Insmed Incorporated (INSM) Earnings Call Transcript & Summary

Good morning, everyone, and welcome to The Future of Rare at Insmed: Functional Genes, AI-Enhanced Proteins, Glowing Algae, and More. For those who may not yet know me, my name is Bryan Dunn, and I have the privilege of leading Investor Relations here at Insmed. And given that the word "Future" is in the name of this event, it will come as no surprise to any of you that we will be making forward-looking statements during today's presentation. So before we begin, on the slide behind me, you will find additional information about risks and uncertainties associated with those statements. With that, we will begin the presentation with this short video. [Presentation]

"Count us in". The idea of "Count us in" comes from a story about a young man who visited Insmed almost 10 years ago with his mom. The whole company numbered about 30 employees at that time, and our inhaled antibiotic was being considered for treating patients with cystic fibrosis. This young man was 1 such patient. He and his mom came to educate us, and they brought 2 shopping bags full of the medicines and devices he had to use every day to help him fight his condition. He was in high school, and he would wake before 6:00 a.m. every day to spend over an hour on his routine to try to prolong his life. "I'm middle-aged", he told us. He was 16. He explained that his life expectancy was 35. We asked him what we could do for him, and he said, stay focused on medicines that will really make a difference. Before he left, he went under account how he had recently become an Eagle Scout, carrying a portable generator on backpacking trips to power his nebulizer so he could continue with his daily treatments. Needless to say, everyone left that day feeling like we could all try a little harder and do a little more. I think it's fair to say it was days before any of us could resume our normal routines without often thinking back on the incredible character of this young man. As he left, he asked me if Insmed would be making the kinds of medicines that would really make a difference someday. I said, yes, you can count us in. Fast forward to today, and while we all realize it wasn't Insmed that ended up fulfilling this ambition for CF patients, that breakthrough ambition has never left Insmed, nor has our commitment to patients. Indeed, it was our feeling that just another inhaled antibiotic for CF patients wouldn't make enough of a difference that motivated us to turn our development attention toward MAC lung disease, where there was nothing approved and where we believe we can make a meaningful and much-needed impact. And we are proud of bringing forward the first approved treatment ever for refractory MAC. Please understand it is not the disease nor the technology, but the impact on the patient that matters. Now the success we have found with MAC is the building block upon which we have now cast our efforts to bring forward a range of therapies, all unified by the ambition to make a real difference in the lives of patients in need, just like that young man who inspired us. At Insmed, we believe in 1 clear idea, the greater the impact of the medicine on the patients, the easier everything else becomes. Now Insmed has always been a student of successful biotechnology companies. And what we've observed amongst the companies that have achieved sustained outperformance is that they generally share 3 key elements that allow them to stand above their peers. And it is this pattern of success, which we are working to emulate. These 3 key elements are: first, a core commercial engine that is foundational with the ability to generate massive revenue on a global scale, providing financial support for the rest of the business. At Insmed, this starts with ARIKAYCE, and we expect it will be expanded upon with ARIKAYCE for all MAC NTM. Brensocatib and TPIP, all with a common foundation in respiratory inflammation diseases. Second, a collection of scientific platforms, technologies and talent that benefit from one another, yielding highly impactful therapies addressing indications beyond the first therapeutic area of focus for the company. At Insmed, this is satisfied by our fourth pillar, which we will explore in detail today. Third, the capability to add even more programs in innovation through licensing, acquisition and successful integration. This business development must be done with a clear set of defined criteria. At Insmed, examples of this include the in-licensing of brensocatib. And as you will review today, the acquisition and development of Deimmunized by Design, Motus, AlgaeneX and Vertuis. Behind these key criteria must lie a distinct culture. Our culture at Insmed is a unifying force that brings all of this together. Great talent, collectively focused on the betterment of patients. This culture is built to align with our mission, vision and values. Now the mission of a company does not change. It's the reason the company exists. Our mission at Insmed is to transform the lives of patients with serious and rare diseases. The vision of a company is what the company expects to become in the next 3 to 5 years. Our vision is to be a globally recognized leading biotech company that empowers great people to deliver with a profound sense of urgency and compassion, life-altering therapies to small patient populations experiencing big health problems. The values of a company are how we operate, the ways we will act, the behaviors you can expect to witness on any given day at Insmed. Our values, our collaboration, accountability, passion, respect and integrity. This culture naturally draws us to one another in a way that makes our collective efforts greater than the sum of the individuals that make up Insmed, and it is a distinct competitive advantage. One of our favorite points of recognition is that we have won the coveted Science Magazine designation as the #1 Best Place to Work 2 years in a row. Only 3 companies have ever achieved this: Genentech, Regeneron and Insmed. These attributes are what have enabled us to construct what many of you have come to know as our 4 pillars. It is these 4 pillars that are reaching the point where they will accelerate our journey to a self-sustaining global biotechnology leader with consistent positive cash flow and earnings generation. What's different about us is that while most companies make that transition slowly over many years, we are capitalizing on opportunities today to accelerate that accomplishment. Now after a multiyear process, we have clear insight into the potential of each of these pillars over the next 4 quarters. And with success, we anticipate we will be able to do in 1 year what many successful companies do in the span of 5 to 10 years. Insmed is on the cusp of multiple catalysts coming from multiple programs in rapid succession. And this starts today with the detailed exploration of the progress of our fourth pillar and what this will mean for patients and our shareholders. I believe you will be hard-pressed to find another company with the kind of potential for this scope of change in that kind of time frame. Let me be specific. If you take just ARIKAYCE and brensocatib, and assume approvals in the indications we're currently studying, I believe we have the potential to exceed $5 billion in peak sales globally from just these products alone. So let's take a closer look at this idea of the imminent transformation of Insmed. It is difficult to overstate the magnitude of the difference between where we are now and where we think we're going to be in the relatively near future. This slide illustrates the step change in terms of the number of patients that our medicines could address. Keep in mind that this is only part of our commercial story because it doesn't include our third or fourth pillars. It also highlights why we must look for new medicines using other technologies and commercial infrastructures. The pulmonary sales force and infrastructure we have built and which we will scale even further will be at full capacity addressing these synergistic opportunities. Assuming success of near-term readouts for ARIKAYCE and brensocatib, the efforts of our pulmonary commercial operation will go from serving thousands of patients to potentially serving more than 1 million, which should comfortably set the company on the path to sustain profitability. What is even more exciting is the identifiable expansion opportunities with brensocatib. As the foundational DPP1 inhibitor, Insmed has the opportunity to mine this novel pathway in a similar fashion to other molecules targeting novel pathways, such as Alexion did with complement, or VERTEX did with CFTR regulation. This opens the door to several multibillion-dollar indications with high patient impact. Our belief in Insmed's future is based on our experience. I take pride in reminding everyone that we have gone from 30 employees to more than 800, on the way creating a track record of success across the entire life cycle of drug development and commercialization. This gives us great confidence as we move forward. Our research colleagues developed both ARIKAYCE and TPIP within our labs. They were also responsible for the scientific due diligence performed on brensocatib, which ultimately led to Insmed acquiring those rights. On the clinical front, we have shown consistent success to date across all of our clinical stage programs. From a regulatory perspective, we have achieved marketing approvals for ARIKAYCE across the U.S., Europe and Japan and have achieved prime and breakthrough therapy designations for brensocatib in the EU and the U.S., respectively. Finally, we have the commercial foundation in place to fulfill the promise of products that emerged from our pipeline, as demonstrated by ARIKAYCE's success as one of the top 10 non-oncology rare disease product launches of all time. Now I want to pause on this slide for a moment and let you take in the strength of what we have in the clinic today. There are other development programs that are not displayed here, like RV94, programs that held great promise but ultimately did not meet our disciplined criteria for future development, so we chose not to move the program forward. Each of the clinical programs included in our first 3 pillars have the potential to be first-in-disease, first-in-class or best-in-class and many of them could qualify for several of those designations. These same principles apply to how we are developing our fourth pillar. Every target within our fourth pillar has the potential to be first or best-in-class or disease and some could potentially qualify for several of those designations. Now I recognize that despite our vision, some of you might be asking why pursue these avenues now? More specifically, why pursue Duchenne Muscular Dystrophy where there are other larger competitors who are further along in development? Why not just stay where you've had so much success? You will hear many supporting details today for why we are so confident that the path we have chosen will be the right one for our patients and our shareholders, but let me offer 3 high-level responses right upfront. First, our end goal for Insmed goes well beyond being a successful niche biopharmaceutical company with a handful of commercial products in 1 area of focus. Genentech, Gilead, Vertex, Regeneron and others all teach a similar lesson. You must have a breakout commercial product, coupled with an internal research engine that can generate additional impactful drugs if you wish to achieve the status of a great and sustainable biotechnology company. Similarly, there are many examples that teach the consequences of not having that research engine. We've always known that if we were to fulfill the kinds of growth ambitions we have for this company, we would have to expand beyond our initial focus. Second, patient impact is what really matters. We intend to bring forward first or best-in-class drugs. Take our Duchenne Muscular Dystrophy gene therapy. It is our belief that the gene therapy we produce for Duchenne will be the best available, period. And the distinction in this regard will not be equivocal or opaque. We will hold ourselves to this standard, so we can deliver for patients and consequently, our shareholders. Any of our drugs developed that do not meet this standard will be discontinued and resources will be redirected to programs where therapies will have that kind of impact. Please look at today's presentation and the various technologies we have assembled with this in mind. Third, we believe this strategy will produce medicines that will not be significantly affected by the Inflation Reduction Act. Clearing this new barrier will differentiate Insmed as one of the successful companies in today's environment. Now given the enormous potential impact of the research, we will be sharing with you today, combined with the fact that all of this continues to account for less than 20% of our overall spend. And I think you would agree, our fourth pillar punches well above its weight. So what principles have informed our pursuit of these technologies? Business development at Insmed is always centered around 5 principles: number one, first or best-in-class therapies and technologies; number two, asymmetric return potential; number three, low upfront cost; number four, success-driven milestones built into the transaction that keep motivation for all involved for many years to come; and finally, number five, consensus that the deal in question is one that the company should do. This is achieved by having all members of our research and leadership team involved in the decision-making and requiring agreement that the opportunity in question is one we all want to pursue. This has led us to walk away from many more deals than we have done. As a result, we've missed many that failed and even some that have succeeded. But we believe this greatly increases the likelihood of success among those we have selected and closed. As an example, these were the principles that guided our decision to acquire the rights to brensocatib, which may end up being one of the better product rights acquisitions the industry has ever seen. The application of these principles has led us to the 4 separate but complementary acquisitions you see here, which are all squarely focused on the one clear idea that patient impact is what matters most. In March of 2021, we acquired a proprietary protein deimmunization platform called Deimmunized by Design, which uses artificial intelligence to reengineer proteins without their immunogenic properties. This platform was started nearly 10 years ago by researchers at Dartmouth. They and their team joined Insmed 2 years ago, and I'm excited you will meet them today for the first time. We completed the purchase of Motus in August of 2021, which brought with it next-generation gene therapies and targeted delivery capabilities, which had already been under development for several years, along with an absolute treasure trove of proven experts with decades of experience in the field. Many of you covered or invested in Dr. Brian Kaspar and his team when they were at AveXis, and we are excited to have him here as Insmed's Chief Scientific Officer, to share with you some of the exciting work they have been doing over the past 2 years. At about that same time, we acquired AlgaeneX, a company that started in 2019, but was based on work that had been underway in an academic lab for a very long time. This groundbreaking work looks to accomplish cell culture production using algae. This has the potential to fundamentally transform protein manufacturing, significantly reducing the cost and time for producing proteins, including, but not limited to AAV gene therapies. Finally, in January of this year, we acquired Vertuis Bio, a company that has pioneered RNA End-Joining technology, which we believe will allow for the delivery of genes that are larger than what can fit inside a single AAV capsid. If successful, this technology, which has been under development outside Insmed since 2018, will enable us to target many diseases currently unreachable with single AAV capacity, and could also enhance the impact that the gene therapy could have on patients with these diseases. While each of these technologies and platforms are compelling on their own, bringing them all together has had a synergistic effect that I think will become clearer as you listen to today's presentations. But let me give you a couple of examples of what I mean among many. Having the gene therapy capabilities for Motus provides a platform for the Deimmunized by Design and RNA End-Joining teams to move faster into the clinic than they could have on their own. And conversely, having those technologies helps to advance and differentiate the gene therapy programs by opening up new potential targets that could benefit from re-dosing or the delivery of larger genes. All of these acquisitions are potentially manufactured using AlgaeneX. This allows us to explore algae cell culture production for the Deimmunized by Design engineered proteins in real time as they are being developed rather than working on each technology independently and then having to do more work to combine them later. This parallel approach could help both technologies reach the clinic and eventually the market faster. Furthermore, if we are able to manufacture AAV capsids using algae, this will transform the cost and time to produce gene therapies. Critically, each of the companies we have acquired has been a cultural fit with Insmed's values, and the result of this has been a rapid and seamless integration. Beyond these 4 companies, we continue to monitor for other attractive early-stage platform technologies and assets that could fit well within our strategy. The pursuit of any future deals would also be guided by the same principles I've highlighted. Now let's turn more specifically to the areas you will review today and how they interrelate. Let's begin with the current challenges preventing gene therapy from reaching its full potential. First, unique technical capability and experience is needed in developing the assays and manufacturing processes to ensure consistency between batches with predictable dose strengths. Second, there are concerns about safety, which are often connected to treatments that require very high doses to achieve the desired efficacy and which are commonly delivered by IV and thus concentrate in the liver. Third, AAV gene therapies cannot target large genes due to the capacity constraints of the vector. Fourth, the therapy must be delivered through a viral capsid, which elicits an immune response and makes it impossible to effectively dose patients who have pre-existing natural immunity or to re-dose already treated patients. And fifth, the treatments can be difficult and expensive to manufacture. The proprietary technologies and talent we have acquired, if successful, have the potential to uniquely address each of these challenges and fundamentally change the treatment paradigm for gene therapy, once again, highlighting the synergistic nature of these acquisitions that we made. By solving these issues, Insmed intends to become a leader in the field of gene therapy. In today's session, we will be sharing with you some of the promising preclinical data we have produced to date from each of these platform technologies. Now as impactful as we believe these platforms can be in the gene therapy space, their application extends beyond gene therapy as well in the realm of therapeutic proteins, immunogenicity concerns continue to limit the usefulness of current treatments and prevent the development of many others with known therapeutic potential. Our artificial intelligence-based Deimmunized by Design technology has the potential to produce better, less immunogenic versions of existing treatments and to create innovative medicines that avoid or greatly reduce activating the body's immune defenses. Today, we are excited to show you the first targets in what we believe could be a broad application of these technologies. Please remember, all of these technologies and personnel have been working for many years before joining Insmed and have continued that work during the last 2 years. So as you will see, we are well along the way to creating value from these efforts. So again, thank you for coming to be with us or for tuning in online. We believe that what you will hear today will be well worth your time, and we can't wait to share it with you. Now please welcome Dr. Brian Kaspar, Insmed's Chief Scientific Officer, to kick things off with a deeper dive into a field of medicine where we intend to hold the dominant position, gene therapy.

