Amylyx Pharmaceuticals Inc

NASDAQ:AMLX

Earnings Call Analysis

Company Reports Q3 Revenue Growth, Awaits Trial Data

The company has reported a Q3 revenue increase to $102.7 million, up from $98.2 million in Q2 2023, predominantly from the U.S. market. Gross-to-net is anticipated to stabilize at 12%-15%, with a COGS projection of 5%-10% of sales going forward. Research and commercial efforts continue for RELYVRIO, a treatment for ALS (amyotrophic lateral sclerosis), with expectations for its applicability in other neurodegenerative diseases like PSP (progressive supranuclear palsy) and Wolfram syndrome. Clinical trials are advancing, and the Phase III ORION trial in PSP is set to launch within the year. Further data from the PHOENIX trial, critical for RELYVRIO's widespread adoption in ALS treatment, is expected in Q2 2024.

Solid Start with Room to Grow Through Focused Strategies

The company kicked off with remarkable initiation, marking its presence strongly across major ALS centers. It is off to a strong start operationally and has made its therapy quickly accessible to ALS patients. Their three-pronged strategy looks promising: first, to enhance clinician engagement in existing markets; second, to expand clinician and patient awareness beyond major centers; and third, to apply the learnings from their Canada operations and insights within the U.S. to foster proper therapy use and ensure patients continue with their medication. They are targeting both the U.S. market, reaching out to roughly 30,000 ALS patients and extending their reach to about 3,000 patients in Canada.

Financial Stability and Profitable Outcomes

Financially, the company is standing on solid ground. The reported net product revenues ascended from $98.2 million in the second quarter of 2023 to $102.7 million in the third, with a substantial contribution from the U.S. market. They're expecting gross-to-net adjustments to stabilize at 12% to 15% in forthcoming periods. Cost-wise, they are within their projected range, with costs of sales at a low 5% of net product revenues, which might escalate to a range of 5%-10%. Net income marks their third consecutive profitable quarter at $20.9 million. Bolstering this fiscal strength is their balance sheet, reflecting $355 million in cash and short-term investments with no debt. Their responsive approach towards financial health positions them advantageously as they anticipate the results from the pivotal PHOENIX trial in the second quarter of the next year.

Expanding the Therapeutic Horizons

The company is not resting on its laurels with just ALS treatment but is aspiring to tackle other neurodegenerative diseases using its therapy, AMX0035, and other clinical trials. They are progressing trials in progressive supranuclear palsy (PSP) and Wolfram syndrome, with expectations to present trial outcomes in 2024. Moreover, they are developing a biomarker for earlier diagnosis of ALS, geared towards improving patient outcomes significantly. An innovative formulation of their flagship therapy, RELYVRIO, is in the pipeline, which could fortify their intellectual property portfolio and is slated for Phase I testing in 2024. It's clear that the company is committed to diversifying its treatment portfolio while ensuring a rigorous pursuit of expanding its current therapeutic applications.

Optimizing Treatment Adherence and Outlook on Therapeutic Impact

In looking at treatment adherence, the company provided insights on therapy discontinuation rates—a crucial measure of the treatment's impact. In the U.S., around 60% of patients maintain therapy at the six-month mark. In contrast, Canada shows a higher persistence at about 80%, indicating an opportunity for improvement in the U.S. market. The company acknowledges this gap and has set forth initiatives to bolster continuity of treatment among patients, with expectations of impacting these metrics positively in the upcoming quarters. Such initiatives are projected to enhance patient outcomes, a steadfast goal for the organization.

Anticipation for PHOENIX Trial Results and Strategic Readiness

The company is eagerly awaiting the top-line readout for the PHOENIX trial, pinpointing the second quarter of 2024 for the results, and is already preparing strategies for rapid movement towards approval contingently on positive outcomes. This trial is not only a significant prospect for the company but also a potentially momentous milestone for the ALS community. The anticipation and the strategy in place signify their preparedness to leverage positive trial results swiftly and effectively, aiming to position its flagship product as the most prevalent ALS medication.

Leveraging Compassionate Use Programs as Stepping Stones

Beyond trials, compassionate use programs, such as the one recently initiated in France, could foster early adoption and experience with their therapy among key centers. While revenue from these programs is poised to be supplemental, the primary focus remains the pursuit of full approval in Europe. Through these programs, the company not only anticipates incremental revenue in the lead-up to formal approval but also views this as an important stage for expanding reach and understanding patient demand in various geographies. Consequently, these insights are equally critical to the company's long-term international market strategy.

