Jazz Pharmaceuticals PLC

NASDAQ:JAZZ

Earnings Call Analysis

Jazz Pharmaceuticals Reports Solid Revenue Growth and Promising Pipeline Developments

In the third quarter of 2024, Jazz Pharmaceuticals achieved over $1.05 billion in revenue, a 9% growth year-over-year, primarily driven by major products Xywav and Epidiolex, which saw a 14% increase. The company reaffirmed its full-year revenue guidance of $4 billion to $4.1 billion, with a projected oncology revenue of $1.08 billion to $1.13 billion. Meanwhile, the upcoming PDUFA date of November 29 for zanidatamab aims to secure approval for second-line biliary tract cancer. Recent trial results for Zepzelca indicate a significant opportunity for expansion into first-line therapy, positioning Jazz for continued growth in the oncology sector.

Strong Financial Growth in Q3 2024

In the third quarter of 2024, Jazz Pharmaceuticals reported total revenue exceeding $1.05 billion, marking a 9% increase compared to the same quarter last year. This growth is primarily driven by the strong performance of key products such as Xywav, Epidiolex, and Rylaze, which together saw a 14% year-over-year growth. The adjusted net income rose to $470 million, reflecting a significant 23% increase from the previous year, and the company generated approximately $400 million in cash from operations during the quarter.

Key Product Performance

Xywav continues to lead as the preferred treatment for narcolepsy and is gaining traction in the less common idiopathic hypersomnia (IH) indication. Xywav's net sales increased 17% year-over-year to approximately $388 million, with a notable addition of 400 net patients compared to the previous quarter. Similarly, Epidiolex reached net product sales of around $252 million, an 18% increase year-over-year. The product is benefiting from an expanding understanding of its non-seizure benefits, contributing to its positioning as a potential blockbuster.

Oncology Segment Updates and Guidance

The oncology division reported revenue of about $285 million, an increase of 9% compared to the prior year, although Rylaze experienced a slight downturn with a 6% decline in sales to approximately $99 million. The company anticipates a temporary revenue impact on Rylaze due to updated pediatric protocols affecting asparaginase administration, which should normalize by early next year. As a result, the oncology revenue guidance has been slightly reduced by $20 million to a range of $1.08 billion to $1.13 billion for 2023.

Future Growth Potential: Guidance and Research Pipeline

Jazz Pharmaceuticals affirmed its full-year revenue guidance for 2023 at $4 billion to $4.1 billion, projecting a 6% increase at the midpoint. The neuroscience revenue is expected between $2.825 billion and $2.925 billion, signaling a 3% rise from 2023 figures. The company is optimistic about driving revenue growth through a combination of double-digit percentage growth from its core products in the upcoming year. They are also actively pursuing promising developments in their oncological pipeline, particularly zanidatamab, with the PDUFA date for second-line biliary tract cancer set for November 29, 2024.

Operational Efficiency and Financial Health

The company's operating margin for Q3 was around 49%, consistent with year-to-date margin guidance of 43%. With a strong cash position of $2.6 billion, Jazz maintains considerable flexibility for future investments in commercial and R&D initiatives. They've reported $1 billion in cash from operations through the first three quarters, emphasizing ongoing operational efficiency and effective capital allocation.

Strategic Focus and Market Adaptation

Management highlighted a strategic focus on prioritizing programs with the highest potential impact. The reduction in R&D guidance by $20 million to a range of $790 million to $830 million reflects a disciplined approach to resource allocation in response to clinical data outcomes and pipeline refinements. Furthermore, Jazz is expanding visibility and clarity for investors by providing detailed geographic revenue breakdowns and share count calculations on their website.

Exciting Developments in Clinical Research

In terms of clinical research, recent data from trials including the Phase III IMforte trial for Zepzelca indicate significant improvements in overall survival and progression-free survival, positioning Zepzelca for a potential label expansion to first-line maintenance therapy. The initial insights suggest that Zepzelca could increase treatment duration and patient eligibility, further broadening its market scope.

Conclusion: A Promising Outlook

Overall, Jazz Pharmaceuticals is navigating a transformative period with solid financial growth, encouraging product performance, and promising developments in its research pipeline. Their strategic focus on priority programs and maintaining robust operational efficiencies positions them well for future growth and enhanced shareholder value.

Earnings Call Transcript 2024-Q3

[Operator]

Ladies and gentlemen, thank you for standing by. My name is Abby, and I'll be your conference operator today. At this time, I would like to welcome everyone to the Jazz Pharmaceuticals Third Quarter 2024 Earnings Call. [Operator Instructions].

And I would now like to turn the conference over to Andrea Flynn, Vice President and Head of Investor Relations. You may begin.

[Andrea Flynn, executive]

Thank you, operator, and good afternoon, everyone. Today, Jazz Pharmaceuticals reported its third quarter 2024 financial results. The slide presentation accompanying this webcast is available on the Investors section of our website. Investors may also refer to the press release we issued earlier today, which is also posted to our website.

On the call today are Bruce Cozadd, Chairman and Chief Executive Officer; Renee Gala, President and Chief Operating Officer; Rob Iannone, Executive Vice President, Global Head of R&D; and Phil Johnson, Chief Financial Officer.

On Slide 2, I'd like to remind you that today's webcast includes forward-looking statements, such as those related to our future financial and operating results, growth potential and anticipated development and commercialization milestones and goals, which involve risks and uncertainties that could cause actual events, performance and results to differ materially from those contained in these forward-looking statements. We encourage you to review the statements contained in today's press release, in our slide deck and the risks and uncertainties described in our SEC filings, which identify certain factors that may cause the company's actual events, performance and results to differ materially from those contained in the forward-looking statements made on today's webcast. We undertake no duty or obligation to update our forward-looking statements.

