamus Fernandez

Great. And, Robert, maybe you can just, chime in on the sort of the focusing of the portfolio and working with Summit to, you know, really kind of streamline the portfolio?

Robert Plenge

Yeah. So, we'd like to start by talking about our principles that we use for a lot of our decision making, and that includes principles for starting new programs, for prioritizing programs, or business development decisions as well. And if you think about just the linear sequence of events for drug discovery, you start with a target, and so we refer to picking the right targets as really leaning into human data, and in particular, what we call causal human biology. Then matching a modality to a mechanism, and there -- it's just about making the right molecule against the right molecular mechanism of action. And third, going from research into early development in particular. That's really when you begin to know if a drug is going to behave the way that you think it's going to behave and see early evidence of clinical efficacy and a good safety profile.

So we call that path to clinical proof-of-concept, and then really once you begin to see that, that's when you really want to be even more aggressive in terms of clinical development timelines and potentially concentrating risk across multiple indications. And then finally, ensuring that you have the right data generation package to position the medicine in the real world, so you have the right market access, and of course, a lot of that has to do with working very closely with our development colleagues.

So you can take those five principles, casual human biology, matching modality to mechanism, path to clinical proof-of-concept, high quality, not just speed, but high quality clinical development, and then -- and market access. And you can begin to use that framework for programs that you decide to start in research, prioritization decisions in development, business development decisions. And so for each and every one, you can say, okay -- we really like -- we'll probably come back to milvexian. We really like the target for milvexian.

We have a small molecule against not just Factor 11, but Factor 11a, the activated form. We know that it works in a particular way. We saw and did the right early clinical development work, so we say, we see in a venous thromboembolism, VTE study, a dose dependent decrease in in clot, so a surrogate for efficacy, without a dose dependent change in bleeding range. We do all the right clinical pharmacology modeling to say this is the dose that we think will be effective in Afib and maybe a different dose that's going to be effective in other indications, such as SSP.

And then deciding to concentrate clinical development across these three areas and ensuring that and we can get back to why we increased the sample size, but ensuring that the timeline for readouts for all of those are beginning to become synchronized, which is important for that fifth-principle market access. So we apply those five principles to all of these different decision making, this decision making framework, and I think that's a very valuable way for us to, I think, make the right sets of decisions all along the way.

Seamus Fernandez

Great. And, there's -- I guess, risk profile in drug development and kind of the consideration of competitive assets. We just got competitive data this morning. What -- in terms of your sort of team development approach, drew you to COBENFY, and what sort of maintains and sustains your excitement for that program and that product as we enter the sort of full launch in 2025, and, advancing from there?

Samit Hirawat

You want to start from the side?

Robert Plenge

Well, yeah, I'll start, and then we can kind of broaden into the various indications that we're going into. So if you go back to those five principles, we had really strong conviction in the M1/M4 direct agonist hypothesis, which is different than M4 alone, different than partial Allosteric Modulator versus Positive Allosteric Modulator versus a direct-acting agonist. So, and that came from the causal human biology of [xanomeline] (ph) in clinical trials in 1990s. So that was the first principle. But the second principle, matching modality to mechanism, you can have a brain penetrant molecule that actually is M1/M4 direct acting, but you have the side effect profile that comes with agonizing those receptors, in the periphery. So that's where trospium comes in.

So now you have very strong therapeutic hypothesis based in causal human biology, xanomeline in-patients. We have the right molecule, M1/M4 agonist with the protective effects of trospium in the periphery.

in the periphery. Karuna did the right early development clinical studies began to see that it was working. And then I think very importantly, the accelerated high-quality clinical development to control-placebo rates while seeing the benefit. So there's a lot of really important patient selection, just making sure you are monitoring the study in the right way and then ultimately, the approval and making sure we get it to the right patients.

So we can then take those same principles and say, okay, we are going to do a number of other indications as well because of our degree of confidence. So adjuvants, schizophrenia, Alzheimer's disease psychosis, et cetera. And Samit can talk more about those trials.

Samit Hirawat

I think from a clinical perspective, you've seen the data come out this morning. And it's unfortunate from the patient perspective because this is a very large indication in market and certainly having more than one modality. We've seen that D2 agonist there are so many of them, and they're all utilized. With that said though, what we see at least from the first data set that we've seen in the public domain that we seen -- several things happened. Placebo rates are high compared to what we saw with COBENFY.

Robert Plenge

Just to clarify – we want to make sure that – taking about Emraclidine.

Samit Hirawat

Yes. This is Emraclidine. Emraclidine data just came out and they just released on the press release. And what we've seen is the placebo rates are high, so change from baseline to post-treatment patients on placebo have a 16-point decrease, I think in one of the trials and about the same in the other one. The treatment arms also have not performed as well. So that's why the difference between placebo and treatment is two to three points only.