Thank you, Will. I can't tell you how wonderful it is to see so many familiar faces and how excited I am to introduce all of you to the unique way we are pursuing gene therapy at Insmed. As many of you might know, I have spent over 25 years in the gene therapy space. And most recently, I had the honor of leading the development efforts at AveXis to move Zolgensma, a gene therapy for the deadly pediatric neuromuscular disease, spinal muscular atrophy, from the bench to the bedside to approval, tackling fundamental gene therapy aspects. This drug has become the most commercially successful gene therapy product in history. But most impressive is a life-saving transformational impact it has had on infants with SMA. Zolgensma set the stage for development of gene therapy and is a hallmark example of how gene therapy can be and was done correctly. This here is Evelyn, a patient with SMA. Children with her condition rarely reach the age of 2. She is now 7.5 years post gene therapy treatment, proving the remarkable durability of this onetime treatment. Today, I am very excited about the world-class team we have put together and the scientific progress we have made at Insmed for multiple new conditions. Together, we hope to provide life-changing treatments for those patients, just as we did with Zolgensma for the patients like Evelyn. In assembling our initial team, I was fortunate to reunite with many brilliant individuals with vast experience in gene therapy. I will highlight Dr. Jim [ Letalien ] who was responsible for the U.S., European and Japanese regulatory approvals for Zolgensma. Between the 5 of us, we have more than 70 years of experience in this space. We have taken these collective experiences and applied the maturity to think about moving new therapies to clinical and commercial success. This all started several years ago, folks. After surveying the landscape, we found significant challenges within the gene therapy field to overcome and pulled a select group of scientists together to explore opportunities to address them. Most concerning to us were the massive doses required to target key tissues that many in the field were pursuing. Next was the incredible strain and difficulty to manufacture these higher dose AAV gene therapies at a commercial scale. Third, we identified the complex challenges associated with analytics, supporting the quality of gene therapy-based products to ensure accuracy and precision of drug product. We founded Motus Biosciences with a vision for addressing these major challenges to the field. In a short period of time, our data showed that we were indeed addressing some of these challenges. Insmed, with whom we have had a relationship for many years, learned about our recent innovations and presented an opportunity for us to join their team. Our company's cultures perfectly aligned, and we saw the mutual vision that we could build one of the leading genetic medicine companies together. It has now been nearly 2 years since we joined Insmed. And truly, we couldn't be happier with that choice as we have been able to build a world-class organization with particular focus on manufacturing as well as quality control on our products. Quality assurance has been paramount throughout our entire organization from day one. We believe that Insmed is uniquely positioned to address challenges in the gene therapy landscape with game-changing novel proprietary technologies. We aim to target rare disorders that have no or limited treatment options representing a high unmet clinical need. To achieve this, we are harnessing the power of our experiences. There are many companies pursuing gene therapies. Yet, there are actually only 5 gene therapy treatments that have been FDA approved. While the field is still maturing, there is a lack of individuals with end-to-end clinical, development, regulatory and commercial experience. This is what we have built over the past 2 years at Insmed. As Will mentioned earlier, there are 5 common challenges in the gene therapy space. The first challenge that any gene therapy company has to solve is how to manufacture with quality and consistency. We have created a GMP manufacturing process that is scalable, reproducible and can meet commercial demand and quality. Most importantly, we have developed analytics in our GMP quality control group that ensures accurate and consistent dose titer, purity and lack of empty particles. We have implemented these processes from day 1, even prior to our 1st IND submission. Beyond the hurdle of quality manufacturing, Insmed has built out game-changing novel proprietary technologies that position us to address each of the remaining major challenges in the gene therapy landscape today, including treatments that require extremely high doses and often result in systemic toxicities, low efficacy and off-target transduction. Certain diseases that remain outside the reach of gene therapy due to the large size of the genes, that must be delivered. Really excited about this point. Treatments that result in immunogenicity and result in an inability to target diseases that require potentially multiple doses. And these treatments often involve very high manufacturing costs with low production and purification yields. The proprietary technologies that we will share with you today has the potential to address each of these challenges. We believe one of the largest challenges in the gene therapy space is scaling the manufacturing process with consistency. Insmed's upfront targeted investment and focus on CMC quality and analytics ensures a locked commercial process to supply the market with control and understanding of the product. We have developed a fully reproducible process currently at the 1,000-liter bioreactor scale. We view this manufacturing process as a platform in itself, which Insmed will be able to leverage for all future gene therapy programs across various indications. We have developed an in-house GMP quality control lab with 25 state-of-the-art assays, which I am really excited about and proud of, which allows us to know the quality of the product as it is made. For example, we implemented Droplet Digital PCR as our method to tighter our drug product. This has resulted in consistent and accurate titers between batches. Additionally, all assays will be qualified and validated prior to our first IND submission, which speaks to our commitment to quality, safety and fully understanding the product before it goes into a single patient. We believe that our focus on quality manufacturing out of the gate has already made a meaningful difference. While others in the space commonly produced gene therapy products with 13% empty capsids, our process has consistently produced gene therapy product candidates with less than 5% empty capsids. I think that's really important folks. Even after addressing quality, consistency and measurability of the manufacturing process, there still remain 4 challenges in the gene therapy landscape today, and Insmed is uniquely positioned to address each of them with our novel and proprietary technologies. For the problem of high dose and the inherent toxicities and other issues, we have pioneered a targeted intrathecal delivery approach that allows for a 10- to 50-fold reduction in the required dose compared to traditional systemic delivery methods. For the problem of not being able to deliver larger genes, a real game changer here folks, we have our proprietary RNA End-Joining technology, which allows delivery of large genes through the traditional AAV capsids. You will hear more about this exciting technology from Dr. Lukas Bachmann, who has joined us today. For the problem of not being able to dose patients who may need it, we have our proprietary Deimmunized by Design platform that Will mentioned, which uses AI to identify and strip away immunogenic pieces of proteins to go undetected by the body's immune system, potentially allowing for redosing of patients or even dosing patients for the first time who have natural exposure to the virus used in the treatment. My colleagues, Dr. Karl Griswold and Dr. Chris Bailey-Kellogg, will go in depth on this work for you. And finally, for the problems of high manufacturing costs and low yield, you have heard we have at scale, 1,000-liter successfully suspension-based bioreactor. But we also have a new technology, AlgaenX, a proprietary technology, which drastically lowers the time and cost to manufacture AAVs, that will be presented by my colleague, Dr. Anthony Berndt. This collection of Insmed technologies, each of which will be highlighted in depth by the respective experts, is highly suited to address the many challenges experienced in the development of therapies for Duchenne Muscular Dystrophy. Current treatments in this space require very high doses administered systemically with significant safety considerations as well as complications scaling manufacturing. We think our solutions here could lead to a future for these patients, that to this point, folks, has only been dreamed of. Rather than have me tell you why I am so excited about this, it is my pleasure to introduce Director of the Neuromuscular Division and Clinic at Stanford University, Professor of Neurology and Pediatrics, Dr. John Day. John?

Thanks a lot, Brian. It's very exciting to be here, and it's great that you've reassembled a lot of the AveXis team now at Insmed. I've had the pleasure of working with Brian and the AveXis team since Brian moved there from Nationwide having developed Zolgensma, what became Zolgensma with Jerry Mendell. And when we dosed the very first patient with the AveXis Zolgensma product, Brian actually came to Stanford to be there for the infusion because he cared about the patient and was there to see and make sure everything went well. And I think that's -- that excitement that we had about what became the first treatment -- gene therapy treatment for a neurologic disorder, now translates into this opportunity for Duchenne. We're tremendously excited about where we are with Duchenne and where we are going to be able to go with the Insmed approach. I actually got interested in Duchenne before I got interested in SMA, because I thought it was a perfect paradigmatic disorder to develop novel treatments. That was in 1986, the year I actually finished my residency at UCSF and the year that Louis Kunkel identified the gene with his incredible team of investigators at Boston Children's. He found the gene that caused Duchenne and created the protein dystrophin. Now this audience has many experts in Duchenne, and I don't need to belabor the details of the disease, but just to level set, this is a huge protein that's missing in Duchenne. It's a very large protein, not the largest protein in the human genome, but it is the largest gene. It is a very, very large gene. And the reason we thought this was a great target for developing gene therapies was because the very stereotypical nature of this disease. It's definable genetically. Most boys start to show signs of weakness at age 3 or 4. They typically lose the ability to walk by 10 to 12 years of age and then develop additional issues of ventilatory problems and at that, that era he would die typically by their late teens or early 20s. So we thought that, that gave us a lot of predictability that we could use to define effective treatment. In addition to that, it's relatively common. So worldwide, about 1 in 3,500 boys are born with this disease, and it's not going to be eliminated by genetic testing and family planning or even preimplantation genetic testing because only 1/3 of the patients with this disease have de novo mutations. So with that, we launched into this study of Duchenne in trying to develop treatments after the gene was found, but we didn't expect the degree of heterogeneity, both genetically, which led to clinical heterogeneity, which really undercut a lot of the trials. So for the next 25 years, we had really marginal success in developing treatments for Duchenne. We did have some success so early on, showed that steroids could help in terms of slowing the progression. And then, within the last decade, have been able to develop an antisense technology that corrected some of the genetic disorder as well as other methods developed for suppressing nonsense mutations. So these were important steps in the development of treatments for Duchenne, and we were very excited to participate in them and see them move forward, but we all have to admit that the effect size has been quite modest. That brings us to the current era where we have been very active in developing replacement gene therapies for Duchenne using microdystrophin products. And as many of you know, these are really moving forward fast. And I'm very optimistic and hopeful that these will go into commercial usage in the near future. I think it's, again, an important step towards our being able to conquer this disease. But there are, again, concerns about this. I think, as Brian already pointed out, we have to use very high doses when we give this intravenously and that's associated with a significant immune response, which, if you look at in composite, the 200 boys that have been treated in clinical trials to date, 2 of them have died. Now my friends at the different companies would say you shouldn't put them together, they're different products. But nonetheless, we have very little information currently. Very few patients and 1% of the boys so far have died. That certainly is a sobering issue that we need to be careful about. And even greater number have had some kind of serious adverse event reaction. And I remind you that this is at the premier clinical sites that know what they're looking for and know how to manage it. So it does require a lot of monitoring. There are concerns about the safety side of this as we move into the treatment era, which, again, I'm very optimistic about and hopeful as a step forward. If we look at that a little more carefully, though, we don't know what population might be eligible for treatment. But if it's, for instance, boys who are greater than 3 years old who are still ambulatory, that could mean 4,000 to 5,000 boys eligible in the United States for gene replacement therapy on day 1, then this would be approved. That's going to be a hard population for us to dose very quickly. And I just gave some numbers there that if we had 50 centers that could do a patient weekly which, as I'm going to point out, is unlikely, that would still take us 3 years to treat the prevalent cases. I don't know how long patients and parents are going to wait for this treatment. It's more likely that we're going to be treating -- at Stanford, we're going to treat no more than 2 patients per month just because of the careful rigorous follow-up that's required for these patients given the serious adverse events that we know can occur. And so then it's going to take even longer. And the concerns about that is that patients might not wait for treatment at the premier sites and start going to sites that have less experience. So if that 1% death rate persists, even as it currently is, we're still looking at 12 to 25 boys dying in the treatment per year of that prevalent population. And that risk is going to go up because rather than in the clinical trials, we're going to be dosing older boys oftentimes, boys that might have some earlier pre-existing conditions that we need to be careful about. They're heavier boys that they're going to have a higher viral load, which is dosed on a viral genome per kilogram basis. And an additional concern is that we might be involving centers with less experience. So I think that provides the opportunity for Insmed and for the programs that Brian has outlined. If there are ways that we can significantly reduce the dose, that would be a potential game changer. We do know that a lot of the risk is dose dependent. If we can reduce the AAV immunogenicity, that also is a potential game changer. And then obviously, there's a significant benefit available if we can increase the size of the construct to one that more closely mirrors normal dystrophin. So I'm very excited, Brian. I'm excited to work with you and excited to work with Insmed to see if we can move these products forward as a new way to hopefully begin to conquer Duchenne. So thanks for having me here.