As noted on Slide 3, we will discuss non-GAAP financial measures on this webcast. Descriptions of these non-GAAP financial measures and reconciliations of GAAP to non-GAAP financial measures are included in today's press release and the slide presentation available on the Investors section of our website. I'll now turn the call over to Bruce.

[Bruce Cozadd, executive]

Thanks, Andrea. Good afternoon, everyone, and thank you for joining us today. I'll start on Slide 5. We are pleased to report on our progress in the third quarter of 2024, which was headlined by delivering strong growth across our commercial portfolio and advancing our zanidatamab development program. Recently, we achieved an important clinical milestone with positive data from our Phase III trial evaluating Zepzelca in first-line maintenance for extensive stage small cell lung cancer.

Diving into a bit more detail, I'll begin with our commercial execution for the third quarter. The durability of our neuroscience therapeutic area was underscored by both Xywav and Epidiolex posting record quarterly sales and year-over-year double-digit growth. In addition, our oncology business reported 9% revenue growth year-over-year, including a strong quarter for Zepzelca.

In our neuroscience therapeutic area, Xywav remains the oxybate of choice as the #1 branded treatment for narcolepsy and the only approved therapy for idiopathic hypersomnia, or IH. In IH, physicians and patients continue to provide positive feedback on the benefits of Xywav as we build the market, and we expect this indication to drive growth for the brand. And in narcolepsy, we continue to see strong patient demand.

Epidiolex growth remains strong as it nears blockbuster status. Patient demand in the U.S. is being driven by multiple commercial initiatives, and we've made steady progress in our ongoing ex U.S. market expansion.

Moving to our oncology therapeutic area. Zepzelca continues to perform well, and we now have an opportunity to move from second-line treatment to first-line maintenance therapy based on the positive results of the Imforte trial. Rob will review the trial results and next steps later in the call.

For Rylaze, we are seeing high utilization in the pediatric population and are continuing to roll out programs to drive adoption in the adolescent and young adult market. A recent update to Children's Oncology Group pediatric treatment protocols for ALL has impacted the timing of asparaginase administration. We expect these new protocols will have a temporary negative impact on third quarter and fourth quarter Rylaze's revenue, after which we expect demand to normalize by early next year.

Turning to our R&D and pipeline efforts. We are focused on rapidly advancing our zanidatamab program. The PDUFA date for zanidatamab in second-line biliary tract cancer or BTC, is coming up at the end of this month and we are well positioned for launch following approval. Our development program includes multiple ongoing trials in a number of HER2-positive tumors across lines of therapy. Zani is our most derisked pipeline asset and we are moving forward with a sense of urgency and purpose in order to deliver this therapy to patients with HER2-positive tumors who are in need of new and effective treatment options.

At the start of the call, I mentioned our recent data readout on Zepzelca. We're excited that patients will potentially have access to this therapy earlier in their treatment where there is the potential to increase duration of response in a broader patient population, delaying disease progression and extending survival. Our commercial execution and focus on operational excellence have kept us in a strong financial position again this quarter. We continue to deliver top line growth and generate significant cash flow from operations. We remain focused on investing in the products, pipeline programs and corporate development opportunities that we believe have the highest potential to deliver sustainable growth and enhance value.

As Phil will cover in more detail later in the call, we are affirming our total revenue and adjusted net income guidance provided on our second quarter '24 call and have updated certain other elements of our guidance. I'll now turn the call over to Renee to review our commercial performance, after which Rob will share an update on our R&D progress. Phil will provide a financial overview, and then we'll open the call to Q&A. Renee?

[Renée Galá, executive]

Thanks, Bruce. I'll begin on Slide 7. We're pleased with the performance of our sleep business this quarter. Total revenue, which includes Xywav and Xyrem net sales plus royalties from high sodium oxybate authorized generics or AG, was approximately $505 million. In the third quarter, Xywav net product sales grew 17% year-over-year to approximately $388 million, and we expect Xywav to continue to be the oxybate of choice in both narcolepsy and IH.

We are focused on enabling as many patients as possible to benefit from low sodium Xywav and saw an increase of approximately 400 net patients exiting the third quarter compared to the second quarter.

In narcolepsy, we are seeing strong demand from both new and transition patients. Further, our ongoing focus on individualized dosing and educating patients and prescribers about the benefits of reducing sodium intake continues to drive growth. And I'm pleased to report, we recorded approximately 150 net narcolepsy patient adds compared to the prior quarter.

Moving to IH. We remain excited about the growth potential of Xywav in this indication. There were approximately 3,550 active IH patients on Xywav exiting the third quarter, an increase of approximately 250 patients compared to the prior quarter, which is in line with the growth we've seen in recent quarters. Our expanded field force is continuing to focus on increasing the depth and breadth of IH prescribers, which is a primary driver of demand. We are also seeing positive impact from our field nurse educator program, which supports both narcolepsy and IH indications. This program enables new Xywav patients to interact in person with trained health care professionals as they begin oxybate therapy providing education during the time when patients are titrating and optimizing their oxybate therapy and are most likely to have questions related to their treatment.

Moving to Slide 8 and Epidiolex, we achieved another strong quarter with net product sales of approximately $252 million in the third quarter representing an 18% increase compared to the same quarter in 2023. Key drivers of increased demand in the U.S. included the positive response to data on the benefits of Epidiolex beyond seizure control, such as language and communication, cognition, executive function and emotional and social function as well as synergies from treatment with Epidiolex plus Clobazam. Building on that body of evidence, which now includes data from more than 2,000 patient experiences, we presented data at the European Epilepsy Congress in September that demonstrated improvements in seizure and non-seizure outcomes in patients receiving Epidiolex in combination with Clobazam.

