Aurinia Pharmaceuticals Inc

NASDAQ:AUPH

Earnings Call Analysis

Aurinia's Revenue Growth and LUPKYNIS Performance

Aurinia Pharmaceuticals reported a strong third-quarter performance with LUPKYNIS net product revenue hitting $40.8 million, a 60% increase from the prior year's quarter. With year-to-date revenue at $116.2 million, up 55% from the previous year, the company is optimistic, revising its 2023 revenue guidance to $155-160 million, up from the initial $150-160 million. The total third-quarter revenue was aided by a $10 million milestone payment and reached $54.5 million. Patient start forms grew by 17%, indicating robust patient acquisition and high treatment conversion rates of about 90%. Persistency rates are at 54% at 12 months, 48% at 15 months, and 43% at 18 months, demonstrating sustained usage. The company focuses on three growth levers for LUPKYNIS in the lupus nephritis market.

Strategic Campaigns and Patient Engagement

The company is actively engaging with patients through various digital and social media channels to enlighten them about their disease and encourage routine physician monitoring. Noteworthy is their collaboration with Toni Braxton, reaching over 750 million media impressions, aimed at educating patients about Systemic Lupus Erythematosus and lupus nephritis. Their medication, LUPKYNIS, is being positioned as a foundational therapy for lupus nephritis (LN), leveraging new clinical data to differentiate it from other therapies.

Financial Health and Product Revenue Growth

The company's cash reserves have decreased slightly to $338.5 million from $389.4 million at the end of last year, mainly due to investments in commercial activities and advancing their pipeline. However, an increase in cash receipts from LUPKYNIS sales partly offset this. Revenues have risen, with net product revenue reaching $40.8 million for the quarter, up from $25.5 million in the previous year, attributed largely to LUPKYNIS's growing market penetration. Overall net revenue for the quarter slightly decreased due to prior year milestone recognitions, while gross margins have decreased to 88% from 96% in the previous year due to increased amortization and inventory reserves.

Cost Management and Net Loss Analysis

Selling, general and administration expenses dipped to $145.0 million from $148.9 million in the prior year, with a notable decrease in professional fees. However, research and development expenses rose due to the advancement of pipeline assets. Despite these efforts, the company recorded a net loss of $13.4 million for the quarter, which is a larger loss than the $9 million reported last year. The company has recorded a $51.1 million net loss over the span of nine months.

Prescriber Engagement and Market Penetration

The company has seen double-digit percentage increases in LUPKYNIS prescriptions, both from repeat prescribers and within their overall prescriber base. They are content with the market penetration among nephrologists and rheumatologists treating lupus and LN, suggesting effectiveness in reaching and engaging the key prescriber demographic.

Forward-Looking Statements and Management's Strategy Review

Management remains cautious in providing sales and patient start form (PSF) expectations for 2024, preferring to offer insights closer to the JPMorgan event next year. They are assessing net pricing trends, aiming to trend closer to their $65,000 average net revenue per patient per year estimation. There's optimism about the recent PSF consistency and potential growth in subsequent months, coupled with a belief that newly released data will enhance performance trends. Additionally, the company is undergoing a strategic review process, taking serious steps at both the management and board levels to accelerate their strategy for LUPKYNIS and any potential opportunities that emerge from this strategic evaluation.

Earnings Call Transcript 2023-Q3

[Operator]

Greetings. Welcome to Aurinia Pharmaceuticals Third Quarter 2023 Earnings Call. [Operator Instructions] As a reminder, this conference is being recorded. I would now like to turn the conference over to your host, Jamie Harrell, Investor Relations for Aurinia Pharmaceuticals. Thank you. You may begin.

[James Harrell, executive]

Thank you, operator, and thank you to everyone for joining today's call and webcast to review and discuss Aurinia's Third quarter and 9 months 2023 Financial and Operational Results. Joining me on the call this morning are Peter Greenleaf, Chief Executive Officer; and Joe Miller, our Chief Financial Officer. This morning, Aurinia issued a press release announcing its financial results and operational highlights for the third quarter and 9 months that ended September 30, 2023. In addition, the company filed its quarterly financial statements on Form 10-Q.

For more information, please refer to Aurinia's filings with the U.S. Securities and Exchange Commission, which are also available on Aurinia's website at auriniapharma.com. During today's call, Aurinia may make forward-looking statements based on current expectations. Those forward-looking statements are subject to a number of significant risks and uncertainties, and actual results may differ materially. For a discussion of factors that could affect Aurinia's future financial results and business, please refer to the disclosures in Aurinia's press release and its quarterly report on Form 10-Q, along with Aurinia's annual report on Form 10-K and all of its recent filings with the U.S. Securities and Exchange Commission and Canadian securities authorities.