Earnings Call Transcript 2023-Q3

[Operator]

Good morning. My name is Keith, and I will be your conference operator today. At this time, I would like to welcome everyone to the Amylyx Pharmaceuticals Third Quarter 2023 Earnings Conference Call. [Operator Instructions] Please be advised this call is being recorded at the company's request.

I would now like to turn the conference over to Lindsey Allen, Head of Investor Relations and Communications. Please proceed, ma'am.

[Lindsey Allen, executive]

Good morning, and thank you for joining us today to discuss our third quarter 2023 earnings. With me on the call are Josh Cohen and Justin Klee, our co-CEO, Margaret Olinger, our Chief Commercial Officer; and Jim Frates, our Chief Financial Officer.

Before we begin, I would like to remind everyone that any statements we make or information presented on this call that are not historical facts are forward-looking statements that are made based on our current beliefs, plans and expectations and are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. These statements include, but are not limited to, our expectations with respect to RELYVRIO and ALBRIOZA, statements regarding our current and planned clinical trials and regulatory developments and the expected timing thereof; our business and marketing strategy and outlook and our expected financial performance.

Actual events and results could differ materially from those expressed or implied by any forward-looking statements as a result of various risks, uncertainties and other factors, including those set forth in our most recent filings with the SEC and any other future filings that we may make with the SEC. You are cautioned not to place any undue reliance on these forward-looking statements, and Amylyx disclaims any obligation to update such statements unless required by law.

Now I will turn the call over to Justin.

[Justin Klee, executive]

Thank you, Lindsey, and good morning. As we sit here 3 full quarters into our U.S. launch in ALS, we are proud of what we have accomplished. We are also keenly focused on the work we still need to do to help transform and improve the way that ALS is treated. Our progress with RELYVRIO continues.

As of September 30, 2023, there were roughly 3,900 people living with ALS, taking RELYVRIO in the U.S. We generated $102.7 million in net product revenues in the third quarter and $272.3 million in the first 3 full quarters of launch. We are incredibly pleased with how quickly ROLIVRIO has been adopted at key ALS centers and with our engagement with clinicians. While we will continue our efforts to grow within these centers, we are now expanding our focus beyond those top centers based on our experience in the field and new research that points to the fact that roughly half of all people living with ALS receive care from clinicians that do not specialize in ALS and are likely unaware of the benefits of RELYVRIO.

A key message that you will hear on our call today is that we are continuing to evolve our commercial focus as we look to transform the ALS market. We recognize that it may take time and additional data from PHOENIX to reach the many clinicians who have yet to prescribe RELYVRIO as we work towards our goal that at least 10,000 people will be taking RELYVRIO at any given time. Margaret will provide additional details. As an organization, we are focused on both delivering on our commercial and R&D goals in the near term and investing for the long term with a pipeline focused on treating neurodegenerative diseases. Importantly, our PHOENIX study is progressing well, and we now expect to report top line data from the 664 participant study in the second quarter of 2024. We continue to be confident in the design and execution of the study. Josh will provide additional details on PHOENIX, review our pipeline and share the key conclusions from data we presented at the Northeast ALS Consortium meeting last month. He will also review data from CENTAUR that was recently published in a prominent peer-reviewed medical journal that reaffirm the confidence we have in the survival data for RELYVRIO.

As a reminder, the CENTAUR study was the basis for the full approval from the FDA that we received for RELYVRIO in late September 2022 and our approval with conditions in Canada. We also remain committed to bringing the benefits of RELYVRIO outside the U.S. and Canada to the more than 200,000 people living with ALS worldwide. Assuming the data from PHOENIX is supportive, we plan to seek approval in the European Union as quickly as possible. In addition, we continue to interact with key stakeholders around the world to explore opportunities for access like we did in Israel and France, and we are engaging with regulators in Japan. RELYVRIO gives us the opportunity to start to transform ALS from symptom management as standard of care to a disease with meaningful interventions, and our team is working hard to accelerate this shift because we know people living with ALS have no time to wait. While we are pleased with the progress we've made to date, there are so many more thousands of people to help and clear opportunities ahead of us for growth in the U.S. and Canada and throughout the world.

I will now turn the call over to Margaret to share some additional detail on our commercial launches and plans in the U.S. and Canada.

[Margaret Olinger, executive]

Thank you. As Justin mentioned, we ended the quarter with roughly 3,900 people on RELYVRIO in the U.S., up from roughly 3,800 at the end of the second quarter. With our goal that at least 10,000 people living with ALS will be taking RELYVRIO at any given time, we are working hard to accelerate this growth, and I will detail some of the specific plans shortly.

