Amylyx Pharmaceuticals, Inc. (AMLX) Earnings Call Transcript & Summary

Good afternoon, and thank you all for joining us today to discuss the Interim Data from the Phase II HELIOS Clinical Trial of AMX0035 in Wolfram Syndrome and the Treatment Landscape for People Living with this Disease. With me on the call today are Josh Cohen and Justin Klee, our Co-CEOs; Dr. Camille Bedrosian, our Chief Medical Officer; and Dr. Fumihiko Fumi Urano, Principal Investigator of the Phase II Clinical Trial in Wolfram Syndrome and the Samuel E. Schechter Professor of Medicine at Washington University School of Medicine in St. Louis. Joining us for Q&A will be Jim Frates, our Chief Financial Officer. [Operator Instructions] Before we begin, I would like to remind everyone that any statements we make or information presented on this call that are not historical facts are forward-looking statements, that are made based on our current beliefs, plans and expectations and are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. These statements include, but are not limited to, our expectations with respect to AMX0035 (sic) [ AMX0035 ], statements regarding regulatory and clinical development, the impact thereof and the expected timing thereof. Actual events and results could differ materially from those expressed or implied by any forward-looking statements. You are cautioned not to place any undue reliance on these forward-looking statements, and Amylyx disclaims any obligation to update such statements unless required by law. Now I'll turn the call over to Justin.

Thank you, Lindsey, and good afternoon. Thank you for joining us today to discuss our program evaluating AMX0035 for the treatment of Wolfram syndrome, a program we have been working on for nearly 7 years. Josh and I founded Amylyx over a decade ago. To develop new treatments, to address the enormous unmet needs in neurodegenerative diseases. Our lead candidate, AMX0035, is designed to slow or mitigate cell death, the fundamental cause of neurodegeneration through simultaneous mitigation of endoplasmic reticulum stress and mitochondrial dysfunction. These 2 connected pathways are disregulated in many diseases, and if left unchecked, can lead to cell death and degeneration. Wolfram syndrome is one of these diseases. Wolfram is a genetic disease caused by mutations in WFS1 that cause endoplasmic reticulum stress and mitochondrial dysfunction, leading to multi-organ cell dysfunction and death, starting with beta cells in the pancreas, then neurons in the visual system, auditory system and throughout the body. Years' of research looking at cellular and animal model studies showed that AMX0035 had the ability to dampen the impact of ER stress and mitochondrial dysfunction across beta cells and neurons, impacted by WFS1 mutations and thereby potentially stabilizing and, in some cases, improving cellular functioning and viability. After promising preclinical data, we are pleased to share today data from the planned interim analysis from our open-label Phase II HELIOS trial evaluating AMX0035 in Wolfram Syndrome. I'll now turn the call over to Josh to share more about our Wolfram syndrome program and then to Dr. Fumihiko Urano, our close collaborator and one of the world's foremost experts in Wolfram syndrome. And last, Amylyx's Chief Medical Officer, Dr. Camille Bedrosian, to present the clinical data.

Thank you, Justin. Several years ago, a family affected by the disease reached out to us and connected us with Dr. Urano at WashU, who is studying Wolfram syndrome. This introduction led to our R&D team working with WashU to conduct in vitro and in vivo studies to evaluate the potential of AMX0035 in Wolfram syndrome. These studies have very promising results, some of which were published in the Journal of Clinical Investigation Insight. In November 2020, the U.S. FDA granted an orphan drug designation to AMX0035 for the treatment of Wolfram syndrome, and we started work together towards what would become HELIOS. We dosed our first participant in the HELIOS trial in April 2023, and we believe this trial will provide key insights to guide future studies that will hopefully support regulatory filings in the future. As Dr. Urano and Dr. Bedrosian will discuss, we are highly encouraged by the improvement in C-peptide levels, the primary endpoint of HELIOS, which we observed through 24 weeks. C-peptide is an established objective laboratory measure of pancreatic beta cell function and glycemic control. Given the progressive nature of the disease, a stabilization of C-peptide levels would have been an exciting result within itself. So seeing an improvement in these levels was unexpected. We believe that the clinical activity we observed in our HELIOS trial suggests AMX0035 has the potential to significantly impact disease progression in people living with Wolfram syndrome. Given the rarity of Wolfram syndrome, the incredibly urgent unmet need and lack of disease-modifying therapies, we plan to engage with regulatory authorities in the near future to align on the development path. We expect top line data for all 12 participants at the 24-week time point in the second half of this year. We are pleased to be on the call today to review our initial data, and we are so honored to be joined by Dr. Fumihiko Urano, an expert in Wolfram Syndrome. I will now turn the call over to Dr. Urano. Operator, please put the slides back up.