Please note that all statements made during today's call are current as of today, Thursday, November 2, 2023, unless otherwise noted and are based upon information currently available to us at this time. Except as required by law, Aurinia assumes no obligation to update any such statements. Now let me turn the call over to Aurinia's President and CEO, Peter Greenleaf. Peter?

[Peter Greenleaf, executive]

Thanks, Jamie, and good morning, everyone. I want to thank you all for joining us on today's call. On this morning's call, we will focus on the company's third quarter and year-to-date performance. We'll discuss key metrics and significant commercial highlights for LUPKYNIS. We'll then provide an update on our progress outside the U.S. and close with a brief update on R&D activities for both LUPKYNIS as well as our pipeline assets. I'll then turn the call over to Joe Miller, our CFO, to provide additional details on our financial results. Now let me dive into our overall business performance. I'm pleased to share that we continue to make progress over the last 3 months and year-to-date with up LUPKYNIS both domestically and abroad.

Highlighting the third quarter, we achieved $40.8 million in LUPKYNIS net product revenue, which represents an increase of 60% versus the prior year's third quarter. We're quite pleased with these results, in particular, in light of the impact that the summer months have had on our business historically. This brings year-to-date LUPKYNIS' net product revenue through the end of the third quarter to $116.2 million. This represents an increase of 55% versus the same time prior year.

As a result of our strong third quarter, we're narrowing our net product revenue guidance for 2023 from $150 million to $160 million to $155 million to $160 million. Additionally, in the quarter, we recognized a $10 million ex-U.S. milestone from our collaboration partner at Otsuka Pharmaceuticals for securing the pricing and reimbursement approval in Europe. This plus royalties from ex-U.S. sales brings our total revenue for the third quarter to $54.5 million.

Leading the company's key commercial metrics for the quarter, patient start forms remained strong throughout the period with 436 PSFs in the quarter. This represents a growth of 17% over the prior year's third quarter. Driving new patient starts continues to be an important area of focus for us, and we're pleased to see that PSFs remained relatively stable throughout the summer. Through the end of October, we recorded approximately 1,510 PSFs since January 1, 2023. Patient conversions to therapy remain at high levels with approximately 90% of all patients who have a patient start form submitted receiving actual treatment.

We're very pleased with the majority, roughly 65% are now starting therapy within 20 days. This represents continued strong execution from our best-in-class patient support services group array alliance. Once we get a patient onto therapy, equally important is how long they stay on therapy as we know their underlying disease is a continuous inflammatory process requiring maintenance therapy.

Our 12-month persistency rates remain around 54%, with 15 both persistency at about 48%, and now we're seeing 43% persistency at 18 months. We had a total of 1,939 patients currently on therapy as of September 30, 2023. While this number continues to grow, there's been a slight increase in the quarter of discontinuations, which is a function of when patients initiated therapy and when they're falling in the persistency curve at the quarter end. We're also pleased to report that we have approximately 4,000 patients who have been treated with LUPKYNIS since launch.

As stated on previous calls, our business plan is focused on activating 3 main levers in the growth of LUPKYNIS and the lupus nephritis market: educating health care providers on the need to screen and treat more aggressively; activating the patient to advocate on their behalf and then lastly; continuing to clinically differentiate LUPKYNIS and position it as part of the foundation therapy in the treatment of LN.

We now have the full complement of data to be able to share with the medical community when we look at the comprehensive data set from the original AURORA trial in our pivotal results, the AURORA 2 extension study, demonstrating long-term safety and efficacy and the biopsy substudy depicting tissue level evidence of no nephrotoxicity associated with LUPKYNIS. We continue to educate physicians on these data sets as we further work to penetrate and grow the lupus nephritis market.

Our first lever is driving health care providers to act with urgency to screen and treat patients more aggressively, getting them to recognize the consequences of their lack of action. We continue to emphasize the importance of treating to goal, and reinforcing the guidelines on rapid and sustained reductions of proteinuria to preserve the kidney to patient's kidney function.

Over the third quarter, we maintained our call activity on high decile targets, driving home the message of treatment urgency, goals of therapy and the benefits of LUPKYNIS in helping physicians meet their ultimate goal of kidney preservation. In the quarter, we increased the depth of prescribing in our current base of customers as well as expanded the total number of new prescribers. Additionally, we're starting to see patients come back to therapy as restarts. We have begun to examine this phenomenon. We believe it is a good indicator for the brand.

