Ladies and gentlemen, thank you for standing by and welcome to the BioMarin Pharmaceuticals fourth quarter and full year 2024 conference call. All lines have been placed on mute to prevent any background noise. After the speakers’ remarks, there will be a question-and-answer session. [Operator Instructions] As a reminder, today's call is being recorded. I will now hand today's call over to Traci McCarty, Group Vice President, Investor Relations. Please go ahead.

Thank you operator. To remind you, this non-confidential presentation contains forward-looking statements about the business prospects of BioMarin Pharmaceutical Inc., including expectations regarding BioMarin's financial performance, commercial products and potential future products in different areas of therapeutic research and development. Results may differ materially depending on the progress of BioMarin's product programs, actions of regulatory authorities, availability of capital, future actions in the pharmaceutical market and developments by competitors and those factors detailed in BioMarin's filings with the Securities and Exchange Commission, such as 10-Q, 10-K and 8-K reports. In addition, we will use non-GAAP financial measures as defined in Regulation G during the call state. These non-GAAP measures should not be considered in isolation from, as substitutes for or superior to financial measures prepared in accordance with U.S. GAAP, and you can find the related reconciliations to U.S. GAAP in the earnings release and earnings presentation, both of which are available in the Investor Relations section of our website. Please note that our commentary on today's call will focus on non-GAAP financial measures unless otherwise indicated. On the call from BioMarin management today are Alexander Hardy, President and Chief Executive Officer; Brian Mueller, Chief Financial Officer; Cristin Hubbard, Chief Commercial Officer; and Greg Friberg, Chief R&D Officer. I will now turn the call over to BioMarin's President and CEO, Alexander Hardy.

Thank you, Traci, and good afternoon, everyone. Thank you for joining us today for our fourth quarter 2024 results update. We are pleased to see BioMarin's new strategic vision, starting to be realized, amplifying our financial performance and creating value for shareholders, and most importantly, making a profound impact on the patients we serve. The specific initiatives introduced throughout 2024 include the prioritization of our most promising pipeline candidates, a reorganization of BioMarin's operating model now centered around business units and the ongoing realization of the $500 million cost transformation program. In mind, these initiatives give us a framework to achieve our ambitious need and long-term growth outlook, we are already producing positive results. Starting with our financial performance. 2024 was a year of record growth and profitability. We are pleased to share that full year 2024 exceeded market expectations across our guided items. Year-over-year, top line grew 18%. Non-GAAP operating margin expanded over 900 basis points, and non-GAAP diluted earnings per share increased 69%. This financial strength puts us on the path to double-digit revenue growth in 2025 and enables our ongoing reinvestment in further innovation and growth. Our confidence is supported by BioMarin's increasingly profitable commercial portfolio. Leadership across skeletal conditions is anchored to global expansion of VOXZOGO for achondroplasia which grew 56% year-over-year with plans to expand into hypochondroplasia 2027, as well as four additional skeletal conditions should data be supportive. Strengthened from our enzyme therapies, growing at 9% in the fourth quarter year-over-year and now approaching $2 billion annual revenues gives us confidence in our long-term outlook high single-digit CAGR on this business unit. The strategic prioritization of our pipeline last year resulted in the advancement BMN 351 for Duchenne muscular dystrophy, BMN 333 a long-acting CNP, two candidates that may provide highly differentiated treatment options for the conditions they address. We look forward to early clinical data results later this year for both candidates. For the year, we plan to share results from our Phase III study with PALYNZIQ for adolescents. This potential age expansion represents an opportunity to provide 12- to 17-year olds significant and sustained fee response as well as unrestricted diet, should data be supportive. In summary, we are excited by the progress we're making at BioMarin. The strategic and operational decisions made last year, yielding tangible results and allowing us to make an even greater impact for our patients, our employees and our shareholders. Looking ahead in 2025, we expect to share clinical data from three of our advancing programs drive double-digit global revenue growth execute on our business development strategy, continue our journey towards delivering the mid and long term financial outlook provided at Investor Day last year. I would like to thank our employees around the world their contributions in 2024. We look forward to the progress we will make together in 2025. Thank you for your attention. I will now turn the call over to Brian to provide an overview of our financial highlights for the quarter.

