Theravance Biopharma Inc

NASDAQ:TBPH

Earnings Call Analysis

Theravance Biopharma Signals Growth and Profits

Theravance Biopharma reported a productive 2023, increasing YUPELRI net sales 9% to $221 million and growing hospital volumes 46%. The company achieved non-GAAP profitability in Q4 and completed a $325 million capital return program. They are on track with the CYPRESS study for ampreloxetine and expect regulatory submission in China for YUPELRI midyear, aiming for greater market share. For 2024, a non-GAAP loss is anticipated in H1 due to seasonal drops in sales and increased R&D spend, with a return to breakeven expected in H2. A $25 million or $50 million TRELEGY milestone is possible, and limited cash burn is projected, with significant milestones anticipated to generate net cash before CYPRESS results in 2025.

Year of Growth and Milestones Pave Way for Continued Momentum

The past year for Theravance Biopharma marked a period of strategic focusing and the achievement of significant milestones. The company zeroed in on growing YUPELRI's market impact and optimizing the value of their Airfox team, while also increasing their capital return program. Their efforts bore fruit with a 9% growth in YUPELRI net sales, reaching $221 million, and an impressive 46% increase in hospital volumes. Amidst these accomplishments, Theravance also achieved non-GAAP profitability for Q4 and completed a substantial $325 million capital return program, all while maintaining a robust financial position.

Robust Pipeline and Potential Milestones Create an Air of Optimism

Looking forward, Theravance is setting its sights higher with anticipations of increased YUPELRI net sales, both domestically and potentially in China with Viatris as a partner. The company is also focused on the CYPRESS study of ampreloxetine, expecting progress and regulatory advancements to unfold through the year. There is anticipation of non-GAAP losses in the earlier parts of the year, but with an aim to approach breakeven as the year progresses, subject to YUPELRI growth and CYPRESS study outcomes. Theravance holds a strong financial position with an eye on sequential value escalation from milestones and royalties on YUPELRI and TRELEGY, including specific onetime sales milestones.

Ampreloxetine's Potential to Meet Unmet Needs in Neurodegenerative Care

Ampreloxetine is poised to fill a critical void in the treatment of symptomatic neurogenic orthostatic hypotension (nOH) in multiple system atrophy (MSA) patients, a group that has not seen therapeutic innovation in over a decade. The drug promises to offer a significant advance thanks to its durable impact on a broad range of nOH symptoms and its safety and tolerability profile, backed by a convenient once-daily dosing schedule. The potential market is sizeable, with an estimated 40,000 MSA patients in the U.S. alone suffering from symptomatic nOH.

YUPELRI's Strong Commercial Performance

YUPELRI has achieved its highest level of profitability since its launch. Net sales for Q4 reached $60.6 million, contributing to the full year's $221 million. The drug's market share reflects its growing influence, evidenced by an uptick in hospital market share reaching 16.6% and a 31% share in the community. Contributing to these gains are its status as the only once-daily nebulized LAMA for COPD treatment and the alignment of its go-to-market strategy with its therapeutic profile.

Financial Fortitude and Fiscal Guidance

Theravance demonstrated strong financial execution, with a non-GAAP profit of $1.4 million in Q4. The company also completed a share repurchase program which resulted in a 37% reduction in share count. As per the latest financial guidance, R&D and SG&A operating expenses are expected to remain within clearly defined limits. A key focal point is the execution of the CYPRESS study, with substantial funding earmarked for this purpose in preparation for NDA submission. Further, initiatives to cut costs and streamlining for G&A have been launched.

Cautious Optimism for Forthcoming Milestones

Strategically, Theravance appears to be on the verge of capitalizing on a series of potential milestones while risking limited capital investments. TRELEGY's strong sales trajectory places the company in a favorable position to reach milestones, with only modest growth required to trigger the first $25 million and second $50 million payouts. Additionally, financial discipline is expected to continue with capped R&D and control over SG&A expenses, as well as a focus on non-GAAP profitability and low cash burn, ensuring stability in anticipation of the CYPRESS study's top-line data in 2025.

Earnings Call Transcript 2023-Q4

[Operator]

Ladies and gentlemen, good afternoon. I'd like to welcome everyone to the Theravance Biopharma Fourth Quarter 2023 Conference Call. [Operator Instructions] Also, today's conference call is being recorded. And now I'd like to turn the call over to Rick Winningham, Chief Executive Officer. Please go ahead, sir.

