Syndax Pharmaceuticals, Inc. (SNDX) Earnings Call Transcript & Summary

Good day, everyone, and welcome to the Syndax Second Quarter 2026 Earnings Conference Call. Today's call is being recorded. [Operator Instructions] At this time, I would like to turn the call over to Sharon Klahre, Head of Investor Relations at Syndax Pharmaceuticals.

Great. Thank you, operator. Welcome, and thank you all for joining us today for a review of Syndax's Second Quarter 2026 Financial and Operating Results. I'm Sharon Klahre, and with me this afternoon to provide an update on the company's progress and discuss financial results are Michael Metzger, Chief Executive Officer; Steve Closter, Chief Commercial Officer; Dr. Nick Botwood, Head of R&D and Chief Medical Officer; and Keith Goldan, Chief Financial Officer. This call is accompanied by a slide deck that has been posted on the Investor page of the company's website. You can now turn to our forward-looking statements on Slide 2. Before we begin, I'd like to remind you that any statements made during this call that are not historical are considered to be forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. Actual results may differ materially from those indicated by these statements as a result of various important factors, including those discussed in the risk factors section in the company's most recent quarterly report on Form 10-Q as well as other reports filed with the SEC. Any forward-looking statements made represent our views as of today, August 4, 2026, only. A replay of this call will be available on the company's website, www.syndax.com, following its completion. And with that, I'm pleased to turn the call over to Michael Metzger, Chief Executive Officer of Syndax.

Thank you, Sharon. Good afternoon, everyone, and thank you for joining us. Starting with Slide 3. The Syndax team delivered another quarter of solid commercial results and progress across our growing pipeline of programs, targeting areas of high unmet need and substantial commercial opportunity. The business fundamentals are strong. Sales of Revuforj and Niktimvo grew to a combined total of $115 million in the second quarter. Both medicines are now annualizing at well over $200 million each, and we have just started to unlock their multibillion-dollar potential. Revuforj continued to grow by double digits with net revenue totaling $55 million in the second quarter, up 91% year-over-year and 12% quarter-over-quarter. These results highlight our continued leadership in menin inhibition, robust demand in both NPM1 and KMT2A, and the positive impact of an increasing average treatment duration driven by multiple factors, including a growing number of patients on therapy for an extended period after receiving a stem cell transplant. As the number of patients on therapy post-transplant continues to stack, this recurring base will be an important driver of long-term compounding growth. Encouragingly, the average duration of treatment is also increasing among patients who are not proceeding to a transplant. As Steve will describe shortly, the positive impact of an extending average treatment duration, which was partially offset this quarter by fluctuation in the number of new patients initiating therapy, one of several drivers of our business. Today, we are even more confident in the forward trajectory and substantial commercial opportunity with Revuforj. Our conviction is underpinned by the multiple drivers for continued growth, including a best-in-class profile valued by physicians, an increasing average duration of therapy, a broad and expanding prescriber base and ample opportunity in NPM1, KMT2A and other menin-dependent acute leukemias. We are well positioned to extend our leadership in menin inhibition into the future and continue driving innovation for patients. Building on a long history of landmark firsts, we are positioned to be first to frontline AML, driven by strong global site initiation and patient enrollment in our pivotal trials. With future anticipated indications in frontline AML, we expect that Revuforj could reach in excess of $2 billion in peak annual net revenue in the U.S. alone. We have another data-rich period ahead for revumenib. In the second half of the year, we will report additional practice-informing evidence from multiple trials at major medical meetings, expanding on the prominent presence we had at ASCO and EHA in June. We also expect to publish data in relapsed/refractory NUP98 rearranged acute leukemia in the fourth quarter. These results could inform clinical practice and guidelines in a patient population similarly sized to KMT2A. Patients with NUP98 urgently need new treatment options, including therapies that may reduce the risk of relapse after transplant, as is the case with KMT2A. Physician feedback indicates that NUP98 rearrangements are more common than once thought, occurring in perhaps 5% or more of AML cases, translating into potentially 1,000 to 2,000 pediatric and adult patients with NUP98 annually. As the first and only company to report clinical data showing activity with a menin inhibitor in this subtype, we have a unique opportunity to pursue a guideline listing that could meaningfully expand the patient population treated with revumenib. Switching gears to Niktimvo and chronic GVHD. Niktimvo net revenue grew to $60 million in the second quarter, up 67% year-over-year. This performance reflects robust demand and Niktimvo's unique ability to address inflammation and fibrosis. Niktimvo is positioned for further growth with strong adoption in the fourth line and increasing uptake in the third line, driven by a broad base of prescribers who are enthusiastic about the results they've seen in their patients. We also have multiple expansion opportunities and important upcoming catalysts for axatilimab with Phase II data in IPF and frontline chronic GVHD expected in the fourth quarter, poised to unlock new multibillion-dollar opportunities. Turning to our pipeline assets. At our R&D event last month, we unveiled 2 innovative assets we are advancing into the clinic, leveraging our world-class R&D capabilities and experience taking revumenib and axatilimab from IND to FDA approval in about 5 years. SNDX-4321 is a novel, mutant-selective, CNS-penetrant, allosteric EGFR inhibitor for non-small cell lung cancer that offers a new approach to addressing patient populations with high unmet medical needs, such as those with L858R mutations and CNS metastases. SNDX-62122 is a next-generation menin inhibitor we are developing for myelofibrosis or MF, building on our extensive experience pioneering menin inhibition in hematology. It is the first molecule from our internally developed and wholly owned library of next-generation menin inhibitors, which we intend to advance into promising new areas. We are entering into another exciting chapter for the company as we build Revuforj and Niktimvo into major commercial franchises and leverage our proven R&D engine to bring new treatment options to even more patients. We are fully funded to execute on our commercial and R&D priorities and continue to advance towards profitability with growing revenue from the first 2 medicines from our pipeline. I will now turn the call over to Steve to discuss our commercial results in more detail. Steve?