Thank you, Alexander. Please refer to today's press release for detailed fourth quarter and full year 2024 results, including reconciliations of GAAP to non-GAAP financial measures. All 2024 results will be available in our upcoming Form 10-K, which we expect to file in the coming days. We are very pleased with BioMarin's execution in 2024, especially during a year of significant transformation. Full year total revenues grew 18% to $2.85 billion and set the stage for record results in 2025. Fourth quarter 2024 revenues increased 16% year-over-year to $747 million. Double-digit increases from VOXZOGO were a strong contributor to growth in the fourth quarter and full year. Also contributing to record results in 2024, the enzyme therapy business totaled over $1.9 billion for the full year, a 12% increase versus the full year 2023, with consistent growth across BioMarin's marketed brands. Moving to expenses. For the full year 2024, non-GAAP R&D expense was slightly higher compared to the full year 2023, primarily due to spending on development of VOXZOGO in five new indications offset by a reduction in spend for deprioritized program. In the fourth quarter of 2024, non-GAAP R&D expense was $159 million and lower compared to the same quarter in 2023 as the impact of discontinued programs was fully realized during the fourth quarter. We expect that R&D expense will increase in 2025, as we ramp up our BMN 351, BMN 333 and VOXZOGO indication expansion studies. For both the full year and fourth quarter of 2024, non-GAAP SG&A expense increased year-over-year, primarily due to a bad debt reserve, higher VOXZOGO commercialization expenses and costs associated with our ERP implementation, partially offset by lower ROCTAVIAN spending. Moving to profitability. We are pleased with the positive impact of BioMarin's strong revenue performance, coupled with the ongoing progress of our…

Thank you, Brian. The team delivered strong growth in 2024, led by the continued global expansion of VOXZOGO, increasing PALYNZIQ penetration and demand for enzyme replacement products, and we expect 2025 to build on this momentum. Record VOXZOGO results and 56% year-over-year growth for the full year were driven by strong demand globally, with a significant number of new patient starts in infants and young children. In the United States, the expanding prescriber base and strong demand from families with children in the zero to five-year old age cohort drove increased growth in 2024. Consistent with prior quarters, the majority of new patient starts in the U.S. were for infants and young children under five years of age. In international markets, we also saw significant VOXZOGO year-over-year growth throughout 2024. In deeply penetrated markets such as Germany, we focused on early diagnosis and treatment of the incident population. In markets with significant expansion potential, we are leveraging BioMarin's robust global footprint and commercial infrastructure to drive awareness and adoption in the eligible patient population. To provide insight into these global dynamics, today, we are providing the percentage of actual total VOXZOGO revenues split between the U.S. and the combined contributions from outside the U.S. or O-US. For full year 2024, VOXZOGO total revenue of $735 million, 24% was from the U.S. and 76% was from all countries outside of the U.S. For fourth quarter 2024 of VOXZOGO total revenue of $208 million, 26% was from the U.S. and 74% was from O-US. Now moving to expansion strategies in 2025. In the United States, we look forward to realizing the growth opportunity ahead and building on the momentum of our growing prescriber base and continued demand from families with infants and younger children based on VOXZOGO's proven safety and efficacy profile.…

Thank you, Cristin. We're making great progress across our pipeline. Starting with BMN 333, Recall that in non-human primates, we achieved sustained [free-CNP] (ph) exposures several fold higher than those demonstrated for other long-acting CNP agents. Our goal for BMN 333 is, therefore, to leverage this potential for greater exposure to deliver superior efficacy while maintaining an acceptable safety profile. As of today, our PK study in healthy volunteers is well underway, and we look forward to sharing top line data from the study in the second half of the year, with detailed data to be presented at a scientific congress in the first half of 2026. For BMN 351 and Duchenne's muscular dystrophy, our Phase I/II study is advancing with enrollment in dosing in the 9-milligram per kilogram cohort. As previously shared, six boys were treated at the 6-milligram per kilogram level, and we are eagerly awaiting the 25-week proof-of-concept biopsy data for this cohort, which we expect to present to the scientific congress in the second half of this year. We believe these 25-week data will give us a clear line of sight as to whether our target of 10% dystrophin levels, will be achievable at steady state in this 6-milligram per kilogram cohort. With VOXZOGO in additional skeletal conditions, we continue to advance our CANOPY clinical programs, our pivotal Phase III study in hypochondroplasia is rapidly recruiting, and we remain on track to complete enrollment to the treatment arms of the study in the first half of 2025. Pivotal data from that program will be available in 2026 and the potential approval could come in 2027, assuming the data are supportive. Our 2 Phase II CANOPY studies, one in idiopathic short stature and another encompassing Noonan syndrome, Turner syndrome and SHOX deficiency are screening and enrolling patients. Moving to PALYNZIQ. Our Phase III study in adolescents, aged 12 to 17 is on track for data readout to support U.S. and European supplemental filings in the second half of the year. Recall, PALYNZIQ works across all PKU phenotypes, delivering potent phenylalanine reduction and can even afford some patients the potential for an unrestricted diet. We believe that this filing for adolescents could allow for patients and their families to manage the challenge of PKU and dietary restrictions from an early age, thereby supporting a smoother transition to independent adult living. Finally, with BMN 349 and oral therapeutic for alpha-1 antitrypsin deficiency-associated liver disease, we are progressing well, having dosed the first cohort in the multiple ascending dose portion of the healthy volunteer study. Following last year's strategic prioritization of the pipeline, the R&D organization is really hitting its stride advancing our most high-impact candidates, and we look forward to keeping you updated on our progress in the coming quarters. Thank you for your continued support, and we now open the call to your questions. Operator?