One, because physicians are comfortable with LUPKYNIS; and two, if they're restarting therapy, they must have had a good experience with LUPKYNIS during their first exposure to therapy. We believe this bodes well for further growing the brand was with a somewhat unique segment of patients. It also becomes an opportunity to discuss extending the duration of therapy in these patients based on both the AURORA extension study, biopsy data as well as the recently published guidelines from EULAR.

The EULAR guidelines further support our messaging and educational efforts. They reinforce the need to routinely screen lupus patients, to treat aggressively, to treat to target proteinuria levels and to maintain proteinuria at manageable levels throughout 3 years.

Let me go into a little bit more detail regarding the recently published EULAR guidelines and their advancement for the treatment approach to LN. At a high level, 4 key areas benefit LUPKYNIS. The first is driving earlier diagnosis. Early diagnosis and regular screening for organ involvement, especially in LN, with prompt initiation of therapy aiming at remission and strict adherence to treatment is essential to preventing flares and organ damage as well as improving prognosis and enhancing patients' quality of life.

The need for routine monitoring is the second. SLE disease activity should be assessed at each clinical visit with an evaluation of organ damage using validated instruments. Vigilant monitoring for new organ involvement, namely kidney organ involvement from LN, especially in the first years of disease and thereafter.

The third is that the committee recognized the need for a treatment paradigm shift that will move LUPKYNIS up in the line of therapy. "With the breakthrough of LUPKYNIS, a novel CNI for LN consider shifting in induction maintenance regimen to early use of combination therapies." And lastly, long-term treatment. Following renal response with LUPKYNIS, treatment of LN should continue for at least 3 years based upon the long-term AURORA extension study, leading that reported stable eGFR throughout the 3 years of data.

We believe these guidelines actively support our strategic approach to the management of LN and how to use LUPKYNIS in the physician's treatment regimen. Our second focus is educating patients on the appropriate seriousness of their condition and to advocate for themselves. We need them to ensure that they are getting screened for kidney involvement with their lupus and that they are routinely monitored to ensure their well-being and kidney preservation. We have several patient-directed campaigns ongoing that are focused on educating the patient about their disease and the consequences of not getting screened.

They also advocate for routine monitoring by their physicians. The majority of these campaigns run through the digital marketing and social media channels to maximize reach to target audiences in a cost-effective manner. We have also been working with Tony Braxton, the spokesperson for our unbranded disease awareness campaign get uncomfortable.

To date, her message has reached over 750 million media impressions and tens of thousands of SLE and lupus nephritis patients. Our third strategy is directed towards clinically differentiating LUPKYNIS from substandard therapies and working to establish LUPKYNIS as a foundational therapy for all LN patients. The company recently announced the launch of the AURORA 2 extension data for LUPKYNIS. In September, the extension data was published in Arthritis & Rheumatology, the official journal of the ACR.

This publication along with our biopsy data gives us a great opportunity to go into the remainder of the year reinforcing the long-term safety and efficacy of LUPKYNIS. In addition, our ongoing medical affairs initiatives are focused on evolving the treatment approach for LN and educating health care professionals about LUPKYNIS. Our medical teams continue to work with the global key opinion leaders to ensure that they have the latest information and support of their guideline writing efforts.

This holds true for the recent EULAR guidelines as well as the upcoming KDIGO and ACR guidelines that are continued under development. Throughout the third quarter, our medical team engaged with physicians and health care providers over 1,000 times. They engaged over 100 clinical data presentations, 95 follow-ups to medical information requests and 150 in light LN related visits.

For the 2 upcoming major medical meetings of the American Society for Nephrology (ASN) and the American College of Rheumatology (ACR) in November, they have 14 abstracts and posters that were accepted in being presented. Now moving on to our globalization efforts for LUPKYNIS. Our collaboration with Otsuka has resulted in significant launch momentum outside the U.S. this year. Having received European Commission, British and Swiss marketing authorizations, Otsuka is now focused on launches and securing pricing and reimbursement approvals in various countries throughout Europe.

In the third quarter, we recognized a $10 million milestone from Otsuka for securing pricing and reimbursement approval in 3 of the 5 major countries in Europe. In addition, this quarter, we started recognizing collaboration revenues related to our mono plant and offsetting a portion of our fixed facility fees as well as royalties on our European sales for LUPKYNIS. Our work with Otsuka in Japan remains on track for a regulatory submission before the end of the year.

Upon approval in Japan, which is currently anticipated for the second half of 2024, we would be eligible for an additional $10 million milestone around the approval in Japan, along with low double-digit royalties on net sales once launched. Now let me close with our R&D activity. We continue to enroll patients in our LN registry, and currently, we have 71 sites activated and a total of 113 patients screened with 111 enrolled. The vocal pediatric study also remains ongoing.