The interest and engagement among our prescribers remains strong, and we saw a steady cadence of new prescriptions written in the third quarter. In addition, fill times were down to about 3 weeks for people living with ALS enrolling in the quarter. As we think about how our growth has evolved this year, the slowdown in net adds this quarter was primarily driven by increased discontinuations for a variety of reasons. We have already begun implementing new educational initiatives, which I will touch on in a few minutes. In addition, we are developing an updated clinician engagement and marketing program in preparation for PHOENIX. We believe support of PHOENIX's results will reinforce the robust data currently available and help all aspects of our launch with greater awareness, demand and greater duration of use. Our hope is that these data will further demonstrate that RELYVRIO can significantly impact people living with ALS.

Turning to the quarter. Prescribing remain concentrated with roughly 80 prescribers mostly at major ALS centers, representing approximately half of all RELYVRIO prescriptions and approximately 300 prescribers representing the vast majority of prescriptions. We are pleased to have a core group of active riders at the top centers, just 3 full quarters into our U.S. launch. And roughly 25% of the people treated at these centers were taking RELYVRIO. There is still a clear opportunity for continued growth, as our research shows that roughly 2/3 of people living with ALS in these centers were on at least 1 approved ALS drug. And like I said, only 25% of patients in these centers were taken RELYVRIO. The top clinics are actively prescribing RELYVRIO, and we continue to educate, optimize and reiterate our messaging about RELYVRIO's efficacy, including the data on early use of RELYVRIO and the importance of staying on treatment as well as the safety profile.

As Justin mentioned, we have also learned through experience in the field in further market research that roughly half of all people with ALS received care from clinicians that do not specialize in ALS. For the most part, this group is not prescribing RELYVRIO. We are developing and we'll be rolling out new marketing initiatives to reach the group of both potential prescribers and people with ALS, who may be unaware of RELYVRIO in its benefits on both function and survival. These include increasing our digital presence, enhancing our nonpersonal efforts and optimizing our field strategy. We view this as a key source of future growth.

Circling back to discontinuations. 60% of people taking RELYVRIO remain on therapy 6 months after initiation in the U.S. We believe some discontinuations are addressable, especially when comparing our discontinued rate in the U.S. to Canada. In Canada, roughly 80% of insured patients, both private and public, are still on therapy 6 months after starting treatment. Our Canadian team has made substantial efforts to educate on the importance of remaining on therapy. While the Canadian system is clearly different from the U.S. including the fact that it is a more concentrated system, we do believe we can leverage our learnings in Canada, in the U.S. and improve our discontinuation rate. We have begun to deploy the learnings and messages from Canada in the U.S. We believe the key is to educate clinicians in their offices on the benefits of RELYVRIO and right expectations with them, so they are prepared to set expectations with their patients. Overall, RELYVRIO is a well-tolerated drug, and we are optimistic that our additional educational efforts in the U.S. will result in increased prescribing and duration of use.

To summarize, we are off to a strong start with significant interest and engagement from the major ALS centers. Operationally, our team is delivering and people living with ALS are able to start therapy quickly. We are focused on 3 goals that will drive our commercial strategy going forward. First, we are optimizing our approach to engaging with key clinicians to maintain and continue to grow that segment of the business. Second, we will increase our programs to build awareness among clinicians and people living with ALS and their caregivers outside of the key centers. And third, we will take the learnings from Canada and our insights in the U.S. to educate on appropriate utilization and to support persistency. We have more work to do, but we are also pleased to be off to a great start and honored to continue to serve more and more of the approximately 30,000 people living with ALS in the U.S. and approximately [ 3,000 ] people living with ALS in Canada.

I will now turn the call over to Jim to discuss our financial results for the third quarter.

[James Frates, executive]

Thanks, Margaret, and good morning. As you've heard, we have an excellent penetration and engagement among the top ALS centers. and we remain optimistic and committed to the potential for RELYVRIO. As we adapt to our focus and await PHOENIX data, we're confident in the long-term prospects of our business. In the meantime, we're profitable and focused on being prepared for success when PHOENIX reads out in the second quarter of next year.

Now let me turn to the financial results for the quarter. Net product revenues were $102.7 million for the third quarter compared to net product revenues of $98.2 million for the second quarter of 2023, with the vast majority of that revenue coming from the United States. Our results were impacted by a number of factors. In addition to what Margaret mentioned earlier, there was also a higher number of people living with ALS receiving free goods, slightly over 15% versus roughly 10% in Q2. Gross-to-net adjustments were approximately 8% in the quarter. This is below our long-term expectations and was similar to Q2. We continued to see lower chargebacks and rebates than we had anticipated. Going forward, we expect our gross-to-net will settle in the range of 12% to 15%.