[Operator Instructions] Your first question is from the line of Philip Nadeau with TD Cowen.

Good afternoon, thanks for taking our questions. We want to 0 in on the VOXZOGO guidance was certainly expected to be up $200 million year-over-year, that's healthy, but it is decelerating. Can you talk a bit more on where you expect that growth to come from? And particularly which territories and whether they are currently reimbursed or new reimbursement will be coming this year? And maybe more generally on the pushes and pulls on the guidance, what could cause performance to be better and what could cause it to fall short? Thanks.

Phil, this is Brian. Thanks for the question. I'll start and then ask Cristin to provide some more color. So in terms of the overall guide, you accurately pointed out that close to $200 million of absolute dollar growth. It's still strong growth. what we're observing here as VOXZOGO global revenue gets to scale at close to [$0.75 billion] (ph) that there's some large numbers at play here. VOXZOGO grew 56% in 2024, which was impressive but not sustainable on this increasing revenue base. Just a reminder that the multi-year compound annual growth rate that we are targeting for skeletal conditions through the long-term guidance in 2027 is greater than -- greater than 25%. And with growth of 56% last year, 25% as implied by VOXZOGO range that we provided today and continued growth in the what may be low 20% going forward, again, the growth rate will decrease over time as the base increases, we are on track for both the $4 billion and the 25% plus CAGR.

Yes, maybe I'll add to that. Thanks so much for the question, Phil. So to give you a sense of the geographies where much of the growth is coming from, I would say, I will call it, certainly the U.S. as our largest single market opportunity, and I will dig into a little bit of what we are doing there and to drive continued growth. We've also seen continued strong growth in our highly penetrated markets Germany being a clear standout that we saw in 2024 and anticipate well into 2025 and beyond. And in our international markets, we are seeing growth around the globe. One of the bigger drivers being Brazil, which again, will continue into 2025. So currently, we are in 47 geographies where we have commercialization efforts ongoing and expect to expand into over 60 by 2027. But to give you a little bit of a sense of the U.S. So as we had mentioned, that's currently about 25% of the revenue contribution, and we anticipate that contribution to grow, as we are putting a lot of energy and effort into it given that it is such a large market opportunity for us. So just as a reminder, in the U.S., there was a bit of delay in terms of the timing of when infants had access to drugs. So it was initially indicated for five years and older. And only in the end of 2023, did we get the expansion into the younger 0 to 5 population. So where we are really seeing a lot of growth coming out is in new patient starts in that 0 to 5 age cohort, which is really exciting because that's well in-line with the international consensus guidelines that have recently come out where really the goal for all three…

Your next question is from Jessica Fye with JPMorgan.

I was wondering if you could spend a little more time talking about your priorities for business development, for example, should we think of BioMarin as more focused on bringing in pipeline assets versus commercial assets to leverage your global footprint? And what's your appetite for clinical risk? And maybe just a quick follow-up. Anything you would call out quarter-over-quarter or year-over-year for the first quarter in the enzyme business, like any international ordering patterns to think about there? Thank you.

Brian, do you want to start with the last question, and then I'll handle the business development?

Yes, of course. Thanks for the question, Jess. I wouldn't point to specific known ordering patterns granted. We're just midway through the quarter here and as you know, our diversified global business, especially across the different enzyme therapy brands is subject to some of that large single payer bolus order pattern dynamic from time-to-time. So nothing specifically to point to there. But since you mentioned the quarters, I will point out as I mentioned in the prepared remarks, we do expect our growth in 2025 to be weighted to the second half of the year. So whether it be the enzyme therapies or VOXZOGO, we are just ramping up on the ambitious plan that Cristin just talked about for 2025 here in the first part of the year. So we expect our growth to be weighted to Q3 and Q4.