And then one other thing, which no pun intended, atypical for a trial is that the lower dose, 15-milligram actually performed better than the 30 milligram. So lots going on over there. As you reminded me earlier today that if you think about COBENFY, EMERGENT-1, EMERGENT-2, EMERGENT-3 China study, they all very consistently showed similar results from a treatment perspective and the outcomes of these patients' perspective. And now EMERGENT-4 and EMERGENT-5 have given us data all the way up to one-year follow-up from these patients.

And the efficacy is maintained. Side Effect profile doesn't get worsened. And so we do know that there are initial phases where there's nausea and vomiting, but that goes away over a few weeks, and then patients continue to get benefit. So I think lots going on for COBENFY. And certainly, adjunctive schizophrenia will be the next readout only 2025, followed by ADEPT trials for ADP. And then next year, we are starting bipolar disorder, Alzheimer disease agitation, enzyme disease cognition trials. And then in 2026, most likely autism will come in once we've done some juvenile tox work, et cetera.

Seamus Fernandez

Right. And when we just sort of think about the big opportunities incremental to schizophrenia, obviously, the things that come to mind are always bipolar depression sort of first and foremost as a major driver of commercial uptake and commercial opportunity. But Alzheimer's agitation is also seeing a resurgence. Maybe talk a little bit about the profile that you think COBENFY offers in Alzheimer's agitation in particular? And then what's the hope for this mechanism in bipolar depression potentially?

Samit Hirawat

It’s Bipolar Mania actually, that we'll be pursuing. Yeah. It’s Bipolar Mania because --.

Seamus Fernandez

Is there a profile in or is there an opportunity in bipolar depression in your view?

Samit Hirawat

Probably not this molecule, but then there are many other things that one could pursue going forward. Certainly, please feel free to add in. But if you think about Alzheimer's disease and as Robert has mentioned many times before and we've talked about it, one of the things that's happening in Alzheimer's disease is, there is a decreased or paucity of acetylcholine. And that's why direct agonism becomes so important, whereas M4 PAMs required that ligand in terms of acetylcholine to be present, and that's what we talked about this morning that it's difficult to imagine developing a drug that does not have a direct agonistic effect on the muscarinic receptors. So that is the biology that supports us going forward in Alzheimer's disease psychosis, agitation and cognition.

We also knew that -- not all three indications can be folded into one because the regulators wanted to see individual indications being followed with the profile of the patient. With those subjective tools that we have, that's one of the things that I always cringe on that Neuropsych is running behind, and we'll have to do a lot of work in terms of continuing to engage physicians so that we don't fall in the same trap of placebo rates being higher and having the subjectivity taken out of all of this as much as possible.

So agitation has a profile that we've already begun to see some of the data emerge from even the early studies in 1997 and then in the schizophrenia program, how patients who are in the psych, let's say, spectrum or psychosis spectrum or agitated how they are performing. And so having the profile that fits very nicely in terms of positive symptoms, as well as the negative symptoms and some improvement in cognition gives us a lot more in terms of confidence of readout of these studies. But of course, we'll only see it in -- starting next year and then beyond.

Seamus Fernandez

Okay. And then for one of the critiques of COBENFY has been, one tolerability is sort of one critique. But maybe the bigger one that some physicians we've talked to have sort of critiqued as the twice-daily profile and the challenge of treating a schizophrenia patient with a twice-a-day drug. How challenging is that in your view? And then separately, what are you doing to basically potentially bring a once daily or perhaps even a long-acting?

Samit Hirawat

Yes. So the intent is not to convert it to once daily because of the metabolic profile of the drug, we certainly do believe that the – first-of-all, getting the ratios right was very important, and Karuna did a wonderful job. In defining the ratio of xanomeline to trospium 5: 1 in the first studies of schizophrenia and then did the study in healthy elderly volunteers to look at what would be required for AD psychosis and there, the ratio is 10:1. And so that has been taken forward as a three times a day dosing because of the metabolism that occurs.

But remember, patients with schizophrenia. How many drugs they are already on. On an average, there are five to seven drugs they're already on. So adding another one that has a side effect profile that is very different than what they are taking today, the atypicals. And that certainly bodes well, as well as seen differently from physicians and patient perspective. So as the beginning, we are starting with a monotherapy for COBENFY. But the Adjunctive Schizophrenia trial is ongoing, which adds COBENFY on top of the background therapies. So what we've not heard, and certainly, had the data read out differently for Emraclidine, this would have been a continuous dialogue QD BID, QD BID.

