Rocket Pharmaceuticals, Inc.RCKTNASDAQ
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Operator: Welcome to the Rocket Pharmaceuticals, Incorporated Investor Conference Call. My name is Vanessa, and I will be your operator for today's call. At this time all participants are in listen-only mode. Later, we will conduct a question-and-answer session [Operator Instructions]. I will now turn the call over to your host, Mayur Kasetty, Director of Business Development and Operations.
Mayur Kasetty: Thank you, Vanessa. Good afternoon, everyone. This is Mayur Kasetty, Director of Business Development and Operations and Investor Relations lead at Rocket Pharmaceuticals. Thank you for joining us. The purpose of this call is to share and discuss key updates on our clinical programs. Before we begin, I would like to briefly discuss the use of forward-looking statements on this conference call. Statements we make on this call may include statements which are not historical facts, and are considered forward-looking within the meaning of the Securities Laws, and which are usually identified by the use of words such as anticipates, believes, estimates, expects, intends, may, plans, projects, seeks, should, will and variations of such words or similar expressions. We intend these forward-looking statements to be covered by the Safe Harbor provisions for forward-looking statements contained in Section 27A of the Securities Act and Section 21E of the Securities Exchange Act, and are making these statements for purposes of complying with those Safe Harbor Provisions. These forward-looking statements reflect our current views about our plans, intentions, expectations, strategies and prospects, which are based on the information currently available to us and on assumptions we have made. Although, we believe that our plans, intentions, expectations, strategies and prospects, as reflected and/or suggested by those forward-looking statements are reasonable, we can give no assurance that the plans, intentions, expectations or strategies will be attained or achieved. Furthermore, actual results may differ materially from those described in the forward-looking statements, and will be affected by a variety of risks and factors that are beyond our control, including without limitation, those set forth in our earnings release issued earlier today and in Item 1A Risk Factors of our annual report on Form 10-K for the year ended December 31, 2020, and as updated by our subsequently filed quarterly reports on Form 10-Q and our other SEC filings. We assume no obligation to publicly update any forward-looking statements whether as a result of new information, future events, or otherwise. Participating on today's call on behalf of Rocket are Dr. Gaurav Shah, Chief Executive Officer, Dr. Jonathan Schwartz, Chief Medical Officer and Clinical Development, Senior Vice President, Dr. Gayatri Rao, Chief Development Officer and Head of Regulatory Policy, Carlos Garcia, Chief Financial Officer, and Claudine Prowse, Senior Vice President of Strategy and Corporate Development. There will be a question-and-answer session at the end of this call, in which we will all participate. I will now turn the call over to Gaurav.
Gaurav Shah: Thank you, Mayur, and thank you, everyone for joining us today. We have several updates to take you through. Let me highlight four key take homes for today. First, regarding the Danon clinical trial, we are reiterating our previous guidance that based on our most recent FDA interactions, and exercising the best of our judgment and estimation we continue to anticipate resuming the trial this quarter Q3. Second, for Danon, the low dose is demonstrating increasing and durable benefit. We'll go over key data points including some new ones in MS. Third, for Danon we are removing the high dose from future dosing plans. Fourth Fanconi Anemia LAD-1 and PKD remains on track, and we will provide the further clinical updates in Q4. Those are the key takeaways. We will now get to some more details. Starting with Danon, we've been working very closely with the FDA over the last several weeks, and through our discussions, we have agreed to modify our immune-suppression and component inhibition protocols to bolster safety guardrails. In addition to these protocol updates, we've had a chance to review updated low dose datasets with the FDA that Rocket believes is supportive of its potential as a viable Phase 2 dose. Notably, photographic evidence for all three low dose patients showed improvements being decrease in our basic vacuoles, a hallmark of Danon disease pathology, as assessed by electron microscopy of cardiac tissue via endomyocardial biopsy. Additionally, two of the three low dose patients were closely monitored immunosuppressive regimen compliance demonstrated improvements in [indiscernible] class from two to one, which translates to no impairment of function. These patients also demonstrated substantial improvement of a key marker of heart failure BNP, which decreased by 75% and 79% versus baseline levels, as well as improvements in cardiac output by 35% to 62% compared to baseline, as measured by invasive hemodynamics. All three treated low dose patients continue to demonstrate stabilization or improvements in BFE [ph] six minute walk