Thanks, Brian. Jess, thanks very much for the question. With regard to business development, yes, we're very excited about the role that business development completed to add to what is already a pretty compelling outlook over the coming years. Last year, as you know, was about setting the strategy for the company and clarifying where we wanted to play in terms of the business department space, making sure we've got the right business development team in place, the capabilities in place. And then obviously, the strong financial results are producing more strategic flexibility for us. And we're very excited about what we're seeing from a business development standpoint. The JPMorgan meeting, we had 155 meetings at JPMorgan. It is a reflection of the recognition of the strengths of BioMarin from a research, development, manufacturing, the commercialization and specifically on the commercialization and what we hear from potential partners is our ability to commercialize across the globe. And we are now in the process of looking at these various assets. You asked what stage these assets are at. We are looking at a range of stages, we're looking at preclinical assets and also clinical assets. Again, we expect to be able to strengthen our outlook for growth into the longer term.

Your next question is from the line of Salveen Richter with Goldman Sachs.

Hi, thanks for taking our question and congrats on the progress. This is [indiscernible] on for Salveen. Wondering if we can get your thoughts on the durability and safety of the growth hormone and CNP combo. Is this something that you may be interested in with 333. And just a follow-up on 333. For the data, could you just frame what you're looking for and help us understand any metrics to guide the translation here to AGV and later studies? Thank you.

This is Greg Friberg. Thank you, Salveen. Let me take the second question first. So I believe your question was about the PK study with 333 and what we're expecting to see. Again, that is a healthy volunteer study. So what we're hoping to see is purely PK in that regard. We'll be looking at the native species of BMN 333 as well as free CNP. And we're hoping to see several fold increases in terms of reaching sustained levels similar to the cynomolgus monkey model that we were referring to. We believe that several fold increases, whether it's an AUC or time above sustained threshold, that, that will give us a chance again, to try to recapitulate what we see in the animal models, which is a significantly greater growth dynamic in their long bones. With regard to the first question, can you just repeat the question for me? My apologies, I missed the nuance of the first question.

It's growth hormone.

With regard to the growth hormone combination, our goal is to develop a single agent [CNP drug] (ph) that delivers not only best-in-class growth for patients, but also the kind of convenience and safety that we think the market demands. In addition to the challenges of two high-priced therapies, we think that trying to optimize the agents that we have available to us or our goal. Certainly, as data evolves, we can -- again, as we always do reevaluate the strategy. But as of now, our goal is to have a single agent therapy that's both convenient and efficacious for patients with achondroplasia.

Your next question is from the line of Cory Kasimov with Evercore ISI.

Hi, good afternoon. Thanks for taking the question. Greg, maybe another one for you on the DMD program. I believe you've mentioned that steady-state dystrophin levels in treated patients are attained at about the one year mark. So when you mentioned this 10% goal. Is that your expectation for the week 25 biopsies? Or should they be somewhere below that? Thank you.

Yes. Thanks for the question, and it is an important point to make. We, of course -- we've picked a chemical backbone and on Morpholino backbone that has a slower in slower efficacy delivery. What that affords us is the opportunity again to open a therapeutic window, which has been challenging the space. We also engineered the molecule again to have some other factors we think will cause significantly higher dystrophin expression once we reach studies. The week 25 data will give us a line of sight. That's the word I would use for that. We have a very clear model of what success looks like. And that is something that again, we think that once we have data from multiple time points at the 25-week moment that we'll be able to have a pretty clear idea of what we are going to be seeing out of the year. Of course, we would ultimately want to demonstrate that with actual data. But the 25-week time point is going to give us a very solid read on our model of where we are headed and whether we're able to reach that. I'll just add that there's one other nuance here. which is we are talking about the 6-milligram per kilogram dose level, and we are going up in the dose as well. So we are in a 9-milligram cohort right now. And again, there are opportunities potentially to go higher. This is a field where of course, we want the lowest efficacious dose to be the one that we bring forward. And we're hopeful, again, that 6 milligrams is going to be able to give us a very clear indication of whether we are on that track for 10% or not.

Your next question is from the line of Christopher Raymond with Piper Sandler.

Two questions. Just on the ERT business. You guys have, I think, for some time now talked about being able to select sort of the demand higher on harmonizing diagnostic protocols, I think, across all geographies. I know this print was helped along by some government buy-ins and I heard you, Brian, on your commentary on '25 being sort of back-end loaded in terms of growth. But any sort of color you can give as to the mix of contribution from this diagnostic harmonization. Is this something that's where are we, I guess, in terms of maybe which inning in terms of being able to effect that change? And then on 351 data timing, maybe splitting errors a bit, but the press release says data second half, the slide say, mid-25. Is this -- are you indicating maybe you'll be top lining the data in mid-25 and then presenting the full data at a conference later? Any sort of color there would be would be great. Thanks.

