United Therapeutics Corp

NASDAQ:UTHR

Earnings Call Analysis

United Therapeutics Forecasts Continued Growth

United Therapeutics holds a strong position, marked by a solid commercial business that continues setting new records with the promise of sustained growth. Their recent operational improvements ensure they can meet current and medium-term demand for Tyvaso DPI. Further increases in capacity are anticipated by the first half of 2024 to accommodate growth in ILD. The TETON pulmonary fibrosis studies remain on track to conclude by the end of 2024, despite an increased enrollment target of 576 patients per study. Importantly, this decision was based on a cautious response to variability in disease progression, without extending the overall timeline. United Therapeutics' promising pipeline is poised to possibly double its revenue by the decade's end, working towards addressing crucial unmet medical needs.

Unlocking Xenotransplantation's Potential

The company is on the brink of revolutionary advancements in xenotransplantation, as it concludes pivotal preclinical studies mandated by the FDA. The anticipated xenokidney transplant in early 2024 is a stepping stone towards discussions with the FDA on human clinical studies for 10-gene xeno organs. Parallel to these studies, a clinical stage-designated pathogen-free facility in Virginia is being prepped to accommodate pigs in early 2024, setting the stage for human clinical trials for both xenokidneys and xenohearts.

Titans of Tissue Engineering

Large mammal testing of manufactured lungs indicates the company's significant progress in regenerative medicine. The team in North Carolina and the New Hampshire-based organ manufacturing group are working in tandem with technology from 3D Systems, advancing towards clinical studies, implying potential near-term innovations in organ replication.

Revenue Ascension and Product Performance

The revenue surge to $609 million, marking their highest quarter ever and an 18% hike, sends a message of strength and growth. The Tyvaso franchise, Remodulin, Orenitram, and Unituxin all posted meaningful growth increments. Particularly, Orenitram and Remodulin saw patient and sales increase, while Unituxin experienced an 11% increase in revenue, thanks to a boost in U.S. sales and distributor inventory build.

Prescription Trajectory and Market Penetration

The company is witnessing just the beginning of what is set to be a period of sustained growth in its existing product portfolio. The ongoing efforts to penetrate the PH-ILD prescriber market and the stable growth of the PAH base business show a promising uptrend that gains the favor of prescribers and patients alike.

Navigating Commercial Viability

Tyvaso's net addition of about 500 patients per quarter signifies a consistent uptick in therapy commencement. From an inventory perspective, a stable trajectory is maintained without significant builds, signaling efficient management of supply to meet demand.

Future-Focused Financial Stewardship

Improving operating margins is on the horizon, though quarter-to-quarter variations are expected due to the annual nature of budget and expenditure reviews related to clinical trials, among other factors. The company is dedicated to judicious budgetary control and financial stewardship, which should continue to underpin their success.

Assuring Supply Amidst Growing Demand

Recent process enhancements will meet near and midterm demand for Tyvaso DPI, with new equipment coming online in the first half of 2024. This prepares the company to not just manage current demands but also be well-equipped for the future growth expected in ILD.

Clinical Trials on Track Amid Adjustments

The company remains on schedule to conclude enrollment for the TETON studies by end of 2024 despite an increased sample size, a change implemented to bolster the probability of successful outcomes due to the variability seen in the disease being studied.

Doubling Down on the Revenue Race

With a robust pipeline of innovative therapies, the company sets ambitious goals, predicting a potential doubling in revenue by the decade's close. Simultaneously, they maintain a focus on fulfilling significant unmet medical needs, all while benefiting stakeholders across the board.

Earnings Call Transcript 2023-Q3

[Operator]

Good morning, and welcome to the United Therapeutics Corporation Third Quarter 2023 Earnings Webcast. My name is Rafael and I will be your conference operator today. [Operator Instructions] Please note, this call is being recorded.

I will now turn the webcast over to Dewey Steadman, Head of Investor Relations, United Therapeutics. Please go ahead.

[Dewey Steadman, executive]

Thank you, Rafael, and good morning, everyone. It's my pleasure to welcome you to the United Therapeutics Third Quarter 2023 Earnings Webcast. Accompanying me today -- accompanying me today are Dr. Martine Rothblatt, our Chairperson and Chief Executive Officer; Michael Benkowitz, our President and Chief Operating Officer; James Edgemond, our Chief Financial Officer and Treasurer; Pat Poisson, our Executive Vice President of Technical Operations; and Dr. Leigh Peterson, our Executive Vice President of Product Development and Xenotransplantation.