test as well as New York heart association class. Given the activity, observe the patients in the low dose cohort, and importantly, to mitigate associated safety concerns in the 14 range, we have decided to forego pursuit of the higher doses meaning 1.1 to 14 factor genomes per kilogram or higher. This is a decision that was made in agreement with the FDA and allows us to focus fully on the low dose moving forward. The 6.7e13 dose, also reduces the total number of patients needed in our Phase 1 study, and potentially allows for more rapid progression to Phase 2. Now as disclosed in December of 2021, patient in the high dose cohort who is the heaviest patient treated day and a half, highly advanced disease, developed complement mediated thrombotic microangiopathy, which result fully would translate into more dialysis. This patient continued to have progressive disease considered unrelated to gene therapy by the trial investigator as well as his transplant cardiologist and successfully went on to receive a heart transplant. The patient is currently doing well clinically and of course resolution of this baseline biography that was present prior to treatment. Analysis of the explanted part demonstrates fibrosis that was consistent with end stage Danon disease. Our belief has always been that the onset of fibrosis in the year or so prior to transplant could diminish the efficacy of gene therapy. And this patient exemplifies the importance of early intervention in this disorder. We at Rocket do not consider this a safety issue and it is not considered related to the whole. We believe it does highlight the importance of the right timing in order for gene therapy to be fully effective. In discussions with the FDA, on this case, we have refined our eligibility criteria to focus on patients earlier in disease. Now, importantly, as of this past week, we have submitted all requested changes to FDA and have confirmation that we have agreement on the updated protocol. As mentioned, we expect that we can resume the trial in Q3 with the revised eligibility criteria in place and refined safety measures in place. Moving forward, we have inbound interest from more than 20 patients for participation in the trial and we look forward to progressing rapidly towards Phase 1 completion and the Phase 2 registration trial. One final point on Danon, throughout the duration of this whole we'd have had an exceptionally collaborative discussion and dialogue with the agency. And with our confidence in the low dose and the modifications to our clinical trial protocol, we are truly excited about the prospects for Danon program and look forward to presenting longer term data both the low and higher dose patients in the fourth quarter of this year. Now turning to our lentiviral programs, we've provided updates at ASGCT for our Fanconi Anemia, LAD-1 and PKD programs and continue our momentum for regulatory filings. For the final line program, we are deeply saddened that the first patient treated in our infantile malignant osteopetrosis Phase I trial had passed away from likely non gene therapy related pulmonary complications with autopsy confirmed evidence of pulmonary hemorrhage that was very likely related to thrombocytopenia following conditioning therapy and also related to underlying osteopetrosis. Of note pulmonary complications occur more commonly in osteopetrosis patients relative to many other non-malignant immunologic diseases, especially in those patients who are undergoing transplant. Consistent with the protocol, we have paused enrollment, pending a comprehensive evaluation in collaboration with an independent data monitoring committee. We look forward to providing updates in all our programs in the fourth quarter of 2021. Finally, as many of you may know, Claudine Kraus will be transitioning out of Rocket to take on a CFO role at another company. Claudine has been with us rocket for 3.5 years and has been an integral part of our growth story from the days of Inotek for those who were there then, to a progressed to a mid-cap public company. While we are and I personally am sad to see Claudine leave us we are tremendously excited for her and sincerely thank her for her contributions here at Rocket. Now I'll pass it to Claudine. .
Claudine Prowse: Thank you Gaurav. Looking back Rocket has had extraordinary growth. Since going public, the company has already delivered a lot of value to shareholders. And I look forward to seeing Rocket's continued success in the future over the long term. I am so truly grateful to be a part of this journey. Mayur?
Mayur Kasetty: Thank you Claudine. This concludes our prepared remarks. The Rocket executive team is now happy to address any questions on this update. I'll turn the call back over to the operator for Q&A.
Q - Unidentified Analyst: Hey, guys. This is Ashwin on for Greg. Thanks for the questions. So it seems like you're pretty much aligned with FDA at this point for resuming Danon. And I guess is there anything else that needs to be done before getting that study started? And just kind of tacked on to that a little bit, with this upcoming AV gene therapy icon with [indiscernible]. Is any chance that's a gating factor? And if not just what are your general expectations for that outcome? Thank you.