Yes, this is Greg Friberg. Thanks. Just to clarify, it, of course, is the middle two quarters of the year. So again, you can read into that -- the both correct statements. We will be presenting it publicly in totality at a scientific congress in the early second half of the year.

And hi Chris, this is Cristin Hubbard. And to answer your question a little bit about the kind of the diagnostic component. So broadly speaking, when we think about a lot of the efforts that are being put out in our new BU model, in particular, across enzyme therapies, we are most certainly, in particular, for MPS and CLN2 really looking at various activities that we can run across different countries in the world. around really understanding what diagnostic tools we can put into certain countries and really help with the diagnosis of both MPS and CLN2. So we've seen great progress already. We are using both gene panels we're looking at Cascade screening, which is basically looking at a family tree and seeing if there's MPS or CLN2 in the Family Tree and ensuring that we are getting the right patients identified, so that we can then help start to get them on to therapy. And so we've done this very successfully, for instance, in Brazil and anticipate we will continue to push on these efforts and a select subgroup of countries where we know that this could be really meaningful. So that's certainly a part of the BU strategy. But I'd also like to talk a little bit about PKU because we are expecting a significant amount of growth coming out of PKU. As you saw with our year-over-year growth with PALYNZIQ alone, we put up 17% growth there and expect that to continue in double-digit growth into 2025. And at the end of the day, this was really driven by the efforts largely in the U.S. and Japan to help get new patients identified and then importantly, and keep them on therapy. So really have adherence programs that keep them on the right dose. And then importantly, finding patients that have discontinued so that they can restart. And so we are seeing great progress with this. And really, what we are hearing is that this is in large part because of the differentiated profile of PALYNZIQ that it works across all PKU phenotypes have the potential for normal fee levels and importantly, the potential for an unrestricted diet. So I think we've seen great progress there, and we'll expect it to continue.

Your next question is from the line of Gena Wang with Barclays.

Thank you for taking my questions. I want to ask one regarding the IP for your CNP franchise. I know you mentioned that you already started processing Europe. Maybe if you can provide some update there and also your strategy in the U.S.? And the second question is regarding the 349 AATD. Are you completed the [SAT] (ph) and also started MAT that end of last year. Maybe you can share with us what you are looking for regarding the data update.

Thanks very much, Gena, for your questions, Alexander. I'll handle the IP questions and then hand it over to Greg. So in essence, I mean, we stay -- as we said in January that we've initiated action against to send us in the unified app court in Munich. We have no further updates to provide on European IP action it's underway. It's in process. And we expect at the moment to receive a decision in the next 12 to 15 months. Should there be an update, we will, of course, provide that to you in due course. As regards to the United States, if and when we see conduct, that we believe infringes our intellectual property in the U.S. or elsewhere, we will take production time to defend against infringement. So those are the updates basically as we go, and we'll continue to keep us updated as this unfolds. But we're following through on our commitment to fund our intellectual property and our innovation. Over to you, Greg.

Yes. Thanks, Gena. I love talking about BMN 349, a molecule for those who aren't familiar for alpha-1 antitrypsin deficiency-related liver disease. So this is a small molecule. It will be titratable. It has the potential to bind to Z protein as it's created in patients who have alpha-1 antitrypsin deficiency. By doing so, it decreases that Z protein's ability to misfold and for polymers in the liver, which lead to fibrosis and ultimately, in some patients liver failure. The oral therapy is one that also -- because it's titratable and because it has about 100, 150-fold a differential between how it binds to the Z protein versus the native protein. It has the potential to be used in patients who are not just homozygous ZZ alpha-1 antitrypsin but heterozygous as well. And the implication here is, of course, we're running a healthy volunteer study, multiple ascending doses. The usual PK, of course along with safety profile will be looked at very closely from that. But there is a nuance in these protocols, where a handful of patients, both with the MZ, as well as the ZZ phenotypes -- excuse me, genotypes are going to potentially -- they are going to be able to be enrolled. And though, again these are limited duration studies we may get some insights into the pharmacodynamics of circulating Z protein and circulating Z polymers as well. So fingers crossed. That study is open for enrollment. Again, for the handful of patients, as well as for healthy volunteers right now. And we are plowing forward working with regulators around the globe also to clarify what the path forward, both for ZZ, as well as NZ genotypes would be for a molecule that can accomplish what I described.

Your next question is from the line of Paul Matteis with Stifel.