As for our pipeline, we remain on track to file an IND for AUR200, our BAFF/APRIL inhibitor by the end of the year. We continue to evaluate potential autoimmune and kidney-related target indications with a high unmet medical need for this asset. As for AUR300, our novel peptide therapeutic that modulates M2 macrophages via this anti-CD206 receptor, we are currently in reformulation work on this product as we work towards an IND submission by the end of 2024.

Before I turn the call over to Joe, I'd like to give you a brief update on the ongoing strategic review, which we announced a few months back. As a reminder, we initiated a strategic review of the company at the end of June. We continue to work through the process of reviewing strategic options for the company, which include a variety of possibilities, ranging from a potential sale, merger or other strategic transaction.

We have no further updates on the matter. Other than that, the process is actively ongoing. We remain committed to running a fulsome process that reflects the best interest of the company, our shareholders and other key stakeholders, including our patients, health care providers and our employees.

We ask for your patience in these matters and know that when we have something material to share at the appropriate time, we will share it with all of our stakeholders. I'd now like to turn the call over to Joe for a more detailed review of our financial results. And of course, I will then return at the end of the call for a quick recap and to open up the line for any questions that you might have. Joe?

[Joseph Miller, executive]

Thank you, Peter, and good morning, everyone. As of September 30, 2023, we had cash, cash equivalents, restricted cash and investments of $338.5 million compared to $389.4 million at December 31, 2022, and $350.7 million at the end of Q2 2023. The decrease in cash, cash equivalents, restricted cash and investments is primarily related to the continued investment in commercialization activities and post-approval commitments of our approved drug, LUPKYNIS, inventory purchases, advancement of our pipeline and mono plan payments, partially offset by an increase in cash receipts from sales of LUPKYNIS.

We believe that we have sufficient financial resources to fund our operations, which include funding commercial activities, including FDA-related post-approval commitments, manufacturing and packaging of our commercial drug supply, funding our supporting commercial infrastructure, advancing our research and development programs and funding our working capital obligations for at least the next few years.

Now let's take a few minutes and go into detail regarding our financial results for the third quarter and the 9 months ended September 30, 2023. Net product revenue was $40.8 million for the quarter ended September 30, 2023, and $25.5 million for the quarter ended September 30, 2022. The net product revenue was $116.2 million for the 9 months ended September 30, 2023, and $75.1 million for the 9 months ended September 30, 2022.

The increase for both periods is primarily due to an increase in product sales to our 2 main customers LUPKYNIS, driven predominantly by further penetration of the LN market. Total net revenue was $54.5 million for the quarter ended September 30, 2023, and $55.8 million for the quarter ended September 30, 2022.

The decrease period-over-period is due to the recognition of a $30 million regulatory milestone from Otsuka following the EC marketing authorization of LUPKYNIS in September 2022, partially offset by the recognition of a $10 million pricing and reimbursement milestone in 2023 as well as additional collaboration revenue from Otsuka in 2023.

Total net revenue was $130.4 million for the 9 months ended September 30, 2023, and $105.6 million for the 9 months ended September 30, 2022. The increase is due to the aforementioned increase in net product revenue, partially offset by the change in milestone-related revenues.

Total cost of sales and operating expenses for the quarter ended September 30, 2023, was $70.8 million and $65.3 million for the quarter ended September 30, 2022. Total cost of sales and operating expenses for the 9 months ended December 30, 2023, was $192.4 million versus $189 million in the prior year period.

Let me now give you a further breakdown of operating expense drivers and fluctuations. Cost of sales amounted to $6.8 million and $2.4 million for the quarters ended September 30, 2023, and September 30, 2022. The increase is primarily due to increased sales of LUPKYNIS coupled with the amortization of the monoplant finance right-of-use asset, which was placed into service in late June of 2023. Cost of sales was $8.8 million and $4.3 million for the 9 months ended September 30, 2023, on September 30, 2022, respectively.

The increase is primarily due to the increased sales of LUPKYNIS coupled with the amortization of the monoplant finance right-of-use asset, partially offset by higher inventory reserves in 2023 due to the write-down of FDA validation batches. Gross margins for the quarter ended September 30, 2023, was 88% versus 96% at September 30, 2022.

Gross margins for the 9 months ended September 30, 2023, was 93% versus 96% at September 30, 2022. Selling, general and administration expenses inclusive of share-based compensation were $47.8 million and $52.2 million for the quarters ended September 30, 2023, September 30, 2022, respectively. The primary driver for the decrease in SG&A expense was a decrease in professional fees and services, including legal fees incurred during the quarters with respect to litigation matters that occurred during the 3 months ended September 30, 2022, partially offset by an increase in share-based compensation.