Gaurav Shah : Thanks for your question. So as of last week, we have confirmation of no further clinical contacts in the protocol. We respect the FDA process. And we're waiting for the FDA to complete their full review. And that's what we can say at the moment. With regard to the upcoming Advisory Committee Meeting, I will actually pass this over to Dr. Gayatri Rao, who is one of the Rocket executive team members and who, as you may know, was the Head of the Office of Orphan Drug Products for seven years at the FDA and now working on this. Gayatri?
Gayatri Rao : Thanks. Hi, everybody, this is Gayatri Rao through how to answer this specific question related to the advisory committee meeting. As far as we know, we really have no reason to believe that there's any sort of relationship between this clinical hold and the timing for the Advisory Committee Meeting. And it's certainly inconsistent with all the communications that we've had with the agency to date. With respect to the meeting itself, we're looking forward to engaging in the meeting and listening and learning from the discussion there.
Unidentified Analyst: Okay, thank you.
Operator: And thank you. Our next question is from Dae Gon Ha with Stifel.
Dae Gon Ha : Great. Good afternoon. Thanks for taking our questions. On the thrombotic microangiopathy, are you able to discuss the details behind the reclassification of SAE [ph]? And I guess, does that have anything to do with -- or has that been reflected in the mitigation strategy as you submitted it last week? And I guess a follow up to that is, in the May call, you talked about two buckets as it pertains to the resumption of the trial, that being risk mitigation and eligibility criteria. So has anything changed in your view or anything in that proposal changed since that May update? Thanks folks.
Gaurav Shah: Absolutely. So the SAE, reclassification was based on recent guidance that we've gotten from the agency. And it is reflected in certain protocol changes that will in the future design such events as SAE, I think that's the bottom line. So it's really part of a tightening of protocol measures and safety monitoring. And with regard to what we have said in May, it's the same thing. We have defined these monitoring parameters more closely. We define handling of SAE. We timed some of the safety guardrails around depression and inhibition and slightly refined eligibility criteria to focus slightly earlier on end stage disease patients. Those are the same points that we had anticipated in May, based on the initial FDA call and they remain the exact same.
Dae Gon Ha : Thank you very much.
Operator: And thank you. Our next question is from Gil Blum with Needham and Company.
Gil Blum : Good afternoon, and thank you for taking our question. Just about the deaths that happened on the IMO study. Is there really any significant differences between the conditioning regimen seeing and transplants in these patients versus the gene therapy? Thank you.
Gaurav Shah: Okay, you mean versus other gene therapies?
Gil Blum : No, just versus hematopoietic stem cell transplant, which is sometimes known as the standard of care.
Gaurav Shah: Got it. Is there any difference between the deconditioning used in ostopetrosis gene therapy versus osteopetrosis transplant? That's what you're asking. Correct?
Gil Blum : Yeah.
Gaurav Shah: Sure, I'll pass that over to Dr. Jonathan Schwartz.
Jonathan Schwartz: Hi, this is Jonathan Schwartz. The conditioning regimen that's used in the osteopetrosis gene therapy study is amyloidosis B cell tran, that's governed by pharmacokinetic guidance or TDM therapeutic drug monitoring. In general, this is a less extensive, mild suppressive and less extensive immunomodulatory regimen that would be utilized in an allogeneic transplant for this condition. Typically your allogeneic transplant regimens will utilize combinations of amyloidosis therapy, sometimes cycloquesoc [ph] and cyclophosphamide, total body irradiation and different chemotherapy regimens and then they also utilize an immunosuppressive or lympho-suppressive therapies as well. So this is this is a less extensive, but nonetheless, amyloidosis conditioning regimen that's part of our gene therapy program.
Operator: Did that answer your question? Sir? Do you have a follow up?
Gil Blum : No, I do not have a follow up. That does answer my question. Thank you.
Operator: Thank you very much. Our next question is from Yaron Werber with Cowen.