Thank you, Mr. Klee, Mr. Cohen for the kind introduction. I am Dr. Fumi Urano, from Washington University School of Medicine. I am the Samuel E. Schechter Professor of Medicine and [ Director ] of Wolfram Syndrome Clinic and Basic Science and Clinical Research Programs on Wolfram syndrome there. Today, I'm going to tell you about Wolfram syndrome and our therapeutic development for the disease. Here are my disclosures. And my research on Wolfram syndrome revolves around extensive collaboration. I have partners both in the United States and around the globe, including patient organizations spanning various countries. I am deeply grateful for their collaborative spirit and the general sharing of their expertise with my team. I have 3 objectives today. First, I will summarize 2 types of Wolfram syndrome and related disorders. Then I will share lessons and stories from past and current Wolfram syndrome clinical studies. And then finally, I would emphasize the need for cooperation with patient organizations and industry partners, especially Amylyx in this case. What is Wolfram syndrome. Wolfram syndrome is characterized by juvenile onset diabetes, and the onset of juvenile onset diabetes is around age 6. As you know, there are some treatments for diabetes mellitus. Around age 11, Wolfram syndrome patients develop optic nerve atrophy. In many cases, sadly, this can lead to vision loss in many of our patients. Around age 14, patients start developing deafness, and there are some treatment for deafness, including hearing aids and cochlear implants. Diabetes insipidus occurs around age 13. Diabetes insipidus is a medical condition. This is different from diabetes mellitus. It's a medical condition that causes the fluids in the body to become out of balance. That prompts the body to make large amounts of urine, and it also causes a feeling of being thirsty even after having something to drink. And there is treatment for this called DDAVP. It's a pill. And the neuro degeneration starts -- begin to appear during the later years of adolescence, and this can lead to the death of patients. Wolfram syndrome is a genetic disease. There are 2 causative genes. These are WFS1 and CISD2. There are 2 types of Wolfram syndrome. Wolfram syndrome Type 1 is caused by mutations in the WFS1 gene. Wolfram syndrome Type 2 is caused by mutations in the CISD2 gene. Most patients, more than 95% of patients with Wolfram have Wolfram syndrome Type 1. Prevalence is 1 in 250,000 to 700,000. However, we have reason to believe that this number of patients is an underestimation of the actual count, and I will discuss this later again. Patients have 2 mutated copies of WFS1 and CISD2. As you know, we all have 2 copies of WFS1 gene, one from our father, one from our mother. Usually, the patients with Wolfram syndrome, their parents are carriers, which means they have one mutated copy and one good copy. If a patient inherits mutated copies from both parents, they develop Wolfram syndrome. Through our clinical studies, we learned that Wolfram syndrome Type 1 is a spectrum of disorders. Some patients have mild manifestations, while the other patients have more severe manifestations. And there are some underlying reasons for those. Females tend to have milder symptoms than males. Patients who carry 2 or 1 missense WFS1 gene mutations tend to have mild symptoms. And this is a technical, but what I mean by that is that there are specific types of mutations that are associated with milder symptoms. Patients who carry 2 frameshift/nonsense WFS1 variants have more severe symptoms. And 40% of the patients in our cohort have this form of disease. We call it classic form. Interestingly, we found a WFS1 gene mutation associated with a very mild form of Wolfram syndrome. This variant WFS1 c.1672C2T variant is a common variant in Ashkenazi-Jewish population, and the carrier frequency is around 2.5% to 3% in this population. Based on my calculation, if we include the mild forms of Wolfram syndrome patients, prevalence could be 1 in 70,000, which means we may have 5,000 patients with Wolfram syndrome in the United States. Next slide. Here is a summary of Wolfram syndrome and WFS1 related disorders. As I just mentioned that Wolfram syndrome patients have 2 mutated copies in the WFS1 gene. We discovered that sometimes 1 mutated copy, some specific 1 mutated copies could cause some medical conditions, such as hearing loss only, optic nerve trophy and hearing loss only. We discovered 3 variants, WFS1 variants that can cause neonatal diabetes, which means diabetes within 12 months of their lives, congenital cataracts, sensory neural deafness, hypotonia, developmental delay and intellectual disability. My point is 2 mutated copies -- to have 2 mutated copies cause Wolfram syndrome. However, some 1 mutated copies could cause medical conditions. And because molecular mechanisms of these different medical conditions are related, we could potentially treat all of these medical conditions with one medication. Next slide, please. Through our clinical studies, we identified 3 major complications of Wolfram syndrome in addition to diabetes mellitus and optic nerve atrophy and vision loss. Neurogenic bladder is one of the common complications seen in patients with Wolfram syndrome. And this is a very challenging medical condition because patients cannot control the movement of their bladder because of the part of the neurodegeneration. Then even adult people may experience accidents. And if a bladder does not work well and cannot push out urine well, then patients may need to do the self-catheterization to remove urine. So this is a very, very challenging medical condition. Respiratory failure is a scary complication of the Wolfram syndrome. This is associated with the brainstem atrophy, the part of neurodegeneration. Because brainstem controls our breathing and swallowing, the brainstem atrophy could cause breathing problems and some patients have stopped breathing while they are sleeping. So they need positive pressure when they sleep. Choking events are scary complication of the Wolfram syndrome. This is also related to brainstem atrophy because brainstem controls over swallowing, too. So when they are eating, if food gets into their lungs, that can cause choking, also that can lead to aspiration pneumonia. Aspiration pneumonia is one of the major causes of death in patients with Wolfram syndrome. So we manage our patients in our Wolfram clinic. So -- and we accept both out-of-state patients and also out of -- patients from abroad and here is our contact information. Because Wolfram syndrome is such a rare medical condition, many doctors don't know how to manage their conditions. So we are trying to create the consensus clinical guidelines in collaboration with Rare-CAP. This is a cloud-based system to create consensus clinical guidelines. This was facilitated by [indiscernible] and patient organizations. We learned a lot through our clinical studies of Wolfram syndrome. However, to develop new treatments for this devastating disorder, we need to understand the mechanisms of the disease. In the past 22 years, my research team has been studying the mechanisms of Wolfram syndrome and revealed that Wolfram syndrome is a prototype endoplasmic reticulum disorder. Endoplasmic reticulum is a cellular compartment performing many important biological functions, including regulation of cellular stress levels, regulation of calcium levels in cells and maturation of newly synthesized proteins. So loss of function of WFS1 protein caused by mutations in the WFS1 gene can lead to high levels of self-stress called endoplasmic reticulum stress, mitochondrial dysfunction and dysregulation of cellular calcium levels. We also learned that in the past 22 years, there are other medical conditions associated with endoplasmic reticulum stress and dysfunction. Some of these conditions are genetic diseases, including Pelizaeus–Merzbacher disease and Wolcott-Rallison syndrome. These are also neurodegenerative diseases. Some common disorders or medical conditions, such as type 2 diabetes, while aging are also associated with endoplasmic reticulum stress and dysfunction. Based on the molecular [ mechanisms ] of Wolfram syndrome, here is our therapeutic development pipelines and the timeline. When considering the molecular mechanisms of Wolfram syndrome and therapeutic development, imagine it as a river. Like a river, there are upstream and downstream components of this. The very upstream of this river is mutations in the WFS1 gene, as we discussed, which leads to subsequent endoplasmic reticulum stress and mitochondrial dysfunction. These events trigger a cascade of downstream events, ultimately resulting in death and degeneration of insulin producing cells in the pancreas, retinal ganglion cells in the eyes and neurons in the brain. The very downstream consequences