Importantly, our improved understanding of the real-world outcomes benefits of Epidiolex not only extends to patients, but to their families and caregivers as well.

We're also continuing to see penetration in the adult patient setting, which is supported in part by data showing that many LGS patients may reach adulthood without a specific diagnosis, and by providing health care professionals with clear diagnostic tools for adult patients. Our virtual nurse navigator program, which we launched earlier this year, provides Epidiolex patients and their families with the resource to discuss medication-related topics such as optimized dosing. While it's still early, we are seeing positive momentum with this program. Further opportunities for growth include focused data generation and geographic expansion beyond the more than 35 countries where Epidiolex is currently approved.

Moving to Slide 9 and our oncology business. Total oncology revenue for the quarter was approximately $285 million, representing 9% growth from the same period last year. Rylaze product sales were approximately $99 million, representing a 6% decrease from the third quarter of 2023. As Bruce noted earlier, over the summer, the Children's Oncology Group updated pediatric protocols for ALL that impact the timing of asparaginase administration. Importantly, the updated protocols do not change the recommended total number of doses of asparaginase, so we do not expect an impact to overall demand for Rylaze. We anticipate the revenue impact of this timing shift to be primarily limited to the third and fourth quarter of this year and to normalize by early next year.

We continue to see the most opportunity for growth in the adolescent and young adult or AYA market and we are continuing to educate oncologists who treat these patients about the benefits of asparaginase therapy. This quarter, we initiated several new programs to drive AYA's adoption and continue to see opportunity to build that market over time.

Turning to Slide 10 and Zepzelca. We delivered another strong quarter with net product sales increasing 10% year-over-year to approximately $86 million. Zepzelca remains the treatment of choice for second-line small cell lung cancer patients and health care providers continue to deliver positive feedback on the product's clinical benefit and ease of use. Last month, we were very pleased to announce positive data from the IMforte trial evaluating Zepzelca in a first-line maintenance regimen. Our team is preparing to submit an sNDA to include first-line maintenance therapy to the Zepzelca label. If approved, this change in practice to first-line maintenance would enable a larger number of small cell lung cancer patients to be eligible for Zepzelca treatment. With that, I will turn it over to Rob for an update on our pipeline and upcoming milestones. Rob?

[Robert Iannone, executive]

Thanks, Renee. Slide 12 provides an overview of the key clinical programs in our pipeline. I'll start with oncology and zanidatamab, our highest priority pipeline program. During the second quarter, FDA accepted and granted priority review for our BLA previously treated unresectable, locally advanced or metastatic HER2-positive second-line BTC setting an action date of November 29, 2024.

Enrollment for our Phase III first-line gastroesophageal adenocarcinoma, or GEA, trial remains on track, and we estimate top line progression-free survival or PFS data to be available in the second quarter of 2025. If the trial is positive based on PFS and supported by a trend in the interim overall survival analysis, we expect it would support registration filings.

We have also recently initiated a Phase II pan-tumor trial, the study zanidatamab in a broad basket of HER2-positive solid tumors. I'll speak more to our zanidatamab development plan in just a moment.

Given the opportunity to help more patients, we are very pleased with the positive results from the Phase III IMforte trial, which were announced last month. The trial evaluated Zepzelca in first-line maintenance therapy of extensive stage small cell lung cancer in combination with the PD-L1 inhibitor atezolizumab or Tecentriq. Atezolizumab is the most commonly used PD-L1 agent in first-line maintenance following standard of care induction therapy with carboplatin, etoposide and immunotherapy. The combination of Zepzelca and atezolizumab demonstrated a statistically significant and clinically meaningful improvement in the primary endpoints of overall survival and progression-free survival compared to treatment for atezolizumab alone.

These results demonstrated the potential of this regimen to delay disease progression and extend survival for patients with this aggressive disease. Importantly, upon approval, patients who have access to Zepzelca earlier in the treatment paradigm, where there's potential to increase duration of response in a broader patient population delaying disease progression and extending survival.

We plan to submit a supplemental NDA to FDA in the first half of 2025 to expand the Zepzelca label to include first-line maintenance. We are also looking at appropriate peer-reviewed forms to present the data, which is an important step toward possible inclusion in NCCN guidelines and compendia listings.

Turning to Epidiolex. In August, we announced top line data from our Phase III trial in Japan. While the trial did not meet the primary efficacy endpoint of change in indication associated seizure frequency during the treatment period in pediatric patients, improvements were observed in the primary and secondary endpoints. We remain confident in the overall clinical profile of Epidiolex, and we are continuing to collect data in Japanese patients. We plan to engage with regulatory authorities in Japan regarding a potential new drug application.

I'll also note the following discussions with FDA, we are now planning to initiate a Phase Ib trial for JZP441, our clinical stage of [indiscernible] receptor agonist in narcolepsy type 1 patients in the first half of 2025.

Turning back to zanidatamab on Slide 13. I want to touch on updated clinical data from zanidatamab in first-line GEA from an ongoing Phase II trial that were presented at the recent ESMO conference in September. Data from 41 patients treated with zanidatamab in combination with physician's choice chemotherapy demonstrated a confirmed objective response rate of 84% and duration of response of 18.7 months highlighting the durability of zanidatamab treatment. We also reported PFS of 15.2 months. And while overall survival was not yet mature after a median follow-up of 41.5 months, the Kaplan-Meier estimated 24-month overall survival was 65%, and the 30-month overall survival was 59%. This adds to the growing body of evidence for zanidatamab in first-line HER2-positive GEA, which also includes promising data presented at ESMO 2023 from a Phase II study of zanidatamab plus chemotherapy in combination with tizolizumab.

