ITEM 3
.
|
Key Information
.
|
|
A.
|
Selected Financial Data
|
Our historical financial
statements are prepared in accordance with IFRS, and are presented in U.S. dollars. The selected historical financial information
as of December 31, 2015 and 2016, and for each of the three years ended December 31, 2014, 2015 and 2016, have been derived from,
and should be read in conjunction with, our audited financial statements and the notes thereto appearing elsewhere in this annual
report. The selected statement of operations data for the years ended December 31, 2012 and 2013, and the selected balance sheet
data as of December 31, 2012, 2013 and 2014, have been derived from our audited financial statements not included in this annual
report.
Until January 1, 2016,
our functional currency was the NIS; however, our presentation currency was and remains the U.S. dollar. As a result, for all periods
through December 31, 2015, our financial statements are translated into the presentation currency as follows: equity accounts are
translated using historical exchange rates (as reported by the Bank of Israel). All other statements of financial position accounts
are translated using the year-end exchange rate (as reported by the Bank of Israel). Statement of comprehensive loss amounts were
translated using the exchange rates prevailing at the dates of the transactions. The resulting translation differences relating
to the conversion from the functional currency to the presentation currency are reported in other comprehensive loss.
Effective January 1,
2016, we determined that our functional currency changed to U.S. dollars. This determination resulted from a change in relevant
circumstances of which, based on our projected level of spending on research and development expenses (mainly related to advanced
clinical trials) and other operating expenses, we concluded that spending in U.S. dollars will exceed that in NIS for the foreseeable
future. As we do not foresee a reversal of this trend, we transitioned the functional currency to the U.S. dollar effective January
1, 2016.
Foreign currency transactions
in currencies different from the functional currency are translated into the functional currency using the exchange rates prevailing
at the dates of the transactions. Foreign exchange differences resulting from the settlement of such transactions and from the
translation at period-end exchange rates of monetary assets and liabilities denominated in foreign currencies are recorded to the
statement of comprehensive loss among finance income or expenses.
As of December 31, 2015,
the representative exchange rate last published by the Bank of Israel was $1.00 = NIS 3.9020.
The information presented
below is qualified by the more detailed historical financial statements set forth in this annual report, and should be read in
conjunction with those financial statements, the notes thereto and the discussion under “ITEM 5 - Operating and Financial
Review and Prospects” included elsewhere in this annual report.
|
|
Year Ended December 31,
|
|
|
|
2012
|
|
|
2013
|
|
|
2014
|
|
|
2015
|
|
|
2016
|
|
|
|
(in thousands, except share and
per share data)
|
|
Statements of operations data:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Operating expenses:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Research and development
|
|
$
|
2,396
|
|
|
$
|
3,426
|
|
|
$
|
8,992
|
|
|
$
|
13,715
|
|
|
$
|
27,005
|
|
Participation in research and development
|
|
|
(41
|
)
|
|
|
(808
|
)
|
|
|
(927
|
)
|
|
|
(908
|
)
|
|
|
-
|
|
Research and development, net
(1)
|
|
$
|
2,355
|
|
|
$
|
2,618
|
|
|
$
|
8,065
|
|
|
$
|
12,807
|
|
|
$
|
27,005
|
|
General and administrative
(1)
|
|
|
449
|
|
|
|
628
|
|
|
|
5,316
|
|
|
|
5,163
|
|
|
|
6,087
|
|
Operating loss
|
|
$
|
2,804
|
|
|
$
|
3,246
|
|
|
$
|
13,381
|
|
|
$
|
17,970
|
|
|
$
|
33,092
|
|
Financial income
|
|
|
550
|
|
|
|
3
|
|
|
|
9,601
|
|
|
|
2,379
|
|
|
|
616
|
|
Financial expenses
|
|
|
2,316
|
|
|
|
83,650
|
|
|
|
26,084
|
|
|
|
18
|
|
|
|
20
|
|
Financial expenses (income), net
|
|
|
1,766
|
|
|
|
83,647
|
|
|
|
16,483
|
|
|
|
(2,361
|
)
|
|
|
(596
|
)
|
Net loss
|
|
$
|
4,570
|
|
|
$
|
86,893
|
|
|
$
|
29,864
|
|
|
$
|
15,609
|
|
|
$
|
32,496
|
|
Foreign currency translation differences
|
|
$
|
280
|
|
|
$
|
2,021
|
|
|
$
|
(1,420
|
)
|
|
$
|
1,741
|
|
|
$
|
-
|
|
Total comprehensive loss
|
|
|
4,850
|
|
|
|
88,914
|
|
|
|
28,444
|
|
|
|
17,350
|
|
|
|
32,496
|
|
Basic and diluted net loss per ordinary share
(2)
|
|
$
|
11.65
|
|
|
$
|
221.49
|
|
|
$
|
12.97
|
|
|
$
|
0.82
|
|
|
$
|
1.48
|
|
Weighted average number of ordinary shares used in computing net loss per ordinary share
(2)
|
|
|
392,320
|
|
|
|
392,320
|
|
|
|
2,302,991
|
|
|
|
19,113,218
|
|
|
|
21,897,095
|
|
(1) Includes equity-based compensation
expenses as follows:
|
|
Year Ended December 31,
|
|
|
|
2012
|
|
|
2013
|
|
|
2014
|
|
|
2015
|
|
|
2016
|
|
|
|
(in thousands)
|
|
Research and development expenses, net
|
|
$
|
11
|
|
|
$
|
102
|
|
|
$
|
2,185
|
|
|
$
|
1,328
|
|
|
$
|
1,995
|
|
General and administrative expenses
|
|
|
26
|
|
|
|
82
|
|
|
|
2,131
|
|
|
|
1,585
|
|
|
|
1,957
|
|
Total equity-based compensation expenses
|
|
$
|
37
|
|
|
$
|
184
|
|
|
$
|
4,316
|
|
|
$
|
2,913
|
|
|
$
|
3,952
|
|
(2) Basic and diluted loss per ordinary share
is computed based on the basic and diluted weighted average number of ordinary shares outstanding during each period. For additional
information, see Note 16 to our financial statements included elsewhere in this annual report.