Thank you, Dr. Day, for your valuable comments and perspective. And I truly remember the day that I was at Stanford for our Phase III trial at AveXis and coming there to support you to be the cheerleader, and I remember your comment as we dosed the first patient in about 2.5 years since our Phase I/II trial at AveXis. There was a lot of holding breaths, and I remember you coming out and said, "It is about as exciting as watching paint dry on the wall, Brian," which folks was exactly what we wanted to hear because we were dosing patients with the largest dose of gene therapy for Zolgensma on an infant who was, I think, was about 9 months old, plus or minus 3 months -- I'm sorry, 3 months old, as Dr. Day is reminding me, 3 months old patient with 1 of the largest doses systemically, Zolgensma. It was uneventful. As exciting as watching paint dry on the wall. And that's exactly what we wanted back in the day. That patient, and Dr. Day can correct me if I'm wrong, responded fantastically to the therapy in that Phase III trial. And it's something that I'm truly humbled but also really gratified on developing that therapy. As you heard from Dr. Day, there are a number of challenges that remain within the treatment landscape for patients with Duchenne muscular dystrophy despite the scientific advances we've seen in recent years. These challenges are interrelated and include very high doses and inherent systemic toxicities along with the manufacturing complexities. We at Insmed have developed a targeted delivery system to overcome many of these challenges. Our methods allow for a 10- to 50-fold reduction in the dose versus the traditional systemic gene delivery which we believe can lead to enhanced safety profiles with similar or better efficacy. In contrast to most of our peers, who administer gene therapy to the patient IV, we were encouraged by the biodistribution profile in muscles, following intrathecal gene delivery approaches that have been reported by multiple groups in rodent studies. We believe that we could achieve the same or better results with much lower doses and fewer systemic toxicities by using the IT route of administration, which, in this case, is an injection in the fluid-filled space between the thin layers of the tissue that cover the spinal cord. Our first experiments were focused directly on that comparison, the results of which you can see on this slide here. Insmed's proprietary intrathecal delivery showed efficient targeting of skeletal muscles with a clear transduction advantage relative to systemic IV dosing in non-human primates. These studies were performed utilizing AAV9 gene therapy encoding the green fluorescent protein or GFP. Rather than showing you images from 1 cherry picked muscle group, we wanted to show you -- we wanted you to see the results across a broad range of skeletal muscles that are affected in patients with Duchenne Muscular Dystrophy to emphasize the breadth of the transduction we are seeing, which is truly remarkable. Three weeks following treatment, we took the muscles from each of the muscle groups and performed immunohistochemistry for GFP expression. As you would expect, there is little to no staining of GFP in the muscle groups in the non-injected muscles. With IV delivery, there is minimal expression and limited targeting in a dose-dependent manner, using either a dose of 9.2x 10^13 or 1.8x 10^14 vector genomes per animal. As we move down to the muscle samples taken from non-human primates treated using the intrathecal gene delivery, you can clearly see that even at the 4.6x 10^13 dose level, which is half of the lowest IV dose, the treatment resulted in a vast number of cells being targeted and transduced within each of the muscle groups shown here. This impact only increases in a dose-dependent manner as you move to the mid-dose level of 9.2x 10^13 and the high dose of 1.8x 10^14. These were total bolus injections, not based on individual animal weight. So we can make a comparison between all of these dosing groups to truly show that IT delivery has the robust expression and tactical muscle fiber targeting at all dosage groups. As you know, there are certain muscles that are especially crucial to target with any gene therapy for DMD because of the complications caused by the deterioration of these muscles in these patients. Here, we show you samples from the diaphragm which is essential for its role in its breathing -- in breathing and the heart, which we all know is affected in DMD. Importantly, for both of those muscle groups, we saw very robust and dose-dependent targeting of cells and transduction, similar to what I showed you on the last slide, across all dosage levels using our intrathecal delivery approach, easily exceeding the effects that we saw in the samples from the animals treated IV. In contrast, to the heart and diaphragm, too much off-target transduction of the liver can lead to safety concerns, as you all know. As you can see with IV dosing, while all sample muscles have some level of targeting, the greatest amount of expression was shown within the liver, the depot or most of the virus lands following a systemic delivery. With our intrathecal delivery, you can see a robust and enhanced targeting of skeletal and cardiac muscles, compared to the IV doses at all dosing levels, with substantially less gene expression within the liver. We have developed a biodistribution assay to quantify the number of AAV vector genomes per nuclei or deploy genome with unprecedented precision utilizing the DD-PCR methods. This allows us to effectively count the number of genomes that transduce each of the muscle nuclei per respective muscle group as well as a number that transduce off-target tissue nuclei. Insmed's IT delivery shows extremely efficient targeting of skeletal and cardiac muscles. On this slide, you can see the results of that analysis. The Y-axis of these graphs reflects the number of vector genomes per nuclei. A Y-axis value of 1 suggest that there is an AAV genome in every single nuclei in that muscle or target tissue. Many of our doses are consistently targeting at least 50% to 100%, if not higher, in many of the skeletal muscles. And in the heart, which we know is so important for DMD, we have shown well over 3 vector genomes being delivered per nucleus. Folks, I cannot emphasize this enough. Each and every single muscle that we evaluated had significant numbers of vector genomes that have been deposited within each of these muscle groups in the nuclei supporting the robust protein expression levels that we saw in the IT treated non-human primates. This data supports the conclusion that an IT delivery method is ideal to efficiently targeting skeletal and cardiac muscles. Our DMD gene therapy program is much more than just a unique delivery method. We have an innovative gene therapy construct specifically designed for cardiac and skeletal muscle expression. It utilizes a recombinant AAV9 capsid shell which has been used now in thousands of patients with a remarkable safety profile to date. This is a single stranded DNA vector with an MHCK7 promoter, driving expression of a microdystrophin construct, which we believe will allow for efficient replacement of the missing dystrophin protein, leaning to improve muscle function. I am about to walk you through several preclinical studies of this construct. All of these studies were conducted using an MDX mouse model, which lacks functional dystrophin and is the most commonly used model to study Duchenne muscular dystrophy. The overall goal of our non-clinical studies was to provide proof of expression as well as efficacy of a GMP-produced AAV9 microdystrophin, utilizing one of the engineering lots in our MDX mouse model. The delivery was an intracerebral ventricular or ICV injection of our Duchenne construct, which is now called INS-1201. ICV injection was utilized in the mouse model to effectively deliver the INS-1201 into the cerebral spinal fluid. Over the next several slides, I will show you the impressive results we produced in these studies in terms of dystrophin expression in the diverse set of muscle tissues and correction of histopathological DMD features at various time points and dosage levels. Here in this slide, we show the effect of INS-1201 in the MDX mice 90 days post administration. These animals were dosed at approximately 30 days of age. So the data that you are seeing are from animals that are about 120 days of age. This slide shows the results for the gastrocnemius muscle tissue. If you first look at Panel A on this chart, you will see the histopathology by hematoxylin and eosin staining. In the vehicle column at the left, you see clear signs of inflammation and lack of myofiber organization. But as we move from the left to the right, you begin to see significant improvements in myofiber organization in a dose-dependent manner with less inflammation, improved myofiber size, less endomysial connective tissue as well as less central nucleation, particularly at the mid and higher doses, in which these muscle samples are looking quite similar to the wild-type animals. In Panel B is a stained picrosirius red that stains for collagen deposition or fibrosis that has happened due to the progressive dystrophic pathology that occurs in this disease. In the vehicle animal in the left column, you see significant amounts of red staining, which would be indicative of damage to the tissues. Once again, as we move to the right, with higher doses of INS-1201, you see less and less of those signs of damage and see results that appear to approach tissues from the wild-type animal. Limonite staining in Panel C looks at the extracellular matrix and evaluates the organization of myofibers. At nearly all INS-1201 doses, one sees a normalization of the myofiber structure, which is indicative of myofiber health as well as function. Finally, when you look at Panel D, dystrophin expression, one sees very little staining of dystrophin or revertant fibers in the MDX vehicle animals. In a dose-dependent manner, you see increased amounts of dystrophin expression with the highest dose of INS-1201, producing a sample that is nearly indistinguishable from the wild-type animal sample. On the top section of this slide in Panel A, we show the quantification of reduced fibrosis as well as in Panels B and C, increased fiber size within the gastrocnemius muscle. We are obviously looking to see a decrease in fibrosis in INS-1201 treated animals as well as an increase in fiber type size, which would be indicative of healthier myofibers. We counted individual fibers in Panel C and plotted them in these histograms to show that treated animals experienced a clear shift in the myofiber size toward wild-type fiber sizes. We have also developed the ability to quantify dystrophin with great precision within our laboratories, which demonstrated that we have shown dystrophin expression in up to 84% of cells, showing a density of the dystrophin signal that is approaching in many of our groups to levels that are comparable to wild-type levels. Once again, in the spirit of not wanting to just pick out 1 muscle group that looks particularly impressive, we are going to show you data from several different muscles to emphasize the broad effect of treatment with INS-1201. We just showed you the gastrocnemius muscle. This now is data from the tibialis anterior. In the interest of time, let me just quickly point out that we once again see an improvement in a dose-dependent manner of the myofiber size, less inflammation, less fibrosis and improved myofiber organization with an increase in dystrophin levels. And here now is the similar quantification data for the tibialis interior. As you can see in the graphics on the top portion of the slide, there was a significant reduction in the amount of fibrosis or collagen deposition and increase now in fiber size with a fiber size distribution shift moving towards wild-type levels, all, again, in a dose-dependent manner. Now looking at the bottom of the slide, one can see also a dose-dependent increase in dystrophin signal with the shift towards the amount of dystrophin signal approaching that of wild-type levels and with positive dystrophin expression in up to 89% of the cells, depending upon the dose. Once again, this level of dystrophin expression in skeletal muscle fibers is truly unprecedented. Another muscle group that is affected significantly by a lack of dystrophin in MDX mice is the diaphram. Again, I won't spend too much time here, but these slides will be available to you via our website for you to look through at your leisure. But we saw a dose-dependent improvement in the diaphram muscles similar to what I showed you before. Moving towards quantification. Now one sees a significant decrease in the amount of collagen as well as a slight improvement in the fiber size with up to 81% of the cells being positive at the high dose group within the diaphram muscle. And our final muscle group, the EDL, that I'll show you, showed very similar findings. Decreased inflammation, decreased collagen deposition in fibrosis, improved myofiber organization and a dose-dependent increase in the dystrophin expression. This muscle has been quantified as all other muscle groups that I've shown you, demonstrating positive dystrophin expression in up to 74% of the cells within the EDL. Now let me just pause here for a second since I've just thrown a lot of information to put this into -- and allow me to put this into context. Across all of these muscle types that I presented, these are truly significant levels of dystrophin expression, at least as good, if not better, than any other DMD gene therapy data produced today. But here is the exciting part, folks. We have found consistent functional as well as histopathological effects observed following intrathecal administration of INS-1201. And this was accomplished using a dose that is 10- to 50-fold smaller than the systemically delivered doses that many within the field are utilizing in their non-clinical as well as clinical studies. For example, the dose is utilized in the IV systemic administration of MDX mouse studies performed by my colleagues at Sarepta, demonstrates very high doses up to 1.2x 10^13 vector genomes per animal. Even the lowest dose utilized in this study, 2x 10^12, is still significantly higher than the doses used in our INS-1201 intrathecal administration study. Despite our lower dose, our data has shown as good, if not better, efficacy based on the histopathological effects in the MDX mouse model. So folks, none of this matters if the treatment is not safe. So let me share with you some information about our preclinical toxicology study. This was a 12-week study with animals taken down at 3, 6 and 12 weeks of age. The study was performed at a third-party GLP toxicology laboratory. Wild-type animals were injected, intracerebroventricularly with the INS-1201 construct at postnatal day 28, with 3 dosing groups up to 8x 10^11, including a vehicle or non-treated group, along with naive untreated animals. Overall, the study showed a very clean safety profile with no off-target effects. There was normal body weight gain, normal blood chemistry and hematology, normal clinical observations throughout the 12-week toxicology study. There was no concerning histopathology found associated with INS-1201. There was a slight mononuclear cell infiltrate that was noted on -- around the blood vessels within the brain, and this was deemed by the pathologist of the study to be associated with a viral gene delivery approach. However, this wasn't dose-dependent and appeared to resolve over time. There were no unexpected deaths in any of the treatment groups, but there was 1 unexpected death in the vehicle-treated control group. Importantly, folks -- and this is important. The no observable adverse effect level, or NOAEL, was 8x 10^11 vector genomes, which was our highest dosage that was given within the study. So in summary here, we are extremely pleased with the safety profile that is emerging for INS-1201, which we believe, based upon these early data, to have the potential to be a safe and tolerable treatment option even at the highest tested dosage levels. The toxicology study I just described also measured muscle biodistribution across skeletal and non-skeletal or cardiac muscle groups using the same DD-PCR technology I discussed earlier. This slide shows the results of the 3-week post-dose time frame. These results showed an obvious dose-dependent increase in all of the muscle groups with many of the muscles expressing close to 1 vector genome per nuclei, represented by the 1 on the Y-axis. And some muscle groups achieved even higher levels of biodistribution at the highest dosage levels. This shows that data, again, but at the 6-week time point post dosing. One can see a similar trend throughout all of the skeletal muscle groups. This is extremely encouraging, folks, showing many of the doses at well above 0.5 to over 1.0 of vector genomes per nuclei. That essentially means that we are targeting a vast number of the nuclei within all of the skeletal muscles that we have evaluated, including the heart. And now finally, here is the 12-week time point, which shows once again, very similar trend of dose-dependent increases in the biodistribution with many of the tissues approaching 1.0 vector genome per diploid -- or per nuclei. Now this next slide is important. Many of you ask about the aspects of durability. What we're showing here is data from the high-dose group in the study, but showing how the biodistribution behaves over time in each of the skeletal and cardiac muscles that were evaluated. Essentially, what this data shows is that it demonstrates that the effects of the treatment were remarkably durable with no apparent decrease in the biodistribution over time in the skeletal muscle groups, which is truly and incredibly gratifying. Look at the heart muscle. We saw very significant and durable targeting of the cardiac muscle with over 1 vector genome per deployed nuclei. Moving now from mouse to non-human primates, this was another study we ran to evaluate the engineering GMP lot of INS-1201 for expression and efficacy in a species more akin to human. I hope you appreciate that we are utilizing a GMP-produced material as part of our engineering lots that has led to a GMP-produced product. So we're utilizing material to truly understand the product that we are producing that is moving towards patients. So now moving to monkeys. Given the larger sizes of these animals, this study was performed using again an IT injection rather than an ICV or intracerebroventricular injection used in the mice and was conducted in 10 non-human primates aged between 2 to 3 years of age. The tissue was analyzed for muscle distribution. Folks, I'm excited to share with you the results of this study because now we're approaching a larger species more akin to a human being. As you can see here now, in non-human primates, we have muscle distribution of INS-1201 demonstrating a dose response and robust muscle targeting. Take a look at the specific biodistribution in this chart. At the middle and high doses, all skeletal muscles and the heart have well over 0.5 and, in some cases, up to 1.0 vector genomes per nuclei. This means we are targeting a vast number of the nuclei, which allows us to express the dystrophin gene throughout the entire myofiber and muscle groups. Equally important, over the 3- to 4-week course of the study, these animals showed normal body weight gain, normal blood chemistries in hematology and normal clinical observations with no mortality or more abundaty in any of the non-human primates dosed with INS-1201. Now I want to share one more preclinical study with you. Actually, I saved this one to the last, because perhaps this is the most exciting yet. As you saw in previous non-clinical efficacy studies, we treated animals at 30 days of age, where animals had shown cycles of the degeneration and regeneration prior to receiving treatment. And even then, we improved the myofiber organization as well as the dystrophic pathologies that are associated with MDX animals. In this new study now, we performed newborn or postnatal day 1 injections in the MDX animals. In these animals, we performed extensive physiology measurements and, quite remarkably, we found that early intervention of INS-1201 in postnatal day 1 mice showed a near-complete correction within the eccentric contraction profile. As you can see here, untreated MDX animals experienced a rapid decrease compared to wild-type animals which also see a decrease but a much lower one. We found in this study that MDX mice treated at postnatal day 1 with INS-1201, is shown in the blue lines on the chart, experienced a near-complete correction towards the wild-type levels in the eccentric contraction profile. Furthermore, when we look at the total force measurement between the post and pre, we see a near full correction in our treated animals at the 9x 10^10 and 2.7x 10^11 dose levels compared to vehicle-treated controls. This data suggests that earlier intervention has the ability to have higher therapeutic benefit. We're excited about the results of our postnatal day 30 treated animals, but this really positions Insmed to initiate an early intervention study once newborn screening is widely available. I think that's a game changer folks. So here, we plan to initiate a clinical trial of INS-1201 within the second half of 2023. Insmed will initiate a Phase I multicenter open-label study to investigate the safety and biodistribution of INS-1201 in male toddlers for the treatment of Duchenne muscular dystrophy. This will be a safety and proof-of-concept study in up to 6 patients. The first 3 patients who successfully complete screening will be dosed intrathecally with an optimized dose with a 30-day safety period between each patient. An independent data safety monitoring committee will evaluate those patients. If there are no concerns cited by that committee for the first 3 patients, we will ask to expand the optimized dose cohort to an additional 3 patients. In the event that safety concerns emerge, we will go to a step-down dose level to treat the next 3 patients. Importantly, while the primary focus of the trial will be on generating safety data for INS-1201, we will also produce muscle biopsy data, which we expect to be available by the first half of 2024, which will be evaluated using Droplet Digital PCR as well as biomarker expression analyses to determine how much INS-1201 is getting to targeted muscles along with histopathology and to evaluate patients' functional measurements. It's now a privilege for me to introduce our new Executive Medical Director for clinical development as well as safety, Dr. Jessica Eisner. Dr. Eisner has over 20 years of leadership experience in medical product development in both industry and government. Her previous positions include a Senior Medical Officer at the Food and Drug Administration, both within the CDER and CDRH groups, where she was a primary medical reviewer for over 150 industry product submissions, including INDs, PMAs and NDAs. She's held a deputy director position within the military infectious disease research program as well as led medical leadership positions at Takeda and Abbott Laboratories. We certainly look forward to having Dr. Eisner discuss, in future meetings, our clinical data with you as we advance towards the clinic. Now I know I've just thrown a lot of information at you folks. But if you remember just one thing from what I've said, let it be this. We believe that just our unique manufacturing quality and intrathecal delivery methods alone will produce a best-in-class gene therapy option for DMD patients by significantly reducing the size of the dose required to deliver a life-changing efficacy outcome. And we feel that we have this -- the early data that indeed supports that belief. But we're not stopping there, not by a long shot, folks. We now have a technology at Insmed, which we believe could unlock the holy grail of gene therapy for DMD patients. The ability to deliver longer length or even full length dystrophin using our proprietary RNA End-Joining technology. In a few moments, I will invite my colleague, Dr. Lukas Bachmann, who has led the efforts around the development of this technology to speak more about it. But first, I'm going to say a few words about the work we've done so far in Duchenne. As you know, the gene that is missing from patients with Duchenne muscular dystrophy is much larger than can be fit into a single AAV capsid. This is why gene therapy solutions to date for DMD have aimed to reproduce a truncated version of the missing dystrophin protein that can fit in the capsid. These smaller versions of dystrophin have been referred to as micro-dystrophin or mini-dystrophin. We believe our RNA End-Joining technology has the ability to deliver a larger dystrophin construct as well as opening up the possibility to treat many other genetic disorders using gene therapy where the gene of interest is too large. On this slide, you can see some of our latest data with RNA End-Joining technology to produce a larger or what we call a mid-dystrophin gene. This now is a 2-construct, which is combined together using the RNA End-Joining technology producing a 253 kilodalton protein from an 8-kilo base mid-dystrophin gene. As we move from micro-dystrophin to mid-dystrophin, we should see improved efficiency and functionality, particularly for the cardiac muscles. In these initial studies, Dr. Bachmann and his team performed intramuscular injections of an AAV8 vector, and this results in dystrophin being expressed utilizing the RNA End-Joining technology in the immunohistochemistry panel shown in green. When you compare that to the panel in the middle, showing an untreated MDX animal, the contrast is extremely clear. In fact, the treated panel looks remarkably similar to the wild-type control. We have now produced an 8-kilo base or 253 kilodalton protein within the injected muscles. This has been confirmed by western blot analysis to demonstrate that the RNA End-Joining technology is indeed producing the 253 kilodalton protein. Now I love this slide because it highlights the reason why it is so crucial that these technologies that Insmed has acquired all reside really under the same roof. In a very short period of time after we brought this RNA End-Joining technology in-house, we began to apply our intrathecal gene delivery approach with this RNA End-Joining technology to produce a 250 kilodalton mid-dystrophin protein using AAV9. The outcome that this combined technology produced was widespread dystrophin replacement with this expanded 250 kilodalton mid-dystrophin gene, which was confirmed in key muscle groups such as the tibialis anterior, diaphram as well as the heart. As a reminder, this is a one-time administration of 2 vectors that have allowed now productive and efficient 250 kilodalton dystrophin to be expressed in all of these muscle groups at very high efficiencies. Calling this unprecedented doesn't begin to describe truly how groundbreaking this data is. Of course, the ultimate vision and what I referred to before folks is the holy grail is for full length dystrophin to be efficiently delivered to muscles. This would be achieved with a triple RNA End-Joining AAV approach. The fact that we can take 2 vectors and see the data that we saw on the last slide was simply remarkable. Now imagine taking 3 vectors and producing a full-length protein. What Lukas and his team did was they broke up a yellow fluorescent protein here into 3 vectors and utilized the RNA End-Joining technology to reconstitute them. Now this 3-vector approach allows for up to a 12 kilobase coding sequence. The result of that experiment of injecting the muscle groups with the 3 AAV vectors was full reconstitution of these 3 vectors and the efficient production of the yellow fluorescent protein. Truly, this is remarkable. This keeps me up at night in a good way, folks. So the team has now taken this approach to a full-length dystrophin. These studies are currently in vitro in tissue culture, but we have split the entire dystrophin gene into 3 constructs and we have applied this technology using the RNA End-Joining that I've just discussed. I'm excited to show you here in Western Blot in the bottom right corner of the slide that now Lukas and his team has successfully reconstituted the full length, not 230 but full length, 460 kilodalton dystrophin protein in cells in a tissue culture dish. Remarkable. Exciting though as this is, there is still work to be done to bring this in vivo. The team's near-term focus is bringing forward the mid-dystrophin with a fast approaching full length dystrophin being brought forward after that. Again, a lot that I've thrown at you folks. But with that, I'm really proud to introduce Dr. Michael Kelly, the Chief Scientific Officer of CureDuchenne to give his thoughts on Insmed's approach to DMD gene therapy. Michael?