Remarks today will include forward-looking statements representing our expectations or beliefs regarding future events. These statements involve risks and uncertainties that may cause actual results to differ materially. Our latest SEC filings, including forms 10-K and 10-Q, contain additional information on these risks and uncertainties. We assume no obligation to update these forward-looking statements.

Also today's remarks may discuss the progress and results of clinical trials or other developments with respect to our products. These remarks are intended solely to educate investors and are not intended to serve as the basis for medical decision-making or to suggest that any products are safe and effective for any unapproved or investigational uses. Full prescribing information for these products are available on our website.

Note that Pat Poisson and I will be presenting in a fireside chat session and one-on-one meetings at the 2023 UBS Biopharma Conference on November 8. And Martine Rothblatt will participate in a fireside chat and one-on-one meetings at the JPMorgan Healthcare Conference in early January.

Now I'll turn the call over to Dr. Rothblatt for an overview of our third quarter 2023 financial results and the business activities of United Therapeutics. Martine?

[Martine Rothblatt, executive]

Thank you, Dewey. First off, I'd like to congratulate our team as we had an amazing third quarter. For the second quarter in a row, I'm thrilled to report our highest quarterly revenue ever, along with double-digit revenue growth as compared to the third quarter of 2022. On top of that, our operational efficiency in the third quarter resulted in one of our highest quarterly net incomes and earnings per share ever.

At United Therapeutics, we're uniquely positioned for 3 waves of growth, with a profile that's unique in biotech. Our first wave of growth will come through our existing commercial business led by Tyvaso in pulmonary hypertension associated with interstitial lung disease or PH-ILD. We continue to post solid growth in our current business with record quarterly revenue and patients on therapy for treprostinil products as a whole. Our growth in PH-ILD and continued leadership in pulmonary arterial hypertension, or PAH, has led to nebulized Tyvaso and Tyvaso DPI products combining to become the most prescribed prostacyclin therapy in the U.S. Michael will go into detail on our commercial business later in this call.

We believe this growth will continue in the near term and we expect at least a $4 billion annual revenue run rate by mid-decade, doubling our revenue from 2022 and implying a double-digit compound annual growth rate.

Our second wave of growth will come from our near-term pipeline led by the TETON program in pulmonary fibrosis and Ralinepag in PAH. These 2 products, if approved, could lead our revenue to double again to $8 billion by the end of the decade. I will provide updates on the TETON and Ralinepag program shortly.

Of course, both of our first and second waves of growth are subject to clinical trial outcomes, regulatory approvals, new competitive entrants, and the potential impacts of the Inflation Reduction Act. But we feel good about our prospects for meeting these revenue aspirations.

Our third wave of sustainable growth will come through the development, manufacture and widespread use of manufactured organs and organ technologies to provide a solution to patients experiencing end-stage kidney, lung, heart and liver disease.

Moving to our near-term pipeline and second wave of growth, we have 2 key registration programs underway: TETON for pulmonary fibrosis, and Ralinepag, an oral therapy for Group 1 PAH. TETON now consists of 3 registration studies, TETON 1 and TETON 2 for idiopathic pulmonary fibrosis, or IPF, and now TETON PPF, for progressive pulmonary fibrosis.

We believe IPF represents a 100,000 patient opportunity in the United States, with only 2 approved therapies that just slow lung function decline. Both TETON 1 and TETON 2 are enrolling patients. And at this time, we are aiming for full enrollment in both studies with 576 patients each by the end of 2024.

Likewise, we believe PPF represents up to a 60,000 patient opportunity in the U.S., which is distinct from IPF. One of the 2 FDA approved IPF therapies is also approved for PPF and, like in IPF, it only slows the decline of lung function in these fragile patients.

As we reported earlier this week, the TETON PPF study has dosed its first patient. We expect this trial to enroll 698 patients.

