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RedHill Biopharma Ltd. (RDHL)

Q3 2021 Earnings Call· Tue, Nov 30, 2021

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Transcript

Operator

Operator

Good day and thank you for standing by. Welcome to the RedHill Biopharma's Third Quarter 2021 Results Financial Conference Call. [Operator Instructions] At this time, I would like to introduce to the conference call RedHill's CEO, Dror Ben-Asher; Micha Ben-Chorin, Chief Financial Officer; Gilead Raday, Chief Operating Officer; Guy Goldberg, Chief Business Officer; Adi Frish, Chief Corporate and Business Development Officer; Rob Jackson, Senior Vice President, Sales and Marketing; Bob Gilkin, Senior VP, Market Access and Trade Relations; and Dr. June Almenoff, Chief Medical Officer. Before we begin, we will read from the RedHill's Safe Harbor statement. Please go ahead.

Alexandra Okmian

Analyst

Thank you, Brian. This conference call may contain projections or other forward-looking statements regarding future events or the future performance of RedHill, including statements with respect to the business promotion and other efforts related to RedHill's commercialization activities and the initiation, timing, progress and results of RedHill's research, manufacturing, preclinical studies, clinical trials, marketing applications and approvals, if any, including the clinical trials of opaganib and RHB-107 for the treatment of COVID-19. These statements are only predictions and RedHill cannot guarantee that they will, in fact, occur. RedHill does not assume any obligation to update that information. Actual events, performance, timing, results, or commercialization activities may differ materially from what RedHill projects today. Additional information concerning factors that could cause actual events, performance, timing, results, or commercialization activities to materially differ from those contained in the forward-looking statements can be found in the company's annual report on Form 20-F filed with the SEC on March 18th, 2021 and in its other filings with the Securities and Exchange Commission.

Dror Ben-Asher

Analyst

Thank you, Alexandra. Good day everyone and thank you for joining our third quarter earnings call. Today, we'll be presenting detailed R&D, commercial, and financial highlights. In light of the recent emergence of the Omicron variant and the risk presented by future variants of concern, we will elaborate on RedHill's strategy with opaganib and RHB-107 and our increasingly irrelevant mechanisms of action potential against the emerging variants. Our U.S. commercial business continues to drive growth, reiterating a second consecutive quarter in net revenue record of $21.6 million despite continuously challenging pandemic environments. Talicia generated another record quarter with 15% growth in new prescriptions, while Movantik continues to perform, adding a 1.1% increase to new prescriptions. Both products are also continuing to make strides in gaining both commercial and government formulary coverage. Rob Jackson, who is heading out Marketing and Sales will further elaborate shortly. Turning to R&D, given the recent emergence of the heavily mutated Omicron or South African variant, as well as likely emergence of other variants of concern over time, the importance of drug candidates that are independently of the viral spike protein is growing. This makes both opaganib and RHB-107 host targeted mechanism of action and expected maintenance of effects against new variants, increasingly more relevant in the battle against COVID-19. The third quarter saw significant focus on completing opaganib's global Phase 2/3 COVID-19 study in hospitalized patients. Specifically in the currently underserved hospitalized moderately severe patient group, which the Pfizer and Merck do not address. A sub-population comprising more than 50% of our total study population, opaganib demonstrated a 62% reduction in mortality, as well as improved return to room air and area hospital discharge. This is consistent with what we have seen in our Phase 2 study and compassionate use experience. The consistency across multiple…

