Roger A. Jeffs
Analyst · Leerink Swann
Sure. It's a great question, Joe. So there's 2 arms to the response to that question. So in the U.S., we don't think the subcutaneous precedent, which we're proud of, 2 studies with p-values slightly greater than 0.05, which is certainly what we've with our FREEDOM-C and C2 study. We actually don't think a combined analysis in the U.S. is needed to get oral treprostinil approved. And the reason is we feel that we're very closely near and, in fact, absolutely meet the guidance document, the 1998 guidance document on product approval for efficacy. And that's principally these 3 things, that it's an alternative dosage form to treprostinil. So once it's in solution, treprostinil diethanolamine, which is the oral salt form that's in the oral Remodulin, oral treprostinil, becomes treprostinil. So it's just -- the body sees the active pharmaceutical ingredient to be treprostinil, and we have, as Martine talked in terms of patient numbers, over 10,000 patients have been exposed to treprostinil. So we have a tremendous experience with treprostinil as an active pharmaceutical ingredient. Further, the labeling is in related use. We're not seeking labeling for a cancer indication, for example. This is for the same indication that Tyvaso and Remodulin are approved. That is in patients with pulmonary arterial hypertension, and then those other routes that certainly substantiate the use of oral treprostinil. And then finally, with intravenous, as Martine said, we did a bioequivalence study, and we actually didn't do a patient trial. Now oral treprostinil is not exactly bioequivalent, so we have conducted a clinical trial, which is the FREEDOM-M, and we have highly significant and clinically meaningful results which we think warrant labeling for frontline use, particularly as it meets all the 3 tenets of the guidance document. So I think we're in very good stead without the need to combine FREEDOM-C and C2. Now having said that, those studies are supportive. They do provide sufficient evidence that we cause no harm, and they have additional safety information. So that's the first arm, which is the U.S. In Europe, we actually are contemplating doing a combined analysis on C and C2 and presenting that to the Europeans because, as we sat down with Tyvaso, single-study approvals are a little bit more difficult because they don't have this guidance document that we can point to and lean on for precedence. So it may require exactly what you're suggesting, Joe, which is insightful, that we do combined analysis, C and C2. We're obviously doing that, and then we'll combine it with the favorable results we've seen in FREEDOM-M and ask for approval. And whether or not they approve it, we'll have to see, and then they may suggest that we do additional studies or not, but that's the approach we're going to take: one in the U.S., which I think is cut and dry, and one in Europe, which is a little bit more ambiguous.