of this river are diabetes, vision loss and neurodegeneration. Initially, we try to target endoplasmic reticulum stress using existing medication. So we studied existing medication called dantrolene sodium for the treatment of Wolfram syndrome because dantrolene sodium targets endoplasmic reticulum stress. And we started preclinical study of this medication in cell and animal models of Wolfram syndrome in 2010. In 2017, we started the trial of dantrolene sodium in patients with Wolfram syndrome. And in 2019, 19 patients completed their Phase Ib/IIa study. Next slide, please. So we published the data in the JCI Insight into 2021. And in short, we did not see statistically significant improvement in diabetes, vision or neurological functions during the duration of the trial. And -- but we learned our lessons from this clinical trial. Next slide, please. So lessons learned from the dantrolene repurposing trial are the following. It was cost effective because generic was already available, less expensive than developing new drugs. Faster development, because we already knew the safety profile of this medication very well. So it clearly speeded up the drug development process. Outcome measures, we learned about outcome measures, how we assess the efficacy of the medication. We learned that 30-minute Mixed Meal Tolerance Test, which utilized, was not sufficient. I will discuss this later. Also, we realized the beta cell functions could potentially improve during the duration of the trial, and the visual acuity could improve during the duration of the trial based on the data from 19 patients. We did see some improvement in a few patients. Two challenges. The medication was clearly not designed to treat patients with Wolfram syndrome. Also limited patent protection, limited patent protection, which can limit financial incentives for pharmaceutical companies to invest in repurposing efforts. So based on this information, we shifted our attention to new drugs, and we identified AMX0035 as a candidate treatment for Wolfram syndrome. Next slide, please. Because AMX0035 has chemical structure targeting endoplasmic reticulum stress and mitochondrial dysfunction, so we started our collaboration with Amylyx in the summer of 2017. I still have the e-mail that was sent to Mr. Justin Klee and Mr. Josh Cohen in 2017. And our collaboration was facilitated by patient organizations [indiscernible] Wolfram syndrome, led by Dr. Sarah Gladstone, Ellie White Foundation led by Beth White and Snow Foundation led by Stephanie Snow Gebel. And it took 5.5 years to start a clinical trial, which was very, very fast. So we started our collaboration in 2017, and we started a clinical trial of AMX0035 in April of 2023. I'd like to show some preclinical data of AMX0035 in Wolfram [ cell ] models. We created induced pluripotent stem cells from patients with Wolfram syndrome, and induced pluripotent stem cells can differentiate into any types of cells, including brain cells, insulin–producing cells. We treated Wolfram syndrome iPSC-derived brain cells with AMX0035 and then assessed cell death levels. Y-axis shows cell death levels, and X-axis shows their names of treatment. Interestingly, and we used 3 different lines from 3 different patients. As you can see in this slide, AMX0035 treatment reduced cell death levels in Wolfram syndrome patients derived brain cells. Interestingly, PBA and TUDCA, these are components of the AMX0035. These compounds, PBA only or TUDCA only could also reduce cell death levels. And by combining these 2, which is AMX0035, we can see synergistic effect on suppressing cell death levels. Next slide, please. Mitochondrial dysfunction is also involved in the pathogenesis of Wolfram syndrome. So we treated Wolfram patients derived -- iPSC-derived neural progenitor cells with AMX0035 and then assessed mitochondrial functions by using -- by monitoring cellular respiration. And by treating these cells with AMX0035, we could include mitochondrial functions. We have published these preclinical data in JCI Insight in 2022. We also included data in our animal models and also we included data showing that AMX0035 could improve insulin secretion. And based on these preclinical data, we have set up the clinical trial of AMX0035 in patients with Wolfram syndrome. And we were interested in 3 different domains of Wolfram syndrome, diabetes, visual activity and the neurological functions. Next slide, please. We are particularly interested in beta cell functions, which means the function of the remaining insulin producing cells and the visual acuity. How we measure remaining insulin producing cells functions? We decided to use Mixed Meal Tolerance Test, which was utilized for the previous dantrolene trial, but we modified it. So we ask our participants to fast overnight, no food overnight, then we ask our participant to take a drink called Boost that contains high carbohydrate, lipid and protein. We draw blood from our participants at minus 10 minutes, 0 minutes of the Boost and 15 minutes, 30, 60, 90, 120, 180 and 240-minute time points. Then we look at the C-peptide levels. C-peptide levels reflect the amount of insulin produced from their own pancreas. So C-peptide levels should go up during the Mixed Meal Tolerance Test. And instead of using 30 minutes, we decided to use 240-minute Mixed Meal Tolerance Test. We also measure visual acuity using Snellen chart. This Snellen chart data is converted into LogMAR score. If you see well, your LogMAR number is lower. And if you don't see well, your LogMAR scare is larger. Next slide, please. The reason we are interested in measuring C-peptide was C-peptide levels progressively decrease in patients with Wolfram syndrome are based on our previous studies. Also, we decided to use 240-minute Mixed Meal Tolerance Test because in normal healthy individual or patients who have developed diabetes due to single gene mutations, their C-peptide levels go up and go down during the Mixed Meal Tolerance Test. And in patients who have a genetic form of diabetes, their peak tend to come later time points. So if you are healthy, your peak of the C-peptide production is at 60 minutes. Next slide, please. We are also very interested in assessing visual acuity and retinal nerve fiber layer thickness in patients with Wolfram syndrome because both visual acuity and average retinal nerve fiber layer thickness decrease -- decline during the progression of the disease in Wolfram syndrome. So we are measuring this during our clinical trial. Next slide, please. Here is our trial team. And I appreciate the hard work and dedication to this project of our trial team at Washington University and also Amylyx Pharmaceuticals. They have been working very hard, and I really, really appreciate their efforts. This video shows how we prepare for AMX0035 for patients for the trial participants. Can you activate the video? So AMX0035 comes as powder in the sachet, then we dissolve the powder in water. Then we dissolve the AMX in water and ask our participants to take it. They take this medication twice a day. Next slide, please. So the data of this ongoing clinical trial will be shown by Dr. Bedrosian later in this presentation. And before I end my presentation, I want to emphasize the significance of working with patient organizations because it's important to raise awareness for Wolfram syndrome, it's -- and we need to work with patient organizations to achieve this goal. Also, patient organizations facilitate collaboration between academic researchers, like myself, and industry. And indeed, our collaboration with Amylyx was facilitated by patient organizations and patient [ mothers ]. Next slide, please. So we have been working with patient organizations to host the Scientific Wolfram Syndrome Symposium. One of the pictures shows the International Wolfram Syndrome Symposium taken at Wolfram syndrome Symposium, hosted by Wolfram Syndrome U.K. and Snow Foundation. Also we have been working with Snow Foundation and Ellie White Foundation and [indiscernible] Wolfram syndrome to raise awareness of the disease. It takes a village to achieve a cure for Wolfram syndrome. To improve clinical care, we need Wolfram syndrome clinic. To raise awareness, we need to work with patient organizations. We need funds to do research. Those could be donations and grants. And also we need to work with their industry partners to develop cutting-edge treatment and bring these new treatments to patients. This is my last slide. I'd like to dedicate my presentation to my mother, who recently passed away, and she was a fantastic pediatrician and also the family doctor. And she was the greatest supporter of my research on Wolfram syndrome. So thank you for your attention, and I will hand over the presentation to Dr. Bedrosian, who is also the female physician and the industry leader in the rare disease domain. Thank you.

