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Hello, and welcome to the 2026 Quince Therapeutics Special Meeting of Stockholders. Please note that this meeting is being recorded, and a replay will be posted to the Investor Relations section of Quince's website. It is my pleasure to now turn the meeting over to Dirk Thye, the company's Chief Executive Officer, Chief Medical Officer, a member of the Board of Directors and Chair of the meeting. Dirk, the floor is yours.

Thank you, and good morning. It's a pleasure to welcome you to Quince's Special Meeting of Stockholders. Thank you for joining us today live via our Internet webcast. It's 11:00 a.m. Eastern, 8:00 a.m. Pacific and time to call to order the Special Meeting of Stockholders of Quince Therapeutics.

I'd like to introduce some members of our management team who are joining me on this virtual meeting today. Brendan Hannah, who is our Chief Operating Officer, Chief Business Officer, Chief Compliance Officer and Secretary, who is also acting as Secretary of this meeting; and John Militello, our Head of Finance. Also with us today is Dan Harris, representing BDO USA, our independent registered public accountant, and he's available to respond to appropriate questions. Lastly, also present is Brittany Wightman, representing Cooley, our outside corporate counsel; and Jordan Hirsch, representing Equiniti Transfer Agent Services acting as our Inspector of Elections.

We will now conduct the formal part of the meeting, which includes voting on the proposals to be considered. The polls are now open. If you have not already voted, you may do so by clicking on Vote My Shares tab at the top right of the screen. Voting procedures will be addressed in greater detail shortly.

The special meeting is being held in accordance with the company's bylaws and Delaware law. The items on the agenda for formal meeting are: number one, to approve the issuance of shares of our common stock upon conversion of our Series C preferred stock and exercise of the warrants and Orphai options, which will, a, will represent more than 20% of the shares of common stock outstanding pursuant to Nasdaq Listing Rule 5635(a) and (b), may, together with certain changes to management and our Board, result in the change of control of the company pursuant to Nasdaq Listing Rule 5635(b), the Conversion Proposal or Proposal #1.

Number two, to approve the issuance of shares of our common stock upon conversion of the PIPE preferred shares and upon exercise of the PIPE warrants pursuant to Nasdaq Listing Rule 5635(d), the Minimum Price Proposal or Proposal #2. Number three, to approve an amendment to our certificate of incorporation to increase the number of authorized shares of our common stock from 250 million to 275 million, the Authorized Share Proposal or Proposal #3.

Number four, to approve the 2026 Equity Incentive Plan, the 2026 Plan Proposal. Number five, to approve the 2026 Employee Stock Option purchase plan, the 2026 ESPP proposal. Number six, to approve the adjournment or postponement of the special meeting, if necessary, to continue to solicit votes for proposals #1, 2 and/or 3, the Adjournment Proposal.

After we vote on these matters, an announcement will be made regarding the preliminary results and the formal meeting will be adjourned. Will the Secretary please report at this time with respect to the mailing of the notice of the meeting?

I have proof by affidavit certifying that notice of this meeting was duly given and that notice of Special Meeting of Stockholders was mailed on or about August 26, 2026, to all stockholders of record at the close of business on August 24, 2026, the record date for the meeting.

Okay. We have appointed Jordan Hirsch, a representative of Equiniti Transfer Agent Services, to act as Inspector of Elections for this special meeting. The Inspector of Elections has signed an oath of office, which will be filed with the minutes of this meeting. Will the Secretary please report at this time with respect to the existence of a quorum?

The Inspector of Elections has advised me that we have a sufficient number of shares to constitute a quorum. Therefore, the meeting is duly constituted, and we may proceed with business.

I will now describe the voting procedures. Stockholders attending the meeting via Internet webcast may vote their shares in real time until the polls are closed. The votes cast today will be counted in the final tally along with the proxies previously received. The Inspector of Elections will provide the preliminary results of voting at the end of the meeting. If anyone has a question regarding voting procedures, please submit the question by clicking on the questions box on the right side of your screen, typing your question into the box and then clicking the submit button.

The polls for each matter to be voted on in this meeting are open. Any stockholder who hasn't voted or who wishes to change his or her vote may do so by clicking the Vote My Shares tab at the top right of your screen. Stockholders who have sent in proxies or voted via telephone or Internet and do not want to change their vote do not need to take any further action.

We have 6 proposals from the company properly before the meeting. Detailed information concerning these proposals is in the proxy statement sent or made available to Quince stockholders. At this time, I'd like to ask whether there are any questions concerning the 6 proposals.

Dirk, I see no questions pertaining to the 6 proposals. Please proceed with the meeting.

At this point, the polls are about to close. If you have not yet voted, please do so immediately.

[Voting]

It is now 11:07 a.m. Eastern Time on October 6, 2026, and the polls for each matter to be voted on at this meeting are now closed. No additional online ballots, proxies or votes and no changes or revocations will be accepted. The proxies and online ballots will be tabulated by the Inspector of Elections. At this time, based upon preliminary information provided by the Inspector of Elections, I can report that all of the following proposals were approved. Number one, the Conversion Proposal; number two, the Minimum Price Proposal; number three, the Authorized Share Proposal; and number four, the 2026 Plan Proposal; number five, the 2026 ESPP Proposal.

Because there were sufficient votes to approve proposals 1, 2 and 3, the Adjournment Proposal was not presented to stockholders. These are the preliminary results of voting. The final results will be reported on our Current Report on Form 8-K to be filed with the SEC within 4 business days after the end of this meeting.

With that, the Special Meeting of Stockholders is now adjourned. Thank you for your attendance and for your continued support of Quince Therapeutics.

This concludes the meeting. You may now disconnect.

Good afternoon, and welcome to the Quince Therapeutics Virtual KOL event. [Operator Instructions] As a reminder, this call is being recorded, and a replay will be available on the company website following the conclusion of the event.

I will now turn the call over to Dr. Brigette Roberts, Chief Corporate Affairs Officer and Board member at Quince Therapeutics. Please go ahead, Brigette.

Thank you, Wilson. So good afternoon, everyone, and thank you for joining Quince's KOL event. For those of you who are not yet familiar with this story -- let me turn to Slide 3, please. Our company is focused on a proprietary once-daily inhaled formulation of rapamycin called LAM-001 that we're studying across 3 pulmonary conditions. The first is PH in the setting of interstitial lung disease estimated to affect about 200,000 patients between the U.S. and Europe. Based on promising Phase IIa data that Dr. Paul Yu presented at ATS this year, we have moved forward into a Phase IIb study in PH-ILD with expected data in the first quarter of 2028.

The second indication is bronchiolitis obliterans syndrome post lung transplant estimated to affect about 30,000 patients between the U.S. and Europe by the early 2030s. And this is a very severe complication post-lung transplant. Unfortunately, the leading cause of death in the majority of patients. We are currently in an investigator-sponsored study being run at UCSF by Dr. Steve Hays, and that data is expected in the first quarter of 2027.

And then finally, we're also studying the drug in a third indication, sarcoidosis-associated pulmonary hypertension estimated to affect about 60,000 patients between the U.S. and Europe. Another very severe disease, complicating about 15% of patients with underlying pulmonary sarcoidosis. And we'll be starting a Phase II study toward the end of this year, with the readout expected approximately 2 years thereafter.

So next slide. The entire premise behind this drug was -- the goal is to try to find a safe and well-tolerated means of delivering rapamycin to patients' lungs in disease settings where the mTOR pathway was known to be truly implicated. And so what we created here is a product where we are delivering 1/20 of that standard oral dose, 100 micrograms is being delivered daily via this DPI, delivered directly to the pulmonary tissues. That is 1/20 of the typical oral dose. And because of that, what we are seeing in humans is a less than 1 nanogram per mL systemic level, which is less than 1/5 to 1/15 the systemic level seen with oral delivery. And thus far, that has translated into a very benign profile in patients. And importantly, at least so far in our initial studies, efficacy as well.

Next slide, please. Next slide. Sorry. So on that prior slide, it just highlighted our upcoming time lines for data sets. We -- as mentioned, we'll have that PH-ILD data in Q1 '28. We'll be delivering this BOS data in the first quarter of 2027 and that SAPH data toward the end of 2028.

So it's now my pleasure to introduce our 3 KOLs who are going to be presenting today. So for the PH-ILD discussion, we're joined by Dr. Aaron Waxman and Dr. Paul Yu. Dr. Waxman is the Director of Pulmonary Vascular Disease Program at the Brigham and Women's Hospital, and he is Professor of Medicine at Harvard Medical School. Notably, he's been the lead PI on numerous PH clinical studies, including the Phase II SPECTRA study for sotatercept and a Phase III INCREASE study for Tyvaso, which led to the first approved agent to treat patients with PH-ILD. He holds an MD from Yale University, a PhD and anatomy and neuroscience from Albany Medical College. He completed his residency in internal medicine at Yale and his fellowship in pulmonary and critical care medicine at Yale. And he's board-certified in pulmonary disease, critical care medicine and internal medicine. Dr. Waxman was the lead PI for our Phase IIa study of LAM that was just presented at ATS, and he's the lead investigator our ongoing Phase IIb study in PH-ILD.

Turning to Dr. Paul Yu. He is the Director of Cardiovascular Research Center at the Massachusetts General Hospital and an Associate Professor of Medicine at Harvard Medical School. He holds an MD from Duke University and a PhD in Immunology from Duke. He completed his residency in internal medicine at UCSF, a clinical and research fellowship in cardiovascular disease at MGH and a post-doctoral fellowship in cardiovascular biology with Dr. Kenneth Bloch at MGH. He's board-certified in cardiovascular medicine.

Dr. Yu has made a significant impact in pulmonary hypertension through his translational work, including the study of BMP and TGF-beta signaling and cardiovascular homeostasis, repair and disease. Among his many contributions to the field, his work helped to elucidate the vascular remodeling activity of sotatercept, the first agent approved for PAH with a disease-modifying mechanism of action.

So turning third to Dr. Steve Hays, who will be leading our BOS discussion. Dr. Hays is the Medical Director of the UCSF Advanced Lung Disease and Lung Transplant program and a Professor of Medicine at UCSF. He holds an MD from the University of Kansas and completed his residency there in internal medicine. He held -- he completed his fellowship in pulmonary and critical care medicine at UCSF and in lung transplant at Stanford University. Dr. Hays is board-certified in critical care medicine and pulmonary disease. His clinical focus is the treatment of advanced lung diseases, and his research focus includes lung transplant immunology and airway remodeling, chronic lung allograft dysfunction, infectious disease and transplant digital health. Dr. Hays is the principal investigator for the ongoing investigator-sponsored Phase II study of LAM-001 in BOS patients.

So before starting, just to note, we're going to be breaking today's presentation into 2 sessions. The first will be in PH-ILD. The second one will cover BOS. And at the end of each session, we'll be opening it up for a 10- to 15-minute Q&A. And questions will be taken in the order in which they are received.

So with that, I'll turn it over to Dr. Waxman and Dr. Yu to discuss pulmonary hypertension.

Okay. Thank you, Brigette, and hello, everyone. We can go to the next slide. So I always like to start out with a general statement of the problem and really just pointing out, which probably isn't that necessary anymore, that Group III PH is something we encounter increasingly as people recognize the disease state and now that we actually have a treatment for it.

I'd like to show these -- the histopathologic slides that are on the right of this slide. Just to illustrate, for so long, we, kind of, ignored the idea of PH in the setting of Group III disease and especially in Group III ILD. But these are all from patients with Group III, except one. And if I were to challenge someone to tell me which one is the PAH patient, I think you would have a hard time doing that. The point is that vascular remodeling is a big deal when it comes to advanced lung disease and something we shouldn't have ignored for the many years that we did.

Next slide, please. This is just a summary of the prevalence and epidemiology of the disease state. I actually think that we underestimate how much is out there. I think part of the problem has been that because we had no treatments until recently, people didn't get right heart cath. They didn't get a diagnosis and were pretty much ignored. But I think there's no question that when we do have pulmonary hypertension in the setting of interstitial lung disease, we see a significant decline in the pulmonary function itself.

And we can go to the next slide. This is, again, restating some of the prevalence of the disease and showing what happens as far as mortality when we add pulmonary hypertension on to interstitial lung disease. And generally, there's about a threefold increase in mortality once patients develop pulmonary hypertension. And it's always been, kind of, siloed into ILD clinics, but more and more as people recognize that pulmonary hypertension is a significant component, it's overlapping with the pulmonary vascular clinic. But in spite of that, I think there's still very significant delays in diagnosis. And as more treatments are coming to trial, I think we'll get better at finding the disease earlier in the disease process.

You can go to the next slide. So this is just the algorithm for diagnosis of PH-ILD because it is now putting 2 bad diseases into 1 patient. I think the things we start looking for and what we're preaching out to the audience of pulmonologists, cardiologists, rheumatologists, is that as patients start to become increasingly short of breath out of proportion to any changes in their pulmonary function or maybe their CT scan, it's time to start thinking about pulmonary hypertension. There are some subtle findings on other tests like EKG. Echo is still an important screen, but Echo becomes much less reliable when patients have advanced lung disease. So we start to look for other clues in the pulmonary function testing realm. If that DLCO, the diffusing capacity, which for those not familiar, is a measure of the surface area of the lung involved in gas exchange, as that starts to fall out of proportion to the forced vital capacity, that's the time to be thinking about pulmonary hypertension. Certainly, if the patients exercise tolerance is on the decline, but one function is not, then we start thinking about it. Echo still remains the important screening tool, but really a low bar to take a patient to right heart cath is key. And I think that is starting to change as treatments become available. But this is the general algorithm.

And no, you can go on to that next slide. So this is just looking at the track record, and I think this raises a couple of important questions. I think we know endothelin receptor antagonists have now got themselves a black box warning, which I think is unfortunate because it's probably related to clinical trial design, more than any harmful effect of the drug itself. But so far to date, trials have not shown any consistent benefit and do raise the question of harm. The data right now does not support their use in PH associated with ILD. If we think about the PDE5 inhibitors, sildenafil and tadalafil. Some studies have shown improved hemodynamics, some have shown some improved quality of life or preserved exercise capacity. But really, the functional benefits to date have been inconsistent. There is always concern that these drugs can worsen gas exchange in patients, especially with COPD, but also ILD.

The prostacyclins have been studied to some limited approach. They may improve some pulmonary hemodynamics and right heart function but have also been found to worsen ventilation perfusion matching and worsen hypoxemia. The inhaled prostacyclins are -- preferentially treat those well-ventilated lung regions. Although Iloprost, which is really not used in the U.S. much anymore, has shown mixed effects on exercise tolerance and oxygenation. And the recent PERFECT trial, which is PH-COPD, also raised some concerns with the drug. But I think that, too, gets to the importance of phenotyping our patients. Overall, the data suggests uncertain benefits of PH-specific therapies in Group III with no clear improvement in mortality or clinical worsening and need for larger long-term trials.

You can go to the next slide. I think there are a number of reasons as we analyze these, and it really comes down to phenotyping these patients properly. There's been biologic mismatch such as with the STEP-IPF and simtuzumab studies that really didn't look to engage the dominant driver of progressive fibrotic disease. So the clinical readouts remained poor in spite of what seemed good clinical rationale.

There are some harmful hemodynamic physiologic aspects, as I mentioned, with the ERAs and now also with riociguat, really suggested that systemic vasodilator strategies can worsen gas exchange and worsen outcomes in fibrotic lung disease, especially when the lung is trying, it's very best to redistribute to -- from poorly ventilated regions to better ventilated and make those better perfused. There's also some late heterogeneous populations. I think what PERFECT showed us is that patients with advanced PH-COPD have a higher comorbidity burden and that can erase the benefit of a pulmonary vasodilator. And one thing we also learned with the PERFECT trial is that patients who have a diffusing capacity that is too low, which was the real fundamental finding in that study, there just may not be enough vasculature to target.

And really, endpoint dilution has also been a big problem with a lot of these clinical trials. Most of the programs were judged by broad functional decline in diffuse fibrotic disease rather than by a vascular endpoint linked to any treatment mechanism.

And you can go to the next slide. And I think one of the big things that changed with INCREASE was the use of the inhaled route. treprostinil, by giving it as an inhaled drug, was delivered to those ventilated lung units, which were preserved and likely improved vascular tone while minimizing ventilation perfusion mismatch with what we saw with systemic vasodilators. Also, importantly, the right phenotype might have been, kind of, stumbled upon, if you will. Patients had established PH-ILD, and the treatment was targeting the pulmonary vascular problem rather than assuming an antifibrotic benefit alone, although as it turned out, there was also an antifibrotic component there.

And we also designed it around the right endpoint at the time where INCREASE showed a 31-meter placebo-corrected improvement in that 6-minute walk distance, also saw improvement in NT-proBNP and also fewer clinical worsening events. All of these would be consistent with a true vascular efficacy.

Next slide, please. So I think what we've learned from treprostinil and maybe from PDE5s is that we have 1 positive trial in this area in PH-ILD, a lot of cautionary history. I think the real clinical reality is that we're balancing symptom burden, oxygenation, RV function and uncertainty. I think INCREASE was a landmark trial, but it certainly did not solve PH-ILD. I think what it taught us was that treating the label helped some patients, but not all, and that it has allowed us to continue, I think, with a better approach overall.

We can go to the next. This is just showing you the recent data from the TETON studies, which were the subsequent studies after we did INCREASE where we saw a preservation of the FVC percent in ILD, suggesting that treprostinil truly does have an antifibrotic effect. I think importantly it, like all the other antifibrotics, simply slowed progression. They did not reverse anything. I think the 1 positive here is that treprostinil not only had a little better preservation than what's out there, but also was better tolerated.

Next slide. So I think the real rationale came down to the inhaled therapy. And treatment with systemic pulmonary vasodilate, as I've already suggested, often results in worsening VQ or ventilation perfusing imbalance, and that leads to worsening oxygenation and can certainly make patients feel worse. Using an inhaled targeted therapy really optimizes ventilation perfusion and allows for drug delivery where it's needed the most and may have the best efficacy. And I think inhaled approaches really are -- have the most potential for increased efficacy and decreased systemic side effects.

Next slide, please. So now, kind of, switching gears to the mTOR pathway, and this is some of the preclinical data. On the left of this slide is a paper that was published by Goncharov and colleagues. Looking at mTORC2 drives abnormal vascular smooth muscle growth and survival in PAH. This was a study looking at pulmonary artery smooth muscle cells that were obtained from patients with idiopathic pulmonary arterial hypertension. And this -- and also complemented by a study of chronic hypoxia in a rat model. The key findings here are that both mTOR 1 and 2 promoted proliferation, and mTOR 2 additionally supported glycolytic energy production and resistance to apoptosis. The treatment effects of an inhibitor where the dual mTOR 1/2 inhibitor or here, they used PP242, induced smooth muscle cell apoptosis and reverse pulmonary vascular remodeling in rats. And this study had supported a targeting the mTOR2 pathway to address vascular remodeling. Obviously, clinical efficacy was not evaluated in this study. The minimal -- sorry, minimal -- the middle panel is a paper by Houssaini et al. entitled The Rapamycin Suppresses Abnormal Smooth Muscle Proliferation in Experimental PH. In this study, oral rapamycin at 5-milligram per kilo per day was evaluated in the monocrotaline model of pulmonary hypertension. And they looked at both prevention and treatment in this study. The key findings were that reduced pulmonary arterial pressure, improved right ventricular hypertrophy and pulmonary vascular muscularization were all noted. The mechanistic findings, there was a normalized exaggerated smooth muscle cell growth associated with suppression of mTOR1 and mTOR2 signaling. Selective mTOR1 inhibition at low concentrations, though, was not sufficient. So I think that's also suggesting a limitation of systemic delivery. The implication here was that preclinical evidence for treating established pulmonary vascular disease with effects dependent on dose and pathway inhibition were the final findings.

And the last study on this slide on the right is by Kato et al. And looked at rapamycin enhancing endothelial autophagy and attenuation of severe experimental PH. Here, they use the Sugen/hypoxia model. Rats were given rapamycin at 5-milligram per kilogram via intraperitoneal injection. This was given 3x weekly over weeks 3 to 8, which allows for establishment of pulmonary hypertension after the treatment of the model.

The key findings here were that they saw reduced right ventricular systolic pressure and improved obstructive pulmonary vascular remodeling. This suggested that increased endothelial autophagy markers. The markers have reduced proliferation and increased apoptosis, accompanied by fewer endothelial cells with DNA damage, all a result of blocking the mTOR pathway. And this study, I think, also supports endothelial autophagy as a potential therapeutic target. And benefits remain preclinical in this study.

And we can go to the next slide, please. And this is the last preclinical study that I'll show. This is a study look -- by Yoshizaki et al. looking at rapamycin attenuating fibrosis into mouse models of systemic sclerosis. Here, rapamycin was given at 1.5 milligrams per kilo per day for 28 days. In these 2 models, one a skin tightening model, and the other, a bleomycin-induced model. The reduced hypodermal thickness and skin collagen content with the mTOR inhibition was about 38% in those skin tightening model mice. And then reduced skin and lung fibrosis in the bleomycin treated mice was also noted. They also saw that a lot of the pro-fibrotic cytokines and inflammatory infiltration was suppressed, as well as fibroblast migration and proliferation. And this study really also supports mTOR inhibition as an antifibrotic strategy. But again, this is all animal data, not human.

And we can go to the next slide, please. So I think to summarize, what I've shown you so far is to ask the question, why should inhaled sirolimus. I think, one, we have a lot of preclinical data that targeting the mTOR pathway makes sense mechanistically. And it's above and beyond any vasodilating approaches. mTOR is upstream of remodeling, and sirolimus can suppress proliferative inflammatory and pro fibrotic signaling, which is all relevant to the pulmonary vascular bed and pulmonary vascular smooth muscle and endothelial dysfunction as well as fibrotic mechanisms involving fibroblast activation and migration.

I think the compartment targeting matters. I think as we've seen with pulmonary vasodilators, it makes sense to target drug into the lung at the disease site, which -- so that inhaled delivery is really designed to maximize drug delivery to epithelial, interstitial and vascular elements of the disease while reducing systemic immunosuppression in any off-target toxicity. I think the potential also of differentiation from pure vasodilators, sirolimus can -- could modify the remodeling biology so that this could provide us with a second disease-modifying drug, potentially with even less side effect potential. I think the most defensible development path as you replicate the INCREASE playbook. By targeting PH-ILD patients, it preserves the inhaled lung selectivity, and we use the same endpoints of exercise tolerance, biomarkers, hemodynamics and disease progression.

And I'll hand it over to Paul at that point.

Thanks, Aaron, for presenting the rationale for our first study. I'm going to provide top line results from an open-label Phase IIa study of dry powdered inhaled or DPI formulation of rapamycin called LAM-001. This was tested with -- in Group I PAH and Group III PH ILD patients with the goal of enrolling 10 of either patient category. All of these patients were on maximal background therapy for pulmonary arterial hypertension or PH-ILD or antifibrotic therapy for ILD at the time of enrollment, and all of them had functional Class III disease.

This was an invasive cardiopulmonary exercise testing study with the primary endpoint of peak oxygen uptake or VO2 max at 24 weeks versus baseline as well as safety and tolerability endpoints. This -- the secondary endpoints included hemodynamics based on pulmonary vascular resistance. Also, exercise function and NT-proBNP was an exploratory endpoint.

Next slide, please. There were 5 Group I PAH patients and 5 PH-ILD patients enrolled in the study. The demographics were very similar to other contemporary PAH or PH-ILD trials. All Group I PAH patients were on stable regimens of 2 or more standard of care PAH drugs at the time of enrollment and throughout the study. And importantly, all the PH-ILD patients received treprostinil therapy in some form at baseline and also antifibrotic therapy, if appropriate, and this was consistent with maximal medical therapy.