We believe there is a relatively high probability of success in the 3 TETON studies based on an IPF subset of the INCREASE study of nebulized Tyvaso in PH-ILD patients. Unlike the 2 IPF therapies on market, nebulized Tyvaso in a safety endpoint showed an improvement of lung function in the subset of patients that had IPF along with pulmonary hypertension. We're also encouraged by a recent review by the Data Safety Monitoring Committee of data from 550 patients in the TETON 1 and TETON 2 studies. The committee completed a routine unblinded safety review of data from these patients and unanimously recommended continuation of both trials without hospitalization.

Our advanced outcome study of Ralinepag in Group 1 PAH continues to enroll patients. And at this time, we are targeting completion of the study in 2025. Ralinepag is a next-generation selective and potent prostacyclin receptor agonist and we are developing it as a once-daily oral therapy for PAH. We believe Ralinepag's once-daily dosing, sustained release profile and titrate-ability could position it favorably against the other oral prostacyclin receptor agonists as well as other therapies currently available for PAH patients.

Ralinepag provides 24-hour coverage with 6.5 to 10x the potency of the other oral prostacyclin receptor agonists on the market. And Ralinepag demonstrated more than 20% improvement in pulmonary vascular resistance in Phase II studies. That's close to the improvement observed in intravenous epoprostenol.

Long-term Phase II open-label studies of Ralinepag also showed sustained improvement in 6-minute block distance. We are pleased to announce that the Data Safety Monitoring Committee for the advanced outcome study met for the fourth time last month and unanimously recommended the continuation of the trial without modification, after evaluating unblinded data from 510 patients enrolled in the study. We are targeting 700 to 1,000 patients in the study depending on the pace of accruing clinical worsening events.

Moving to our organ programs. We have been developing several investigational approaches using different technologies with different organs. The first is our ex-vivo lung perfusion service, or EVLP, which has led to over 350 lives saved with lungs that have undergone EVLP. We're also developing Xeno transplantation products consisting of hearts and kidneys. Finally, we've been working on 3D printing and regenerative medicine technologies to develop manufactured lungs and kidneys.

At United Therapeutics, we always want multiple shots on goal. To that end, we recently acquired privately held Iviva Medical based out of Woburn, Massachusetts. Iviva's core technology is an engineered kidney implant that mimics native kidney elements with a simple architecture to achieve implantable, durable blood purification, much like a native kidney. Iviva's kidney is seeded with the patient's own cells, eliminating the need for immunosuppression.

Also, earlier this week, we announced an agreement to acquire publicly traded MiroMatrix Medical, a company focused on ending the waiting list for organ transplantation. MiroMatrix utilizes an organ manufacturing platform that consists of decellularized porcine organs that are then recellularized with cells derived from nontransplantable donor human organs. These organ constructs are intended to replace some of the functionality of human organs using standard organ transplantation techniques and immunosuppression regimens.

Miro Matrix has 3 key programs that would broaden our existing manufactured organ pipeline. MiroliverELAP, which is ex vivo or outside the body and intended to provide temporary external liver dialysis for acute liver failure. Mirokidney, a fully implanted kidney, and Miroliver, a fully implantable liver.

Moving to Xenotransplantation. We continue to work with the FDA on a clinical path forward. We're underway with what we call pivotal preclinical studies in baboons at the request of the FDA. Specifically, for our 10-gene program, we expect the last preclinical xenokidney transplant to occur in early 2024. After collecting the data, we'll meet with the FDA to discuss the IND and clinical protocol for human studies for our 10-gene xeno-organs.

In parallel with the pivotal preclinical studies, we're wrapping up construction of our clinical stage Designated Pathogen Free facility, or DPF, in Virginia. We expect the facility to begin receiving pigs in early 2024 and for the facility to grow its population through the balance of 2024 in preparation for clinical studies in humans for both xenokidneys and xenohearts.

Behind our xenotransplantation programs, our manufactured lungs now in large mammal testing by our North Carolina-based regenerative medicine team. And behind that, our 3D printed autologous lungs by our New Hampshire-based organ manufacturing group using technologies from our partner, 3D Systems. We look forward to sharing more detail on these programs as they progress towards clinical studies.

I'm thrilled that we're in such a great position at United Therapeutics. We have a solid commercial business posting record results with continued strong growth ahead, a pipeline of novel therapies that could again double our revenues by the end of the decade. And on top of all of that, we have a long-term plan to address one of the largest critical unmet medical needs while helping our patients, employers and the employees and shareholders all succeed.

