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Msg  14799 of 15712  at  2/11/2019 10:02:43 AM  by

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Physician survey signals continued growth for Nuplazid

Physician survey signals continued growth for Nuplazid
BAML - Industry Overview Equity | 11 February 2019

Nuplazid as a key part of PDP treatment algorithm

As part of our continued monitoring of the Nuplazid launch, we recently surveyed 26
physicians (17 neurologists and 9 psychiatrists) to better understand the use of Nuplazid
in their current treatment algorithms. We see dissipating negative impact of CNN
articles from last year, and the survey strengthens our thesis that Nuplazid sales growth
will continue to be sustained. We highlight our key takeaways: (i) Nuplazid has become a
key part of Parkinson’s disease psychosis (PDP) treatment paradigm with 41% of their
patients on Nuplazid (compared to 43% on Seroquel and 6% on other antipsychotics).
Psychiatrists are adopting Nuplazid faster than neurologists (51% on Nuplazid vs 36%,
see Chart 2); (ii) On efficacy, 92% of physicians view Nuplazid as equally or more
efficacious than antipsychotics (44% of psychiatrists and 41% of neurologists view
Nuplazid as more efficacious); (iii) On safety, physician satisfaction is even higher
compared to satisfaction with efficacy (see Chart 7). We highlight that the most
common advantage of Nuplazid over antipsychotics cited by more than half of
physicians is the avoidance of motor complications from treatment (consistent with
previous checks). Our detailed doctor feedback from a neurologist in academic center
and a psychiatrist in private practice confirms our findings from the survey (see page 8
for detailed feedback).

Nuplazid use to increase by 24% over two years
Our survey signals healthy growth of Nuplazid over the next two years (see Chart 9). We
note that a bigger portion of growth will come from neurologists (26% growth over two
years compared to 20% from psychiatrists). We believe the expected growth trend is
bolstered by the positive impact from FDA’s reiteration of confidence in Nuplazid’s
safety (from September) and launch of branded direct-to-consumer campaign including
television commercials. We believe patients can now transition from any past negative
perception of Nuplazid primarily based on media reports to learning more about efficacy
and safety profile of Nuplazid in PDP.

Stronger growth expected from non-LTC channel
Nuplazid appears to be more widely adopted in long-term care (LTC) facilities compared
to private practice and academic centers. Recall that publicly available scripts data from
IMS and SHS only capture a segment of the LTC channel (contributes one-third of sales).
We note that while non-LTC channel currently adopts less use of Nuplazid compared to
LTC channel, we expect stronger uptake from non-LTC channel in the next two years
(see Chart 17).

Our estimates for future Nuplazid sales
We currently assume $277mn (+24% y/y) for Nuplazid PDP sales in 2019 ramping up to
$732mn in 2026. We view upcoming data from schizophrenia (ph 3 ENHANCE readout in
mid-2019) and dementia-related psychosis (ph 3 HARMONY interim readout in 2H19
and full data in 2020) could provide additional source for future revenue growth. We
maintain our Buy rating on Acadia Pharmaceuticals (ACAD) with a $27 PO.

Nuplazid survey signals healthy growth

Survey of 26 physicians using Nuplazid to treat PDP

We conducted a survey of 26 US physicians (17 neurologists and 9 psychiatrists) who
treat Parkinson’s disease psychosis (PDP). Physicians were required to satisfy the
following: (i) US-based; (ii) practiced for at least three years; (iii) active prescribers of
Nuplazid with more than 15 patients on Nuplazid; (iv) used Nuplazid for at least 12
months. Our respondents treat an average of 57 PDP patients with Nuplazid and half of
them practiced for 15 years or longer. Our respondents include 6 physicians from longterm care (LTC) facility, 7 physicians from private practice and 13 physicians from
academic medical center. Together, they treat over 1.4k PDP patients with Nuplazid.
Physicians are readily employing Nuplazid in their treatment algorithm
We asked physicians about their treatment paradigm for PDP patients. We note that use
of Seroquel and Nuplazid was comparable and together accounts for 84% of drugs
currently used for PDP patients (See Chart 1). Other drugs include donepezil, trazodone
and benzodiazepine prescribed by two physicians. We view the prevalent use of Nuplazid
in PDP patients as expected given physician’s view on efficacy and safety profile of
Nuplazid. We also note that more than half of physicians viewed “no need to modify
dosing of drugs for motor symptoms” as the greatest advantage of Nuplazid over
antipsychotics.

Out of 26 respondents, psychiatrists (n=9) have incorporated Nuplazid more into their
treatment paradigm compared to neurologists (n=17). This is not surprising as
psychiatrists have viewed Nuplazid efficacy and safety profile more favorable than
neurologists which led to higher uptake of Nuplazid into their treatment algorithm (see
Chart 2).