But right now, I think BID is what we have. And we have not heard anything major in terms of BID is going to be a detriment to prescribing it, et cetera. And the easy way to think about it, take it as soon as you wake up and take it as you're going to sleep. So BID fits from that paradigm perspective, and that's the way physicians also think about it. Patients will be thinking about it. We have not heard anything wrong, anything untoward from that perspective. We continue to work on a formulation even for the agitation and psychosis trials where we want to provide a BID formulation for these patients, as well as we go forward. So that should be instituted in the next trial that we start and agitation cognition bipolar. And hopefully, we'll be able to bridge it back into psychosis as well to convert that into a BID.

Seamus Fernandez

Great. Robert, you mentioned milvexian. We got some updates on the third quarter results conference call. Maybe you could just walk us through some of those updates, but also a little bit of the battle that you've actually had to fight in the wake of another competitive failure. I mean I would also argue like thankfully, this other -- maybe the trial hadn't failed in the midst of your own Phase III clinical program, as it relates to COBENFY. But the asundexian situation from buyer really put -- was a headwind for the milvexian program. Maybe tell us how you feel about it today.

Robert Plenge

Okay. Well I'll start and Samit can actually fill in the details on the clinical trial acceleration and the expanded sample size. But I mean this is such a hard business and to have really strong conviction in those principles that I mentioned at the very beginning, that guides a lot of what we do. So if you take and apply those principles again to milvexian, Factor 11, great genetically validated target and we had a molecule that we believe could actually inhibit it in the way that we thought could actually recapitulate that human biology. But we also did a tremendous amount of work in our preclinical animal models, and this rabbit model of arterial thrombosis in particular where we could actually test milvexian against apixaban against asundexian against Factor 11 ASOs to say, all right, this is the level of inhibition that's actually required for clinical benefit with a decreased bleeding risk.

Animal models or animal models, these do have predictive value. We've published a lot on these animal models. So you can read about them. But you need to get into clinical development, and we did really good, very extensive early clinical development, not just in healthy volunteers, but in venous thromboembolism VTE studies that allows us to test a very broad dose range and depict the right dose for the right indication where we saw a dose dependent decrease in rates of thrombosis surrogate for efficacy here without a dose-dependent increase in any bleeding.

So now we have, we think not just the right target, the right molecule. Now we've done the right early clinical development study, and we did a tremendous amount of clinical pharmacology modeling to say, all right here are the exposures, here are the responses. We take that back, look in the animal model data, compare it to apixaban and ultimately, we say these are the right doses. Of course, at that point, you are placing an enormous bet down on what you think is the right dose for a very large expensive Phase III study. But that's where conviction matters. And suddenly, you say, okay, we believe we have the right molecule, the right dose and now we're going to do the large Phase III clinical trials, and Samit can provide the details, but it's moving in the right direction, I think.

Samit Hirawat

I think the only thing I would add to what Robert is saying, number one, 3 times now in the last just few months that it has happened that gives me conviction that we've got wonderful scientists in the lab, wonderful drug developers. Because it's not that we didn't look at the competitive molecule when we were looking at Karuna. We did -- and we decided to go with Karuna. Milvexian came out of our own labs. LPA1 came out of our own labs.

So thankfully, we are making progress in the right direction with the right attitude, right thinking, right conviction, right science behind it for all the principles that Robert talked about. So hopefully it continues, and I would rather be on this side of it than the other. And for milvexian, I think what we learned from the data that were presented earlier this year was truly the right Phase II trials are so important to pick the right dose.

We did a 16-fold range in terms of looking at the various doses and then said, okay there is a differential dose that we'll need to pick for atrial fibrillation as opposed to when you're combining with a background therapy of antiplatelet agents. So we went with a single agent as in our 100 milligrams BID for AF. If you remember the competitive molecule, the maximal dose tested was 50, and they just went with 50. And then for ACS and SSP, we went with 25 BID with a background therapy of antiplatelet agents, when they're as well with 50. So we'll see what happens ultimately.

But we are confident. We look -- continue to enroll in our trial. You just saw that we increased our sample size because our event rates are very low. And so to catch up on those event rates, we've increased the sample size so that we can keep the overall time lines in 2027 readout.

Seamus Fernandez

Right. And your confidence and conviction that the result is just like clearly is not an asundexian result seems extremely high at this point. Can you just remind us why it's so high?

Samit Hirawat

So what we saw in our clinical trials, as Robert pointed out, we did see a dose dependent an increase in efficacy without a dose-dependent increase in safety or bleeds. Second, the preclinical experiments and now of course, we've seen the clinical experiment as well, asundexian had 3 times the event rates for strokes and thrombosis, as opposed to apixaban within the same study. Apixaban actually overperformed compared to what the assumptions are.

If you recall our assumption in our clinical trial at the end of the study would be 1.33 events per 100 patient years. Apixaban was 1.03, asundexian was 2.33%, I think. And so when we look at our trial, our event rate, blended event rate overall in a blinded fashion is running much lower. So as we go forward, picking the right dose without added safety issues because the DMC continues to look at the data, gives us confidence that we are in the right direction. And they said they didn't say no to us increasing the sample size as well. So I think overall, we feel good where we are. But of course, when the Phase III reads out, then only we'll know what ultimately transpires.