Hi. Thanks for taking our questions. This is Julian on for Paul. Just curious if you'd be able to share a little bit more color on what you learned from the two biopsies that you did in the DMD study. And since they were at a relatively early time point, just curious what were you looking for exactly in order to be confident in your assumptions and goals for this 10% dystrophin goal that you've laid out? Thank you.

Yes. Thank you, Julian. This is Greg Friberg, again. And I think you said it nicely. These were -- 2 biopsies done of the muscles of boys who have been treated at the 6-milligram per kilogram cohort for just 12 weeks, 12, 13 weeks. And so in that regard, if you have an S-shape curve in terms of what we would expect in terms of over time in protein expression, we were not at the steep part of the curve yet. So there is a limited amount that one can say mathematically, but I will tell you that directionally, we wanted to ask a couple of really key questions. One was whether or not our assumptions with the modeling would translate into humans. Are we able to get the drug into the muscle and our -- and we could quantify it as well? And the answer there was yes. The second question would be we are targeting a novel splice variant. Again, the goal here is to produce not microdystrophin, but near full-length dystrophin. And so from that standpoint, we were able to see that the gene product was being produced in the cells of these boys. And finally, of course, the end at least end of the biomarker story would be to measure that near full-length dystrophin. And we were able to measure that consistent with our models. And so in that regard, we are hopeful, again, that this 25-week data is going to be very helpful in giving us a line of sight for whether or not that 10% target is going to be achievable. I would say that pertinent negatives were taken off the table that had never been tested in humans before. And though it's just two patients and now it's early. That gives us a good line of sight that when we hit 25 weeks, this is going to be a useful information.

The next question is from the line of Akash Tewari with Jefferies.

Hi, thank you so much. Maybe just on BD, I mean, if you think about infigratinib, there is this kind of potential of an oral therapy that has similar if not better efficacy than VOXZOGO. And I think for a lot of investors, that's a big reason why they have difficulty modeling the terminal value on VOXZOGO. There are companies like Relay, which have assets that have the same mechanism as infigratinib, and I think they're looking for strategic options. What's the appetite for BioMarin to kind of have their own infigratinib -like approach in achondroplasia. Is your team very confident that CNP is the only way forward? Or is there a potential that you could be looking to in-license one of these assets? Thank you.

Thank you for the question, Akash. Our business development focus is really around genetically defined conditions. We're certainly interested in leadership positions that we're establishing in skeletal conditions and that we already have in enzyme therapies. So that is somewhat of an overlay to our business development activities. But we're very comfortable right now with our leadership position with the indications in development for VOXZOGO, which is really exciting in so much that CNP can reach those indications like ISS and Newtons and [Turners SHOX] (ph), which is not a possibility, as you know, for FGFR. And in these sorts of disease states, efficacy is very important, but so is safety and the profile of safety in CNP and treating from infancy is absolutely critical. And it's -- that's a hurdle, a high hurdle that any FGFR is going to have to establish and produce a significant amount of evidence to really, I think, reassure both physicians and caregivers. So it's a high bar. Right now, we are focused on CNP. We think that at the moment is the path to sustained leadership in skeletal conditions.

Your next question is from the line of Eli Merle with UBS.

Yeah. Thanks so much for taking the question. So for VOXZOGO, do you expect the mix of U.S. and ex U.S. revenues to remain stable or do you see the contribution from ex U.S. increasing over '25 and '26? And then in the U.S., I guess, what's the proportion of eligible patients with achondroplasia who are not currently treated. And I guess, for those patients, why do you think this is -- is it that the patients aren't currently under care by the right prescribers? Or do you expect less penetration in the older patients? I guess what do you see sort of longer term as the potential for uptake and penetration into this population? Thanks.

So thank you so much for the question. I think that first -- to the first question in terms of the contribution of the U.S. being at roughly 25% today, we definitely see that increasing over time. As you know, our overall portfolio, the contribution from ex U.S. is about two-thirds, it's split two-thirds and one-thirds in the U.S. And so we certainly anticipate the U.S. contribution increasing over time as we continue our growth trajectory in the United States specifically. Now in terms of your question around patients not treated, I mean I do want to come back to the fact that where we are seeing the bulk majority of new patient starts is in the 0 to 5 population today. That, of course, was not the case when we were first launched. We launched in the five-plus year-old cohort. And so of course, that was where the bulk of our patients were. So the rough split today, if you just look at how many patients are on treatment in the rough split, it skews more towards the 0 to 5, but that's a timing component. So really new patient starts were really targeting the youngest patients. And in terms of patients not treated the why. I mean I'd say that there's probably a myriad of reasons that we could conclude. Some of it would be awareness. Some of it would be knowing where the prescriber or the treater would actually be. They might be being treated in pediatric offices today. and that is precisely why we are really, really focused on ensuring that there is broad awareness of the treatment options, seeing that VOXZOGO was the first and the only treatment option for achondroplasia. So we want awareness and then comfort with the treaters and prescribers. We want them to be very comfortable using it, and that's precisely what we're working on, and that is why we're increasing our commercialization efforts in the United States to ensure that. I know, Greg, you might have something to add.