The results from these separate cohorts give us confidence in both treatment arms of the Phase III Horizon GA01 trial we as approach the data readout expected next year.

Moving to Slide 14, and an overview of our development strategy for zanidatamab. We remain excited about its potential to transform the current standard of care in multiple HER2-expressing cancers, including in cases resistant to prior HER2-targeted therapies. BTC represents our first potential approval for zanidatamab with the PDUFA action date set for November 29. Our confirmatory Phase III trial in first-line DTC is enrolling, and we are pursuing multiple indications for HER2-positive tumors beyond BTC. As I noted, our Phase III trial in GEA is ongoing. We have also initiated the Phase III EMPOWER trial, which is designed to evaluate zanidatamab in combination with chemotherapy after progression on T-DXd where we have the opportunity to be the first HER2-targeted therapy to demonstrate efficacy and safety in breast cancer patients post T-DXd.

Additionally, we recently initiated a Phase II pan-tumor trial. Zanidatamab monotherapy has shown promising activity across a range of tumor types. And this trial is an opportunity to efficiently generate additional data across a variety of HER2 expressing solid tumors. The trial is enrolling 3 cohorts: a pan-tumor cohort including patients with HER2-positive tumors who are HER2 treatment naive as well as 2 cohorts of patients who previously were treated with T-DXd. One of these cohorts is enrolling HER2-positive GEA patients and the other is enrolling HER2-positive breast cancer patients.

Overall, we're excited about the prospect of delivering zanidatamab to BTC patients in the near term, and we're executing on a robust development plan based on our conviction that zanidatamab has significant potential to improve care for patients with multiple HER2-expressing tumors. Now I will turn the call over to Phil for a financial update. Phil?

[Philip Johnson, executive]

Thanks, Rob. I'll begin on Slide 16 with our top and bottom line results. As a reminder, our full financial results are available in our press release issued earlier today and in our 10-Q, which will be filed tomorrow morning.

During the third quarter of 2024, we generated more than $1.05 billion in total revenue, a 9% increase compared to the third quarter of 2023. Our strong top line performance was driven by the growth of our key products, Xywav, Epidiolex and Rylaze, which combined grew 14% year-over-year. In addition, our adjusted net income of [ $470 ] million for the quarter represents an increase of 23% compared to the third quarter of last year. We continue to generate significant cash from our business recording approximately $400 million in cash from operations in the third quarter and roughly $1 billion through the first 3 quarters of the year.

Our strong overall financial position, including $2.6 billion in cash and cash equivalents, [indiscernible] have significant flexibility to invest in priority commercial and R&D programs and corporate development opportunities.

On our cash investment balance, I would highlight that we intend to make a substantial payment on our Term Loan B following the mid-January 2025 expiration of the 1% prepayment premium in place after our most recent repricing.

Turning to Slide 17 and guidance. We are affirming full year revenue guidance of $4 billion to $4.1 billion. This represents a 6% increase in 2023 total revenue at the midpoint. We are also affirming neuroscience revenue guidance of $2.825 billion to $2.925 billion, which is a 3% increase from 2023 revenue also at the midpoint. Based on the temporary impact to Rylaze's revenue resulting from treatment protocol updates that Bruce and Renee spoke to earlier, we are lowering our oncology revenue guidance by $20 million to $1.08 billion to $1.13 billion.

We continue to expect total revenue growth for 2024 to be driven by double-digit percentage growth of Xywav, Epidiolex and Rylaze combined.

Moving on to the next slide and non-GAAP adjusted guidance. We are maintaining our prior SG&A guidance and lowering R&D guidance by $20 million to [ $790 million to $830 million ]. The reduction in expected R&D spend is primarily driven by ongoing strategic pipeline prioritization, including in response to clinical data readouts. We continue to direct investments to programs with the potential for highest impact.

Our effective tax rate guidance remains at a range of 10% to 12%. Adjusted net income guidance remains unchanged at $1.275 billion to $1.35 billion while we are increasing our EPS range to reflect the impact on our share count of our election to settle the principal amount of our 2026 convertible notes in cash as well as a share repurchase than in conjunction with the issuance of our 2030 convertible notes. I also highlight that operating margin for the quarter was approximately 49%, bringing year-to-date operating margin to 43%, in line with our full year guidance.

Before I turn it back over to Bruce for closing remarks, I wanted to call your attention to some additional information posted on our website. In conversations with investors and analysts since joining Jazz, some investors express interest in gaining greater visibility into the geographic breakdown of our revenue, and others ask for greater clarity on how we arrive at the shares outstanding for our GAAP and non-GAAP EPS calculations. On our website, you'll find an Excel workbook that contains historical information responsive to these requests. We hope you find this information useful in analyzing our results, and we'll continue to look for opportunities to enhance our disclosures in ways that are meaningful for investors. With that, I'll turn the call back to Bruce for closing remarks.

[Bruce Cozadd, executive]

I'll conclude our prepared remarks on Slide 20. Our commercial execution in the quarter resulted in record quarterly revenue increasing the number of patients benefiting from Xywav with the addition of approximately 400 net patients exiting the third quarter compared to the second quarter and driving growth of Epidiolex and our oncology franchise. .

Our R&D engine continues to be productive, advancing our zanidatamab development program and generating data for Zepzelca that may enable us to reach more patients in critical need. And we continue to focus on operational excellence, strategic and disciplined investments in our business and retaining our strong balance sheet, which enables future growth. We're excited about the future of Jazz and believe we are well positioned to deliver growth and shareholder value. That concludes our prepared remarks. I would now like to turn the call over to the operator to open the line for Q&A.