High physician satisfaction in efficacy especially from psychiatrists
We believe Nuplazid becoming a key part of treatment algorithm by physicians is driven
by satisfaction in both efficacy and safety. Our survey signals that over 92% of
physicians view Nuplazid efficacy as equal as or more efficacious than antipsychotic
treatments (See Chart 3). We highlight that psychiatrists have viewed Nuplazid efficacy
as more favorable than neurologists which is to be expected as we have seen more
psychiatrists adopting Nuplazid into their treatment paradigm (see Chart 4). On average,
physicians rated efficacy of Nuplazid as 3.96 and antipsychotic drugs as 3.46 (out of 5).
We asked physicians about their satisfaction with Nuplazid efficacy by providing three
options: (1) “Very satisfied”; (2) “Somewhat satisfied”; and (3) “Not satisfied”. We note
that all 26 respondents have selected “very satisfied” and “somewhat satisfied” with
none expressing discontent with Nuplazid efficacy (See Chart 5). Physicians who picked
“very satisfied” underlined use of Nuplazid as both first line treatment for new patient
starts and potential switch/add-on option to current treatment paradigm. From
“somewhat satisfied” physicians, common theme was subset of PDP patients not
responding well to Nuplazid. We believe this is consistent with our expectations and
there was only one physician who pointed out reimbursement/bad coverage. We
highlight several of our respondents’ answers below.

Physicians “very satisfied” with efficacy (n=18)
• “Good option for first line therapy.” Neurologist with 70 patients on Nuplazid
practicing in academic center
• “Works well in Seroquel failures.” Neurologist with 15 patients on Nuplazid
practicing in academic center
• “At least as efficacious as current atypical antipsychotics.” Psychiatrist with 15
patients on Nuplazid practicing in academic center
• “Great addition to my arsenal against PDP and allows me to add more dopaminergic
agents.” Neurologist with 40 patients on Nuplazid in private practice
Physicians “somewhat satisfied” with efficacy (n=8)
• “About 25% of patients don’t respond to it well.” Psychiatrist with 45 patients on
Nuplazid in academic center
• “At approved doses it seems to significantly reduce or eliminate psychosis in over
50% of cases; higher doses may be better but data and experience are limited.”
Neurologist with 28 patients on Nuplazid in academic center
• “The medication appears more effective than Seroquel for treatment of PDP, but
poorly covered and hard to get approved by insurance.” Neurologist with 55
patients on Nuplazid in private practice

Physicians are even more satisfied with safety profile of Nuplazid

On safety, we note that a higher percentage of physicians deemed Nuplazid safety as
“very satisfied” (81%) compared to 69% of physicians who viewed efficacy as “very
satisfied”. We note that majority of physicians are highly content with the safety profile
of Nuplazid as no severe side effects or tolerability issues have been encountered (see
Chart 6). We highlight several of our respondents’ answers below. Consistent with how
psychiatrists viewed efficacy, we note that psychiatrists viewed Nuplazid safety as more
favorable than neurologists (see Chart 7).

Physicians “very satisfied” with safety (n=21)
• “No obvious motor safety concerns, no worsening of tremor or extra-pyramidal
symptoms.” Neurologist with 50 patients on Nuplazid in academic center
• “No long term safety concern encountered”, “So far, no severe side effects that I
encountered.” Two neurologists with 57 patients on Nuplazid in private practice and
academic center
Physicians “somewhat satisfied” with safety (n=5)
• “Too early to tell for some patients.” Neurologist with 30 patients on Nuplazid in
LTC
• “As of now there is no evidence that it is less safe than antipsychotics we currently
use.” Neurologist with 55 patients on Nuplazid in private practice….

…. Impact from CNN article is largely going away
Our respondents signaled that 81% of physicians were aware of the CNN article (see
Chart 13). Of those 81% of respondents, we note that 24% of physicians (n=5) have
seen impact to their prescription of Nuplazid after the CNN article (see Chart 14). Those
five physicians highlighted that 13.3% of their patients discontinued due to the article.
Upon the FDA statement in September reaffirming Nuplazid’s safety in treating PDP,
85% of physicians were aware of the FDA statement. From the five physicians above
who had discontinued patients due to CNN article, four physicians replied “This has
alleviated some of the fears”, “I can reassure patients with this information”, and “Now
[I] can reference both article and FDA statement, seems to be a non-issue now.” We
note that only one physician continued to have “patients [who] were still concerned
after article.” We view this as reassuring given that the impact of CNN article, if there
were any, has now subsided and will prevent discontinuations due to bad publicity.


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Replies
Msg # Subject Author Recs Date Posted
14800 Re: Physician survey signals continued growth for Nuplazid Sundance_Al 2 2/11/2019 1:21:44 PM
14808 Re: Physician survey signals continued growth for Nuplazid tblant 0 2/13/2019 6:14:22 AM


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