|
|
As of December 31,
|
|
|
|
2012
|
|
|
2013
|
|
|
2014
|
|
|
2015
|
|
|
2016
|
|
|
|
(in thousands)
|
|
Balance sheet data:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Cash and cash equivalents
|
|
$
|
1,847
|
|
|
$
|
2,435
|
|
|
$
|
43,238
|
|
|
$
|
84,735
|
|
|
$
|
107,178
|
|
Short-term bank deposits
|
|
|
-
|
|
|
|
-
|
|
|
|
-
|
|
|
|
15,103
|
|
|
|
45,058
|
|
Working capital
(1)
|
|
|
(1,479
|
)
|
|
|
(1,246
|
)
|
|
|
39,299
|
|
|
|
96,651
|
|
|
|
148,409
|
|
Total assets
|
|
|
2,787
|
|
|
|
3,050
|
|
|
|
43,914
|
|
|
|
100,868
|
|
|
|
156,063
|
|
Total non-current liabilities
|
|
|
9,649
|
|
|
|
4,970
|
|
|
|
-
|
|
|
|
-
|
|
|
|
-
|
|
Total shareholders’ equity (deficit)
|
|
|
(11,028
|
)
|
|
|
(3,646
|
)
|
|
|
39,469
|
|
|
|
97,056
|
|
|
|
149,570
|
|
(1) Working capital is defined as total
current assets minus total current liabilities.
|
B.
|
Capitalization and Indebtedness
|
Not applicable.
|
C.
|
Reasons for the Offer and Use of Proceeds
|
Not applicable.
Our business involves
a high degree of risk. Please carefully consider the risks we describe below in addition to the other information set forth elsewhere
in this annual report and our other filings with the SEC. These material risks could adversely affect our business, financial condition
and results of operations. See “Cautionary Note Regarding Forward-Looking Statements”.
Risks Related to Our Financial
Position
We have a history
of net losses and we expect to continue to incur substantial and increasing net losses for the foreseeable future.
We are a clinical-stage pharmaceutical
company with a limited operating history. In the United States, we
are currently pursuing
a comparative bioavailability regulatory path for our lead product candidate, ND0612, based on comparative pharmacokinetic, or
PK, trials. In the European Union, or EU,
we are concurrently pursuing
a clinical,
efficacy based regulatory development strategy
for ND0612. We curently expect to submit applications for regulatory approval
in the U.S. and in the EU in 2018. We are also planning to pursue
a comparative bioavailability
regulatory path for ND0701 in the EU and plan to discuss this approach with EU authorities in the
first half of 2017
.
We are at earlier stage of clinical development of product candidate ND0801. Investment in pharmaceutical product development
is highly speculative because it entails substantial upfront capital expenditures and significant risks that any or all potential
product candidates will fail to demonstrate adequate effect or an acceptable safety profile, gain regulatory approval and become
commercially viable. We have no products approved for commercial sale and have not generated any revenue from product sales to
date, and we continue to incur significant research and development and other expenses related to our ongoing operations. We are
still in the clinical development process of our product candidates; as a result, we are not profitable and have incurred significant
operating losses, including operating losses of $13.4 million, $18.0 million and $33.1 million for the years ended December 31,
2014, 2015 and 2016, respectively.
As of December 31, 2016, we had an accumulated
deficit of $180.7 million (which includes $99.8 million of non-cash financial expenses incurred since January 1, 2013 related
to the increase in the value of loans that had been provided to us, fair value of embedded derivatives and warrants, the issuance
of new shares to noteholders that was treated as an induced conversion expense, and convertible loans designated at fair value
through profit or loss). We expect to continue to incur significant expenses and suffer substantial operating and net losses and
negative cash flow for the foreseeable future. These losses and negative cash flows have had, and will continue to have, an adverse
effect on our shareholders’ equity and working capital. We anticipate that our expenses and future capital requirements may
increase substantially if we:
|
■
|
conduct our comparative PK trials for U.S. regulatory approval with respect to ND0612;
|
|
■
|
continue our trials for European marketing approval with respect to ND0612 and ND0701, respectively;
|
|
■
|
seek regulatory and marketing approvals for our product candidates that successfully complete clinical
trials;
|
|
■
|
initiate additional preclinical, clinical or other studies for our current product candidates and
seek to identify and validate new product candidates;
|
|
■
|
acquire rights to other product candidates and technologies;
|
|
■
|
increase the manufacturing and supply orders for our product candidates;
|
|
■
|
invest further in developing pump delivery systems for our products;
|
|
■
|
change or add suppliers or manufacturers;
|
|
■
|
maintain, expand and protect our intellectual property portfolio;
|
|
■
|
attract and retain skilled personnel;
|
|
■
|
engage third-party manufacturers to commercialize any of our product candidates for which we obtain
marketing approval;
|
|
■
|
create additional infrastructure to support our operations as a public company; and
|
|
■
|
experience any delays or encounter issues with any of the above.
|
We may never achieve
profitability.
Because of the numerous risks and uncertainties
associated with pharmaceutical product development and commercialization, we are unable to accurately predict the timing or amount
of future revenue or expenses or when, or if, we will be able to achieve profitability. We have financed our operations primarily
through convertible shareholders’ loans, issuance and sale of equity, including ordinary shares, preferred shares and warrants
and government and third-party grants. The size of our future net losses will depend, in part, on the rate of growth or contraction
of our expenses and the level and rate of growth, if any, of our revenues. If we are unable to successfully commercialize our product
candidates or if revenue from any of our product candidates that receives marketing approval is insufficient, we will not achieve
profitability. Even if we do achieve profitability, we may not be able to sustain or increase profitability.
We may need substantial
additional capital in the future, which may cause dilution to our existing shareholders, restrict our operations or require us
to relinquish rights to our product candidates or intellectual property. If additional capital is not available, we may have to
delay, reduce or cease operations.
In the past two years, we raised an aggregate
of $152.7 million of net proceeds in two public offerings. In order to continue the development of our clinical trials for our
product candidates, we may need to seek additional funding through additional equity offerings, debt financings, collaborations,
licensing arrangements or any other means to conduct clinical trials, develop our product candidates and expand our sales and marketing
capabilities or other general corporate purposes. Securing additional financing may divert our management’s attention from
our day-to-day activities, which may adversely affect our ability to develop and commercialize our product candidates. Additional
funding may not be available to us on acceptable terms, or at all. We believe that based on our current business plan and our existing
cash and cash equivalents, we will have sufficient funds to meet our currently anticipated cash requirements through at least the
next 12 months.
To the extent that we raise additional
capital through, for example, the sale of equity or convertible debt securities, ownership interest of our shareholders will be
diluted, and the terms may include liquidation or other preferences that adversely affect our shareholders’ rights as a shareholder.