Next slide. All of our patients who completed the study were seen to improve across several functional hemodynamic and biomarker endpoints. There were 4 early terminations that were not attributable to study drug, but due to unrelated hospitalizations and complications, including acute coronary syndrome in 1 subject and a classic vaping induced lung injury in another subject. So the 6 patients completing the protocol had improvements across most, if not all of the primary and secondary endpoints shown on the table on the left and by forest plot on the right. And what we saw was a highly consistent effect in directionality for each of the endpoint ,6-minute walk distance, VO2 max, percentage change of forced vital capacity, pulmonary vascular resistance, measured both under exercise loading conditions and under supine static conditions, as well as NT-proBNP. And these improvements were seen whether we looked at the population as a whole or with PAH or PH-ILD.

You can see that there was a median increase in 6-minute walk distance of 60.1 meters. That was true among the overall population in the PH-ILD group. And there was an improvement in VO2 max of 5% predicted among the overall group, slightly higher in the PH-ILD group. There was a reduction in the PH-ILD group in the pulmonary vascular resistance of 38.6% under exercise and minus 43.7% under supine conditions and approximately a 28% drop in NT-proBNP. The forced vital capacity improved across the whole cohort, 3.5% as a whole and 1% within the PH-ILD group. So with the caveat of this being a very small cohort, the magnitude of these changes compares favorably with other modern Phase II and Phase III studies in PAH and PH-ILD. These include the INCREASE study that Aaron just told you about, as well as PAH studies such as PULSAR and STELLAR for sotatercept.

Next slide, please. Okay. Consistent with those objective endpoints, the functional classes were also seen to improve, with 100% of completers improving from their baseline functional Class III to at least functional Class II by week 24. And in fact, 2 of the patients improved to functional Class I.

Next slide. In this trial, LAM-001 was well tolerated with few Grade I or II adverse events involving either cough, productive cough or gingivitis. There were no dose interruptions or discontinuations due to drug, and there were no drug-related serious adverse events.

So to summarize, this open-label study, LAM-001, demonstrated favorable tolerability improvement or stabilization in multiple cardiopulmonary exercise capacity, hemodynamic and functional status endpoints, suggesting physiologic benefit. And these provide our rationale for the new randomized control study, this Phase IIb study of LAM-001 in PH-ILD. This will involve 2 doses of LAM-001, the dose that was tested in the open label as well as a higher dose to explore whether there's greater efficacy. And the similar endpoints, except that the primary endpoint for this Phase IIb trial will be pulmonary vascular resistance.

So in looking at the therapeutic landscape, mTOR is known to be a master integrator of metabolic state, environmental stress, and lies at, sort of, the intersection of many growth factor, cytokine and hypoxic stress signals. And this results in the ability to influence a lot of downstream processes important to PAH and ILD, including cell growth, cell fate and metabolic adaptation. So while many of the other investigational approved drugs in this space can, in theory, affect these processes, including pulmonary arterial smooth muscle cell proliferation, fibrosis and inflammatory cell recruitment, mTOR lies really in a central position in many of these pathways. And by virtue of its long-standing clinical experience as an anti-vascular proliferative drug in cardiovascular indications as well as being an established immunosuppressive agent in transplant medicine, it has really a clinically known ability to target many of these drivers of obstructive vasculopathy and fibrosis in PAH and ILD. And so I think it makes a lot of sense based on both the mechanistic understanding of how mTOR inhibition works as well as the clinical track record of this particular agent and its potency.

With that, we can open this up to questions.

Thank you, Dr. Waxman and Dr. Yu. [Operator Instructions] So our first question comes from Mazi Alimohamed at Oppenheimer.

So as we think about the BOS trial -- and maybe this is one for Dr. Hays mostly. How are we thinking about the potential for advancement as we think about a Phase III and as we think about kind of -- as we think about investors, how should we think about the Phase II readout? And how should we think about that as it determines the potential registrational path forward for a Phase III? And what endpoints do you think would be most useful here and thinking through with the FDA as we align on a Phase III?

And that's specific to the BOS study? So I think...

Yes, specific to the BOS study.

Because I think Dr. Hays is going to be talking about the BOS data, and that would probably be a better time.

Oh, I see. Oh, I didn't realize -- okay. So then I can flip that for this one as we think about PH-ILD. So then maybe I'll switch to thinking about -- as the readout. So as we think about even the BOS readout coming up, as we digest that and we think about PH-ILD moving forward. And I think the 2 things that I was thinking about for the PH-ILD is, how should we think about target engagement and safety profile in the upcoming readout? And how does that de-risk or add risk to the possible future in PH-ILD?

I guess the issue of risk, are we talking about the potential adverse effects of the drug?

Yes. And how we should think about the safety profile as it relates to PH-ILD in that landscape?

I think as we've seen it and as Brigette pointed out in the very beginning, the dosing of this drug is orders of magnitude less than what we would do normally with this drug as a systemic drug. And at least our limited experience would suggest that it's extremely well tolerated. And the benefits that we're seeing, again, in small numbers but are impressive, especially in comparison to other drugs that are out there since not much else has worked in this target space. I mean, Paul, do you want to?

Yes. I think what we want to see in our Phase IIb RCT as continued evidence of that same really promising open-label experience. There's no substitute for an RCT, as we all have learned in this area. But I think with more patient exposure, especially in that population, we'll get an even stronger sense of the tolerability. We know that the approved medications are limited in their tolerability due to the frequency of cough. And hopefully, that advantage that we think might be present with this in terms of tolerability and lack of cough, which is specific to different agents even with the inhaled modality will bear out and that we'll hopefully see a similarly low frequency of adverse events, I think, afforded by that therapeutic index of having really good tissue delivery without exposing systemically our patients to this drug.

Our next question comes from Joe Schwartz at Leerink.

Great. Thanks for hosting this great event and taking my questions. One for Dr. Waxman and one for Dr. Yu. Dr. Waxman, you ran SPECTRA, and the LAM-001 Phase IIa used a similar open-label CPET design. So -- and I guess having seen how SPECTRA carried into controlled trials, how does this signal that you're seeing here compare at the same stage and -- for sotatercept? And what part of it do you expect to hold up under blinding?

I think great question, obviously comparing 2 different or very different populations of patients. I think the important things that we saw with these patients on LAM, the improvement in the VO2 max was really impressive. And that says that exercise tolerance is clearly improving on a physiologic basis purely because of the drug because these patients did not exercise and did not go into physical therapy or really have any other training exercises. And even though those numbers seem small, I think when you do a lot of exercise physiology, and this was actually a little bit better than what we saw with SPECTRA, that percentage improvement is impressive. I also think the 6-minute walk distance goes along with that. So I think I would probably characterize it -- and again, stressing that these are very different patient populations, pretty comparable positive findings that we saw with this approach.

And then if I could just ask Dr. Yu, given we saw the ILD patients improved a functional class in some cases, really early, I was just wondering based on the mechanism here, what could explain that speed? And how does it influence your view of how the drug works, be it through inflammation, blood vessel lining or right heart unloading? What do you think drove some of the impressive early responses we saw in functional class?

That's a great question. It always has surprised us when we looked at recent trials such as with sotatercept, how quickly we're starting to see symptomatic benefit with drugs that are trying to correct the situation, we think that developed over years, if not decades. And the answer might lie in sort of what is causing a lot of that chronic disease state physiology. We think -- we now know that sotatercept has probably some very early hemodynamic effects when people look very closely using a continuous invasive telemetry devices, and it seems like that possibility could exist here. We would have to look, but there may be more rapid improvements in symptoms and functional class due to acute effects on smooth muscle cell function is what I would predict. But I couldn't rule out anti-inflammatory effects. We expect that antifibrotic effects would probably take more time for the extracellular matrix to remodel and change. But my best bet is that there's a very potent effect on smooth muscle cell biology.

Our next question comes from Sam Slutsky at LifeSci Capital.

I guess as we think about PH-ILD and the potential future treatment approaches, how do you envision combo therapy advancing here? Do you see potential synergy with LAM-001 in inhaled treprostinil standard of care? And then just any thoughts on how Roivant's mosliciguat monthly could have an impact on development paths, if any?

Great question. And I think there's no question that combination therapy in this disease state will be standard of care. Just right now, we don't have that option. And I think that last slide that Paul showed really suggests some of the potential overlap and synergy that one could expect with combination therapy. I think importantly, mosliciguat even though the data was really good in regards to 6-minute walk and time to clinical worsening in NT-proBNP. It is a pure pulmonary vasodilator. It is not an antifibrotic. I think where one could envision combination therapy working really well and also, I think, really importantly, simplifying the patients' daily need for drug is a combination of this LAM-001 with something like TPIP, if it should get approved, or even treprostinil, even though it's 4 times a day. But sotatercept and the TGF-Beta signaling pathway could also make sense, but I'm not aware of anyone who's going to study that yet.

But one could really simplify our patient's care by adding something like treprostinil plus LAM-001. The other drugs in -- on that list, I think as pure pulmonary vasodilator, it's hard to say. Combination with nerandomilast could even be synergistic there as well.

And I would just add real quick to what Aaron said is that the combination therapy is the opportunity. And yes, a once-a-day therapy based on treprostinil, like the prodrug, TPIP, could be a great match for this agent, LAM-001. But we're in an era now where we have to demonstrate efficacy on top of inhaled treprostinil. And in this open-label experience and in our randomized controlled trial, I think we're going to make every effort to maintain that as we did in the open-label. So it's very hard to understand how mosliciguat being primarily a vasodilator would compound or build efficacy on top of that. If they're in the current trial, the rate of inhaled treprostinil was a bit lower, closer to 25%, I believe. So not only is it an opportunity, but it is a new high bar that I think all these drugs will have to meet.

Thank you for your question, Sam. Our next question comes from Olivia Saunders at Cantor. Olivia, you may be on mute. Okay. I'm going to take the next question. Please hold.

All right. Thank you for your questions. To our analysts and speakers, this is all we have time for this first Q&A session. But as a reminder, there will be a second Q&A session after Dr. Hays' presentation.

I will now turn it over to Dr. Hays. Please go ahead. Dr. Hays, you may be on mute.

Yes. Thanks, Wilson. Next slide, please. So today, I'm going to talk to you about the use of LAM-001 for a syndrome that many of you may not be familiar with, but it's one of the leading causes of death after transplant, and that's known as bronchiolitis obliterans syndrome. And it is -- it falls into a disease entity which we call chronic lung allograft dysfunction, that is what we used to refer to as chronic rejection. And bronchiolitis obliterans syndrome is the most common phenotype or endotype of that syndrome. It occurs in 50% of patients by 5 years. And it is -- while rare in the first year, it may affect 40% to 80% of people in the first 5 years and is the leading cause of death by 10 years. 90% of patients either have bronchiolitis obliterans syndrome or have died from their transplant.

And ultimately, this is the final common path of a dysregulated repair and fibrosis of the small airways, the bronchioles in the lung. And you can see by the histology here, the bronchial tube, which normally might look like this, then becomes fibrotic and essentially occluded by this fiber proliferative tissue. In this more cartoon illustration, you can also demonstrate this. So you could imagine this would cause severe airflow limitation in these patients.

Next slide. So how do we define BOS? Bronchiolitis obliterans syndrome, unfortunately, it's very difficult to diagnose by pathology. So it's a clinical diagnosis of exclusion. And it is identified when someone's lung function declines, and it's persistent over the course of 3 weeks. And by a lung function decline, specifically, I mean, the forced expiratory volume in 1 second. So the amount of air somewhat can blow out in 1 second. And when that's sustained over the course of 3 months by 20%, that's considered bronchiolitis obliterans syndrome if you've ruled out other reversible causes such as infections, acute rejection and that kind of thing.

So FEV1, which is the measurement of lung function, really is the primary surveillance tool. And it's important that we're measuring this on a regular basis because oftentimes in the early stages of bronchiolitis obliterans syndrome, patients are asymptomatic. They may not pick up on it. Unfortunately, it carries a very grim prognosis. 3 to 5 year is the median survival after the diagnosis of BOS. The clinical progression is variable. There are patients that progress relatively rapidly, whereas other patients may progress a bit more slowly or a medium term.

Next slide. Now there are a lot of risk factors. We don't completely understand the pathophysiology around what causes bronchiolitis obliterans syndrome, other than that we know it's an adherent healing response to a injury to the bronchial tubes. And the injury could be an alloimmune injury such as acute rejection or an antibody-mediated, but it also may be a more blunt or activation of the innate immune system, as which occurs during infections or gastroesophageal reflux disease with micro aspiration. So there's numerous risk factors for the development of this entity.

Next slide. Currently, we don't have any accepted FDA-cleared treatments for BOS, but we have many strategies which we try to employ with limited efficacy. One of the most common is to intensify immunosuppression by increasing corticosteroids and/or cell cycle inhibitors. That has not been shown to be effective in most patients. One entity I will point out is that there is a group of patients who develop bronchiolitis obliterans syndrome that is responsive to macrolide therapy. This is an entity known as neutrophil responsive airway disease. These patients do tend to improve with macrolide therapy at least initially, and they may, at some point in the future develop progression.

Treating chronic or recurrent infections is an important mainstream treatment. And then some treatments which have been shown to have some efficacy in some patients, but unfortunately, have not undergone rigorous trials include extracorporeal photopheresis, which is an interesting therapy. Quite arduous, similar to dialysis where patients' blood is removed exposed to psoralen, which makes the blood and the white blood cells sensitive to UV light. And that induces apoptosis of leukocytes and stimulates Treg production. And then finally, retransplantation is an option for some patients who have progressive BOS and respiratory failure.

Next slide. There is an evolving experimental landscape in bronchiolitis obliterans syndrome. Most of these therapies are still in Phase I and II, including LAM-001, which I'm going to talk to you a bit more about the design. But JAK inhibitors and ROCK2 inhibitors are also being trialed currently as a treatment. And most of the foundation of those trials comes out of hematopoietic stem cell transplant-related bronchiolitis obliterans, which has some similarities, but obviously, the underlying disease and causes is different.

In terms of Phase III, there is an -- ARINA trial, which is basically, like an antioxidant therapy that's nebulized. And liposomal cyclosporine A, which is again an inhaled therapy, which did not meet the primary endpoint. And then finally, as I mentioned, extracorporeal photopheresis is considered to be rescue therapy for BOS. It is not undergone rigorous double-blind placebo-controlled trials, and therefore, is not approved by CMS Medicare. And then antifibrotics are also used as salvage therapy. And there have been -- there are large European-based Phase III studies ongoing. However, I think initially, the readout is that these may not be shown to be effective.

Next slide. So what's the rationale for mTOR inhibition in BOS? Similar to what Dr. Waxman pointed out, there are multiple different pathways of potential efficacy in lung transplant recipients. Immunomodulation may be one where there's decreased proliferation of T-cells as well as increased regulation of Tregs. These drugs are also thought to be renal protective, so they allow us to reduce the amount of calcineurin inhibitor therapy to salvage kidney function. There are antiviral effects of mTOR inhibitors, including suppression of particularly herpes virus, namely CMV and antifibrotic effects, which I think we are capitalizing with the treatment in bronchiolitis obliterans syndrome where there's decreased fibroblast activation and decrease in extracellular matrix deposition.

But finally, anti-oncogenic effects. This is another use case in lung transplantation in patients who have unrelenting skin cancer. We use mTOR inhibitors to decrease the calcineurin inhibitor use, which is the most potent pro-cancer drug. And then there are cardioprotective effects in heart transplantation. For example mTORs are considered essential therapy for graft vasculopathy, which is the form of chronic rejection in heart transplant.

Next slide. So there are some both animal studies and some sort of preclinical studies that I'll review briefly, but there's really been no significant randomized double-blind placebo-controlled trial in lung transplantation with oral mTOR inhibitors. There is a biologic foundation, though, similar to in pulmonary hypertension. There have been some tracheal transplant models in mice. For example, this study exposed -- tracheal transplant is considered to be a sort of biologic correlate of bronchiolitis obliterans syndrome, but clearly, there's some differences in that, this occurs relatively rapidly after transplantation as opposed to in the actual human transplant. But exposure to rapamycin and mice that have had the tracheal transplant show 2 interesting findings: one, there is a marked reduction in the fibroblastic proliferation in the trachea in those patients who are treated with rapamycin comparable to those rats who had an isotransplant. The other finding that was interesting was that there was an upregulation by 28 days of both Treg and Breg and anti-inflammatory cytokines. So rapamycin and the tracheal transplant model appears to not only reduce the amount of fibroblastic proliferation in the airway, but also upregulate both Treg and Breg.

Next slide. In the humans, there is a couple -- are several case series, retrospective studies, these both coming out of Spain, this -- 1 of the graph on the left shows 57 patients who were treated with everolimus after the diagnosis of bronchiolitis obliterans syndrome. And you can see that the rate of decline pre-everolimus significantly reduced in the post-everolimus group. And the challenge of looking at these data, there is no control group. So there is, kind of, a natural sort of decrease in the rate of decline in bronchiolitis obliterans syndrome, but it's still a very impressive flattening of this curve. The challenge in both of these trials, the second trial being in rapamycin, a much smaller trial of 11 patients, which also showed a pretty dramatic decrease in the rate of decline of FEV1, the main challenge of both these trials is they had a very high rate of dropout, meaning about 30% to 35% of patients who were treated with oral everolimus and oral rapamycin ended up stopping it a median of 12 months after initiation due to side effects.

Next slide. And this has really been one of the big limitations in mTOR inhibitors, at least in lung transplantation, has been the incidence of side effects. This is why the inhaled preparation of sirolimus is so exciting to our field. But as we've already heard, oral ulcerations or mucositis, hyperlipidemia, specifically hypertriglyceridemia, some GI side effects and hematologic side effects such as leukopenia and thrombocytopenia are relatively common. The other side effect we oftentimes see in our patients is edema, peripheral edema lymphedema occurring in up to 12% of patients.

Next slide. So there are many potential advantages of using inhaled sirolimus in lung, similar to Dr. Waxman had described, they're really delivering the drug to the site of disease activity, which is the small airways of the lungs, and it provides this potent immunosuppressive and antifibrotic and antiproliferative effects by achieving these high concentrations in the lung without having high concentrations in the serum, which are associated with most of the side effects. It's easy to use as a once-a-day dry powder inhaler. And as I mentioned, it reduces the systemic exposure versus oral therapy, which we anticipate would lead to fewer systemic side effects, such as bone marrow suppression, nephrotoxicity, which includes proteinuria and the edema and GI side effects.

Next slide. So we've designed and are fully enrolled in a Phase II randomized placebo-controlled trial looking at 100 micrograms of LAM-001 versus placebo in a group of patients who have been diagnosed with bronchiolitis obliterans syndrome. The trial extends for 48 weeks, and the patients are able to transition over into an open label extension. We're including all-adult patients over the age of 18, who have newly diagnosed bronchiolitis obliterans syndrome, which is study defined as a persistent drop in lung function from baseline of greater than 15% to 50%.

The primary endpoint at 48 weeks is a change in the percent of FEV1 across the 48 weeks of the trial. We have numerous secondary endpoints, which include the absolute change in FEV1 at 48 weeks, as well as a change in the rate of progression in FEV1 at 48 weeks versus pre-enrollment. Progression-free survival, Level 1, which is basically a 10% drop in FEV1 after enrollment, is considered progression. And we have exploratory endpoints, which include some patient-reported outcomes and 6-minute walk distance, in addition to some biologic studies looking at UCSF CLAD gene signature profile as well as activation of the mTOR pathway. As I mentioned, the study is currently fully enrolled, and we're anticipating the final 48-week data collection in early December with readout of top line in the first quarter of 2027.

Next slide. So what we're hoping to find in this Phase II trial is that the safety and tolerability are equivalent to placebo. I think if we see that there's a 5% to 10% difference between the drug and placebo arms in the change in FEV1 over 48 weeks, that would be clinically meaningful, as well as a decrease in the slope of decline and a trend toward progression-free survival.

Next slide. And where do I see this following into the BOS therapeutic landscape? Well, as I mentioned at the very beginning, we currently have 0 FDA-cleared treatments for bronchiolitis obliterans syndrome in transplant. In fact, we've had no randomized placebo-controlled trials that have shown a therapy to be significantly beneficial. So I think this would become the standard of care for patients who have bronchiolitis obliterans syndrome in lung transplantation if this passes through our Phase II with significant top line and we get through Phase III.

And I think that's the last slide. I'm happy to open it up to questions.

Thank you, Dr. Hays. [Operator Instructions] So our first question comes from Olivia Saunders at Cantor.

Hopefully, you guys can hear me okay now. Dr. Hays, given that FEV1 trajectories in BOS patients can be pretty variable, what were the main things that you actually look for when you were selecting patients just to make sure that you enrolled patients with truly progressive disease? And then I've also got a quick follow-up on drug delivery.

Sure. Yes, this is tricky. I mean, I think that inherent in this disease and I think most diseases, there's quite a bit of heterogeneity in terms of disease progression. And because we are using this physiologic metric, we did want to make sure that we were enrolling patients that had evidence of new BOS with progression. And so we have a screening protocol at our institution where we're looking at every FEV1 that's generated by patients. And when patients enter into this point where they've had more than a 10% drop in FEV1, they appear on to our watchlist, so we can follow them more closely over the ensuing months. And when the patients do drop into the inclusion criteria, which means a persistent drop in FEV1 of greater than 15%, then we're able to screen those patients. So how we're ensuring that we're really identifying patients who we think would benefit are, one, we're really trying to identify those patients who have a new decline, so new BOS. We think that enrolling patients early gives us the best chance of making a meaningful impact. And then we're making sure that they have a sustained drop. So it's not a one-off drop, but they have to have repeated measurements that meet criteria that are at least 30 days apart. And so by the time they come in for screening and enrollment, they've had at least 3 FEV1 measurements that meet criteria. And that's the method that we've used. I think that there are other trial designs which include looking at the rate of decline as a potential inclusion criteria. And I think that's something that we may consider for larger trials. But for a single center trial where we have pretty good control over the patients that we're enrolling, our methods worked really well.

Okay. Very helpful. And then, yes, on the drug delivery question, BOS, obviously, a small airway disease. So what's your view on whether inhaled LAM-001 is actually getting into the affected bronchioles? And could that get more difficult as the disease progresses and the obstruction potentially gets worse?

Great question. I think that the preclinical data shows that the -- with both the -- and again, maybe Keith Fandrick would like to jump in on this. But I know that the preclinical data suggests that the design of the drug was that it would make it all the way to the alveolar spaces of the lung. I recognize that as the small airways do start to become more narrow, that might theoretically decrease the deposition of the drug in those airways. But again, I think we don't anticipate it necessarily being blocked from the small airways of the lung even in those patients who have some disruption, but it's certainly something that we'll learn over time. Keith, do you want to dive in any more detail about that?

Yes, I think you said it very well. Our drug has been well formulated in a classic DPI configuration or particle size, which is actually measured with an impacter, which kind of [indiscernible] the lung, clearly shows that the drug is deposited effectively everywhere where the lung will be aerated. And I think at the end of the day, it's going to be our efficacy study from these trials that are going to eventually gets the right place at the right amounts to perform and as expected.

Our next question comes from Gavin Clark-Gartner at Evercore.

Thanks for all the insights here. This is super helpful. So the 5 of 19 blinded FEV1 decliners is a really interesting data point here, especially since the study is on top of triplet background therapy and given what happened in Zambon's previous studies. So maybe you could help us contextualize that data point? And I guess more specifically, based on the patient selection criteria that you just walked through, how are you expecting the placebo arm to perform on FEV1 in this study?