Thank you, Brian, and good morning, everybody. Glad to see you all here. I'm going to talk about CureDuchenne Ventures and really talk about the landscape through the lens that we have in that. And you'll see how we've looked at that landscape and impacted it. But I think as I walk through the next handful of slides, you'll see how we look at this technology and how I think it impacts and why we're so excited about what we're looking at. CureDuchenne Ventures is part of the larger CureDuchenne organization. we're celebrating our 20th anniversary this year and while a lot has happened in this disease over the last 20 years, the Ventures team was formed really to impact research. We fund programs at various stages of development, and we really want to do that in a fashion that moves research much faster through the development sideline into treatment options for patients. And we're early funders. We've been involved in company formation. We've also been involved in seed as well as Series A and Series B. And you can see -- and I'll show you some of the syndications that we've done there that are out there. But during that either company formation or relationship building, we build long-term relationships with organizations. As you could imagine, we have deep domain expertise in Duchenne, both on the non-clinical side through our contacts with CROs and SOPs that run through the non-clinical models, as well as our network of KOLs that can lend expertise into clinical trial design. So that's an important component of beyond just the money that we bring. We really do focus on bringing expertise and technology to bear in order to accelerate treatments for individuals. The success of what we've done is one of the bullet points on this slide. Over the last 5 years, the investments that we've made have attracted almost $3 billion in follow-on money, both from VC side as well as from public funds, really into Duchenne, exclusively into Duchenne. And it really speaks to the power of what the organization has been able to achieve and the way the pipeline has matured. And in fact, 17 of the projects that we funded have moved forward into clinical trial, which I think is a real acknowledgment to what the organization is capable of doing. This gives you a sense of what we funded over the last number of years. And the focus of what we've done really has changed almost on an annual basis. As the pipeline changes and the risks change, what we're looking for to fund in the future is not the same as the past. But we do have a bias on therapies that put dystrophin back into muscle. It's obviously the key protein that's missing in this disease. And you can see a swathe of different investments, both in RNA and DNA in there, from very early investments going all the way back to Prosensa, to some of the very latest ones in exon skipping, in companies like PepGen, Avidity, DINE, et cetera, where they're using muscle targeting or cell-penetrating peptides in order to really make that they're much more efficient from an exon skipping perspective. We've been involved in the early days of gene therapy with investments in Bamboo that are now the Pfizer program as well as gene editing. We were founders of Axonics, along with the team out of UT Southwestern. Axonics is using CRISPR/Cas9 in this disease, and that's now in the hands of Vertex. And beyond the dystrophin funding, we've also been looking at ways to non-dystrophin. The reasons behind this is we totally expect that this disease is going to be treated by combination therapy. Combination therapy really entails some other non-dystrophin methods such as the new steroids, the new differentiated steroids from ReveraGen, that's up for approval late this year, all the way through to programs that target the bone toxicity in this disease. So one of the more latest ones is what we've gotten there. One of the most latest ones is actually to ReveraGen where they're looking at very unique ways to stop dystrophic muscle from actually destroying itself. So we've had a very long history of investments in that space. We've done that there, as I say, through both private and public funds. And there's a number in the room today, whom we've syndicated with. I've put along -- a short list actually of some of the ones that we've syndicated, particularly during the Series A and Series B. But as you've looked through the lens of what we've invested over the last 3, 4, 5 years, today is quite different. We're looking at a landscape today that's going to be dominated by therapies that are in clinical trials right now, but there are significant limitations to treating the disease. And I want to talk a little bit about that as we look forward into where we're going over the next few years. The gaps and opportunities that are right there are real and they're meaningful, not just impactful from a gap that exists in technology, but a gap that exists into treatment options for patients. And some of the ones I've mentioned on this slide are really pertinent to what we're looking to fund over the next few years as we shift our focus. And the delivery and cost of AVs is going to impact the availability of those for everybody. And I want to say a little bit about what Brian's mentioned a couple of times, which is delivery. We're focused on ways to actually improve the delivery of this, but the technology that Brian has talked about, where we're able to really have much more focus on delivery to muscle with a 10-fold to a 50-fold reduction in dose is really impactful in the way that we look at in this disease. This has got enormous impacts where it leans into both the manufacturability and lowering the cost of this as well as leaning into the safety profile that we know exists right there right now. I think what we've learned in Duchenne is that we're close to the limits of what we can dose in AAV in the human and we need to step back and get there. And part of the work that we're seeing that's come out of Motus over the last couple of years has really leaned into advising us that, that there is a direction that we need to take. The second is gene size. We're obviously limited because of the nature of an AAV to its carrying capacity of less than 5 kb. And that provides us with a gene that's roughly about 1/3 the size of normal dystrophin. We've never seen that in a human before. We're learning about it through the early clinical trials that are going on right now. And from our mind, it's very clear that we need to mimic what nature has done. In Becker muscular dystrophy patients, whom we follow, we can watch truncated forms of dystrophin that are about double the size of the mini gene, and that the protein is associated with a very mild almost asymptomatic disease, where patients can walk into their 60s and 70 years of age. And that there clearly is somewhere we need to go to. We feel that, that there's an enormous step or leap in the right direction, but it's also moving forward into trying to get the full length dystrophin gene that we think is ultimately where we're going to end up. The third is treatment. And it was touched upon -- I listened carefully as you talked about the SMA patient and particularly the one that you injected, John, at 3 months of age. Right now, the durability of what we're looking out of AAV, we've known to be a challenge for a long time. And it's something that we've tried to address from the number of diffractions that we've invested in on the previous slide. But today, we know that we need to get into children younger and younger. On an adult who's going to be dosed and say -- in an adult Duchenne patient, may have a one-and-done treatment if they've been treated at 20 years of age. Treatment of a child at 5 years of age or 4 years of age, we can imagine there's going to be a very narrow time frame whenever we need to redose. But where we need to be in this disease is dosing a diagnosis. And we recognize much of your SMA example of dosing a child at 3 months of age. That's where the sweet spot is going to be in this disease. And so the importance of getting in nerve is going to maximize the benefit of the therapy against the fact that the disease hasn't gone on and ravaged itself for 4 or 5 years before you actually treat. And that there brings in all the options of how does one dose at that age and how does one redose. And so the technology that brings that there together is going to be critically important as we manage all of these different components. And for reasons like that, it's very clear why I'm here to try and give you a description of what we're looking to invest in over the next few years because technology has brought us to this point. We can see the gaps. We can see the weaknesses. We can see the opportunities. But the work that has been going on independently at Motus has really guided some of our thinking over the last few years. Now unbeknownst to many in the room, which shouldn't shock you that I think it was about 3 JPMorgans ago that we first met the Motus team in which we were discussing the technology then, in the very early stages of what we were doing. And we've been following and talking with the company over the last couple of years as the program has evolved, and we're able to see the technology and the results that we presented today. And also independent of that, we were working with the team at Vertuis and following the work that came out of the Salk Institute. And we're really excited by End-Joining technology. Because we recognized that, that was going to be an objective that could realize one of our goals, that goal of getting to a much larger dystrophin transcript. But that our goal required a couple of things that we wanted to try and put in place. One was to industrialize that and get it into the hands of drug developers with deep pockets. And the other was we thought a key to unlocking that technology was more potent viruses, ways to reduce the dose by 10-fold to 50-fold, because that was a key to actually going in with 2 viruses for RNA End-Joining in order to make that their larger transcript. And I can't tell you how delighted we are to see all of that there come onto the umbrella of Insmed. I think it was a marriage that was well made and bringing all of this technology together clearly fits where we see the gaps, where we see the opportunities over the next few years. And for those reasons, as I put in this slide, we're delighted to announce our support for this. We have done with Brian and the team for quite a while on our investment in Insmed in order to move this technology forward as quickly as we can help you guys in order to get it into the clinic and then to patients. So with that, I'll hand it back to you, Brian.

Thank you, Dr. Kelly. I think that was extremely well put, a marriage of great science, and that is exactly what we have tried to do here at Insmed, really with a focus on the holy grail for what patients need and how we can get best outcomes. Thank you, Dr. Kelly, for the partnership of CureDuchenne and for the investment in Insmed and our continuing efforts to bring it forward new and innovative approaches to improve the treatment options for people living with Duchenne muscular dystrophy. Prior to Dr. Kelly's remarks, I have introduced a topic of RNA End-Joining and what that could mean in the future for patients within -- with Duchenne muscular dystrophy. It's now my pleasure to introduce Dr. Lukas Bachmann, who truly has pioneered this technology, to tell us more about his work on the RNA End-Joining platform and additional other targets that might benefit from it. Dr. Bachmann?

Thank you, Brian. So earlier, Dr. Kaspar highlighted the power of our RNA End-Joining technology and how it can be used to deliver larger genes such as mid length or full-length dystrophin. And there's a number of diseases that would be in principle suitable for AAV gene therapy if it weren't for the large size of the disease-associated gene. So our technology really opens the door to developing therapies now for these diseases that were previously out of reach for AAV gene therapy. And in this session, I would like to provide a bit more mechanistic detail on how this technology works that we have developed here and then highlight 1 new disease program here at Insmed that we are working on for the treatment of a form of inherited blindness. Now the key challenge that we're trying to solve here is that even though AAV is the preferred vector for gene therapy, it does have a limited carrying capacity of approximately 5 kilo basis. And this limitation is caused by a physical space restriction or limitation inside the AAV capsid, which is depicted here on the slide. And the field has really been limited by this 5 kilo base packaging capacity for a single-stranded AAV genome. And so there remains a high unmet patient need for many diseases where the gene is too large to fit into a single AAV. So to address this need, we have developed our RNA End-Joining technology. And the way we overcome the cargo limitation is by taking a gene of interest, breaking the gene into multiple fragments and then taking these fragments, delivering them using separate AAV particles, and then using Insmed's proprietary RNA End-Joining technology, we take these fragments inside the cell and we stitch them back together, join them back together at the RNA level, which then results in a full length coding RNA. So this technology is highly efficient. It's highly precise. It's broadly applicable, really to any large gene in a plug-and-play manner. And with 5 kilobases being the space limitation for a single AAV vector, using this as a 2-vector approach, our technology allows us to deliver up to 8 to 9-kilobases of payload. And using a triple vector approach, we can deliver up to 12 kilobases of coding sequence. So let me now dive into a bit of the details on how this RNA End-Joining technology works. So in this schematic, starting in the upper left corner of the diagram, you see full-length gene that we start with. This could be any gene of interest that is too large to fit into a single conventional AAV. And then we take this gene, and we split it typically roughly down the middle to maximize the payload delivered in a 2-vector system. These 2 fragments are then packaged into separate AAVs, 2 separate AAVs, each one with their own promoter and their own regulatory elements. And these 2 AAVs are then co-formulated and administered to the tissue of interest. Cells are then inside the tissue are targeted by both these AAV vectors. They infect the cell, and the AAVs then shuttle their genomes into the nucleus of the co-infected cells. And they start producing inside a nucleus, start producing the messenger RNA, or mRNAs. And these 2 mRNAs derived from the first and the second AAVs are shown here in the diagram below. So the contents from the first AAV contained the first half of the coding sequence, which is then followed by a domain which we call the reg donor domain, which is approximately 250 nucleotides in length. The contents of the second AAV start with a reg acceptor domain, approximately 350 nucleotides in length, followed by the second half of the coding sequence. The proprietary reg donor and reg acceptor domains are shown here in purple and orange in the schematic. And they are composed of a structured RNA dimerization domain, which is shown here in purple, which mediates a very efficient non-covalent binding of the 2 RNA molecules, which ultimately allows for the precision and efficiency of our Joining technology. So the domains shown in this diagram in orange and the yellow are synthetic half intron domains, which result in very highly efficient recruitment of the spliceosome to this complex of the 2 RNA molecules. The spliceosome is now tricked into looking at these 2 RNA molecules as one linear pre-mRNA, and the spliceosome then joins these 2 coding fragments together into a full-length RNA, which then in turn gets translated into the desired full-length protein. So now you might be wondering about the efficiency of our technology compared to other approaches that address larger genes. To that end, we benchmarked our technology, our reg technology against an existing dual AAV technology. We ran this comparison using a yellow fluorescent protein coding sequence that was split into 2 fragments which were then delivered using either a DNA recombination-based dual AAV system, referred to in the field as the DNA hybrid system, or our own reg technology. In these panels here, you see a macroscopic fluorescent image of 8 mouse legs per group in each row. In the second row, you see the DNA hybrid system injected legs. And in the third row, you see the reg construct injected legs. And as you can see, the reg system results in vastly more fluorescent protein production, which is pseudocolored here in green as compared to the DNA hybrid system. And when we quantify this difference between the 2 approaches, we find that our reg technology is approximately 15-fold more efficient, which clearly demonstrates the superiority of our approach here. So actually, looking at injections with a conventional single AAV vector, expressing a full-length YFP, which is shown in the last row on this slide, we can see just how efficient our reg joining is. So next, we went on to test whether the reg technology is broadly applicable to various tissues. So in the panel on the left -- in the panels on the left, you can see expression after systemic administration of AAV split YFP vector using our reg technology. An expression can be seen in a range of tissues ranging or including liver, diaphragm, heart and skeletal muscle. And the distribution here, which we see, really, reflects the biodistribution of the AAV vectors or AAV serotypes that we used for these experiments, which really indicates that the reg technology works in all cell types targeted across different tissues, which opens the opportunity to use reg technology in many different tissue types. On the right side on the slide, after local administration into the brain or the eye, you can see that Reg gives strong expression in neurons in the mouse motor cortex as well as photoreceptors in the retina, which demonstrates that we can use this technology across cell types, including those which are post mitotic. Now an obvious first area of interest for application of the reg technology or really any monogenic diseases which would be in principle suited for gene replacement therapy, but the disease -- where the disease-causing gene is too large to fit into a single AAV vector. And there's a number of diseases that are in a range of tissues that we are exploring, including muscular and cardiac such as Duchenne muscular dystrophy, but also retinal, respiratory, CNS and other disease areas. And so focusing in on retinal diseases, Stargardt disease is one of the most prevalent forms of inherited blindness. It's caused by the loss of function of the ABCA4 protein and vision loss typically begins in childhood and it starts from the center of the visual field and then progressively moves outwards. Because ABCA4 is -- exceeds the AAV cargo capacity, currently, there are no treatments available or treatment options available really for -- there are approximately 1 in 10,000 or approximately 40,000 people in the United States suffering from this disease. So this led us to set out to generate gene replacement construct for ABCA4 using our RNA End-Joining technology. So let me begin with the ABCA4 protein. The function of ABCA4 is essentially to transport spent fuel from the photoreceptor discs, which is a specialized domain of the retinal photoreceptors. And it's -- ABCA4 transports that fuel out. So that's -- the photoreceptor is where we need to replace the ABCA4 protein. In absence of ABCA4, toxic pigments start accumulating in the retina and the surrounding support tissue, which eventually results in photoreceptor degeneration and, ultimately, the loss of vision. So if we can replace the ABCA4 protein in photoreceptor, we have a pretty good chance to prevent or halt the loss of disease or prevent or halt the disease progression. So in an initial set of experiments, we took the ABCA4 coding sequence. We broke it into 2 AAV compatible halves. We transfected these 2 halves in cell culture side by side with the following control. And then in the western blot on the right here, you see in the first 3 lanes, the full length control for ABCA4 and then followed by 3 lanes where we express the 2-way split reg version of that gene. And as you can see, we find that we get very strong expression of the full length ABCA4 protein using our reg technology which shows the efficiency of RNA End-Joining for this particular large team. So given this great initial results, we took these constructs and we packaged them into an AAV8, driven by a photoreceptor-specific promoter. And we injected these viruses subretinally in the Stargardt's disease mouse model, which is ABCA4 deficient. In the western blot here, you can see on the right, you see whole retinal lysates. They are probed for ABCA4 and the ABCA4 band shows up at the expected size of approximately 250 kilodaltons. So in the first 3 lanes, you see the wild-type animals and the levels of ABCA4 that are expressed in wild types, whereas in the last line, you see the levels of ABCA4 being absent in the knockout animal. The injected animals here are shown in the 5 lanes which are inside the red box. These are animals -- knockout animals, which were injected with ABCA4 reg -- AAV8 ABCA4 reg construct. And these animals now show physiological or even super physiological levels of ABCA4. And considering that the literature suggests that in Stargardt disease, approximately 10% to 15% of ABCA4 replacement should be disease correcting, this likely achieves the therapeutic index for Stargardt's disease, and we have new dose-ranging studies planned for that. So with these promising results, we are moving forward with the preclinical development of this construct. We are running additional efficacy studies, safety studies as well as manufacturing and analytics to support an IND submission for Stargardt's disease by the end of 2024. And with this, I'd like to thank everyone for the attention here in this morning session. We will now pause the presentation for 10 minutes and then resume after that. [Break]