SG&A expenses inclusive of share-based compensation was $145.0 million for the 9 months ended September 30, 2023, versus $148.9 million at September 30, 2022. The decrease was primarily due to a decrease in professional fees and services, including legal fees and other corporate costs, including rent and insurance, partially offset by an increase in share-based compensation expense.

Noncash share-based compensation expense included within SG&A expense for the quarter ended September 30, 2023, was $9.6 million versus $6.6 million for the prior year period. Noncash share-based compensation expense included within SG&A expense for the 9 months ended September 30, 2023, was $27 million versus $21.5 million for the prior year period.

Research and development, R&D expenses, inclusive of share-based compensation, were $13.6 million at September 30, 2023, versus $11 million for the quarter ended September 30, 2022. The primary driver for this increase in both quarters was due to an increase in CRO and development costs as the company advances its pipeline assets. R&D expense inclusive of share-based compensation expense was $39.4 million and $35.1 million for the 9 months ended September 30, 2023 and September 30, 2022.

The primary drivers for the increase in the 9-month period were an increase in cost to advance its preclinical assets and an increase in share-based compensation expense, partially offset by the decrease in costs associated with the completion of the AURORA continuation study and drug-to-drug interaction study, which were substantially completed in 2022. Noncash share-based compensation expense included with an R&D expense was $2 million and $1.5 million for the quarters ended September 30, 2023, and September 30, 2022. Noncash share-based compensation expense included with an R&D expense was $5.7 million for the 9 months ended September 30, 2023, and $3.5 million for the 9 months ended September 30, 2022.

Interest income was $4.5 million at September 30, 2023, versus $1.5 million for the prior year period. Interest income was $12.4 million and $2.2 million for the 9 months ended September 30, 2023, and September 30, 2022, respectively. The increase for both periods is due to higher yields on our investment as a result of increased interest rates.

For the quarters ended September 30, 2023, Aurinia recorded a net loss of $13.4 million or $0.09 net loss per common share as compared to a net loss of $9 million or $0.06 net loss per common share for the quarter ended September 30, 2022. For the 9 months ended September 30, 2023, Aurinia recorded a net loss of $51.1 million or $0.36 net loss per common share as compared to a net loss of $82.1 million or $0.58 net loss per common share for the 9 months ended September 30, 2022. With that, I'd like to hand the call back over to Peter for some closing remarks. Peter?

[Peter Greenleaf, executive]

Thanks, Joe. As you heard throughout the call, we're obviously excited about our strong results for the quarter and our momentum through the first 3 quarters of the year. We continue to focus on business fundamentals and commercial execution. Our commercial teams are concentrated on delivering the newly published data from the AURORA 2 extension study and educating health care providers on the promise of kidney prevention for their lupus nephritis patients.

Our R&D teams are focused on our regulatory commitments for LUPKYNIS and advancing our 2 pipeline molecules into the clinic. And our executive team and our Board are working behind the scenes of our day-to-day business on the strategic review process to deliver value to all stakeholders in Aurinia. We remain focused on delivering LUPKYNIS to patients in need and driving results in the U.S. and key markets globally. We look forward to keeping you all posted along the way. I want to thank you all for joining us today. And I'd now ask the operator to open lines for any questions there may be. Operator?

[Operator]

[Operator Instructions]. Our first question is from Maury Raycroft with Jefferies.

[Farzin Haque, analyst]

This is Farzin on for Maury. It's good to see the persistence stabilizing so far at 12 months and 18 months. So can you talk more about the feedback you're getting from the prescribers for those patients? And how much leverage you are doing the guidelines to further educate.

[Peter Greenleaf, executive]

Yes. I mean listen, thank you for the question. Yes, we're encouraged by not only the 12-month persistency but 18 months and as we didn't report on the call, 24-month persistency, it kind of shows a flattening of the curve after 12 to 18 months, which is encouraging. I think the key takeaway should be most of this was driven in a time period where we had launched the product and got approval with the original AURORA data, which was 1 year data. And since that time period and has recently come to a head with the publication of the AURORA extension study, which has added an additional 2 years of data on top of the 1-year data, so 3 years of safety and efficacy now.

And the biopsy data, which was recently presented at one of the regional meetings and will continue to be presented at ACR and ASN are all adding to our ability to go out there and promote actively through the right channels in the right way through medical affairs and through providing information on medical requests that data to physicians. So we're encouraged by it. Feedback we get from physicians and patients is -- historically, this has been sort of a start-and-stop disease and patients actually show a reducing of proteinuria, many times, physicians will remove meds, and that includes MMF and steroids.