Inventory levels at quarter end were as expected, with approximately 2 weeks of inventory in the channel at specialty pharmacies similar to what we've seen in previous quarters. Cost of sales were $5.2 million for the quarter, roughly 5% of net product revenues. This is within the range of our expectations. Q3 was helped by a low rate of scrap and the completion of our royalty obligations in the second quarter. Going forward, we expect COGS to be in the range of 5% to 10% of sales. Research and development expenses were $30 million for the quarter. You should expect R&D expenses to be in the range of $35 million to $40 million in the fourth quarter as we start enrolling participants in our new global Phase III trial in PSP and advance other programs in our portfolio.

Selling, general and administrative expenses, or SG&A, were $48.7 million for the quarter compared to $43.4 million in Q2. The increase was mainly driven by increases in marketing expenses, personnel and additional charitable contributions in the quarter. We expect SG&A expenses to be in this range for the fourth quarter. These results led to a strong bottom line. We generated $20.9 million in net income, representing our third quarter in a row of profitability.

Finally, we ended the quarter with cash and short-term investments of $355 million and 0 debt. Our balance sheet remains strong as our assets increased $13 million in the quarter, and we paid down approximately $18 million in payables during Q3. We're pleased with our strong financial position, and we are well situated as we await the completion of the PHOENIX trial. Our launch has shown the value of and interest in RELYVRIO among the top ALS centers. We're confident in our ability to continue to grow our top line, invest in our pipeline to provide much-needed additional treatments for neurodegenerative diseases and to deliver on our bottom line.

I'll now turn the call over to Josh to discuss our R&D program updates.

[Joshua Cohen, executive]

Thanks, Jim. We believe RELYVRIO, also known as AMX0035, may have applicability across other neurodegenerative diseases, and we are actively advancing clinical trials to evaluate AMX0035 in progressive supranuclear palsy or PSP and Wolfram syndrome as well as advancing an antisense oligonucleotide in ALS. AMX0035 is comprised of sodium phenylbutyrate and taurursodiol and work synergistically to prevent or slow cell death. We are on track to launch the Phase III ORION trial of AMX0035 in PSP during this year.

We recently presented the ORION study design at the Neuro 2023 Conference and received positive feedback from the community there. Additionally, we continue to progress our Phase II trial in Wolfram syndrome and expect to report results in 2024. We are also advancing AMX0114, our antisense oligonucleotide targeting calpain-2 through IND-enabling studies and expect to enter the clinic in 2024. We recently presented preclinical data at the NEALS conference on this candidate. In addition to advancing these new therapeutic programs, we are also advancing a new composite biomarker to diagnose ALS earlier. Current data suggests that diagnosis takes about a year. The goal of this program is to create a tool that allows for earlier diagnosis of ALS, which may result in earlier treatment and better outcomes. We shared that we are conducting this program at NEALS this year. We intend to provide a full set of results from initial experimentation in 2024.

For several years, we have also been working on a new taste mask formulation of RELYVRIO. This formulation may allow for new intellectual property. We are planning to file an IND and conduct Phase I testing for our innovative formulation in 2024. This quarter, we also continued to publish RELYVRIO data. RELYVRIO is the first and only approved treatment for ALS to demonstrate a statistically significant benefit in function in a clinical trial as well as a survival benefit in a longer-term post-hoc analysis. Just recently, an analysis comparing the long-term survival of participants in the trial to a historical clinical trial control group was published in the annals of clinical and translational neurology. The results of this post-hoc analysis demonstrated that the median overall survival was 10.4 months longer in the AMX0035 group than in the historical clinical trial group.

As we -- finally, as we approach the top line readout for PHOENIX, we are focused on our execution and confident in our setup for success. First, travel design is based on the success we saw in CENTAUR, which was a randomized, placebo-controlled study meeting its prespecified primary outcome. Second, while we design the study to allow for a broader entry criteria, the population that enrolled are very similar to CENTAUR, as shown in a poster presented at NEALS. Lastly, we enrolled 664 participants in a 3 to 2 randomization and serve roughly 5x the size of CENTAUR in the step. Interest among investigators is high, and we have so far executed well and enrolled per our planned time line.