We are going to be starting up again in another minute or so, so please find your seats. Thanks, everybody.

Welcome, everyone, to this next session highlighting Deimmunized by Design. The third platform supporting Insmed's strategy for creating next-generation bio drugs with transformative potential for patients. Now as with all serious endeavors, the character, capabilities and the passion of the people involved is the foundation for success. And I want to emphasize that Insmed research is powered by a deep bench of multidisciplinary scientists and engineers, only a few of whom you are meeting today. In addition to the pioneering gene therapy team in San Diego, I'm joined by Chris Bailey-Kellogg, Executive Director of Computational Biology; and Franzi Leifer, Director of Biologics Research, who, along with Dr. Sasha Rose and I, are helping to lead the development of new, high-performance gene and protein therapies that can be safely and effectively redosed. Our work is motivated by the fact that the protein universe represents a largely untapped reservoir of therapeutically relevant agents. Now while many of these protein nano machines have transformative medical potential, from the perspective of the human body, they are non-self and they can elicit antidrug immune responses that have the potential to undermine drug efficacy and compromise patient safety. So to address this inherent limitation of bio drugs, we have developed the Deimmunized by Design platform, an AI-driven protein engineering technology that takes potent but immunogenic biotherapies shown at the left with immunogenic epitopes in red, and it transforms them into immunologically stealthy drug candidates, shown at the right. Now fundamentally, this idea of protein deimmunization aims to create new differentiated drugs that are specifically engineered to enable safe and efficacious redosing of an otherwise high-risk immunogenic biotherapy. Our proprietary Deimmunized by Design platform allows us to circumvent critical steps in immune surveillance pathways and mitigate detrimental antidrug immune responses. So imagine that we have a patient being dosed with biotherapy. Once inside the patient's body, the drug can be internalized by professional antigen-presenting cells, such as B cells and dendritic cells. Those antigen-presenting cells then unfold the protein and proteolytically process it into short fragments that are then displayed on the cell [indiscernible] in complex with Class 2 MHC proteins, where they can be surveilled by cognitive receptors on the surface of CD4 plus helper T cells. Now true immunogenic peptides or T cell epitopes facilitate formation of a ternary MHC2 peptide T cell receptor complex that sets off a signaling cascade causing T-cell activation and, ultimately, maturation of plasma cells that secrete large quantities of high affinity [indiscernible] gene antibodies able to bind to the surface of the intact biotherapeutic agent. Now these antidrug antibodies can cause a range of clinical complications, including drug inhibition, discontinuation of an otherwise effective biotherapy or even preemptive exclusion in patients from promising treatment options as well as a range of other serious impacts on efficacy and safety. So the immunogenicity of biotherapies and, in particular, the production of antidrug antibodies is a barrier to more effective deployment of these drugs. As pharma companies and regulators have gained a deeper understanding of immunogenicity issues, some level of immunogenicity risk assessment has become increasingly common in preclinical development. But importantly, our platform goes beyond simple risk assessment, employing molecular design and engineering to proactively eliminate immunogenic subsequences from drug candidates and, as a result, derisk their clinical translation and deployment. So if we stop and think about it for a minute, treating someone with an immunogenic biotherapeutic is pretty much the same as vaccinating them. The immune system builds up a defense against this non-self thing that it sees there. So how can we avoid that? Well, the key is that the response is driven and coordinated by T cells and a necessary step in this process is the molecular recognition of peptides, these little pieces, parts that were chopped up. These immunogenic epitopes are digested from the therapeutic and presented by MHC to T cell receptors. So if we can change or mutate some of the amino acids in the biotherapeutic, so that its pieces and parts are not recognized as immunogenic epitopes. Then the T cells won't be activated. They won't help the B cells change against the biotherapeutic and then they won't produce these potent ADAs. Now to delete epitopes, what we need to do is to go in and surgically mutate key amino acids so that the biotherapeutic isn't leaving these red flags, calling attention to itself as on itself. But instead, it's kind of flying under the immune system's radar. So epitope deletion really is a form of disguise, making our biotherapeutic stealthy, able to evade immune recognition. Now since epitopes can be throughout the protein, these epitope-deleting mutations can also be spread throughout the protein. So we need to be really careful in mutating so that as we make these mutations throughout the protein, we still maintain the protein's therapeutic function. But if a patient is already been treated with a drug and built up a response, what can we do other than just taking them off the therapy? Likewise, if the drug is from some natural source, as in the case of a bacterial toxin or a viral vector for gene therapy delivery, to which a patient might have already been naturally exposed, what can we do other than just excluding the seropositive patients from therapy? Well, B cells and associated ADAs are very specifically targeted against particular parts of the protein. These are also called epitopes, but they're quite different from T cell epitopes. In particular, B cell epitopes are generally on the surface, they're patches on the surface of the protein for which the B cells have kind of developed a taste as they've been matured. So if we can make mutations to some of the amino acids that make up this surface, that make up those tasty bits, that the antidrug antibodies recognize, then the antibodies won't see what they want to see, and they won't hinder our stealthy new biotherapeutic variants. Again, these epitopes can be spread all over the surface. So as we're stealthifying, making mutations to the surface, we have to be really careful to make sure that we don't destroy the protein's therapeutic activity. Now these problems of immune recognition are ubiquitous, right? And they're holding back the industry's ability to make use of all these kind of amazing proteins that have powerful functions with potential clinical use. In the very special case of monoclonal antibody therapeutics, immunogenicity is largely handled due to the fact that humans ourselves make antibodies and all antibodies are like more or less the same. So platforms for humanizing non-human antibodies are displaying for experimental selection fully human antibodies often do quite well in mitigating the immune recognition. Unfortunately, the vast majority of proteins have no human counterparts. So Karl and I started studying this problem in our academic work at Dartmouth over a decade ago. We spun off a company, Stealth Biologics to put these ideas to use in therapeutic development, to make biologics stealthy from immune systems perspective. Since then, we've developed this novel proprietary platform, Deimmunized by Design. This is an integrated computational experimental platform that can be brought to bear on any protein to design variants that are deimmunized but maintain their potent therapeutic function. We call that functionally deimmunized and it's super important to maintain both aspects, function and deimmunization. That's one of the key advantages that we've honed through our extensive experience, developing and applying our AI-based design methods and corresponding cutting-edge experimental approaches. Now in brief, DBD-based functional deimmunization proceeds through 1 or more computational experimental rounds. We start off with existing data, both function and immunogenicity for the protein, in particular that we're working on and the protein universe more generally and the immuno more broadly as well. This data provides the basis for learning predictive models, and we develop and apply state-of-the-art machine learning methods to predict what we need to do to this protein to help it escape immune detection and what we can get away with doing to it without making it too unhappy functionally. We then move from machine learning to artificial intelligence. From mapping and predicting to -- from modeling and predicting to mapping and design, to planning. From recognizing, hey, there's a road and there's a pedestrian to actually charting a course down the road that doesn't run over the pedestrians. So this mapping and design is the cornerstone of our methodology, and it's really what distinguishes our platform. Our AI methods map out this rugged landscape near our protein. We call this the design space. And chart out course is to go from our beautiful wild-type protein that has an immunogenicity problem to various destinations that are demonized, avoiding these pitfalls, these accidents where the protein falls apart or is ineffective or amount of whopping immune response. Based on our mapping of the design space, we designed a portfolio of variance. And it's all good portfolios. They have to have balanced risks. We're balancing the risk of the ability of our protein to evade immune detection against the risk of losing function. After optimizing this portfolio, we gather experimental data. How do our new variants perform in terms of function and in terms of immunogenicity? And we do this both in vitro and in vivo. Given this data, then we are going to repeat as needed. We use the data to tune our models, improve our mapping of the design space and optimize another portfolio based on what we've learned. In this way, we can explore the corner of the protein universe where our target resides exploiting what we know and have learned so far and, ultimately, driving therapeutically potent but immune-evading, functionally deimmunized by therapeutic candidates. So in this nutshell, you can see that DBD is a versatile platform that can be applied to all manners of potential biotherapeutics to help them evade immune recognition and thereby improve clinical utility. In the next few sections then, we will illustrate some of the exciting results we've had from a few such biotherapeutics. We're going to start with our first complete proof of principle, lysostaphin, which is a potent anti-Staph aureus enzyme. In fact, lysostaphin is a beautiful story of what you can get if you start looking around the protein universe to derive new biotherapeutic. It's produced by a bacterium called Staph simulans that develop this enzyme to kill off its competitor, Staph aureus. In contrast to traditional small molecule antibiotics, lysostaphin is an active agent. It's an enzyme that's really like a pair of molecular scissors. It hones in on Staph aureus' cell wall very specifically, chopping up those links, moving from 1 to another until eventually, the bacterium just pops. And as a result, these so-called lysines or lytic enzymes are able to clear bacterial suspensions really quickly, as you can see in this video. Lysostaphin has lots of great features. It's effective against a wide range of drug-resistant strains. It synergizes with traditional antibiotics. It has minimal off-target effects and so forth. So it's been used in the clinic and pursued in clinical trials. Unfortunately, it is a bacterial protein. It's not human. And so it has significant immunogenicity issues. So in our previous company, Karl and I took on the task of functionally deimmunizing lysostaphin as a significant and important challenge for our DBD platform. Now we need to enable repeat dosing with lysostaphin. So that means we need to delete these T-cell epitopes. And so we applied our DBD platform through several rounds, starting off with what we know about lysostaphin, sequence, structure, immunogenicity. We learned and applied machine learning models to predict what could we do mutationally to evade immune recognition while maintaining this potent lytic function. We mapped out the design space, and we optimized libraries of variants for screening. And we used functional experiments, including a radial diffusion screen to identify potentially good variants from the population that we computationally optimized. Then we did more detailed in vitro analyses of their potency. Now once we identified highly potent candidates, it was critical that we validate their reduced immunogenicity as the next development step. An important point is that we specifically deimmunize lysostaphin for human use, for mice or rats, canines, nonhuman primates or other standard preclinical models. So how do you measure human immunogenicity risk in a preclinical setting? Here, I'm showing you ex vivo peripheral blood mononuclear cell assays or PBMC assays. These are 1 of our key tools in preclinical immunogenicity risk assessment. So as shown in the upper graphic, in these experiments, we incubate protein candidates with human immune cells in tissue culture and we then quantify the extent to which those protein candidates activate T cells as a result of MHC2 presentation of their peptide fragments or T-cell epitopes. Now an important feature of these assays is that we can run parallel experiments wherein we feed either wild-type lysostaphin, shown on the upper side of the graphic or a deimmunized candidate shown directly below that. And if we've successfully deimmunized the target protein, our engineered variant will exhibit a reduced degree of T cell activation. So shown in the bar graph below is the result of the PBMC assay. The Y-axis is a stimulation index, which is a measure of T cell activation. A higher stimulation index indicates a stronger T cell response. And on the X-axis is the Class 2 MHC genotype of 9 donors that showed any measurable response against either wild-type lysostaphin in gray or the deimmunized LIT 100 candidate in green. And you can immediately see that there is a dramatic silencing of T cells for the LIT 100 candidate relative to wild type. So in short, wild-type lysostaphin activates T cells among a panel of genetically diverse human PBMC donors, which is consistent with prior clinical evidence of immunogenicity, while the Deimmunized by Design LIT 100 candidate silences T cell activation among those same donors. These PBMC assays provide a direct measure of success for our design and engineering objective. But I want to emphasize that silencing T cell activation is only useful if it mitigates the ensuing antidrug antibody response. And so now we're faced with the challenge of measuring the risk of a human antidrug antibody response in a preclinical model. So to address this challenge, we employ humanized HLA transgenic mice that are genetically engrafted with a human MHC2 protein. So they present immunogenic T cell epitopes in the same way that humans do. These transgenic mice are therefore an ideal model for assessing whether or not a Deimmunized by Design biotherapy has indeed reduced the in vivo antidrug antibody response. Now in this particular study, we immunized groups of DR4 transgenic mice once weekly for a month with either wild-type lysostaphin shown in gray or the deimmunized LIT 100 candidate shown in green. And we collected plasma to quantify antidrug antibodies. On the right is a graph of the ELISA data for these 2 groups, showing that LIT 100 significantly reduced the antidrug antibody response with 4 out of 5 animals exhibiting low to no detectable anti-LIT 100 antibodies. Now together with the previous slide, this result shows that by specifically silencing human T cell activation, we can significantly reduce antidrug antibody titers in a clinically relevant humanized mouse model. However, I note that we only care about reducing antidrug antibodies to the extent that it yields a more effective drug candidate. And so to assess this critical objective, we tested LIT 100 in a recurrent MRSA infection model using the same humanized DR4 mice. Here, we give mice a lethal infection with a MRSA clinical isolate and 1 hour later, we provide a bolus systemic administration of either wild-type lysostaphin in gray or the LIT 100 candidate in green. Now mice that are rescued from the initial infection are given a week to recover and then they're reinfected and retreated. And we continue this cycle of weekly challenges and treatment for 1.5 months. This allows us to evaluate longitudinal efficacy in the context of any antidrug immunity that might result from repeated drug exposure. The Kaplan-Meier graph highlights the clinical potential of the deimmunized LIT100 candidate. While wild-type lysostaphin rescues the majority of mice through the first 2 cycles of infection and treatment, its efficacy plummets 14 days after initial drug exposure, which is coincident with the appearance of high-titer antidrug antibodies. In stark contrast, the LIT 100 candidate, at the same dose, rescues all of the mice to 1.5 months of repeated infection and treatment, and this is consistent with the lower anti-LIT 100 antibody levels in these mice. So to our knowledge, this work with lysostaphin represents the first direct and controlled demonstration, the deletion of human restricted T cell epitopes results in enhanced in vivo efficacy. So to summarize, we've definitively shown that the Deimmunized by Design platform can delete widely distributed T cell epitopes while maintaining or improving upon the parental protein's function. We've shown that T cell epitope deletion results in silencing of human T cell activation. We've demonstrated that T cell silencing dampens the antidrug antibody response in a clinically relevant HLA transgenic mouse model. And finally, we've shown that reduced in vivo antidrug antibody titers translate to a more efficacious drug candidate in the context of repeat dosing. So this highlights the power and the potential of the Deimmunized by Design platform, but engineering a deimmunized next-gen antibiotic was just the beginning of what we aim to do.