Thank you so much, Dr. Urano. Your presentation is very informative, and I appreciate your kind words as well. Good afternoon, everyone. As you learned from Dr. Urano, Wolfram syndrome is a rare fatal monogenetic neurodegenerative disorder that progressively impacts multiple organs and systems. As Dr. Urano indicated, the disease manifests in childhood initially, presenting as diabetes mellitus that progresses over time. Also in childhood, optic nerve atrophy begins and ultimately progresses to blindness. I reiterate these key manifestations as we will be sharing the interim results of AMX0035's impact on these systems in the HELIOS study. The majority of people with Wolfram syndrome carry mutations in the WFS1 gene, which encodes a protein that spans the membrane of the endoplasmic reticulum called wolframin. Loss of wolframin function leads to ER stress and consequently impaired mitochondrial dynamics, which in turn leads to dysfunction and apoptosis of cells. Because of the clear link between WFS1 mutations and ER stress, Wolfram syndrome is considered a prototypical ER stress disorder. Pancreatic beta cells and neurons are particularly vulnerable to the loss of Wolfram inactivity. So how many people actually have Wolfram syndrome? Like most rare diseases, incidents and prevalence studies on Wolfram syndrome are limited. The literature often cites a few studies that were performed quite some time ago prior to the identification of the WFS1 gene and thus molecular genetic testing. These studies estimate a U.S. prevalence of anywhere between 500 to 3,400 cases. More recent studies evaluating genetic causes of diabetes indicate that Wolfram syndrome may be more common than the older studies estimate. One example is shown in the bottom row of the table on this slide with extrapolation to the U.S. population. We share this example less to support a specific number, but rather to indicate more work is needed to understand the true incidence and prevalence. We found Dr. Urano's perspective on these points enlightening as well. Wolfram syndrome is a genetic disorder that is generally misdiagnosed at first. Now that the Wolfram syndrome gene has been identified, genetic testing can provide a definitive diagnosis and should shorten the time to diagnosis from initial symptoms. It is likely that definitive testing together with evaluation of potential therapies will further enhance disease awareness. Under or misdiagnosis has been seen in many rare diseases, including the examples summarized in the table shown on the right of this slide. Amylyx is committed to supporting awareness and the diagnostic efforts. Both Dr. Urano and I have mentioned that Wolfram syndrome is a prototypical ER stress disorder, with this stress impacting mitochondrial dynamics and leading to cellular dysfunction and cell death. The scientific rationale for AMX0035 in Wolfram syndrome is strong as it targets both the ER and mitochondria and has been shown to reduce both ER stress and cell death synergistically in a variety of models. In the next few slides, we'll preview the preclinical data in Wolfram syndrome. Apologies, we will review the preclinical data. As Dr. Urano mentioned, his lab performed a series of preclinical efficacy studies to evaluate AMX0035's effect on different pathophysiological aspects of the disease. Models of ER stress, mitochondrial dysfunction and some of the clinical manifestations were characterized using several nonclinical approaches. First, patient-derived iPSCs or pluripotent stem cells with homozygous WFS1 mutations were used to generate pancreatic beta cells and neuronal progenitor cells. These cells exhibit hallmark features of Wolfram syndrome as noted. And second, the WFS1 knockout mouse model, which shows a diabetic phenotype and dysfunction in insulin response to glucose stimulation, was used as an in vivo model of poor pancreatic beta cell function. This slide summarizes patient-derived beta cell models. In the series of graphs, the pink bars represent AMX0035 treatment and the blue bars represent controls. First, on the far left, AMX0035 treatment increases WFS1 protein levels, indicating that treatment is working on the root cause of the disease. This impact led to significantly improved patient-derived beta cell viability and survival, as shown in the graphs in the middle panel. The substantially reduced magnitude of the pink bars representing AMX 35 treatment indicates that there is significantly less beta cell death. This translated to improved insulin secretion as shown in the graphs in the panel on the far right. This series of experiments evaluated 3 patient-derived neuronal cell models to understand the impact of AMX0035 on neuronal cell death. Once again, the pink bars represent AMX0035 and the blue bars represent controls. Each purple bar represents 1 of the 2 AMX0035 components alone. We can see that AMX0035 results in the least cell death compared to the control as well as either component individually. The last preclinical model is the WFS1 knockout mouse model mimicking some of the clinical manifestations. Once again, the pink lines and bars represent AMX0035 treatment, the blue lines and bars represent controls and the green, the wild-type mass. Both graphs illustrate that AMX0035 significantly delayed the progression of the diabetic phenotype. So to summarize, studies of several nonclinical models of Wolfram syndrome supported the potential of AMX0035 in addressing the etiology of Wolfram syndrome. These preclinical data provided strong evidence to proceed to a clinical study, HELIOS and people living with Wolfram syndrome. Now we'll review how progression is measured in Wolfram syndrome as a foundation for a discussion of HELIOS trial design and interim results. Wolfram syndrome has a variety of clinical manifestations as shown in the left figure, which means there are several potential measures we could evaluate in a clinical trial. For today's presentation, we will focus on measuring the progression of diabetes mellitus, vision loss and overall symptom burden. Starting with measures of diabetes progression, the first measure of interest is C-peptide. Here, we are setting the ability of the pancreatic beta cells to produce insulin. As shown in the figure on the right, there is a series of steps in processing and secreting insulin that includes C-peptide. C-peptide levels are well established surrogate marker of pancreatic function and glycemic control and have been used as the primary outcome in several major diabetes trials because C-peptide is secreted in 1:1 ratio with insulin, degraded at a slower rate, is not cleared by the liver, can be measured in the blood, is not confounded by external insulin use and has been shown to predict future diabetic complications and glycemic control. C-peptide levels are assessed following a Mixed Meal Tolerance Test, or MMTT, also mentioned by Dr. Urano. This test is a physiological stimulation test using a standardized liquid meal ingested in the morning after an overnight fast, followed by timed measurements over a predetermined time period. In this study, we evaluated beta cell response through 240 minutes, or 4 hours. C-peptide is expected to progressively decline over time in Wolfram syndrome confirmed by our recent natural history study as noted on the slide. Because of this, HELIOS was designed to measure a slowing of the decline. Hemoglobin A1c in plasma is a well-recognized measure of diabetes progression. The hemoglobin A1c measures glycosylated hemoglobin and provides a sense of glycemic control of diabetes during the previous 2 to 3 months, whereas we want C-peptide to be higher with improved pancreatic response, A1c should decrease as diabetes is better controlled. In Wolfram syndrome, we would expect A1c levels to stay stable as blood glucose is well controlled with exogenous insulin and diet. Over time, it may become more difficult for A1c levels to remain stable as disease and glucose intolerance progresses. Moving from measures of glycemic control to measures of visual acuity. The measure here is the Snellen's eye chart, with which we are all familiar when we visit our optometrist or ophthalmologist. In Wolfram syndrome, visual acuity is expected to worsen over time, also as shared by Dr. Urano. As shown on the right, from a recent natural history study, visual acuity declined over time in all participants. Some had faster declines than others, but all declined. We also sought to understand patient and clinician reported outcomes on a more global holistic scale. So we included the patient and Clinician Reported Global Impression Of Change. Both use a 7-point scale to evaluate the change in Wolfram syndrome-related symptoms since initiating drug. Because again, Wolfram syndrome is progressive and declines are expected, HELIOS defines a responder on both scales as no change or improvement. So now on to the results of the HELIOS study as well as the trial design and -- including interim efficacy and safety. First is study design. Helios is an open label study, in which all participants receive AMX0035 for up to 96 weeks. The primary endpoint is to evaluate beta cell function as measured by C-peptide levels at 24 weeks. We also present 12-week results today. Adults, aged 17 years or older, with a genetically confirmed diagnosis of Wolfram syndrome were eligible for the trial. Importantly, participants were required to have insulin-dependent diabetes at baseline due to Wolfram syndrome and also were required to have some residual pancreatic function at baseline. So they could respond to a Mixed Meal Tolerance Test. Participants also were required to wear a continuous glucose monitor for the study duration, and the use of GLP-1 agonist was not permitted during HELIOS. The data we are sharing today are from an interim analysis performed as of data cutoff date of March 5, 2024, when 8 participants have completed their 24-week assessment. HELIOS is fully enrolled with 12 participants. There have been no dropouts or discontinuations thus far. As noted, the efficacy data presented today are from the 8 participants, who have completed their week 24 assessments. There are 4 more recently enrolled participants, who have not yet reached week 24 and therefore, are not included in the efficacy portion of the interim analysis, they are summarized in the demographic data as well as included in available safety data reported. Participants in HELIOS at baseline range in age from 18 to 39 years with a median age of 25 years. 83% of participants are female. The median time since diagnosis was 5 years, and median age of diagnosis was 20 years. The age of onset of Wolfram syndrome manifestations aligned to natural history with diabetes occurring first, followed by vision loss. A variety of endpoints are being measured in Helios as summarized on this slide. The interim analysis we share today is largely focused on diabetes and vision assessments in 8 participants. Later this year, the final week 24 data will include 12 participants and the additional assessments. The primary endpoint of HELIOS is the change in C-peptide levels over time, a measure of residual pancreatic beta cell function. Here is a graph of the mean C-peptide levels after Mixed Meal Tolerance Tests. The Y-axis is a mean C-peptide level. The X-axis shows the time course of Mixed Meal Tolerance Test. The curves represent 3 different assessments during HELIOS. Dark blue dash line is screening, teal is 12 weeks and orange is 24 weeks. In Wolfram syndrome, there -- where a deterioration in beta cell function is expected to result in a decrease in C-peptide response during -- decrease in peptide response during AMX0035 treatment, we instead see improvement in beta cell function as evidenced by the increased C-peptide response. Here, we are visualizing the C-peptide data in a different way. Specifically, we are looking at the area under the MMTT C-peptide curve that we just reviewed in the last slide. The area under the curve, or AUC provides a single numeric estimate of C-peptide response at various times. Consistent with the previous graph, we see an improvement in C-peptide response at both weeks 12 and 24. Shown on the left are the week 12 C-peptide responses at 90, 120 and 240 minutes in the MMTT. The same time points for week 24 are shown on the right. As a reminder, the expectation is for C-peptide response to decrease over time on Wolfram syndrome, since it is a neurodegenerative progressive disease. So actually, our initial goal in HELIOS was to see a slowing in this decrease. However, here, we are seeing an improvement in C-peptide response both at weeks 12 and 24 compared to screening. We also evaluated the change in delta C-peptide at weeks 12 and 24, as shown on this slide. Change in delta C-peptide provides insight into changes in beta cell responses over time. Positive values indicate increased responsiveness, while negative values indicate decreased responsiveness. Here, we see an increase in Delta C peptide at both weeks 12 and 24 compared to baseline. Shown on the left is the week 12 change from baseline at 90, 120 and peak in the MMTT. And the same time points for week 24 are shown on the right. Again, the expectation is for delta C-peptide to decrease over time in Wolfram Syndrome as the mutations in WFS1 drive beta cell dysfunction and apoptosis with AMX0035, although we are seeing an improvement in beta cell responsiveness, both at weeks 12 and 24 compared to screening. Looking at the C-peptide response at the individual level, 7 of the 8 participants are showing a shorter time to peak C-peptide at week 24 compared to screening. This shorter time indicates improved pancreatic function. The pancreas is able to respond more quickly to a glucose challenge to the MMTT than at screening. The stars indicate those who have responded more rapidly to the glucose challenge by at least 30 minutes. We just shared several analyses of pancreatic beta cell function in this interim analysis of 8 participants. And now I turn to Dr. Urano. Dr. Urano, we welcome your perspective on all these data. What do they tell you about the potential of AMX0035 in Wolfram syndrome?