Guy Goldberg

Analyst

Thank you, Dror. As we near the end of the year, RedHill is at a very important point. I will start with the bottom of the side, focusing on RedHill's pandemic program with Omicron and the potential for future variants dominating the attention of public health officials, what they have been saying loud and clear is that a simple, scalable, effective, and safe therapeutic is desperately needed. As we all know, the hope that vaccines alone will get us out of this pandemic will most likely not become reality. RedHill is uniquely positioned to make a difference with its two oral COVID vaccine -- sorry two oral COVID therapeutic candidates. First, opaganib, our novel orally administered first-in-class SK2 inhibitor addressing the moderately severe in-patient hospitalized population. With its method of action targeting the host cell rather than working on the virus directly, which we believe we can cast a wider that of efficacy against emerging variants such as the Omicron variant. We have conducted two clinical studies, a Phase 2 and a Phase 2b study in hospitalized COVID patients, both demonstrating the potential of opaganib and Gilead will provide more detail of the Phase2/3 study that is the focus of our submissions in several countries around the world. These submissions open up a potentially milestone-rich upcoming few months as we get feedback from these regulatory agencies as far as next steps. Gilead will also provide important new updates later in the presentation of the timelines for regulatory feedback as well as new biomarker data and support that are post-hoc analysis as identified the correct target population for opaganib. Second, we have RHB-107 or upamostat, an orally-administered inhibitor, a best one family of trypsin-like serine protease, being developed as a treatment for non-hospitalized COVID patients. upamostat has demonstrated protein inhibition of…

Gilead Raday

Analyst

Thank you, Guy. In the following slides, I will provide an overview of our advanced COVID-19 programs, specifically with respect to the promise for addressing the Omicron variant and the growing concerns due to potential emergence of resistance to current vaccines and antibodies. I will also provide further data and analyses from the global Phase 2/3 study, some of which has not been shared before, which bolster our previous reporting of an apparent meaningful benefit of opaganib to the survival of moderately severe hospitalized COVID-19 patient. As a reminder, opaganib is an oral pill, which is a first-in-class proprietary selective sphingosine kinase-2 inhibitor. Through inhibiting this host factor enzyme, opaganib exerts a dual action against COVID-19, inhibiting viral replication on the one hand and reducing the body's excess immune response to the infection on the other hand. Preclinical efficacy has been demonstrated in numerous anti-inflammatory and anti-viral models, including demonstrating the blocking of SARS CoV-2 viral replication across several variants in human bronchial tissue. Multiple Phase 2 studies and compassionate use in COVID and non-COVID indications have shown promising signals of activity and safety in hospitalized patients. The recently completed global Phase 2/3 study in COVID-19 show opaganib's apparent benefit to the survival of hospitalized COVID-19 patients in moderately severe condition. These are patients with COVID-19 pneumonia, who require supplemental oxygen of up to 60% fraction of inspired oxygen, or FIO2 in short. These patients represent a large underserved COVID-19 patient population, which the Pfizer and Merck pills do not address. The hospitalized patient population that opaganib benefited in the study was far more advanced in disease progression than the early stage outpatients which participated in the Pfizer and Merck studies. opaganib benefited a population of hospitalized patients in moderately severe condition, with a median of 11 days from the…

Guy Goldberg

Analyst

Thanks Gilead. So, we'll start with RHB-204. RHB-204 is a novel combination therapy of three antibiotic drugs that are active against non-tuberculous mycobacteria infection or NTM disease. We're currently in a Phase 3 study as a first-line therapy. This is important and its value-driving study because NTM is a difficult to treat infection with no FDA approved first-line standard-of-cure treatment. In addition, this is an orphan disease with an estimated 110,000 pulmonary NTM patients in the United States. RHB-204 has been granted orphan drug designation, qualified infectious disease product designation and Fast-Track designation. With these designations, it is eligible for priority review of the NDA and 12 years of market exclusivity. This slide shows the study design. We are testing RHB-204 as a potential first-line standalone oral therapy. The randomized placebo controlled Phase 3 study is planned to enroll 125 subjects. The key study endpoints of sputum culture conversion and patient reported critical outcomes will be evaluated but six with longer term follow up including the post treatment benefits of conversion. An important recent change is that we added an interim sample size we estimate at approximately 50% enrollment. In addition to accelerate recruitment, we're planning to expand the study to additional territories outside the United States, including the U.K. and Japan. I will now provide an updated RHB-104, our innovative treatment for Crohn's disease. As Dror mentioned, based on recent published research, potential progress in Mycobacterium avium paratuberculosis or MAP, diagnostic technology may enable us to advance the program towards a confirmatory study and Mathcad positive, moderate severe Crohn's patients subject, of course, to required regulatory input. As a reminder about this program, there is growing evidence that intracellular mycobacteria play a crucial role in Crohn's disease. Investigators have specifically identified MAP as the putative cause of the disease.…