I'll now turn the call over to our President, Michael Benkowitz, who will give an overview of our commercial performance and progress for our near-term goal of a $4 billion annual revenue run rate by mid-decade. Mike?

[Michael Benkowitz, executive]

Thanks, Martine, and good morning, everyone. As Martine noted, today, we reported our highest revenue quarter ever at $609 million, up 18% from the third quarter of 2022. We saw meaningful growth for each of the Tyvaso franchise, Remodulin, Orenitram, and Unituxin.

With respect to Orenitram, we saw revenue of $92 million during the quarter, which was up 5% from the prior year. This growth reflects increases to both patient growth and average dose. In the third quarter, following the publication of 2 peer-reviewed manuscripts, we are also able to commence education efforts by our field-based teams on the EXPEDITE protocol which is based on our rapid Remodulin titration and transition to Orenitram study, allowing patients to get to higher doses of Orenitram quicker and with less side effects than starting Orenitram de novo.

Remodulin revenue of $131 million was up 15% from last year, reflecting both U.S. patient growth from the third quarter of 2022 as well as an increase in international sales from the same period last year. Patients who use our Remunity Pump now make up more than 50% of subcutaneous Remodulin patients in the U.S. compared to under 10% at the same period just last year. Remodulin continues to be the #1 prescribed parenteral therapy for PAH in the U.S.

Moving to Unituxin. We saw revenue of $51 million, which was up 11% from the prior year quarter. This growth was driven by an increase in U.S. sales and includes a modest inventory build at our U.S. distributor.

Finally, Tyvaso. We saw revenue of $326 million for Tyvaso DPI and nebulized Tyvaso combined, which was up 26% from the prior year quarter and was the highest Tyvaso revenue quarter ever. This growth was principally driven by new patients on therapy. This performance reflects the rapid uptake of Tyvaso DPI among physicians and patients, as well as continued expansion into the PH-ILD market. We saw the highest number of referrals and patient starts for the combined Tyvaso business during the quarter. I'm proud to report that Tyvaso is now the #1 prescribed prostacyclin treatment in the U.S. and remains the only approved therapy for PH-ILD.

Regarding Tyvaso DPI inventory, the first phase of process improvements and new equipment at our partner MannKind that went online in June has meaningfully helped to expand the supply of Tyvaso DPI. These enhancements, coupled with a further expansion that will come online next year, have us well positioned to provide ample supply of Tyvaso DPI moving forward.

We're now working to drive growth in PH-ILD, where Tyvaso remains the only approved product, as I mentioned before. We have been increasing the size of our field-based teams over the last 12 months, adding medical science liaisons, regional nurse specialists and, more recently, sales representatives and reimbursement specialists to our team. With this expansion, we're able to both reach more prescribers and, importantly, focus on driving depth within these prescribers.

And we've already made great progress. On the last earnings call, I mentioned that we've more than doubled the number of Tyvaso prescribers since the PH-ILD approval in 2021, and maintain depth, defined as 3 or more patients per prescriber, at about 40% of these prescribers. Peeling that back a little bit, about 50% of the growth in those total prescribers are true ILD prescribers, which means we're now starting to see these physicians begin to treat the disease rather than refer these patients into the PAH clinics. Depth within our true ILD treaters is also coming along nicely with about 20% of those prescribers having 3 or more patients on Tyvaso.

Our recent sales force expansion will allow us to continue to lean into the ILD physicians, particularly in the community setting. While Tyvaso DPI has been a tremendous -- has been a source of tremendous growth since we launched it last year, we continue to appreciate the value of nebulized Tyvaso in our portfolio. Some physicians and patients continue to prefer the nebulizer because of its profile or for reimbursement reasons.

In addition, we're aware that some pulmonologists prefer to start and titrate their PH-ILD patients using the nebulizer before switching to Tyvaso DPI. This allows more precise titration in 1 breadth increments compared to the 3 breath equivalent increments of Tyvaso DPI. We expect this platform strategy to become a competitive advantage over other potential DPI products should they reach the market.

Before we move to the Q&A, I want to take a moment to address some questions we've received around potential competition and reiterate our confidence that we're well positioned for growth in the near term with our current commercial portfolio. Questions have centered primarily around sotatercept and a potential inhaled treprostinil competitor.