Thank you, Dr. Bedrosian. I think these results are pretty encouraging. The reason because of this -- because of the 2 reasons. First, beta cell dysfunction can cause the delayed glucose stimulated insulin secretion. And in patients treated with AMX0035, we see rapid -- more rapid response to glucose stimulated insulin secretion. In this case, actually Mixed Meal Tolerance, the Boost mediated glucose -- Boost mediated insulin secretion. So this is a good sign. And also, we know that Wolfram syndrome patients, their C-peptide level has declined over time, progressively decline. And during this trial in the first 6 months in 8 patients, we saw an increase in C-peptide levels. So both of these are pretty encouraging results.

Thank you very much. Now we'll move on to the secondary end points. The larger C-peptide values we saw with the primary endpoint were associated with lower hemoglobin A1c values. Shown on the left are the overall findings among the 8 participants in this interim analysis. And the individual results are shown on the right. As a reminder, the expectations for hemoglobin A1c to stay stable and blood glucose is well controlled, and may get more difficult for levels to remain stable as disease progresses. Contrary to the natural history of the disease, here, we are seeing an improvement in glycemic control at week 24 compared to screening. We also assess changes in the degree of glycemic control through continuous glucose monitoring. Specifically, we evaluated the change from baseline to week 24 in the overall time and target glucose range, which is defined as a percentage of time glucose values are between 70 and 180 milligrams per deciliter. A well-recognized way of assessing changes in glucose metabolism. Again, shown on the left are the overall findings among the 8 participants in this interim analysis, and on the right are the individual results. Consistent with hemoglobin A1c findings, the majority of participants demonstrated increased time and target glucose range from screening to week 24, with the majority meeting a goal times in range as defined by the recommendations from an international consensus report endorsed by the American Diabetes Association and the American Association of Clinical Endocrinologists. Dr. Urano, I turn to you again. What are your perspectives on these additional measures of glucose metabolism, including hemoglobin A1c and time in target glucose range?

Yes. I think both of these are associated with the increased levels of C-peptide. It has been shown in Type 1 diabetes patients, not in Wolfram. It has been shown in type 1 diabetes patients. Higher levels of peptide is associated with better glycemic control. So the improvement in hemoglobin A1c and improvement in continuous critical monitoring data are both associated with the improved beta-cell functions treated -- are patients treated with AMX0035.

Thank you, Dr. Urano. Very helpful. Now on to the next. As mentioned earlier, optic atrophy represents a significant morbidity in Wolfram syndrome. There are no proven effective medical treatments for optic nerve atrophy on Wolfram syndrome at this time. And visual acuity is expected to decline over time in all people living with Wolfram syndrome. We evaluated the effects of AMX0035 on best-corrected visual acuity over 24 weeks. And as shown on the left, we saw a trend to our potential visual acuity improvement compared to screening. On the right, when looking at the individual data, 5 of 8 participants experienced improvement in visual acuity in at least one eye. And this includes one participant who is blind at baseline, who now has some vision in one eye. Dr. Urano, we would appreciate your perspective on these data as well.

This is pretty encouraging because the vision loss is the most devastating symptom in patients with Wolfram syndrome. And so we sent out questionnaires to our patients suffering from Wolfram syndrome and found that pure vision is the most troublesome symptom in most of our patients. So this is pretty encouraging. And I think this reflects the fact -- this is my speculation, but probably the remaining retinal ganglion cells are working better after the treatment with the AMX0035. I think it is unlikely that AMX0035 based on the mechanisms of action increases the number of retinal ganglion cells, but functions of remaining cells could be improved, and that's what I speculate, and we need to see more data at later time points and more patients.

Very helpful. Thank you, Dr. Urano. Now on to the next slide. Given the many potential manifestations of Wolfram syndrome that go beyond diabetic and visual acuity measures, we wanted to understand symptom burden on a more global holistic scale. Shown on the left is the Patient Reported Global Impression of Change. And the same is shown on the right from the clinician perspective. For the majority of participants, both by self and clinician report, improvements in symptom burden were noted. As a reminder, given the progressive nature of Wolfram syndrome, even no change in symptom burden is considered different from the usual course of the disease. Therefore, all participants met responder criteria at weeks 12 and 24. Again, Dr. Urano, we would appreciate your perspective on these data as well.