[Operator]

[Operator Instructions] And your first question comes from the line of Jessica Fye with JPMorgan.

[Jessica Fye, analyst]

I was wondering on Xywav, can we think of the 150 net patient adds in narcolepsy as reproducible in the future? It's a big uptick from what we saw last quarter. So I'm curious how you're thinking about that. And if this might be the impact of the field nurse educator program helping with persistence in the early treatment phase? .

[Renée Galá, executive]

Yes. Thanks, Jess. I really appreciate the question. So definitely, we are seeing greater persistency and benefit from the field nurse educator program in addition to our wraparound services that we provide to both physicians and to patients. And that's something that we spend a lot of focus on. We think that's an important differentiator of Xywav.

With respect to narcolepsy, we have seen some variability. I think what's most important to focus on is what is the source of the demand. It is coming from new patient starts. It's also coming from patient transitions from high sodium oxybate, including reversions [indiscernible]. Probably the biggest factor that's driving the demand continues to be the ongoing appreciation of the benefits of low sodium by physicians and patients. Keep in mind, Xywav is the only oxybate therapy that doesn't carry a warning related to high sodium intake. So as we look holistically at the business, we're really pleased with that 150 net patient add. For the quarter, we are seeing definitely improved persistency from the field nurse educator program as I've mentioned, real appreciation, continued appreciation of the low sodium messaging and importance, in particular in this patient population that's predisposed to cardiovascular conditions.

And then also, it's worth noting that this is all underpinned by what we're seeing by our field teams, which is really a strong focus on execution.

[Operator]

And your next question comes from the line of Jason Gerberry with Bank of America.

[Jason Gerberry, analyst]

On Zepzelca, I'm wondering -- if you can kind of help us frame the reg past. Is this submission just on the Phase III result alone? Is there any implications to this Phase III [ Lagoon ] study being confirmatory? Or does the frontline data just kind of stand on its own, and it would be its own unique, I guess, indication? And thinking about the commercial opportunity. I mean, you haven't given detailed data, but presumably, you said it's clinically meaningful. So it's adding a few months of PFS. So should we just think about this as expanding the market about 7,000 patients and adding a couple of cycles of therapy. Is that the right way to be thinking about sort of the relative impact here?

[Robert Iannone, executive]

Yes. I'm happy -- this is Rob. Thanks for the question, Jason. So the Phase III trial, which we said, resulted in not only statistically significant, but clinically meaningful benefit in PFS and overall survival, which was on an interim analysis. We think those data stand alone would support an expansion of the label into a frontline indication. And as we said, we're working as quickly as possible to get a submission and ultimate approval in frontline, we think this will change the standard of care in frontline therapy. And we said that submission is planned for first half next year.

Part of your question was, could that also be confirmatory to our existing accelerated approval in second line. We think it can, that may depend ultimately on the timing of this submission relative to when the [indiscernible] data would come in. But we certainly think these data demonstrate the benefits of Zepzelca in frontline, and that has knock-on effects for the overall activity of whether it's used in frontline or in second line.

As we've said in the past, there's about 30,000 new small cell lung cancer patients every year, maybe 27,000 of those are extensive stage and a fraction of those are treated. So we do think that it's a larger number of patients that likely to have a longer duration of therapy as well.

[Operator]

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

[Marc Goodman, analyst]

Can you give us your latest thoughts on the orexin class, the recent data releases from competition, how you're thinking about it? And what can you share about your product 441, -- any data that you can comment on any of the commentary on the adverse events that stopped you from working on this before. Just anything more you can tell us about your product as well?

[Bruce Cozadd, executive]

Yes. Rob, why don't you jump in on orexins.

[Robert Iannone, executive]

Yes, I'm happy to. So Marc, the field is certainly advancing, especially in the NT1 space. But I would say still relatively early in a couple of respects. One is that we don't yet know what the best-in-class profile would be. Certainly, it's one that is safe and well tolerated. And over time, we'll see what -- how these compounds compare 1 to the other with regard to things like potential for hepatic toxicity, potential for polyuria, visual disturbances or even insomnia based on possibly a longer half-life. We also think that this class potentially has the benefit beyond NT1, depending on the profile of the asset and NT2, IH or even other conditions of daytime sleepiness.

As we mentioned, we have a plan Ib study next year with 441 at a dose that would evaluate -- that we would evaluate in NT1 patients where we think we have potentially a therapeutic index to some of the toxicities we've seen. And that will inform not only whether 441 could go forward in any of those indications, but also potentially inform our backup programs.

[Operator]

And your next question comes from the line of Ami Fadia with Needham.

[Ami Fadia, analyst]

Just on the topic of [indiscernible]. In GEA, you're conducting the Horizon 1 trial. Can you give us some sense of in the Phase II study, what percent of patients for PD-L1 positive versus negative and if you saw any difference in the efficacy results across the 2 subsets. And just thinking about the [indiscernible] trial. Maybe if you could just give some color on how -- I believe that [indiscernible] had done some work before you guys took on zani in other cancer types. So how this basket trial and likely to be broader in kind of what areas it might be exploring?

[Bruce Cozadd, executive]

Rob?

[Robert Iannone, executive]

Yes, happy to take that Bruce. So on the first one, in terms of the data we've published frontline GEA, we haven't looked at the PD-L1 status, but we also don't think in that or at least yet, we don't think that, that has any bearing on whether [indiscernible] would be effective in that setting. Overall, we think the epidemiology suggests that maybe about half of patients are PD-L1 positive depending on how you define that and how you define it certainly is important because it should be defined in terms of what the cutoff is that would predict benefit from the use of a PD-1 or PD-L1 agent.