Seamus Fernandez

And in previous conversations, you mentioned, it is important to keep in mind this is a non-inferiority trial design. Can you just help everybody understand why it's okay in a non-inferiority trial design to increase the size of a study and not be concerned?

Samit Hirawat

Yes. So non-inferiority really means that both your drugs will be similar in terms of the efficacy, but our hope over here is that from a safety perspective, this will have a better profile. Now as we think about the event rate, as we said we were hoping for 1.33. Right now, we're running behind. There are only two ways to keep watching it now, either you just wait for events to happen, but then it will read out much later or you can increase the sample size, so you can accumulate more events.

So we wanted to keep the 2027 time line in hand. The reason for doing that is we wanted to have the three studies read out in close proximity to each other. And the other two are running as planned, and they should read out in 2026. So getting SSP, ACS in 2026 and AF in 2027 gives us that ability to bring all of this together. And we've always talked about in the era of IRA, it is going to be important to have the maximization of that commercial potential starting right at the beginning, so that you're not losing at the back-end from an ROI perspective.

Seamus Fernandez

Great. Maybe we'll shift gears a little bit. We have some data -- earlier data coming up very soon, maybe even in the middle of this week. At ACR, can you maybe just help us understand the profile and the opportunity that you see for CAR-T therapy in immunology, in particular.

Samit Hirawat

Do you want to start and then --.

Robert Plenge

Yes. So I'll start. So I always like to – Samit's heard this a bunch. But I always like to start with -- I used to practice clinical rheumatology. And so I saw patients with these serious autoimmune diseases, including lupus, and it is really hard for a patient who's in there or early 20s and 30s to be told they had to take immunosuppressive therapies for the rest of your life. So the unmet medical need here is to be able to get patients off of all immunosuppressive therapies and to have a functional cure. And that is a massive unmet medical need for these patients. And not just for lupus, but for a variety of autoimmune disease, whether it's inflammatory myositis, scleroderma, multiple sclerosis.

And so what was shown a couple of years ago is the potential for a CD19 CAR-T to be able to reset immune memory and we now have clinical data. The abstract, I think, has four patients with lupus, and we'll present more data later on this week on additional patients with lupus. And consistent with what others have shown, we are able to reset immune memory. That doesn't mean that every single organ that was damaged previously gets better. So if there was prior kidney damage, almost certainly that kidney damage will remain. So it's not as if it's reversing all of those damages, but patients are getting off all of the immunosuppressive therapies. So that's really exciting. It is still very early, so we still have a relatively modest number of patients that have actually been treated, but it's all moving in the right direction.

And you could think about building on this, not just via CD19 CAR-T, but are there other mechanisms to depletes T-cells, or are there other mechanisms to reset immune memory for t-cell mediated diseases? And how do you think about going to earlier lines of patients? So there's a lot of creativity, I think, that will have to happen over the next few years. But what it is showing us is -- it is possible, and it's really exciting for us to really be at the front-end of that, I think paradigm changing approach.

Samit Hirawat

And I think the profile of the patient, as you will see the data, small number of patients, but that profile actually starts to give you an idea of where the drug really is needed as a high unmet medical need.

So these are relapsed or rather refractory to treatment patients who've got severe disease. So you'll want to see the baseline characteristics of these patients, [high scores] (ph), and the organ involvement that, Robert was talking about. But then post treatment, what happens to them? Are we causing a b-cell depletion or not? Are these b-cells, then again starting to repopulate? And what is the profile of these b-cells? What's happening to their background therapies that they're on? Are they going off of that or not? Are their clinical signs and symptoms improving?

And as they're improving, what's happening to their longevity and that? So not all patients remember, we only started the study in November of last year. So it's about a year that the first patient was infused. And then is the profile emerging from a safety perspective that would be tolerable and acceptable? So all these four or five things you want to observe now, and then you want to obviously continue to see if others are having the same thing or not.

As Robert said, kidneys are not liver, so they don't regenerate. So some of the things that kidneys cause when they're harmed is proteinuria and all that. So we have to keep in mind that this is not magic. Right? This is going to be important, treatment to these patients, but some of those, organ dysfunctions that are present may last. But what does that really mean from a patient perspective? Does that really matter from a patient perspective? Those are going to be the critical parts that we'll have to keep an observation on.

Robert Plenge

Yeah. It seems pretty high impact would be an ability to just sort of sustainably reduce or even eliminate prednisone, some oral prednisone, things like that.

Seamus Fernandez

Not just prednisone, but all immunosuppressants.