I found this result pretty encouraging because of 2 reasons. The first reason is that during the dantrolene sodium trial, we assessed their quality of life, patient reported quality of life during the treatment. And after the 6 months treatment, we did not see any improvement in the quality of life of our participants in the dantrolene trial. And clearly, it's difficult to exclude the placebo effect for this endpoint. But I found this very interesting because this is something I did not see during the dantrolene trial. Also, I think Clinician Reported Impression of Change is also interesting because we always assign different doctors to assess this. And it seems like it's consistent between different doctors. So because of these 2 reasons, I found this result pretty interesting and encouraging. But we need to get more data on this for sure.

Thank you very much. Very helpful also. Now turning to safety findings. In HELIOS, the safety findings were consistent with previous AMX0035 clinical trial data, namely AMX0035 was generally well tolerated. Diarrhea was the most common treatment-emergent adverse events. It is important to note that while nearly all participants reported at least 1 treatment-emergent adverse event, none led to discontinuation. So in summary, the available clinical data reinforce and build on our preclinical findings. From the perspective of diabetic measures, we would expect to see progressively declining pancreatic function and worsening glycemic control based on the natural history of the disease. By contrast in HELIOS, we see partial reversal of diabetic phenotypes with AMX0035. We also have early evidence of some improvements in visual acuity with AMX0035. And finally, importantly, from the perspective of the investigating clinician and the participants in the trial, we've seen an improvement in perceived symptom burden with AMX0035. As a reminder, these are interim findings and more detail will become available as participants undergo additional follow-up. We are excited about the potential impact of AMX0035 for people living with Wolfram syndrome. We are most grateful to the Wolfram community, including those participating in HELIOS, their loved ones, Dr. Urano and the entire clinical staff at Washington University in St. Louis for their support in these important efforts and the HELIOS trial. I will now turn back the call to Justin and Josh.

Thank you, Camille. And echoing Camille, we are deeply grateful to all of the people participating in HELIOS, their families and caregivers, Dr. Urano and the team at WashU and the Wolfram syndrome community, who continue to partner with us on this important research. To recap what we've shared today, we believe there is strong scientific rationale to study AMX0035 in Wolfram syndrome. Wolfram syndrome is a progressive fatal genetic disease caused by mutations in WFS1 that cause endoplasmic reticulum stress and impaired mitochondrial dynamics. There is a clear match between the mechanism of AMX0035 in Wolfram syndrome as demonstrated in our compelling preclinical data across cell types. And in the interim analysis data shared today, AMX0035 demonstrated improvement or stabilization across measures in different organ systems, including pancreatic function, glycemic control, vision and overall disease burden.

With this data in hand, we are evaluating options for future development and planning to engage with regulatory authorities to align on the development path. We expect top line data for all 12 participants at week 24 in the second half of 2024. We know Wolfram syndrome has clear urgent unaddressed needs, and we are committed to working expeditiously on behalf of the thousands of people living with Wolfram syndrome in the U.S. and individuals and families around the world. Now I would like to open the call up for questions.

Thanks, Josh. Just as a reminder, if anybody wants to submit a question, you can just put it into the chat. Our first question comes from Mike DiFiore at Evercore. What -- on that point, what could the development path forward look like? Is there a universally accepted regulatory endpoint that can be used for Wolfram trials?

So we would be the first drug ever approved in Wolfram syndrome. So I do think we are paving a new path here. But I think it's likely that regulators will look for what they often look for, which is clinically meaningful evidence of benefit. Here, we're looking at outcomes across many different domains of the disease. We're looking across diabetic phenotypes across the visual phenotypes and importantly as well across the patient's perception of how they're doing. And I think those are the types of things that ultimately can become convincing that there is a clinically meaningful difference. But maybe I'll pass to Camille, if you want to add anything else there as well.

Sure. To reiterate, this is a very rare disease for which there really haven't been any industry studies leading that are seeking to address in a fulsome manner, Wolfram syndrome and be made available for the community. It is a very rare disease. And as such, we would consider the pathway forward, consistent with other rare diseases, where the population is relatively small, relatively smaller trials would be adequate. In this case, we have objective measures as well, C-peptide which will explore as potential end points together with the impressions of change, et cetera, that we've had. So we look forward to our discussions going forward and putting forth proposals to the regulatory auth agencies so that we can proceed to as the data hold up, proceed to seek approval for this indication.

And Mike also noted that there were a few patients who didn't improve on many of the endpoints. Are there any inferences to be gained here in terms of baseline characteristics, did these non improvers have any biomarkers, et cetera, and comment?

Maybe first, I'd say that if you actually look across the endpoints, we kept the color coding consistent, so that may help when looking back at the slides every patient shows an improvement in at least one of the outcomes. So they are not patients that did not show anything. But I also want to, again, kind of reiterate the expectation of this disease' progression. This is a fatal disease where people progress and lose critical functions. So to see improvement is unexpected. It's surprising and to see it consistently. This effect is not being driven by 1 patient or 2 patients. This effect is being driven across the study, which I think is very encouraging to us.

And I might ask Dr. Urano, I know you were commenting on this during the presentation, but just a little more on the -- what you might expect to see in people with Wolfram syndrome and why, therefore, you're encouraged by the data here?

So I have been encouraged by the current results because of the improvement in the diabetes-related outcome measures. In my personal opinion, as a physician treating patients with Wolfram syndrome, there are 2 clinically significant outcomes of treatment for Wolfram syndrome. These are decrease in insulin dose and stabilization or improvement in the visual acuity. And as Mr. Cohen and Mr. Klee, Dr. Bedrosian commented that this should decline over time in patients with Wolfram syndrome. So if we can improve a little bit that's significant. And it's worth noting that AMX0035 was originally developed for neurodegenerative disorders, not for diabetes. So if it improves diabetes in Wolfram syndrome, that strongly suggests that AMX0035 targets upstream mechanisms of the Wolfram syndrome. This means it should improve multiple downstream consequences including vision and potentially neurological problems.

Thank you so much. And Mike also asked what gives us confidence that we're using the right dose.

Yes, it's a great question. So I think we've selected our dose, kind of going back even to the preclinical data, the most data as well, and we've tried to target a similar concentration range when we've been in clinic. But it's something that we certainly will continue to explore. Wolfram syndrome also has pediatric concept. So as we pursue the pediatric population, we'll certainly look to dose there as well.

Great. Our next set of questions comes from Corinne Jenkins at Goldman Sachs. Dr. Urano what is a clinically meaningful improvement in Wolfram syndrome patients.

So I just mentioned 2 things. There are 2 clinically significant improvement, vision and insulin dose. The reason insulin dose is important is that if patient starts producing more insulin from their own pancreas, it's much easier for them to control their blood sugar levels because they need to use less insulin or other diabetes medications. That can also reduce the incidence of hypoglycemia or hyperglycemia. So to reduce a decrease in insulin dose is very important. And stabilization or in this case, we saw a slight improvement in visual acuity in this patient population treated with AMX0035. And as I mentioned during -- as I just mentioned, we sent out the questionnaire to all the patients, all the patients who we know with the Wolfram syndrome regarding their most troublesome symptom and the most troublesome symptom by far #1 was the lower vision. So these 2 are the most important clinically significant outcomes. And that's why we chose these actually outcome measures for this particular clinical trial.