In terms of the pan-tumor study that we just started, you're absolutely right. We do have a broad experience from Phase I and from different cohorts we've run in patients who are overexpressing HER2. And what we find is wherever patients are overexpressing HER2, we see strong activity with zanidatamab. And based on its differentiated mechanism of action, we think that compares favorably to other agents that have been tested across a variety of tumor types. So what the pan-tumor study allows us to do is extend that experience, especially in a variety of rare tumors who are naive to HER2 therapies. So that could ultimately depending on the results, could ultimately support an expanded label.

It also allows us to get some additional data in patients who are experienced with other HER2 agents, such as in breast cancer and gastric cancer with monotherapy that overall could support a pan-tumor indication as well.

[Operator]

Your next question comes from the line of Gregory Renza with RBC Capital Markets.

[Unknown Analyst]

[indiscernible] on for Greg. And continuing on zani, just curious with respect to the opportunity in [indiscernible] cancer. Could you share with us perhaps your current thinking on how the peak assumption look like and how the ramp to that peak assumption look like in second-line [indiscernible] cancer?

[Renée Galá, executive]

Yes. So I think with respect to how to think about the ramp, it's important to remember, first, keep in mind, we don't provide product-specific guidance. But I would just remind you that BTC represents a very small patient population. And therefore, with this first indication that we're going after, the revenue expectations are quite low. When we think about BTC, this is a rare cancer, about 3,000 patients in the U.S. in the first line and second line. However, it's also a devastating cancer with 5-year survival rates less than 5% in the metastatic setting. And so for this reason, we feel very strongly in bringing the therapy forward for patients as quickly as possible, but this is not the largest opportunity set.

Now with that being said, we do see a much broader opportunity, 1 being $2-plus billion in peak with those larger opportunities coming from GEA on target to read out in the second quarter of next year and then, of course, metastatic breast cancer and also now the pan-tumor study underway.

[Operator]

And your next question comes from the line of Joseph Thome with TD Cowen.

[Unknown Analyst]

This is Payton on for Joe. I guess sticking with the GEA study in zanidatamab, how important is it for the study to hit both on the doublet, RMB and the triplet RPC primary endpoint. Do you think that there will be a path forward as you see any benefit in 1 of this subsets? And could you maybe walk us through different scenarios for the [indiscernible]?

[Robert Iannone, executive]

Yes. Thanks for the question. So you're absolutely right. The trial is set up so that we have 2 shots on goal. There's a control arm, and then there's zani plus chemo, then there's zani, chemo with the addition of [indiscernible], which is a PD-1 inhibitor. And certainly, for approval, which we think would be supported on the basis of progression-free survival data as long as the trend in overall survival is going in the right direction.

For approval, we need to show benefit of either arm over the control arm for the arm that includes the PD-1 agent, that has to be incrementally better than zani and chemo, so so-called contribution of components. And so we think we'll need to demonstrate that. But certainly, it gives us 2 shots on goal. We have confidence based on the data that have been published in the 2 cohorts of first line that zani plus chemo will do very well regardless of the patient's PD-L1 status, as I mentioned before, and the addition of PD-1 gives us another opportunity because it's clear that for patients who truly are PD-L1 positive that PD-1s can incrementally improve the benefit.

[Operator]

And your next question comes from the line of Akash Tewari with Jefferies.

[Unknown Analyst]

This is Dennis Deja on for Akash. So you mentioned earlier that you have a Phase III [indiscernible] in HER2, HER2+ breast cancer setting. Could you give us some more details on that, maybe like the development plan, study design, timing, if you're planning any additional studies and what that patient opportunity might look like relative to GEA. And maybe just how confident you are in the HER2 resistance mechanisms [indiscernible]?

[Robert Iannone, executive]

Yes. So thanks for the question, and I'll start with the last part of it. We really feel that zanidatamab as a highly differentiated, best-in-class HER2 agent. And that's based on published data, not only on the mechanism of action and preclinical data, which you can find in Nature Communications. But the steady stream of very encouraging data across different tumor types in different combinations. And that includes several different cohorts of breast cancer patients.

The opportunity we see with the now ongoing Phase III trial is to generate data in those patients who are either intolerant to or progressed on T-DXd. As T-DXd has taken a foothold in second line and potentially moves up into frontline, -- that's the main data gap, what to treat patients with once they progressed on T-DXd. We think we have a growing body of data that supports the use of zanidatamab in that setting, it's differentiated, and that we see activity in patients who progressed after trastuzumab and PERJETA, patients who progress after PD-1 as well, PD-L1 as well as T-DXd. And so that's the basic concept here is that we'd be the first to generate data in those space, and it's going to be a significant unmet need, and we hope to be the first into that space.

The basic design is for patients in that third line plus space, a physician would choose the backbone chemotherapy and then they would be randomized to receive [indiscernible] on top of that or trastuzumab. And these would be patients who had already progressed on trastuzumab where the standard of care is otherwise fairly unclear. So we think our data are very supportive of winning in that space.

[Operator]

And your next question comes from the line of Annabel Samimy with Stifel.

[Unknown Analyst]

This is [indiscernible] calling in for Annabel. And it's related to Zepzelca. You guys showed efficacy in the first-line maintenance setting, do you now have a better idea of what the peak opportunity could be for the product? And how do you think physicians will receive the data? And will they be quick to adopt it. And then on the flip side, does that take away from the second line setting?

[Renée Galá, executive]

Yes, I'm happy to jump in on that. So first of all, we're really excited about the results in the first-line trial, as Rob had mentioned earlier. We do think it will be practice changing, and we look forward to sharing the full data set in the future.