Rob Jackson

Analyst

Thank you, Guy and good morning. Over the next few minutes, I'm going to summarize the excellent progress we made during the third quarter in our sales, marketing, and market access activities, so that you can understand how we've developed our business and why we feel increasingly confident about the fourth quarter and 2022. In the third quarter, RedHill achieved record quarterly prescription volume for Talicia despite the continuously challenging pandemic environment. Talicia prescription volume grew by 117% over Q3 2020 and by 15%, a five-point improvement over the second quarter growth rate of 10% Simultaneously, we added growth of Movantik over second quarter of 2021. RedHill continues to maintain clear market leadership of the PAMORA class and we are confident in our ability to capitalize on an improving selling environment during the fourth quarter. In the second quarter, RedHill grew Movantik volume by 5.6% over first quarter of 2021 and we added an additional 1% growth in third quarter. We achieve this by taking a disciplined approach to focusing on the pain segment. In tandem, we're also executing marketing strategies that focus on growing the PAMORA market. This is a key objective of Movantik as the established market leader. We've invested heavily in digital marketing tactics to first raise opioid-induced constipation awareness with patients and prescribers and secondly, to educate these potential customers about how Movantik can help provide relief from the symptoms of OIC. During the third quarter, we also achieve significant market access successes with key payers that we believe will yield further growth Movantik during the fourth quarter and 2022. A key predictor of the health of the OIC market is the growth or decline in the rate of opioid prescribing. As you can see here, opioid prescribing continues to stabilize during 2021, a major improvement…

Micha Ben-Chorin

Analyst

Thank you, Rob. Good morning. Good afternoon. I will provide a short financial summary of the quarter. Revenue is executing on a consistent growth and value creation strategy, enabling us to be near quarterly commercial non-GAAP EBITDA breakeven by the end of this year. We have achieved another quarterly record of net revenues and gross profits, accompanied by a reduction in operating and net loss. Our cash balance of $51.5 million as of September 30th, 2021 has been supplemented by more than $20 million in equity financing during this month of November. Net revenues were $21.6 million for the third quarter of 2021, a second consecutive quarter of record net revenues attributable to an increase in revenues from both Talicia and Movantik, as shown by Rob. The record net revenues also contributed a quarterly record gross profit of $12.4 million, an increase of 14% from previous quarter, which represents 57% gross margin from net revenues compared with 51% in the previous quarter. On the expenses side, we had substantially lower expenses in the third quarter during the second quarter, $29.8 million compared with $35.8 million, mainly attributable to the completion of our global COVID-19 Phase 2/3 study with opaganib. Operating loss was approximately $17.4 million compared with $24.9 million in the previous quarter, a decrease of 30%, which was mainly attributable to increase in revenues, increase in gross profit, completion of our -- great majority of our COVID-19 programs, and reduction in share-based compensation expenses. Net cash used in operating activities was approximately $19 million for the third quarter of 2021, similar to the second quarter of 2021. We've ended the quarter well-positioned for potential quarterly commercial non-GAAP EBITDA breakeven by the end of this year. I will now turn it over to Dror for Q&A.

Operator

Operator

Thank you. [Operator Instructions] And your first question comes from the line of Brandon Folkes from Cantor Fitzgerald. Your line is now open, you may asked your question.

Brandon Folkes

Analyst

Hi, thanks for taking my questions and congratulations on all the progress in both the pipeline and the commercial front. Maybe just firstly on opaganib, I appreciate all the additional data there. Should we think about the EMA as being the most receptive here and potentially, I know you said we're going to expect feedback from them first, is that indicative of that opaganib is probably going to be in the lead in the EMA versus the U.S.? Maybe secondly, just staying on the pipeline on 204, you talked about expanding the territories in the Phase 3, is that just to speed up the pace of enrollments and the program or should we think of something else driving the potential expansion there? And then lastly, if I may just slip in all three up front, on the Talicia coverage, obviously, congratulations, great coverage there. Just going forward, should we expect additional wins here or improvements in coverage? Or do you believe you're in a very strong steady state now and it's really just executing on those coverage points? Thank you.