In closing, our launch is off to a strong start, and we have made great progress towards our goal of RELYVRIO becoming the most commonly used medicine in ALS. We eagerly await the data from PHOENIX now expected in Q2 2024 and are simultaneously exploring if RELYVRIO can help people with other neurodegenerative diseases, including PSP and rofamzyndrome. Overall, we are very pleased with what we have achieved as an organization to date and with the substantial opportunity ahead of us, both with our commercial launch and our pipeline.

Now we'd be happy to take your questions. Operator, please open the call up to Q&A.

[Operator]

[Operator Instructions] And the first question comes from Corinne Jenkins with Goldman Sachs.

[Corinne Jenkins, analyst]

So can you just help clarify a little bit on the discontinuations that you're seeing? Or are these primarily due to adverse events, disease progression or kind of patients ultimately dying? Or are you in the kind of as a follow-on from that? Are you seeing any change in the type of patients that's coming on to drug now versus during the early launch, particularly with respect to time on diagnosis?

[Margaret Olinger, executive]

Yes. Thank you very much for the question. This is Margaret. So yes, on the discontinuations, there's a variety of reasons why people discontinue ALS therapies. But it's important to remember that in many ways, it's really connected to the disease state sadly. So as we mentioned, we're deploying tactics designed to help lower the rate of these types of discontinuations, including taking the key learnings from Canada, where we heavily focused on the importance of remaining on therapy because our long-term efficacy is really based on being on therapy for the long term. So that's highly what we're focused on. And the second question regarding mix of therapies. We continue to see a mix of therapies, a mix of patients coming on therapy with the prevalent patients. But I would say in the third quarter, we've probably seen a slightly higher mix of patients coming on that were more newly diagnosed patients, and we define that as patients that have been diagnosed in the last 6 months.

[Justin Klee, executive]

Yes. And maybe the only thing I'll add there as well. Just going to the discontinuation specifically, at 6 months in the U.S., we're seeing roughly 60% of people remaining on therapy. In Canada, however, we're seeing roughly 80%. So what this tells us is that we believe that we can impact this. And so that's what we're going to be trying to do over the coming quarters.

[Corinne Jenkins, analyst]

And do we know what kind of the industry standard is for ALS drugs on the whole, like what's sort of the average duration of therapy or discontinuation rates for the broader cost of therapies in that indication?

[Joshua Cohen, executive]

Yes. It's a little hard to say. Obviously, we're all kind of pulling different data on different therapies and probably don't talk too much about the other therapies on the market. But again, I think our goal is to be best-in-class here. And looking at Canada and some of the data we're seeing there, we believe this is an area we can continue to see opportunity and continue to grow.

[Margaret Olinger, executive]

Yes, and I would just say -- sorry, and I was just going to add to that. We continue to believe that patients who get on therapy earlier and stay on therapy longer, we'll have better patient outcomes, and that's certainly our objective and mission moving forward.

[Corinne Jenkins, analyst]

Okay. And then I guess, how quickly can we expect to see you guys toggle this, in particular, given the acceleration in patient growth in the first half of this year? Or should we expect this to be a big factor into the fourth quarter? And if you could comment on kind of trends you're seeing there would be helpful as well.

[Joshua Cohen, executive]

Yes, I'd say it's probably early to comment on how the next quarters will land. But what I can say, and I think, as Margaret mentioned, we have a number of initiatives that we're rolling out that we hope will impact things. in the top centers and while we have percent of people on therapy with -- or 25% of people on RELYVRIO, roughly 66% of people are in any ALS therapy. So we see a big opportunity there, and we're going to continue optimizing that. And then as we share what we found is roughly half of people are not actually seen by a la specialist. And so there's a big opportunity to get RELYVRIO broader beyond just the key ALS centers. And then I think finally, as we touched on, too, on the discontinuation side, we've seen tactics that have worked in regions. And we're going to try to use those in the U.S. as well and hopefully continue to see growth there.

[Justin Klee, executive]

And Karen, just bringing it back to the picture, I think in short, we see great near-term growth opportunities and also long-term growth opportunities. I mean we have 3,900 people on treatment as of the end of the quarter, and there are roughly 30,000 people in the U.S. at any one time who have ALS. And while we have the growth opportunities, as Josh was outlining, we also have the PHOENIX study results, which we think will be a huge milestone for the ALS community, the first time that a treatment would have positive results from 2 studies. So I think we have great growth opportunities ahead of us right now, and we have the PHOENIX trial results, which we think will further accelerate that.

[Operator]

And the next question comes from Geoff Meacham with Bank of America.