First, with respect to sotatercept. It's important to note that it will not be indicated for PH-ILD if approved next year, and therefore, will not be a factor in the source of our most recent growth and expected near-term growth. In Group 1 PAH, where it will be indicated if approved, it appears this drug will be a nice addition to the PAH armamentarium. But based on the clinical data and our experience with new agents entering the space, it will be an addition, not a replacement, for existing therapies. And therefore, we remain extremely confident in the durability of our PAH business.

Targeting multiple pathogenic pathways is considered the current standard of care for PAH. This mirrors therapy for other serious conditions that result from multiple pathways of pathogenesis like cancers, heart failure and some viral infections. In fact, sotatercept was studied only in combination with other PAH products, including 70% of patients on concomitant prostacyclins or prostacyclin analogs, including our treprostinil products.

We believe the convenience of Tyvaso DPI allows physicians to easily, relatively speaking, cover the prostacyclin pathway for those patients not already on a prostacyclin. And if the addition of sotatercept helps patients live longer, that's phenomenal for the patients, of course, and likewise, benefits us from a revenue standpoint because patients will be on our medicines longer.

Moving to the other inhaled treprostinil that could reach the market. We believe we have a preferred product with Tyvaso DPI. Tyvaso DPI demonstrated 98% patient satisfaction in the pre-study and has now been prescribed to more than 4,000 patients, a clear demonstration of patient physician interest and our DPI format.

Tyvaso DPI is differentiated from its potential competitor because of its simple, easy-to-use inhaler that patients just open load and inhale with only 1 breath per cartridge 4 times a day. Tyvaso DPI's low-flow profile also facilitates treprostinil delivery deep and consistently into the lungs with generally only tidal breathing required to actuate a dose. On top of that, the Tyvaso DPI inhalation device requires no cleaning and patients can hold the inhaler in an actual position when using the device.

So to wrap up, we're extremely proud of our record performance this quarter, and we think we're in the early stages of sustainable growth for our current commercial portfolio as we continue to make inroads with PH-ILD prescribers and our base business in PAH will continue to be appreciated by prescribers and patients alike.

So with that, Martine, I'll turn it back over to you for the Q&A.

[Martine Rothblatt, executive]

Thanks, Mike. I hope everyone can tell that United Therapeutics is a truly compelling investment with a strong cash-generating commercial business supporting novel R&D efforts in rare lung disease, coupled with the revolutionary potential for our organ manufacturing programs. Operator, let's start the Q&A session.

[Operator]

[Operator Instructions] Today's first question comes from Terence Flynn with Morgan Stanley.

[Terence Flynn, analyst]

Great. Congrats on all the progress. I was just wondering, maybe it's a question for Mike, if you can offer any perspective on Tyvaso net adds in the quarter, if that's been pretty consistent at that 500 patient level. And then are you able to tell us where inventory levels shook out for the quarter? Like was -- did the quarter include a significant build? Or was this all demand driven? Thank you, on Tyvaso specifically.

[Martine Rothblatt, executive]

Thank you, Terence. Mike?

[Michael Benkowitz, executive]

Sure. Yes. So the net adds continue to kind of clip along at kind of that roughly 500, sometimes a little higher, sometimes a little lower, but kind of in that range per quarter. So we're really happy with that, that continued progress. And as I said in the third quarter, we saw a record number of prescriptions and starts. And so just continue to kind of pull that through and keep those patients on therapy. So we're pleased with the progress on that front.

From an inventory standpoint and the revenue numbers, not -- I think what you can infer from the revenue numbers is that the revenues number -- revenue numbers reflect underlying patient demand. So there wasn't really a significant inventory build in the quarter. And as I said, with the enhancements that we've seen at MannKind since June, we think we're, plus what's coming next year, we're really well positioned from an inventory standpoint going forward.

[Martine Rothblatt, executive]

Thank you very much, Mike. Operator, next question please?

[Operator]

Absolutely. Our next question comes from Hartaj Singh with Oppenheimer.

[Hartaj Singh, analyst]

Great. Thank you for the question, and really nice quarter. Just maybe a little bit of a different tack, which is that you had really nice revenues across the board, especially Tyvaso, but you're really holding your OpEx pretty firm and staying to that algorithm that James has talked about previously. Your operating margin just seems to keep on getting better. Can you just talk a little bit about that progression? And do you expect that to keep getting better as your PAH franchise becomes even more profitable?