Dror Ben-Asher

Analyst

Thank you. Its Dror here. Starting with the question about EMA and whether this is likely to be the most important response in the short-term. So, you're right about saying that this is likely to be first responder as Gilead said before the end of the year. It's an expedited review, which we're very happy about, but it does not necessarily mean that this is the territory where we expect the fastest progress. We are applying in many more countries, some of them with a very high degree an increasing need for treatment for this patient population in Latin America, in Europe, Israel, Switzerland, India, South Africa, and others and we do not know at this point which country or countries will be the most promising for an advance towards the market. Your question about RHB-204 for NTM infections, yes, the speed of enrollment is the main reason that we are expanding the study to additional territories. The other reason is that we see strong need for RHB-204 for NTM infections in other countries, such as Japan, where there's actually more patients than in the U.S. Your last question about Talicia coverage and whether we should be expecting additional coverage further improvement. Right now coverage is excellent, but it can be improved. I refer this to Bob Gilkin who is heading our Market Access team. Bob, would you like to elaborate on the Talicia coverage and what we can expect moving forward?

Bob Gilkin

Analyst

Sure. Thank you, Dror. Appreciate that. So, first, Rob and I are committed with pulling through the great coverage that we have for Talicia, eight out of 10 commercially insured patients have access Talicia. Most of those patients have access with no restrictions. We are committed to expanding that coverage. Our national account executive team is working hard diligently. We have of many things in the works right now. I cannot elaborate at this time, but definitely expect to see more wins as we go into 2022. We're not done yet. If there's any indication of our ability to get it done, take a look at Movantik and what we were able to do once we acquired it from AstraZeneca. Our team is -- has continued to improve coverage and we expect to do the same thing with Talicia. Like I said that Rob and I are committed with pulling our current coverage through with our gritty at TCs out there in the field. Thank you.

Brandon Folkes

Analyst

Great. Thank you very much. Appreciate all the detail.

Operator

Operator

Thank you. We will now be taking our next question that comes from the line of Ram Selvaraju from H.C. Wainwright. Your line is now open, you may ask your question.

Boobalan Pachaiyappan

Analyst

This is Boobalan dialing in for Ram Selvaraju. Can you hear me okay?

Dror Ben-Asher

Analyst

Yes, we can.

Boobalan Pachaiyappan

Analyst

All right. Awesome, great. Great presentation, congrats on your progress. Just a few questions from our end. So, your Phase 2b post-hoc analysis looks solid and convincing. So, with respect to using FIO2 as a medical irrelevant parameter, so just curious, have you spoken to KOL and received any preliminary thoughts regarding its feasibility in current medical practice? Also, are there any limitations that you're aware of in using FIO2 as a relevant parameter in treating COVID patients?

Dror Ben-Asher

Analyst

Thank you. Certainly we have interacted with KOLs and we will have further interaction as we indicated with regulators This is a change from what the standard World Health Organization Ordinal Scale characterizes a severity, but certainly FIO2 is a very well-known measure and parameter that is being used by the treating physicians and KOLs and we get feedback that is certainly a feasible parameter to utilize going forward, but we will have more inputs and further information once we have the regulatory feedback as be explained.

Boobalan Pachaiyappan

Analyst

Okay, thanks for the clarity. So, with respect to the RHB-107 Phase 2/3 study, the data readout is expected in first quarter 2022. So, can you remind us whether you expect to report any preliminary efficacy data in addition to the safety?

Dror Ben-Asher

Analyst

Sure. So, the RHB-107 study is two stage study. Part A is the part that we're currently completed enrollment for and expect topline readouts in Q1. This was a 60 patients part of the study, evaluating primarily the safety aspects of the two doses that we are evaluating and that will be the main outcome. We will get, of course, and capture also efficacy endpoints and parameters, but given the relatively small size of the cohort, we don't expect to have clear indications on efficacy, but we may follow signals that we get and certainly, select a dose for optimal productivity going forward into the part B of the study, which will be the main part with efficacy.

Boobalan Pachaiyappan

Analyst

Okay, thanks for the clarity. So, yes, with respect to RHB-107, are there any benefits limitations from a safety efficacy perspective in targeting serine proteases in COVID treatment? Also, are you aware of any competitors working in this space?