If I could just add as well. I mean, it is, of course, a complex decision that patients and their families go through with their physicians, whether to treat or not treat. What we are focused on in the R&D organization is continuing to provide data continuing to build on the data set that we have out there. Again, this is not just a story about one-year average growth velocity. We want to publish our 2, 3, 4-year data. We have over 6,000 years -- patient years of safety data at this point. And again, these are infants. So again, that means something to those treaters. And finally, this isn't just a story about AGV or even final adult height by itself. The story, of course, is all about the wellness and of these patients. And we've recently published our proportionality data at three years that's statistically significant compared to control, quality of life measures, we published these craniofacial Frame and Magnum. Again, you put all of this together, and then, of course, seeing the community evolve and seeing the guidelines, the independent guidelines that were published identify these patients start them as early as possible. We’re hoping that, that starts to tip the balance with the comfort level when the physicians are in the office with these infants and their parents making these decisions.

Your next question is from the line of Kostas Biliouris with BMO Capital Markets.

Hi, everyone. Thanks everyone for taking our question and congrats on the strong numbers. Great to see that three-fourth of VOXZOGO sales coming from ex U.S. Maybe one question follow-up on Akash's question on BP. In the [indiscernible] can address both the liver and the lung manifestation of the disease. And these approaches already have clinical validation, early clinical validitation. Given your interest in that space, would you consider different modalities to complement your pipeline modalities or you prefer to go only with one modality in that disease. Thank you.

I believe we were talking about the alpha-1 antitrypsin patients. And I'm sorry, it broke out a little bit and the disparity between liver and lung, does that?

I was asking about RNA editing approaches in alpha-1 efficiency and whether you would have interest in such approaches to complement your approach in your pipeline?

With regard to BMN 349, you are correct, it's focused on the liver. And again, the challenges of trying to solve both the lung and the liver problems we've seen across the industry. We've focused on a mechanism, again, that is liver-focused. Now presumably because of the difference between selectivity for M and Z protein, this would be a therapy that could be given in conjunction with enzyme replacement as well, which would address some of the lung challenges. As of this point, that's our approach from the R&D standpoint. And Alexander, anything that you want to add from a strategic.

I think you said it well.

Yeah. It's early days, and we're very hopeful, again, that we're going to have a differentiated mechanism of action that might work quite nicely in combination with other therapies like enzyme replacement potentially others.

Your next question is from the line of Mohit Bansal with Wells Fargo.

Hi. This is Sadia Rahman on for Mohit. Thanks for taking our question. Another question on DMC. So are there any biomarkers like slicing levels that would be presented this year that could help us understand how compared to other agents. And can you talk about how those biomarkers are tracking in that early data? And also your decision to go up to 9-mg per kg to initiate that cohort. Wondering if that was based on the analysis that you did on the 13-week data at 6-mgs? Yeah, thank you.

Yes. Thanks for the question. Let me take the second question first. The 9-milligram cohort was a planned step and there could be potentially another step as well. The trigger to open, that was simply one from the data monitoring committee. The independent DMC. And again, nice to know that they, again approved that, and that speaks to again, the safety and the benefit that they were seeing. Your other question was with regard to other biomarkers. We only look at the muscle biopsy in those patients at 13 weeks, and I've shared with you what we've looked at in those. Of course, how you measure full length dystrophin can be different. And we’ve seen that, again, whether you’re looking at normalized values, which assay. Suffice to say, we’re actually looking at multiple different assays for dystrophin levels, and we will be as transparent as possible when we present our data will want to make sure again that, that totality of the data is represented in addition to the clinical and PK data that’s available. So nothing else to share now, but we’re absolutely looking at a variety of not only biomarkers, but we are measuring functional levers in these patients as well. And our of course, ultimate hope is that we’re not just treating to increase dystrophin but to make these boys lives better and have them be more functional. So more to come, but nothing else to share at this point.

Your next question is from the line of Olivia Brayer with Cantor Fitzgerald.