The incurrence of indebtedness or the issuance of certain equity securities could result in increased fixed payment obligations
and could also result in certain restrictive covenants, such as limitations on our ability to incur debt or to issue additional
equity, limitations on our ability to acquire or license intellectual property rights and other operating restrictions that could
adversely impact our ability to conduct our business. In addition, the issuance of additional equity securities by us, or the possibility
of such issuance, may cause the market price of our ordinary shares to decline. In the event that we enter into collaborations
or licensing arrangements in order to raise capital, we may be required to accept unfavorable terms, including relinquishing or
licensing to a third party on unfavorable terms our rights to product candidates or intellectual property that we otherwise would
seek to develop or commercialize ourselves or reserve for future potential arrangements when we might be able to achieve more favorable
terms.
If we are unable to raise additional capital
when required or on acceptable terms, we may be required to:
|
■
|
significantly delay, scale back or discontinue the development, manufacturing scale-up or commercialization
of our product candidates;
|
|
■
|
seek corporate partners on terms that are less favorable than might otherwise be available; or
|
|
■
|
relinquish or license on unfavorable terms our rights to our product candidates that we otherwise
would seek to develop or commercialize ourselves.
|
Any such consequence will have a material
adverse effect on our business, operating results and prospects and on our ability to develop our product candidates.
Risks Related to Our Business
and Our Industry
Even if our products
obtain regulatory approval, they may cause undesirable side effects or have other properties, which may limit market acceptance.
We are planning
and/or conducting clinical trials, including
our ongoing long-term
safety
trial “BeyoND”, to determine the safety and efficacy of our product candidates. Through
such trials we will continue to add to our current collection of data of local tolerability and side effects related to our product
candidates. However, some of our patients have only used our product candidates for up to 21-day periods during our clinical trials
with ND0612L and up to 28-day peroids during our clinical trials with ND0612H. Based on the results of our completed Phase II studies,
ND0612H and ND0612L were generally well tolerated, with no particular systemic adverse events. Patients may decide to use other
currently available treatments instead of our product candidates based on the prevalence and severity of any side effects associated
with our product candidates. For example, patients suffering from moderate Parkinson’s disease may be less tolerant of inconveniences
that may be associated with the use of ND0612L and may instead continue using currently available orally administered LD/CD. Similarly,
if patients experience adverse side effects from our other Parkinson’s disease product candidates, patients who suffer from
moderate to severe Parkinson’s disease may opt for other treatments. In addition, certain patients may find our belt pump
administration systems to be unduly burdensome or restrictive.
Upon the conclusion of our trials, and
if we receive marketing authorization for a product candidate, we will be required to list side effects associated with the product
candidates. However, if after we receive marketing authorization, we or others identify previously unknown problems with our product
candidates, including adverse events of unanticipated severity or frequency, problems with our manufacturers or manufacturing processes,
or failure to comply with regulatory requirements, the following consequences, among others, may occur:
|
■
|
restrictions on the marketing or manufacturing of the product, withdrawal of the product from the market, or voluntary or mandatory product recalls;
|
|
■
|
fines, warning letters or holds on clinical trials;
|
|
■
|
harm to our reputation, reduced demand for our products and loss of market acceptance;
|
|
■
|
refusal by the regulatory authority to approve pending applications or supplements to approved applications filed by us, or suspension or revocation of product license approvals;
|
|
■
|
product seizure or detention, or refusal to permit the import or export of products; and
|
|
■
|
injunctions or the imposition of civil or criminal penalties.
|
Any of these events could prevent us from
achieving or maintaining market acceptance of our product candidates, which would adversely affect our business, prospects, financial
condition and results of operations.
If clinicial trials
of our product candidates fail to demonstrate safety and bioavailability and/or efficacy to the satisfaction of regulatory authorities
or do not otherwise produce positive results, we may incur additional costs or experience delays in completing, or ultimately be
unable to complete, the development and commercialization of our product candidates.
We have invested a significant portion
of our efforts and financial resources in the identification and preclinical development of product candidates. Our ability to
generate product revenues, if ever, will depend heavily on our ability to advance our product candidates through clinical trials.
We have also conducted, and will continue to conduct, at our own expense, clinical trials for our product candidates to demonstrate
that the products are safe, including our
ongoing long-term BeyoND safety trial, iNDiGO
phase III efficacy study and PK studies
. Even if we believe that our clinical trials demonstrate the safety and efficacy
of our product candidates, only the FDA, EMA and other comparable regulatory agencies may ultimately make such determination.
Clinical testing is expensive, is difficult
to design and implement, can take many years to complete and is uncertain as to outcome. A failure of one or more of our clinical
trials can occur at any stage of testing. We may experience numerous unforeseen events during, or as a result of, the clinical
trial process. Even if preclinical or clinical trials are successful, we still may be unable to commercialize the product, as success
in preclinical trials, early clinical trials, including Phase II and Phase IIa trials, or previous clinical trials, does not ensure
that later clinical trials will be successful.
Additionally, based on our ongoing and
planned clinical trials, we may alter the concentration of carbidopa in our LC/CD product candidates. If we were to alter the carbidopa
concentrations, the completion of our clinical trials may be delayed. Any requirement to conduct additional trials or failure to
follow an abbreviated regulatory pathway for our product candidates would delay receiving marketing approval for our product candidates
and adversely affect our business, prospects, financial condition and results of operations.
Based on our End-of-Phase
2 meeting with the FDA, we have amended our clinical development strategy for ND0612H and ND6012L to a comparative bioavailability
505(b)(2) regulatory pathway in the U.S.; however, we may be unsuccessful in meeting the requirements set forth by the FDA.
In late
October 2016, we held an End-of-Phase 2 meeting with the FDA, during which we discussed the regulatory development strategy for
ND0162H and ND0612L. Based on such discussions and responses from the FDA, we have amended our clinical development strategy for
these product candidates. Instead of conducting large Phase 3 clinical efficacy trials, we intend to pursue marketing approval
in the United States for ND0612L and ND0612H via a comparative bioavailability 505(b)(2) regulatory pathway. In order to submit
an 505(b)(2)-based NDA, we plan on conducting comparative PK studies against Duodopa
/Duopa
,
an FDA-approved drug for the treatment of “late stage” and “advanced” Parkinson’s disease. We will
continue to preview our trial designs with the FDA in order to ensure compliance with the FDA’s proposed recommendations
for such PK studies; however, we may be unable to conduct these trials in a timely manner, achieve the trials’ objectives
or comply with the FDA’s recommendations, which may result in us having to conduct extended PK studies or efficacy-based
trials or even being unable to rely on such 505(b)(2) regulatory pathway, resulting in an inability to timely enter the U.S. market.
For the risks associated with conducting clinical trials, see “—If clinical trials of our product candidates fail to
demonstrate safety and bioavailability and/or efficacy to the satisfaction of regulatory authorities or do not otherwise produce
positive results, we may incur additional costs or experience delays in completing, or ultimately be unable to complete, the development
and commercialization of our product candidates” and “— If we experience delays in our clinical trials, our costs
may increase and our business may be harmed.”