Thanks, Gavin. So great question. I think you're referring to some safety data, looking at just ensuring that we had a sort of an expected number of patients who've had what we call progression. Progression was defined in the trial as a drop in FEV1 of 10% from the enrollment baseline. And in our pre-study planning, we looked at a cohort of patients with bronchiolitis obliterans syndrome over the course of 3 years at UCSF. And we showed that about 50% of patients have a 10% decline or what we would define as progression over the ensuing year following the diagnosis of bronchiolitis obliterans syndrome, and that kind of helped us power our study and also understand what to expect. And so I guess my -- we weren't surprised that we had a certain number of patients develop that endpoint of progression because it was -- it fell in line with what we were estimating from our preclinical data from our cohort.

That's helpful. And this may be a slightly more technical question, but for the patients that did have that over 10% FEV1 decline, was this based on multiple visits? Or was it just at a single point in time they had that drop?

Yes, good question. So for both enrollment as well as the diagnosis of the progression endpoint, they had to have repeated measures that met the criteria separated by 30 days. And so -- or [indiscernible] provided greater than 3 weeks, I'm sorry. And so typically, when patients have what we diagnose as progression, we bring them back at 3 weeks to document that they have continued progression. Then those patients are obviously offered other alternative treatments such as extracorporeal photopheresis that is also directed by the clinical team.

Great. And sorry, just last quick question. Have you said anything about the discontinuations or drop-off rates throughout the course of the study?

Have I done what?

Have you disclosed anything about the discontinuations or dropout rates on a blinded basis over the course of the study?

No, we have not published that. I think our -- I would say, in general, our data aligns pretty well with Dr. Waxman's and that we've had very high tolerability. Of course, we're still very -- we're still completely blinded with very limited dropout due to drug intolerance.

Our next question comes from Michael King at Rodman & Renshaw.

I'm stepping in for my colleague, Seema Sheoran. I guess, Dr. Hays, the magnitude of improvement in decline that you mentioned, how clinically relevant is that? It seems like with the heterogeneity of decline, that 5% to 10%, how meaningful is the 5% to 10% improvement in the rate of decline to your patients?

Good question. I think that it's sometimes easier to put this -- well, there's, I guess, a couple of answers to that question. One is that from a physiologic perspective, many -- I mean, many of these patients start off with an FEV1 of, say, 2 liters. So this is essentially a difference of 200 milliliters, which again, is well outside the expected change you'd see with day-to-day variability. I mean, it's considered a clinically significant difference. But the other factor is that it is this kind of 10% change that predicts whether someone is going to have a really poor prognosis after the diagnosis of bronchiolitis obliterans. By that, I mean, in population studies looking -- or registry studies looking at the progression of bronchiolitis obliterans syndrome, those patients that have had a 10% decline in FEV1 after diagnosis have a much poorer prognosis overall than those patients who did not meet that progression threshold. And so that's another reason why I think that from a clinical perspective that is meaningful.

Our next question comes from Mazi Alimohamed at Oppenheimer.

So I think one, again, around the heterogeneity of the disease. So with that, do you expect LAM-001 to only work in obstructive BOS? And then how early in the disease course does it need to be given to matter? And then maybe as a follow-up to that, as we think about steroid use, is this something that you would use kind of alongside existing systemic immunosuppression or something you think could be swapped in? And with that, I'm also kind of thinking with the calcineurin inhibitor and mTOR interactions, how could that complicate the use of concurrent therapies at the same time?

Okay. I should start writing these questions down. Okay. So I think the first question was with the heterogeneity, how important do I think that it's going to be to enroll these patients early. And I think we don't know for sure. I mean, again, this is a fairly small study. I mean, I think it's going to be a meaningful trial, but it's a fairly small trial. I think based on just prior experiences at other studies and even looking at potentially some subgroup or post hoc-analysis on some of the earlier trials, it does suggest that patients who are started on treatment and diagnosed and start on treatment early in the disease process have a much better likelihood of having a response. So we believe that. I think that as we gain more experience, and I'm sure as we develop our -- the Phase III and start enrolling in the Phase III trial, there is going to be the potential for increased -- some increased heterogeneity in the enrollment. And so we'll probably have some experience in how patients do who are enrolled later in their BOS journey. I certainly hope that this therapy would be available and be meaning -- make a meaningful difference in that group, too.

In terms of the other question, I do, at least at the time -- at the current time, we consider that this treatment would be an add-on treatment to the standard immunosuppression therapy that patients are on. In fact, it's a requirement of the trial that patients are on 3 drug immunosuppression prior to enrollment because we didn't want to introduce another potential variable that might impact outcomes. I think that, that will be the way we design the Phase III trial as well, I presume. Though I do think in the future, I could see this potentially replacing or allowing us to limit other maybe noneffective immunosuppression in the setting of BOS because of its both immunosuppressed -- local immunosuppressive effects as well as these antiproliferative effects.

Got it. And then I guess maybe for on the first question. So because of FEV1, what I guess I was getting at, is it something you think will only work in patients like obstructive [ BOS? ] Or can it be generalized?

I missed that part of your question. I actually don't have any reason to think it wouldn't necessarily be effective in the RAS phenotype or endotype. The restrictive allograft syndrome, which is a bit of -- it's a much more of a fibrotic disease that does impact both more the alveolar space and the sub-plural space. I think for the purposes of a clinical trial, I think we want to try to make the group as, I guess, homogeneous as possible. So I think as we move forward, it may be a different subgroup that we look at. Because I don't see a reason why it wouldn't necessarily be effective in that group, given it's kind of antifibrotic, antiproliferative effects which ultimately is some of the pathology around RAS.

Got it. And then last 1 for us is I think just the commercialization aspect of this, as we think about the patients, like how concentrated is the care of these patients across sites in the U.S.? And how do you think about that as you think about if this were to be approved in the future about how fast the uptick would be amongst the providers and transplant surgeons who are caring for these patients?

Yes. I mean, I think that -- I think similar to a lot of these orphan diseases, including PH-ILD, these patients do tend to be cared for by very specialized transplant centers. So there's a little more than 50 in the United States. And I think that in the end, does increase and speed the uptake of these treatments for these patients because it's a very focused and kind of well versed group of physicians who are specialized physicians who are taking care of these patients. So I think the uptake and the -- this distribution will be pretty rapid if these Phase III trials are positive.

Our next question comes from Sam Slutsky at LifeSci Capital.

Two for me. On concomitant medications, are they able to be changed after enrollment in the ongoing study in a way that could alter FEV1, independent of LAM-001? So that's the first question.

And then second, you touched on it a bit, but how is baseline FEV1 defined? Is it a single study visit, kind of an average of repeated measurements, et cetera? And how much variability could we expect between kind of a screening and baseline measurement?

Yes. So in terms of the con meds, we do not -- so patients have to -- they're required to be on 3 drug immunosuppression in enrollment. After enrollment, their medications can be adjusted by the clinical team. However, the -- essentially, the patients are not -- they're not as prescribed or given other types of, say, experimental treatments unless they have the defined progression, which is an FEV1 decline of 10% or greater. And that, again, is something that's a bit easier to do in an IIT that's at the center. We have a very engaged lung transplant pulmonologists who are in our group who then -- who understand the trial and the mechanisms of the trial. So we don't think that there's going to be any medications that interact with the primary outcomes of the trial. Just so you know, the 1 treatment that I think could potentially have the most impact would be the extracorporeal photopheresis, which again, in some patients, does seem to allow for some stabilization. And again, that treatment is not rolled out to patients unless they've hit the endpoint of progression of 10% decline.

In terms of the baseline FEV1, that's a standard calculation of the average of the 2 highest FEV1s after lung transplantation that are separated by greater than 3 weeks. And that's what's considered like a standard post-transplant baseline FEV1. I don't know if that's the baseline that you're speaking of or are you speaking about the enrollment baseline?

Enrollment baseline.

Okay, got it. So the enrollment baseline is the baseline at the enrollment visit. It's not the average of multiple measurements. And ultimately, we can expect anywhere from like a 1% to 3% variability in FEV1. Again, which is why we have the bar of a significant progression at 10%.

Thank you for your question, Sam. Our next question comes from Joe Schwartz at Leerink.

So I guess, Dr. Hays, how much weight do you put on the registry data showing better survival on sirolimus containing regimens? Obviously, those are retrospective analyses. But just knowing what you know about the patients that are captured in those different data sets relative to those that you're enrolling now, how much weight do you put on those studies?

Yes. Yes. Good question. I mean, I think there's been a couple of registry studies that have shown if we're looking at all the different immunosuppressive regimens, patients who are on an mTOR-based immunosuppressive regimen tend to have the best long-term outcomes. And I think that in terms of how much weight they put on those, I mean, they're more like hypothesis generating. I mean, I think they should definitely make everyone interested in knowing more about why this signal might be there. I would say that there are some challenges in over interpreting that data because certainly, patients do have certain kinds of medical complications such as cardiac issues or lipid issues or things like that may not do well in mTOR, and so there may be a patient selection bias there. But having been in this field for 25 years, and our center has been fairly avid users of mTOR inhibitors for specific reasons, which include renal sparing, cancer sparing and graft sparing causes, I do think that there may be something to that registry data, and that is why we're diving into this.

Makes sense. And then given the trial includes bronchoscopy with BAL, I was just wondering, what are you hoping to see there, what you'll be looking for there?

Yes, a couple of exploratory things. UCSF has developed a kind of an epithelial cell gene profile, which has been validated to be -- to demonstrate patients who are high risk for progression of CLAD. And so we're looking at that gene profile and seeing whether or not that is valid in this trial and/or if there's any other signals that could be interesting using that brushing sample. And then we're also in the BAL sample, we're looking for evidence that there is inhibition of the mTOR pathway as well as looking at sirolimus levels in the alveolar space. So that's not really been measured or identified yet in clinical trials is how -- what concentration of sirolimus is in the alveolar space at 3 months post dosing. So those are kind of some of the general scientific questions that we're answering.

Thank you for your questions, Joe. Our next question comes from Jon Wolleben at Citizens.

Thanks for the session today and taking the questions. Wondering if you could recall how long it took to enroll the trial and the primary reasons for folks screening out of it? And then looking ahead, what would you expect or hope from FDA in terms of a regulatory endpoint here? It seems like given the severity of disease, that outcomes may not take too long to accrue. But what would you hope and what do you expect from FDA in terms of a registrational endpoint?

Yes. Good question. So in terms of the speed of enrollment, we -- we estimated, just based on our patient population, our experience enrolling in [ BOSTON ], we would be able to enroll about 1 patient per month. And we were pretty close to that target with this particular trial, again, enrolling 20 patients over the course of, I think, around maybe 30 months. The -- there were a couple of reasons for the delay that were more logistical than based on the design of the trial or the patient population. In terms of those patients that screen out, we do have -- I would say that for patients who underwent screening, I don't have this number exact, but my estimation is around 3/4 of patients passed the screen to enrollment by 1/4 that screened out ended up usually not meeting criteria from an FEV1 perspective. Their FEV1 either didn't continue to progress or didn't make the screening -- the enrollment criteria. There are a few other esoteric reasons, but that was the main cause or the main reason patients screened out.

In terms of like the -- what I hope for -- hope to see, I'm not sure -- I mean, I think that this is still something that's being developed within the lung transplant community or what of the most meaningful outcome metrics. I would say that we are kind of right on target with these current outcome metrics that we're looking at, which are primarily lung function-based, so either a stabilization or a decrease in the progression of lung function decline in the patients who are treated. I think it's going to be probably the primary endpoint that the FDA is going to be looking at. Obviously, other endpoints, which include patient-reported outcomes and possibly an outcome metric related to functional status could be something that we would want to incorporate into the phase -- what we have incorporated in the Phase II that incorporated into the Phase III. But I think the primary outcome metric is going to be physiologic and related to FEV1 decline.

And 1 more, if I may. What would an untreated annual FEV1 decline look like in this enrolled population?

Yes, good question. I think that -- again, we know that 50% of patients -- in our hands, 50% of patients have a 10% decline, which is again, a clinically significant decline over the first year. If we put that into real numbers, that would be an average of around 200 to 300 milliliters of lung function over the course of the year. And so again, between 0.25 and 0.5 liter of loss of lung function.

Thank you for your questions, Jon. Our final question comes from Albert Lowe at Craig-Hallum.

I was wondering -- going around stabilization, do you know if any of the patients in those studies of oral mTOR inhibitors have shown any improvement in FEV1? And how often have you observed patients improve in FEV1? And how surprising would this be in this ongoing study?

Good question. I can't say that I have that in these larger kind of more retrospective studies, I don't have like the individual patient FEV1 data to know if there were patients in those groups that had improvement of their FEV1. I think that -- I think most lung cancer pulmonologists may be surprised if there were an increase in FEV1 in the trial, just because I think in most diseases that involve fibrosis, which this disease does, we haven't seen an agent that has been able to reverse fibrosis, per se. I think there may be other potential -- just, like, I think we can say in pulmonary hypertension, there may be some remodeling that occurs that may be directly related to mTOR inhibitors. That is certainly -- there's certainly potential for that. So I'm, of course, hoping the patients have an improvement in lung function, but it's not something that we initially expected or would expect based on the design of the trial. So I think we're going to, I think, know more, hopefully in the next few months or whether that is at all feasible. I would say that -- the other thing I would note is that when we look at the -- when we look at the pathology of patients with bronchiolitis obliterans, it isn't -- I guess what I would say is that there's a potential that there may be some not just fibrosis, but inflammation edema swelling of the airways that are contributing to the lung function decline. And certainly, that has the potential to get better with certain types of treatment. So it's not completely out of the question.

Thank you, Albert, and to all of our analysts for your questions. I will now turn the call over to Brigette for closing remarks.

Yes. So I just wanted to thank everybody for joining today and spending the past 1.5 hours with us. And importantly, I want to thank our KOLs for all the time they've dedicated on this call and frankly, throughout the year. It's really, really helping to move LAM-001 forward.

Thanks, Wilson.

Hello, and welcome to the 2026 Quince Therapeutics Annual Meeting of Stockholders. Please note that this meeting is being recorded, and a replay will be posted to the Investor Relations section of Quince's website.

It is my pleasure to now turn the over to Dirk Thye, the company's Chief Executive Officer, Chief Medical Officer, a member of the Board of Directors and Chair of the meeting. Dirk, the floor is yours.

Thank you, and good morning. It's a pleasure to welcome you to Quince Annual Meeting of Stockholders. Thank you for joining us today live via our Internet webcast. It is 10:00 a.m. Pacific and time to call to order this Annual Meeting of Stockholders of Quince Therapeutics.

I'd like to introduce several members of our management team who are joining me on this virtual meeting today. Brigette Roberts, MD, Chief Corporate Affairs Officer of Quince and former CEO of Orphai Therapeutics; Brendan Hannah, our Chief Operating Officer, Chief Business Officer, Chief Compliance Officer and Secretary, who is also acting as Secretary of the meeting today; and Sandy Leng, our Controller, Executive Director of Finance and Accounting.

We also have members of our Board of Directors present today. Also with us today is Dan Harris, representing BDO of USA, our independent registered public accountants, and he is available to respond to appropriate questions. Lastly, also present is Dan Lyman, representing Dorsey & Whitney, our outside corporate counsel; and Jordan Hirsch, representing Equiniti Transfer Agent Services, who is acting as our Inspector of Elections.

We will now conduct the formal part of the meeting, which includes voting on the proposals to be considered. The polls are now open. If you have not already voted, you may do so by clicking on the Vote My Shares tab at the top-right of the screen. Voting procedures will be addressed in greater detail shortly. The annual meeting is being held in accordance with the company's bylaws and Delaware law.

The items on the agenda for the formal meeting are: number one, elect the Board of Directors Class I nominee, June Bray for director to serve until the 2029 Annual Meeting of Stockholders and until her successor is duly elected and qualified; number two, approved amendment to our ended and restated certificate of incorporation to effect a reverse stock split of our outstanding shares of common stock by a ratio ranging from 1:10 to 1:100 with the exact ratio to be set within that range at the discretion of our Board of Directors without further approval or authorization of our stockholders.

Number three, ratify the selection of BDO USA as the independent registered public accounting firm of the company for the fiscal year ending December 31, 2026. Number four, on an advisory basis, the compensation of the company's named executive officers as disclosed in the proxy statement. Number five, approve the adjournment or postponement of the annual meeting to a later date or dates, if necessary, to permit further solicitation and vote of proxies in favor of the foregoing proposals. And number six, transact any other business as may properly come before the annual meeting or any adjournment or postponement at the annual meeting. After we vote on these matters, an announcement will be made regarding the preliminary results, and the formal meeting will be adjourned.

Will the Secretary please report at this time with respect to the mailing of the notice of the meeting?

I approve by affidavit certifying that notice of this meeting was duly given and that the notice of Annual Meeting of Stockholders was mailed on or about April 30, 2026, to all stockholders of record at the close of business on April 23, 2026, the record date for the meeting.

Thank you. We have appointed Jordan Hirsch, a representative of Equiniti Transfer Agent Services, to act as Inspector of Elections for this annual meeting. The Inspector of Elections has signed an oath of office, which will be filed with the minutes of this meeting. Will the Secretary please report at this time with respect to the existence of a quorum?

The Inspector of Elections has advised me that we have a sufficient number of shares to constitute a quorum. Therefore, the meeting is duly constituted, and we may proceed with business.

Okay. Thank you. I will now describe the voting procedures. Stockholders attending the meeting via Internet webcast may vote their shares in real time until the polls are closed. The votes cast today will be counted in the final tally along with the proxies previously received. Inspector of Elections will provide the preliminary results of voting at the end of the meeting.

If anyone has a question regarding voting procedures, please submit the question by clicking on the questions box at the right side of your screen, typing your question into the text box and then clicking the submit button. The polls for each matter to be voted on at this meeting are open. Any stockholder who hasn't voted or wishes to change his or her vote may do so by clicking the Vote My Shares tab at the top right of your screen. Stockholders who have sent in proxies or voted via telephone or Internet and do not want to change their vote do not need to take any further action.

Okay. The proposals. We have 5 proposals from the company properly before the meeting. Detailed information concerning these proposals in the proxy is in the proxy statement sent or made available to Quince stockholders. At this time, I'd like to ask whether there are any questions concerning those 5 proposals.

Dirk, I see no questions pertaining to the 5 proposals, please proceed with the meeting.

Okay. At this point, the polls are about to close. If you have not yet voted, please do so immediately.

[Voting]

It is now 10:06 on June 11, 2026, and the polls for each matter to be voted on at this meeting are now closed. No additional online ballots, proxies or votes and no changes or revocations will be accepted. The proxies and online ballots will be tabulated by the Inspector of Elections. At this time, based on preliminary information provided by the Inspector of Elections, I can report that June Bray has been elected as Class I director to serve until our 2029 Annual Meeting of Stockholders and until her successor is duly elected and qualified.

The amendment to Quince's amended and restated certificate of incorporation to effect a reverse stock split of all of our outstanding shares of common by a ratio ranging from 1 for 1:10 to 1:100 with the exact ratio to be set within that range at the discretion of our Board of Directors without further approval or authorization of our stockholders has been approved.

The selection of BDO USA as our independent auditor for the fiscal year ending December 31, 2026, has been ratified. Approve on an advisory basis, the compensation of the company's named executive officers as disclosed in the proxy statement; approve the adjournment or postponement of the annual meeting to a later date or dates, if necessary, to permit further solicitation and vote of proxies in favor of the foregoing proposals and transact any other business as may properly come before the annual meeting or any adjournment or postponement of the annual meeting.

These are the results -- these are the preliminary results of voting. The final results will be reported on our current report on Form 8-K to be filed with the SEC within 4 business days after the end of this meeting. And with that, the Annual Meeting of the Stockholders is adjourned. Thank you for your attendance and your continued support of Quince Therapeutics.

Thank you for your participation in today's meeting. This concludes the program. You may now disconnect.

Good morning, and welcome to the acquisition of OrphAI Therapeutics by Quince Therapeutics Webcast and Conference Call. [Operator Instructions] Please be advised that this audio presentation is being recorded. I would now like to turn the call over to Corey Davis of LifeSci Advisors. Please proceed.

Good morning, everyone, and thank you for joining us. Two press releases went out this morning, which are also available on our website. A replay of this webcast, along with the presentation materials will also be available on the company's website following today's call. Before we begin, I'd like to remind everyone that statements made during this conference call and the accompanying presentation may include forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995.

These forward-looking statements include, but are not limited to, statements regarding the anticipated benefits of the transaction and financing, the expected closing of the private placement and the anticipated use of proceeds there from, company's strategic plans, anticipated clinical development activities, ongoing clinical trials, planned regulatory interactions, expected milestones and data readouts, expected IP protections, projected cash runway and the potential therapeutic and commercial opportunity of the company's pipeline.

These statements are based on current expectations and assumptions and are subject to risks and uncertainties that could cause actual results to differ materially from those described in the forward-looking statements. Additional information concerning these risks and uncertainties are contained in the company's filings with the Securities and Exchange Commission, including our press releases issued this morning and our Form 8-K filed with the SEC announcing the transaction and our most recent quarterly report on Form 10-Q which are available at sec.gov or on our website.

The company undertakes no obligation to update any forward-looking statements, except as required by law. This communication is for informational purposes only and does not constitute an offer to sell or the solicitation of an offer to buy any securities or a solicitation of any vote or approval. In connection with the matters subject to stockholder vote in connection with the transaction, the company will file a proxy statement with the SEC. Investors and security holders are urged to read the proxy statement and other relevant materials filed with the SEC carefully and in their entirety when they become available because they will contain important information about the transactions and the related stockholder vote matters.

Investors and security holders may obtain free copies of these documents when available and other documents filed with the SEC by the company through sec.gov or on our website. Free copies of these documents, when available, may be obtained from the company directly if requested. During today's call, we will review the rationale for the transaction, provide an overview of our pipeline and development strategy, discuss the concurrent financing and outline expected upcoming milestones and operational priorities.

Joining me on the call today are Dirk Thye, who will discuss the details of the transaction; Brigette Roberts, the company's Chief Corporate Affairs Officer and the former CEO of OrphAI, who will explain the strategic rationale and vision for the company and provide an overview of the pipeline, clinical development plans and anticipated milestones; and Dr. Paul Yu, Director of the Cardiovascular Research Center at Massachusetts General Hospital and Associate Professor of Medicine at Harvard Medical School, where he holds the Charles and Elizabeth Sanders Endowed Chair, who will review the recent Phase IIa data with LAM-001 presented at the ATS meeting.

And with that, I'll turn the call over to Dirk, CEO of Quince Therapeutics.

Greetings, Quince stockholders, and thank you for joining the call to announce the acquisition of OrphAI. After an exhaustive search of the competitive landscape for acquisitions to maximize stockholder value and with the help of LifeSci Capital as our financial adviser, we selected OrphAI. We believe the acquisition of OrphAI represents the best possible outcome for our stockholders, and you're about to hear about the scientific programs and pipeline we acquired and our strategic plan for the future.

This acquisition was structured as a stock-for-stock merger, whereby all of OrphAI's outstanding equity interests were exchanged for a combination of shares of Quince's common stock and shares of a newly created Series C nonvoting convertible preferred stock. The acquisition closed on May 18, 2026. With the acquisition of OrphAI, Quince entered into a definitive agreement for the sale of Series C nonvoting convertible preferred stock and warrants in a private placement to a group of accredited investors from leading health care-focused institutional investors.

The private placement is expected to result in upfront gross proceeds to Quince of approximately $115 million before deducting placement agent and other offering expenses and up to an additional approximately $72 million in gross proceeds upon exercise of accompanying warrants. The private placement is expected to close on May 21, 2026. Subject to approval of Quince's pre-acquisition stockholders, each share of Series C nonvoting convertible preferred stock will automatically convert into 1,000 shares of common stock, subject to certain beneficial ownership limitations set by each holder.