Thank you, Michael. Starting with Revuforj on Slide 4. We delivered our sixth consecutive quarter of double-digit Revuforj net revenue and prescription growth and continue to track well above launch benchmarks set by other mutation-directed AML therapies. Net revenue totaled $55 million, up 12% from the prior quarter. Total prescriptions were approximately 1,500, up 15% from the prior quarter. These results reflect robust demand and an increasing average duration of therapy, one of several important drivers of our business. We have dominant share of the overall menin business today, having treated over 1,600 patients commercially since launch, including 250 new patients added in the second quarter. We saw some fluctuation in new patient starts in Q2 relative to prior quarters, reflecting typical variation quarter-to-quarter in the number of available patients with a rare disease and market dynamics when physicians have more than one drug in class they can consider using depending on the patient's mutational profile. To ensure we leave no appropriate patient behind, we have optimized our established customer footprint and targeting, expanded our ability to leverage lab data to engage physicians when they have a suitable patient in their care and increased our promotional efforts and educational activities. We remain confident we will continue to lead this market with the strongest efficacy profile in an efficacy-driven market and multiple drivers supporting long-term growth. Our business in KMT2A and NPM1 is strong, and it is growing. Revuforj is the standard of care for relapsed/refractory KMT2A-translocated acute leukemia and remains the only targeted therapy for an aggressive cancer with no other effective treatment options. We continue to expand into our second indication with NPM1, accounting for at least 40% of new patients in the second quarter and more than 30% of the $55 million in net revenue. All indicators suggest Revuforj will continue to be the menin inhibitor of choice for all menin-dependent acute leukemias. Physicians value having one efficacious and well-tolerated drug they can use across multiple acute leukemia subtypes in both adults as well as children. They appreciate that the efficacy they see with Revuforj in the real world is consistent with or, in fact, even better than the clinical trial results. They value individualized dosing, not having to worry about reduced efficacy when their patients are taking commonly prescribed gastric acid-reducing agents like PPIs and H2 blockers and the lack of any clinically meaningful pruritus, an adverse event that can be impactful for patients and very difficult for clinicians to manage. This combination of efficacy, tolerability and dosing flexibility is why Revuforj is and will remain the drug of choice for physicians. Turning to Slide 5. There are 2 fundamental drivers of our business: new patients and average treatment duration, and both are building. The unique breadth of our indication provides us with the opportunity to target approximately 2,000 patients diagnosed annually with relapsed/refractory KMT2A-translocated acute leukemia, plus 4,500 with relapsed/refractory NPM1 mutated AML. And we've made excellent progress reaching this population with more than 1,600 patients treated with commercial drug since launching in KMT2A in the fourth quarter of 2024 and NPM1 in the fourth quarter of last year. Importantly, there's still plenty of room to reach more patients each quarter. For instance, of the annual 4,500 relapsed/refractory NPM1 patients, we estimate that less than 15% have received a menin inhibitor, highlighting the substantial opportunity for further growth. Compared to KMT2A, where we saw a steep uptake curve due to the lack of other approved or impactful therapies, we expect our NPM1 business will build over time due to other options that physicians may consider for this population depending on their co-mutations or other factors. The second fundamental driver is average treatment duration, which is increasing due to evolving clinical practice and a product profile that is conducive to patients staying on therapy for extended periods of time. Physicians are reaching for Revuforj early in the relapsed/refractory treatment paradigm and are often choosing to use it in combination with other therapies with the goal of driving responses and extending the duration of effect. Claims data shows 75% of use in the second and third line and approximately 40% of use in combination. Encouragingly, a significant proportion of patients are proceeding to stem cell transplant after receiving Revuforj, which is the goal in the relapsed/refractory setting for both KMT2A and NPM1 patients who are fit enough to receive a transplant. We continue to observe approximately 50% of KMT2A patients proceeding to transplant. About 50% of those patients have resumed therapy thus far after pausing for 3 to 6 months, up from an estimated 45% last quarter. We expect this percentage will continue to increase as our colleagues in medical affairs report additional evidence from the post-transplant setting in collaboration with leading treatment centers, building on the encouraging data MD Anderson presented at ASCO and EHA this past June. Over time, we expect that up to 70% to 80% of transplant patients will ultimately return to therapy for 1 to 2 years based on feedback from physicians and clinical trial and real-world experience. These evolving treatment patterns are increasing the average treatment duration, especially the growing number of patients on therapy post-transplant. This group is already averaging at least 9 months of therapy with this duration expected to steadily increase as we continue to follow patients over time. Among patients who do not receive a transplant, over half are still staying on therapy for a significant period with an average treatment duration that is already over 7 months and building. With a significant addressable patient population and an increasing average treatment duration, we are confident in our ability to build a sustainable business with our first 2 indications for Revuforj. Moving to Slide 6. We have a solid commercial foundation in place to support the success of Revuforj, including a highly accomplished team with deep and strong customer relationships. Our already robust prescriber base has continued to expand quarter-over-quarter, including our activation of Tier 1 and Tier 2 accounts, the highest volume centers in the U.S. who treat 2/3 of our target population. Nearly 90% of these accounts have ordered, up from 70% prior to the approval of Revuforj in NPM1. Overall, more than 580 accounts have ordered Revuforj, up 11% from the prior quarter, reflecting growing adoption from centers of all sizes, including community practices. Our growing prescriber base reflects physicians' enthusiasm for Revuforj and positions us to drive further penetration for both indications. We have excellent payer coverage, and physicians can access the menin inhibitor they prefer. As of the end of Q2, Revuforj's formulary coverage was 98% of all covered lives for both indications, a coverage position that leads the class. In addition to having nearly 100% formulary coverage, Revuforj has preferential coverage on plans representing 17% of all covered lives versus less than 2% of lives for the other menin inhibitor. Turning to Niktimvo on Slide 7. Niktimvo net revenue totaled $60 million in the second quarter, up 67% year-over-year and 9% quarter-over-quarter. This result reflects strong and consistent new patient starts and solid persistency. More than 300 new patients were added and about 5,750 infusions were administered in the second quarter. Niktimvo is annualizing at $240 million and continues to track with the launch of Rezurock, a drug that reached $500 million in annual U.S. net sales within the first 4 years of launch in the same indication. Moving to Slide 8. The fundamentals of our Niktimvo business are strong with multiple drivers for continued growth. The first is continued adoption in the fourth line and steadily increasing uptake in the third line as clinicians gain experience with Niktimvo. Within 1.5 years of launch, Niktimvo has captured approximately 1/3 of the third line plus chronic GVHD market. As the patient mix shifts more towards patients with less advanced disease, we expect this will extend the average treatment duration. This is a chronic disease with the potential for patients to stay on therapy for long periods. We've observed solid persistency in the commercial setting with 60% to 70% of patients staying on Niktimvo for at least 12 months. Our clinical trial experience suggests the duration of therapy could be measured in years for a meaningful proportion of patients. Our Niktimvo business benefits from a broad and productive prescriber base and commercial synergies for both Syndax and Incyte. Nearly every bone marrow transplant center in the U.S. has prescribed Niktimvo and become a repeat customer. Physicians continue to report impressive activity in multiple organs with particularly notable responses in the lungs and skin, some of the most difficult to treat organs. All these drivers position us to expand our impact in third line plus chronic GVHD, a $2 billion U.S. market opportunity. Looking ahead, the ongoing trials in frontline chronic GVHD and IPF could unlock additional multibillion-dollar opportunities. With that, I'll hand the call over to Nick to talk about our development programs.