Even if we are successful in such PK studies
and submit an 505(b)(2)-based NDA, we may be excluded from marketing our product candidates in the United States given the orphan-designated
status of existing Parkinson’s disease drugs. Generally, if a product with an orphan drug designation subsequently receives
the first marketing approval for the indication for which it has such designation, the product is entitled to a seven-year period
of market exclusivity, which, subject to certain exceptions, precludes the FDA from approving another marketing application for
the same drug for the same indication during such period. See the risk factor entitled, “—
If our competitors are
able to obtain orphan drug exclusivity for their products that are the same drug as our product candidates, or can be classified
as a similar medicinal product within the meaning of EU law, we may not be able to have competing products approved by the applicable
regulatory authority for a significant period of time.
” In this instance, we would need to show that ND0612 is clinically
superior (by means of greater effectiveness or greater safety, or that it provides a major contribution to patient care) to an
existing Parkinson’s disease drug with orphan-designated status to ensure that its orphan drug exclusivity will not block
the approval of ND0612H or ND0612L. If we are unable to prove that ND0612H or ND0612L is clinically superior to such existing orphan-designated
drug, we may need to amend our regulatory development strategy for ND0612H and ND0612L and restart preparations to launch the previously
planned Phase III clinical efficacy trials, which could require a significant portion of our efforts and financial resources.
We may be unsuccessful
in our clinicial studies for marketing approval of our product candidates in Europe.
In January
2017, we held a meeting with EMA’s Scientific Advice Working Party to discuss ND0612. Based on this meeting and on the preliminary
results of trial 006, we have modified our EU clinical and regulatory development path. Upon the completion of our ongoing trials,
we plan to submit a marketing application based on the results of an amended iNDiGO phase III efficacy study and the ongoing long-term
BeyoND safety trial, seeking to obtain a broader label for ND0612 than the label that could have been granted under a PK regulatory
route in the EU.If we are successful in such studies and the EMA accepts our clinical study results, we expect to seek marketing
approval in the EMA in 2018. Although we believe that we have developed our clinical trials based on a framework that would allow
for marketing approval submission in 2018, the EMA or other drug regulators in the EU may require us
during
interim consulations or following submission to
modify our existing trials or to conduct additional,
small or large PK efficacy or safety trials. Thus, our ongoing clinical trials may be delayed or fail to provide adequate results,
which could delay our submission. See “—
If clinicial trials of our product candidates fail to demonstrate safety
and bioavailability and/or efficacy to the satisfaction of regulatory authorities or do not otherwise produce positive results,
we may incur additional costs or experience delays in completing, or ultimately be unable to complete, the development and commercialization
of our product candidates.
”
If our competitors
are able to obtain or maintain orphan drug exclusivity for their products that are, for the purposes of the FDA approvals in the
U.S., the same drug as our product candidates, or can be classified as a similar medicinal product within the meaning of EU law,
we may not be able to have competing products approved by the applicable regulatory authority for a significant period of time.
Regulatory authorities in some jurisdictions,
including the United States and the European Union, may designate drugs for relatively small patient populations as orphan drugs.
Generally, if a product with an orphan drug designation subsequently receives the first marketing approval for the indication for
which it has such designation, the product is entitled to a period of market exclusivity, which, subject to certain exceptions,
precludes the FDA from approving another marketing application for the same drug for the same indication for that time period or
precludes the EMA and other national drug regulators in the EU, from accepting another marketing application for a similar medicinal
product for the same indication. The applicable market exclusivity period is seven years in the United States and 10 years in the
European Union. See “ITEM 4.
Information on the Company
—B. Business Overview—Government
Regulation—United States—Orphan Drug Designation and Exclusivity” and “ITEM 4.
Information
on the Company
—B. Business Overview— Government Regulation—European Union—Orphan Drug
Designation.” If a competitor obtains orphan drug exclusivity for, and approval of, a product with the same indication as
any of our product candidates before we do and if the competitor’s product is the same drug or a similar medicinal product
as ours, we could be excluded from the market during the market exclusivity period. However, if a product candidate that is the
same drug or a similar medicinal product as an approved, orphan-designated product is shown to be clinically superior (by means
of greater effectiveness, greater safety, or that it provides a major contribution to patient care) to such orphan-designated product,
the orphan drug exclusivity will not block the approval of such competitive product. In addition, orphan drug exclusivity will
not prevent the approval of a product candidate that is the same drug as such orphan-designated product if the FDA or EMA finds
that the product sponsor or marketing authorization holder cannot assure the availability of sufficient quantities of the orphan-designated
product to meet the needs of the persons with the disease or condition for which the drug was designated.
For example, AbbVie Inc.’s product
Duopa, approved in the United States, has received orphan drug designation in the United States for the treatment of “late
stage Parkinson’s disease” and “advanced idiopathic Parkinson’s disease with severe motor complications
and not responding to oral treatment.” Because Duopa received marketing authorization as an orphan drug in the United States,
if the FDA determines that ND0612 is limited by Duopa’s potential market exclusivity, we may be precluded from receiving
marketing approval for ND0612 until the expiration of the orphan drug market exclusivity period, which will occur seven years after
Duopa’s approval.
In the European Union, Duodopa received
marketing authorization via the mutual recognition procedure for “treatment of advanced levodopa-responsive Parkinson’s
disease with severe motor fluctuations and hyper-dyskinesia when available combinations of Parkinson medicinal products have not
given satisfactory results.” See “ITEM 4.
Information on the Company
—B.
Business Overview— Government Regulation—European Union—Marketing authorization.” In May 2001,
the EMA granted NeoPharma Production AB orphan drug designation for LD/CD (gastroenteral use) for the treatment of “advanced
idiopathic Parkinson’s disease with severe motor fluctuations and not responding to oral treatment.” The sponsorship
of this orphan designation was transferred to AbbVie Ltd. in February 2013. As the orphan indication is different from the approved
indication for Duodopa, it is possible that AbbVie Ltd. could still seek approval of a product for that orphan indication.
If that occurs, and we wish to market a product with the same indication but are unable to show that our product
candidates are clinically superior (due to greater efficacy, greater safety or a major contribution to patient care) to the approved
orphan drug, we may be precluded from receiving marketing approval for product candidates seeking to treat advanced idiopathic
Parkinson’s disease with severe motor fluctuations and not responding to oral treatment until the expiration of the orphan
drug market exclusivity period, which is at least 10 years after the orphan drug is centrally approved, unless the EMA exercises
its discretion to reduce that period to six years on the basis that the product no longer fulfills the orphan criteria when the
authorization is renewed after five years.