No stockholder approval was or will be required for the closing of the transactions under applicable law or NASDAQ listing standards. However, stockholder approval for, among other things, the conversion of the Series C nonvoting convertible preferred stock into common stock will be sought during a meeting of stockholders expected to be held later this year. As a result of the acquisition, Quince's pre-acquisition equity holders will own in the aggregate approximately 17.8% and OrphAI's pre-acquisition equity holders will own in the aggregate approximately 82.2% of the post-acquisition company before the private placement transaction. And approximately 6.9% and 31.9%, respectively, after the private placement transaction.

And the private placement investors will own in the aggregate approximately 61.2% of the post-acquisition company. And in each case, calculated on a fully diluted as converted to common basis and without giving effect to any beneficial ownership limitations using the treasury stock method and based on the implied equity values of Quince and OrphAI.

Quince expects to use the proceeds from the private placement primarily to advance LAM-001, including initiation of a Phase IIb trial in pulmonary hypertension associated with interstitial lung disease with data anticipated in 2028, and delivery of Phase II data in bronchiolitis obliterans syndrome post lung transplant in the first quarter of 2027. And Phase II data in sarcoidosis associated with pulmonary hypertension in late 2028. We note that this description of the transaction is not complete. We refer our stockholders to our filings with the SEC, which incorporate by reference the material agreements in connection with the acquisition and the private placement.

With that, I will turn the call over to Brigette to provide the strategic rationale and vision for the company, an overview of the pipeline, clinical development plans and anticipated milestones.

Thank you, Dirk. So turning to Slide 5. We believe this acquisition offers a unique opportunity to build a leading clinical stage biotechnology company centered around LAM-001, a novel [ once-off ], once-daily inhaled formulation of rapamycin with potential applicability across multiple pulmonary indications. The first indication is pulmonary hypertension associated with interstitial lung disease or PH-ILD, which affects approximately 200,000 patients across the U.S. and Europe. Approved therapies in PH-ILD are largely focused on vasodilation rather than addressing the underlying disease biology.

LAM-001 is designed to target and help reverse the pulmonary arterial smooth muscle cell hyperproliferation, inflammation and fibrotic vascular remodeling underlying the disease state. Just yesterday, at the American Thoracic Society, OrphAI presented encouraging Phase IIa data of LAM-001 in pulmonary hypertension, demonstrating clinically meaningful improvements when added to standard of care, thus supporting our plans to initiate a Phase IIb trial in the middle of 2026.

The second indication is bronchiolitis obliterans syndrome or BOS, which is a severe complication of and the leading cause of death post lung transplantation, which is estimated to affect approximately 28,000 patients across the U.S. and Europe. Median survival is only 2.5 years, and there are no approved medications for this condition today. A placebo-controlled investigator-sponsored Phase II study in BOS is ongoing with top line data anticipated in the first quarter of 2027.

And finally, we intend to advance the program into sarcoidosis associated pulmonary hypertension or SAPH, which affects an estimated 60,000 patients across the U.S. and Europe and which similar to BOS, currently has no approved therapies. The planned Phase II study is expected to initiate late in 2026 and is supported by prior proof-of-concept clinical efficacy data generated in pulmonary hypertension patients.

Importantly, we believe the LAM-001 program benefits from our ability to leverage the highly efficient 505(b)(2) regulatory pathway. Additionally, LAM-001 offers a strong intellectual property estate with expected protection extending into the mid-2040s. The program has received orphan drug designation in both the U.S. and Europe across multiple indications, and we have received supportive regulatory feedback through prior pre-IND and end of Phase II interactions with the FDA. Overall, we believe this portfolio offers a compelling combination of validated biology, significant unmet medical need, regulatory advantages and multiple near- and midterm clinical catalysts.

So turning to the development time line, beginning with PH-ILD. As mentioned, following the encouraging Phase II data just presented at ATS, we plan to initiate a Phase IIb study in the middle of this year with top line data expected in the first quarter of 2028. In bronchiolitis obliterans syndrome post lung transplant, the ongoing Phase II investigator-initiated trial is expected to generate top line data in the first quarter of 2027. And finally, in SAPH, we expect to initiate a Phase II study in late 2026 with top line data anticipated in the fourth quarter of 2028.

Turning now to Slide 7. Why not oral rapamycin? First, when delivered by mouth, like any medication, oral rapamycin distributes throughout the body systemically. And unfortunately, with rapamycin, this systemic exposure is associated with a number of side effects highlighted on this slide that have precluded its broad adoption in pulmonary diseases. Additionally, the systemic toxicity can limit achievable dosing, thus preventing sufficient drug exposure directly within lung tissue, which can be particularly important in pulmonary diseases where localized target engagement may be critical for efficacy.

And finally, oral rapamycin has demonstrated low and highly variable bioavailability, which often necessitates therapeutic drug monitoring and dose adjustments, creating additional burden for both physicians and patients. Collectively, we believe these limitations have constrained the use of oral rapamycin in pulmonary diseases despite evidence supporting the importance of the mTOR pathway in disease biology.

So turning to Slide 8. We believe LAM-001 has the potential to address many of these key limitations. First, our inhaled delivery is designed to maximize exposure locally at the site of disease in the lungs while minimizing systemic exposure and concomitant toxicity. And second, our proprietary rapamycin formulation possesses physical chemical properties that we believe are ideal for pulmonary delivery, supporting the potential for improved tissue penetration in the lungs and thus therapeutic activity across multiple pulmonary indications.

These properties combined have allowed us to dose LAM-001 at just 100 micrograms daily directly to the lungs. This is 20-fold lower than the standard 2-milligram daily oral dose. As seen in the graph on the right side of the slide from our Phase I/II study in LAM patients, this 100-microgram dose has been observed to translate into steady-state systemic exposure below 1 nanogram per ml, which is 1/5 to 1/15 the 5 to 15 nanogram per ml systemic levels typically observed with the standard 2-milligram oral rapamycin dose.

Importantly, as well, animals treated with the equivalent of that single 100-microgram human dose achieved lung concentrations resulting in greater than 90% inhibition of the mTOR target out to 24 hours. Collectively, we believe these data support the potential for reduced systemic toxicity along with clinically relevant lung exposure.

So with that, I'll ask Dr. Yu to present the latest data from our Phase II study evaluating LAM-001 in pulmonary hypertension. By way of introduction, Dr. Yu is Director of the Cardiovascular Research Center at Massachusetts General Hospital and Associate Professor of Medicine at Harvard Medical School, where he holds the Charles and Elizabeth Sanders Endowed Chair. A physician scientist trained in immunology and cardiovascular medicine, his research focuses on BMP and TGF-beta signaling in cardiovascular homeostasis, repair and disease. His work spans pulmonary vascular disease, cardiovascular rheumatology and rare disorders such as fibrodysplasia ossificans progressiva.

Dr. Yu has translated several scientific discoveries into therapeutics, including contributions to sotatercept for pulmonary arterial hypertension and the clinical repositioning of sarcatinib for FOP. He has published over 120 peer-reviewed studies and has been elected to the American Society for Clinical Investigation.

Thank you, Dr. Roberts. To preface the Phase IIa trial results, I'd first like to highlight the unmet need in pulmonary hypertension associated with interstitial lung disease or PH-ILD. This is a major cause of Group III pulmonary hypertension associated with lung disease, and the pathophysiology is similar to other types of pulmonary hypertension in that pulmonary arterial smooth muscle cell proliferation, fibrosis and endothelial dysfunction lead to progressive narrowing and loss of vessels. The prognosis for this condition is worse than for pulmonary arterial hypertension or interstitial lung disease alone with just 1/4 of patients surviving 5 years after diagnosis.

There are currently 2 approved drugs for this condition that are inhaled forms of treprostinil, and there are an estimated 86,000 and 120,000 patients in the U.S. and the EU, respectively. LAM-001 or rapamycin DPI is uniquely suited to targeting PH-ILD pathology as it inhibits mTOR signaling, which is a master regulator of signaling pathways governing smooth muscle cell proliferation, fibrosis and inflammation and is a key integrator of hypoxic stress.

Inhibiting mTOR with LAM-001 has the potential to improve disease by arresting or reversing the obstructive vasculopathy. There is evidence of markedly upregulated signaling both upstream and downstream of mTOR in the distal arteries and distal arterial smooth muscle cells of patients with idiopathic PAH, shown in the left 2 panels, which correspond with smooth muscle cell proliferation, survival and metabolic stress. On the right panels, we see that rapamycin is shown to prevent or treat experimental pulmonary hypertension and vascular remodeling shown here in the monocrotaline model in rats.

For the treatment of PH-ILD, in addition to the 2 approved treprostinil inhaled formulations, there are several other programs at various stages of development, spanning preclinical to Phase III. Several of these programs target the prostanoid pathway by inhaled delivery, others target the ROCK1 and 2 and the soluble guanylate cyclase pathways. Among these, LAM-001 is relatively unique in its antiproliferative and antifibrotic mechanisms of action.

The Phase IIa trial of LAM-001 was designed to capture changes in cardiopulmonary function in Group 1 PAH and Group III PH disease via invasive cardiopulmonary exercise testing, or CPET. This was an open-label study of adults with functional Class III disease on background therapy. The primary endpoint was peak oxygen uptake or VO2 max as well as safety and tolerability. Secondary endpoints included PVR or pulmonary vascular resistance, the 6-minute walk distance and WHO functional class with an exploratory endpoint of NT-proBNP.

The enrolled patients in this trial were comparable in age and demographics to recent trials in PAH and pulmonary hypertension, including the STELLAR trial and the INCREASE trial. Of note, all PAH patients were on stable and maximal therapies, in most cases, triple vasodilator therapy. And all of PH-ILD patients were on maximal therapies, including background treprostinil therapy. 10 patients were enrolled and 6 patients completed the trial. All of the discontinuations were unrelated to the study drug.

For the primary and secondary endpoints, we saw very promising signals of efficacy in both the overall evaluable population that completed the protocol as well as the subset of PH-ILD patients. A mean improvement of 81.3 meters in the overall cohort or 67.4 meters in the PH-ILD subset was seen in the 6-minute walk distance. The VO2 max was also seen to improve. The pulmonary vascular resistance decreased by 25% to 35% under exercise conditions and 28% to 33% under static conditions. NT-proBNP decreased by nearly 30%. When we examined forced vital capacity as a percentage of predicted, we saw a 4.8% increase among the overall cohort and a 1.8% increase among the PH-ILD subgroup.

All of the evaluable patients in the study improved to functional Class II by week 24, starting from Class III at enrollment. Many improved as early as 12 weeks and 2 patients improved to functional Class I. For comparison, in the sotatercept Phase III study, 29% of patients improved functional class at 24 weeks. In this study, there were drug-related adverse events, including Grade 1 productive cough, cough and gingivitis. Overall, LAM-001 was well tolerated, and there were no dose interruptions due to AEs. There were no discontinuations due to drug, and there were no SAEs related to drug.

To summarize, in our Phase II study, we saw compelling evidence of clinical activity, notably with a 67-meter improvement in 6-minute walk distance among PH-ILD patients comparing favorably with existing therapies in recent trials. This benefit was seen on top of standard of care in heavily pretreated populations and there were consistent signals of patient benefit seen across multiple measures. The tolerability was favorable, again, with no dose interruptions, discontinuations or SAEs related to drug.

Thank you, Dr. Yu. So turning to Slide 21. We are outlining the design of the Phase IIb study of LAM-001 in pulmonary hypertension associated with interstitial lung disease or PH-ILD. The study is expected to enroll approximately 75 patients across an estimated 40 clinical sites and is designed as a randomized, double-blind, placebo-controlled multicenter trial evaluating LAM-001 as an add-on therapy on top of stable background therapy.

Patients will be randomized 1:1:1 to receive either 100 micrograms once daily of LAM-001, 200 micrograms once daily of LAM-001 or placebo over a 24-week blinded treatment period, followed by a 12-month open-label extension phase. The trial is expected to enroll adult PH-ILD patients with WHO functional Class II or III disease who remain symptomatic despite stable background therapy, which may include background treprostinil similar to our Phase IIa study.

Importantly, these are patients with significant unmet medical need and limited treatment options beyond vasodilatory approaches available today. The primary endpoint of the study is change in pulmonary vascular resistance, or PVR, which we believe represents an important hemodynamic measure of disease activity in this population and is an accepted endpoint for Phase II studies in pulmonary hypertension. Secondary endpoints include change in 6-minute walk distance, time to clinical worsening, incidence of clinical worsening events as well as safety and tolerability assessments.

The study will also evaluate a number of exploratory endpoints, including change in WHO functional class, NT-proBNP, forced vital capacity and patient-reported outcomes using the K-BILD questionnaire. Overall, we believe this study is designed to comprehensively evaluate both the hemodynamic and functional impact of LAM-001 in a patient population with substantial unmet need.

So let's turn now to bronchiolitis obliterans syndrome or BOS. BOS is the leading cause of death post lung transplantation. Unlike pulmonary hypertension, this disease is centered around the airways, not the pulmonary arteries. As seen in the picture on the right, it is characterized by a progressive infiltration of inflammatory and fibrotic cells that occlude the small airways, resulting in substantial airway obstruction and irreversible decline in lung function and ultimately graft failure.

The number of lung transplants continues to grow, approaching nearly 4,000 lung transplants annually in the United States today, translating into an estimated addressable BOS patient population of approximately 17,000 patients in the United States and 11,000 patients in Europe. There are currently no FDA-approved therapies for this disease, and the program has received orphan drug designation in both the United States and Europe.

Turning now to Slide 24. The median survival post lung transplantation is 6.2 years. And unfortunately, over the course of 10 years, 94% of lung transplant patients will develop BOS. BOS is the #1 leading cause of death post lung transplant. And once BOS has taken hold in the setting of a lung transplant, the median survival is just 2.5 years.

Turning to Slide 25. The key measure for BOS diagnosis, progression and prognosis is FEV1. BOS is diagnosed when a patient's FEV1 has declined to 80% or less of baseline levels with baseline being defined as FEV1 levels post lung transplant. And progression of disease or BOS grade is then measured by further sequential declines in FEV1, as shown in the box on the far left of this slide. And importantly, studies have shown that each 1% decline in FEV1 is associated with a 3.4% increase in mortality. And in a recent survey that we conducted across 48 clinicians treating BOS patients, FEV1 decline was highlighted as the single most important criteria for escalating BOS therapy.

Turning to the next slide. Before embarking on our BOS program, as we did with our PH program, we searched for off-label proof-of-concept data with the oral form of the medication. And we found a small study that had been conducted in the early 2000s in 11 patients with progressive BOS. In this study, as seen in the graph on the right side of the slide, prior to rapamycin dosing as is typical in this disease process, FEV1 declined over the course of 12 months. However, over 12 months of subsequent rapamycin treatment, FEV1 demonstrated stability or even improvement in 8 of 11 patients.

Given this supportive proof-of-concept data with oral rapamycin, combined with the mechanistic rationale, a randomized double-blind, placebo-controlled investigator-sponsored study was initiated at UCSF under Dr. Steven Hays, evaluating LAM-001 in 19 double lung transplant patients with newly diagnosed BOS. In this study, patients were randomized 1:1 to receive either LAM-001 100 micrograms QD or placebo over a 48-week blinded treatment period, followed by an open-label extension phase. The primary endpoint is the percent change from baseline in FEV1 at that 48-week time point.

Overall, this is a small study and has been designed as a safety and signal-seeking study to evaluate the potential for LAM-001 in this underserved patient population. Enrollment for the study was completed in January 2026 and an interim safety review conducted in February 2026 showed that 5 of 19 patients enrolled demonstrated a 10% or greater decline in FEV1 versus study baseline. Dosing continued as planned following that interim safety review and top line data are currently anticipated in the first quarter of 2027.

Turning now to Slide 29. We believe we have established a broad and multifaceted intellectual property strategy designed to support long-term exclusivity across the inhaled rapamycin platform. The portfolio includes claims protection across drug substance, drug product and method of treatment, including composition claims related to particle size, formulation, delivery and dosing as well as treatment claims in pulmonary hypertension and chronic lung diseases.

The company currently has 9 issued U.S. patents with expected exclusivity extending into 2035, alongside pending patent applications that, if granted, are expected to extend protection into 2047. Importantly, the portfolio is further strengthened by orphan drug exclusivity in both the U.S. and Europe across multiple indications. And finally, we have secured exclusivity with the device manufacturer for the use of rapamycin in the RSO1 dry powder inhaler device we have been using in our clinical trials and plan to use for our commercial launch, if approved. Overall, we believe this layered IP strategy provides meaningful protection for the platform.

Turning now to Slide 30. We believe we are well capitalized, having raised $115 million in upfront gross proceeds in an oversubscribed private placement that is expected to close on May 21, 2026. Based on the current operating plan, we expect our cash runway to extend through the end of the fourth quarter of 2028, which should allow us to deliver on the multiple anticipated clinical readouts highlighted on the following slide.

Turning to that slide. As noted, OrphAI just yesterday presented Phase IIa pulmonary hypertension data in an oral presentation at the American Thoracic Society Conference. Looking ahead, anticipated milestones include top line Phase II data from our BOS program in the first quarter of 2027, followed by Phase II PH-ILD data expected in the first quarter of 2028. We also expect top line Phase II data from the SAPH program in the fourth quarter of 2028. Overall, we believe these milestones should provide multiple opportunities for clinical and operational value inflection across the platform.

In summary, the company's mission is to transform the lives of patients facing serious underserved diseases. The clinical data we shared today represents an important step in advancing this mission. And our acquisition of OrphAI, along with the concurrent pipe financing provide us with the resources to further advance our goals. We hope you share our excitement as we move forward to the next set of milestones. Thank you for your time today.

Ladies and gentlemen, this concludes today's event. You may disconnect your lines or log off the webcast at this time, and enjoy the rest of your day.

Greetings, everyone, and welcome to our first ever Investor Day for Quince Therapeutics. My name is Dirk Thye, and I'll be walking you through the beginning elements of our presentation. We've got a full agenda for you today. I'm going to start by giving you an overview of Quince Therapeutics, our technology, our development plans and our key investment highlights.

And then I'm going to hand it over to a series of departmental and technical experts that are going to walk you through the elements of the technology itself. I'll come back and talk about previous clinical studies and the development plan. We'll hand it over to Caralee Schaefer to explain to you some very interesting and compelling new data on the mechanism of action of encapsulated dexamethasone.

Then we'll talk about some elements of the regulatory plan and go into some details on our commercial planning for post-approval activities. These are some of the people you'll be hearing from today. There are some additional team members on this slide. And the point here is to demonstrate that we've got a very good team of people with a lot of expertise and experience in their particular functional area.

And as I said, some of the key speakers are listed on this slide as well. But let me start by going over the overview of the company and some of the key highlights. This slide outlines my disclosures. And our fundamental technology here is a machine that performs a process that we call AIDE, Autologous Intracellular Drug Encapsulation. And it's a method by which you can take a patient's own red blood cells, so autologous blood and you can treat them so that they can encapsulate a molecule, a small molecule, a large molecule, even a protein into their own red blood cells and then reinfuse those drug-loaded red cells back into the patient.

Some of the highlights of our current status are that we are in Phase III. We have completed enrollment in our pivotal Phase III trial. That trial is in the lead indication of the ataxia-telangiectasia, and you'll hear a lot more about that disease and that study in the following slides. There are no currently approved therapies for this terrible pediatric disease, and it's a large and important commercial opportunity.

The current Phase III trial is called NEAT, N-E-A-T. And as I mentioned, we've completed enrollment. We enrolled 105 patients, 83 in the primary analysis population, and I'll give you details about the study and its operations later in the presentation. The key here, though, is that if we are successful with encapsulated dexamethasone and ataxia-telangiectasia, we have a large list of other rare diseases we can pursue with this same drug.

And next on the list would be Duchenne muscular dystrophy, which would be a really terrific disease target for this particular therapy. And then we have a prioritized list of rare diseases we could pursue thereafter. For the commercial phase, we're already planning ahead even though we don't have our Phase III results yet. But a key element of that will be our recently announced partnership with a company called Option Care, which is an outpatient infusion network around the United States with about 170 different locations in the U.S. And you'll hear from Charles Ryan more about that particular partnership.

Importantly, we were successful in raising some money earlier this year to extend our runway and that extends our runway for several months after we get our top line results from our pivotal trial. So that gives us -- puts us in a good position to get results and thereafter executing additional financing and/or partnerships of some sort, following data in the first quarter of 2026. Well, let's go back to the technology. I mentioned it's a machine. This is a tabletop machine. It can sit on a cart. It can sit at the patient's bed side. It can be put in the lab. It is a mobile machine. It's about the size of an old-fashioned desktop computer, and you see a picture of it here on the top right of this slide.

Over the years, it has been adapted and amended to be a fully automated system now. It's a 17-step process that uses that touch screen you see on the computer -- on the screen on the front of the machine. And essentially, what it does is you take a small volume of the patient's blood, you take 50 mls of the patient's blood, that's about a double espresso worth of blood. And it's in a bag, you hook up the bag to the machine and then you just press start on the touchscreen.

Over the next 90 minutes, what that machine does is it uses a series of hypotonic solutions to slowly swell the cells. They thereby become porous and then you incubate them with the drug cargo. And then as hypertonic solution and excipients will then be used to shrink the cells back down and the drug target gets trapped inside of the red blood cell. Our lead program is dexamethasone sodium phosphate. Dexamethasone sodium phosphate is a previously approved prodrug of dexamethasone. It has a phosphate group attached to it. It's therefore ionic.

And when it gets trapped inside of the cell, it cannot escape because it's a charged molecule. So I can't diffuse across the lipid bilayer. But then what happens over time is intracellular phosphatases will clean that phosphate group. It renders dexamethasone, the parent drug, nonpolar. And then that nonpolar dexamethasone can thereby diffuse out of the -- through the lipid bilayer out of the red blood cell as the red blood cells are circulating throughout the body.

The key to this is to be able to facilitate the safe and chronic use of dexamethasone. So conventional dexamethasone administration looks like this. This is a graph of daily 6-milligram dexamethasone doses. And you can see because of the short half-life of dexamethasone, you get peaks and troughs. So this is 30 doses over 30 days. And regardless of the approved formulation of dexamethasone, whether it's subcutaneous or pegylated or liposomal, you still have to give it frequently enough that you're going to have these peaks and troughs many times over the course of a month.

And when you do that, even at the lowest effective doses, what happens is you exceed these plasma drug concentration thresholds that lead to toxicity. You see 3 dotted lines here, horizontal dotted lines across the graph, representing plasma drug concentrations that if exceeded over time will lead to toxicity.

You see one for glucose sensitivity, you see one for immunosuppression and the most sensitive one is for adrenal suppression. Adrenal suppression is, of course, the most important and the most damaging long-term toxic effect of corticosteroids. And it's associated with all kinds of adverse events that you can see listed at the top of the slide, you get growth delay, delay in puberty, you get weight gain and Cushingoid. It can lead to diabetes and behavioral issues, hypertension, osteoporosis, many, many problems.

So you really can't take corticosteroids for more than a couple of weeks before you start running into these problems related to adrenal suppression. And therefore, despite the fact that corticosteroids would be just a wonderful therapeutic for lots of different diseases where chronic inflammation is a major component of the pathophysiology, you can't take them because they're just simply too toxic. And I'd mentioned DMD, Duchenne muscular dystrophy, previously. Almost every child with DMD is on chronic corticosteroids and it's a major, major problem in their life. So our technology is designed to fix that. And we do that by allowing the chronic administration of corticosteroids while avoiding these toxic drug level thresholds. And let me explain to you how that works.

First of all, in order for corticosteroids to be efficacious, you need a couple of key pharmacodynamic elements to be satisfied. One is that you need an initial Cmax that is high enough to give you receptor saturation or near saturation in important tissue beds. Then what you need is receptor occupation over time, persistent receptor occupation over time. So you need long-term drug exposure.