Thank you, Steve. Turning to Slide 9, I'd like to highlight the progress we've made advancing our scientific leadership in menin inhibition with a strong presence in medical meetings and 2 landmark publications. At ASCO, we had 4 revumenib abstracts, including an oral presentation of post-transplant maintenance data from a cohort of heavily pretreated patients with KMT2A, NPM1, or NUP98 alterations who resumed revumenib post-transplant. This analysis showed a 2-year overall survival rate of 90%, which is nearly double the historical rate observed prior to the introduction of revumenib. Moving on to EHA. We have 12 revumenib abstracts, highlighting the clinical activity with revumenib in multiple acute leukemia subtypes and settings, including in combination with standard of care therapies in the frontline and relapsed/refractory setting. In June, data from the relapsed/refractory cohort in the Phase I/II SAVE trial were published in the Journal of Clinical Oncology. The results observed with the all-oral combination of revumenib, venetoclax and decitabine/cedazuridine in a heavily pretreated population of patients with NPM1, KMT2A or NUP98 AML are impressive. 88% achieved an overall response. 80% of evaluable CRc responders achieved MRD negativity and 45% of patients proceeded to transplant, with 63% receiving revumenib post-transplant. These results are similar to outcomes observed in real-world cohorts treated with revumenib-based combinations, underscoring the potential to reproduce these results in clinical practice. In July, we and our collaborators published the results of groundbreaking preclinical studies with revumenib, which showed menin is a novel dependency in a proliferative megakaryocytes, major drivers of myelofibrosis. These data provide the basis for our innovative clinical development program in myelofibrosis. Looking ahead to the second half of the year, we will deepen our scientific leadership with new revumenib data from across the acute leukemia treatment continuum, including from the maintenance and real-world setting. We also look forward to presenting more mature frontline data in the fourth quarter with updates expected from SAVE and Beat AML trials of revumenib with low-intensity chemotherapy and from the 708 trial with intensive chemotherapy. We expect these data will be impactful for the clinical community and provide strong support for our ongoing pivotal frontline combination trials. We also expect to publish data in relapsed/refractory NUP98 rearranged acute leukemia in the fourth quarter, followed by submission of this important publication for the clinical guidelines for consideration. Patients with NUP98 rearrangements have poor outcomes, and there is an urgent need for new treatment options with many parallels to the unmet needs in KMT2A prior to the introduction of revumenib. Physicians are positive about the potential for revumenib to provide a new treatment option for this disease subtype based on the data reported. At EHA, we presented data from 25 heavily pretreated relapsed/refractory NUP98 patients showing a 28% overall response rate with 43% of responders proceeding to a transplant and all resuming revumenib post-transplant. Turning to our pipeline on Slide 10. I'd like to highlight just a few key points. First, we are rapidly advancing an integrated evidence generation plan designed to establish revumenib as the menin inhibitor of choice across the acute leukemia treatment continuum. Importantly, we maintain good momentum to be the first to deliver pivotal frontline data for menin inhibitor. Global site activations and patient enrollment is well established in our pivotal trials, informed by an extensive body of clinical evidence, allowing for optimization of endpoint assumptions and other aspects of the study design. Second, we are nearing 2 important axatilimab readouts. We are on track to report top line data from the Phase II MAXPIRe IPF trial in the fourth quarter. Positive data would open a transformative opportunity for axatilimab and provide a strong biological rationale for its mechanism in several other diseases where the pathology is underpinned by fibrosis and inflammation. We also anticipate top line results from the Phase II trial of axatilimab in combination with ruxolitinib in frontline chronic GVHD in the fourth quarter. Positive outcomes with the novel combination could begin to unlock the potential for a steroid-sparing regimen in newly diagnosed chronic GVHD. Third, as highlighted at our recent R&D event, we announced 2 new pipeline assets, SNDX-4321 and 62122. In line with our focused R&D strategy, these are targeted molecules, both with first- and best-in-class potential supported by compelling preclinical data, mechanistic insights and advocacy of leading researchers and clinicians. With both revumenib and axatilimab, we have demonstrated our ability to efficiently generate clinical data that validates new therapeutic targets, leading to new approvals, a strength we will leverage again as we advance the next chapter of our R&D strategy. Turning to Slide 11. 4321 is a novel mutant-selective CNS-penetrant allosteric EGFR inhibitor. We're developing it for non-small cell lung cancer patients with high unmet needs, such as those with the L858R mutations, CNS metastases and atypical activating mutations or resistance to current therapies. In contrast to ATP site-directed third- and fourth-generation EGFR inhibitors, 4321 binds at a pocket adjacent to the ATP site. This is only accessible in the presence of L858R and certain other EGFR mutations. The allosteric approach allows for high selectivity and a double lock approach to inactivating the receptor. 4321 and ATP site-directed therapies can bind EGFR at the same time at different sites on the receptor, potentially enhancing efficacy and delaying resistance. We expect to submit an IND for 4321 by the end of 2026 with an assessment of monotherapy activity expected in early 2028. 62122 is our next-generation menin inhibitor in development for myelofibrosis that could offer a novel and potentially disease-modifying approach. It is the first candidate from our library of internally developed and wholly owned next-generation menin inhibitors that we plan to advance into new areas. We expect to submit an IND and initiate Phase I trial of 62122 in 2027. This program will be informed by a proof-of-principle trial of revumenib in myelofibrosis that will be conducted in partnership with world-leading experts in myelofibrosis. We expect this trial to initiate in the fourth quarter with initial data anticipated in the second half of next year. In summary, we've made enormous progress advancing our late-stage trials and expanding our pipeline of differentiated assets. We are nearing several important data readouts and have multiple opportunities to transform the standard of care for some of the most difficult-to-treat diseases. With that, I'll turn the call to Keith to discuss our financials.