Hi, good afternoon. Thank you for the question. How are you guys thinking about the level of growth that we might see from the enzyme business over these next couple of years? I know you talked about a high single-digit CAGR over the next or so years, but what about for '25, '26, '27. And then any comments around what the margin expansion could look like for that enzyme franchise? Just especially considering patients getting older and some of these medicines are wheat-based. Thank you.

Yes. Thanks, Olivia, for the question. This is Brian. I'll handle that one. So you commented on that high single-digit CAGR over the long term. That's also the goal for the midterm as well and part of what supports the $4 billion in 2027. There is going to be different dynamics based on the brand, any particular brand from year to year. I mentioned, for example, this year, NAGLAZYME had some of that additional buying in 2024, which flattens out the growth rate of it in 2025. Likewise, for ALDURAZYME, which BioMarin revenue is not based on their tile directly to end patient demand, but supply to Sanofi. Likewise, we expect that to be more flat than '25 over '24. But over these next couple of years, high single digit across that franchise is the goal. And within that, just a reminder Cristin touched on it earlier, the key driver is PALYNZIQ. We think we've got more market penetration to go there, healthy double-digit growth in PALYNZIQ and then continued sustained growth in the enzyme business. And you're exactly right, you said margin, but then kind of talked about kind of some of the individual patient dynamics. I'll touch on both. We don't disclose business unit operating margin and profitability at the business unit level, but I'll share that both of the primary business units are substantially profitable with healthy operating margins well above our consolidated global operating margin, which includes corporate costs and some unallocated R&D for the pipeline. So both franchises are generating substantial margin. And part of the sustainability and durability of that enzyme business is the patient dynamics. These patients are doing well. It is a weekly infusion for life, the enzyme therapies. And you mentioned the weight-based dosing. So that by means is part of the durability of that franchise.

Your next question is from the line of Alex Hammond with Wolfe Research.

Thanks for squeezing me in. Just quickly on VOXZOGO. Can you provide any color on the expected degree of switch market dynamics following potential competitor launches? And just a follow-up on that as well. Can you kind of dimensionalize how those dynamics may differ across geographies, as well as patient age groups?

Yes. So thank you very much for the question. So just to be very clear on our VOXZOGO numbers, I mean competition has always been modeled into any of the assumptions we put out there. And so I just want to make that clear. Not to mention, I think competitive landscape is not a bad thing. I think, honestly, like raising the awareness around this disease and the factors treatments around it is always a good thing. But to speak specifically about where we think we will continue our leadership position, in particular, in achondroplasia, I think that there is multiple dynamics here. You can talk about certainly the notion of the potential for switching from VOXZOGO to another compound should it become available? And we do believe that there's going to be some stickiness to being on VOXZOGO, so that it's almost kind of like a start-and-stay paradigm that we are really looking to achieve. We know that what we hear in the real world in new market research is that when patients and caregivers and their HCPs are seeing a positive experience the barrier to switch becomes much higher because it's a trusted compound. You know what's working in that patient and so switching that adds an element of risk that some will not choose to take. Not to mention, this is VOXZOGO is a very trusted. It will -- it's a very trusted compound at this point in time. We have over 6,000 patient years of safety and efficacy data that is growing, and we're building on that body of evidence that goes well beyond hype, but really talking about the overall health of these patients. Not to mention just thinking of the experience, we have a high compliance rate. So we see, on average, about 95% compliance rates across the globe, that is both in the U.S. as well as outside the U.S., which is really important that we continue to build on that and that we leverage that. Now thinking -- I've talked a lot about what's happening in the U.S., but to remind you, 68% of the total addressable patient population lives outside of the U.S. And so these markets where we have an entrenched global footprint and a lot of experience in understanding the local dynamics in those markets. This is an area where we really think that BioMarin has a strategic advantage in so much as we have this global footprint where we know a lot of those patients are going to be. So we really do see a lot of stickiness to our business over time, both in the United States, as well as ex-U.S., and we really look forward to building on this leadership position.

Thank you. This does conclude today's Q&A portion of today's call. This also comes to the conclusion of today's presentation. We thank you for joining. I would now hand today's call over to the CEO for any closing remarks.

Thank you, operator, and thank you all for joining us today, and thank you for your interest in BioMarin. As you've heard, the strategic and operational decisions that made last year and yielding tangible results and enabling ongoing investment in innovation and growth to make even greater impact with our stakeholders. We expect continued high performance as we benefit from BioMarin's revamped corporate strategy and operating model in 2025 and beyond and look forward to keeping you all apprised of our progress. Thank you so much, and have a great day.

This concludes today's call. Thank you for joining. You may now disconnect your lines.