Now with that being said, as we look at where we are today, it's important to note that until we have approval, we won't be actively promoting on the first-line indication, of course. I would expect we'll get use once we are adopted by NCCN guidelines, but until we get the data out there, we would not expect a ton of use in the first line. In the meantime, we're continuing to see strong use of Zepzelca in the second line even with [ tarlatamab ] on the market. We have several years of being the standard of care in the second line, we have physicians getting a lot of experience with Zepzelca, and we get a lot of positive response regarding its clinical benefit, ease of use, recall, it's given in the outpatient setting and doesn't require inpatient monitoring. And so we think this will bode very well for adoption in the first line once the data is available and as Rob had mentioned earlier, there's about 27,000 patients in the first line, the vast majority of those being extensive stage.

So we do expect an overall increase to the revenue opportunity, given that once we get into first line, we'll be looking at a larger patient population as well as longer treatment duration. Rob, did you want to jump in as well?

[Robert Iannone, executive]

Yes, I love to. I mean, as we said before, we do think these data are practice changing. We haven't shared the data themselves, but we've said not only static, but clinically meaningful differences on both PFS and overall survival, remember that overall survival was at the time of a planned interim analysis. So we think, given that we're going to move as quickly as possible, we think it's a compelling case. And physicians will find the data compelling as well, and there will be significant uptake there.

As I mentioned before, that does mean that it's a larger patient population that we can address, and we currently can in second line. We do expect it to be a longer duration of therapy. Remember, patients typically do not get a complete remission after their chemotherapy induction, and so they have active residual disease under the current standard and are essentially waiting to progress. And so this has preemptively treats those patients rather than waiting for clinical progression in second line. And I think that just now the data show that, that gives them an opportunity to benefit for a longer period of time. So we do think it's more patients for a longer period of time.

If a patient has received Zepzelca in frontline. And remember, unlike traditional induction chemotherapy, patients will get Zepzelca until progression. So we do think in that case, they wouldn't then go on to get Zepzelca again second line. But the point is that we will have preemptively use Zepzelca, which access more patients for a longer duration.

[Operator]

And your next question comes from the line of David Amsellem with Piper Sandler.

[David Amsellem, analyst]

So my question is also on Zepzelca. And specifically, I wanted to get your thoughts on the exclusivity runway for the products. So in the orange book, you've got a patent expiration in December of '29. And then you have [ orphan ] exclusivity expiring in '27. With the first-line data, do you expect to get an ODE on extensive Sage [indiscernible] first line? How should we think about how your exclusivity runway may or may not change with the first-line data?

[Renée Galá, executive]

Yes. So just to jump in here in terms of thinking about the exclusivity runway, I don't think we're in a position to speculate right now on any particular updates. We're thrilled with the data that we've recently generated. As we said, we really look forward to sharing that and getting that out into the market to be able to drive further understanding of the use of Zepzelca in the first line, but I would say any further updates on IP changes over time as a result of this would be something that we would update at the time it might be relevant.

[Operator]

Your next question comes from the line of Andrea Newkirk with Goldman Sachs.

[Unknown Analyst]

I was just wondering here if you could provide more color on the pipeline prioritization that you mentioned? And how we should think about the makeup of the portfolio now. And then given these changes, how does that impact your appetite for potential BD transactions, whether it be in neuro versus oncology?

[Bruce Cozadd, executive]

Yes. Maybe I'll take the first part of that and then Phil, happy to have you jump in on the [indiscernible] piece of it. In terms of portfolio prioritization, we are always trying to invest in those programs that we think have the most potential, particularly after we've done some derisking or proof-of-concept work, we clearly have prioritized any data map first among our existing pipeline assets given the potential broad applicability of that molecule and our excitement about that in multiple settings. We do have some earlier programs we don't talk about as much on these calls, but you'll see are progressing. You can always get more information on that on our website.

And then we do see some variation in R&D spend quarter-to-quarter depending on exactly what phase of clinical trials were in, in some cases, milestone payments if we're in partner programs. So I wouldn't read too much into that particular comment, Phil, on CorpDev.

[Philip Johnson, executive]

Yes. Andrea, I'd put it in the context of our overall capital allocation. So clearly, we're seeing great growth among a number of our products that are currently on the market. So we're ensuring that we're putting the right investment behind those to maximize the benefit to patients as well as the revenue to Jazz, and then prosecuting the pipeline that we currently have in house where, as you heard on the call, zanidatamab really is sort of the key to that near-term and medium-term pipeline, and then we are looking to continue to bolster our future growth prospects through [indiscernible].

I would say anytime you have negative readouts that probably increases the desire to do things. Obviously, we have positive readouts and things are advancing, that creates some of the internal movement that may obviate the need for some of the BD or corp dev. We definitely are actively looking at a variety of opportunities not only in oncology, but also in neuroscience as well as in select rare opportunities where we think we could deploy our capabilities, footprint to benefit patients and rapidly bring innovative therapies to market. We do have very strong cash flow, as I mentioned earlier on the call and accessibility to capital, whether that's cash on the balance sheet or through the debt markets to back those corp dev efforts.

[Operator]

And your next question comes from the line of Jeffrey Hung with Morgan Stanley.

[Michael Riad, analyst]

This is Michael Riad on for Jeff Hung. Circling back to the discussion on the Orexin program. For the Phase Ib, do you have any additional color you could provide on the level of dose reduction you'd go for with for [indiscernible] in Q1? And would there be like enough leeway to potentially accommodate expanding to other types of narcolepsy or IH?