[Geoffrey Meacham, analyst]

Just had a few. So on PHOENIX, the first one is I know it's splitting hairs, but mid-24% versus 2Q? Is that based on a faster event rate? Or did you guys just want to get more specific with the guidance? And the second question is compassionate use in France and maybe other geographies. How much incremental revenue could we expect to see from some of these? Just thinking about going into formal full approval as you think about Europe, but does compassionate use kind of be a -- is that a leading indicator, I guess, of ultimate demand?

[Joshua Cohen, executive]

Yes. So maybe on PHOENIX first. I think we first said mid- maybe at this point over a year ago or otherwise. So I do think it's just a case of getting more specific as we're getting closer and nearer to the readout there. And then I'll pass it over to Jim to talk about the compassionate use impact on revenue.

[James Frates, executive]

Yes. We just started up in France late last month. So it will be interesting, and it remains to be seen the demand that we see there. I do think this will be incremental revenue if we see it through -- as we see it through 2024 and then hopefully, ultimate approval. That said, it is going to be an important opportunity to have the key centers get experienced with RELYVRIO. And additionally, those centers tend to be more concentrated in Europe than they are in the United States. So it's important for us to get access to patients. But given the size, frankly, of our revenues in the United States, while it will be -- it will certainly be incremental, but the main driver we're looking for is full approval in Europe.

[Geoffrey Meacham, analyst]

Got you. And just a follow-up to that real quick. When you think about filing in Europe, I know you guys have been through a back-and-forth process as of now. But for PHOENIX, do you think you would have to wait for OS to hit? Or do you think you could file theoretically, if you hit on just the functional data set for next year?

[Joshua Cohen, executive]

Yes. So I'll say, ultimately, we can never project or speak for the regulators. But certainly, our intention is with positive PHOENIX results, especially coming out of the top line readout, we will want to push forward towards approval as quickly as we possibly can.

[Justin Klee, executive]

Yes. And just adding, I mean, I think further to your questions, too, I think we remain confident in the design and execution of the study. It's -- again, it's a 664 participant study, our team is executing. And I think that those results will be a major milestone for the ALS community, the opportunity to have 2 positive studies in a disease where there's been so much historical clinical trial failure, I think it's hard to overstate what a big deal that will be for the community.

[Operator]

And the next question comes from Umer Raffat with Evercore ISI.

[Umer Raffat, analyst]

I have 2. Let me start with this perhaps. If I just look at the fact pattern on how you implemented the data restriction on IMS and Symphony vendors this summer and how that coincided with this massive slowdown? It just really puzzles me because I feel like not only was the street ready from communication on your end, but also I feel like you limited the channels to which street could have been ready for today. How do you -- can you expand on that? Because it looks like it looks like you may have had a sense for discontinuations really picking up around July time frame.

[Joshua Cohen, executive]

Well, yes, maybe I'll start. So our intention at launch was always to have the limited distribution model. And so we updated everyone in February that we thought we had identified one of the areas where there is some data coming out, and so we had addressed that. So that was back in February. And I think the most important thing here, though, is that we have huge long-term growth opportunities ahead of us. We're very proud that we're helping 3,900 people as of the end of the quarter. But again, I'll reiterate, there are 30,000 people with ALS at any 1 time. And the last thing I'll say, too, is that we're really trying to transform the disease space here. As I said in my remarks, ALS historically is focused on symptom management, and we're trying to shift the field to focus on meaningful interventions, -- that's not going to happen overnight, but we think we've done a great job so far, but we've also identified even further opportunities to start to transform the landscape. So we think we have great growth opportunities ahead of us.

[Umer Raffat, analyst]

Got it. And let me just follow up. Just on, a, am I right in calculating about 5,500 patients may have started therapy since your launch? And secondly, if I model out on discontinuations. What I feel is it's not just the discontinuation. It's also the new starts might have dropped about 35%, 40% quarter-over-quarter from 2Q to 3Q. Is that right? Because I feel like you may have had about I don't know, 750 discontinuations in 3Q. But if that's the case, you might be in for another about 650 to 700 discontinuations in 4Q, which makes it very hard to again put up a very meaningful net add number in 4Q unless your new ad picks up meaningfully versus where it was in 3Q. Am I on the right track there?

[Joshua Cohen, executive]

Maybe we haven't commented on any of those metrics, but maybe just to circle back. There are roughly 30,000 people living with ALS in the United States. We have 3,900 on therapy. So we certainly see an opportunity to continue to grow. And that's what we're going to be out here trying to do. I think we shared several of the tactics that we think will achieve that.