In particular, we're currently applying DBD to functionally deimmunize the enzyme uricase, which can degrade the uric acid that contributes to crystals that are a hallmark of gout. Since gout is a chronic condition, we need to enable redosing with enzyme escaping immune detection through repeated treatments. Now a particular uricase, known as pegloticase, has been approved for treatment of refractory gout when patients aren't responding to small molecule approaches that attempt to block serum uric acid production. In contrast, uricase directly attacks and degrades uric acid enzymatically and can help those patients. Now humans actually have a uricase enzyme in our genome, but it's inactive. So this marketed drug is derived from other species that are close to human, but they aren't us. As a result, there are substantial immunogenicity problems. There have been other approaches to deal with immunogenicity by essentially suppressing the immune system, either by co-administration of methotrexate or by tolerization. But these have their own limitations and risks. So we elected to develop an immunologically stealthy variant using DBD to directly engineer out the immune red flags that are the core problem here. So we need to enable redosing, that means we need to delete T cell epitopes. Given prior data on sequence, structure, function and immunogenicity of uricase, we built our predictive models assessing the potential effects of possible mutations and combinations of mutations on function and immunogenicity. We mapped out the uricase design space and optimized a portfolio of variants that balance the risk of immune detection against the risk of loss of function. We then leveraged an experimental screen that allows rapid identification of the best-performing models -- members of our computationally optimized population. Subsequently, properties of these best-looking candidates were assessed with detailed in vitro assays and ex vivo immunoassays.

All right. So the first measure of success for our engineering campaigns is retention of high-level protein function. Shown on the left of this graphic are the results of Michaelis-Menten kinetic analysis on 4 top candidates. And on the right are the best fit kinetic parameters for those enzymes as well as for the wild-type uricase shown in green. So I'll summarize by noting that 3 of the 4 variants exhibited faster than wild-type kinetics in these preliminary studies with the fourth enzyme having wild-type like kinetics. And these results are a further demonstration that the Deimmunized by Design platform can generate deimmunized candidates that maintain or improve upon the activity of the parental molecule. But what about immunogenicity? We need to know whether or not these engineered uricase variants present a lower risk than wild type. And so here, we again leveraged our ex vivo human PBMC assays performed on the 4 uricase variants as well as the wild-type enzyme. On the right bar graph, each enzyme is indicated on the X-axis with a measure of T cell proliferation on the Y-axis. In this case, higher proliferation is indicative of a stronger T cell response and the points for each average bar indicate individual donor response levels where the same donor set was tested for each protein. All 4 of these deimmunized candidates mitigated the T cell response that was directed against the wild-type enzyme with 2 of the variants exhibiting near background levels of T cell activation among this small initial panel of human PBMC donor. So these human cellular immunoassays provide direct evidence that the initial Deimmunized By Design variant substantially silence human T cell activation, and we're currently pursuing further rounds of engineering and design to develop a translation-ready lead candidate. Now to further emphasize that Deimmunized By design is a rigorously vetted and broadly applicable platform technology for addressing biotherapeutic immunogenicity, I'll point to just a few of our peer-reviewed publications in this space. And it was this demonstrated success and the broad utility of the Deimmunized By Design platform that was a prime motivator for Insmed's acquisition of this technology. Now as Insmed, we're bringing the platform to bear on new opportunities to develop safer and more effective deimmunized protein therapeutics that are designed to broaden addressable patient populations and ultimately to improve lives. We have two advanced programs, including uricase, for which we anticipate lead candidates in the second half of 2023. We have a third protein therapeutic program that was initiated earlier this year, with additional prioritized opportunities that will fill our research pipeline as successful engineering campaigns transition to IND-enabling work. So in summary, we're moving with determination and purpose to bring the benefits of Deimmunized by Design biotherapies to the clinic. So given this broad perspective on biotherapeutic immunogenicity and our Deimmunized By Design immuno engineering platform, I now want to connect the dots with Insmed's mission to revolutionize AAV gene therapy. Now specifically, AAV vectors are known to contain potent immunogenic epitopes that drive strong anti-capsid immune responses, which in some cases, can limit efficacy, reduce durability and even preclude treatment of patients that have preexisting immunity. To address this fundamental limitation of AAV vectors and unlock the full potential of gene therapy, we are using the Deimmunized By Design platform to reengineer AAV capsids, eliminating immunogenic elements and creating first-in-class redoseable gene therapies. Now our focus on redoseable gene therapy is motivated in part by monogenic diseases for which redosing is likely necessary in order to achieve a therapeutic effect. Examples include: pediatric onset diseases involving organs with high cell turnover, such as the liver; diseases with on-target toxicity, where a redoseable gene therapy would enable a dose to affect treatment paradigm; and diseases where high therapeutic transgene dose necessitates a comparably high and toxic viral vector load for which could be spread out over several smaller and safer doses with a deimmunized capsid. Our goal at Insmed is to bring redoseable gene therapy to these and other underserved patient populations. Now this long-standing challenge in AAV gene therapy is centered on the fact that the human immune system has explicitly evolved to detect and neutralize foreign invaders, such as AAV and other viruses. So when we encounter AAV, either as a natural infection or during gene therapy, T cell epitopes are presented, and that drives downstream production of high-affinity antibodies against the viral capsid. Now fundamentally, the AAV capsid is really just a large protein complex. And that means our Deimmunized By Design platform can be brought directly to bear on creating immunologically stealthy viral vectors. Highlighted in purple, as objective #1, is the case of patients with no pre-existing AAV immunity. Here, we need to reengineer the peptide-based T cell epitopes within the capsid proteins, such that we can subvert this upstream T cell epitope recognition event that drives the downstream production of anti-AAV antibodies. These T cell epitope-depleted vectors could represent a redoseable option for AAV naive patients since the vectors are designed to minimize the anti-capsid antibody response upon initial dosing. Highlighted in turquoise as objective #2 is the case of patients who have preexisting anti-AAV antibodies, due either to natural exposure or prior gene therapy with a wild-type capsid. Here to treat seropositive patients, we need to reengineer the surface of the capsid in order to remove the antigenic B cell epitopes or these molecular handles under which the antibodies bind.

Now we've also begun working on other aspects of antigene therapy immune responses, but we've really focused on and have made significant progress already in using our DbD platform to delete both B and T cell epitopes in order to enable repeated delivery of gene therapies. Let's first consider naive patients. We need to delete T cell epitopes to enable them to receive multiple AAV deliver gene therapy doses. We started off with available data about the AAV verse, sequences, structures, immune recognition. We proceeded to build and apply our predictive models, mapped out the design space and designed libraries of T cell epitope-depleted AAV capsid variants. Now the experimental component here is a little bit more complicated. It involves its own iterative process with multiple cycles of selecting the fittest variants in a population, in terms of their ability to transduce the target cells. After selecting the best ones, we put them back in for another cycle to keep on competing. We select for function, for example, in the case of liver-targeted capsids, either in cell culture or in humanized mice, mice that have human liver so that we're testing the ability of our engineered capsids to transduce the desired cells in vivo. Now over the repeated cycles, we can keep ramping up the competitive pressure, and thereby select the cream of the crop deimmunized capsids. In this process, we obtained both viral titers as well as deep sequencing data, revealing the relative transduction ability of different capsid variants. And each capsid variant has a different combination of T cell epitope-deleting mutations comprising it. So population-wise, we're beginning our selections with over 1 million different computationally optimized capsid variants. And over these repeated cycles, we see the pressure winnowing down to the best of the best. The capsids that survived all the way to cycle 5, and there's roughly about 1,000 of them there. 1,000 is still a lot of diversity when we think -- each of those represents a different pattern of T cell epitope-deleting mutations. So we can then use our NGS data, our next-gen sequencing data, to dig in and look at the trends for specific capsids. Those that I showed here, I picked up 5, they each are being enriched or at least holding their own over these repeated cycles. There's roughly about 1,000 more that look more or less like this. And then there are many others that also died off during this competitive selection process. So we use the information encapsulated here about the relative performance of different sets of T cell epitope-deleting mutations to improve our mapping of the design space and go back and design a second-round library for screening. Now let's consider seropositive patients who, otherwise, wouldn't be able to take a gene therapy. We needed T cell epitopes for these patients to enable the capsid to evade preexisting ADAs. We again have this iterative experimental selection process, and each cycle pulling out the best-looking competitors so far and then passing them forward to the next cycle. But now we can also include immune evasion as part of our selection process. We pre-incubate our capsid library and the mixture of antibodies. And we can control the extent of expected neutralization and ramp it up over the cycles to, again, select the fittest of the fit. Let's first look at the overall population fitness, in terms of what fraction of the population was neutralized and didn't survive selection. In the first cycle, we eliminated about 78% of the wild-type capsids, antibodies got rid of them, but only about 7% of our library is neutralized. That means that we designed a library that was highly evasive of these antibodies by putting in targeted B cell epitope-deleting mutations. In cycle 2, we bumped up the neutralization pressure. So now about 94% of wild type was neutralized, but still only 42% of the library was neutralized. Over half of it is caped neutralization. Now let's look at some trends for some specific capsids. Without the antibody, the relative fitness is wild type or maybe a little bit lower. But as we start increasing the neutralizing antibody pressure, the variants start to take over. And one guy that I marked there with an asterisk because it's about 600x is fit as wild type under that cycle 2 stringent selection. Now each of these capsid has a different combination of B cell epitope-deleting mutations. That enables us to learn from the patterns of what was functional, what escaped and how well and what didn't to design another library, another round to select even more functional and even more antibody-evading capsid libraries. So this gives you a taste of how we're pursuing both B and T cell epitope deletion. And we made actually substantial progress on two different serotypes already, with others on deck and underway. After completing our rounds of AI-driven engineering, we'll do a detailed analysis of both function and immunogenicity at the clonal level. The lead capsids that emerge from this will each represent a platform that could carry any therapeutic transgene. But we ourselves are pursuing some. So the next steps will be to construct these and validate their therapeutic effect, setting up IND-enabling studies to be done in collaboration with our San Diego colleagues. Now while this capsid engineering is still ongoing, we've actually been actively developing the appropriate therapeutic constructs and the disease models. So this will all come together, and we'll be able to plug those therapeutic constructs into our engineered capsids and move quickly towards IND-enabling studies. I'll now hand it over to Dr. Franzi Leifer to discuss our work on developing multi-dose gene therapies.

Thank you, Chris. We have selected argininosuccinic aciduria as one of the first indications to demonstrate the benefit of deimmunized redoseable AAV gene therapy. Argininosuccinic aciduria, or ASA for short, is the second most common urea cycle disorder. It primarily affects the liver and has typically very early pediatric onset, which makes it ideally suited for and even likely requires re-doseable gene therapy because single-dose liver-targeted gene therapy in very young children, which the majority of ASA patients are, is expected to have limited durability. ASA is caused by deficiency of the enzyme argininosuccinate lyase, or ASL, whose primary function is as part of the urea cycle, which eliminates toxic ammonia from the body. Deficiency of the ASL enzyme prevents the urea cycle from functioning properly and leads to the buildup of ammonia in the blood, which can cause coma and death. ASA has a very high unmet need. The standard care regimen includes ammonia-scavenging therapy and dietary restriction to reduce protein intake, but it is very burdensome and incompletely effective, and many patients continue to experience hyperammonemic episodes and long-term cognitive impairment. At Insmed, we have developed an AAV transgene construct that encodes human argininosuccinate lyase, which has shown strong efficacy in a mouse model of ASA. For our in vivo efficacy studies, we use what we call ASA mice, which is a genetically modified mouse strain with about 15% residual ASL enzyme activity. This reduced ASL enzyme activity causes the mice to develop many of the symptoms of human ASA disease. They have high levels of blood ammonia or hyperammonemia. They have elevated plasma levels of argininosuccinate acid and citrulline, which are both urea cycle intermediates upstream of the ASL enzyme to have abnormal hair patterning and severely stunted growth, which you can see in the image here of an 18-day-old ASA mouse compared to a healthy wild-type mouse, and they also have a dramatically shortened lifespan. Now what we would hope to happen following AAV gene therapy that delivers functional ASL enzyme is that each of these disease symptoms are successfully addressed. And we are very excited by the results that we have seen thus far for our construct. First, our ASA AAV gene therapy nearly normalizes the metabolic profile of ASA mice treated at 1 month of age. The three bar graphs here summarize whole blood ammonia levels, plasma argininosuccinic acid levels and plasma citrulline levels. The last most bar in each plot represents healthy wild-type animals, and the bar next to that, ASA animals prior to gene therapy treatment. About 4 weeks after receiving gene therapy at high, mid and low doses, there's a clear dose-dependent correction of all three metabolic parameters. Blood ammonia levels have come down to within the normal range, following high and mid doses. And plasma argininosuccinic acid and citrulline levels are significantly reduced. Based on our review of the literature and the severity of disease in these animals, these are very compelling data. The correction of the animal's metabolism also results in a strong survival benefit. Without treatment, ASA mice have a median survival of only 19 days. Following gene therapy, all animals survive significantly longer. Low- and mid-dose-treated animals have a median survival of 106 and 124 days, and more than 80% of animals in the high dose group have survived beyond 175 days so far. Consistent with the short survival, vehicle-treated ASA animals also don't gain much body weight, which maxes out at about 5 grams. Once we dose these animals with gene therapy, there is a clear and immediate increase in body weight gain. We have also seen remarkable clinical improvement at ASA mice who have received gene therapy treatment. These two videos show ASA mice that were treated with gene therapy at birth, and are here 19 and 100 days old. In the first video, there are three mice to pay attention to, in particular. A vehicle-treated ASA mouse, which is circled in red, an ASA mouse that has received high dose gene therapy treatment circled in blue, and this animal, you will be able to recognize by the three dashes on its tail once the video starts, and the third mouse that is a healthy wild-type mouse circled in green. As the mice are moving around, you can see there is quite an amazing difference between the gene therapy-treated and vehicle-treated ASA mouse. While the vehicle-treated mouse can barely ride itself, that gene therapy-treated mouse is very active and looks nearly as good as wild type. In the second video, there are two gene therapy-treated ASA mice: a low-dose treated animal, which you can recognize by the large bold spot on its back is circled in light blue, and the high-dose animal is circled in darker blue. The healthy wild-type mouse is again in green. Notably, there is no vehicle-treated animal in this video because none of these animals have survived nearly long enough. Looking at these mice, even 100 days after dosing, both ASA animals that have received gene therapy look almost as active and agile as the wild-type mouse. You will also notice that the low-dose mouse has developed a more abnormal hair pattern typical for ASA. This is likely, at least in part, due to a dose-dependent waning effect following the huge increase in body weight after dosing. This dose-dependent waning effect is consistent with our hypothesis that while this disease is very amenable to remarkable improvement with the gene therapy, sustained efficacy will require redosing with our deimmunized capsids. In summary, the data I've shown you clearly demonstrates the compelling therapeutic efficacy of Insmed's human ASL transgene construct in a mouse model of ASA and provides strong support for the potential utility of AAV gene therapy in the treatment of argininosuccinic aciduria disease. We believe that delivering the human ASL transgene construct, with a redoseable deimmunized AAV capsid, could lead to a durable and highly effective treatment for even the youngest ASA patients. Importantly, a similar strategy could be applied to the development of gene therapies for other urea cycle disorders and inherited metabolic disorders in general. Next steps for this work include in vivo proof-of-concept studies of redoseable AAV gene therapy, which we hope will path the way to unlock possible treatments for argininosuccinic aciduria and many other diseases that so far have no cure.