So you get that with conventional steroids, as I just showed you in that last graph by giving them frequently. But on the next slide, what you'll see, the way we achieve that is to have monthly dosing of dexamethasone that is slowly released from the red blood cell as the red blood cells are traversing your body. Initially, what happens because there's a high concentration entrapped within the red blood cell as you get a peak of concentration. And it's important to have a peak concentration of about 100 nanograms per ml or more, you get that with the encapsulated version.

But then instead of it falling off quickly and having to be redosed, you get this long, slow release of corticosteroid from the RBC over time. And it pretty quickly gets below these plasma drug concentration thresholds that you saw in the previous slide and that are redrawn here at the same concentrations.

Over the first couple of days, you're below the glucose sensitivity and immunosuppression thresholds. And then after about 7 to 10 days, you're below the adrenal suppression threshold. And one question you might ask is, well, you're still above that threshold for 10 days a month, is that enough to generate adrenal suppression?

And the answer to that is no, we have a very strong safety database consisting of about 70 patients that had taken the drug monthly for over 3 years and had no signs of adrenal suppression and no signs of corticosteroid toxicity. And there are, in fact, 3 children that have been taking this now monthly for 13 years back to the original exploratory trial in ataxia-telangiectasia.

And those 3 children have no adrenal suppression and no signs of corticosteroid toxicity after 13 years of administration. So it's pretty phenomenal. And as a drug developer, I would say that's strong evidence that we don't have a safety issue when it comes to chronic dosing of encapsulated dexamethasone given through the red blood cell.

So I'm going to tell you more throughout the course of the day about ataxia-telangiectasia, about our Phase III study, NEAT. But I also want to mention that this really is a platform, a platform that can be used with lots of different diseases where corticosteroids could be really beneficial if they could be given chronically. And again, I think DMD is a good example of the problems that come with the chronic administration of corticosteroids. But this technology has been in development for well over a decade now.

The first machine was developed in about 2008, and there were a variety of investigator-initiated trials starting around 2010 in ulcerative colitis, Crohn's disease, cystic fibrosis and COPD. And all of those small studies showed very interesting results with signals of efficacy and no safety issues. So we are using dexamethasone sodium phosphate encapsulated into the RBC for rare diseases, but we will pursue betamethasone encapsulated into the RBC for non-rare diseases, including some of these you see on this slide.

So with respect to A-T, we'll get those results in the first quarter of 2026. And if that's positive, it really opens the door for us to pursue a variety of other rare disease indications. We'll show you a list of those later in the presentation today. As I mentioned, DMD is the first on that list. And then we will also develop betamethasone for a variety of non-rare diseases, and we'll be announcing that program in the near future. So I'm going to hand it over to Giovanni to take you through some of the technical aspects of the machine.

My name is Giovanni Mambrini, and I'm Chief Technology Officer at Quince. I'm co-founder of our predecessor company, EryDel, in 2008, and I'm pleased to be here today to provide you with insight into our journey to advance our AIDE technology and lead asset eDSP. Over the past 2 decades, we have made significant strides in advancing this innovative technology.

The journey began in 1998, when an initial patent was filed and it was the first of numerous patents on AIDE technology. This moment set the foundation for future development. In 2008, the start-up EryDel was founded, marking the beginning of a dedicated effort to develop the AIDE technology. Red Cell Loader was CE marked in 2010. This regulatory approval allowed the technology to be clinically used in Europe for the first time on COPD patients.

Since the company obtained IND approval in 2013, we have initiated and completed a lot of studies, bringing us closer to our goal. Phase I studies on PK and red blood cell survival in circulation in healthy volunteers. Phase II study on 80 patients, The ATTeST controlled randomized Phase III trial comparing placebo with low dose and high dose arms and the open-label extension study.

In 2021, the Human Factors program was completed. And in the following year, FDA granted a special protocol assessment on pivotal Phase III NEAT trial. In 2023, Quince Therapeutics acquired EryDel and started the NEAT trial right after. More recently, enrollment completion of our Phase III NEAT study was reached in July this year, which set up for top line results in Q1 2026. It's a very exciting time for the company as we work to bring these 20 years after to fruition.

Next, we thought it would be helpful to show you how our unique drug device combination works in the clinical setting. So let me walk you through our eDSP drug encapsulation process. So you can see our technology in action and what the patients experience when they come in once a month for eDSP treatment. So once you have all supplies you need, just switch on the Red Cell Loader or RCL. The RCL is super smart and fully automated with a user-friendly interface that guides you step by step.

You see clear text and images on the touchscreen, making it easy to read, visualize and confirm each action. You'll always know exactly what you are doing and how long the process will take to completion. Next up, you'll install the EryKit on the RCL. For convenience, the EryKit comes preassembled with all tubing and components.

There, EryKit is a sterile all-in-one system designed to handle blood, drugs and solution in a controlled way, thanks to the Red Cell Loader's automation. The EryKit's parts like lines, bags, blood separator, are set up for quick and easy installation. The tubing connects the reservoir and filter pneumatic and runner pumps and the disposable blood separator. The system contains multiple sensors to enable automation and support consistent process outcomes.

EryKit is designed as a single-use sterile components that is disposed off after use, thereby avoiding any possibility of cross-contamination as the RCLs does not come in contact with blood or solutions. The system runs a self-diagnostic test during set up to test the functionality of all actuators. Tubing are automatically positioned around the 3 pumps.

The process requires injectable-grade saline to wash red blood cells and resuspend them before infusion. Two specific hypotonic solutions, hypotonic solution 1 and hypotonic solution 2 are connected to the kit. They are intended to temporarily reduce the osmolarity of red cells and cause their permeability while hypertonic saline solution is used to restore physiological osmolarity after drug encapsulation.

The syringe kit collects a 50 ml of blood from the patient, 2 millimeter heparin are added through a sterilizing filter. The filter is removed and the syringe is connected to the IV cannula. 50 ml of patient's blood is collected. After touching the syringe containing 50 ml of blood to the EryKit, you start the procedure via the RCL's user interface. The RCL takes care of the 18 phases of the eDSP process automatically. The procedure involves preparing dexamethasone sodium phosphate solution 25-milligram per milliliter in a syringe.

As soon as dexamethasone is injected via the port, it enters by passive diffusion into permeabilized red blood cells. The entire process takes about 90 minutes from start to finish, while the patient waits nearby for the red cell loader to encapsulate dexa into their own red blood cells.

At the end of the encapsulation process, the resulting eDSP is transferred to the collection bag for immediate refusion to the patient. So this is an overview of the process that the patient would experience for the once-a-month administration of eDSP.

Finally, a full procedure report is available for download and printing at any time for recordkeeping purposes. We have also gathered a remarkable clinical experience behind the eDSP.

Over the years, this therapy has been applied across a range of challenging conditions, Crohn's disease, ulcerative colitis, COPD, cystic fibrosis and mainly ataxia-telangiectasia. To date, that has translated to more than 425 participants who have received at least 1 dose of eDSP, including more than 240 patients. That truly stand out is the depth of our clinical exposure. We have administered more than 7,800 infusions to A-T patients alone and some of them have been treated monthly since 2012. This experience not only demonstrates the reach of eDSP, but also set the basis for safety and efficacy profile, which we must establish.

Finally, it is worth highlighting that our technology is further supported by a rigorous regulatory review to date. In Europe, we have secured the CE mark ensuring full compliance across new medical device regulation. Our consumable kit reflects extractable and leachable validation that have been secured in compliance with European and U.S. regulations. We also get asked the question a lot about the stability of the system, which is insured throughout our [indiscernible] 17-step automated process that you saw in our demonstration video.

The eDSP system was also designed and deeply automated for high-quality processed red blood cells, which resulted in having an in-vivo life span similar to products for transfusion. And for over a decade, we have maintained an active investigational new drug demonstrating our ongoing commitment to the high standard requested by the agency.

All this to say that a tremendous amount of effort and oversight has been invested in our technology to date and gives us the confidence in our pathway forward. I hope you find this discussion helpful, and I look forward to answering any questions you might have during the Q&A session.

Hello, everyone. Dirk here again. I'm going to walk you through some of the details of our lead indication, ataxia-telangiectasia. So ataxia-telangiectasia is a tragic and terrible pediatric rare genetic disease. It's an autosomal recessive disease. Typically, one mutated allele is inherited from each parent. And typically, the parents don't know that they carry this allele. And it's a rare disease that has about 5,000 patients in the United States. It's primarily at a very young age, neurodegenerative so the children start to lose neurological function around the age of diagnosis, which is typically in the ages of 2 to 4 years. And they typically end up in a wheelchair by about the age of 10 to 12.

And then during the course of their disease and into their teenage years, they develop multiple infections and frequent infections and then cancer and the life span is typically into the mid-20s. And now we'd like to show you a short video of a patient named Shane and his family, which is really illuminating and powerful story about the journey of an A-T patient and their family and what they go through.

[Presentation]

So the typical pathophysiology is that when the child is born there's nothing evidently wrong that child seems normal. And typically, parents don't notice anything abnormal until later in development, maybe around the age of 2 to 3 years of age. There is no prenatal -- standard prenatal testing for this. So it's a hard diagnosis to make because it's so rare. And parents start seeking help with the diagnosis around the time they see some abnormal development. And then as the child gets into the ages of 4, 5 and 6, it's clear that they're having problems walking, learning to walk or persisting with their previously effective walking.

And then as I mentioned previously, their neurological deterioration leads them to end up in a wheelchair around the age of 10 to 12, and then they get infections and cancers throughout their later years and their lifespan at their mid-20s, as I mentioned previously. So this is -- there is nothing approved for this disease. These children get physical and occupational therapy and supportive care consisting of treatment for their infections and their cancers. But there is no disease-modifying therapy ever approved.

We are in the process of trying to change that with our study -- NEAT study in A-T, but the NEAT study was preceded by a study called the ATTeST study, which has been previously published, and you may have seen that publication if you're an investor in the company. It was the largest trial of A-T ever performed with 175 patients around the world. And it looked at a neurological outcome measure called ICARS, which I'll describe to you in more detail and actual modification of that ICARS score, as mandated by the FDA. And the results were good. I'll walk you through those results. But with respect to the primary endpoint, it's called ICARS.

And it's one of these neurological scoring tools that is used by neurologists where you run the patient through a battery of tests, and there's a scoring system associated with each of the tests. It's a little bit like SARA or mFARS or even ADAS-Cog for Alzheimer's disease. You can see here in the left-hand column, the full ICARS score adds up to 100 points. But over the years in the company's communication with the FDA, the FDA changed their focus on which of the elements of the ICARS they wanted most emphasized to reflect the patient -- how the patient feels or functions.

And so over time, they revised what they wanted to see to a subset of the ICARS of 54 points, which is called the modified ICARS and that's the primary endpoint that was used in that ATTeST study. I'll show you some of the results on that study in a moment. And the current primary endpoint for the NEAT study is the endpoint that the FDA has mandated under a special protocol assessment.

We have a special protocol assessment in place for the NEAT study. So if that study is positive, it can act as a single pivotal trial for approval. And the FDA has now dictated that they want us focused primarily on posture and gait to measure how a patient feels or functions. And so that subset of the ICARS scores is 29 points out of the original 100. The good news is when you look back at the ATTeST results and you look at the RmICARS versus the mICARS versus the full ICARS, the RmICARS actually was the most sensitive indicator of change from baseline to month 6.

So it's not a bad thing that we're using the RmICARS that I think of these 3, it is the most sensitive endpoint. Now the ATTeST study was technically a negative study with the P value at the end of the study of 0.07. So they didn't miss by much, but there's a good reason for that, and that's because they studied children 6 years of age and above.

And here, what you're looking at is a graph of the natural history of neurological function over time in patients with A-T. And you can see that from the time of diagnosis about the age of 2 to 4, until they get to be 10 or 12, they have rapid neurological deterioration. And I mentioned a couple of times, they end up in a wheelchair by the age of 10 or 12. You can see thereafter the neurological deterioration starts to plateau out. And in the previous ATTeST trial, the enrollment ages were 6 and above in order to be inclusive and have the broadest label. But the problem in that study was that half of the patients enrolled were above the age of 10, 10 or above. And you can see from this graph that if you're studying neurological deterioration over a relatively short period of time, like 6 months, you want to study the population that's deteriorating the most rapidly.

So you want to look at those years in the green shaded bar. If you're looking to the right of the green shaded bar, your probability of seeing a change in a 6-month period is much, much less. That's obvious from this graph. And that's what they saw in that study. I told you the overall P value was 0.07. So in the overall population, they're narrowly missed. But in that green shaded bar, it was highly statistically significant at 0.009 for RmICARS, the FDA mandated endpoint in the NEAT trial.

And just to put that into context, that's about a 24% difference versus placebo over a 6-month time point. So that's a pretty big change over a short period of time. We looked very carefully at these results before we bought the company that performed the study, and we looked at secondary outcome measures and additional outcome measures. We looked at trends. We looked at a variety of different analyses and different subpopulations. And they all pointed in the same direction, the direction that suggests success in that younger age group.

In addition to the suggestions of efficacy, we carefully looked at safety, and there were no major safety concerns from that trial. There was no adrenal suppression, no steroid toxicity in either the low dose or the high dose group from the ATTeST trial. There was a little bit of a dose response in adverse events. The low dose was pretty similar to placebo actually with the high dose being slightly higher.

The major difference in adverse events between the low dose and high dose were primarily a higher number of infections that were not serious or significant and a higher rate of pruritus. But to me, that's a positive sign because it demonstrates that there's assay sensitivity with respect to adverse event reporting. So there were no safety concerns from the ATTeST trial with respect to the high dose. And that's the dose we took forward into the NEAT trial. So the NEAT trial is just high dose versus placebo.

And you can get all of the details of that previous ATTeST trial by reading the previously published article in Lancet. We also have another article published in Frontiers in Neurology, which describes the long-term open-label extension safety data that emanated from that trial. So a lot was learned from that trial, and we acquired the company that performed it, and we used their work to build upon. Instead of enrolling the entire population of 6 and above, we're focusing it just to that population between 6 years of age and 9 years of age where they're deteriorating rapidly.

And I think that gives us the best probability of success because as described, that's the population that is most sensitive to change over 6 months. And some bad luck that the previous company had was that they ran that study during COVID, and they ran it in places, including places like India and Tunisia, that had a lot of logistical and infrastructure problems related to COVID.

And when that occurred, they had a lot of missing data and a lot of dropouts, which was adverse to their overall outcome. And we've been able to avoid that bad luck. So that makes our statistical powering and our study operations stronger than in that previous trial. This is just an outline of the study design for the NEAT trial. As I mentioned, it's under a special protocol assessment with the FDA. It's being run primarily in the United States and Western Europe, Scandinavia and one Eastern European country, Poland, with 2 sites in Poland.

We've completed enrollment now with 105 patients and 83 in the primary analysis population of 6 to 9 years of age. And that gets us at least power of 90% to determine statistical significance. And on the next slide, I'll describe why it might even be higher than 90% power. But it's just high dose versus placebo. It's 6 months, 1 dose per month with then a 30-day safety follow-up thereafter.

And after the NEAT trial, primary assessment visit is done, the patients have the opportunity to roll into an open-label extension trial. And so far, every patient in NEAT has elected to do so. With respect to the strength of the operations and statistics on the NEAT trial compared to a ATTeST, this is why I think we have at least 90% power to determine statistical significance. The assumptions that went into the sample size for NEAT came from ATTeST.

So the point estimates of response and the confidence intervals around those point estimates came from ATTeST. And those, of course -- those confidence intervals are, of course, affected by the amount of missing data or dropouts because with larger amounts of missing data, you have to use imputation methods that lead to broader confidence intervals.

Therefore, if we have fewer discontinuations and less missing data, we will have more narrow confidence intervals. With more narrow confidence intervals, you have increased power to determine statistical significance. So we use the factors in the right-hand column to determine sample size, but we're ending up with variables that are shown in the left-hand column, we have 6% missing data versus 26% in ATTeST.

So that gives us a tremendous advantage and strengthens our statistical power to determine significance in this trial. So I'm feeling very good about how that's rolling out. In addition to the NEAT trial, we have initiated our PED study. It's called the PED study, P-E-D. It's a study required by the EMA for our pediatric investigational plan. And this study is going to take place in younger children. So instead of taking 50 mls of blood, you take 30 mls of blood.

That results in a dose of about 12 milligrams instead of about 17.5 milligrams. And this study is going to be run in children between the weights of 9 kilograms and 15 kilograms. That will equate to an age range of about 2 years of age to 6 years of age. So this is a mandatory study required by the EMA.

It's primarily a PK and safety study. But we're also using wearable devices. You can't use ICARS or any other neurological assessment physical exam tool in this population because the kids are just too young to follow the instructions. So you can't use what's typically used. What we are doing is we're using wearable monitors on the wrist and ankle so that we can explore different -- there are a lot of things you can do with this wearable device data, but we're going to explore what type of endpoint would be best sensitive and best to reflect function in this population. So that's exciting data to me that will be really informative.

And I think if we can help develop such an endpoint, it would be much superior to these typical neurological assessment tools that we currently use. We are -- we've initiated our operational planning on the study, and we will be enrolling this study at the beginning -- towards the beginning of 2026. And we'll see how enrollment goes.

We will -- if we finish enrollment quickly, we'll include the data in the NDA, but more likely it won't be ready in time for the NDA submission, so we can supplement our U.S. data thereafter and satisfy our requirements for the EMA by finishing this trial. We sometimes get asked about whether there are advocacy groups in this indication because with other rare disease, advocacy groups play a really important role, certainly with diseases like DMD and cystic fibrosis. They're incredibly important to the community.

A-T is much less well known to the average investor, but there are advocacy groups, and we have a very strong relationship with them. The 2 largest and strongest advocacy groups are the one in the United States called the A-T Children's project and the one in the U.K. called the A-T Society. There are a variety of smaller country-based advocacy groups throughout Europe, but they work in conjunction with the U.K. A-T Society.

They do a lot of things together. And so we know people at all of them, but primarily maintain relationships with everyone through A-T CP and the U.K. A-T Society. And they're instrumental in helping us find patients and communicate with the families of patients about the opportunities for being included in our clinical trials.

So just with respect to our chances of success for Phase III, I'm extremely confident. I've done a lot of Phase IIIs in my time. I think I feel the best I have the highest probability of success with this particular trial. And I base that on the fact that we saw those ATTeST trial results previously, and we dug into them very carefully. And I'm convinced that they look good.

We took the best elements of that ATTeST study and then we're producing it in the right population. And as I mentioned, we have a very high statistical power to determine significance. So I'm feeling very good about the results. I'm eager to see them, and we'll get them in the first quarter of 2026. But I'd like to hand it over to Caralee because we sometimes get questions about other than evidence from the ATTeST trial and just evidence about the dexamethasone mechanism of action in general, it's not obvious why dexamethasone as an anti-inflammatory would benefit a neurodegenerative disease.

So we do have fascinating and compelling data from that previous clinical trial with respect to quantitative RNA sequencing and what that means for the mechanism of action. And Caralee Schaefer, Head of Nonclinical Development, is going to walk you through those results now.

I'm Caralee Schaefer, and I'm the Vice President of Nonclinical Development at Quince. I'm excited to share an overview on the mechanism of action of eDSP, and the results of RNA sequencing work that we recently completed. But first, before we get into that, I'd like to show you a short video describing the eDSP mechanism of action.

[Presentation]

Before we get into the RNA seq data, I want to delve a little deeper into the pathogenesis of A-T. A-T is caused by mutations in the ATM gene. These mutations lead to a deficiency in ATM protein, which plays a central role in DNA repair, cellular stress response and immune regulation. The clinical burden of A-T is significant with these young patients experiencing ataxia, immune deficiency, recurrent infections and a heightened risk of cancer.

Progressive loss of neurons is a hallmark of A-T, in particular, cerebellar Purkinje neurons. At the cellular level, the absence of functional ATM disrupts the response to DNA double-strand breaks and oxidative stress. This leads to elevated reactive oxygen species and altered redox status contributing to genomic instability. Importantly, ATM dysfunction also triggers chronic activation of NF-kappa B and then an increase in pro-inflammatory cytokines and chemokines, leading to a persistent neuro inflammation and immune dysregulation. Overall, ATM deficiency results in DNA damage and genomic instability, oxidative stress, mitochondrial dysfunction, chronic inflammation and neuro inflammation, all leading to progressive neuro degeneration.

Next, I want to walk you through the design of our recent RNA sequencing project, utilizing whole blood samples that were available but had never been analyzed before. These are from the prior ATTeST Phase III trial, RNA sequencing was performed to investigate the mechanism of action of eDSP, and to identify biomarkers that may predict treatment response.

ATTeST was the largest clinical trial ever conducted in A-T, featuring a 3-arm design where patients receive monthly doses of either high-dose eDSP, low-dose eDSP, or placebo. Whole blood samples were collected for RNA sequencing at 3 key time points in the ATTeST study, at baseline, immediately before eDSP infusion at month 2 and immediately before eDSP infusion at month 6. It's important to point out that the 2 and 6 month time points were collected around 30 days after the last eDSP dose. So these are considered trough samples.

In total, we successfully sequenced RNA from approximately 300 ATTeST blood samples, spanning placebo, high-dose and low-dose eDSP groups. There were 29 placebo-treated, 33 high-dose eDSP treated and 35 low-dose eDSP treated patients, all with baseline 2-month and 6-month whole blood samples that we sequenced. This gives us a robust data set to investigate the mechanism of action of eDSP, and identify potential treatment responsive biomarkers through gene expression changes. Additionally, we also collected whole blood samples from 10 healthy adult volunteers to use as negative controls. We then compared the transcriptome of all A-T baseline samples from ATTeST to those healthy adult controls. This allowed us to investigate the biology of A-T and potential disease-specific biomarkers.

The next slide describes the RNA sequencing workflow implemented for the ATTeST samples. We completed RNA sequencing on whole blood collected at baseline month 2 and month 6 again at trough. This allowed us to capture stable treatment effects over time. The whole blood was collected in the Pax Gene RNA tubes, which are designed to stabilize RNA for sequencing. From there, we performed RNA extraction, achieving high-quality RNA in over 96% of our samples. cDNA libraries were prepared and the sequencing was performed using the Illumina platform. The final step was bioinformatics and data analysis, focusing on differential gene expression and pathway level changes.

The result is the most comprehensive RNA-Seq data set ever generated from the largest A-T clinical trial to date, giving us a very unique window into both the underlying biology of A-T and how eDSP impacts disease biology at the molecular level. With high-quality RNA sequencing data in hand, we next asked, what does the transcriptomic landscape of A-T actually look like?

This slide presents a comparison between all A-T baseline samples in ATTeST and the healthy adult controls, revealing widespread gene dysregulation and offering critical insights into A-T disease biology. Comparing the A-T patients to healthy adults revealed striking shifts in gene expression with more than 6,000 genes differentially expressed.

This gives us one of the clearest molecular signatures of A-T ever defined. The volcano plot on the right shows gene expression in A-T samples compared to healthy adult controls. On the right-hand side of the plot, past the hatch line, are the genes that were significantly up-regulated in the A-T samples. On the left side of the plot, past the hatch line, are genes that were significantly down-regulated.

Many of these differentially expressed genes are directly tied to disease biology. Key pathways affected in the A-T samples included DNA repair and redox response, which are central to ATM function. We also saw significant reductions in immune-related genes, including those involved in B cell and T cell development, highlighting the immunodeficiency seen in A-T.

There were also significant increases in pro-inflammatory cytokines and chemokines. Importantly, we also observed a marked up regulation of interferon-stimulated genes in the A-T samples, which are known to contribute to chronic inflammation and may service potential biomarkers of disease activity. Additionally, we found significant dysregulation in ion channels, neurotransmitters and mitochondrial genes.