Robert Plenge

All immunosuppressants. I mean, if you're a young person who has to be on immunosuppressants, and when I give you patients these medicines, you have to go through the long list of potential side effects, whether it's infections, cancer risk, how they actually have to just sort of manage their lives, not to mention all the adverse effects that come with prednisone and the medicines. I -- that's a big deal. So to be able to say that you're off all immunosuppressive therapies, and you have a functional cure, I mean, that -- that changes the way that people approach their lives.

Seamus Fernandez

Great. In terms of, you know, sort of other assets, there's a lot going on, at Bristol. Maybe we can sort of take a quick step back and go through, you know, Samit – I went through this earlier, so we can go through the family, the family tree of assets that are coming. But, you know, if you wouldn't mind, maybe walk us through the assets that are most important, and then it'll give us an opportunity to walk through LPA1.

Samit Hirawat

Yeah. Absolutely. So I maybe I'll change my family tree a little bit because the big brother I said was milvexian. But today, morning, I think it's milvexian is now twin brother with COBENFY, which is already there. And both of them are going to be very, very critical. And I think the way to think about it is for COBENFY, there is pretty much a readout for an indication every year until the end of the decade. So next year, we're looking at our eyes. The year after that would be ADEPT. The year after that could be agitation. The year after that could be bipolar. The year after that could be cognition. The year after that, autism. And of course, in between whatever else might come because, even in AD psychosis, there are two indications. There's the acute and then there's a relapse prevention, for example. Both studies are ongoing right now.

If you think about milvexian, we've talked about in 2026, two studies read out, 2027, 3rd study reads out. This year itself for Sotyktu, you have the readout of psoriatic arthritis, 2 studies, before the end of the year. And then in 2026 will be SLE and 2027 will be Sjogren's. If you think about CAMZYOS next year, first half, non-obstructive hypertrophic cardiomyopathy. And then we have Reblozyl reading out next year for myelofibrosis, the independent study. And then there will be a lot of the Phase 1 data that comes out. 2026 is a big year. 2026, we'll have the radioligand therapy first Phase 3 study that should read out. GPRC 5D, multiple myeloma study should read out. Iberdomide, one study should read out. Mezigdomide, at least one of the studies should read out for multiple myeloma.

SLE, I've already talked about what else am I missing around? Golcadomide is late, though. Golcadomide would be late because that's first line diffuse Large B-Cell Lymphoma. And then once we start the other studies, then they will -- it'll add on. So early pipeline will start a lot of studies next year as well. PRMT 5 will go into Phase 2 studies that could lead to, regulatory discussions and as to how to conduct these studies. EGFR, HER3, ADC starts Phase 3 studies next year. So that will start to contribute towards the back end of the decade. AR LDD will start, Phase 3 study next year. So that'll contribute to back end of the decade.

FucGM1 in small cell lung cancer starts Phase 3 study next year. That will contribute to the back end of the decade. That's why I was saying at the beginning of this conversation that as you look towards the back-end of the decade, our reversal back into -- from a revenue perspective is a very accelerated, reversal. Obviously, dependent on the successful outcomes of these.

Seamus Fernandez

Maybe an unfair question.

Samit Hirawat

And by the way, CD19 CAR-T for SLE -- readout.

Seamus Fernandez

For sure. And maybe a little bit of an unfair question, but, you know, we are a week away from the election. But a lot of the molecules you just mentioned are small molecules. Is there, from your perspective, any chance, hope, that one of the real, I think, disconnects in the IRA legislation, does have a chance of being corrected, which is the small molecule, you know, sort of disentangling the nine year versus 13 year discussion.

Samit Hirawat

I don't think any one of us has any clue, and nobody has a magic aid ball, to really predict what that would mean and how that would happen. With that said, as we think about clinical development and the pipeline, we do believe that all modalities are going to be important. As we think about small molecules, we'll just have to get better and better in terms of thinking as we were talking on milvexian. The reason I say that we have to bring together the three readouts in close proximity is to maximize that return on that investment. But there are also going to be, places where we will not be able to recoup, and then we will have to make decisions that we won't. And we talked about it already. Even two years ago, we talked about iberdomide. That we can't do a de novo newly diagnosed multiple myeloma study because the readout for that study is 10 to 12 years.

And if our clock starts in 2027, there is just not enough time to do that. And that'll happen again and again as we think about earlier application into adjuvant settings for some of the studies. And especially if you really need good data, as well as project optimus comes into it when you have to pick the right dose for adjuvant. It just delays the start of these earlier studies, and then, of course, there will be an impact. So I feel bad from a patient perspective. I feel bad from an innovation perspective, but the reality is going to hit us that way. But I hope that there is an opportunity to engage in that dialogue. I hope that there is a differential thinking, coming in from a policy perspective, but that's just a hope for now.