The new guidelines published or future guidelines coming from ACR and ASN, we're encouraged that we already see a reinforcement of the importance of keeping patients on therapy and maintaining the control of that inflammatory process because, obviously, the results would be quite negative for patients. So there's a shift happening and we're encouraged by the data. So the feedback we've gotten so far has been good.

[Farzin Haque, analyst]

And then based on your efforts so far, do you have a sense of whether they are leading to increased diagnosis rates yet?

[Peter Greenleaf, executive]

All we have is qualitative data at this point on that front. And what I would tell you is the qualitative is yes, but we look forward to reporting more quantitative as it's important for the future growth, not only of the brand, but of the market in total. So encouraging qualitative data, but nothing quantified yet.

[Farzin Haque, analyst]

And then quickly for Joe, the COGS scheme is significantly higher versus prior quarters. If you can provide some color on that.

[Joseph Miller, executive]

Yes. Farzin, as mentioned in the prior quarter call, the monoplant came online right at the tail end of the second quarter. So this quarter, third quarter, we had a full absorption of the mono plant facility, of which a portion, approximately 50%, is actually reimbursed via Otsuka under the supply agreement, which is reflected in the collaboration revenue. So you see a little bit of an offset reflected in the collaboration revenue.

[Operator]

Our next question is from Joseph Schwartz with Leerink Partners.

[Joseph Schwartz, analyst]

I was wondering, first of all, if you could talk a bit about how you arrived at your new guidance and why it might not be proportionately higher to what you delivered this quarter. It looks like you will be able to hit the low end even if sales decrease from the third to the fourth quarter, especially given the robust patient start forms numbers we've seen for October. So I'm just wondering if there's any reason for pensiveness or if you can give us your insight into that? And then I have a follow-up.

[Peter Greenleaf, executive]

Yes. We expected the question, Joe. The short answer is we raised the low end of the guidance because I think you're right. I think you'd have to decline to even get to the low end of guidance. We've tightened the range because based upon the quarter and the new patient starts that we actually saw in the quarter, we wanted to be somewhat conservative about where we were going to fall in that range. So for example, if we saw the same sort of new patient starts in Q4, we feel conservatively that we can still hit that guidance range. If you fell below, you'd have to decline in the quarter to be below that guidance range. And I think there's just a level of conservatism there that we wanted to be predictable and be consistent with our performance. Had we seen a higher number of new patient starts in Q3, there's no doubt we would have taken off the upper end of that range.

[Joseph Schwartz, analyst]

And then how has the number of prescribers and repeat prescribers been trending relative to the total number of patients on drug? We appreciate the latter numbers, but any insight into the former would be helpful. I'm just wondering how satisfied you are with the breadth of LUPKYNIS prescribers relative to the penetration for LUPKYNIS within each practice.

[Peter Greenleaf, executive]

Yes. I think as you know, Joe, we haven't given the total prescriber numbers yet, but it's one for us to go back and chew on and think about reporting. Some of that's been for competitive reasons. But what I can tell you is there now are thousands of physicians within that total universe that have utilized the product and that we've seen double-digit increases in terms of percentages on both volume of prescribing from our repeat prescribers and in our prescriber base. So we're happy with the penetration.

As we've said all along of the universe of nephrologists and rheumatologists that prescribe products for the treatment of lupus and LN, the 80-20 rule applies here, 80% of prescriptions come from somewhere around 20% of the prescribers. And we think our penetration within that universe is actually quite good, and the depth of our prescribing and there continues to improve. As we get on future calls, we'll look into whether we want to start reporting the specific numbers. But as I said, that's more for competitive reasons as to why we haven't rolled that out.

[Operator]

Our next question is from Stacy Ku with TD Cowen.

[Unknown Analyst]

Peter and Joe, congrats on a very strong quarter. This is Vish on the line of Stacy. So given we have results from 3 quarters behind it, could you talk a little bit more about your expectations for next year? How do you see sales and patient start forms panning out over 2024?

[Peter Greenleaf, executive]

Yes, I have a fast response to that. I mean we're going to try to stay consistent with what we did last year and give some sort of steer prior to or around or before JPMorgan next year. And I think there's a lot of things weighing on that, but that's what we did last year. I think we gave some characterization in Q3 due to the summer challenges we saw in 2022. And then we reaffirmed that or got tighter on it prior to JPMorgan. So we're going to stay consistent with that and not give any look for 2024 until then. You had another question, [ Vish? ]

[Unknown Analyst]

Yes. I had a question regarding the net pricing. So based on the information given in the press release and on the call, it seems that even for Q3 the net price that we're seeing is a little bit above the guided price. How do you see that settling over Q4?