[Rick Winningham, executive]

Good afternoon, everyone, and thank you for joining the Theravance Biopharma Fourth Quarter and Full Year 2023 Earnings Results Conference Call. Turning to Slide 2, I remind you that this call will contain forward-looking statements that involve risks and uncertainties, including statements about our development pipeline, expected benefits of our product candidates; anticipated timing of clinical trials, regulatory filings and expected financial results. Information containing factors that could cause results to differ materially from our forward-looking statements is described further in our filings with the SEC.

Today, I'm joined by Aine Miller, our Head of Development, Rhonda Farnum, Theravance's Chief Business Officer; and Aziz Sawaf, our Chief Financial Officer.

On Slide 4, I'll begin by hitting high points for a very productive 2023 for Theravance. We began the year with the decision to focus on driving YUPELRI growth and maximizing Airfox team's value while increasing our capital return program. I'm pleased to report that our team delivered on these objectives. For both the fourth quarter and the full year, we increased the power net sales 9% from $61 million and $221 million, respectively, as is recorded by Viatris. We grew hospital volumes at outstanding 46% for the year and set the business up for continued momentum in 2024. We initiated ampreloxetine CYPRESS study and began -- immediately began evaluating and activating sites around the world. In May, we were granted orphan drug status, which confers important financial advantages such as tax credits and user fee exemptions and shields ampreloxetine from price negotiations associated with the Inflation Reduction Act. CYPRESS enrollment remains on track, and we look forward to enrolling the last patient in the open-label portion of the study in the second half of this year.

Turning to our corporate progress. I'm proud we delivered on our promise of reaching non-GAAP profitability in the fourth quarter, which involves significant efforts on the part of the entire Theravance team. In addition, we completed our $325 million capital return program within the first few days of January while maintaining a strong financial profile.

Now on Slide 5, I'll cover plans and anticipated financial performance for the upcoming year. Beginning with YUPELRI. We expect to grow YUPELRI net sales in partnership with Viatris and build on profit margin improvements experienced in 2023. We set ambitious goals for our hospital business in 2024, which we believe will translate into future share gains in the long-acting nebulization market. Finally, we look forward to Viatris submitting a regulatory application for YUPELRI in China by midyear, which will put us on a path towards achieving meaningful economics in that territory.

Turning to ampreloxetine. We're focused on completing the CYPRESS study. In addition, we expect to initiate regulatory and early commercialization preparations as we progress through the year. We're very excited to host a virtual investor event during the second quarter, where we will bring MSA experts and senior leadership from Theravance together to discuss the unmet need in MSA patients with symptomatic NOH and the expected benefits of ampreloxetine. Turning to our 2024 financial outlook. We expect annual collaboration growth to remain strong for our quarterly financial results to improve as the year progresses.

During the first year, we expect to report losses on a non-GAAP basis. During the second half of the year, subject to timing of YUPELRI growth and CYPRESS progress, we plan to approach breakeven on a non-GAAP basis. We plan to limit cash utilization, and we believe we are in a strong position to achieve the $25 million TRELEGY sales milestone in 2024 and possibly the higher $50 million milestone.

If you turn to Slide 6, you'll see an updated summary of our compelling value proposition. In addition to YUPELRI and ampreloxetine, we're in a strong financial position with over $100 million in cash as well as the potential to accrue significant value through milestones and royalties on YUPELRI and TRELEGY over time. Specifically, in addition to the TRELEGY milestones that I referenced, we stand to receive a onetime sales milestone of $25 million when the U.S. YUPELRI net sales reached $250 million in any calendar year. Additional information on our milestones and royalties may be found in our SEC filings.

Moving to Slide 8 to focus on ampreloxetine. We're motivated to make ampreloxetine available to patients as expeditiously as possible. Should the CYPRESS results support approval for the tens of thousands of MSA patients around the world who suffer from symptomatic NOH without effective treatment options. Data thus far support ampreloxetine's potential to represent a major advance for these patients. The company retains commercial rights to ampreloxetine worldwide.

On Slide 9, I'll start with a considerable unmet need in the United States. MSA is a neurodegenerative disease that shares features with other movement disorders such as Parkinson's disease. It's often misdiagnosed with many patients not confirmed to have MSA for months to years after symptoms begin. Unfortunately, most epidemiology research was conducted decades ago on Parkinsonism, more generally using survey techniques with significant limitations. For example, one off sided study relies on a 25-year-old survey of 15 general practices in London. Using this limited sample, some have suggested that there are approximately 14,000 individuals with MSA in the United States given the country's current population. In contrast, recent analysis rely on the use of real world's claims databases and capture important geographic variances and demographic trends, which affect MSA prevalence estimates. These analyses support a much higher estimate of roughly 50,000 individuals, which is consistent with estimates from both the UCSD Department of Neurosciences, an MSA Center of Excellence and the National Institutes of Health. Based on this figure, we believe that the addressable U.S. population for ampreloxetine is approximately 40,000 MSA patients suffering from symptomatic NOA.