If we experience
delays in our clinical trials, our costs may increase and our business may be harmed.
We do not know whether clinical trials
will begin as planned, will need to be restructured or will be completed on schedule, or at all. Drug development is a long, expensive
and uncertain process, and delay or failure can occur at any stage of any of our clinical trials. Our product development costs
will increase if we experience delays in clinical testing. Significant delays could also shorten the patent protection period during
which we may have the exclusive right to commercialize our product candidates or could allow our competitors to bring products
to the market before we do, impairing our ability to commercialize our product candidates. Events may delay or prevent our ability
to complete necessary clinical trials for our product candidates, including:
|
■
|
regulators may not authorize us to conduct a clinical trial within a country or at a prospective trial site or may change the design of a study;
|
|
|
|
|
■
|
delays may occur in reaching agreement on acceptable clinical trial terms with regulatory authorities or prospective sites, or obtaining institutional review board, or IRB, approval;
|
|
|
|
|
■
|
delays in reaching agreement on acceptable terms with prospective CROs and clinical trial sites;
|
|
|
|
|
■
|
failure of our third-party contractors, such as CROs, to satisfy their contractual duties or meet expected deadlines;
|
|
|
|
|
■
|
our preclinical tests or clinical trials may produce negative or inconclusive results, and we may decide, or regulators may require us, to conduct additional trials;
|
|
|
|
|
■
|
the number of patients required for our clinical trials may be larger than we anticipate, enrollment in our clinical trials may be slower or more difficult than we expect, or patients may not participate in necessary follow-up visits to obtain required data, any of which would result in significant delays in our clinical testing process;
|
|
|
|
|
■
|
insufficient or inadequate supply or quality of a product candidate or other materials necessary to conduct our clinical trials;
|
|
|
|
|
■
|
our third-party contractors, such as a research institute, manufacturer or supplier, may fail to comply with regulatory requirements or meet their contractual obligations to us;
|
|
|
|
|
■
|
we may be forced to suspend or terminate our clinical trials if the participants are being exposed, or are thought to be exposed, to unacceptable health risks or if any participant experiences an unexpected serious adverse event, or if our product candidates prove to be ineffective;
|
|
|
|
|
■
|
regulators or IRBs may require that we hold, suspend or terminate clinical research for various reasons, including noncompliance with regulatory requirements;
|
|
|
|
|
■
|
undetected or concealed fraudulent activity by a clinical researcher, if discovered, could preclude the submission of clinical data prepared by that researcher, lead to the suspension or substantive scientific review of one or more of our marketing applications by regulatory agencies, and result in the recall of any approved product distributed pursuant to data determined to be fraudulent;
|
|
|
|
|
■
|
the cost of our clinical trials may be greater than we anticipate;
|
|
|
|
|
■
|
an audit of preclinical or clinical studies by regulatory authorities may reveal noncompliance with applicable protocols or regulations, which could lead to disqualification of the results and the need to perform additional studies; and
|
|
|
|
|
■
|
delays may occur in obtaining our clinical materials.
|
For example, in June 2014, the FDA placed
a hold on the U.S. clinical development of ND0612H and ND0612L, requesting additional information on the accuracy, safety, and
compatibility of the devices used to deliver the drug. We subsequently completed the required compatibility study and submitted
the requested additional information to the FDA. In May 2015, the FDA lifted the clinical hold and our U.S. clinical development
program was cleared to proceed, with several studies accordingly commencing in late 2015 and throughout 2016. Although we have
not experienced other risks involved with conducting clinical trials, including increased expense and delay, to date, there can
be no assurance that we will not experience delays or such risks in the future as we progress with our planned clinical trials.
Any delay in receiving regulatory clearance to commence our clinical trials or any suspension of clinical trials may delay possible
regulatory approval, if any, and adversely impact our ability to develop products and generate revenue.
Positive results
in previous preclinical or clinical trials of our product candidates may not be replicated in future clinical trials of our product
candidates, which could result in development delays or a failure to obtain marketing approval.
Positive results in previous preclinical
or clinical studies of our product candidates may not be predictive of similar results in future clinical trials. In addition,
interim results during a clinical trial do not necessarily predict final results. Interim data are also subject to the risk that
one or more of the clinical outcomes may materially change as patient enrollment continues and more patient data become available.
As a result, preliminary and interim data should be viewed with caution until the final data are available. A number of companies
in the pharmaceutical and biotechnology industries have suffered significant setbacks in late-stage clinical trials even after
achieving promising results in early-stage development. Accordingly, the results from the completed preclinical studies and clinical
trials for our product candidates may not be predictive of the results we may obtain in later stage trials. Our clinical trials
may produce negative or inconclusive results, and we may decide, or regulators may require us, to conduct additional clinical trials.
Moreover, clinical data are often susceptible
to varying interpretations and analyses, and many companies that believed their product candidates performed satisfactorily in
preclinical studies and clinical trials have nonetheless failed to obtain approval from the FDA, the EMA or other regulatory agencies
for their products.
Development and
commercialization of our product candidates in the United States and elsewhere requires successful completion of the regulatory
approval process, and may suffer delays or fail.
We are required to apply for and receive
marketing authorization in a jurisdiction, including the United States and Europe, before we can market our product candidates
in such jurisdiction. This process can be time consuming and complicated and may result in unanticipated delays. To secure marketing
authorization, an applicant generally is required to submit an application that includes the data supporting preclinical and clinical
safety and efficacy as well as detailed information on the manufacture and composition of the product candidate, control of product
development, proposed labeling and other additional information. Before marketing authorization is granted, regulatory authorities
generally require the inspection of manufacturing facilities and quality systems of our third-party manufacturers at which the
product candidate is produced, to assess compliance with strictly enforced current good manufacturing practices, or cGMP, as well
as potential audits of the non-clinical and clinical trial sites that generated the data cited in the marketing authorization application.
We cannot predict how long the applicable
regulatory authority or agency will take to grant marketing authorization or whether any such authorizations will ultimately be
granted. Regulatory agencies, including the FDA and the EMA, have substantial discretion in the approval process, and the approval
process and the requirements governing clinical trials vary from country to country. The policies of the FDA, the EMA or other
regulatory authorities may change or may not be explicit, and additional government regulations may be enacted that could prevent,
limit or delay regulatory approval of our product candidates. We cannot predict the likelihood, nature or extent of government
regulation that may arise from future legislation or administrative action, in the United States, Europe or elsewhere. If we are
slow or unable to adapt to changes in existing requirements or the adoption of new requirements or policies, or if we are not able
to maintain regulatory compliance, we may lose any marketing approval that we may have obtained and we may not achieve or sustain
profitability.