Thank you, Nick. Pardon me. Earlier this afternoon, we reported detailed second quarter 2026 financial results. And I'll highlight a few key points on Slide 12. Total revenue for the second quarter of 2026 was $72.8 million, up 92% over the same period last year. This consisted of $54.7 million of Revuforj net revenue and $18.1 million in Niktimvo collaboration revenue, which equated to 30% of the Niktimvo net revenue reported by our partner, Incyte in the quarter. We expect Niktimvo margin contribution, defined as the collaboration revenue recorded by Syndax as a percentage of Niktimvo net sales, to continue to be in the 25% to 30% range in the near term and increase longer term as sales grow. We expect revenue from both Revuforj and Niktimvo to continue growing and advancing the company towards profitability. Our guidance for R&D plus SG&A expenses in 2026 remains approximately $400 million, excluding the impact of $50 million in estimated noncash stock compensation expense. We ended the second quarter with $575 million in cash, equivalents and investments. This includes $244 million in net proceeds from the issuance in June of $250 million of 2.25% convertible notes. That deal provided the lowest cost of capital that Syndax has ever accessed and positions us well to build shareholder value over the long term. We're fully funded to execute our commercial and R&D priorities, including our late-stage trials of revumenib and axatilimab and the development of our pipeline assets. With relatively modest investments in proof-of-principle trials of SNDX-4321 and 62122, we believe we can quickly generate early clinical data that creates significant value for the company and its shareholders. With that, I'll hand the call to Michael for closing remarks.