Turning to Slide 10. Our goal is to make ampreloxetine available to MSA patients with symptomatic NOH worldwide. In Europe and Asian countries, including the EU5, Japan and China, the number of addressable patients is several-fold larger than it is in the U.S. And in some territories, the range of therapeutic options is even more limited than in the U.S.

At this point, I'd like to turn the call over to our new Head of Development, Aine Miller, to characterize the value that we see in ampreloxetine and provide an update on the progress we are making with Cypress. Aine?

[Aine Miller, executive]

Thanks, Rick. Let's begin on Slide 11. MSA is an incurable neurodegenerative disorder associated with inappropriate deposits of alpha-synuclein in the brain. MSA patients experience a progressive loss of autonomic functions as well as challenges with standing, walking, speaking and swallowing. Many also experience depression and anxiety. According to a 2018-'19 U.K. survey of over 10,000 patients with neurological disorders, MSA ranks as having the second most severe impact on quality of life of any neurological disorder study ahead of disorders like progressive supranuclear palsy, Huntington's disease and Parkinson's disease, among others. Neurogenic orthostatic hypotension, which causes significant and unremitting drops in blood pressure upon standing affects about 4 and 5 patients with MSA.

Patients with symptoms of NOH may feel dizzy upon sitting or standing and become unable to stand or walk for even short periods of time, feel pain associated with a lap of perfusion in their upper extremities and face a higher risk of falls. Not surprisingly, a significant majority of patients with symptomatic NOH report that they have a reduced ability to perform daily activities while many also expressing a lot of independence.

As I'll discuss on Slide 12, MSA patients with symptomatic NOH, lack a safe, convenient and durable effective treatment option. While nonpharmacological therapies are available, they are often insufficient to control symptoms. About 30 years ago, the FDA approved a product called Midodrine on the basis of its ability to increase blood pressure. However, Midodrine is not indicated to improve symptoms of NOH, must be taken 3 times daily and carries a black box warning for its potential to lead to a marked elevation of supine blood pressure.

Nearly 20 years later, the FDA approved a second drug called droxidopa to treat dizziness patients with NOH. Based on the still high unmet need for these patients, the FDA granted droxidopa, a conditional or accelerated approval. After initially having rejected of sponsors applications and despite droxidopa having failed in sale 2 of the 4 Phase III studies included in the application. As with Midodrine, droxidopa is dosed multiple times a day and carries a black box warning for supine hypertension. It has never demonstrated a durable effect on NOH symptoms beyond 2 weeks of treatment in a double-blind study. And more recently, based on data reported on cinecotyles.gov, it failed to demonstrate a benefit in the confirmatory study requested by the FDA known as RESTORE.

Based on third-party analysis of claims and prescription data, droxidopa is still only prescribed to a small percentage of MSA patients with NOH. Let's fast forward to today, and it has been more than a decade since MSA patients with symptomatic NOH have been offered a novel treatment alternative. While we still have important work to do to confirm its clinical profile in the CYPRESS study, we anticipate that ampreloxetine will represent a significant advance for these individuals, given the benefits that have demonstrated to date, ampreloxetine's durable impact on a broad range of nOH symptoms in MSA patients in Study 170, coupled with its safety and tolerability profile and convenient once-daily dosing is expected to drive high levels of adherence. Moreover, as the first novel therapy in years, we are optimistic we will be able to build a case for a broad access and significant adoption in the population for which it is indicated, should ampreloxetine be approved.

Now shifting gears to the CYPRESS study on Slide 13. I'd like to share our approach and the progress that we are making. As many of you know, Theravance is directly managing study for CYPRESS rather than utilizing the traditional CRO model. By design, we are deeply involved in identifying sites with high standards for clinical conduct investigators who understand the complexities of managing nOH and MSA and patients who best case the criteria of the CIPR study. We are informed by our experience in Studies 169 and 170 and have reinvested many of the same sites and KOLs involved in those studies. Beyond this, we have enriched our network through AI efforts that leverage claims information, the work of data scientists and our own expertise. This has allowed us to identify additional qualified sites in the United States.

Finally, we are early adopters of Telehealth and have incorporated option for patients and clinical personnel to participate in CYPRESS even if factors limit patient's ability to undergo evaluations in the clinic. We are pleased with the internal metrics we are monitoring thus far, which are consistent with our expectations on Study 170. While we don't comment specifically on enrollment, we continue to make excellent progress activating sites, including many outside of the United States.