[Martine Rothblatt, executive]

Thank you very much, Hartaj. James Edgemond is our Chief Financial Officer. So James, could you please answer that question?

[James Edgemond, executive]

Yes. Thanks, Martine. Thank you for the question. As a reminder, and you alluded to this in your question, we still and will apply that budget algorithm where we will spend no more on cash operating budgets in 2023, for example, that exceeds 50% of prior year revenue. So our budget algorithm this year and continuing forward, we expect to apply.

With respect to your question on the operating margin, specifically, in an environment of continued revenue growth, which we've demonstrated, you will have improving operating margins over time. But remember, that can bounce around quarter-to-quarter because we typically look at our budgets and our budget spends on an annual basis. And those expenses could be impacted by clinical trial enrollment and the timing around that, for example.

But from a fiduciary and kind of fiduciary responsibility perspective, we do want to continue and we will expect to continue to apply the budget algorithm, be good financial stewards of the expenses. And as you heard, Michael, talk about in a very successful quarter and growing revenue when you think about some of the investments that Michael has made as well. So thank you very much. And Martine, back to you.

[Martine Rothblatt, executive]

Thank you, James. Thank you, Hartaj. Operator, next question please.

[Operator]

Our next question comes from Joseph Thome with TD Cowen.

[Joseph Thome, analyst]

Obviously, a lot of progress on the organ side of the business this quarter. When we think about the Xeno kidney, the Miro kidney and the Iviva kidney implant, should we think of these largely as sort of 3 shots on goal in kidney transplant? Or are there discrete populations that could benefit from each of these products? How do you view that?

[Martine Rothblatt, executive]

Thank you, Joe. I think the answer is all of the above, both of the above to be specific. Definitely, positively, there are multiple shots on goal. But there is a large diversity of different types of manifestation of end-stage organ disease generally and specifically within kidney disease. So I could very much see products from one of the other groups, whether it's a Xeno kidney, or Autologous Iviva kidney or a allogeneically cellularized with primary cells. Miro kidney going to different end-stage kidney disease patient populations.

As you know, Joe, there are more than 0.5 million people just in the United States on dialysis. So the level of demand is really off the charts, and we're confident that each of these kidney technologies and our other organ technologies we'll find very, very receptive physicians and patient populations for their use. Thanks for the question, Joe. Operator, next question please.

[Operator]

Absolutely. Our next question comes from Eun Yang with Jefferies.

[Eun Yang, analyst]

So you recently started another Phase III TETON study for progressive pulmonary fibrosis. I'm just wondering why you are not using the DPI formulation in the trial. And once it's approved, do you think you may not need a bridging study to DPI from the nebulizer similar to PH-ILD?

[Martine Rothblatt, executive]

Very good question. I'd like to ask the clinical trial executive responsible for that study, Dr. Leigh Peterson, if she could please answer your question.

[Leigh Peterson, executive]

Yes, sure. Thanks for the question. Regarding why we're not using the DPI. We want to use the nebulizer to remove as many variables as possible between the studies. So between the INCREASE study and TETON 1, TETON 2 and TETON PPF, so we're sticking with the same delivery device for those. And yes, we'll definitely seek approval for the DPI once we see the results of these studies with a nebulizer. It's -- we're still having ongoing conversations with FDA to determine what will be required for that approval.

[Martine Rothblatt, executive]

Thank you very much, Dr. Peterson. Thank you very much, Eun, for your question. Operator, next question please.

[Operator]

Our next question today comes from Jessica Fye with JPMorgan.

[Jessica Fye, analyst]

Question on Tyvaso. So recognizing that titration dynamic you mentioned, which could suggest that the mix of the new starts between DPI and nebulized Tyvaso understates the longer-term proportion who might end up on DPI. Can you talk about what you're seeing as the mix among new starts as well as your latest expectations for the longer-term mix of Tyvaso DPI and nebulized Tyvaso within the franchise?

[Martine Rothblatt, executive]

Thank you very much, Jess. Mike, would you be able to give some color on that question, please?