Thank you, Keith. Syndax is well positioned for long-term growth and success with multiple blockbuster opportunities and upcoming milestones as highlighted on Slides 13 and 14. We have a best-in-class menin inhibitor that is positioned to be the first to frontline AML and deliver peak annual net revenue in excess of $2 billion in the U.S. alone. We are nearing data readouts in the fourth quarter that could unlock multibillion-dollar upside for Niktimvo in IPF and frontline chronic GVHD. We have a proven track record of successfully developing and commercializing novel medicines and are bringing forward 2 new pipeline assets with best-in-class and blockbuster potential in EGFR-mutated lung cancer and myelofibrosis. With $575 million on the balance sheet and growing revenue from 2 products, we are funded through profitability and have the capital to realize our pipeline opportunities and drive significant long-term value. I will close by thanking our dedicated employees and the many patients, clinicians and scientists who support our work and inspire us to pioneer bold new approaches to some of the most devastating diseases. And with that, I would like to open the call for questions. Operator?

[Operator Instructions] And the first question is from Anupam Rama with JPMorgan.

This is [ Joyce ] on for Anupam. Could you discuss the physician feedback you received at ASCO and EHA on the Revuforj data that you guys presented there, especially the post-transplant maintenance data? And how soon could those data have positive pull-through to the launch in terms of what you're seeing as the proportion of patients going on maintenance therapy?

Joyce, thanks so much for the question. So I'll direct the first question to Nick.

Thank you for the question. I think the data was very well received. I think it's a remarkable outcome when you look at the proportion of patients alive at 2 years, 90%. It's obviously not randomized, but MD Anderson did a very nice job comparing it to the current standard of care, which is considerably less than that. So I think they're very encouraged by that. We have significant research efforts ongoing to further elucidate the benefits of giving revumenib in the -- within the post-transplant setting. It's really important, I think, to optimize the dose. We're learning a lot about that, and we have a dedicated Phase I study ongoing to optimize dose, and we hope to report on that later this year. We also actually have the first prospectively randomized study called the MenTain study that was recently announced on ct.gov in collaboration with Dana-Farber and other collaborators, which will hopefully further elucidate the benefits of maintenance which will be extremely helpful and it's an important study to do. Generally, however, we are seeing the uptake of maintenance very much in clinical practice, and that will be evidenced by the real-world series we've already reported upon where you see high rates of post-transplant and then patients going back on to transplant -- back on to therapy after transplant. And we'll be updating on those further in the year with more data, which I think support and perhaps even exceed what we've seen to date.