Thanks, Dr. Urano. The next set of questions comes from Charlie Yang at Bank of America. Are there preclinical data looking at GLP-1s versus AMX0035? And how do they compare?

Maybe I'll pass to Dr. Urano to start there. I know you have a lot of experience in that space.

Yes, that's a really good question. So we don't have data comparing the difference between GLP-1 and AMX0035 side by side. I want to mention that GLP-1 receptor agonist and AMX0035 have different mechanisms of action on the endoplasmic reticulum or endoplasmic reticulum stress. AMX0035 reduces endoplasmic reticulum stress and improves mitochondrial function. GLP-1 receptor agonists act differently on endoplasmic reticulum. It weekly activates the endoplasmic reticulum stress response and then makes these cells more resistant to endoplasmic reticulum stress mediated cell death. So in short, we did not compare what we did not do a side-by-side comparison of GLP-1 receptor agonist and AMX0035. But my guess is that because these 2 different medications target different pathways, we may see synergistic effect by taking both GLP-1 receptor agonist and AMX0035. Many of our patients are actually taking GLP-1 receptor agonist because it is an approved medication for the diabetes treatment. And for this particular trial, in the first 48 weeks, we have asked our participants to not to take the GLP-1 receptor agonist to remove this one of the confounding factors. But in the future, maybe we should see what we should study the synergistic effect of AMX and the GLP-1 receptor agonist. And this is pretty important because GLP-1 receptor agonist is widely taken in patients with Wolfram syndrome.

And Charlie asked to how are you thinking about a pivotal trial design in terms of patient inclusion criteria with or without GLP-1s?

Yes. So we're still in discussions with the regulatory authorities and otherwise, we have not presented a final pivotal trial design. I'd say as we think about Wolfram, there are many different -- there may be a couple of different populations we want to focus on, including both pediatric and also adult people of Wolfram syndrome. And I'd add that while I think there's a lot of excitement, maybe appropriately so around GLP-1s. Even with GLP-1s, Wolfram remains a progressive disease. And so it's important that the other manifestations of the disease beyond, let's say, just the diabetic phenotype also need to be addressed. And I think that's part of the value in seeing things like the global symptom burden and otherwise, that we see in the majority of participants improving or at least being stable in the HELIOS trial, that's why those things are so valuable because those go beyond just the diabetic phenotype.

Yes. Just underscoring that. So if you think about the mechanism of Wolfram syndrome, it's caused by WFS1 mutations, which cause ER stress and mitochondrial dysfunction and thereby reducing cellular function in the cell type as well as eventually cell death. So that's why you first see you first see loss of function in the beta cells and then cell death and then in various parts of the nerve system, so I think what we know about the glimpse today is mostly about how they work in diabetes, right? But it's not getting at the heart of Wolfram syndrome, which is caused by these WFS1 mutations.

And then the last question from Charlie is for the individual who was blind, how long was he blind for? Could it be a spontaneous recovery.

Maybe pass to Dr. Urano.

That is a very good question. So in out of 8 patients, I think 2 patients are legal -- actually, 3 patients are legally blind. And so I'm not so sure a spontaneous recovery of the vision loss happens in under any circumstances. So we need to see more data in this population. But I think spontaneous recovery is unlikely.

Thanks, Dr. Urano. The next question comes from Graig Suvannavejh at Mizuho. What additional information will we receive at the top line data readout.

Yes. So one, I'd probably refer a little back to the slide that had kind of the full set of endpoints. We focused on a series of key endpoints for this interim analysis. We'll have the full set of endpoints, when we have the full data analysis. And then I think importantly as well, we'll have all 12 participants having completed 24 weeks as well, which should give a larger sample size as well in analyzing these results.

And what's -- what are the next steps for the program? What data are required for Phase III? Would that design looks similar to a Phase II, what would be the best way to find patients? And are there any screening tools being worked on?

So I'd say, first, the real goal of this trial was to both evaluate the outcomes and evaluate the potential of AMX0035 and Wolfram syndrome. As was mentioned, the original design or goal of the trial was to see if we could slow progression in a progressive disease. What we're seeing across multiple systems now is, in fact, stabilization or improvement and in a reasonably short period of time. So I think that's very encouraging. So I think the next steps are to propose sort of the next plans with the regulatory authorities. And then in terms of the next trials, we've already started to discuss that with Dr. Urano. I think that there are with results like this. One, I think I can say there's a lot of excitement in the Wolfram syndrome community. And I think the question will be how do we run studies in the right populations and it may be multiple different types, so that we can see the -- we can properly evaluate this multi-organ, multisystem disease. But to start, when we're seeing effects across pancreatic function, potentially visual functioning sort of whole disease with a global impression, we're very encouraged.

Yes. And just one marginal comment as well. You asked about finding patients as well. One, I'll definitely I have Dr. Urano add, but there is a genetic test for the vast majority for the WFS1 mutations. So there is testing available to be able to find this disease as well as on various clinical work ups. But I'd pass to Dr. Urano to add more detail there.

Yes. So we can certainly find more patients for sure. The reason is, so I don't anticipate any difficulties as we are receiving a significant number of calls and e-mails from patients who are interested in participating in the ongoing, this clinical trial. We have already recruited 12 for this trial, so we cannot enroll anyone else, but we are getting so many calls and e-mails. And one of the challenges we may face is that we have so many potential patients who can participate. But if we set the strict inclusion and exclusion criteria, we may need to exclude many patients. So for example, if we exclude patients who are producing -- who are not producing enough amount of C-peptide. We have to exclude many patients or if we exclude patients who have low vision, we may need to exclude many patients, and we cannot recruit any pediatric patients right now. And so -- but in my personal opinion, we have a better chance to see improvement in pediatric patients who are still at the early stage of the disease. It's difficult to see the efficacy of any treatment patients at late stage of -- at later stages of patients with Wolfram syndrome. So these are the things we should discuss with the -- I should discuss with the Amylyx team with Dr. Bedrosian and Mr. Klee and Mr. Cohen.

Thanks, Dr. Urano. The next question comes from an investor, week 24 C-peptide data look numerally worse over time -- or sorry, worse than week 12, is the effect waning over time.

Yes. So I'd say, first of all, we don't think so. We think that first, it's really important to note that we expect that this marker would progress over time. And so again, to be still seeing an improvement at 24 weeks was even more impressive than seeing an improvement at 12 weeks where more time has elapsed and more time has passed. I think additionally, when we look at week 24 across all the other outcomes, we're seeing some of those benefits on C-peptide start to manifest in other manifestations of diabetes whether that's the HbA1c, or the time and range or otherwise. And of course, we're seeing that global impression of change, both at week 12 and week 24. And if anything, it seems that going in the right direction. So we don't think that there's a particular waning here, and we're still seeing that unexpected improvement at 24 weeks.

And maybe Dr. Urano is obviously, you're seeing the participants in the study. We'd love your thoughts there as well.