[Justin Klee, executive]

Yes. And I think that our initiatives are designed at, again, transforming ALS. We have initiatives to help in the top centers where we think there's further opportunity in the market, we found that there are far more people in the broader neurology community. And so we think there's great initiatives we can do for further awareness. And as we showed in Canada, we think that we can use our strategies to show that staying on therapy longer matters. And again, that's part of transforming the disease space. So in answer to your question on sort of both growth in terms of new people coming on as well as staying on treatment, we think we have great strategies to address all of those.

[James Frates, executive]

Yes. Let me just take number 2. I think as you do your calculations, actually, Margaret mentioned in her remarks, we've had actually steady new prescriptions from Q2 into Q3. So while we obviously want to see more growth and accelerated growth in that, and we touched a little bit about that in our remarks. There's no real distinctive change in terms of the new adds. Certainly, it slowed down from Q4 and into Q1, and we talked about that on the last call, but we've seen steady new adds. And just another point of that -- it's not like we've seen a major drop off here. This has been a slightly steady decline as we move through time. We've always cautioned about what the right discontinuation model is, right, because we can't model 6 months or 9 months discontinuations until we get there. So we've been tracking the CENTAUR data through last quarter. It's gotten a little higher than that discontinuation rate over the last couple of months. That's different in Canada. So we actually think that as we lean into this a little bit more and adjust our tactics here on what has been a very solid launch so far in our first 9 months. This is an adjustment of tactics, and I think we can hopefully get back to seeing growth again.

[Operator]

And the next question comes from Marc Goodman with Leerink Partners.

[Marc Goodman, analyst]

Yes. Maybe you can give us a flavor for how October went to give everybody a sense of trends versus what we just talked about?

[Joshua Cohen, executive]

Yes. We usually don't report month-to-month. But what I'd say is that we're certainly rolling out many of the things that Margaret described. And certainly, there's nothing revolutionary there in terms of things are continuing. We're continuing to see net adds at a steady pace.

[Justin Klee, executive]

Yes. I think just reiterating what Margaret and Jim were saying, the slowdown in that patient adds we saw was primarily driven by discontinuation. And we think we have great things to address there and as well as new opportunities for growth as well.

[Marc Goodman, analyst]

So just to be clear on the new patient adds, from second quarter into third quarter, you had a steady increase in new patient adds. And so whatever that steady pace was month-to-month, is that what it was? October, everything is just kind of the same, similar slowing down, speeding up? Just give us a sense.

[James Frates, executive]

Yes. I'd say steady is steady. And so what we want to see is a reacceleration of that growth, right, back to the levels that we saw when we were first launching the drug. And I think a very important point to make here is that we're doing exceptionally well in the key centers. And 1 of the things that we're doing, right, and it was a logical place for us to focus. We're going to keep that focus on those key centers where we've got penetration up to roughly 25% of all patients, as Margaret talked about. But what we have to do now is continue to grow there, but expand into the next deciles down. Deciles, through is where we're going to be focused.

[Marc Goodman, analyst]

But is it fair to say that steady means steady, like October was steady trends, just like the previous quarter because here's an opportunity to kind of comment on it given what happened this past quarter. I know you don't normally do it, but maybe you could make an exception this time.

[James Frates, executive]

Yes. Well, I think, Marc, the trouble is, right? This is not another factor that's going on here, right, is we had an additional 5% of the people that were on free drug. -- right? So if those folks -- if we remain at the 10% range instead of the 15% range, right, sales would have been a lot higher and closer to people's expectations. So I think month-to-month, single months matter still even at these levels. And so we're only 1 month into the quarter, and it's very hard to predict where we're going to be at the end of the quarter where we sit today.

[Operator]

And the next question comes from Graig Suvannavejh from Mizuho Partners.

[Graig Suvannavejh, analyst]

It's Graig Suvannavejh. I've got 2, if I could. First, I know a lot of the growth now is going to be focused on the non-ALS center setting. And I was wondering if you could just maybe provide additional color around the pace with which you think you can penetrate that non-ALS enter setting? And then my second question just has to do with kind of with PHOENIX, now a second quarter event. And as you think about current usage of the product, whether it's views by physicians or patients, I'm wondering if you feel and maybe help us understand this, if you feel that there is some element of you not being able to capture more patients because of anticipation around PHOENIX? In other words, how much do you think if you do end up getting positive PHOENIX data that, that will really drive growth over and above what you're experiencing right now?