Shifting now to the right-hand side of Slide 13, we have aligned with the FDA and the design of CYPRESS, including the use of the OHSA composite score, a 6-item assessment of orthostatic hypertension symptom severity as the primary end point. When using patient-reported outcome measures such as OHSA, the FDA recommends anchoring these data in order to determine clinical meaningful. In November, at the AAS Annual Meeting, we presented data from our anchor-based analysis of Studies 169 and 170, which support the use of the OHSA composite score for MSA patients with NOH as well as the threshold for which is considered a clinically meaningful change. Our analysis demonstrated that threshold improvements and worsening of approximately 1 point on OHSA composites were considered clinically meaningful. This is important as it supports our CYPRESS study design and compares favorably to the 1.6 points benefit we saw on this measure in MSA patients in Study 170.

Finally, in order to minimize the time from Cypress completion to potential commercial availability, we have already completed much of the work required for our NDA submission and are in the process of ordering the application. At this point, I'll turn the call over to Rhonda to discuss YUPELRI.

[Rhonda Farnum, executive]

Thanks, Aine. Beginning on Slide 15, I'm pleased to report that the Theravance and Viatris commercial partnership finished the year strong, having driven YUPELRI net sales growth of 9% for the full year of 2023. Fourth quarter net sales reached $60.6 million and full year sales reached $221 million with YUPELRI recording its highest level of profitability since launch. Although quarter-to-quarter results can vary, depending on the timing of shipments and other seasonal factors, we remain optimistic for YUPELRI's continued growth based on the success we are delivering in the hospital channel as well as several key performance indicators we track across the business. While realized sales this quarter closely tracked with demand generation, we have traditionally experienced seasonal dips in reported net sales as we transition from the fourth quarter to the first quarter of the following year.

Moving to Slide 16. I'm also very pleased to share with you the exceptional finish to the year our hospital team was able to deliver. Hospital doses shipped in the fourth quarter increased 37% year-over-year with full growth reaching 46%. This was easily the highest volume quarter for the hospital channel delivered since launch. As you know, our goal continues to be to increase the number of patients exposed at YUPELRI during hospitalization, who are then discharged on YUPELRI as maintenance patients. This is achieved by gaining support for formulary inclusion, implementation of hospital protocols involving all nebulization strategies and therapeutic interchanges and equally important high-touch transition of care programs. Our market research continues to demonstrate that the vast majority of patients who initiate YUPELRI in the hospital setting receive a prescription for YUPELRI maintenance care at discharge. It is with the execution of this winning strategy that our small but focused commercial organization is able to make a considerable contribution to the overall YUPELRI business, both directly and indirectly.

Turning to Slide 17. On the left side, you can see the impact our efforts have had on our hospital market share. During the quarter, our share of the long-acting NIM market in the hospital segment increased to 16.6%. While on the right side of the slide, YUPELRI achieved a 31% share in the community, up nearly 4 percentage points year-over-year. We attribute both segments share growth to the increasing traction of our concomitant therapy messaging. This taps into the significant number of COPD patients who remain symptomatic on LABA therapy and could benefit from the addition of a LAMA, which is foundational in the treatment of COPD and references the 2022 changes to the Gold Report guidelines, which recommend dual LABA/LAMA therapy for Category B and E patients. As a basis for speaking to the trends we have achieved in the retail setting, where we have our most real-time and current demand view outside of the hospital channel, we felt it might be helpful to share another visual.

If you turn to Slide 18, we provide data on the fulfillment growth trends in both the total community and retail segment settings through the third quarter of the year. At the time that we share our quarterly results, we do not have a completed data capture of fulfillment in the DME channel, which accounts for approximately 60% of our total community business because retail, which accounts for the other 40% generally correlates with total community fulfillment over time, we have historically offered this view.

You will find our most up-to-date performance in the retail channel on Slide 19. Looking at the left side of Slide 19, retail prescriptions grew a robust 7% sequentially during the quarter, which is consistent with recent brand performance trends. Looking to the right side of the slide, we also grew new product starts a sequential 7% in Q4. You may remember from our last update that we had experienced some quarter-to-quarter seasonality in new starts, which is not atypical for this metric in Q3. As anticipated, however, we were able to drive a sequential return to growth in Q4.