Yaron Werber : Great, thanks for taking my question. Gaurav, maybe two questions. The first one is when you did your echos, did you see any left ventricular ejection fraction benefits? Or were patients essentially sort of normal a baseline? And what about stroke volume because it's obviously related to cardiac output. And then any updates on six minute walk testing with longer follow up? And with all of that in mind, based on what you're seeing, what do you think might be a primary endpoint for pivotal? Thank you.
Gaurav Shah: Hi, Yaron. On the echo ejection fraction many patients -- most patients have preserved ejection fraction until they reach a stage disease. This is true for most of the patients that have been enrolled in the trial. We have disclosed previously, that the assumption here was that last patient who did, as I mentioned earlier, move on to have a transplant. That patient was starting to lose cardiac function. More on that as we update our criteria. And sorry, you have to ask the second one again, a couple in there.
Yaron Werber : Yeah, the second one, what about stroke volume because it's obviously determinant of cardiac output. Yeah. And then six minute walk testing?
Gaurav Shah: Stroke volume, and then we'll get to six minute walk. So on cardiac output, the data that was revealed in December, there is the current data set that we're working on that we've also shared with the agency. Some of these patients do start having worsening cardiac output even before there's a loss of ejection fraction. And in two of the three patients have mentioned, we have started to see increases in cardiac output as measured by the basic dynamics. In terms of six minute walk tests, we now and this is new information from before have demonstrated six minute walk test stabilization or improvement in all three of the low dose patients. So that's the law of site stabilization, or improvements in BNP as well as your consultation class. So that's the information. On the endpoints, we have cast a wide net in terms of capturing appropriate endpoints to help us guide towards phase two. These include biomarkers and the kind that we've discussed, BNP, [indiscernible], clearance, as well as imaging endpoints such as injection fraction, clinical functional endpoints, such as six minute walk test, or even quality of life endpoints such as NYHA class. So any of these could be part of the endpoints, we can't speculate on what that will those will be until we have an end of Phase 1 discussion with the FDA. I think there's been about a quarter delay here on the trial right now. At the same time, we've had a collaborative discussion with the FDA. Sometimes you don't have these discussions about endpoints until later in development. We're hopeful that potentially we can expedite the trial based on the conversations we're having right now.
Yaron Werber : And to make sure I got that right, the six minute walk test, I'm sorry, if I missed it. You mentioned you saw an improvement in six minute walk and NYHA class, and I'm sorry, in BNP and New York art class. But did you also say six minute walk it was stabilized or improved?
Gaurav Shah: Yeah, so I'll go to detail. All three patients have stabilization or improvements in BNP six minute walk, test and cardiac output -- sorry BNP, six minute walk test and heart lung. All three patients have stabilization or improvement. The two patients who have monitored immune suppression regiment and closely monitored, those two patients specifically had drops in BNP from 75% to 79% versus baseline. And also they had improvements in New York Heart Association class. Those are the two patients who had the larger immune suppression. But all three patients had stabilization across all parameters. Six minute h walk test specifically, we haven't revealed those data. We will in fourth quarter, but patients been stable or improved in all three of those patients as well at this point.
Yaron Werber : Great, thank you.
Operator: And thank you. Our next question is from Mani Foroohar with SVB Leerink. Please go ahead.
Mani Foroohar : Hey, thanks for taking the question. My first question is are there any changes to the protocol for Danon disease that can potentially change the proportion of patients that would be eligible for the trial and follow up?
Gaurav Shah: Hi, Mani. We are identifying patients that we would consider end stage disease. We've always said that in the last year or so prior to transplant, the onset of fibrosis is such that gene therapy probably would not be affected. Those patients were never considered to be part of the treatable population. So overall, the answer is it does not change the treatable or addressable market.
Mani Foroohar : Great. You said you're looking forward to meeting and listening and learning at the September ADCOM. Can you confirm whether or not you're invited or will be participating in the proceedings yourself?
Gaurav Shah: Yeah, we have had no discussions with the FDA about the ADCOM. Today, we have not been invited but we'll certainly be listening.
Mani Foroohar : Thanks. That's helpful, guys.
Operator: And thank you. Our next question is from Raju Prasad with William Blair.