All right. Let's reflect for a minute on everything that we've told you about the Deimmunized by Design platform. First off, immunogenicity is a major challenge, holding back our ability to effectively use a wide range of biotherapeutics. To address this challenge, we've developed a DbD, Deimmunized by Design platform, that can reengineer immunogenic biotherapies into immunologically stealthy drugs, functionally deimmunizing. The platform has been validated preclinically with lysostaphin as we show you today, along with several other therapeutic proteins. We're now actively deimmunizing a number of therapeutic proteins, which we believe could yield multiple INDs over the upcoming years. Furthermore, because an AAV capsid is nothing but a big bunch of proteins, we're applying DbD to deimmunize the AAV capsid, and we believe that, that could unlock the potential for redoseable gene therapy. We intend to demonstrate clinical proof of concept in diseases like ASA that are amenable to gene therapy, but likely to require redosing for sustained effect. Now once we've developed all these -- engineered all these revolutionary deimmunized biotherapeutics and capsids, we actually need to produce them at clinical scale. So to discuss pioneering work on this front, I turn it back over to Dr. Brian Kaspar.

Thank you, Chris, Karl and Franzi. I hope you share the excitement that I feel. I truly have the privilege of leading truly brilliant minds in our research and development and translation here at Insmed. I couldn't be more proud of such a group of individuals for what they do on a daily basis, each and every day, pushing the boundaries of science and pushing the boundaries of moving life-saving therapies towards the clinic. As you've seen, Insmed has successfully scaled to a 1,000-liter suspension-based bioreactor, which is meeting commercial scale for many disorders. In parallel, we've been working on a next-generation manufacturing platform where we have rethought the manufacturing process really entirely. As this audience is well aware, perhaps the most significant challenge in gene therapy today lies in the extremely complex and costly manufacturing process. The yields are low, resulting in extremely high drug costs that are unsustainable in the long term, and now encountering severe pushback, especially ex U.S., where many are simply pulling out of the market completely. As we think of larger disease populations, there is a massive bottleneck when it comes to manufacturing. The current technology involves several complicated steps, using difficult-to-source raw materials and long production times. We are reminded frequently about the backlogs of plasma sourcing, GMP transfection reagents, GMP space availability, media shortages, sterile bioreactor bag and tubing set shortages, along with chromatography columns and the equipment backlogs, such as the bioreactors and downstream equipment. Indeed, there is a lot that can and certainly does go wrong on a manufacturing floor. At Insmed, we have been quietly developing a solution that brings first true-step function of innovation in AAV manufacturing and has the potential to drastically reduce the cost, time and complexity of gene therapy manufacturing by using unicellular algae to grow the virus. With that, I am going to turn it over to my colleague, Dr. Anthony Berndt, whose career has been spent working with algae to explain how this amazing technology works. Anthony?

Thank you, Brian, and thanks, everyone, for giving me the opportunity to AlgaeneX our proprietary manufacturing platform that we believe could be the future of mass gene therapy production. As the name suggests, AlgaeneX is a unicellular algae production platform, which may cause some of you to wonder, how exactly are we using algae? Well, first, micro algae can grow 2 or 3x faster than mammalian cells, which means scaling up to large volumes is much easier and faster. Inherent in the synthetic biology design of our platform, our cell lines contain stably integrated AAV genes to make the adeno-associated viruses. So this means no transfection is required with costly plasma DNA and transfection reagents. Thus, we can select a stable producer cell line for each product. This is much like current monoclonal antibody production, but in this case, algae clones. Finally, our algae production platform can be grown in animal product free, highly defined media that consists of water and some basic nutrients, representing a massive cost savings compared to complex medias currently and used for mammalian cell manufacturing. Further, the cells themselves can be grown in much simpler culture vessels that are required for animal cells. Overall, this makes each production run substantially cheaper and easier than current animal cell-based production systems, while also improving the biosafety profile. To date, there's been dozens of peer-reviewed studies showing successful production of animal -- sorry, of human recombinant proteins in multiple different algae species. The low cost of goods and capitalization costs as well as a simple and fast production process, make this an attractive choice for the next-generation gene therapy production platform. I would now like to walk you through our algae-based algae production process. First, we take expression vectors specifically tailored to work on our algae cell lines, transform them into the algae to make stable expressing lines, screening these lines for optimal expression and then scale them up. AAV virions can then be extracted either from the surrounding media or the cell pallet or both and purified using conventional processes before testing for potency and activity. We believe that our new platform could be used to make any of the AAV vectors you've heard about today from Insmed as well as any of the other proteins in the future that we may address. We also have reduced the complexity of the genetic engineering problem. Previous work by multiple groups over the past 2 decades has shown that there is a minimum number of genetic parts needed to make an infectious AAV for gene therapy. There are three viral coat proteins, VP1, VP2 and VP3 as well as two replication factors, Rep78 and Rep52. These rep proteins rescue, replicate and package the gene therapy DNA payload that is flanked by inverted terminal repeats. Collectively, these make a functional recombinant AAV. Insmed has developed a novel expression system for expressing proteins in more than one algae species. The first thing we did is test how consistently we can deliver transgenes to engineer a particular algae species to produce proteins. We used the molecular biologist's favorite tool, green fluorescent protein, or GFP, and integrated our new expression cassettes into the genome. To do this, we utilized a novel construct with an antibiotic resistance cassette and transform the algae with the plasma and DNA, and then screen stably integrated clones. When we first selected for an antibiotic resistance [indiscernible] enterology transformants, we found that we consistently saw strong GFP expression in about 90% of the integrated clones. What you're looking at here on this Western blot is untransformed algae on the left, and then 9 genetically unique transformants isolated from single cells that strongly express GFP. The western blot here is probed with anti-GFP. The takeaway message is that we've established a unique transgene expression system, coupled to a rapid and reliable selection method for expressing proteins using our new algae system. We then took same transgene design we used to express GFP and swap the GFP coding sequence for either AAV9 VP1, VP2 or VP3 capsid genes. We were able to successfully express each protein with our algae. What you're looking at on this slide is a western blot probed with anti-AAV capsid protein antibodies. We can detect unique bands corresponding to AAV9s VP1, 2 or 3 at the expected molecular weights in our algae lysates. Collectively, this demonstrates that we can produce all three of the AAV capsid proteins using our proprietary manufacturing process. We're building the next-generation gene therapy production platform using a completely new genetic toolkit that allows for low cost and high yield production of AAVs in an animal product and animal cell-free system. This also means that we're constantly improving and updating our synthetic biology tools. On this slide, we're looking at some low-magnification micrographs. These blobs on the left are whole algae colonies representing thousands of cells. On the right are the same colonies, but imaged using a red fluorescence filter to look at a red fluorescent protein transgene reporter. The middle panels represent some of the early work we completed on the way to our current solution. Notice that when looking at a whole population, we see some high expressing cells, but there are many with low to no expression. Improving expression levels and consistency of expression of our algae system is key to increasing AAV production yields and bringing down costs. In the lower panel, we have our improved second-generation expression vectors. At the same camera setting, we're absolutely blowing out the exposure by just how much stronger the fluorescent reporter protein expression is. And it's not just that it's stronger, it's stronger, more uniformly across the population. What we can do here for this fluorescent reporter is what we are doing for viral protein expression and how we're going to achieve high AAV production in our systems? This has never been done before, and we believe this represents the biggest change in AAV production that the industry has seen to date. We still have some work in front of us, but we're highly encouraged by our accomplishments to date and look forward to keeping you informed of our progress on truly disrupting the manufacturing bottleneck. I'll now turn this over to Roger Adsett, our Chief Operating Officer, to close out the presentation.

Thank you, Anthony. Over the past several years, Insmed has used a disciplined approach to identify and acquire products, technologies and companies with impactful science that have the potential to profoundly impact patients around the world. We believe this strategy will bear fruit and build on the success of Pillar 1, and the anticipated successes of Pillar 2 and 3 and answer what's next. If we succeed as planned, we will continue to deliver durable and diversified revenue growth. We've also been thoughtful about the specific problems we are trying to solve in the context of the environmental and regulatory forces influencing our industry. Incentives to develop medicines for rare diseases continue to enjoy broad support. The most recent example of this, in public policy, came when single indication orphan products were exempted from the Medicare negotiation in the Inflation Reduction Act. The interest in gene therapies from patient advocacy and regulatory bodies continues to be very strong. And pricing for gene therapies is also strong, particularly in diseases where years of invasive, expensive therapies can be replaced with a single dose of gene therapy that is expected to be durable for a number of years. And that value proposition becomes even more compelling if patients can receive additional doses of gene therapy should efficacy start to wane over the years. The FDA has signaled willingness and desire to work with the industry to bring badly needed medicines to devastating diseases with limited to no options. And importantly, this could lead to an accelerated path from IND to approval, particularly if there are appropriate biomarkers available. Now we believe our differentiated gene therapy programs may well benefit from these trends, which could lead to a faster time to market, cutting years off the traditional development time line. So right now, on average, it takes about 10.5 years to get from IND to approval. And our ambition is to significantly reduce this time. Now Brian and his team got Zolgensma from IND to approval in less than 6 years. That's the fastest for any gene therapy approved thus far. We believe we can replicate and perhaps even improve on this mark. Now it's an understatement to say that gene therapy is very hard to do. There's very few teams that have the proven ability to produce life-changing medicines that lead to approval, reimbursement and ultimately, administration to patients around the world. We have what we think is the preeminent team in gene therapy who are hard at work, building an engine that can replicate this success with regularity over the coming years. The skills to do this represents a substantial competitive advantage. And while there are many, many gene therapy companies, only a handful of their teams have succeeded in getting a product approved, and even fewer have seen the sort of transformational impact and uptake of the medicine that they've created. We have combined this team with other scientists across Insmed to tackle some of the persistent issues facing gene therapy. Safety; the cost of goods, given the difficulty of manufacturing; redosing, in case of loss of durable effect; and the delivery of large genes beyond what current AAV capsids can carry. We believe solving these problems with the technologies we have in-house and the scientific expertise we have gathered to collaborate on these problems will position Insmed as the premier gene therapy company. We intend to be the company that has a safer doses of gene therapy with lower volume of viral load delivered intrathecally, lowest cost of goods by manufacturing with our allogeneic platform and the ability to target genetic diseases that are currently largely untargeted because of the need for larger transgenes or repeat dosing. We've also invested in our Deimmunized by Design technology, that allows us to harness artificial intelligence to not only address redosing in gene therapy, but to also create new molecular entities, in this case, complicated large molecule proteins that offer therapeutic advantage by evading the immune system. We will target discrete populations, including rare diseases. And biologics enjoy favorable treatment compared to small molecules under the IRA. So we believe this translates into a more durable revenue stream given delayed price negotiation in the current biosimilar erosion dynamics. As we developed our Deimmunized by Design platform, we will also look to apply our allogeneic technology to more cost-effectively produce our biologic medicines. Our fourth pillar offers unique advantages to complement the rest of our business, and we have the ambition to file 6 INDs by the end of 2025. We believe these products will receive favorable regulatory and pricing treatment potentially resulting in faster time to market with durable revenue streams. We have the proven ability to commercialize given our top 10 non-oncology rare disease launch for ARIKAYCE, and we will apply that commercial acumen in rare diseases to bring in these new medicines to market, including a bespoke go-to-market approach to commercialize our gene therapies. Now we've described how we have assembled the scientific talent through multiple company acquisitions over the past few years. And these companies could be stand-alone businesses in their own right, but these technologies are highly complementary, even synergistic when combined within Insmed. We offer the opportunity to collaborate and bring our expertise in areas such as clinical trial design and execution, regulatory and patient advocacy to compress time lines and reduce risk. So we believe we have the premier gene therapy team in the industry, with the potential to deliver best in disease and first in disease gene therapies. The End-Joining technology allows us to target diseases such as Stargardt where there's no current gene therapy under development, but also deliver on ambition for mid-length or even full-length dystrophin. This is a technology that has application across a number of diseases requiring larger transgenes. We intend to deimmunize the full AAV capsid library using our Deimmunized by Design technology. Won't cut envision partnering or licensing these capsids to other companies who may have an interest in allowing repeat dosing of their gene therapies or applying the Deimmunized by Design technology to Novel Biologics, while in development prior to getting to market. This, in addition to developing biobetters or proteins already on the market with neutralizing antibody issues, limiting efficacy or utility, offering new molecular entities with longer patent lives. Both could open significant partnering opportunities. AlgaeneX is a potential game changer in AAV manufacturing, potentially 1/3 the time at a fraction of the cost. But this new proprietary manufacturing process has broad application beyond gene therapy and could be applied to manufacturing of large molecules, such as biologics. And one could imagine that there would be substantial interest in licensing this technology to significantly reduce cost of goods across biologic manufacturing. And so while we're most excited about the Insmed products coming out of these platforms, I think it's also interesting to contemplate future potential revenue streams by applying our technology to partnerships or licensing arrangements. We are motivated to bring first-in-disease or best-in-disease medicines with the highest impact to patients. This initial set of gene therapy candidates that we talked about are examples of our team's passion and commitment to doing just that. We want to transform the treatment of Duchenne. Our dream is that these kids never see a wheelchair, and we think Brian and his team can get us there. Our first medicine will generate microdystrophin, and we'll do so with a potentially better approach with a much lower viral load that should be safer and offer what we hope will be an efficacy advantage. But we're already thinking about building our DMD franchise with mid-length and ultimately, full length dystrophin production. So these kids could be wheelchair-free, feed themselves, breathe independently and live a healthy life. In the center of this page, you have one of the 34,000 to 42,000 Stargardt patients in the U.S. who is starting to notice a problem with their central vision, it's blurry, It's distorted. And currently, these patients all progress to legal blindness. And unfortunately, there's no available treatment for Stargardt, and we aim to change that with the first approved gene therapy for Stargardts. On the right is a picture of Olivia. She was born a beautiful, healthy baby. And within the first few days of her life, she was in the pediatric intensive care unit. She had a rare urea cycle disorder, ASA, and ammonia accumulating in Olivia's bloodstream was causing brain damage. After the initial crisis caused by elevated blood levels of ammonia and establishment of the diagnosis, treatment for patients like Olivia consisted of a low-protein diet and arginine supplementation. And while there are medicines to help with ASA, including ammonia scavengers, currently, there is no cure for ASA. As a potential best-in-disease gene therapy for DMD, we believe there's a $1 billion plus annual total market opportunity for newly diagnosed DMD patients. We -- base this on the incident population, which we estimate to be 750 to 1,100 new DMD cases each year across the seven major markets. And we believe Insmed will be the preferred gene therapy for DMD. In addition, as Dr. Day mentioned, even if there is an approved gene therapy for DMD before Insmed's, which we assume is our base case, we believe it's plausible that there may be existing DMD patients from the prevalent population who may be eligible for Insmed's medicine. We see Stargardt's disease as a blockbuster opportunity as we believe Insmed will bring forward the first and only gene therapy for these patients who are faced with progressive vision loss leading to blindness. Stargardt disease is usually diagnosed in people under the age of 20 and patients with the childhood onset of symptoms, which is the majority of patients are more severely affected and have a faster rate of visual decline. And again, there's currently no treatment available for Stargardt. We estimate around 78,000 to 97,000 Stargardt patients across the seven major markets. And of these, we estimate approximately 40% may be eligible for gene therapy since their vision has not declined too much. So they have mild or no visual impairment, so their vision could be preserved. In addition to this prevalent pool, we estimate there are around 1,200 to 1,350 new Stargardt cases each year across the seven major markets. Typically, onset of ASA occurs within the first few days of birth, and it's readily diagnosed as all 50 states in the U.S., including ASA and their newborn screening program. And since the patients are still in the growth phase, we believe that there is a likely need for redosing of gene therapy. And because of this likelihood, we are unaware of any other companies targeting ASA. We expect to be the first and only gene therapy for ASA. And we're excited about the potential of bringing the first redoseable gene therapy to market, leveraging our Deimmunized by Design technology helping babies born with ASA progress towards a normal life through redoseable gene therapy would be a paradigm shift towards lifelong gene therapy. And while ASA is the first indication we are targeting with redoseable gene therapy, it opens up opportunities in many metabolic disorders and respiratory diseases. Besides the prevalent pool, we estimate the 40 to 100 ASA cases annually across the seven major markets. And with redosing, this becomes a lifelong therapy. With 80% of rare diseases being genetic in origin, the opportunity from gene therapies is tremendous. Gene therapies will transform how we treat and potentially cure some of these rare diseases. And Insmed's gene therapy approach is well positioned to establish us at the forefront of rare diseases. Besides delivering improved patient outcomes, gene therapy is also helping reduce the health care cost burden by offsetting medical and treatment costs. There are five gene therapies currently approved in the U.S., starting with an ocular gene therapy in December 2017, and the most recent one for hemophilia B in November 2022. And three of the 5 approvals were in the last 9 months. So clearly, the pace of gene therapies entering the market is accelerating. And as you can see, the list price of gene therapies is rising over time. But importantly, these prices are anchored in clinical evidence and cost offsets. By eliminating the need for expensive chronic treatment over many years and the associated medical costs to say nothing of the improved health and quality of life for these patients and their families, gene therapies are significantly reducing the long-term cost for the health care system. Pricing watchdogs, such as ICER, have been broadly supportive of these prices to date given the cost offsets and long-term clinical benefits. And we think the value proposition will continue to be strong for our gene therapies. We have multiple near-term catalysts from our first three pillars over the next 12 months, so truly an exciting and transformational time for Insmed. And we are also excited about the early-stage pipeline as well as our new proprietary manufacturing technology that we secured today. We expect to progress DMD gene therapy into the clinic in the second half of 2023, with early clinical data in the first half of 2024. Stargardt gene therapy is anticipated to follow soon thereafter as we anticipate an IND in the second half of 2024 and first clinical data in 2025. And we expect to have the INDs for chronic refractory gout and ASA gene therapy submitted in 2025 based on preclinical data in 2024. And finally, we plan to get into the full capsid production mode with AlgaeneX in 2024, which aligns perfectly with our continued gene therapy and therapeutic protein pipeline growth. And what we have shared today is merely a subset of programs that we have within Pillar 4, and we will share details about additional programs as we progress further in our research. So to summarize, we have a tremendous growth opportunity with our fourth pillar, while incurring less than 20% of overall expenditures in Pillar 4. We have assembled an enviable scientific team whose collaborations position Insmed to be a leading biotech company for the foreseeable future. We believe we have the premier gene therapy team, and our first gene therapies are first-in-disease or best-in-disease. And together, they represent a multibillion-dollar annual revenue potential and demonstrate the application of next-generation-targeted gene delivery, RNA End-Joining (REJ) technology to deliver larger genes and redoseable gene therapy, leveraging deimmunized AAV vectors. We aim to get DMD kids out of wheelchairs. We hope to preserve vision and wear off blindness for patients with Stargardts. And we intend to introduce lifelong gene therapy, starting with babies diagnosed with ASA, to hopefully, arrest the progression of that devastating disease, and that's just the beginning. Our scientific platform technologies are designed to solve the big issues facing current gene therapies, enable us to harness AI to create novel new molecular entities to evade the human immune system and a manufacturing technology with potential broad applicability to significantly reduce cost and time to manufacture proteins. With multiple catalysts for our first three pillars due to hit in the next 12 months, we are on our way to becoming a self-sustaining biotech company, and we have strategically positioned Insmed for further success by delivering first-in-disease or best-in-disease medicines, by focusing on rare diseases and BLAs, which receive favorable regulatory and pricing treatment and delivering a strong differentiated pipeline with an ambition of 6 INDs by the end of 2025. So with that, that concludes our prepared remarks. I'd like to hand it over to Will to lead our Q&A session and have our panel come back up on stage, please.