Our next question is from Brad Canino with Guggenheim.

Maybe 2 for me. One, just any quantification you can provide on the duration of treatment increasing, either numerical or some estimation of a relative increase in the DOT you saw? I'm just trying to judge the magnitude of increase. And then two, have you seen any indication of an inflection in the maintenance rate? It sounds like it was 50% is what you're up to for this past 2Q. But any inflection in July after showing the maintenance data at ASCO and EHA as you've been going out and talking with physicians?

Brad, thanks so much for the question. So first of all, in terms of the duration of treatment, we're very much encouraged by what we're seeing. I think the -- for patients who are actually going on to maintenance, we know that cohort of patients is out beyond 9 months. And so that's an increase from what we've seen previously, and we feel quite encouraged by that. And what's also -- you might have picked up in my remarks, what's also encouraging are patients who don't go to transplant, who remain on therapy for an extended period of time are well beyond 7 months at this point, and building. So that is -- that's sort of new news and very encouraging for what we think will continue to build the recurring revenue within the franchise. Thank you. And then in terms of inflection in maintenance rate in July, that was a pretty specific question. I'll just say that we are seeing continued buildup in maintenance. I don't think we've quantified it quite for July, but we feel very encouraged by what we've seen coming out of last quarter and into this quarter. And so we believe that will continue to build. We've talked about reaching 70%, 80% of patients getting on maintenance. We believe that assumption will hold as we build beyond the 50% that we saw this quarter. When exactly that will get to the 70, 80 percentile will take a little bit -- 70%, 80% will take a little bit of time, but we do feel quite encouraged by the momentum we're seeing coming out of the last quarter.

The next question is from Faisal Khurshid with Jefferies.

This is Faisal from Jefferies. I just wanted to ask, this looks like the first quarter that you actually took a step down in new starts. Can you give any more specificity on the reasons for this? And also in terms of modeling this going forward, what are the forward trends that we should expect on new starts, each in KMT2A and NPM1?

Thanks so much for the question. So maybe I'll turn it over to Steve to make some comments on new starts for this quarter.

Yes. Thanks for the question. I appreciate you pitching it to me, Michael. Overall, I mean, good performance. I mean, it's a sixth consecutive quarter of double-digit revenue and demand growth. And I think interestingly, we grew 15% on TRx demand, and that was in the face of what you noticed is a falling number of patient starts from Q1 into Q2. And the reasons for that that there are just multiple drivers to the business. A lot of our prepared comments around the KMT2A business, how it's advancing, it's heading exactly in the direction that we predicted it would, higher transplant rates, higher restart rates relative to the clinical trials, which is really driving the DOT. And I'd say for NPM1, it's still early days, but we know that the business is growing. It's growing nicely. Our revenue and our patients on drug from Q1 into Q2 advanced as well. So new patient starts are simply just a part of the growth story, but not the only part. A couple of things I hit out in the prepared comments, I'll maybe add a different flavor to it as well. But this is normal. You're going to see, at least in the larger targeted AML therapy class, new starts do jump around. There's typical variability. We see it month-to-month. You're going to see it quarter-to-quarter. We've been largely immune to that, right? Rev has existed in the space, and we've either had the same number of new starts or grown them quarter after quarter. But this is a fundamental aspect of the market that is typically there. It's -- the other things that we've mentioned, physicians have more than one drug class to consider, right? And there is a big focus on the NPM1 patient. Based on that patient's mutational profile, physicians are going to make a choice. I think they're still figuring out how to -- where the menin fit. So is it before a FLT3, is it during FLT3, or perhaps after. So that will play its way out. But ultimately, patients will relapse and Rev will play a role. And the last piece are just clinical trials. So when you sign up to be in this business, oncology, hematology, you're advancing drugs through the clinic and you're also commercializing them. And we've done that successfully since the launch of Rev. So this isn't something that's entirely new. But there are new trials that pop up from time to time. As they get established, patient flow will ultimately work its way through and opportunities for commercial patients are going to stabilize. Many of these are placebo-controlled trials. So we expect to still treat many of these patients either when they relapse. Not all patients are obviously eligible for clinical trials. And we made a conscious decision about a year ago to go to a much broader audience. So as we updated in this call, we're approaching 600 accounts that are prescribed. Many of those are medium sized to smaller accounts, less impacted by clinical trials, and we find meaningful patient build there as well. So these factors can cause some lumpiness and fluctuation quarter-to-quarter, but we were able to flex and change our business as needed. So we're confident in the forward. So I think one of the questions was what is the trend moving forward. We look at this quarter as an anomaly. We feel confident about finding patients and getting back to levels that we've seen historically.