Raju Prasad: Thanks for taking the question. With the agreement the FDA cannot go into the high dose, what should we expect for the clinical progression of this program? Is it the lower dose with more adult patients, and then going into a pediatric population, or do you plan on kind of advancing in the pediatric population once you can re-enroll patients into the trial and then I had a question on the special regimen?
Gaurav Shah: Hi, thanks for the question, Raju. Our intent is to move forward right away with the pediatric population logos and we'll have update as that happens.
Raju Prasad: Okay, great. And maybe can you just clarify the changes that were made to the immunosuppression regimen as far as complement activation goes on, that'd be helpful. Thanks.
Gaurav Shah: We will definitely update as the trial progresses and certainly in the fourth quarter. I don't want to provide too many specifics during an active FDA dialogue. But yes, we will definitively update. There's nothing in there that that we would consider major. It's refinements, revisions, tightening of the protocol. And nothing that really affects the types of patients that we can treat other than the eligibility points made or affects the trial conduct in anyway.
Raju Prasad: Great, thank you.
Operator: And we have our next question [Indiscernible] with UBS.
Unidentified Analyst: Hey, thank you for taking my question. I have just a couple. One is on the patients with the fibrosis. You've kind of defined the market as about 33,000 patients across the U.S. and the EU. And is that 30,000 patients with fibrosis that are in advanced stages, or how are you kind of whittling down from there to your enrollment criteria?
Gaurav Shah: Yeah, that's a good question. We think that the number of patients with fibrosis, that's probably about the impact of gene therapy is very small. It's really going to be boys in the months and maybe a year or so leading up to the actual heart transplant, or unfortunate cases death. Females, which is a population we haven't really talked about yet, and certainly very liable as we move the program forward, have different sorts of heart disease, and certainly would not be affected in the same way. So I think that if you're looking for exact numbers within those 30,000, those numbers are general there. We think if anything, they're going to get validated by a third party. Now. As we capture even more types of mutations, there's a possibility that those numbers could expand. So I don't think that sliver of sort of patient baseline characteristics that will eliminate end state diseases is going to get into that progress number too much.
Unidentified Analyst: Yes, thank you. And we kind of -- you've kind of mentioned females consistently since the start of the trial. What are -- what exactly do you need to see in the current patients that are enrolled to move forward with girls?
Gaurav Shah: With females?
Unidentified Analyst: With female?
Gaurav Shah: Yeah, we don't really need to see that much. I think we want to get a little bit closer, further into the Phase 1, and start thinking about what Phase 2design will look like in boys first, but there's nothing more we really need to see to start a trial on females. We have not given any guidance when that trial will start, but it's certainly in the near to medium term plans.
Unidentified Analyst: Got it. Okay. And just to clarify, the Phase 2 trial, you're planning will be only invoiced then.
Gaurav Shah: The current Phase 2 -- not the current, the upcoming Phase 2 will be based on the current Phase 1, and we would want to extrapolate what we learned in Phase 1 to Phase 2. So that first trial, which we hope will be registration in nature wouldn't be limited to voice. And in parallel, we would start exploring a trial and females that would support a separate trial.
Unidentified Analyst: Okay, thank you. That's very helpful.
Operator: Thank you. Our next question is from Josh Schimmer with Evercore.
Josh Schimmer : Great, thanks for taking the question. Just continuing on the topic of the Phase 2 registration study for Danon, what kind of data is that that you are looking to capture from the pediatric patients enrolled in that -- in the Phase 1 study? And how do you think that will ultimately inform the design of the Phase 2? What are the different parameters here you're considering that are still not yet determined that will be informed by Phase 1? And then separately for the unfortunate patient who passed -- with IMO who passed away, are there any unique features about that patient that that might have explained the unfortunate outcome whether they were older or more advanced disease than patients who might have otherwise gone for a traditional stem cell transplant? Thanks.