Together, this provides a landmark RNA-seq data set with the most comprehensive molecular characterization of A-T generated to date. With a clear view of the transcriptomic disruption in A-T that I just shared with you, the next slide focuses on how eDSP treatment modulated these pathways, highlighting gene expression changes that provide insights into the eDSP mechanism of action as well as potential treatment responsive biomarkers.

RNA-seq data from eDSP treated patients refilled modulation of pathways directly implicated in A-T disease biology, along with the evidence of the gene expression signature that's consistent with methylprednisolone exposure. First, interferon-stimulated genes, which are typically elevated in A-T and contribute to the chronic inflammation scene were significantly down-regulated after treatment with high-dose eDSP.

Down-regulation of interferon-stimulated genes are the hallmark glucocorticoid gene signature. The significant down-regulation of interferon-stimulated genes by eDSP reflects a marked impact on decreasing the inflammatory state of A-T. These genes may also serve as potential treatment responsive biomarkers. We also saw meaningful changes in immune and inflammatory pathways.

There was an enrichment in humoral immune response genes and a significant reduction in pro-inflammatory gene expression indicating a shift toward a more regulated immune profile after eDSP treatment. Third, we found modulation of neuroprotective genes. For example, Wnt signaling genes, which has been shown to be neuroprotective in other neurodegenerative diseases like ALS, Parkinson's and Alzheimer's were up-regulated after eDSP treatment. Wnt activation has been shown to promote neuron survival, reduce oxidative stress and enhance DNA repair, mechanisms that are all highly relevant in A-T.

Finally, ion channel genes, which are critical for neuron excitability and function were also modulated by eDSP. Since Purkinje neurons are highly vulnerable due to disrupted calcium homeostasis, this finding is very important as it ties directly to mechanisms driving neurodegeneration in A-T.

The graphs at the bottom of the slide show the striking down-regulation of interferon-stimulated genes after high-dose eDSP treatment. Interferon alpha gene shown in the graph on the left, and on the right, we're showing interferon gamma genes, all down-regulated after eDSP treatment.

Overall, these results reveal novel insights into the mechanism of action of eDSP as well as potential treatment responsive biomarkers. The next slide offers an overview of how high-dose eDSP impacted gene expression in ATTeST, highlighting the key pathways and their therapeutic relevance. On the left, the bar chart highlights the direction of change across these key pathways with significant suppression of interferon-stimulated genes and inflammation and up-regulation of adaptive immunity, mitochondrial function and neuroprotective genes.

The robust suppression of interferon-stimulated genes is a hallmark of glucocorticoid activity while the down-regulation of NF-kappa B dependent pro-inflammatory cytokines and chemokines quite directly reduced inflammation after eDSP treatment. Mitochondrial dysfunction drives neurodegeneration in A-T and we saw up-regulation in mitochondrial genes that play roles in both restoring energy metabolism and function, which is consistent with neuroprotective effects.

We also saw up-regulation of neuroprotective genes and neurotransmitters that promotes synaptic resilience and neuron survival. Excessive calcium influx leads to mitochondrial stress, oxidative damage and cytotoxic neuron death. Ion channels are known to regulate neuron excitability and calcium homeostasis. And modulation of these genes stabilize neuron firing and protect against Purkinje neuron dysfunction and death. Overall, the key takeaway here is that high-dose eDSP, not only reproduced the expected glucocorticoid gene signature, but also drove modulation of key disease-relevant pathways, including inflammation, oxidative stress, neuroprotection and ion channel biology.

The next slide summarizes the key goals and results of our RNA seq project and some next steps that we're taking to build on these results. Our [ HS ] RNA seq project was designed to expand our understanding of A-T biology, demonstrate that eDSP has a measurable biological effect and show that the magnitude of those changes is meaningful compared to other traditionally administered steroids. First, we obviously succeeded in expanding our knowledge of A-T biology. By comparing A-T samples to healthy adult controls, we identified over 6,000 differentially expressed genes, providing a comprehensive data set for discovering potential biomarkers of disease activity.

Next, the data revealed novel insights into the eDSP mechanism of action with the significant number of genes differentially expressed after treatment. These gene expression patterns were similar across both the 2- and 6-month time points. Notably, this activity was measured at trough approximately 30 days after the last eDSP dose, confirming that eDSP has sustained and durable biological effects throughout the 30-day treatment period.

Lastly, Pathway analyses uncovered evidence of a classic methylprednisolone gene signature, reinforcing that eDSP engages steroid responsive pathways, while also revealing unique treatment responsive biomarkers. Looking ahead, we're working to correlate gene expression changes with clinical outcomes and genetic mutations in the ATTeST trial, and we're continuing to investigate potential disease-specific and treatment responsive biomarkers. Importantly, the RNA seq results that I've shared today have been confirmed using an orthogonal method, which is long-read DNA sequencing, which underscores the robustness of this data set. We're very excited to continue to pursue this work and expand upon this landmark data set from the largest clinical trial ever conducted in A-T, which we believe will be foundational for the discovery of biomarkers of both disease activity and eDSP treatment response.

The final slide summarizes the synergistic mechanisms of action of eDSP including a unique and optimized PK profile that enables sustained dexamethasone exposure, while avoiding severe toxicity, improving both safety and efficacy, optimized glucocorticoid receptor occupation, maximizing exposures and improving efficacy, systemic and targeted biodistribution to the CNS.

And importantly, eDSP engages both genomic and nongenomic glucocorticoid pathways, providing immediate as well as long-term anti-inflammatory immunomodulatory and neuroprotective effects. And given the compelling transcriptomic data from ATTeST, we are really optimistic about the potential of eDSP to deliver the first disease-modifying treatment for A-T, which would be an incredible step forward for patients and their families.

In closing, I thank you for your time, and I look forward to answering any questions you might have during our Q&A session.

Hi. My name is Pamela Williamson, and I'm serving as Head of Regulatory Affairs for Quince Therapeutics. It's my pleasure to be able to take you through a high-level overview of our current regulatory planning. By way of background, orphan drug designation has already been granted by the U.S. FDA and the EU EMA for the treatment of A-T.

As you may know, Orphan drug designation provides certain benefits in each of these jurisdictions, including, but not limited to, waiver of certain fees such as the application fee, which in the United States can be several million dollars and also affords marketing exclusivities following approval for those first to market.

In the United States, we've also been granted Fast Track designation by the U.S. FDA for treatment of A-T. This affords the company additional opportunities for interactions with the FDA to move the program through more expeditiously and hopefully to approval. While not guaranteed, Fast Track designation often connotes the opportunity for priority review once the application is submitted, which allows for a shortened review clock.

The eDSP system is regulated in the United States as a drug device combination product. This means that the primary center for review at the FDA will be the Center for Drug Evaluation and Research, however, they will also consult with the Center for Devices and the Center for Biologics. The eDSP system devices and the single-use treatment kit are already EU CE marked, further derisking the evaluation of the device components in the United States.

Next slide, please. In the United States, the Phase III NEAT trial, which is the pivotal Phase III trial, is being conducted under a U.S. FDA special protocol agreement. The SPA includes the primary endpoint of the rescored modified ICARS tool with a primary efficacy population of the 6- to 9-year olds. The FDA has reviewed and agreed with the design of the protocol and also the statistical analysis plan.

In Europe, there's also a pediatric investigational plan referred to as the PIP. In the United States, a pediatric investigational plan is not required. It's waived when you have an orphan drug designation. In the EU, we will be conducting an additional study, which is about to commence for those patients that weigh between 9 and 15 kilos, so smaller patients that are currently in the current NEAT trial.

The design of this protocol has also been agreed to by the PDCO in the EU. In the United States, the regulatory pathway that we will be following for the NDA is referred to as a U.S. 505(b)(2) pathway. This allows sponsors to rely on data and findings from outside of their program in order to support FDA's review of safety and efficacy. In this particular context, because dexamethasone has been approved for many, many years and is very well characterized, we will be able to rely upon nonclinical data not generated by the company. Therefore, additional nonclinical studies are not expected to be required. Ultimately, the U.S. NDA submission is currently planned for the second half of 2026 given that the recruitment has been completed and we anticipate data readout in Q1 of 2026.

I'd be happy to answer any questions that you have during the upcoming Q&A session.

Thank you. Hello. My name is Charles Ryan, and I serve as President of Quince Therapeutics. In my role, I oversee a number of functions and activities, including legal, finance, quality, day-to-day management of our Italian operations as well as working closely with the team to support our effort to prepare eDSP for commercial launch. So let me begin by talking a little bit about the commercial opportunity that we see ahead for us for our lead indication of A-T. At a high level, A-T represents a rare opportunity to provide a real benefit to patients and create a $1 billion-plus market.

To ensure we fully capture the scope of this unmet need, we have completed extensive work to understand the true size of this market, both from a prevalence, physician and payer perspective. We estimate that the prevalence of A-T patients is approximately 5,000 patients in the U.S. I'll get into the details in just a moment. Assuming we have success with our final clinical study, we are also in an advantageous position as eDSP holds the potential to be first to market to meet the high unmet need of A-T as there are currently no approved therapeutics on the market.

Our prospects are further supported by attractive comparables in rare disease with a number of recent launch analogs that we can look to that provide us with a good line of sight and understanding of pricing dynamics in this area. We're also in a strong position from a financial perspective, and we stand to benefit from both a highly scalable manufacturing infrastructure and a very low cost of goods.

And finally, relative to exclusivity, we have an orphan drug designation, a very strong patent position and additional technology barriers that should serve us well and provide for long-term market exclusivity. And all of these factors translate into the $1 billion plus opportunity in A-T alone with more opportunities ahead for Quince. So let me talk about each of these things in a little bit more detail, beginning with existing epidemiology.

Unfortunately, epidemiology in the literature is not great. And what is there is from the '70s and '80s before genetic testing was even available. Instead, we turn to third-party resources, and we partnered with IQVIA, which is one of the leading providers of work in this area, and you'll see our findings here. We worked very closely with IQVIA to go through their medical claims database. And we found approximately 4,600 diagnosed patients with A-T in the U.S. by utilizing ICT 10 codes to validate the number of diagnosed patients. And we were able to corroborate this patient finding size with a genetic prevalence study conducted at Baylor University that found approximately 6,000 patients in the U.S. using a genetic database.

Comparatively, that helps to look to Friedreich's

Ataxia, which has a very similar epidemiology and market size with 5,000 diagnosed patients in the U.S. So all of these factors give us confidence in this starting place for accurately sizing the U.S. market at approximately 5,000 A-T patients today, creating a very strong commercial opportunity for us. But we are also aware that because there's no currently approved treatment, there's a number of patients out there who could have A-T who don't currently present in the marketplace.

To that end, we think we can increase the number of treatable patients with additional market awareness, increased testing, working with our partners at key advocacy groups and launching an approved product for A-T patients. So we believe that once we get the drug approved and it's launched, we're actually going to see some greater awareness in the marketplace, both with caregivers and patients.

And this should actually help improve the commercial size of the opportunity ahead for us. The key takeaway is that we believe that this is a strong starting place as eDSP is well positioned to meet the high unmet need in A-T, quickly becoming the standard of care.

Now you've heard from Dirk and others speak about the patient journey from diagnosis to rapid neurodegeneration. That's further complicated by frequent infections, respiratory issues as well as heightened risk of cancers. Unfortunately, patients really have a very challenging time in the earliest of days with this devastating disease. Our goal at Quince is to offer eDSP treatments as soon as possible, targeted at the neurological symptoms that prevail throughout the entire A-T patient journey.

What that means from a commercial perspective, we will seek every opportunity to expand access to this therapy. While the NEAT study is focused on treatment effect in patients 6 years and older, you've also heard that we're beginning a pediatric study to reach smaller, younger children with the hopes of providing our treatments to kids early in their life and having them on eDSP as soon as they're diagnosed for the rest of their life.

As we introduce the drug to the marketplace, we also recognize that we're going to gain a deeper understanding of the impact of our therapy for these patients. And as we collect more data with eDSP over time, we hope to see a reduction of infections in cancers and hopefully extending life, all of which will certainly help advance and support our commercial efforts. Another important factor that will underpin prospects for commercial development is to capitalize on our first-to-market potential and establish eDSP as a standard of care in A-T by matching the benefits of our innovative therapy to the clear unmet need in this space.

First and foremost, A-T is underdiagnosed and the time for diagnosis is quite extensive. With increased awareness, the company's a first-to-market therapeutic, along with support from KOLs and advocacy groups, we expect to bring increased awareness and diagnosis to support early treatment. And since there is no existing therapy today, our focus will be on communicating the value of eDSP to hopefully help modify or even slow the progression of the disease, which will be the key value proposition.

Another standout is our ability with a successful readout to validate not only the efficacy of steroids for the treatment of A-T, but also to dose steroids chronically and safely without toxicities, opening up another therapeutic avenue that is simply not currently available. And finally, current treatment options are really just limited to things like physical therapy and other types of supportive care with the goal of retaining ambulation as long as possible.

Our hope is that our therapy will play a role in keeping kids out of wheelchairs and dramatically altering the life of patients day-to-day. Put it all together, an eDSP really checks all the boxes, a first treatment that directly addresses the key challenges patients with A-T and their families and caregivers face. Since this is a drug device combination, one thing I wanted to highlight here is the work we're doing around a number of supporting materials that are required to run the red cell loader.

We've worked with a leading provider in understanding the best way to organize the materials for each monthly infusion, and that's reflected here in the eDSP EasyKit. Our goal is to launch a product that is easy as possible for physicians and infusion centers to use with no issues, while establishing clear processes that promote consistency and quality from one site to another. It's also going to improve our packaging footprint, and we'll be able to just drop ship materials as needed and help streamline supply chain overall. I'm pleased to say that we've completed this work. The final prototype is ready. We filed the patent application, and now we're working to select the commercial CDMO, so we'll be launch-ready.

So now let me talk to you a little bit about other companies across the A-T landscape. Given the size of the potential commercial opportunity, the development pipeline for A-T is quite minimal. In addition to Quince, there are a few other players that are looking to provide a treatment for ataxia-telangiectasia, which are summarized here. I won't go through each of these assets. But I do want to note that we are uniquely positioned in many ways.

We have the benefit of positive Phase III efficacy signals from our previous ATTeST study, which is very encouraging to us. We also have treated hundreds of patients already, and we know that our therapeutic is both well tolerated and has a very good safety profile. And for the patient, our treatment is a once-a-month therapy that delivers benefit throughout the entire course of treatment. I would point out here that [indiscernible] is the only other therapeutic in late-stage development.

Our current Phase III trial includes patients of over the age of 4 and only provides treatments for 3 months, which increases the difficulty for their trial, but we'll be watching this one closely. However, as is the case with many severe diseases, our therapy currently has ability to be dosed concomitantly should one of these assets advance to approval and be available for physicians and patients. But we have a lot of confidence in the prospects of our success for all the reasons I shared.

Now let me talk to you a little bit about pricing. We continue to do the work to understand our market and all of our stakeholders. Certainly, in drug development, one of the key stakeholders is the payers. To that end, we recently conducted a qualitative payer research study. This study involved qualitative research with payers that covered more than 200 million lives in the U.S., quite extensive in terms of the coverage of patients.

Our initial research was both insightful and encouraging. What we learned is that many of the payers were not immediately familiar with A-T. This wasn't surprising to us as the lack of knowledge of A-T reflects the absence of sponsor engagement due to the modest product development pipeline I just discussed. However, what was encouraging is that within just a limited amount of education, payers quickly understood the graveness and burden of the disease and a significant unmet need, and that our asset really holds the potential to dramatically alter the life of patients with A-T for the better.

So we really found a very supportive voice within the payer community. In terms of pricing, we have a number of comparables with other rare disease therapies that have recently come on to the market, which you see highlighted here on the right. But we certainly have more work to do in this area. After the completion of the NEAT Phase III study, we will have a comprehensive data on efficacy and safety, and now we can establish the value of eDSP and our pricing. Then we will continue with a more thorough quantitative payer research study to gain a deeper understanding of what price points would be appropriate for this therapy, and we'll keep you updated on that progress.

In terms of effectively delivering this therapy, in early August, we announced an exciting partnership with Option Care Health. Option Care Health is the nation's leading outpatient infusion provider. They have more than 180 sites around the country, which will allow us to have the ease of a single contract provider while benefiting from greater geographic flexibility to match patients locations with sites strategically located throughout the U.S.

So as we gain a deeper understanding of our patient community, where they're located, we want to do everything we can to make sure that we can provide our therapy in the easiest way possible for these patients. And certainly, going to an Option Care Center where you pull up and walk through the front door is much easier than navigating a large major medical center especially when these kids are not highly mobile. This strategic relationship will also play a role in improving and standardizing the patient journey with higher control and consistency across Option Care sites, while offering a comprehensive suite of enhanced capabilities to handle commercial services for us as well.

Finally and importantly, Option Care will also allow us to have the ability to roll out other therapies like treatments for DMD and to leverage this partnership to execute these programs seamlessly to support our pipeline expansion. So it's a really exciting program for Quince. And we're delighted to have Option Care as a partner in providing eDSP to patients.

Lastly, let me tell you about our substantial market exclusivity position and how we believe we're well protected from generic competition. Because eDSP has orphan drug designation, we automatically get 7 years of market exclusivity here in the U.S. and 10 years in Europe. This is a really significant amount of exclusivity. But in addition to that, we have an extensive patent portfolio and our patents run until 2036, with some additional extensions available. And we also have other patents that we are currently pursuing.

In terms of technology barriers, as you know, this is a drug device combination, and our red cell loader has a lot of proprietary components and processes that would make it very difficult for a generic competitor to copy. For example, they would need to have extensive clinical studies and processed validation to even considering copying our technology. So we really look at our technology as having a unique position in the market in terms of our ability to have competition kept at bay.

In closing, we are very excited about the market opportunity of eDSP, with the potential to be the first approved therapy for A-T, an area with no existing treatments. And we believe eDSP has true blockbuster potential. We have engaged leading consultants with proven success in commercializing rare disease therapies, and we are working closely with physicians, patients, caregivers and payers to ensure a successful and timely launch. We are confident that eDSP can deliver a meaningful impact for patients and significant value for all of our stakeholders.

Thank you so much for your time, and I look forward to answering your questions during our Q&A session.

Hi, everyone. I'm Brendan Hannah, the COO and CBO of Quince. You've heard a lot of great information from our team so far today. But now I'd like to spend some time detailing how we believe our efforts will translate into driving value creation for our shareholders. Quince is very well positioned with a highly innovative asset that has potential to be the first steroid that can safely be delivered chronically.

We're lining up for a very large value inflection point with Phase III data coming in Q1 of next year with a differentiated rare disease asset in an indication with no currently approved therapies. And given the profile of eDSP being a very potent, let's say, steroid, there's a large number of different indications we can go into to significantly increase the value of the product and then the company as a whole.

We're in a great capital position. We finished Q2 with about $35 million in cash, which provides a runway through Phase III data and into the second quarter of 2026. We're also setting up for both strategic and financing activities following data like [indiscernible] capital all the way through launch.

Now taking a look at the orphan disease landscape. Over the past couple of years, there have been several rare disease drugs launched as the first product for a disease, which we believe serves as a strong comparable for eDSP's commercial potential. These drugs are Daybue for Rett syndrome, Skyclarys for Friedreich's ataxia and Vyjuvek for DEB.

These were all launched with premium pricing in the small populations and are forecast to attain at least $1 billion in peak sales. And what's interesting here is that within 18 months of launch, they were all on annualized run rates of about $400 million, either primarily or exclusively from U.S. sales. So it shows the pent-up demand for new products and indications, particularly in rare disease where nothing currently exists like that in A-T.

A great case study is Reata's Skyclarys for Friedreich's ataxia. The epidemiology and market size for Friedreich's are roughly similar to that of A-T with about 5,000 diagnosed patients in the U.S. Skyclarys is the first drug approved for Friedreich's and has forecasted peak sales of over $1 billion. Both Friedreich's and A-T have very similar symptoms regarding ataxia and then moving towards non-ambulation, but A-T is actually more severe and has a shorter life expectancy.

And from clinical trials, Skyclarys has shown modest efficacy in its Phase III study at 48 weeks with some significant adverse events while eDSP has shown a much larger effect 6 months in the younger population and was well tolerated. But shortly after launching Skyclarys, Reata was acquired by Biogen for over $7 billion, which just goes to show the value of a rare disease drug in a population of 5,000 patients in the U.S., especially considering Skyclarys can't be used for other indications.

With A-T alone, we think there's potential blockbuster sales. But given the profile of eDSP being a potent, let's say, steroid, there's a significant number of indications we can go into. We completed a comprehensive analysis of a wide variety of indications where steroids are standard of care or would be if it wasn't for steroid toxicity. And then we assess each potential indication with a few key factors in mind.

First, we narrowed down the list based on indications allowing for the same pricing as A-T, then we condensed it to chronic diseases where patients would be treated on an outpatient basis. With an eye towards commercial synergies, we also focused on pediatric indications that could be sold through a single sales force. And we only targeted orphan indications that would not trigger IRA price negotiations. Another one of the key variables was diseases with over 5,000 patients in the U.S. given that it appears to be a standard cutoff for many investors and potential partners.

And then to do the final cut, we interviewed KOLs and treating physicians to understand if eDSP would be viable clinically and commercially given the current treatment landscape and development pipeline. And to give you a better idea of the disease funnel, we've reviewed nearly 100 indications at this point and narrowed the list down on epidemiology, competitive landscape, commercial opportunity, steroid usage and clinical impact.

We narrowed the list down to 20 diseases following interviews with KOLs and treating physicians better understand the unmet need and commercial opportunity for eDSP. And then we did a final cut down to 12 indications based on clinical trial size, timing, cost, feasibility and probability of success. So as a result of this robust diligence process, we've selected DMD as our second indication to follow A-T.

And then we prioritized rare neuromuscular, autoimmune and rheumatological diseases where patients will be willing to go in [indiscernible] for an infusion given the severity of their disease. These indications should allow for similar pricing as A-T and there is a significant commercial opportunity in each of these potentially allowing for hundreds of millions of dollars of sales per indication, if not more.

And then given the wide applicability of eDSP and unmet needs in many of these indications, there is ability for it to become a blockbuster product in multiple indications. But from this assessment, DMD was the clear second indication. While it's seemingly crowded competitive landscape and commercial market, there are a significant amount of unmet needs in DMD, especially in the steroid space.

Regardless of other drugs that patients are on, steroids are standard of care in DMD, they usually add 2 to 4 years of ambulation. So even a patient is on the gene therapy or an exon skipping therapy, they're still on steroids and the vast majority of toxicity, which leads to tapering dosing, intermittent dosing or fully taking the patient off the steroid. So the physicians we've talked to said that DMD is the obvious second choice for eDSP, as patients are currently losing out on efficacy while still having toxicity.

So if we can provide equivalent efficacy while mitigating the safety issues, treating physicians have said that they want to try it out in the vast majority of their patients. And the clinical team has finalized 2 different clinical study designs, one in treatment-naive patients that we used for approval and the other in patients transitioning from standard steroids, which would be more of a real-world use case. Then we plan to start dosing patients in these studies next year.

To provide a quick comparison of eDSP to other steroids commonly used for DMD. On the left side, you can see prednisone/deflazacort, which are standard of care and they have reasonable efficacy but a whole host of safety issues. Whereas Agamree was launched about 18 months ago by Catalyst in the U.S. and it doesn't hit the bone as much as it doesn't have growth suppression and seems to have less osteoporosis, but it still has all the other steroid-related safety issuance.

So it's definitely better than the older steroids, but it's viewed as only an incremental advancement. But given the comprehensive safety data package of eDSP in over 600 years of patient safety data, we believe that eDSP has a fundamentally different safety profile that allows for steroids to be dosed safely, chronically.