Seamus Fernandez

So let's maybe move back to immunology. There were some programs that you didn't mention in immunology that I think are worth talking about. You know, you have a positive Cendakimab, results. It was just presented, at a recent meeting in EOE. You know, maybe just give us your thoughts on that program and you conducted a robust program according to the opinions of the experts. It's a fairly robust result. What are the plans for, you know, IL-13 in that regard? And if there aren't plans to advance that, what's the sort of commercial argument?

Samit Hirawat

Yes. So right now --.

Seamus Fernandez

It's an unfair question because we're not talking about commercial, but the clinical commercial.

Samit Hirawat

Sure. No, I think the way to think about it, we presented the data, as you said, the trial did meet its endpoint. And we now -- the discussions that we are having is putting in the context of what is the incumbent right there. And it's a very strong incumbent that's out there. So we'll have to put all of that in that framework as we think about conversations on regulatory path and moving forward. I don't have an answer for you as to what the time lines are and how it looks. But those are the discussions that we truly have to have on the table. And that's why we have to keep in mind the commercial opportunity, what it truly is and then make the decisions on the time lines and what the next steps would be.

Seamus Fernandez

Okay. Robert, in immunology, maybe just sort of bring us back to -- there's a vast array of mechanisms. We're starting to actually see for the first time, combinations that are working. And what I mean by that is my recollection is all the way back to the IL-1 RA combination with TNF, which was just disastrous from an infection perspective. But now we have IL-23 in combination with TNF that's starting to show some really intriguing results in areas like IBD. How do you think about the opportunity for combinations versus sort of single mechanisms in immunology going forward?

Robert Plenge

So we've put forth this paradigm that we call a sequential immunotherapy paradigm. And we published on it a few months ago in Nature Reviews Drug Discovery article. And the idea is if you are a patient coming to your physician, you almost always present in the setting of acute inflammation. So step one in this paradigm is to be able to control inflammation largely with immunosuppressive therapies. But for many diseases, there is this efficacy ceiling. And so in order to really do better compared to standard of care therapies, you likely either have to go into much more precise patient subsets whether it's genetically defined or some other biomarker or to your question, you have to use combinations. But the combinations have to be done in a way that's safe because you can't just do one inflammatory cytokine on top of potentially another overlapping inflammatory cytokine because maybe you're hitting it too hard.

But that's step one, controlling inflammation, combinations, potentially patient segments are one way to get at them. Then step two is what we talked about a few minutes ago, which is to be able to reset immune memory. So basically, sort of turning your computer on and off to reboot the system to hopefully get rid of those pathogenic autoreactive cells, whether they are B cells or T cells.

We're seeing promise in that with the CD19 CAR-T approach, but there are potentially other ways to reset immune memory and we are exploring those that I know others are as well. But then once you reset immune memory, there's an open question about whether those auto-reactive cells come back or whether you have to either repeatedly dose these step two medicines? Or is there an alternative way to promote homeostasis and repair and there are a few different ways in which one could consider that.

But that's sort of the paradigm where step 1 control inflammation, step 2 reset immune memory, step 3, promote homeostasis and repair. And I think we are going to really see in the next five to 10 years, a lot of those clinical studies play-out in terms of how you mix and match all of these different mechanisms together. But it's a pretty exciting area, and I think it offers a lot of hope for patients.

Samit Hirawat

And right now in the portfolio, we have drugs that are part of each of those three pillars that Rob just described. If you think about Sotyktu, it takes care of the inflammation. If you think about CD19 CAR-T cell therapy, that's about resetting the immune system, [nivolumab] (ph), we are going to be testing out actually starting next year and a couple of indications there as well. And then we have drugs for the homeostasis part as well. So I think our pipeline has the ability to do that. But of course, we'll continue to observe how the space evolves.

Seamus Fernandez

Right. Multiple myeloma, the level of expertise there is obvious, unquestionable. The dynamics in the market in multiple myeloma, I think are interesting. But when you look at the pipeline, Robert was talking about segmentation. How important is segmentation going forward in multiple myeloma and how is Bristol approaching it?

Samit Hirawat

Yes. I think it's a natural segmentation because of the modalities and because of the need. As things start to become used earlier and earlier, unfortunately because the disease is not being cured, you're accumulating the prevalence population as you go later and later. So as we think about, we just saw the data of CD38 getting into a newly diagnosed patient population.

So what happens as we look to the future as cell therapies like Abecma or Carvykti move earlier, what happens after that, as T-cell engagers move earlier what happens after that. And I think we're only talking about biologics right now, but small molecules will have their own space, because combinations are just easier with the small molecules, hard to combine Carvykti with something, hard to combine T-cell engages for their profile with something right now. So we'll have to continue to find what is the best way to continue to provide combination therapies for better outcomes from an efficacy and tolerability for these patients. And that's why we've taken a multi-modality approach to it.