Any delays or failures in obtaining regulatory
and marketing approval for our product candidates in the United States, Europe or worldwide would adversely affect our business,
prospects, financial condition and results of operations.
We may be unsuccessful
in commercializing our products due to unfavorable pricing regulations, third-party coverage and reimbursement policies or healthcare
reform initiatives.
If we receive marketing approval for any
of our product candidates, we cannot guarantee that we will receive favorable pricing and reimbursement in any jurisdiction. The
regulations that govern marketing approvals, pricing and reimbursement for new products vary widely from country to country. In
some foreign jurisdictions, including the European Union, the pricing of prescription pharmaceuticals is subject to governmental
control. In these jurisdictions, pricing negotiations with governmental authorities can take considerable time after the receipt
of marketing approval for a product candidate. As a result, we might obtain regulatory approval for a product in a particular country,
but then be subject to price regulations that delay our commercial launch of the product and negatively impact the revenue we are
able to generate from the sale of the product in that country. Adverse pricing limitations may hinder our ability to recoup our
investment in our product candidates, even after obtaining regulatory approval.
The United States
and several other jurisdictions are considering, or have already enacted, a number of legislative and regulatory proposals to change
the healthcare system in ways that may affect our ability to sell our product candidates profitably, if approved.In the United
States, there have been proposed in Congress a number of legislative initiatives regarding healthcare, including the possible repeal
and replacement of the
Patient Protection and Affordable Care Act
.
In addition, in January 2017, an Executive Order was issued allowing administrative agencies to roll back certain provisions of
the healthcare reform law. The effect of these developments is uncertain and any changes to, or replacement of, the
Patient
Protection and Affordable Care Act
could impact the degree of health insurance coverage for treatment with our product candidates,
if and when they are commercialized. With growing pressures on government budgets due to the current economic downturn, government
efforts to contain or reduce health care spending are likely to gain increasing emphasis. It is uncertain what impact the incoming
U.S. presidential administration will have on healthcare spending. If enacted and implemented, any measures to restrict health
care spending could result in decreased revenue from our products, when they are commercialized, and decrease potential returns
from our research and development initiatives. For example, the new U.S. president recently signed an executive order directing
federal agencies with authorities and responsibilities under the Patient Protection and Affordable Care Act, or the PPACA, to waive,
defer, grant exemptions from, or delay the implementation of any provision of the PPACA that would impose a fiscal or regulatory
burden on certain entities, and members of the U.S. Congress have drafted legislation to repeal and potentially replace the PPACA.
Changes to the PPACA, including any legal uncertainty surrounding rules governing reimbursements, could make it more difficult
for us to sell our products profitably in the United States, thus materially and adversely affecting our business, financial condition
and results of operations.
The continuing efforts of governments,
insurance companies, managed care organizations and other payors of healthcare services to contain or reduce costs of healthcare
may adversely affect:
|
■
|
the market acceptance or demand for our product candidates, if approved;
|
|
■
|
the ability to set a price that we believe is fair for our product candidates, if approved;
|
|
■
|
our ability to generate revenues and achieve or maintain profitability;
|
|
■
|
the level of taxes that we are required to pay; and
|
|
■
|
the availability of capital.
|
Additionally, we cannot be sure that reimbursement
will be available for any of our product candidates that we commercialize in the future and, if reimbursement is available, what
the level of reimbursement will be. Reimbursement may affect the demand for, or the price of, any product for which we obtain marketing
approval. If reimbursement is not available or is available only at limited levels, we may not be able to successfully commercialize
any of our product candidates that we successfully develop. Eligibility for reimbursement does not imply that any product will
be paid for in all cases or at a rate that covers our costs. Interim payments for new products, if applicable, may also not be
sufficient to cover our costs and may not be made permanent. Payment rates may vary according to the use of the product and the
clinical setting in which the product is used, may be based on payments allowed for lower cost products that are already reimbursed
and may be incorporated into existing payments for other services. Net prices for products may be reduced by mandatory discounts
or rebates required by government healthcare programs or private payors and by any future relaxation of laws that presently restrict
imports of products from countries where they may be sold at lower prices than in certain other countries, such as the United States.
In the United States, third-party payors often rely upon other payors, such as Medicare coverage policy and payment limitations
in setting their own reimbursement policies. Our inability to promptly obtain coverage and profitable payment rates from both government-funded
and private payors for any of our product candidates could have a material adverse effect on our operating results, our ability
to raise capital needed to commercialize products and our overall financial condition.
The commercial success
of our product candidates will depend upon their degree of market acceptance.
Even if we obtain marketing authorization
for a product candidate, it may not gain market acceptance by physicians and their teams, healthcare payors and others in the medical
community. Each of our product candidates is being developed to treat diseases for which there are established standards of care.
For example, the “gold standard” of care for Parkinson’s disease for the past 30 years has been oral administration
of the drugs levodopa and carbidopa, or LD/CD, and physicians and patients have grown accustomed to such treatment. Although many
physicians throughout the United States, Europe and other international markets may use our product candidates as part of our clinical
trials, we cannot guarantee that use of our product candidates will be accepted in the market. If our product candidates do not
achieve an adequate level of acceptance, we may not generate revenue and we may not achieve or sustain profitability. The degree
of market acceptance of our product candidates in a jurisdiction in which we receive marketing approval will depend on a number
of factors, some of which are beyond our control, including:
|
■
|
the willingness of physicians to administer our products and their acceptance as part of the medical department routine;
|
|
■
|
compliance by patients with treatment protocols;
|
|
■
|
relative ease and convenience of administration;
|
|
■
|
tolerance of the drugs by patients, including prevalence and severity of side effects;
|
|
|
|
|
■
|
obtaining third-party coverage or reimbursement for our products;
|
|
■
|
the ability to offer our product candidates for sale at an attractive value;
|
|
■
|
the efficacy and potential advantages of our product candidates relative to the current standard of care; and
|
|
■
|
the efficacy, potential advantages and timing of introduction to the market of alternative treatments.
|
Failure to achieve market acceptance for
our product candidates, if and when they are approved for commercial sale, will have a material adverse effect on our business,
financial condition and results of operations.
We face competition
from the existing standard of care and potential changes in medical practice and technology. In addition, our competitors may develop
products, treatments or procedures that are similar, more advanced, safer or more effective than ours.