Dror Ben-Asher

Analyst

So, in terms of the safety aspect, RHB-107 has been studied already even prior to COVID and other indications, extensively clinically, over 200 -- 400 I think patients altogether and the safety aspects are very well-established and adequate for treating the early stage patients -- outpatients of COVID-19. In fact, RHB-107 was provided on longer term basis in other indications. So, we're not concerned about safety aspects. In terms of the second part of the question, can you remind me what else you asked?

Boobalan Pachaiyappan

Analyst

Yes, just curious whether there are any -- are you aware of any competitors working in this space?

Dror Ben-Asher

Analyst

In terms of the protease inhibitors, there are competitors that are targeting protease inhibitors or other compounds in a similar class. The serine proteases that our viral targeted, like the Pfizer drug are different class and different targets.

Boobalan Pachaiyappan

Analyst

All right. Thanks for taking my questions. Congrats again.

Dror Ben-Asher

Analyst

Thank you.

Operator

Operator

Thank you. We will now be taking our next question that comes from the line of David Hoang from SMBC. Your line is now open, you may ask your question.

David Hoang

Analyst

Hey. Thank you for taking the questions. So, I had a few here. First one, just on, I guess, the scenario expectations for your discussions with regulators regarding the opaganib post-hoc analysis, you talked about running a confirmatory trial in using FIO2 to select patients. Is that -- I guess, is that definitely occurring? Or is that subject to regulatory feedback? Or any other factors in terms of your decision to pursue another trial?

Gilead Raday

Analyst

Sure. Thank you, David. Certainly, everything that we have discussed is subject to the regulatory feedback that we will receive with -- according to the timelines that we illustrated of the expected feedback, initial feedback. Certainly, for further full approval processes, it's quite clear that additional study in the target population is likely to be required. The question will be that of timing, in terms of whether it is in parallel or prior to any other potential emergency uses in parallel to the study that we may contemplate. And of course, the use of FIO2 is a selected parameter of the target population. Again, we think that it's very feasible and makes a lot of sense. But we will get regulatory feedback in that respect also.

David Hoang

Analyst

Okay, got it. Thanks for that. And then on Talicia, I just had a question maybe you can helped me understand a little bit in terms of squaring the excellent script growth you're seeing in Talicia with the revenues reported for the quarter. So, can you just give a sense of maybe what type of rebating is going on for the product? And is there -- has there been any material change into gross to net for Talicia over recent quarters?

Dror Ben-Asher

Analyst

Thank you, David. It's Dror here. Specific numbers for rebaiting is not something that any company would disclose. However, we can make general comments and I'll refer this to Bob.

Bob Gilkin

Analyst

Yes, thank you Dror. Appreciate that. We are well within industry standards, probably doing a little bit better than industry standards as it relates to rebate contracting with our payer customers. We are -- we take a very conservative approach to discounting, we really watch our gross to net, we've been very fortunate with a product like Talicia, where the clinical attributes of the products are really the how it fares and does much better than the clarity base therapies really provides an advantage for us and payers do see the value in the product. So, we've been very fortunate on that front. But we've been able to maintain and hold on to that rebate line. One of the challenges that we do see is that payers continue to increase rebates and more deductibles that we're seeing across the board. So, obviously, we're trying to kind of manage that and make sure that our products are affordable for our patients. Thank you.

David Hoang

Analyst

Great, really appreciate you sharing that. And then just last question on RHB-104 and Crohn's disease. I guess do you provide any more color on the maybe expected timelines for further development there and your level of confidence in being able to secure the companion diagnostic tests?

Dror Ben-Asher

Analyst

Thank you, David. Its Dror. I'm glad you asked because we are as committed as ever to RHB-104 for Crohn's disease. We have been asked by investors and numerous patients on a daily basis from all over the world what is happening with this program? How can we access this product for compassionate use? Numerous questions on a daily basis. And we do understand that this is a potential breakthrough in the treatment paradigm. And the Phase 3 results that the Guy mentioned briefly, are robust and very, very promising. We're aware of all that. But in the last three or four years, we were reluctant to move forward into a confirmatory Phase 3 study without making sure that we are right on target when it comes to the patient population. And the right types of patient population directly related to our suggested mechanism of access is Mycobacterium avium paratuberculosis infected Crohn's patients, as opposed to all-comers. Even though we were very successful in all-comers. And very recently, there was, for the first time a peer-reviewed publication that disclosed a very important progress in detecting MAP which we believe gives us a decent chance of running the study that we always dreamed of. Now, to the timelines, we expect to have some kind of idea about validating the test within weeks and we are highly committed to this program. So, we intend to go to the regulators quickly with proposed design and take it from there. I'll remind you that the Holy Grail in Crohn's treatment is mucosal healing imaging and the mucosal healing data, which is completely objective from our Phase 3 study is very, very promising. We've shown significance in mucosal healing, despite a relatively small number of patients. So, again, we are very excited about this program and we are fully committed to moving it forward as quickly as possible because the patients are waiting for it and now, it seems that at last, we have a way forward.