First, we have the small molecules. We were developing a [biospecific] (ph) or rather the -- yes, the T-cell engager [relatlimab] (ph), which we took away because we were not going to be first. In fact, we were going to be fourth or fifth. So we took that away. But we have the broadest cell therapy approach to it. So Abecma was the first one. GPRC5D is the second one. And the third one is a Dual CAR, which is the BCMA and GPRC5D on the same CAR. So that's the third one. We hope that GPRC5D applicability, pre and post-BCMA is going to be equally important. But if you can then further improve on that, maintaining the safety profile with a Dual CAR, taking BCMA and GPRC5D, that would -- that can be a game changer if the safety profile is tolerable because you know both nodes are important.

You know we've seen the data when the 2 T-cell engagers were combined, the response rate was like 97% or 96%. But the problem was the safety profile. So if you can get the same outcome with a better safety profile, that could be a real game changer in this patient population.

Seamus Fernandez

Right. And coming up, we've got ASH. It's right around the corner, it feels like, but it will still probably feel like it's decades away.

Samit Hirawat

There is so much happening.

Seamus Fernandez

Exactly. Can you maybe just walk us through what's coming at ASH. Are you excited about anything that could be presented there?

Samit Hirawat

With the portfolio that we have in hematology, we have to be excited, right? There is so much happening. And there will actually be an encore, by the way although it's not a rheumatology meeting, but there will be more data presented for the cell therapy CD19 in autoimmunity at ASH. But beyond that, I would say, watch out for Golcadomide data, further updates on the large B-cell lymphoma as well as I think follicular lymphoma is there as well.

If you think about mezigdomide, more data being presented over there, especially novel combinations. As we think about the mezigdomide cell therapy, cell therapy data should be the additional cell therapy data, including GPRC5D updated data that will be presented over there. What am I missing?

Robert Plenge

BCL6 LDD and then we have a hemoglobin F inducer that will be presented as well.

Samit Hirawat

That’s preclinical right?

Robert Plenge

The preclinical data, but it's a pretty remarkable preclinical package, including non-human primate data on the HBF inducer.

Seamus Fernandez

Okay. Great. Maybe go to some other assets HFpEF, the EMBARK study, you mentioned the opportunity there. And I guess with the second-gen MYK-224 asset. Can you just talk a little bit about what sort of separates the two? What you think is going to really differentiates MYK-224 from Camzyos?

Robert Plenge

Before we get there, we went a little too quickly over BCL6. I feel like you deserve just a little bit more time because I think it's a really interesting assets. So then we'll come back to this one.

Samit Hirawat

We can see the passion here.

Robert Plenge

So this has been one of these transcription factor oncogenic drivers for a very long time. It's been very difficult to drug. So there is a very strong casual human biology. We now have a ligand-directed to a grader, other referred to them as protax, and we are showing that we're actually getting a degradation of the target. And we're beginning to see, I think promising signs of clinical activity as well.

Samit Hirawat

Single agent.

Robert Plenge

Yes, as a single agent. So this is one where it fits all of the principles that we've actually talked about. Strong casual human biology, very unique modality [master] (ph) molecular mechanism, very clear clinical proof-of-concept study, and we're beginning to see how that data will actually present itself. And then because we're in a very unique position of having golcadomide and other agents in lymphoma, we can now figure out how to position this particular medicine in a way that I think is pretty unique. So now let's go back to HFpEF. But I just wanted to make sure that we spend a little bit of time on BCL6 LDD.

Samit Hirawat

That’s great. Pretty hard turn from hematology to cardiovascular disease. So I think MYK-224, we did a study in Obstructive Hypertrophic Cardiomyopathy to define and differentiate what it looks like. The data looks pretty similar from an efficacy perspective. But certainly gives an opportunity for the second cardiac myosin inhibitor to bring into cardiology. And so EMBARK study has already shown, from a principal perspective, we can decrease the NT-proBNP in substantial number of patients, and there is a class change from an NYHA perspective. So heart failure is improving in these patients with HFpEF.

So now we have the proof of principle from CAMZYOS. Now we want to test it out in a larger population with MYK-224. Those studies are ongoing. We've treated three cohorts. The fourth cohort is going to start soon now. And that data reads out end of '25, early 2026. That will pave the way for a later-stage development. Remember, in HFpEF, we have only three or four drugs to-date. And there is a lot of unmet medical need. And it will then provide opportunities to see their combination approaches that we can take forward.

We are seeing emerging data with the GLP-1s as well. Many of the patients who -- we are enrolling in our trial and they're coming into the background of GLP-1 as well. So we'll be able to see what we are adding or what we are differentiating on, what the data will be differentially looking in these two different populations. So there's a lot to learn over the next one-year from this program, and that will then define what we do for the Phase III.