And moving on to finance. We finished Q2 with about $35 million in cash that provides a runway through data into Q2 of next year. We have a very capital-efficient operating model and development plan for A-T and plan to use investigator-initiated studies to get data in additional indications.

And given that we own worldwide rights to eDSP, we have the ability to partner ex U.S. rights following Phase III data to provide additional runway as we start preparing for our own U.S. launch of eDSP. We've also had a very robust engagement with investors and potential strategic partners, hopefully setting up for a range of different options post Phase III data. I hope you found this helpful and I'll be happy to answer any questions you may have during the Q&A session.

Well, thank you, everyone, for joining us today. I hope you found the [Audio Gap] Okay. I think that was a great overview of all the activities we're working on. I'd like to open the floor to questions now. This is Dirk, by the way. Jon, you're on mute.

Can you guys hear me now?

Yes.

Sorry about that. Jon Wolleben from Citizens. Thanks for hosting the day. Very helpful information. I just want to focus in on the upcoming readout, Dirk, and I was hoping you could...

I cannot hear you.

Can you guys hear me now?

Yes. Yes.

For the upcoming readout, what are your powering assumptions? And then when we look back at RmICARS, you gave us those 2 charts showing the more sensitivity for RmICARS versus the other endpoints. But wondering if you could -- I'm confused by the placebo-adjusted benefit and then the worsening of symptoms. So can you tell us if the change is driven by stabilization and worsening of placebo or a drug effect? And then when you talk about worsening of symptoms on a scale like this, is this like patients have any worsening? Or is there some categorical consideration to say that their symptoms have worsened?

Okay. Let me start with the question of powering and then I'll move on to RmICARS versus ICARS and the magnitude of change versus placebo over time. So I mentioned this in my part of the presentation, but the statistical assumptions for powering the NEAT study came from a test and the test had that problem with 26% missing data.

So the confidence intervals around the point estimate of response were wider than we will see in ours. Nevertheless, those are the assumptions we use to come up with the sample size originally of 86 patients. As you'll recall, we ended up enrolling 83 of the planned 86. It was powered at 90%. And I think we're at or above 90% because we only have 6% missing data versus 26% that was used for the data set that generated the statistical assumptions.

So does that address the question around the powering.

What's the effect size you're powering for though?

I think it was -- Brendan, you might have it in front of you, but I think it was at [ 2.14 ] points versus placebo.

Correct, 2.4 points against placebo and then confidence intervals of 3 for active and 3.7 for placebo.

Yes. Okay. So now with respect to your question about, is this disease-modifying or delays progression? So the placebo group gets worse over time and the ICARS score goes up over time, and the treated group stabilizes. So it's really a delay in progression of disease and 2.4 points of an RmICARS is pretty significant over a 6-month period relative to placebo. It's about a 24% difference. So the full ICARS itself is divided into different domains. You have gait and posture, kinetics, speech and oculomotor and each of those 4 domains has a number of points.

And over the years when the FDA started narrowing down what they wanted to look at, they focused more and more on the gait and posture domain. So when you get to -- from the ICARS to the RmICARS, you end up going from 100 points to 29 points. And most of those, the vast majority of it is in the gait and posture domain.

So really what we're looking at when we look at a 2-point difference versus placebo, it's mostly with respect to the ability to walk. And a 2-point difference, for example, could be -- could mean for RmICARS the difference between walking autonomously and walking with help. So it's a big -- it's a very clinically significant difference over that short period of time.

This is Elemer Piros from Lucid Capital Markets. So I would like to go back to the RNA sequencing study for a moment. Is there a difference between low-dose and high-dose eDSP in terms of the magnitude of the changes in gene expression that's...

There was a very strong dose response that was one of the exciting things that we saw in that data set, but I'll let Caralee expand upon that.

Yes, Dirk is absolutely correct. There was a dose response, especially in the genes that we highlighted today to you. We really wanted to focus on the high dose for this presentation since that's where we saw efficacy in ATTeST and where we're focusing NEAT.

And have you been able to pick up a signature and the difference between responders -- medical responders and nonresponders?

Great question, and we're actively working on that now. So stay tuned.

Okay. And I just have two more. I don't know, Dirk, if you talked about the size of the pediatric trial that the EMA requested. And was there a discussion about the wearable device? Or what sort of potential efficacy indicators you might be able to pick up? Was it their suggestion? Or was their requirement purely focused on the safety aspects?

Their requirements are purely focused on PK and safety, and I did not mention the number of patients, which is 12 evaluable patients dosed over 6 months, 6 doses over approximately 6 months. It's only safety and PK. And the wearable device was my idea, and I had to battle some of my team members to actually implement it because it's expensive and it's not generally considered standard. But I think these devices, to me, they're really interesting because they will -- they have the potential to be far superior to these physical exam tools that we use right now.

So we don't know exactly -- it's exploratory work. It hasn't been discussed with either agency in Europe or the U.S. But we'll collect a lot of data, and we're working with academic investigators who have experience in these neurological rare diseases to look at a variety of different endpoints. I don't expect that we'll be able to use it for any type of efficacy claims, but I do think it will be extremely valuable for guiding future work. That's especially important in these young kids, too, because you can't even use these neurological assessment tools. You can't walk them through the physical exam components in order to do the score.

Yes. I just have one more, maybe for Charles. When you look at the IQVIA data and look at the geographic distribution of the patients and compare it to the footprint what Horizon has. Roughly what percentage of the 5,000 patients would be close enough to these infusion centers to go on a monthly basis?

So our analysis is that we could capture at least 80% in a very close geographic range so you certainly could have some outlier patients that are in a more remote area. But the nice thing about Option Care is that they have a very significant footprint, and they're continuing to expand. So we think that there's a lot of flexibility even relative if we were to have some pockets of populations that were not geographically connected now that we could actually resolve that.

And it looks like we have a couple of questions from Hartaj in the chat box here. One is I'm going to direct to Pam. Well, the pediatric trial, I think he's referring to the PIP requirement from the EMA, supplemental NDA, get a pediatric priority review.

And I don't think that's the right way to look at it because it's a requirement at the EMA to study the safety and PK in that population. It's not designed to get an indication. But Pam, do you want to -- is that correct? Do you want to expand upon that?

Yes, I can. So of course, you cannot request a priority review until you actually submit the marketing application or in this particular example, the supplemental marketing application or NDA. However, if the main application receives a priority review, there's no reason to suggest that the smaller weight children supplement would not also receive a priority review.

Importantly, for the study that we're referring to in the EU, the data being generated are indeed safety and PK primarily, as Dirk has described with an exploratory use of the wearables. But those data are then intended to be included in a currently existing PK and simulation model, which would allow confirmatory dosing in those smaller patients, which we anticipate could in fact allow the supplement to be supported in terms of efficacy for the small children.

Okay. Second question is assuming a positive Phase III in an approval of the product in A-T, how long will it take to screen, treat and record revenues from an A-T patient? This lag can often affect first and second year revenues. Brendan?

Yes, I can handle that one. So it's going to depend on the patient. Some are already known and either in a registry with ATCP in the U.S. or known through IQVA or one of the genetic testing databases. So with them, it's going to be much quicker. They'll have to go through the patient hub, usually work through a prior authorization with the physician and then we'll be able to record revenue shortly thereafter, hopefully within a month or two as we'll be shipping just in time to each Option Care site.

For those that haven't been confirmed as A-T yet, they will need a genetic test likely for the prior authorization. So that will take additional time to actually get patients diagnosed, work through the patient hub, get them on therapy and record revenue. So it's going to be dependent on patient.

Jason here representing Leland Gershell in Oppenheimer today. Great presentation and progress so far. I have two questions. First is going to be what disease-specific biomarkers or treatment responsive biomarkers are you going to be looking at as you build on the RNA sequencing pathway analysis? And do you have any insight on how that might map to the NEAT trial outcomes?

The short answer is not exactly, not yet, but I'll let Caralee walk through some of the details there.

Yes. We're taking a broad look at the treatment responsive biomarkers on all possibilities from the ATTeST study. We're also going to be doing this in NEAT. And we'll focus especially on anything that comes out confirmed through the DNA sequencing that we're doing as well on the same samples.

Great. And one more question. So unlike A-T, there are a couple of steroids approved for DMD, some of which are generically available. I guess how do you see eDSP's opportunity given the landscape and how you're thinking about positioning that product?

Yes. I'll say a couple of things, and then I'll let Brendan expand on some of the commercial details about it. But -- yes, if you go to the last couple of years, I've gone to the DMD academic conference, a big academic conference. It's a really interesting conference because it's very much patient centered and there are a lot of patients and their families that attend the conference.

And one thing that's very obvious when you go to this conference is that a lot of the discussion is focused on the problems associated with the therapies and corticosteroids are the primary therapies for almost all of the children despite ASOs and gene therapies, almost everyone is on steroids, and it is -- other than the underlying disease, it's the biggest problem in their lives. It causes a lot of adverse events.

They get a lot of weight gain, they get Cushingoid, behavioral issues, osteoporosis, they develop diabetes. So it's a major, major problem. And deflazacort and vamorolone have slightly different safety profiles and some marginal benefits. But even when you speak to the KOLs in this field, they'll tell you, they're still steroids. They're still very, very toxic.

So I think if we can demonstrate that we have comparable efficacy, doesn't need to be better efficacy, just comparable efficacy and we can eliminate the adverse effects. And this was, by the way, EryDel years ago did a study in ulcerative colitis, where they took steroid-dependent patients and they randomized them to converting over to encapsulated versus staying on their current steroid and then they weaned both groups. And upon weaning, 80% of the patients that remain on standard of care had a recurrence and only 20% in the encapsulated group had a recurrence and all the steroid toxicities resolved. So that's what we want to see in DMD.

We want to see that the efficacy is the same or even better maybe, but the steroid toxicities resolved. If that happens, it's not -- it's less convenient than taking a pill, you have to go to the clinic every month. But if we can demonstrate that we're likely going to have a different price point. So we anticipate. And this is where I'll hand it over to Brendan, but will anticipate you'll have to step through a couple of therapies before you're authorized to take ours, but I'll let you carry on from there, Brendan.

Yes, Dirk is completely right. So there's likely going to be step edits for prednisone/deflazacort and even vamorolone before getting to [ EDSD ] given the premium price point. And as he mentioned, nearly 100% of these patients have toxicity. So we don't expect there to be issues with prior auths given that the first and second line steroids are considered toxic. So even with a small percentage of DMD patients, you're still getting to very significant sales with about 15,000 DMD patients in the U.S.

Great presentations. So I just had a couple of questions with regard to the timing of the NDA filing. What needs to be done before you can file the NDA? And how quickly can you supplement the NDA?

When you say supplement, are you talking about...

Pediatric.

Yes, yes. Okay. Well, the first thing that has to happen is we have to have positive data. So that's the thing we're all eagerly looking forward to in the middle of Q1 next year. And we're already planning and working on elements of the NDA as we speak. But I'll let Pam outline for you kind of the major milestones along the way in the NDA process. And with respect to the -- she can add comments about the mechanism by which we would supplement with the younger data, the PIP data, but we don't yet have an exact idea of how quickly we'll be able to enroll that study.

I'm not sure if it will go quickly or if it will be a little bit challenging. We do have a bunch of pre-identified patients and we only need 12, so it's possible it could go pretty quickly. And most of the patients should be eligible because the screening criteria are not extremely strict. But Pamela, I'll let you kind of walk through the major milestones along the way with respect to the NDA filing.

Sure. Thanks, Dirk. So as we've mentioned, we are looking forward to seeing top line data in Q1 2026. And assuming that those data are positive, we have a very good plan in place to efficiently develop and submit our NDA in the last half of the year. We intend to continue, and frankly, we are already engaged in routine discussions with the FDA as we move forward here to make sure that what we include in our application is going to meet their standards.

And as I mentioned during the earlier presentation, in addition to the actual protocol, which has been reviewed and agreed by the FDA, they have also reviewed and agreed to the statistical analysis plan. So prior to database lock, we intend to provide the final versions of those documents. And then after top line data are available, we'll move forward with our -- earnestly with our NDA submission process. We have work streams in place already for each of the functional areas.

We have plans in place for inspection readiness. We have plans in place for pre-submission meetings with the FDA prior to submission of the NDA to make sure that we're all on the same page with respect to the content and format of what will be included. And then we look forward to submitting last -- towards the end of the year. While we mentioned it cannot guarantee a priority review, we have every reason to believe that the application in the unmet medical need, assuming positive data that we would be eligible for a priority review.

When it comes to the second part of your question and the pediatric study that's ongoing in the EU, as Dirk has mentioned, we don't have timing for completion of that study yet. If it's not completed in time to include in the initial NDA, then that would be submitted as a supplement as you've indicated earlier, and that would be submitted as soon after the initial NDA approval as possible.

Okay. Great. And in terms of the label expectation, is it that it will be 6 years and older initially. And once you have a supplemental, it will be from 2 years and older?

So while we can't -- until the final label negotiations are completed, we can't state that emphatically, but my speculation would be that they would not necessarily need to be a limitation of 6- to 9-year olds, especially since while the primary efficacy analysis is on the 6- to 9-year olds, this study is actually enrolling patients above -- 10 above. And that was actually at the recommendation of the FDA, so that we were not excluding the older patients, even though the efficacy signals for the older patients may be more difficult to detect.

And that group of older patients isn't included in the primary analysis population, so it doesn't have an adverse effect on our chances of success for the primary outcome measure.

Looks like we're coming up at the end of our time. Thank you very much for joining us today. There was a lot of effort to put this together. So it's great to see people actually show up and listen to it, and thank you for your great questions. And we look forward to updating you as we generate more news throughout the rest of the year and into next year when we'll have data from the Phase III NEAT trial. Take care, everybody.

Good morning, everyone. I'm Andrew Fein. I'm one of the biotechnology research analyst at H.C. Wainwright. It's my pleasure this morning to host a HCW @ Home event, even though many of you probably are not at home, with Quince Therapeutics. Here from the company are its CEO and Chief Medical Officer, Dirk Thye; and Brendan Hannah, its Chief Operating Officer and Chief Business Officer.

So thank you both very much for being here this morning. We appreciate it. And maybe with that, the best place to kind of kick off is for people less familiar with the story, maybe you can give an overview and kind of speak to your focus on rare diseases, and then we'll go from there.

Sure. Thanks, Andrew. This is Dirk Thye here. I'm the CEO and the Chief Medical Officer, and the name of the company is Quince Therapeutics. We have a drug device combination, which is a platform technology. It's a machine, a tabletop machine that takes blood a small volume of blood from a patient, 50 mills, so about the amount of double espresso. You take that amount of blood in a syringe, you hook it up to the machine and you process the blood to encapsulate a molecule inside of the patients on red blood cells. So it takes a small volume of autologous blood and you're capable of putting a drug, a small molecule, a large molecule or even a protein inside of the patient's red blood cells.

And then a couple of hours later, for the blood has been processed, you reinfuse that back into the patient. And depending on what that molecule is, it may have a variety of benefits. In the case of our lead compound, it's dexamethasone. It's actually a prodrug of dexamethasone, dexamethasone sodium phosphate. And the advantage of putting dexamethasone into a patient's red blood cells and giving it back to them is it facilitates what we believe is an efficacious dose. We're in Phase III right now to prove that. But it facilitates giving steroids chronically without any toxicity which, of course, is -- would be a huge medical advancement.

And we already actually have quite a bit of safety data to support its safe use over many years. This technology has been in development now for about 20 years, about $100 million of venture capital money has gone into it. We acquired the innovators of this technology 3 years ago, a company out of Italy called EryDel. We've been working on it over the past 3 years and advancing it now into Phase III.

There are -- going back to the Phase II studies, the original Phase II studies in our lead indication, which we'll talk more about, it's called ataxia telangiectasia. There have now been 3 children receiving it monthly for 13 years, and they have no evidence of adrenal suppression and they have no chronic steroid toxicities. And then going back to the previous pivotal trial that EryDel ran, there are about 70 patients that have been receiving it now for over 3 years on a monthly basis. it's a monthly dosing. And they also don't have any adrenal suppression or any chronic toxicity issues related to steroids.

So we have a lot of evidence that this is method of giving steroids chronically without any toxicity. And the task now is to prove in Phase II that it's efficacious for this initial indication of ataxia telangiectasia, and if that's true, then thereafter, we'll be able to chase many, many different applications, both within rare disease and outside of rare disease.

Maybe given the seemingly broad-based applicability of the technology, maybe you can speak a little bit about the process by which you chose your initial indication? And why it's a natural spot in which to deploy the assets?

Yes. I think that's definitely worth discussing. We get that question why AT? Most people have never heard of AT. And as I just said, there are many, many diseases that could benefit from chronic steroids without toxicities. And some of it is -- some of the decision is a logical intellectual exercise and some is just serendipity, but I mentioned that this company, EryDel, had been working on this technology for 20 years, and they did pilot studies in a variety of diseases. They studied cystic fibrosis. They studied inflammatory bowel disease, both ulcerative colitis and Crohn's disease. And they also looked at rare disease like AT.

The data in ulcerative colitis is actually pretty impressive, extremely impressive, but they pivoted to rare disease about over 10 years ago. And the reasons were that were primarily regulatory and commercial, as everyone knows, it's a lot cheaper and easier and faster to get an approval in an indication, a rare disease indication with nothing approved that is to go into something like ulcerative colitis that is a more complicated landscape of approved therapies where there's still a medical need, but the clinical trials would be bigger, longer, more complicated, more expensive.

I think EryDel rightly believed that going into a disease like ataxia telangiectasia, where there's a big medical need, small population, but a big medical need when nothing approved allows one to do a placebo-controlled trial. And in the event that you have some good efficacy, a rapid pathway toward approval. And they, EryDel, previously performed the largest ever clinical trial in that indication, ataxia telangiectasia and had very compelling data in a subset of populations that would -- if you go back and look at who should be studied in the ataxia telangiectasia disease indication, within that group of patients, they had very, very compelling data.

So after we acquired them, it was the obvious choice to continue for a next indication, but it also places the drug squarely within rare disease, which is a good thing. And within rare disease, we've looked at 70 different diseases that we could pursue, and we've got a list of about a dozen that we would want to pursue after this first indication. For example, Duchenne muscular dystrophy, almost every child with Duchenne is on steroids.

And the over many years, there's been a big effort to find new types of steroids that don't have the same toxicities and there have been a couple of new steroids introduced, deflazacort and vamorolone, that have a slightly different AE profile, but steroid toxicity is still a huge problem in that population. And so there's another obvious place to go with this drug. And then there are, like I said, they're other indications in rare disease that we would like to pursue.

So AT, which I can explain in more detail during the course of our conversation is the fastest least expensive way to get a foothold within rare disease and it's a placebo-controlled trial in an indication with nothing approved. So it's a really good place to start. And then we can -- if successful, we can move on thereafter.

And then just so everyone is clear, the technology is steroid agnostic, right? You can put you can use any steroid theoretically in the technology to encapsulate it in the patients on red blood cell?

Yes, we've started with dexamethasone because there's that long history of use in those other indications with dexamethasone, and I'll have to describe why putting it in a red blood cell matters. But because dexamethasone now -- it's actually dexamethasone sodium phosphate, it's a prodrug formulation of dexamethasone that has been approved. It's a generic drug. Because we're using that for rare disease, the commercial approach of course for rare disease is different than for non-rare disease.

So for non-rare disease, we'll be initiating soon development program for betamethasone. And betamethasone and dexamethasone sharing a lot of pharmacological properties. They have some slight differences, but they're very similar. But betamethasone can be pursued for non-rare disease things that would be more appropriate, for example, for a Medicare population like rheumatoid arthritis or like the ulcerative colitis indications I mentioned earlier.

And so what -- maybe it's worth before we get into AT a bit, just explain to folks what happens on the intellectual property front. How does IP play into use of these generic drugs in your technology? And what happens with IP issuance? And how does that get impacted?

Right. It's not IP around dexamethasone sodium phosphate itself, which I mentioned is generic and will be pursue the approval will be pursued through a 505(b)(2) pathway, but I'll hand it over to Brendan to discuss the IP portfolio and how that protects both the machine and the process.

So we have IP around the machine, the process of encapsulating different drugs inside the patients on red blood cells and then the treatment of AT. But in addition to that, we also have orphan drug designation and to come up with your own generic, you'd have to come up with your own machine, your own kit, likely run the full battery of safety and efficacy studies. So it's a huge barrier for any merit company to come out with a generic version of it.

That's very helpful. And maybe just as a follow-up, just the regulatory process post the Phase III data. What is the regulatory process look like?

It's an NDA. It's a 505(b)(2) approach. It's regulated through CDER,CDER, the DN1 division of neurology. And although they run the review process, they get consultations from both the Biologics division, CBR and the Device division.

Okay. Got it. But CDER captains the process?

Yes, CDER DN1.

Very helpful background. Okay. Perfect. So maybe with that as the backdrop, you can spend a few minutes speaking more specifically about AT because as you mentioned, it's not an indication that there's a tremendous amount of familiarity with. So maybe you can speak to the unmet need, the prognosis of the patient journey and kind of give people some sort of background on patient numbers and all that kind of stuff?

Sure. Well, it's a terrible disease. I've been in our discussions with investors, I've been a little bit surprised with the lack of familiarity in AT because the epidemiology is very similar to Friedreich's ataxia, about 5,000 children in the United States and another 5,000 in the major markets in Europe with this disease. So in terms of pricing -- in terms of just market size, epidemiology and pricing, it's very similar to Friedreich, which a lot of people know about. But I think many people don't know about ataxia-telangiectasia because there hasn't been really any significant drug development other than EryDel's previous attempt, there hasn't been much research in ataxia-telangiectasia.

But there's a really large medical need. These kids are very, very ill. They're born more or less normal. It's an autosomal recessive genetic disease. So you inherit 1 allele from each parent or in some cases, you could inherit 1 allele and then have a spontaneous mutation and the other allele. Vast majority of cases are inherited. And at a young age, there's apparently nothing wrong. But then when the child starts to go and develop around the age of 18 months to 3 years or so, the parents will notice some oddities in development and some movement problems.

And usually, it gets -- it's a very hard diagnosis to make. Usually, the diagnosis is made somewhere between the ages of 2 and 4 years of age. And at that point, the primary symptom is that the children start deteriorating neurologically. So their development slows, their growth slows and their movement improvement doesn't progress like a normal child. And from the age of around 2 to 4 from diagnosis until the age of 10 or 12, they have rapid neurological degeneration. And they usually end up in a wheelchair by the age of 10 or 12. They also develop speech difficulties during that time due to the neurological problems.

And then as they grow older, they also have problems with immunosuppression, so they get repeated infections and then they develop cancers and their lifespan is typically into their mid-20s. There is a slight spectrum of severity of disease, but the classic disease fits what I just described. So there's nothing approved for no disease-modifying therapies. These children just get supportive care. They get physical therapy, occupational therapy, psychological family support, they get treated for infections and possibly treated for cancers. But yes, they typically die in their 20s. So it's a very, very terrible disease.

And so the ability to treat them with steroids could potentially be disease-modifying to the extent that it would delay the progression of the disease, hopefully, by a number of years, thus delaying the delaying the degeneration that leads to being in a wheelchair and possibly even helping with infections and cancers over a period of time. The best way to think about AT is that the ATM gene is a gene that sits really high in the biological cascade of events. So it's involved with cellular proliferation and maturation and it has a really important role in DNA double-stranded repair.

So the easiest way to remember why these kids get problems is that if you interfere with double-stranded DNA repair, you're likely to have problems and cell populations that divide really rapidly or can't repair themselves. So neurons don't divide rapidly. They rarely divide it all. And so if you have a cellular dysfunction and a neuron, it's very hard to replace it. So that's why they get neurological damage. And then their immune system cells, there's high turnover in those cells. So those cells die off really, really quickly. And then of course, without double-stranded DNA repair, you're prone to developing cancers as well. So that's why they have those 3 main areas of pathology.