[Robert Iannone, executive]

Yes, we haven't yet disclosed the doses that we'll evaluate in the study that we described, but we will look at multiple doses because part of the goal there is to really understand relative to what we observed in healthy volunteers where we think we had a very robust effect. What's the dose that we're going to need in NT1. Obviously, we've watched other programs and we kind of see the relative dose of [indiscernible] versus what they've observed in Q1. And so we need to see where we land where we think we have enough of a safety margin, and that will ultimately dictate whether we have a path forward in NT1 or in other indications where you're likely to need higher doses. So it's really the goal of the study to better characterize some of the aspects you highlight.

[Operator]

And your next question comes from the line of Joon Lee with Truist.

[Joon Lee, analyst]

[indiscernible] hear our questions. It's nice to see the growth of EBITDA like 6 years since the launch, how much of it is geographic expansion versus greater penetration? And for the former, what gives you confidence in approval in Japan. And for the latter, -- is there a particular segment or line of use within epilepsy that's driving growth?

[Renée Galá, executive]

Yes. Thanks for the question. I'll start out with comments on what's happening with the business currently and then ask Rob to jump in to talk a bit about the path forward in Japan. So I would say with Epidiolex, we're really pleased with the growth that we saw, 18% year-over-year. It's our highest net sales quarter to date with more than $250 million of sales. So you can see we are well on our way to having a $1 billion franchise.

In terms of what's driving the growth, we continue to have Epidiolex just seen as a highly differentiated product. That starts with the data. First and foremost, we have a robust body of evidence that supports both the seizure and non-seizure benefits and that non-seizure benefit data really resonates with physicians and caregivers on those benefits such as cognition behavior, emotional, social function. So that is a very strong differentiator for Epidiolex and having an impact in the market.

Also seeing really strong execution from the team here focused on our key drivers of growth. We've had good momentum in the adult and long-term care setting. Within the U.S., we've provided some new screening tools there that we talked about earlier. We have breadth and quality of our access that's continuing to improve. That's both in the U.S., but also some multiple positive reimbursement decisions outside the U.S. Also in how we're operating, we've made some structural changes to how we're organized and how our field teams collaborate, that is having a positive impact in terms of our effectiveness, and we're piloting some new programs where we're also seeing some early success in the U.S., we talked about the virtual nurse navigator program. We've rolled out new campaigns, some highly targeted consumer ads and even added a few virtual account manager positions.

And the good thing about doing these pilots is, you can see what's working, you can invest more behind them and then really drive greater growth by understanding what's having an impact. Rob, would you like to cover Japan?

[Robert Iannone, executive]

Yes. Just to remind folks that the -- what we reported on previously was based on an interim analysis had 13 weeks. We know the trial needs to continue to collect additional safety data at 26 and 52 weeks in order to support registration in Japan. We do think that while the efficacy at the interim didn't hit its prespecified mark, we do think the data could support registration in Japan, and we are planning to by midyear next year, have an interaction with PMDA to clarify next steps.

[Operator]

And your next question comes from the line of Mohit Bansal with Wells Fargo.

[Unknown Analyst]

This is [indiscernible] on for Mohit. I wanted to ask on the lowered oncology guidance. And if that's all due to Rylaze and the political change in the pediatric study? Or is slower than expected update in that adolescent and adult market, also a factor?

[Bruce Cozadd, executive]

It's entirely due to that temporary impact we're seeing on Rylaze. That's what drove the change.

[Operator]

And your final question comes from the line of Gary Nachman with Raymond James.

[Gary Nachman, analyst]

Just following up on oncology. So specifically with Rylaze, just talk about your initiatives to expand more in AYA. And has anything changed and where you see the peak potential for that opportunity? And then also, [indiscernible] was noticeably higher in the third quarter. So anything worth highlighting there just if that's durable going forward?

[Renée Galá, executive]

Yes. Thanks for the question. So maybe I'll just start with [ Defitelio ]. Of course, as you know, this is a product that has quarter-to-quarter variability given that historically it has given that is used to treat an ultra-rare condition. With respect to what we saw in the current quarter, we did see an increase in both the U.S. as well as ex U.S. I would say ex U.S., very much related to timing and quarterly variability. Within the U.S., we saw an increase across both our adults and pediatric patients because this is weight-based dosing, you would see revenue uptick coming from an increase in adult patients, and then we've also separately seen increased use of [ inotuzumab ]. This is something that is used typically to prep patients for stem cell transplants. It could be driving greater use of Defitelio because it's also a risk factor for VOD. But it's a little too early to tell if this is going to be durable. I would for the time being, think about it as that typical variability that we'll continue to monitor.

With respect to Rylaze, we did talk about the temporary impact to Rylaze from this protocol update, which by the way, is great news for patients because ultimately, the change was driven by data that showed really meaningful improvements in survival rates by adopting this new protocol. And for this reason, we do have confidence that the protocol will be widely and rapidly adopted. And given this protocol emphasizes the same number of doses of asparaginase treatment, it also underpins the importance of asparaginase treatment as part of this overall pediatric ALL protocol.

With respect to AYA, that build is happening probably a little more slowly than we had originally anticipated. With respect to initiatives that we have underway, we've continued to educate on the benefits of the [indiscernible], focusing on the importance of that in treating the AYA population. We're also doing some piloting to see what is having an impact in moving the needle here. I won't go into all of those, but similar to what I described in our Epidiolex franchise where the field teams are continuing to work through what can have the most impact.

[Bruce Cozadd, executive]

All right. It looks like that was our last question. So let me wrap by recognizing our Jazz colleagues for their efforts on behalf of patients and their families and thank our partners and shareholders for their continued confidence and support. Thank you all for joining us today.

[Operator]

And ladies and gentlemen, this concludes today's call, and we thank you for your participation. You may now disconnect.