David Hoang

Analyst

Okay, thanks for the additional color Dror really appreciate it. That's it for me.

Operator

Operator

Thank you. We will now be taking our next question that comes from the line of Bert Hazlett from BTIG. Your line is now open. you may ask your question.

Robert Hazlett

Analyst

Yes, thank you. Congratulations on the progress, especially impressed with Talicia and the efforts you're making there. Do you have any anecdotal -- along those lines, do you have any anecdotal evidence or circumstances you can present with regard to field force engagement? How's the traction growing or not with regard to your sales effort? And is -- could you describe the market a little bit, is it improving the diagnosis of the condition actually improving itself? Thank you.

Dror Ben-Asher

Analyst

Thank you very much, Bert. Wonderful questions. I'll refer them to Rob.

Rob Jackson

Analyst

Thank you Dror. Great question. We're definitely seeing a lot of improvement in what's happening in the field. I mean our team is executing better, but we're also seeing a lot of growth week-after-week, not only in volume, but also in consistency. So, I would say the traction is definitely improving in the field for Talicia. In terms of the diagnostic component, I think the conditions have certainly improved if you go back to the peak of COVID last year or earlier this year, a lot of prescribers were not performing breath testing, for obvious reasons, as well as endoscopic biopsies in the hospital that has changed significantly. So, the -- although COVID is still a bit of an issue for us out there, it's certainly better than it was at the beginning of the year.

Robert Hazlett

Analyst

Okay, thank you for that. And then maybe you mentioned it, and maybe I missed it, my apologies. Is there any chance you could give us a breakdown of revenue may be in percentage terms of Movantik versus Talicia in the quarter? Thank you for that. And apologies if I've missed it.

Micha Ben-Chorin

Analyst

Sure. Thank you, Bert, this is Micha. So, about a little over $19 million coming from Movantik and almost $2.25 million coming from Talicia.

Micha Ben-Chorin

Analyst

Terrific. Looking forward to hearing of the growth of Talicia going forward. Thanks.

Operator

Operator

Thank you. We will now be taking our next question that comes from the line of Scott Henry from ROTH Capital. Your line is now open, you may ask your question.

Scott Henry

Analyst

Thank you and good morning or afternoon, possibly over there. I have a couple questions on the commercial operations and I may be a little more critical, but that's only because I want to understand exactly what's going on there. Sequentially, from 2Q to 3Q, revenues only went up about $100,000. So, I have to assume Movantik was down sequentially, is that the correct assumption? And is that seasonal or how should we be thinking about that?

Dror Ben-Asher

Analyst

Thank you. Its Dror here. No, it's not related at all. Doctor referrals and scripts are very different things sometimes.

Scott Henry

Analyst

Okay. But Dror as you can see revenue is going down--

Micha Ben-Chorin

Analyst

But I can add there Scott that both revenues from Movantik and Talicia went up and we took a negative impact from Aemcolo. So, both Talicia and Movantik are up.

Scott Henry

Analyst

Can you give me any idea of how large the negative impact on Aemcolo was?

Micha Ben-Chorin

Analyst

It's not very big. It's towards the neighborhood of $100,000.

Scott Henry

Analyst

Okay. And with regards to Aemcolo, what are your thoughts there? Is it burning a lot of cash marketing the product, it means there's virtually no revenues coming from it, but I don't know -- which is understandable given COVID, but what -- is it taking a lot of resources is the question and how long can you keep doing that?