Very helpful. So in the context of the current standard of care, where does steroids fit in? What's kind of the ideal time to start them? And what limitations do physicians encounter where your use of your technology might offer a key advantage?

Yes. I mentioned there's nothing approved, and there's also no real standard of care, except for supportive care and steroids are not typically used off-label for this disease either. And the reason is because they're toxic and their toxicities exacerbate some of the problems with the disease like immunosuppression. But the whole rationale behind why this might work if you had a safe steroid, why am I work in this indication comes from initially a case report about 12 or 15 years ago, there was a case report of a child with an asthma exacerbation who was treated with a course of short-term course of steroids. And it was reported that their neurological dysfunction rapidly improve during the time they were being treated with corticosteroids.

So that led a few different groups to do some studies in this indication, small pilot studies, academic studies in small numbers of patients around 6 to 10 patients and they were using low-dose steroid regimens in an effort to avoid the toxicities and see if they could generate some efficacy in these populations. And there were some signals of efficacy. But in all cases, and I think there were 3 main studies, and they tried different regimens and they try different approaches to avoid toxicities like 1 day on, 1 day off, 2 weeks on, 2 weeks off. But in all cases, they did see a little bit of efficacy, but in all cases, they had toxicity issues.

And the toxicities are a big problem because you don't want osteoporosis in this population that's already going to be wheelchair-bound. You don't want immunosuppression because they already have problems with infections. So it was never adopted as a standard of care. However, if you could have the benefit, the anti-inflammatory and the other biological benefits of steroids related to the pathophysiology without the toxicity, then it could be a huge advantage. And so that's where it doesn't make sense to use dexamethasone alone. But if you can encapsulate it in the red blood cells and eliminate the toxicities, then it does make sense.

Great. And maybe before we move on, you can just go back for a moment. and speak to the learnings from the work that EryDel did in terms of how you factor that into your trial design and how your current trial design reads out -- excuse me, differs relative to what EryDel had done?

Okay. Yes. I think it will be helpful to show a slide here on the slide. So yes. I was able to share it, but I'm not able to manipulate -- here you ago, okay. Okay. Let me show you -- can you see this?

Perfectly.

Okay. This is a graph demonstrating neurological function over time using a scale that measures different neurological functions to scoring system. So basically, the line going down means you're getting worse, and this is following a group of patients longitudinally over time. So you can see that from the time of diagnosis when you're on the order of 2 to 4 years old until you're 10 or 12 years old, you're going to deteriorate really rapidly. And then thereafter, your neurological dysfunction is going to plateau partially because you're already in a wheelchair, but also just then you've lost so much neurological function that the tests that you run to measure neurological dysfunction, they rely on gait and lower limb function and a lot of some upper limb things and some vocal and ocular things.

But by the time you're at above 10 or 12 years of age, the neurological dysfunction really slows down. So if you were to design a study looking at neurological dysfunction over a short period of time, 6 months, which is what EryDel did, if you're selecting a population for a study, you would obviously want to select this patient population in the green bar that's deteriorating really rapidly because that's going to be the population in which you have the most sensitive effect.

What EryDel did was they studied children 6 years of age and older, and they didn't limit they didn't limit the number of older children that could be enrolled. So what happened, I think they wanted a broad label and because these studies are hard to enroll, they wanted to facilitate enrollment. And I believe they were confident about the effects of their drug and children of all ages. So what happened in their study is they ended up enrolling half of the children who are younger in the 6- to 9-year old age group and half of the children were 10 years of age and older.

So the younger population that you would expect to do very well actually did extremely well. In the FDA-specified end point, which is the one on the right here called the RmICARS. It's a neurological scoring system that I can describe in more detail if you want. But that's the one that's specified by the FDA as their desired primary endpoint, and it's the one that is specified in our special protocol assessment with the FDA for our ongoing Phase III trial.

If you look at that younger age group with that endpoint, they did great, highly statistically significant. If you look at the 10-year and older population with that same endpoint, you saw very, very minimal difference, as you would expect. So if you were to design a de novo, like I said, you're going to want to target these patients. So that's what we're doing. We saw those results and it was a prespecified subgroup for the EryDel studies, that 6- to 9-year old population. So we took that population, and we're repeating a Phase III study just in that group of patients with a single dose of encapsulated dexamethasone sodium phosphate versus placebo over a 6-month period.

And just remind people of the timing?

Enrollment has completed. We enrolled 83 patients. And I should also mention the FDA asked to include at least 20 patients over the age of 10 years, but they're not included in the primary analysis population for the reasons I mentioned, and that's agreed to under the SPA. The purpose for including patients over the age of 10 is to collect safety information, we do have efficacy, but it won't be statistically powered to look at differences there so that you don't have an age restricted label. So there are, I think, 22 such patients, 10 years of age or older included in the study for a total of 105 patients. And we will get top line data in the middle of Q1. So in February of 2026, we'll have top line data.

Okay. Great. So maybe now we can move on a bit to the platform. If the Phase III data are positive, maybe you can speak to read through. I mean, to what extent should people think about probabilities of success if you're successful in this clinical study to additional use of other corticosteroids in your technology, whether it be for DMD or other indications that you might pursue down the road, to what extent does come a derisking event for the platform?

Yes, it's a good question. I think the derisking is all about efficacy, do we have the right dose to prove that it can be efficacious in a disease where it might benefit a patient population? Because the dosing due to just the pharmacokinetics and pharmacodynamics of delivering it through red blood cell, it dramatically changes the biodistribution, the pharmacokinetics, the pharmacodynamics. So you can't think of this as a one-to-one dosing equivalent. Dexamethasone is dosed typically at about 6 milligrams per day. And so over the course of 30 days, you'll have 180 milligrams.

With ours, over the course of 30 days, you'll have about 1/10 of that. 1.4 milligrams on average over the course of 30 days because it's a once monthly dosing regimen where the drug is very slowly released out of the blood cell as the cells are circulating. So and that's sometimes hard for traditional pharmacologists to get their head around because the PK/PD relationships are so much different for this. So that raises questions about, well, is that the right dose? You have such a low dose? Is it going to be effective because we know that low doses give an IV, given that low are not going to be effective?

So that's the real question that's being answered here because as I mentioned at the beginning of our discussion, I believe I already have enough data to convince pretty much any regulator anywhere on planet Earth that this is safe I mean we set 3 kids have been taking it for 13 years monthly with no steroid toxicities, and we've got that group of 70 that have been taking it for over 3 years. So it's definitely a safe way to give steroids. If we show that it's also an efficacious dose, then that opens up a ton of other indications, beginning with DMD because that will be one of the first questions people or physicians that treat DMD and their families will ask is, well, how do we know this is going to work. We already know steroids work, but yes, we have toxicities, but we know how to dose them?

So if we demonstrate an AT that, yes, this has important biological effects that can help with neurological pathology that will be very convincing. And in addition to that safety data, we haven't published it yet because we haven't finished our analysis, but we do have quantitative RNA expression profiles from that previous Phase III study that demonstrate that we have, at trough levels, at 1 month after a dose on months 1, 2 and 6 at trough. We have significant biological effects as measured by gene transcription. It's quantitative RNA.

So that's another supportive data point, extremely supportive data point to show that even with these lower doses, 30 days after a dose, you are still affecting gene expression in a very significant manner. -- through a variety of pathways, upregulation and down regulation of genes involved with neurological transmission, mitochondrial function and inflammation pathways.

Are there learnings from the previous early-stage investigator-led studies in different indications comparable to the learnings you described in AT where you know you can use the previously generated information to figure out perhaps the ideal segment of a patient population to pursue or how to think about disease severity when enrolling the clinical study or aside from DMD, are there natural spots you can foresee taking the asset to going forward?

Yes. But every disease is different. So you have to -- every disease has a little bit of a complicated -- AT is the least complicated because there's nothing approved and you could do a placebo-controlled trial. But for example, in DMD, there are several steroids that are used and approved and a lot of kids are on, and you can't do a non-inferiority study because that would be huge and take forever and be extremely expensive. So every disease is a little different. So you have to analyze where is the medical need within the patient population with that specific disease. What is the competitive landscape? How can you design a study that's at least feasible from a timing and financial viewpoint. So it's hard to make generalizations about all the diseases as a group.

But I guess, one thing that is tangentially related to what you said about, is there anything in the body of evidence that EryDel previously generated that can help guide us on what to study, there is -- while you're asking that question, I was thinking about the previous data in ulcerative colitis because that was extremely informative. So what they did was they did a pilot study where they took patients with ulcerative colitis or Crohn's, and the patients were steroid-dependent. So they were in remission but steroid-dependent and they had a history of steroid dependence.

And then they randomized this group of patients -- I think it was on the order of 30 patients or so. They randomized into 2 groups, one that would stay on their steroid regimen, or one that would get converted over to encapsulate dexamethasone. And then what they did in both groups is they tapered the conventional steroid regimen. So the control group would get tapered to basically placebo. They get tapered off steroids. And then the active group would get tapered off, but they're still getting encapsulated at approximately 1/10 of the dose.

And in that study, over time, they had the control group that ended up basically they were steroid-dependent and their steroids are tapered, they had an 80% recurrence rate. And in the encapsulated group, they had a 20% recurrence rate. So that demonstrates that the encapsulated dose was able to maintain remission in these patients. Furthermore, these patients all had preexisting steroid toxicities and the steroid toxicities resolved in the group converted over to encapsulated. So that's extremely strong supportive evidence of the fact that these lower doses when encapsulated into red blood cells do have an efficacious effect in diseases where anti-inflammatory properties are important and it's also extremely compelling evidence regarding the safety profile.

So that helps guide us with respect to your question about what do you know from that? I mean it helps guide us at least in ulcerative colitis or Crohn's disease on which types of patients might benefit, how we might design a study I'm not sure you could pull off that tapering to placebo arm these days, but that was done quite a while ago. But it also tells us about dose and the different components that we might be able to measure over time and the relative time course of effect for those variables.

Very interesting. I guess is there something in the pharmacokinetic or pharmacodynamic work that you've done, which sheds light on the right equation to think about in the context of dosing? Or how do you approach it when thinking about new indications?

Yes. Let me show you something really important because it's a little bit complicated for -- it's complicated to just explain this for the first time because like I said, people think they think about dexamethasone on a milligram per milligram basis, but these are completely different ways of delivering the drug to the tissues where it's having an effect. So you can't just think about, oh, is it this many milligrams per kilogram given over this period of time because they're totally different.

So this is just a graphic of how it works. You take the blood, you run it through the machine. This is what the machine looks like sits on a table top. You take the blood of 50 mills, not very much blood, 1% of your circulating blood volume. You hook it up to the machine over 90 minutes, it uses a series of hypotonic solutions to condition the wells to make them porous incubate them with the dexamethasone somodium phosphate and then hypertonic solutions and excipients shrink the cells back down and the dexamethasone sodium phosphate gets trapped inside of the cells. It doesn't quickly leak out of the cells because the phosphate group is ionized so I can't diffuse across the lipid by layer.

But then what happens intracellularly is intracellular phosphatases will cleave that phosphate group, and it renders dexamethasone nonpolar -- and so dexamethasone, the nonpolar native dexamethasone will diffuse through the lipid bilayer as the red blood cells are traversing throughout the body. And those red blood sets are going to spend more time in tissues with large capillary beds like the lungs or the brain or the spleen, and there's also going to be cellular turnover in the spleen. So you're going to have dexamethasone being in golf directly by macrophages.

So there are a lot of complicated and hard to study variables related to biodistribution and immunology. But simply from a PK perspective, it takes the PK curve over 1 month that looks like this. This is a standard dexamethasone dosing 6 milligrams per day, and you give it once a day, over 30 days, the PK curve looks like this. Even if you're dosing the lowest effective dose of dexamethasone, you are going to continually exceed these toxicity thresholds I mentioned the list of toxicities for corticosteroids. They're up here. You get hyperglycemia that leads the diabetes and immunosuppression. But the most sensitive parameter is adrenal suppression and even at low doses, you're going to get adrenal suppression after a week or 2 of steroids. And those are the big problems that people have who need to take steroids over time.

So this is what it looks like if it's an efficacious dose of steroids and note the Cmax here because it's important. We take that PK curve and we change it to look like this over 1 month. So it's a once monthly dosing of the encapsulated drug. The important features that are required for efficacy for corticosteroids are an initial Cmax, a Cmax of about 100 nanograms or per mill or more is important to create near saturation in different tissue beds of the corticosteroid receptors, and that's demonstrated most clearly in studies in ARDS from COVID.

So with conventional steroids, you can get that Cmax, no problem. You just have to keep dosing it. With our dosing, you're going to get that Cmax of above 100, but then what you need is receptor occupation over time. With conventional steroids, you get receptor occupation over time by giving it frequently. And that's true, by the way, of alternative formulations, pegylated or liposomal or IM, IV, subcu. You have to give them frequently in order to get the persistent receptor occupation.

But here, you have this long tail of drug exposure as the red blood cells are circulating throughout the body. And that's what gives you, we believe the persistent receptor occupation that will lead to efficacy. Now the proof will be in our Phase III AT results. These things are very hard to study nonclinically for a variety of reasons. But the proof of weather this PK curve actually leads to efficacy will be this Phase III results in February of next year.

I think that was very helpful. Maybe given the time remaining, we can shift a little bit to the AIDE technology platform. And maybe you can just explain people what it is and given an old view and how it works and how it's better than conventional therapies?

The AIDE platform?

Yes.

Okay. Well, yes, that was basically what I was just showing there.

Yes. I guess maybe you could speak about how it I guess you touched upon it but I think the question comes up about how does it compare to liposomal or pegylated steroid delivery?

Okay. Yes. I think my best answer for that without getting more complicated is what I just said. So what we call AIDE is just the process of encapsulating drug inside of a red blood cell. It's Autologous Intracellular Drug Encapsulation. We call it AIDE. But it's essentially what I was just describing on the slide about what this machine does. So this is the machine. It sits in the clinic or in the lab or on a tabletop or on a cart wherever the clinic wants it to. It's not hooked up to the patient, you just take the blood from the patient and you connect the syringe of blood to this machine. It's fully automated software-driven process.

You can see the touch screen here. You hook up the bags of fluid in the tubes and you push start. In over 90 minutes, it will encapsulate a molecule doesn't have to be dexamethasone sodium phosphate. It will encapsulate a molecule inside of the red blood cells. So depending on -- you're going to have different effects depending on what you encapsulate dexamethasone or betamethasone, phosphate will have the advantages that I demonstrated with those PK curves where you have kind of your initial Cmax, and then you have this long, slow tail, and that will provide benefits for steroid delivery.

But you could, for example, put an enzyme inside of a red blood cell. So enzyme replacement therapies have issues with enzyme degradation or immunogenicity when they are injected. -- you could put an enzyme replacement therapy inside of a red blood cell. In that case, it would be a totally different approach because the enzyme would just stay within the red blood cell and you'd have to get the substrate to get inside the red blood cell to be metabolized.

So that's the exact opposite of what we're talking about. We're talking about taking a drug and having it leak out you could also take a therapy and put it in the red blood cell and have the substrate brought in for metabolism. So depending on the disease that you're approaching, there are different methods you could use to provide advantages. I think for us, dexamethasone, betamethasone. Those 2 things are alone are enough to keep me busy for the rest of my life. We could study 100 different indications and we can study rare disease with dexamethasone and non-rare disease with betamethasone.

For other applications such as enzyme therapies or other drugs, you could put chemotherapeutics in there. you could do a lot of different things. We would approach those via partnerships just because it would be impractical for us to try and do everything. But that would be the idea with the technology platform. Hopefully, if we show that it works, it will open the eyes of potential partners to start thinking about what other applications they might be able to pursue with it and so that we could enter into research partnerships with them.

And Andrew, going back to your point about technologies to extend the half-life of steroids like pegylation or liposomal dexamethasone, we have seen some of those compounds taken into the clinic, and it does significantly extend the half-life, but it appears that they're still having the same steroid-related AEs. So by encapsulating it inside of patients on red blood cells, it seems like it changes the PK enough to have to be fundamentally different where you're not seeing the steroid related AEs from it.

Got it. Can you speak a little bit about the, either of you, the machine itself and maybe learnings from the European experience in terms of machine placement, how do you decide which clinics have the machine? Is it something someone buys? How does all that work logistically?

Go ahead, Brendan.

Yes. So the plan is to provide the machines for free to the site. And we have a partnership with Option Care. That's the biggest outpatient infusion network in the U.S. They have about 180 sites. And they'll handle the administration, the pharmacy, the 3PL distribution patient hub. So it makes it much easier for a small company to launch a product on their own and use essentially a single contracted entity as opposed to going out to 50 different centers of excellence.

So the machines are pretty cheap, and we think at peak will need about 50 sites in the U.S. to cover at least 80% of the AT patients within a 90-minute drive of each site. But using Option Care makes it much easier for the patients as opposed to going into a big academic center where you're parking a half mile away, going up and down stairs, elevators, and a lot of these patients are not highly mobile, they can just pull out right at the site, get their blood drawn within 15 minutes and be out within a couple of hours.

So the patient experience is going to be much better. And then the reimbursement pathway is, well, since we'll be providing the machines for free, what we will be charging for is the monthly administration kit. So that's going to include the drug, the process solutions, the tubing, everything you need for each infusion and the direct cost tickets on that are incredibly low. And then that's going to be reimbursed under the medical benefit like a standard on monthly infusion.

All right. Very helpful. Maybe you can kind of speak about kind of maybe the open-label data you guys have seen so far and what can signal about the durability of effect?

Okay. That's a good question. So there was an original Phase II study performed in a relatively small number of patients. I think there were 20 patients or so, and that was 13 years ago. And as I mentioned, several of those have continued under a compassionate use program in Europe. And then there was the original study that EryDel performed that we previously talked about, and we have 65 or 70 still ongoing in that open-label extension several years later. And then our current trial also allows for open-label extension following the end of the 6-month treatment period for up to 2 years. And so far, 100% of the patients that have completed the 6-month treatment period have elected to go into the open-label extension.

So I guess just based on the number of patients and families that decide to continue therapy in an open-label manner, I guess that's anecdotal information that they believe they're getting something beneficial out of it because we're still in the research phase. So it's not always convenient for these patients to get to the clinic. A lot of them actually have to take a flight for significant distances to get treated every month. So it is for them, quite a commitment. But despite that, they've continued.

From a purely scientific perspective, it's really hard to justify definitive conclusions about efficacy in the open label. So it's open label, it's noncontrolled, there's no placebo group. Historical comparisons with natural history studies are fraught with all kinds of scientific confounders. So I don't think you can make definitive -- basically, there's no good natural history data set for this disease. So even making such comparisons would be difficult. And if we tried would be highly criticized I'm sure by the scientific community. So I don't think you can make definitive conclusions with respect to efficacy, but you can for safety because safety is very clear.

There are physiological parameters that we measure over time. Lots of blood tests. We look at weight, height growth curves. Even growth curves are hard to compare to natural history data sets. But overall, it's clear that there are no safety liabilities over many years when this is given monthly. So I think that data set is going to be highly supportive for our NDA. On efficacy, I think it's a much stronger argument for in a double-blinded placebo-controlled setting. So I think that's what's going to drive the efficacy conclusions.

And we have heart, too, from some of the PIs and the open-label extension of when patients drop off drug just because it was too much flying every month for the child that they had a pretty rapid decline as well, like maybe on placebo.

Very interesting. I guess with the caveat that ultimately, it will be driven by what you show from an efficacy perspective, just broadly, how are you thinking about pricing the AT indication right now?

Yes. So from a pricing perspective, we're still doing payer research at this point. But based upon initial care research in the U.S. and recently launched rare disease drugs. It seems like the $600,000 to $700,000 per year range is kind of standardized now for a severe rare disease like this and similar epidemiology.

That's helpful. And then on the strategic partnership you mentioned that you guys signed with Option Care. Did they assist in the marketing at all or it's simply the deal simply focuses on having the machine at their infusion sites?

Yes. So they're purely administration and 3PL and pharmacy. And so the marketing would be coming from us. We think with having option care, we can have a very capital-efficient commercial organization likely maybe at peak, 10 reps and 5 MSLs should be able to cover the vast majority of the U.S. So it's something that a smaller company launching their first product, that could be bite-sized for them and actually feasible.

I mean, given the proximity of the data release, right, next February, how do you think about kind of the right time to start laying the groundwork from a commercialization perspective?

So we have been doing some of the groundwork of patient sizing working with Option Care, building out the plans for T minus 24 to launch. But I think the big inflection point is going to be Phase III data. And from that point, we're going to go full speed all the way through launch.

I'll quickly post data release, do you think you can give folks clarity on the regulatory process and the expected timing there in and all that sort there?

Well, drug device combinations are definitely more complicated and harder and have longer time lines to NDA than molecule drugs, average for small molecules is around 6 months, and the average for drug device combinations is about 10 months. But we have a couple of advantages in our favor that could shorten those time lines. One is that the device itself, a lot of work has gone into it over that 20-year period, it's actually already CE marked in Europe. So the device is approved in Europe as a demonstration that it does reliably and reproducibly what it's supposed to do, which is encapsulate molecules. But it's not approved for use with the drug in Europe, of course.

So the regulatory pathway in Europe is a little bit different for that reason. In the U.S., it's regulated as a drug device combination. But the fact that it's 505(b)(2) simplifies the drug product, which is dexamethasone sodium phosphate the drug product aspect of the NDA is more straightforward, and we've already completed our 3 validation batches for the manufacturing of that. So CMC, which is typically rate limiting for NDAs. And if something goes wrong in CMC, it takes a long time and a lot of money to fix it. So that is quite derisked in our case and will allow us to expedite our filing.

And then I mentioned the machine work that we're already writing up the aspects of the NDA with respect to that. So it's going to be -- and because it's 505(b)2, there's no significant nonclinical portion of the NDA. So all of those things make it a little bit easier for us. I mean we'll be shooting to beat that 10-month time line. I anticipate it will be somewhere on the order of 7 to 9 months, hopefully. And we should be able to guide people with more clarity, I would say, by the middle of next year, middle of 2026. So data will become come in mid-Q1. And then by midyear, we should have a clear idea on the specific timing of the NDA.

Great. Well, I guess, we're almost out of time. So maybe I'll leave it to you to offer any final thoughts sort of touch upon something that maybe have not touched upon.

Well, I appreciate the opportunity to try and get this in front of a broader audience. We bought this company 3 years ago, and Brendan discovered the opportunity. And when he showed it to me, it is a little complicated at the machine and the device, but the ability to give steroids in an efficacious manner without toxicity is would be huge I mean not just for rare disease, but imagine all the non-rare diseases in all the different populations and how it would radically transform your ability to treat many, many different diseases.

And I don't -- I think that's been underappreciated. When we talk to investors a lot of times we focus on AT because that's the near-term opportunity. And people try and compare this to regular steroids as well and this is a fundamental transformation if we show that it's efficacious in AT, it's a fundamental transformation of how one could use steroids in many, many different areas. So to me, having worked drug development, biotechnology for many years, it's the biggest opportunity I've ever worked on. It's groundbreaking and trying to get people to think of it in that way, as has been surprisingly difficult.

So hopefully, this discussion opens people's minds a little bit to think about this differently, but I'm really excited about the future. And I think our chances of success in AT are very, very high. The average Phase III study might have a 65%, 67% chance of success. I put ours at over 85%, and I base that on all the variables we discussed previously with respect to the previous Phase III trial that was done and the data in the subpopulation that we're studying right now. So I think we're in great shape, and we're not too far away from the answer. So in February, we'll find out.

Great. Well, very exciting. We're on the precipice of a potential transformation, I suppose. So thank you. Thank you very much for speaking with us this morning. We appreciate it. Both of you.

Okay. Bye now.

Bye.