Gaurav Shah: Right Thanks, Josh. So in terms of what we would need to see in the pediatric Phase 1 LOTOS [ph] to start Phase 2. I think that's the discussion that obviously we'll have with the agency at the end of Phase 1 meeting. I think if we see more of what we saw in the low dose adults and confirmation of the potential prospect of direct benefit of pediatrics, if we can confirm that, then, we'll be moving toward Phase 2 relatively rapidly. In terms of how to define the final endpoint, for the Phase 2 trial, I think that's still under discussion that will be had as soon as possible. I think the dialogue we've been having over the last several weeks, hopefully, primes the end of Phase 1 dialogue and accelerates Phase 2 development plans for pediatrics, as well as adults potentially. On the osteopetrosis patient, I will defer to Jonathan, whether there were any differences in that patient versus other osteopetrosis patients that might have predisposed.
Jonathan Schwartz: Can you repeat the question with respect to the osteopetrosis patient?
Josh Schimmer : Yeah, Jonathan, just wondering if there are any clinical features that might have portended the outcome that they had whether it was more advanced disease, older patient who maybe had not been eligible for an earlier stem cell transplant, that might explain why they had that death
Jonathan Schwartz: Yeah, so we'll provide more comprehensive information regarding that specific individual as we disclose clinical data at relevant conferences later this year. I don't think that there was necessarily anything that we would identify in this patient as either low or high risk. One thing that we're very much aware of is that in osteopetrosis, many of these patients do have chronic lung compromised, that's related to the bone abnormalities that the ribs cause a restricted lung pattern. And some of the sinus abnormalities create sort of a chronic inflammation in the bronchitis and pulmonary parenchyma, which is why -- probably why these patients do have a high degree of pulmonary complications in allogeneic, transplant settings. Obviously, our intent is to provide a therapy that is less overall chemo then you'd have in a transplant. But nonetheless, you're still talking about many of these patients having fairly complex, lung environment. I don't think we can comment right now that there was anything specific about this patient that we'd be able to say, made him or her different from a typical osteopetrosis patient. All these kids have pretty severe underlying disorder.
Josh Schimmer : Okay, may I ask one quick follow up on the Danon pediatric patients and next phase of the trial? If they are younger, are they unlikely then to have baseline abnormalities that would be amenable to improvement? And I guess for older patients, you could see the improvement in BNP and performance and heart failure, if you're enrolling younger patients, are you unlikely to see that just because they have not deteriorated to a degree that they would have meaningful baseline abnormalities.
Gaurav Shah: Hi, Josh, Gaurav here. There are a number of pediatric patients who have onset of cardiac disease even earlier than the adolescence that we're treating. And remember the cut off here is age 15 for young adults, adolescents. Below that is considered pediatric. And the disease is although inexorably leads to heart failure around the [indiscernible]. On average, it is heterogeneous. So there are many pediatric patients who do have some signs or symptoms of cardiac disease. Those are the ones that would be enrolled in the pediatric Phase 1 to ultimately who may want to move to therapy even before onset of cardiac disease as a preventative measure, but that's not what this trial is about. All pediatric patients will have some sign or symptom, of class 2 heart failure or higher.
Josh Schimmer : Okay, got it. Thanks very much.
Gaurav Shah: And before we move to the next question, Josh, I also wanted to add IMO that the protocol has defined measures by which we apply for trial. We have shared this information with the FDA, and we have not been asked to put the trial on hold. It's a self-mandated pause based on the protocol, just to be clear.
Jonathan Schwartz: And also, Josh, I know we're spending a lot of time, you had asked about what other information could help us move the trial, the pediatric trial forward into Phase 2. We're also developing a final version of our natural history output. We're learning a lot about how patients decline, especially in the early teenage years. And we hope that side by side with activity that we're starting to see in a low dose can justify a trial that could potentially be a single arm trial. So that that's the idea here, moving to Phase 2.
Operator: And thank you. Our next question is from David Hoang with SMBC.
David Hoang : Hi, thanks for taking the questions. So I want to ask about the decision to discontinue the high dose, I mean, clearly it makes sense for all the reasons we talked about. But I remember you had pursued it, in part, because you thought there may be some extra cardiac benefits. So without I guess maybe capturing dose now that you have the option of the high dose, do you think that that impacts the overall value proposition of the gene therapy to any significant degree.
Gaurav Shah: So Danon disease is multi-organ, as you say. It would be nice to treat the full spectrum of disease, if possible. However, the mortality in this disease is cardiac. So we were able to address the cardiac aspects of disease. Extending life is in our estimation, the ultimate value proposition, and especially if we can confirm normal longevity on these patients who would otherwise pass away or being a heart transplant by age 19, or 20. So it was a strategy that we had in place, but I think we go with what works and what works in a very major way.