Dror Ben-Asher

Analyst

Thank you Thank you, Scott about. I'll let Rob answer. Obviously, before I turn to Rob, the pandemic has had a very negative impact on travel to high risk territories. Therefore, what we have said in the beginning right before the pandemic with Aemcolo, which was very nice trend has come to a halt -- complete halt. I'll let Rob explain what we are doing right now in terms of our own investment, we're big believers in the product as the pandemic gradually hopefully eases. Rob?

Rob Jackson

Analyst

Thank you, Dror. To answer the question relative to Movantik and Talicia, Aemcolo is taking very few resources right now. It's typically in a second or third position detail when the opportunity arises. So, I would not be concerned looking at this from the outside that we're overweighting our effort or our spend on Aemcolo relative to what we're able to deliver right now during the pandemic.

Scott Henry

Analyst

Okay, I guess Rob and this is a question for you, because I know you sound very enthusiastic about the direction of the commercial division. But when I look at it, I mean, yes, the loss went way down in Q3 from Q2. But that's largely because it went way up from Q1 to Q2. So, I mean, if I compare Q3 to Q1, the story isn't as attractive. So, my question is, when are we going to see an inflection point and really start to get that loss in a declining mode versus up one quarter, down one quarter? When can we see a sustainable improvement? Thank you.

Dror Ben-Asher

Analyst

Rob, would you like to take this?

Rob Jackson

Analyst

Sure. Certainly, in terms of Talicia, we are seeing a sustainable improvement. If you look at the slide in our deck for Talicia, we break out the prescription volume by month, you will see that there has been a sustainable improvement since the end of second quarter. We have put more focus on Talicia second half of the year and we're definitely seeing an uptake and I know, based on what I'm seeing already, I'm very confident we're going to have a strong fourth quarter as well. So, we're heading in the right direction. And if you take that and combine that with the Medi-Cal win we have, it's going to kick into effect in January of next year. I think between the sustained performance we're seeing in our core business plus what we'll get for Medicaid plus potentially some spillover there on the commercial side, I expect we'll be able to continue that trend right through 2022 and continue to accelerate.

Scott Henry

Analyst

Okay. Just looking forward to seeing that commercial breakeven. And when I speak of the trends, obviously, I see the Talicia scripts every week, they look great, but just want to see that loss start to decline, because it is still a significant number. But shifting gears, I did want to ask the gross margin in the quarter looked pretty good. How should we think about that going forward?

Micha Ben-Chorin

Analyst

So, you're right that we have a substantial increase this quarter and this is compared to previous two quarters in which we had the smaller margin mainly due to the shorter exploration of Talicia which comprise the part of the of the inventory and the channel. And now after we got the FDA extension of the expiration from two years to three years, this is -- allows us to much better flexibility in the operations and also contribute to the increase margin. So, we will see an increase of margin going forward is compared with Q1 that you mentioned for example.

Scott Henry

Analyst

So, I guess, what I'm saying is do you think Q3 gross margin, can you maintain that level going forward from Q3 number?

Micha Ben-Chorin

Analyst

Q4 may be a little lower than Q3, but above Q1 and Q2 gross margins.

Scott Henry

Analyst

Okay, that's helpful. Thank you. And then your final question -- I think it'll be the final. On opaganib, if you do have to do a confirmatory trial, how long do you think that would take from start to finish?

Gilead Raday

Analyst

Thanks Scott. Gilead here. We think the last study that enrolled 450 -- over 450 patients actually was completed in a year -- close to a year. We think that given the positive data from the study targeted to the right population of the moderately severe hospitalized patients, we can probably do better than that. And given resources and potential support from external sources also, these public platforms or other sources, we could go even broader in terms of the number of sites and get the study done in under a year. So, that would be our target.

Scott Henry

Analyst

Okay, great. Thank you for that color. And thank you for taking the questions.

Dror Ben-Asher

Analyst

Thank you.

Operator

Operator

Thank you. So, no further question came through. Sir, please continue.

Dror Ben-Asher

Analyst

Thank you, Brian. Thank you all for joining the call. Please feel free to reach out to us if you have any additional questions. Keep safe and have a pleasant day.

Operator

Operator

Thank you. That does conclude the conference for today. Thank you all for participating. You may all disconnect.