The medical, biotechnology and pharmaceutical
industries are intensely competitive and subject to significant technological and practice changes. We expect to face competition
from many different sources with respect to our product candidates or any product candidates that we may seek to develop or commercialize
in the future. Possible competitors may be pharmaceutical companies, academic and medical institutions, governmental agencies and
public and private research institutions, among others. Should any competitor’s product candidates receive regulatory or
marketing approval prior to ours, they may establish a strong market position and be difficult to displace, or will diminish the
need for our products.
Our commercial opportunity could be reduced
or eliminated if our competitors develop and commercialize products, treatments or procedures that are safer, more effective, have
fewer or less severe side effects, are more convenient or are less expensive than any product that we may develop. Specifically,
we may compete with companies that attempt to decrease the sharp fluctuations and improve the bioavailability and half-life associated
with orally administered LD/CD, such as Impax Laboratories Inc., XenoPort, Inc., Intec Pharma Ltd. and Depomed, Inc., which have
developed or are developing oral LD/CD drugs that include a controlled release or gastric retention attribute in order to decrease
the gastronomical tract’s impact on the concentration of levodopa. Similarly, Synagile Corporation is developing a new intra-oral
semi-contionus delivery device for the administration of a liquid formulation of LD/CD ester, and Abbvie is developing a liquid
levodopa formaultion for continuous subcutaneous administration. If such products are approved and successfully improve the bioavailability
of LD/CD or an alternative drug, the demand for our Parkinson’s disease product candidates may be significantly reduced.
Companies
may also develop products that address other aspects of Parkinson’s disease, such as Acorda Therapeutics, Inc., which is
developing a levodopa product to address “off” episodes commonly associated with levodopa therapy, or Sunovion
Pharmaceuticals, Inc., which is also developing an apomorphine product to address “off”
episodes. While such products would not directly compete with our Parkinson’s disease product candidates, as they address
specific effects of Parkinson’s disease, such treatment may reduce the demand for our Parkinson’s disease product candidates.
Moreover, if one of our Parkinson’s
disease product candidates obtains approval in the future, we believe that we would compete with existing drug treatments of Parkinson’s
disease, including the “gold standard” of treatment for the past 30 years, oral administration of LD/CD. We may also
directly compete with traditional surgery such as deep brain stimulation, or DBS, and AbbVie Inc.’s product, Duodopa, a LD/CD
drug in a gel form administered directly into the duodenum via a surgically inserted tube, is approved in several jurisdictions
including the United States, Europe, Canada and Australia.
In addition, if approved, our apomorphine-based
product candidate, ND0701, would directly compete with other non-LD/CD treatments. For example, in Europe, Britannia Pharmaceuticals
Limited (part of the STADA Arzneimittel AG group of companies) currently markets a Parkinson’s disease therapy called Apo-Go
that administers apomorphine via a belt pump.
Similarly, if ND0801 obtains approval
in the future, we would compete with currently existing products. For example, we are aware that a number of existing treatments
for ADD/ADHD are currently on the market and are marketed by pharmaceutical companies that may be far larger and more experienced
than us. Current competitor drugs to ND0801 include stimulants such as Ritalin and Adderall, as well as the non-stimulant drugs
Strattera, Intuniv and Kapvay. We recognize that patients and doctors are often unwilling to change medications, and this factor
may make it difficult for ND0801 to penetrate the market, even if it receives FDA approval.
Many of our current or future competitors
may have significantly greater financial resources and expertise in research and development, manufacturing, preclinical testing,
conducting clinical trials, obtaining regulatory approvals and marketing approved products than we may have. Mergers and acquisitions
in the pharmaceutical and biotechnology industries markets may result in even more resources being concentrated among a smaller
number of our competitors. Smaller and other early stage companies may also prove to be significant competitors, particularly through
collaborative arrangements with large and established companies. These companies compete with us in recruiting and retaining qualified
scientific and management personnel, establishing clinical trial sites and patient registration for clinical trials, as well as
in acquiring technologies complementary to, or necessary for, our programs.
We rely on third-party
manufacturers to supply the drug substances and the medical devices necessary for administration of our product candidates. We
do not have long-term contracts with most of such manufacturers or suppliers.
We depend on third-party
manufacturers for the supply of the drug products and associated medical devices for our product candidates for use in our clinical
trials. Any problems we experience with any such third parties could delay the manufacturing of our product candidates, which could
harm our results of operations.
In February 2015, we
entered into a long-term manufacturing contract with a reputable U.S. cGMP drug production manufacturer for the reformulated LD/CD
drug product used in our LD/CD product candidates. We expect these drug products to be sufficient to support our clinical studies
through commercialization of ND0612H and ND0612L. In parallel, we entered into an agreement with a European manufacturer as alternative
supplier for the LD/CD drug product.
We also source from
third-party developers and manufacturers the CRONO ND and CRONO Twin ND belt pumps, which are the current delivery devices
for our Parkinson’s disease product candidates, and we engage third-party developers and designers to develop
the patch-pump, which is intended to be the second-generation delivery device for certain of our product candidates in
the future. We currently purchase the belt pump devices from an Italian manufacturer, Cane S.p.A., on a purchase order
basis. While we have not entered into supply agreements with any medical device suppliers, we are in discussions with medical
device suppliers to establish long-term supply agreements.
As we do not have agreements
in place that guarantee the supply or the price of the medical devices necessary to produce our product candidates, any significant
delay in the acquisition or decrease in the availability of such materials could considerably delay the manufacturing of our product
candidates, which could adversely impact the timing of any planned trials or the regulatory approval of that product candidate.
If we are unable to arrange for alternative third-party sources, or to do so on commercially reasonable terms or in a timely manner,
we may be delayed in the development of our product candidates.
Reliance on third-party
manufacturers entails risks to which we would not be subject if we manufactured product candidates or products ourselves, including
reliance on the third party for regulatory compliance and quality assurance, the possibility of breach of an agreement by the third
party because of factors beyond our control (including a failure to manufacture our product candidates or any products we may eventually
commercialize in accordance with our specifications) and the possibility of termination or nonrenewal of the agreement by the third
party, based on its own business priorities, at a time that is costly or damaging to us. We may therefore be subject to unexpected
increases in the cost of devices, which may far exceed the cost of producing drug substances and require increased capital expenditures.
We are subject to
a number of manufacturing risks, any of which could substantially increase our costs and limit supply of our products.
If our offices, which house all of our
research and development facilities, or any facility of our third-party drug and device manufacturers or suppliers were to suffer
an accident or a force majeure event such as war, missile or terrorist attack, earthquake, major fire or explosion, major equipment
failure or power failure lasting beyond the capabilities of its backup generators or similar event, we could be materially adversely
affected and any of our clinical trials could be materially delayed. Such an extended shut down may force us to procure a new research
and development facility or another manufacturer or supplier, which could be time-consuming. During this period, we may be unable
to receive our product candidates.