Got it. And Steve, if you don't mind just a quick follow-up. So am I to take your comments to mean that new starts on commercial drug in relapsed AML as a whole were down quarter-over-quarter? And if so, are you able to quantify that at all?

Probably we don't have the full data set to look across all of AML. We're limited in what we can see on our drug. But perhaps that is the case. I would bet that it is. And again, it will jump around from quarter-to-quarter.

The next question is from Phil Nadeau with TD Cowen.

Congrats on the progress. A few commercial questions from us. So first, in the NPM1, I apologize if I missed this. Did you say where you estimate your share of NPM new patient starts was this quarter and how that compared to last quarter? That's first. And then second, I think you said 15% of NPM1 patients have been on a menin. And that's after approximately 3 quarters of your launch. Is that trend that we should continue into the future? So in another 3 quarters, should we expect maybe 30% of NPM1 patients will be on a menin? Or is there any reason to think that would either accelerate or decelerate? Then finally, on maintenance, can you kind of tell where -- tell us where maintenance is being used today in terms of what centers and where is the growth going to come from? What new centers could come online over the next several quarters to drive increased use of maintenance across the market?

Great. Phil, thanks for the question. So first question I took as what's our NPM1 share. And I think as we stated in our prepared remarks, we're about 2/3 of the business right now. I mean, if you think about where we were last quarter, it was roughly about the same, 2/3 or more of the overall business. And so we expect that to continue to build over time. But we do have a dominant position. I would also say in terms of relapsed/refractory business, we're probably assuming our competitor gets close to their numbers, we're probably 85-plus percent of relapsed/refractory. So we are quite dominant in the space and expect to continue to build that. We did make a comment about 15% of the patients, this is your second question, 15% of the NPM1 patients have seen a menin inhibitor, and that's not only our drug, but our understanding of what -- how our competitor contributes as well. So that's 15% total. We do expect that to expand meaningfully. And from quarter-to-quarter, we expect that to grow, accelerate. In a year from now, we'll be at 30%. Well, we would hope that it would be even greater than that. And it's supported by all the data that we're generating. Nick mentioned the presence at our congresses and what we've provided in terms of monotherapy and combinations, and that has shown Revuforj to be a very useful drug in a number of ways. So we expect that we'll be treating NPM1 patients and continuing to penetrate that market very meaningfully, hopefully well beyond 30% in a year. And then maintenance, maybe I'll turn to Nick on this one. Maintenance, where is it being done? What are those centers? I mean, we won't list them all. Academic centers for sure, maybe Nick can make a comment there. And where is the growth going to come from in terms of maintenance? Nick?

Well, I think the growth will come from a number of drivers. I mean, #1, is patients getting treated earlier on. They're getting treated increasingly in combination. That's just driving response rates higher. We know that if a patient gets a response, they're eligible for transplant. Having had a transplant, the likelihood of them going on to post-transplant maintenance as we gather more data and present more data there. I think physicians are feeling more confident. They understand how to manage the dose better. These patients after transplant are particularly prone to cytopenias generally. So you really do need to manage the dose, and that's something we'll be presenting updated data on later this year, and I think they're getting confidence to do that. And really just the real-world experience from academic centers. We've seen extremely high rates. They're feeling more confident doing it. Their intent is to treat out to 1 year to 2 years. Most of our clinical trials include therapy out to 2 years. And given the high rates of relapse after transplant without any active therapy, they really want to just do their best for the patients and think that revumenib gives them the best chance of a durable remission. And so we're seeing uptake increase. From a research perspective, it's our efforts to further confirm that benefit, who's most likely to benefit and how we can make sure that the drug is well tolerated. But I think we're very encouraged by what we're seeing in the uptake, and we'll be presenting more data on that again later this year with a big focus on this whole post-transplant maintenance area.

The next question is from Stephen Willey with Stifel.

Congrats on the progress. I guess Niktimvo sequential growth has kind of flattened out here over the past couple of quarters. So just curious how you're thinking about the near-term growth opportunity for this franchise prior to potential label expansion? And then I was also just wondering if you can confirm whether the definition of event-free survival, which is being used in the Phase II frontline trial that reads out later this year plus Rux is the same as the Phase III frontline trial that's looking at Niktimvo combination with steroids?