[Peter Greenleaf, executive]

I think the best way to think about this -- and I realize we've been pretty dogmatic about our estimate of average net of $65,000 per patient per year. But I think I would hope that everyone can appreciate that we have slowly sailed down closer and closer to that point. We don't give quarterly guidance, so not going to be much very helpful there. But, I guess, what I would encourage you to do is just look at the trend and then continue to trend it downward into the quarter, and we think as that settles out, it will be closer to an average of 65 net per patient per year.

[Operator]

Our next question is from Olivia Brayer with Cantor Fitzgerald.

[Olivia Brayer, analyst]

I wanted to drill down on PSF trends. It looks like there's a downward trend in October versus what you saw in August and September. So how should we be thinking about patient start for growth over the next few months? And then I got a quick follow-up.

[Peter Greenleaf, executive]

Yes. Well, the first thing I would just take it backwards a little bit on is it was encouraging to see the PSF work that we did in those summer months that we had not historically seen the 2 years before that. And then the trend in October was still higher than what we had seen in the same time period last year. So, I guess, what I would lead with is we're trying not to read too much into it. And recent numbers look encouraging is all I will leave you with. And we're talking somewhere around 5 to 10 PSF difference from what we saw in those summer months to what we saw in October. So I'd say there's a level of consistency there. And our hope would be, as we get into now October, November, December, that we're going to see an increase in that trend, so.

[Olivia Brayer, analyst]

Yes. And can you give us any color or any more color on how the strategic review process is going? And really, I guess, my question is whether there have been any learnings or takeaways from the process since you began it back in June?

[Peter Greenleaf, executive]

As I'm sure you can appreciate my hands are somewhat tied on what I can and can't say here. So I'm going to stick to that outside of saying that we're working hard. And we're taking it very serious, and that's both at the management level and the Board level. We see this as a real opportunity to accelerate our strategy and keep an open mind in all directions, not that we've not historically done that, but this gives us a very focused way to do it. When we have more or something material to report, it's in obviously our best interest to report that out, and we'll make sure to do so. But outside of that, I can't give much more color.

[Operator]

Our next question is from Justin Kim with Oppenheimer & Company.

[Justin Kim, analyst]

I just wanted to touch on the script question again. Have you kind of seen maybe more of a smoothing and avoiding of maybe that seasonality this summer? Just curious, do you have any color as to what might be driving that smoothing or whether there's sort of a new level being reached here? Just any additional sort of color that maybe is more certification and prescriber practice base would be helpful.

[Peter Greenleaf, executive]

Justin, I hope Philadelphia is going well for you. Our team is on the ground as well for ASN. We worked a lot of different angles. And I think that in the summer months and I give credit to the people who are driving this, which is our marketing and sales people out there doing their work on a day-to-day basis. I think the data around the extension study being published was quite helpful. The biopsy data is quite helpful. We had a bit of tactical execution during that time period. I think all points to potential levers.

I think the base of your question and the one that we need to continue to prove out is that it's consistent and that it can pull forward and that we're going to start reaching new levels on PSF trends. It's important for the, not just the near-term execution, but more importantly, the long-term growth and how big the product can be in the future. So yes, outside of a host of different tactics and the new data that we have to bring to bear on the market, those are the 2 things I would point to. And then, I guess, reinforce what your underlying question is, which is we need to continue to see -- well, we need to see a new plateau start to be reached in terms of PSF performance, moving from that, let's call it, 450 or so PSFs per quarter to 480 and 500 and 500 and beyond. And we believe that this new data alongside of our push on talking about guidelines, impacted disease, treating to target are all parts of key components of unleashing that.

[Operator]

Our next question is from Ed Arce with H.C. Wainwright.

[Peter Greenleaf, executive]

Peter, Joe, congrats on a strong quarter, and let me add my greetings as well from ASN. I wanted to ask you about the guidelines. And as you mentioned, some of the points from the EULAR guidelines, it seems really quite supportive of LUPKYNIS. But I wanted to ask, as the guidelines from KDIGO and ACR are forthcoming, how do you view these as important in driving awareness with physicians and growing scripts more consistently? And would you expect these other 2 guidelines to be as supportive as you are? And, I guess, along with that, would they include the 3 major studies that you mentioned as well as the DDI study?

Obviously, I can't predict where the guidelines will go, but I'm hopeful that they will be somewhat in line with where EULAR is, which with emerging therapies and pipelines starting to show productivity for many companies within our space today, you're going to have to address novel therapies and novel treatment approaches. And I think there'll be consistency, although I can't think for that group as they do their work. But we're predicting that they'll address more aggressive use of novel therapies.