[Margaret Olinger, executive]

Yes. Great. So just to answer your first question, certainly, we see our growth coming in 3 different buckets. One is we do believe we have continued focus and opportunity within the top ALS centers. as we've already talked about, we have 300 physicians that are prescribing in that bucket of patients. They're prescribing about 25% of all their patients on alivio treatment but they are treating 2/3 of their patients with any patient -- any drug available for ALS. So that's a 40% growth opportunity in front of us that we are heavily focused on driving our education the first and only product to have function plus survival. And we really believe that we can be foundational treatment. And again, just to reiterate, we have full approval in the U.S. We are confident in our sent to our data, and we were studied in monotherapy and combination therapy. So we believe that just in that bucket alone, where we've been heavily focused and concentrated on, there's a tremendous amount of opportunity. The second bucket, as you mentioned, is really growing into the non-ALS specialists where we've identified a number of strategies and tactics that we'll be focused on. It's hard to predict exactly how quickly we'll have an impact on that, but we absolutely do think we'll have an impact on that. And we've started to implement some of that it will probably take a little bit of time. And as Justin mentioned, we're transforming the landscape in ALS treatment. They have had a little bit of appetite because they haven't had a lot of tools in their tool in the past, and we're trying to change that literally, we believe that every patient living with elastic benefits from our treatment should have access to our treatment and work function and survival. So we believe that's a tremendous amount of opportunity for us moving forward. And the third bucket would be really driving the persistency, taking the learnings we have from Canada, taking the learnings we have in the AL and really focusing our educational efforts, not only on function but survival. But the long-term efficacy comes with being on therapies for the long term. So that's our focus there. We believe that will have an impact on us. And then the second question regarding PHOENIX data. is we're doing a lot of this in preparation for our PHOENIX readout. We are incredibly bullish on our PHOENIX data. We believe we're going to have successful data. That's certainly what we're planning for. And we believe it will have an inflection point on our business both from an awareness and demand generation and a duration of use perspective.

[Operator]

And the next question comes from Ananda Ghosh with H.C. Wainwright Company.

[Ananda Ghosh, analyst]

One of the questions -- I have 2 questions. The first one is based on looks like the absence of PHOENIX data is a kind of hindrance in terms of relieve your uptake with the specialists. My question is what about the nonspecialists, how much aware they are with respect to the center data? And what's the strategy around kind of educating the nonspecialists as you think about the next quarter?

[Joshua Cohen, executive]

Well, yes, thank you for the question. And maybe to clarify, I mean, I think we're off to a great start with -- particularly with the specialists. I mean a year into launch, we have roughly 25% people with ALS on RELYVRIO in those key centers. Now obviously, there's more to do. But when you think that ALS historically focuses mostly on symptom management, and we're trying to say, no, there are meaningful interventions, I think that that's quite good for a year into launch. Now there's obviously more work to do. But again, that's -- we've talked about where we see those opportunities for growth in the key centers. In terms of the non-key centers, just, I think, reminding everyone, for many of these people, they learned about ALS last time in med school, and ALS is a diagnosis that no one wants to give because there's very little you can do for those patients. And we obviously think that's not true. They're therapeutic and nontherapeutic interventions that are very meaningful. But that's what it means to transform a disease landscape. Now on top of all of those things, we think that the PHOENIX trial results will be a major milestone for the community because, again, having the first treatment with 2 positive studies in ALS is a really big deal. On top of, of course, the central results, which is the first time the treatment showed a benefit on both slowing disease progression as well as increasing lifespan. So that's why we feel like we have great near-term opportunities in both the key centers as well as the broader neurology community. And then we think PHOENIX will just further accelerate all of that.

[Ananda Ghosh, analyst]

Great. My second question is on the discontinuation rate. The difference which you see in Canada and U.S. I mean it's quite prominent. And the question is, like, can you be more specific on what exactly Canada, like how exactly Canada is different than U.S. that you see the [ stock ] difference in discontinuation rate?

[Margaret Olinger, executive]

Yes. So thanks for the question. Canada really focused from day 1 on driving the importance of remaining on therapy. And just to mention -- I mentioned it in the comments, but concentrate Canada is a really concentrated market. They have about 17 key centers of excellence. So it's a little hard -- a little easier to control sort of that getting that message down to the HCPs and then having them communicated to the patients, which is incredibly important, where it's a little bit more decentralized in the U.S. So while we certainly have in communicating those messages, I think getting those treatment expectations and just doubling down on that messaging is going to be really important. But I think the important point is we know that when done and done well, you can achieve better persistency rates.

[Operator]

Thank you. And this concludes the question session at this time. I'll turn the call back to Mr. Klee.

[Justin Klee, executive]

Thank you, operator, and thank you all for joining us on our call today and for your support. We hope you have a good day.

[Operator]

Thank you. The conference call has now concluded. Thank you for attending today's presentation, you may now disconnect your lines.