Finishing on Slide 20. We think it is important to highlight the unique and compelling value proposition we offer patients and caregivers as the only once-daily nebulized LAMA for maintenance treatment of COPD. YUPELRI has demonstrated consistently meaningful lung function benefits that's typically available at low out-of-pocket cost and requires only a few minutes to administer once per day. As such, we believe YUPELRI plays a key role in the COPD market where there remains a substantial opportunity to reach patients who could benefit from YUPELRI. Our go-to-market strategy aligns with this profile, which we believe is why YUPELRI is only 1 of 3 branded COPD maintenance therapies in the U.S. that is delivering consistent growth.

Looking ahead, we expect to achieve continued growth and value creation for YUPELRI, driven both by continued penetration of the U.S. maintenance COPD market and the potential launch of YUPELRI in China. Lastly, in the U.S., we are eligible to receive a onetime sales milestone of $25 million from Viatris when YUPELRI net sales reached $250 million in any calendar year. In China, where Viatris is planning to file for regulatory approval by the middle of this year, we are eligible to receive a $7.5 million milestone upon approval as well as additional sales milestones and upwardly tiered royalties of between 14% and 20%. That brings us to the end of the YUPELRI update. So I will turn things over to Aziz to cover our financials. Aziz?

[Aziz Sawaf, executive]

Thanks, Rhonda. Starting off with the results for the quarter. Slide 22 and 23 cover the detailed financials. I'll cover the highlights on Slide 24. Starting with collaboration revenue. We reported an all-time high of $17.4 million, representing year-over-year growth of 19%. Operating expenses were in line with expectations for the quarter, resulting in full year operating expenses, excluding share-based comp to be under the low end of R&D guidance and within the range for SG&A and total OpEx. The combination of judicious expense management and increased YUPELRI net sales led to a non-GAAP profit of $1.4 million in the quarter.

Please note that our GAAP loss of $8.5 million was affected by a larger-than-expected income tax expense in the quarter, primarily due to better-than-expected results and other noncash charges from one of our operating entities. However, this is a noncash item, and we expect to have immaterial if any, cash taxes payable for 2023.

In Q4, we repurchased approximately $30 million worth of shares, leaving $400,000 on the return of capital program at quarter end, which was completed in early January. This reduced our share count by 3 million shares in the quarter and by 31 million shares from the program's inception, a 37% reduction in share count. We closed the period with $102 million in cash and approximately 48 million shares outstanding.

On Slide 25, I'll provide an update on our potential to earn milestones from TRELEGY, noting that GSK delivered another excellent quarter of growth. Quarterly and year-to-date sales reached $737 million and $2.7 billion, respectively, up 35% and 28% year-over-year. As a result, we are well positioned to achieve milestones in 2024 and beyond. Compared with 2023 actuals, we need only 5% growth in annual net sales to achieve the first $25 million milestone and 17% to achieve the second $50 million milestone. As a reminder, these milestones are not cumulative. If both milestones were to be achieved, we would receive a total of $50 million, not $75 million.

Lastly, turning to financial guidance on Slide 26. We will continue to provide R&D and SG&A operating expense guidance, excluding share-based comp in 2024. In addition to enhance our financial disclosure, we will be adding noncash share-based compensation to our guidance metrics. For R&D OpEx, excluding share-based comp, we are expecting between $30 million and $36 million, which will be exclusively allocated to ampreloxetine. A significant majority of this will be for the CYPRESS study execution. In addition, guidance includes gated spend towards NDA preparation primarily during the second half of the year. The ungating of this spend will depend on being on track with CYPRESS enrollment in line with industry best practices.

For SG&A OpEx, excluding share-based comp, we are expecting between $45 million and $55 million. While our YUPELRI-related spend will be largely flat year-over-year, guidance includes incremental spend for Ampaloxteme prelaunch commercial activity, primarily in market research, medical affairs and market access, which will occur mostly in the second half of the year.

Given our focus on expected return on invested capital, any incremental spending for prelaunch activities will be gated based on CYPRESS enrollment and will be subject to Board approval. Partially offsetting these increases is a reduction of G&A spend by approximately 20%, driven by ongoing cost-cutting initiatives. Starting in Q1, we will break out G&A separately from SG&A within our MD&A commentary in our 10-Qs and 10-K.

For share-based comp, we are expecting between $18 million and $22 million, the midpoint reflecting a year-over-year reduction of approximately 20%. In terms of our non-GAAP metric, we expect we will turn from a non-GAAP profit in Q4 2023 to a non-GAAP loss in early 2024. This is due to an expected decrease in collaboration revenue in Q1 from Q4 of 2023, driven by typical seasonality for YUPELRI net sales, as mentioned by Rhonda, combined with a temporary increase in R&D spend due to the expected ramp in patient enrollment and site initiation for the CYPRESS study. Turning to the second half of 2024, we expect our non-GAAP metric to approach breakeven, which will be dependent on continued net sales growth for YUPELRI as well as the amount of spend on ampreloxetine prelaunch commercialization. As discussed on prior earnings calls, this non-GAAP metric is a proxy for cash flow, and we therefore expect limited cash burn in 2024, most of which will be incurred early in the year.