Stephen, thanks for the question. Maybe I'll take the first with maybe a comment on the second from Nick. So Niktimvo, look, I don't agree with the characterization that it's flat, first of all, Niktimvo is not flat, it's growing, and we see it tracking very nicely to what Rezurock has done. And so we expect it to continue to grow meaningfully. And what I'm talking about is third and fourth line. So we've penetrated well into the fourth line. Third line, we have about 1/3 of the -- third-line population at this point, which is very meaningful about a year post launch. So I think we will continue to build that and be meaningful in third and fourth line. So you should expect continued growth there. And then, of course, we have expansion opportunity with the new data coming at the end of the year with combination with ruxolitinib. And so we feel like that's an obvious expansion opportunity as we're on our way to the frontline. And we'll also have steroid combination in early '28. So a lot of data to come. I think physicians are eager to see the combinations and how our drug combines with Jakafi. And in the meantime, we'll have considerable growth, we believe, over the near term with third and fourth line. And then maybe I'll turn it to Nick on definition for event-free survival.

Steve, the event-free survival endpoint is in the -- for the frontline steroid combination Phase III. So that does have an event-free survival primary endpoint. For the Phase II, 3-arm study, we're actually going to look at overall response rate at 6 months. So as you recall, this is steroids versus Rux versus the combination of Axa and Rux. We expect a benchmark from that based on our publication in 2022 to be about 40% response rate for steroids alone at 6 months. We're looking for a meaningful improvement over that. I think for the combination, it could be considerably higher than that. It's not formally a comparative study. It's randomized 1:1:1, about 120 patients, you'll recall. So yes, we'll look at overall response rate, but I think also the duration of response will be very important to look at in that study to see whether the combination and Rux alone can offer a meaningful alternative to steroids. So that's what we will report on and looking forward to seeing that readout. So I think it could be very informative and potentially practice and guideline informing readout if either or both of those combinations beat steroids alone.

The next question is from Etzer Darout with Barclays.

A quick one for me. Just wondering for the proof-of-principle trial of revumenib in multiple fibrosis, what is the primary analysis? What will that entail? And what endpoints will you be evaluating there just as a potential, obviously, read through to the next-gen menin inhibitor?

Great, thanks for the question. Maybe I'll turn to Nick on the proof-of-concept trial.

Yes, this is a study we're doing with the MPN Research Consortium with John Mascarenhas and collaborators. It's not under our sponsorship. It was recently posted on clinicaltrials.gov. It's quite a full posting, if you want to look at some of the details of the study there, but I'll just summarize it for you. Cohort 1, which is primarily the safety assessment, we'll look at just dose-limiting toxicities. It's going to be relatively few patients treated, around 6. In Cohort 2, where we will look for the combination of Rev in combination with Jakafi, we'll be looking at standard response criteria. So we'll be using the ELN response criteria looking at anemia, spleen response and symptom benefit. We'll be looking at SVR less than 35%. So in patients that have a suboptimal response on Jakafi alone and are stable on Jakafi for 12 weeks, we'll add in revumenib and then we will be looking for using standard ELN response criteria to generate proof-of-principle data, which will be incredibly informative to our development program and really catalyze, I think, when we go into Phase I in 2027 with our next-gen menin inhibitor in myelofibrosis.

Our next question is from Yigal Nochomovitz with Citigroup.

This is [ John Kim ] on for Yigal. I was wondering with regards to your expanded use of lab data, I believe that you had mentioned, to engage physicians when they have a suitable patient. Just wondering, to what extent can that help smooth new start variability, particularly in NPM1, where the population is larger, but co-mutations can help influence the treatment choice? And then also with regards to the MAXPIRe trial, just wondering, since patients can be on pirfenidone or no background antifibrotic. If the study is positive, how should we think about the extent to which the background therapy could help define axatilimab's role, whether it's add-on or potentially if the patients are not getting much benefit from current treatments?

Great. Thanks for the question. So first, with the use of lab data, maybe, Steve, do you want to make some comments on how we identify patients?

Yes, sure. So we do use lab data, as pointed out in the question, it enables us to find diagnosed patients. We buy lab data. We can identify patients that may be suitable. It's obviously de-identified. We can target accounts that we know patients exist, it's largely worked since launch. I think that really speaks to why we've been so successful, particularly at the KMT2A launch. We've modified our approach over time. We've been able to bring in new lab data sets. We've been able to apply some applied artificial intelligence and machine learning principles. So it still holds. I think specifically, the question was, can you use that to smooth out new starts? The market is the market. Patients are going to come in at often a random pace. So over a year, you kind of know what it is, but month-to-month, it's going to be different. We will find every possible patient that we can, right? And we've shown we've been able to do that, and we're going to get better simply over time. So that's something we remain committed to.