David Hoang : Understood, thanks for that. And then I would bring with the -- ease what's the appropriate endpoints for Phase 2 in Danon? Is your baseline assumption that the approval that you'll get, would that be accelerated? Or do you think you'd be able to get full approval -- you basically use this to do additional clinic work after the initial approval?
Gaurav Shah: Yeah, it's hard to speculate at this point, I think that we have a range of biomarkers that could support an accelerated approval plan. At the same time, we also recognize that a mortality benefit is the ultimate marker of clinical success here. So at the moment, we can't really speculate. But we hope to have answers as we start having the Phase 1 biological agency. And I will also ask Jonathan, to weigh in here, and also comment on some of the other extra credit manifestation points that were there.
Jonathan Schwartz: Thank you Gaurav. Jonathan Schwartz here. Again, I think it's important to emphasize that although obviously, the cardiac disease is fatal in essentially all male death and disease patients, and that's where we'll build the endpoint around. I don't think we can yet discount whether the low dose can or can't affect the non-cardiac manifestations. Importantly, if you look at them in female patients, they don't have substantive extra cardiac manifestations. So we may well see benefit in neuromuscular or neurocognitive aspects of the disease in these male Danon patients with the levels of transaction that has protein expression that has been seen in the low dose adults treated to date. Likely that will take a little bit longer to determine than the cardiac benefits that we believe we have seen to date. But certainly is possible that we may also substantively affect those the non-cardiac elements in these patients, just as the females who have likely 30% to 50% of normal lab to expression largely are unaffected by those aspects of this disorder.
David Hoang : Okay, thanks so much for taking the questions.
Operator: And thank you. Our next question is from Patrick Delvaux with LifeSci Capital.
Patrick Dolezal: Hi, thanks for taking my questions. As it relates to the patient that underwent heart transplant, you mentioned fibrosis was apparent. However, was there any worsening myocarditis observed in the expanded heart or evidence that an immune response contributed to the need for heart transplant? And if so, has there been anything similar observed and biopsies from patients [ph]. Thanks.
Gaurav Shah: Hi, Patrick, no, no myocarditis, no inflammatory changes. And we also didn't see any of those technologies on the other low dose patients that we've looked at.
Patrick Dolezal: Got it? Thanks.
Operator: And thank you. Our next question is from Eric Joseph with JP Morgan.
Eric Joseph : Hi, good evening. Thanks for taking the question. I joined late. So sorry if the questions already being addressed. But maybe just a clarification question as it relates to the potential pivotal Phase 2 for Danon? Should we be -- are you contemplating a single program that addresses both adolescence and pediatrics? Or would they be programs when in parallel? And I guess to the extent it's the latter, can you just maybe just articulate what some of the gating factors would be to an end to Phase 1 meeting? The data that you have so far, in terms of patient numbers in the follow up sufficient? Or would you need to see incremental data with the revised protocol, or new patient data with the revised protocol? Thanks.
Gaurav Shah: Yeah. So with regard to start of Phase 2, what we need to see is, number one, some data in pediatrics, for sure. We need to see the output from a natural history so that we can define the protocol design and also figure out what the right endpoints are going to be in cooperation with the FDA. And those are the things that are engaging. We don't think that we need to add more patients to get there, if anything, actually, since we've cut out the high dose now, the number of patients needed to the end of Phase 1 ne meeting is likely going to be smaller. So that's one point I want to make. For your first question, we anticipate one trial for pediatrics and adolescence. We don't anticipate two separate ones there. So right now, the gating factors are the ones you described and we hope to do…
Eric Joseph : Okay, got it. Very helpful. And thanks for taking the question.
Operator: And thank you sir. And we have no further questions in queue. I would turn the call over to Gaurav Shah, CEO for closing remarks.
Gaurav Shah: Thank you, everyone, for participating in today's call, and we look forward to updating you again soon.
Operator: And thank you, ladies and gentlemen. This concludes our conference and we thank you for your participation. You may now disconnect.