Given multiple potential milestones in 2024 and beyond, such as $25 million or $50 million milestone for TRELEGY, we expect to generate net cash prior to the CYPRESS top line data readout in 2025. Lastly, we may continue to incur noncash income tax expense of several million each quarter. However, we continue to expect to have immaterial, if any, cash taxes in 2024 from ongoing operations. With that, I'll pass it back to Rick to conclude. Rick?

[Rick Winningham, executive]

Thanks, Aziz. On Slide 27, we summarize Theravance's compelling vision and value we offer shareholders. Having focused our organization's efforts behind YUPELRI and ampreloxetine, the Theravance team is now unified in pursuit of 3 objectives. First, we'll work to drive U.S. YUPELRI net sales growth in the hospital while collaborating closely with our partners at Viatris to maximize the brand's overall potential in the hospital and community settings. Second, we'll continue to work diligently in pursuit of the CYPRESS study successful completion while making appropriate regulatory preparations and laying the ground to work for its broad access at approved.

Third, we'll maintain a strong capital structure as we work to deliver value for shareholders. Based on the choices we made regarding YUPELRI, ampreloxetine and TRELEGY, we believe we're at the crossroads of Theravance's evolution, where we stand poised to deliver significant incremental value through our operational assets as well as near-term milestones and royalties while making limited incremental investments in managing risk. We thank you for your time and attention this afternoon, and we're ready to take your questions. Operator?

[Operator]

[Operator Instructions] And our first question comes from the line of Doug Tsao from H.C. Wang.

[Douglas Tsao, analyst]

Can you hear me?

[Rick Winningham, executive]

Yes, we can hear you.

[Douglas Tsao, analyst]

Congrats on the progress. Just a couple of questions. First, maybe starting with YUPELRI. Rhonda, I'm just curious, when we think about the share gains that you're seeing, especially those in the hospital, to what extent are those coming from adding new accounts versus gaining share within the existing account base? And then I've got a follow-up.

[Rhonda Farnum, executive]

Thanks, Doug. Great question. Actually, thinking about that share gain up to 16.6% for the quarter, that is drawn both from the new accounts, but I would say the predominant growth there is from those accounts that continue to build upon their base business where we are converting them to therapeutic interchange. And for those accounts where we do have that all med strategy implementation as well as therapeutic interchange, we see that the market share is even higher in those accounts.

[Douglas Tsao, analyst]

Typically, maybe just as a follow-up to that, Rhonda, what's the process? Or how long does it take to get the hospital to sort of move to that therapeutic interchange and all net approach?

[Rhonda Farnum, executive]

If we are moving from their initial formulary to therapeutic interchange that can range anywhere from 6 months to a year. If we're converting prior existing formulary review approvals, it's usually 6 to 9 months -- that's on average.

[Douglas Tsao, analyst]

And within your account base, I mean, what percent would you say are at sort of doing the -- have achieved therapeutic interchange and then all that approach?

[Rhonda Farnum, executive]

That varies just based on the growing base, but roughly 2/3 of our volume already have a therapeutic interchange or I should say 2/3 of our volume is driven from those therapeutic interchange accounts, if that makes sense.

[Douglas Tsao, analyst]

Well, but I guess -- and then as a follow-up to that, though, what percentage of your accounts are therapeutic interchange because obviously, given that 2/3, it would seem that there's significant growth by getting accounts to that to that...

[Rhonda Farnum, executive]

Yes. You've got it, Doug. If we move them to therapeutic interchange, that automatic substitution is what converts every existing LAMA weather handheld from the past experience over. So that is the ultimate of what we are trying to achieve here with these new games.

[Douglas Tsao, analyst]

I get it, but what percentage of your overall accounts are there? Have you achieved that? Is it 10%, 20%, 30%? Just to sort of help understand the magnitude of the opportunity still in front of you.

[Rhonda Farnum, executive]

Roughly 35% of our COPD focused accounts have a therapeutic interchange.