Seamus Fernandez

Great. This is sort of like a random walk down Wall Street conversation on the very robust portfolio of choices that we have to go to. But LPA1, we haven't talked about yet. Let's kind of go through the opportunity in IPF and PPF as well as again, what differentiates your LPA1 program from some others that have been challenged separately?

Robert Plenge

Okay. So we've got, I think, a lot of good casual human biology around this node. Not just from some genetic support, although indirectly for LP1 as a target, but just importantly, from the first generation molecule, which had good efficacy in an IPF study. There were some liabilities of that molecule. So we went back and made it a second molecule and have brought it forward, and that's the current molecule that's now in Phase 3. So we correct the liabilities but we repeated a Phase 2 study that showed very consistent effects on clinical improvement for forced vital capacity. So it's not just really one Phase 2 study, it's really several and not just in a one indication IPF, but in a related indication PPF.

And in the latter, in particular, you see a dose-dependent improvement in forced vital capacity. So I think there is a lot of good cause human biology to support the target, a very good molecule. We have a lot of early clinical data to help us with the dose. And then this leads to, I think, how we select the dose going into our Phase 3 and then maybe just a quick comparison to competitor molecules as well. And so we did -- you'll notice a theme with all of this, which is we did a lot of really good clinical pharmacology work to say, this is a dose that we believe is going to be effective.

And we actually did even a higher dose in the Phase 3 study to make sure that we had the right inhibition of the target. And this is different than what others have done. So with the competitor molecule from Amgen Horizon, where there is a different profile of protein binding, so you do not have the same level of exposure.

So effectively, their dose is several fold less than the dose that we've actually taken into our clinical study, which is why we have confidence going into our Phase 3 study. But good target, really good molecule, a lot of clinical data to support not only the indications, but the doses that we've gone into and the Phase 3 study is going really well so far.

Samit Hirawat

The only thing I would add is we also have the ability to look at the data for background therapy because that's allowed for these patients. And second, we didn't want to leave any efficacy on the table. So we've actually -- although we didn't test it out in the Phase 2 studies, so we took the maximal dose from the Phase 2 study, 60 milligram BID in the trials, but then we also put in a 120 in there. And so we've looked at the safety for Part 1, and it looks pretty safe. So we are now enrolling very well in the Phase 3 portion of the study.

Seamus Fernandez

Great. So I think we only have two minutes left, slightly wrong up there. But -- maybe just we -- I think, we went through a little bit of the family and the grandchildren as well. But if you were to just sort of say, okay, these are data sets that I'm particularly excited to see in the next 12 months to 18 months in the sort of Phase 2 plus time frame. What are you most focused on?

Samit Hirawat

So I mentioned a lot of them in terms of the Phase 3s. So all of those are going to be important from a company perspective and our own drug development progress and research perspective. Beyond that, so beyond the general ones that I've already spoken about at milvexian GPRC5D, COBENFY and SLE for Sjogren's. So all life cycle management in the Phase 2 program.

The ones to watch out also are going to be the [anti-TAL] (ph) molecule. It's in randomized Phase 2 study right now. That is '26 and '27 timeframe and it's -- because it's a long follow-up that you need for these patients. So that's going to be important. Another drug that we are taking into Phase 2 is FAAH and MAGLipase inhibitor. Again, dual inhibitor, there are lots of others who are doing it as singular inhibitors. The dual inhibition approach that we are taking in Alzheimer's disease is going to be important. So watch out for that again, 2026, 2027 time frame.

Some of the early data that is going to be emerging in next year and the year after would be the radioligand therapy in breast cancer and small cell lung cancer, that's going to be important. As well as, I think 2026 will be GPC3 [Penile squamous cell carcinoma] (ph) for radioligand therapy that's going to be important. I think from cell therapy, next year, watch out for data for not only continuous emergence of SLE, but as we think about data from the sclerosis or scleroderma perspective, myositis perspective and then hopefully, MS as well that will come out.

So I think these are ones that we don't normally get to talk about. And one molecule that I know Robert and I are both passioned about CCR8 in oncology, looking at certainly impact on T-regs and then combination thereof with PD-1 inhibitors and immuno-oncology agents. So those are all going to be very, very critical. And I know today, thankfully, we didn't talk about OPDUALAG because I get 15 questions every time. But OPDUALAG is another one which is going to be important, and you'll continue to see emergence of that data. I think next year, we'll be able to talk about the overall survival data from the randomized Phase 2 study that we conducted. So that data will read out next year as well. So that will then hopefully give you a little bit more confidence as to why we plan the study, the way we planned it and execute on the Phase III.

Seamus Fernandez

And I'll apologize to all the people who are looking for a laundry list of BD development targets from Bristol-Myers Squibb. I didn't even get to that question because there's plenty going on. So thank you so much for joining us. Really thrilled to have both of you here with us today. Samit, Robert thanks for taking the time.

Samit Hirawat

Thank you Seamus.