Right. So first of all, their beta cell function should decline over time. So even slight improvement is still encouraging. And also, we need to wait for the additional results at 36- and 48-week time points because we have started getting data at 36- and 48-week time points in some of our participants and there is a possibility that the beta cells may start producing more insulin again. But we -- because we are still getting data, we just need to wait. I think there is a reason, there might be a reason that we see some decline at a 24-week time point as compared to 12-week time point and most likely, there are 2 different insulin producing cell populations in patients with Wolfram syndrome. So beta cell population, still secreting some insulin, although they are undergoing stress. And the beta cell population that has stopped producing insulin due to the high level of endoplasmic reticulum stress. In the first 12 weeks, maybe AMX0035 act on the fast population, which is the cells producing -- still producing insulin, although they are experiencing endoplasmic reticulum stress. And because these beta cells need, can secrete more insulin because of the AMX and reduction of endoplasmic reticulum stress, these beta cells may get a little tired, they may start producing a little less insulin. But my hope is the AMX0035 continues reducing endoplasmic reticulum stress levels in the second population, which has the footprint population that has stopped producing any insulin. And if we can wake up these sales with AMX0035 by reducing endoplasmic reticulum stress, which should start seeing the upgradation of C-peptide levels again. So we have many explanations on the beta cell data we have seen or we have obtained so far. But my impression is that we should wait for the data of 36- and 48-week time point. And also that we are supposed to see the decline in beta cell functions. So the slight improvement is still clinically meaningful.

Thank you. Our next question comes from Basma Radwan at Leerink. What is the regulatory path for approval in Wolfram syndrome? And have you started to engage with the FDA yet?

Yes, I think that's your next main step. We will be defining together with the agency, the regulatory path in Wolfram syndrome. I think in Wolfram, as in many other diseases, the key question is showing clinically meaningful data. And that's what we will be working to convince and show ultimately that we have and that we can continue to generate as well. And as Dr. Bedrosian shared as well, this is also a very rare disease, and that always goes into the consideration for the path to approval as well.

And one other important point, as Dr. Bedrosian who is saying as well, while this is Wolfram syndrome, there are no approved treatments for Wolfram syndrome. These are very well-known objective measures, C-peptide, time in range, HbA1c, visual acuity, et cetera. These are very well known and clearly meaningful outcomes.

Our next question comes from Ananda Ghosh from H.C. Wainwright. Although a monogenic disease, data from earlier trials indicate heterogeneity based on the mutation types and the Wolfram syndrome, one gene, how are you thinking about heterogeneity aspects of the disease.

Well, I'll certainly pass quickly to Dr. Urano, but I'll just say that my own view is that this is an area where translational medicine is really powerful. And so we can test certain mutations in vitro, in vivo preclinically and then see how those things translate into people living with the disease, which is why this has been a collaboration -- among many reasons is why it's been a collaboration. We've been so excited about for many years. But Dr. Urano, I will pass to you for more.

Yes. So that's definitely a great question. There is heterogeneity in patients with Wolfram syndrome based on the types of mutations in the WFS1 gene they have. So what we did -- in my presentation, I showed the data of the 3 lines, 3 iPS lines from patients with Wolfram syndrome. However, we actually tested more lines in -- during our preclinical study phase. And we chose lines that carry mutations associated with mild manifestations and we chose lines from patients who have the more severe manifestations. So in short, we treated the patient-derived cells and we treated both lines derived from patients with severe manifestations and mild manifestations and different types of mutations. And in all the lines, we saw some beneficial effects, improvement in cell survival and the improvement in mitochondrial functions. So because we are targeting the common molecular pathways altered in Wolfram syndrome patients, we should see beneficial effects in all the patients, in all the patients who have Wolfram syndrome because we are targeting the common molecular pathways altered in most of the patients. To see the efficacy of AMX0035, we may need to choose some specific population because there is a possibility that some specific patient population carrying as specific types of mutations are more responsive to AMX0035 treatment. So that's something we need to think carefully for the next phase of the trial. And because we need to be careful because we don't want to exclude too many patients.

The next question comes from an investor. Is there any chance of an accelerated approval given unmet need?

Yes. I mean, so I'd say that the field has long discussed on C-peptide as a validated surrogate marker and that's usually what the type of thing FDA looks at for accelerated approval. That being said, we're in the early -- we're just starting those discussions, so I don't want to state what will or will not be the regulatory path that quite yet.

And are these interim findings statistically significant?

They are across many of the time points. So yes, across many of the time points. But again, this was an exploratory initial study. So we weren't really kind of that wasn't essentially the goal of the study. But yes, as you can kind of look at the error bars, you can see pretty clearly that these are pretty statistically robust findings.

And the next question comes from Joel Beatty at Baird. Would it be feasible to run a randomized controlled trial of AMX0035 and Wolfram syndrome?

I think it depends on the regulatory feedback. And of course, the impression of the data here. Again, the original goal of the study was to see if AMX0035 with slow progression. We're seeing evidence of stabilization or even improvement, so I think we'll discuss that with the regulatory authorities.

The next question comes from an investor. If AMX0035 was approved for Wolfram syndrome, how do you expect -- how long do you expect patients to stay on treatment.

Well, maybe I'll pass that to Dr. Urano to answer that question.

Yes. So patients with Wolfram syndrome may need to take AMX0035 for life, similar to how patients with hyperlipidemia take statins for life. As they may be able to stop taking it if a cure for Wolfram syndrome is achieved through maybe gene editing therapy, but it will certainly take time to achieve that. So in short, they need to take AMX for life, similar to how patients with hyperlipidemia take statins for life.

Thanks, Dr. Urano. I might just add as well. One very encouraging thing in HELIOS as well was that we had no drop out. So over 6 months, we've seen 100% of the patients complete the study.

And then just a quick follow-up from that investor. If AMX is approved for Wolfram syndrome, who would you prescribe it to? Would you prescribe it to all patients or a certain subset.

Maybe I'll pass that to Dr. Urano.

Yes. Yes. I would prescribe it to all patients who have Wolfram syndrome regardless of the stage of the disease they are in. This includes those who have not yet developed all the characteristic symptoms such as diabetes and optic nerve atrophy. And this is particularly important for patients who have a mild form of the disease who are in the early stages of the disease, especially children. In short, I would prescribe it to all the patients. Even though who are at the late stage of the disease, but probably, it's more important to prescribe this to patients who are at the early stage or early stages of the disease, including children. So I think the study in children is very important.

Thank you. Okay. We are at time. I -- we see a few other questions in the chat, and we'll absolutely get back to folks. Thank you, everyone, so much for joining. And I'll turn it back to Justin to close this out.

Well, first of all, yes, thank you all very much for joining us. Thank you for the great questions. We're both encouraged by the data, but also appreciate the opportunity to get to share more about Wolfram syndrome, which is a really unmet need I'd say a real heartfelt thank you also to the participants in the study and their families. We -- this has been a wonderful collaboration and we are so excited to continue that collaboration together. And then a special, special thank you to Dr. Fumi Urano, who is both a world leader in this space, has been a wonderful collaborator over many years and is one of the kindest most passionate doctors, I've had the privilege of working with as well. So thank you all very much, and we look forward to talking more about this.

Thank you.

Thank you.