[Douglas Tsao, analyst]

Yes, that's really helpful. And then just, Rick, as a follow-up, obviously, you have now brought yourself in the company to expense management and some difficult choices to a point where your cash burn is pretty minimal. You are also on the cusp of seemingly we're starting to bring in some milestones, be it for TRELEGY as well as it seems like YUPELRI, which could begin to enhance your cash balance -- when you think about YUPELRI and the success you're achieving in the hospital, does it ever -- how close are you to the point where it would make sense strategically to gain some leverage with that sales organization and bring in another product and not necessarily one even of the same magnitude of opportunities of YUPELRI just something that could give you some efficiency or sort of some additional leverage because in theory, even a small product could drive some pretty nice incremental margins on that sales force?

[Rick Winningham, executive]

Yes. Doug, that's a good question. A couple of points. One, we see such significant opportunity in ampreloxetine and the execution of the CYPRESS study and the preparatory work over the next year, both on the regulatory side as well as some very early commercial preparation work that any distraction from anything else, I think, would be net harmful from where we are right now.

I'd say the second point is, as Rhonda mentioned, we have a small sales force, and they're doing an outstanding job executing a particular strategy. And we are in the early days of the execution of the strategy both at Theravance and I'd say, in particular, in combination with the efforts of Viatris. So we've got a significant amount of opportunity, I think, within the hospital with YUPELRI, and we would pay some opportunity costs by shifting our focus to anything else, given sort of where we sit with those accounts where we're on formulary and we need to move and take the next step towards therapeutic interchange. And those steps that those institutions largely, which are multihospital sort of groups of going from not being on formulary to being on formulary with therapeutic interchange. So we really view is there's just such significant opportunity behind both YUPELRI and ampreloxetine that we need to keep our focus on those 2 assets.

[Operator]

One moment for our next question. And our next question comes from the line of David Risinger from Leerink Partners.

[David Risinger, analyst]

Yes. Thank you for the update. So my first question is, can you talk a little bit about how you're thinking about the introduction of ensifentrine from Verona and what implications that might have for YUPELRI. And then second, if you could just provide a little bit more detail on the execution of the ampreloxetine trial from here, the event path and then the likely timing of the press release with the results.

[Rick Winningham, executive]

Okay. Ron, do you want to take ensifentrine.

[Rhonda Farnum, executive]

Absolutely. Thanks, David, for the question. We're very excited about the opportunity for ensifentrine having additional share of voice focused on a nebulized asset and the COPD maintenance space would be tremendous. And thinking about as well how that particular product would enter the market and most likely still needing the backbone or the foundation of therapy, Thinking about that as an add-on therapy, it's a great opportunity for us to both ensure that the patients that could benefit from both products have that chance.

[Rick Winningham, executive]

So on ampreloxetine, obviously, we're -- we've initiated a lot of sites as Aine had on her comments, high-quality sites with physicians who understand MSA patients, understand the care of MSA patients and understand the execution of the clinical trial. We'll continue to activate sites and there is some work that's necessary there. But more and more work, obviously, is focused on just getting patients into and through the sites for the study.

We're making very good progress, making very good progress there. And I think if you split that, we've got -- this year is really about -- is a little bit tilted towards patients as opposed to sites, and that's where our focus will be. In terms of the -- where the study is, I think we'll enroll our target. And right now, that's what we believe we can do is enroll the last patient into the open-label portion in the second half of the year, this would sort of lean data probably sometime in the first half of next year. And that's what we'd be looking forward to. But stay tuned as we progress throughout the year.

I think the -- from -- at least from the science of the medicine part of ampreloxetine and the value that it can provide for patients with MSA and nOH, I think, hopefully, our investor event that we have in the second quarter, we'll be able to provide good information to investors about the opportunity that we see there.

[Operator]

One moment for our next question -- and our next question comes from the line of Eva Privitera from Cowen.

[Eva Xia Privitera, analyst]

Congrats on great quarter. I have a question about the Q2 investor event for ampreloxetine. Will there be any additional analyses that we haven't seen before...

[Rick Winningham, executive]

Yes. Thanks, Eva. I think relative to ampreloxetine, I think the additional analysis will be relatively limited. I think with -- as we mentioned, we will have opinion leaders there that present other analyses, obviously, in both nOH and MSA patients as part of their presentation that outlined the medical need and the opportunity that ampreloxetine has to meet that medical need through the data that they have and that is currently published, but certainly consolidating it into one particular event.

[Eva Xia Privitera, analyst]

Got it. That's helpful. And another 1 for me. How should we think about ampreloxetine's market opportunity relative to Northera, which I believe, achieved $400 million in peak sales, given all of Northera shortcomings and ampreloxetine's differentiation, how much bigger could ampreloxetine be?