[Michael Benkowitz, executive]

Sure. Happy to. So, Jess, with respect to -- sorry, with respect to the mix between the nebulizer and the DPI. I think we said for the last couple of quarters that it's been kind of in the neighborhood of 2/3 DPI, 1/3 nebulizer. That continues to hold true. That's what we saw in the third quarter. That actually was a couple of points higher on the nebulizer in the third quarter than the prior quarters, but it's generally kind of in that kind of 2/3, 65% to 70% DPI. 30% to 35% nebulizer.

I kind of expect that it's going to stay there. It could tip up a little bit towards DPI after the first of the year when some of the new Medicare Part D redesign elements kick in under the IRA and patient out-of-pocket goes down. So to the extent that reimbursement challenges or a reason for using the nebulizer, that might tilt things a little bit more towards DPI. But I do -- as I said in my opening -- my opening comments, I continue to think that there's going to be a role for nebulizer. I think what we have learned over the 25 to 30 years that we've been in this space is that patients are very different, and some react better to one delivery device over another and vice versa. So we're just really happy that we have multiple options to offer patients. And at the end of the day, we're really -- we're kind of agnostic as to which device it is because, either way, the patients are benefiting from the United Therapeutics product.

[Martine Rothblatt, executive]

Thank you so much, Mike. And Jess, thank you for the question. We're at the end of the call, but we have time for just one last question. Operator, last question, please.

[Operator]

Our final question today comes from Ash Verma with UBS.

[Ashwani Verma, analyst]

Congrats on the quarter. Thanks for taking my question. So I have 2. On the manufacturing expansion for Tyvaso at your partner, MannKind, for the DPI, that was up 2.5x in June. Is that now allowing you to fulfill the minimum contractual levels at your distributors? Or would that level of supply only be fully enabled by the second production line that MannKind is building? That's first.

And I mean there's a lot of pipeline for Tyvaso, very excited about PPF, IPF. But just curious, the time lines for enrolling these studies are a little bit protracted. Is that primarily because of the heterogeneity of the disease? Or just curious if there is any other factor playing in that.

[Martine Rothblatt, executive]

Okay, Ash, thanks for that question or that compound question. So let's have the first part of your question relating to manufacturing be answered by our Executive Vice President for Technical Operations, Pat Poisson. And when he's done answering the first part of your question, the second part of your question relating to the time lines for enrollment in the pulmonary fibrosis study, that one will be answered by Dr. Leigh Peterson. Pat, can you go first?

[Patrick Poisson, executive]

Sure. Thanks, Martine, and thanks for the question. So the process improvements we implemented earlier this year will fulfill demand both near and midterm or Tyvaso DPI. Longer term, as we see growth in ILD, we'll certainly need the new equipment that is coming online in the first half of 2024. So as of right now, we're able to fulfill demand and maintain inventory levels at the [ SPs ]. And we'll be able to do so until the new equipment comes online. And then we'll be well prepared for the future.

[Martine Rothblatt, executive]

Thank you, Pat. Dr. Peterson?

[Leigh Peterson, executive]

Yes. So thanks for the question on our TETON program. We actually haven't increased our time line -- I mean we're still on target to finish enrollment of the TETON studies at the end of 2024. But you're right, we have increased the sample size. And we're now targeting the enrollment of the 576 patients in each study.

And the reason for that is, you're exactly right, you mentioned the variability of the disease. And we do routine blinded data looks, and that is what we saw. There was some basically standard deviations of the FVC and the completers, prompted us to just out of caution to increase the sample size to increase the chance of success. But again, just because of the pace of enrollment into these studies, which is fairly rapid, we haven't increased our overall time line to enroll those additional patients.

[Martine Rothblatt, executive]

Thank you so much, Dr. Peterson. Ash, thank you so much for the question.

In conclusion, as mentioned earlier, we're really happy to be in such a great position here at United Therapeutics. We have a solid commercial business, posting record results with continued strong growth ahead. We have a pipeline of novel therapies that could again double our revenue by the end of the decade. And we have a long-term plan to address one of the largest critical unmet medical needs. All of the above while helping our patients, employees and shareholders succeed.

Operator, you may now terminate the call.

[Operator]

Thank you for participating in today's United Therapeutics Corporation Earnings Webcast. A rebroadcast of this webcast will be available for replay for 1 week by visiting the Events and Presentations section of the United Therapeutics Investor Relations website at ir.unither.com. You may now disconnect your lines, and have a wonderful day.