Thanks, Roger. Thanks, everyone. So what we're going to do is invite you to -- we've got three microphones here. If anyone has questions, please just line up one in each aisle, and then we'll just take questions. First questions goes to Ritu. Is that mic on? Let's just make sure. I want to make sure that people can hear it online.

Is it good?

Yes. There you go. Great.

Ritu Baral, TD Cowen. I wanted to ask about the mechanism for the DMD -- the new DMD gene therapy. How exactly -- Dr. Kaspar, how -- what's the current working the as to how it's getting from intrathecal from the CNS so widely diffused in peripheral muscles? Is there something going on at sort of the neurotransmitter plate, that sort of junction? Or what's the working theory? And I'd love to know, given the time lines that you've laid out, where you are in regulatory approvals to start clinical trials, whether U.S. or ex U.S.?

Go ahead, Brian. It's a great question.

Ritu, fantastic question. So let me just start off. First off, I wish I could explain how AAV9 crossed the blood-brain barrier and targeted motor neurons as efficiently as it does for the remarkable gene therapy of Zolgensma. I haven't figured that one out. And we haven't figured this one out either. But let me just tell you a couple of things that we've been thinking about with the delivery via intrathecal. So one thing we and others have shown that intrathecal delivery targets skeletal muscle as well as cardiac extremely efficiently, much better than systemic dosing. And when you look at systemic dosing, the first pass typically goes right directly through the liver. The liver is -- the depot sucks up the majority of the virus. That does not happen with intrathecal delivery. So how could that be the case? One is -- number one, the CSF turns over 6 times per day in a human being. And there is a slow flow into the bloodstream. That's happening. It's probably not explaining a slow delivery method that targets skeletal muscle and cardiac efficiently. So potentially one mechanism, but probably not the mechanism. Then we think about the lymphatic system and the glymphatic system that looks very akin, but differentiated from the blood connections throughout the entire body. That could be a mechanism that we know the CSF targets the lymphatics and glymphatics to deliver peripherally. Then if you look at, call it, the peripheral nervous system, if you look at the CNS -- peripheral nervous system connection, it almost looks like the blood circulation system. So the virus could be transported. We know these viruses can transport with a retrograde as well as an anterograde fashion. So these viruses could be utilizing these connections via CNS as railroad tracks to deliver their genes. We know these all come into the CSF connections here. So I guess I'm not answering fully your question other than to say, we are trying to design some experiments. Certainly, to decipher how this is remarkably doing what it's doing to get to where it's going. And right now, I'll take it on the safety and the efficacy that we've seen to say, even though we might not be able to fully address how it's getting to where it's getting, we are so pleased and gratified on the aspect of this delivery method that's avoiding the liver. And that substantially reduces the viral load to effectively target the tissues that we need to be targeting in Duchenne muscular dystrophy. So that adds to the safety profile. And again, we've seen people go in systemic and the problems that Dr. Day addressed of the challenges that we have in this field that we're really excited about the ability to get in target skeletal muscle to target the cardiac more efficiently. We're going to keep after this -- trying to understand the mechanism, "Look, if there's someone out there that has an idea, please contact me day or night to design an experiment or tell me what's -- how this is truly doing, what it's doing. We are open to doing those experiments." I think the second part of your question?

Regulatory.

Regulatory. So one thing that we've approached and Will, please add anything that I might miss here. From the get-go, we have scaled up manufacturing. This is not an academic process or production method. We're at a 1,000-liter scale. We're approaching 2,000-liter scale. That's not a change in process. So we feel very confident about how we're thinking about the manufacturing of this. And then I'd also -- not to belabor this, but I really want all of you to appreciate how we've thought about the analytics. A 25 tests, we've got to get the titer right. We can't change the titer. I've been through this in my past life, about having to go from qPCR, to ddPCR, to something, we're not doing that this time. We are approaching the analytics with now locked down analytics that we understand the product. And when we go to the regulators, we got manufacturing locked down. We've got the analytics locked down, and there's not going to be any surprises of saying, "If we get the NSAA scores on these patients, if we have the biomarkers on these patients, if we've got the dystrophin expression on these patients." We've got things locked down in a manner that is, call it, BLA-ready."Because we've taken that maturity that the folks that I get to work with into consideration, that we're not going to treat a patient until we fully understand our product, that we can truly scale the product and that we can meet commercial demand that if, indeed, we are as safe as what we think it's going to be and as efficacious that we're going to be, we're to be able to hit the market with everything in place. That's what the regulators are looking for. That's our strategy. I've got a tremendous number of individuals. We've talked to KOLs, Dr. Day included. We've got a regulatory team led by Dr. Jim L'Italien, again, someone who has multiple new drug applications under his belt. And then we have Dr. Eisner, who I introduced, who really brings a perspective of, what do we need to do to get a drug out there? I get the privilege of doing the science. I get the privilege of thinking about the assays that we need to do. And then we have a dedicated manufacturing and the QC team that delivers on that promise to get this to patients. That's our North Star to get to patients.

And just to clarify. The first-in-human, will that -- have you decided whether that will be in the U.S. or not?

That's planned for the U.S. to start out.

It's planned for the U.S.

And we're imminently filing our IND. It turns out through no coordinated effort of our own that there's another company that's doing something in gene therapy that has some information that will be forthcoming later this week. And we thought it might be interesting to listen to. So we're going to be attentively watching that and then moving rapidly thereafter.

Jeff Hung, Morgan Stanley. Can you talk a little bit more about how you're optimizing the dose for the first three patients in the 1201 Phase I proof-of-concept study? How will you -- how will those doses compare to the non-human primate doses? And then if you have to step down the dose, how would you determine the magnitude of the step down?

Brian, do you want to take that?

Okay. Once again, a fabulous question. Let me just state how we think about dosing. And I'm going to take a step back and talk about my experiences with Zolgensma. It started in my laboratory in a mouse model. We took that mouse model into a nonhuman primate and then we took that nonhuman primate into humans, and just had miraculous results. And what we've learned from those lessons, there was not in the SMA work. But now there has been refinement as we looked back and understood the translation from mouse to monkey to humans. Now that's a systemic dosing. We're not doing systemic dosing. So what we've relied upon here is taking those lessons non-clinically and working with the clinician to understand how do we get the right dose for that first-human patient, that optimized dose. Now I think what differentiates us from others is that many in the field do not appreciate biodistribution studies is we appreciated, and we know the regulators appreciate it. People have tried in the gene therapy space to get rid of the biodistribution studies. If anything, we've double down, triple down and embraced the biodistribution because essentially, what that allows us to do is to understand the doses that are going to have a clinically meaningful effect. I'll walk you through a little bit of our process. I can't get into the exact specifics to tell you exactly how we got to that optimized dose when we launched the clinical trials. But number one, what we have done is Droplet Digital PCR, where qPCR, you can have up to 100 to 150 or more percent variants. The CV values of qPCR based upon the operator, it can be great, but usually, it's not that great, and you see 150% variance. Droplet Digital PCR, we're less than 5% variance, less than 10% variance at most. So the assays that we have coming in and the numbers that we have coming in, we feel confident about those numbers because there's not that much noise. So we're applying those to our mouse studies. And in the MDX model, it affords us to establish a noneffective dose, a minimally effective dose, and then therapeutic doses, where we have either functional changes, grip strength, physiology, histopathology improvements. So we know the minimal number of vectors in multiple muscle groups that doesn't have an effect. We know the minimal amount of vector genomes in multiple muscle groups, that do have the minimal and then therapeutic effects. We then take those numbers and we apply then principles of scaling into a nonhuman primate. And we say at doses a -- and remember we've done -- we're not just doing one dose in a mouse or one dose in a monkey, we're doing like 3 to 5 doses in each. And then we go in and we say, "Well, when we inject a monkey with our route of administration intrathecal, how much gets into the quadriceps, the TA, the gastroc, et cetera?" And each of those dosing groups with those defined assays, bingo. Now I got the number to go from mouse to monkey. What I can't tell you because it's a little bit of our secret sauce is how we go from a monkey to a human being, and that's where we have the experts like Dr. L'Italien, Dr. Eisner, Dr. Thompson and our research teams that really have that translational experience that we get the right dose. So long answer, but I really wanted to spend -- sorry, Will, because I'm talking a lot. I hope this is helpful because it's something that -- my job, my only job sitting here is to establish a safe dose and effective dose. So when I meet with Dr. Day, I can show him how we have outlined our preclinical or nonclinical studies to prove safety and efficacy for patients. Duchenne muscular dystrophy is a pediatric patient population. We are mandated by regulation to go in with a therapeutic dose that we believe will have a clinical meaningful impact. And I take that really seriously. If I do anything -- and I've done it once, right? We got that dose for Zolgensma that now 3,000 patients have been dosed. And I give a tremendous applause to those individuals who continue to work to this day, Novartis Gene Therapies, to get that dose right. Droplet Digital PCR, that was actually developed in our research and development laboratories, passed on to QC. I'm going a little bit longer because I hope you see the connections that we're trying to make from research and development that go into the QC and then go into the translational, got to get that dose right, got to make sure that Batch 3, is the same as Batch 33, is the same as Batch 333. And guess what, Novartis Gene Therapies has done that successfully. We're building that same infrastructure to do it as good, if not better. Hopefully, that helps.

No. I think that highlights why we value so much the experience of the team because you have to have done this before to know where the pitfalls are and then how to correct for them. Liisa?

Liisa Bayko from Evercore ISI. Will, you alluded to the fact that it might be sooner than later that we do have a gene therapy available for DMD. And you also talked about the context of maybe 3 to 6 years to sort of treat the majority of prevalent population today. I'm just curious how you're thinking about your opportunity? And any potential -- what opportunity may shift as gene therapies roll out ahead of you given your timing? And any potential for redosing? So just how you're thinking about all of that.

Yes, there's a lot here that we've talked about today that we anticipate will come together over a number of years to come. But maybe I'll ask Roger to talk about how we're thinking about this, from the point of view of our assumption that there will be approved gene therapies that are out there. And notwithstanding that, we think we will still have a significant opportunity.

Yes, sure. Thanks, Will. So I think our base case is that there will be DMD gene therapies approved prior to Insmed's gene therapy making it to market. We did allude to the prevalent population in DMD, and it will take a while for all of those patients to get treated. And certainly, we hope, again, focusing on that disease, that as many patients as possible can get a therapy that's going to help them. But as we focus -- again, as our base assumption that we won't be first to market, we focus largely on the incident population. And I think we're talking about somewhere about 750 to 1,000 kids newly diagnosed across the seven major markets. And we'll have to make an extrapolation of what the price looks like, but you've seen the pricing and the strong support based on the therapies that are being replaced for gene therapy. So just on the incident population, we think that total addressable market is probably about $1 billion annually easily, based on the lower range of the gene therapies for the pricing that we've seen. And again, fundamental to our belief is we think that the approach that Brian and his team are coming up with, which is that lower dose, and we're hoping we'll see more profound efficacy as well, will really position Insmed as the preferred gene therapy. So if we focus just on the incident population, we think we'll take the lion's share within that marketplace, and that's a substantial opportunity over time. And again, we're thinking about this as a franchise, and I'm sure that came across today as well. So we're starting with our microdystrophin, but then we'll go to the mid-length, and then we'll hopefully get to the full length. We'll see how durable this is. I think there was an article -- was in [ stat ] the other day, talking about the kids that were initially dosed, I think it was with the Pfizer gene therapy for DMD, remarkable miraculous results immediately and then heartbreakingly over time, a little bit of a waning of effect, which I think -- as I think about it, as a parent myself, they must be devastating to watch that. And so as we get more clinical experience and as we see the impact that we have across these various lengths of dystrophin, potential redosing is something -- that may be something that we could think about in the future and would target if we do see that redosing is needed. And that's really a paradigm shift that we think about lifelong gene therapy, which would add into that incident population. So I think the franchise approach that we're thinking about for DMD, I think is truly, really incredibly exciting.

I would just say it's very energizing to think that we could have full length dystrophin as a possibility. That seems like it's within sight. The ability to redose gene therapy. The ability to dose through a unique delivery mechanism, with clear benefits and almost a magical transduction capability. And the idea that we'd be able to manufacture that in algae and the cost and time benefit that, that would represent. We are talking about, yes, delivering an effective therapy for these patients. We're also talking about rewriting the whole disease. And I think that's where we set our distance compass point. The one in the middle.