[Rick Winningham, executive]

Well, I think we're very -- we're optimistic on ampreloxetine. That's 1 of the reasons why we focused on both in my comments as well as Aine's comments on patient populations and the fact that there really is no solution that's adequate out there for patients that have MSA and nOH but in a population of 40,000 patients with MSA and nOH and given that, as Aine presented, this is, in fact, a debilitating condition that keeps many of them really unable to interact with their environment. I think that being able to show among multiple different parameters as measured by the OHSA composite score that we improve the well-being of these patients. I think should open up a significant opportunity for us. And as a reminder, we did -- we were granted orphan drug designation. This is an orphan drug for a rare disease.

So we're quite excited about obviously continuing to progress with the study the investor event that we have in quarter 2, which I think will fill in some more information and then continue to provide additional information as we work towards closing the study and data so.

[Operator]

Thank you, 1 moment for our next question. And our next question comes from the line of [Julian Harrison] from BTIG.

[Unknown Analyst]

Congrats on the quarter. It was great to see a positive outcome from your Phase III trial of YUPELRI in China back in November. I'm wondering if you could remind us about how you're thinking about the China market opportunity there? And what are the gating steps to filing later this year. And then on CYPRESS, do you have a good sense now for what the U.S. ex U.S. enrollment split will likely look like? Any big differences there relative to the 170 study?

[Rick Winningham, executive]

Rhonda, do you want to comment on China? And then Aine, maybe give just a high-level comment on U.S. non-U.S. on Cypress Rhonda first?

[Rhonda Farnum, executive]

Yes. Thanks, Julien, for the question and recognizing the positive outcome of that Phase III that Viatris completed. So they will be continuing to prepare and as they've indicated, we'll be striving to make that filing for the application by the midpoint of this year. And thinking about the market for YUPELRI, we haven't made an outwardly communication around an absolute market projection and just thinking about -- certainly, it's a very significant financial burden on that health care system not too dissimilar from the U.S. we can ensure that we continue to evaluate what that opportunity can be for YUPELRI.

[Rick Winningham, executive]

Yes. And I think just to add to that, Julian, Viatris will be commercializing the medicine in China. They have a substantial organization in China, which is 1 of the reasons that we licensed YUPELRI to them in China. I think that they've -- since it is sort of their commercial responsibility -- they have -- I think their call is coming up and you may get some ask a question of them on opportunity. But obviously, the China market and COPD is very, very large, and it's about capturing as much of that opportunity as really makes economic sense.

[Rhonda Farnum, executive]

Julien, just to give you some fact basis for the China market itself, COPD affects about 100 million patients in that marketplace and a significant, roughly 40% of those patients are moderate to very severe patients suffering with COPD. So as you can think about that relative to that being the focus for us here in the U.S. I think that can give you some estimates.

[Aziz Sawaf, executive]

Julian, it's Aziz. Thanks for the question. One additional point in our 10-K, which we'll file in a couple of days now, we're going to be actually disclosing the YUPELRI economics for both the U.S. sales milestones and the China milestones and royalty rates in more detail. So we'll actually break out the sales milestone and you can see for the first time we broke out the actual percentage of the royalties 14% to 20%. So a pretty significant royalty in a huge market, obviously. So we're really excited about the opportunity and the economics there.

[Rick Winningham, executive]

Aine, do you want to talk about ampreloxetine study.

[Aine Miller, executive]

Julian, thanks for the question on the CYPRESS study. As I alluded to earlier, we've already made a lot of great progress activating sites in Europe and the U.S. And we have reengaged a lot of the sites in the U.S. and Europe that we had previously engaged in the prior studies. I would expect that we -- the majority of patients will still come from Europe as it did in the previous program. Although we are making efforts to expand our footprint in the U.S. and identify additional qualified sites, and I spoke about how we're going about that in terms of using an AI tool. So overall, I think the more patients will come from Europe, but the actual percentage of the split may differ for CYPRESS study. Hopefully that helps.

[Operator]

Thank you, this does conclude the question-and-answer session of today's program. I'd like to hand the program back to Mr. Winningham again for any further remarks.

[Rick Winningham, executive]

Yes, thank you. I'd like to just thank everyone for joining us today. We're pleased with the accomplishments of 2023 and look forward to what we can accomplish in 2024 both through effective financial management of the business as well as the growth of YUPELRI and the execution on the CYPRESS study in order to bring what we believe will be an important medicine to patients with MSA and nOH. Thank you very much.

[Operator]

Thank you, ladies and gentlemen, for your participation in today's conference. This does conclude the program. You may now disconnect. Good day.