I guess just to rewind back prior to the EULAR guidelines, the new ones being published when there was the old approach to EULAR, KDIGO and ACR, there are several things in there that reinforce really important components for us. One is doing consistent diagnosis for SLE patients. We believe only about 50% of SLE patients have visited an office practice on any given day, get a urine screen for lupus nephritis. The guidelines have always been consistent that every time an SLE patient visit the office and need to be screened.

We see that as a huge driver potentially newly diagnosed or existing patients that aren't currently getting diagnosed. The second is treating to target and trying to reach certain proteinuria levels by 3 months and 6 months and a year target levels that we know today, rheumatologists and nephrologists don't aggressively treat to. And aligned with our data, we're the only product that actually shows consistent performance at those levels aligned to the guidelines.

So there is a lot of gems within the guidelines and if we can just get physicians treating, I guess, in a more congruent fashion, that we can actually see the market start to grow. Your last question of whether they'll incorporate the new data. Published data is usually what they look for. And the extension data has now been published. The AURORA study has been published. The biopsies and poster form. We'll see when they actually published these guidelines. We're working hard to get the biopsy study published too. But usually, they point at published data, not stuff that's been an abstract or poster. Sorry for the length of the question.

[Operator]

Our next question is from Sahil Dhingra with RBC Capital Markets.

[Sahil Dhingra, analyst]

This is Sahil Dhingra for Doug Miehm. I have 2 questions. My first question is on the comment made in the prepared remarks that there were some higher discontinuation this quarter. So is it related to summer seasonality to a degree? Or is it more dependent on for how long the patients have been on the drug?

[Peter Greenleaf, executive]

It's the latter. I think you have to think about this in a dynamic -- as you model it, think about it in a dynamic fashion. And during this quarter, we saw more patients who had seen therapy for longer periods of time. And, obviously, the discontinuation rate for patients who've been on drug for 12 months versus patients who have been on drug for 9 months, if you see a higher average of them in a quarter, you're going to see higher discontinuation rates. There's no that we can tell some rationale as to why it was more just a mix of the patients in the quarter. Do you have another question?

[Sahil Dhingra, analyst]

Yes. And my second question is related to the prescribers, I know this was asked before, but if you could provide more color. I think in one of the earlier calls, you had mentioned that 55% of the prescribers are not repeat prescribers. How has that trend changed given the new data that we have on hand?

[Peter Greenleaf, executive]

The short answer is we've seen improvement across the board, and we see less patients than 55% now a higher percentage or prescribing more than having a higher dependence upon first-time tries initial tries. So as I said, the reason we haven't -- because we segment this data pretty -- we do a lot of quant on this. We haven't rolled that out primarily because we think we give a lot of data. And this one, I think, is important, at least at this stage, to keep a little closer to our best in terms of the competitive set that's out there. But I can tell you that whether it's depth of prescription and our/or total number of prescribers, we've made meaningful movement on both fronts during the quarter.

[Operator]

Our next question is from David Martin with Bloom Burton.

[David Martin, analyst]

The first one is a follow-up to the question I'd asked. Have you made any progress in getting the nephrotoxicity language changed on the U.S. label based on the AURORA extension and the biopsy data? And when the U.S. guidelines are crafted, do you think they'll be affected by that language in the label or more by the EULAR type language?

[Peter Greenleaf, executive]

Well, I can't predict where the agency is going to go, but I can reinforce to everyone on the call that we announced in June that we had submitted this data to the U.S. FDA. It was expected the extension data and the biopsy data as substudy and extension study were both expected from the agency. We're hopeful that this will be incorporated in a meaningful way into the label here in the U.S., but we can't predict where the agency is going to land on. And we've not heard back anything from the agency at this stage.

[David Martin, analyst]

And do you think the guidelines are swayed by the label that much or not?

[Peter Greenleaf, executive]

No. I think it's a published data.

[David Martin, analyst]

Second question, do the restarts require new PSFs?

[Peter Greenleaf, executive]

The restart require new PSFs? No.

[David Martin, analyst]

And last question, what pricing did you get in the European countries where you got the pricing?

[Peter Greenleaf, executive]

We can't speak specifically for every country and sort of it's a [indiscernible] domain. So I'm not sure how much of this they want to disclose. But I can just give you the color that in terms of appropriate pricing as we see it in terms of reference pricing, would be novel therapies like Benlysta, the negative outcome would be getting pricing in the generic set like a trolmus or something like that.

[James Harrell, executive]

In fears that that's all the questions we have for today. I want to thank you all for your time, and we look forward to talking to you again next quarter. Thank you very much, and have a great day.

[Operator]

Thank you. This will conclude today's conference. You may disconnect your lines at this time, and thank you for your participation.