The process of manufacturing the active
drug in our product candidates and related medical devices is complex, highly regulated and subject to the risk of product loss
due to contamination, equipment failure or improper installation or operation of equipment, or vendor or operator error. Even minor
deviations from normal manufacturing processes or quality requirements for our product candidates could result in reduced production
yields, product defects and other supply disruptions. If microbial, viral, or other contaminations are discovered in our product
candidates or in the manufacturing facilities in which our product candidates are or will be made, such manufacturing facilities
may need to be closed to investigate and remedy the contamination. Any adverse developments affecting manufacturing operations
for our product candidates may result in shipment delays, inventory shortages, lot failures, withdrawals or recalls, or other interruptions
in the supply of our product candidates. We may also have charges and expenses for our product candidates that fail to meet specifications,
undertake costly remediation efforts, or seek more costly manufacturing alternatives.
The ability of our
third-party manufacturers to continue manufacturing and supplying our product candidates depends on their continued adherence to
current good manufacturing practices regulations.
The manufacturing processes for our product
candidates are governed by detailed cGMP regulations. Failure by third-party manufacturers and quality operations units to adhere
to established regulations or to meet a specification or procedure set forth in cGMP requirements could require that a product
or material be rejected and destroyed. Adherence to cGMP regulations and the effectiveness of our quality control systems are periodically
assessed through inspections of manufacturing facilities by regulatory authorities. Such inspections could result in deficiency
citations, which would require action to correct those deficiencies to the satisfaction of the applicable regulatory authorities.
If critical deficiencies are noted or if recurrences are not prevented, we may have to recall products or suspend operations until
appropriate measures are implemented. Since cGMP reflects ever-evolving standards, manufacturing processes and procedures must
be regularly updated to comply with cGMP. These changes may cause us to incur additional costs and may adversely impact our results
of operations. For example, more sensitive testing assays (if and when they become available) may be required or existing procedures
or processes may require revalidation, all of which may be costly and time-consuming and could delay or prevent the manufacturing
of our product candidates or launch of a new product.
If we change the
manufacturers of our product candidates, we may be required to conduct comparability studies evaluating the manufacturing processes
of the product candidates.
The FDA and other regulatory agencies
maintain strict requirements governing the manufacturing process for medical devices, such as the pumps used in our product candidates.
For example, when a manufacturer seeks to modify or change that process, the FDA typically requires the applicant to conduct non-clinical
and, depending on the magnitude of the changes, potentially clinical comparability studies that evaluate the potential differences
in the product candidates resulting from the change in the manufacturing process. If we were to change manufacturers of our drug
substances or our devices during or after the clinical trials and regulatory approval process for ND0612L or any of our other product
candidates, we will be required to conduct comparability studies assessing product candidates manufactured at the new manufacturing
facility. Delays in designing and completing a comparability study to the satisfaction of the FDA or other regulatory agencies
could delay or preclude our development plans and, thereby, delay our ability to receive marketing approval or limit our revenue
and growth, once approved. In addition, in the event that the FDA or other regulatory agencies do not accept non-clinical comparability
data, we may need to conduct a study involving dosing of patients comparing the two products. That study may result in a delay
of the approval or launch of any of our product candidates.
We rely on third
parties to conduct our preclinical and clinical trials. The failure of these third parties to successfully carry out their contractual
duties or meet expected deadlines, could substantially harm our business because we may not obtain regulatory approval for or commercialize
our product candidates in a timely manner or at all.
We rely upon third-party CROs to conduct,
monitor and manage data for our current and future preclinical and clinical programs. We expect to continue to rely on these parties
for execution of our preclinical and clinical trials, and we control only certain aspects of their activities. Nevertheless, we
are responsible for ensuring that each of our studies is conducted in accordance with the applicable protocol and legal, regulatory
and scientific standards, and our reliance on the CROs does not relieve us of our regulatory responsibilities. We and our CROs
are required to comply with current Good Clinical Practices, or GCP, which are regulations and guidelines enforced by the FDA,
the EMA and comparable foreign regulatory authorities for all of our products in clinical development. Regulatory authorities enforce
these GCP through periodic inspections of trial sponsors, principal investigators and trial sites. If we or any of our CROs fail
to comply with applicable GCP, the clinical data generated in our clinical trials may be deemed unreliable and the FDA or comparable
foreign regulatory authorities may require us to perform additional clinical trials before approving our marketing applications.
We cannot assure you that upon inspection by a given regulatory authority, such regulatory authority will determine that any of
our clinical trials comply with GCP requirements. In addition, we must conduct our clinical trials with products produced under
cGMP requirements. Failure to comply with these regulations may require us to repeat preclinical and clinical trials, which would
delay the regulatory approval process.
Our CROs are not our employees, and except
for remedies available to us under our agreements with such CROs, we cannot control whether or not they devote sufficient time
and resources to our ongoing clinical, nonclinical and preclinical programs. If CROs do not successfully carry out their contractual
duties or obligations or meet expected deadlines or if the quality or accuracy of the clinical data they obtain is compromised
due to the failure to adhere to our clinical protocols, regulatory requirements or for other reasons, our clinical trials may be
extended, delayed or terminated and we may not be able to obtain regulatory approval for or successfully commercialize our product
candidates. As a result, our results of operations and the commercial prospects for our product candidates would be harmed, our
costs could increase and our ability to generate revenues could be delayed. To the extent we are unable to successfully identify
and manage the performance of third-party service providers in the future, our business may be adversely affected.
We currently have
limited sales and marketing staff and no product distribution network. If we are unable to develop sales and marketing infrastructure,
we will not be successful in commercializing our products.
We do not currently have a sales or marketing
infrastructure and do not have experience in the sale, marketing or distribution of pharmaceutical products. To achieve commercial
success for our product candidates in the United States, the European Union and other jurisdictions, we may enter sales, marketing
and distribution agreements with third parties in respect of the commercialization of our product candidates in such jurisdictions.
Entering into arrangements with third parties to perform these services may result in lower product revenues and profitability,
if any, than if we were to market, sell and distribute our product candidates ourselves. In addition, we may not be successful
in entering into arrangements with third parties in the future to sell, market and distribute our product candidates or may be
unable to do so on terms that are favorable to us. We likely will have little control over such third parties, and any of them
may fail to devote the necessary resources and attention to sell and market our products effectively.
Risks Related to Government Regulation
and Other Legal Compliance Matters
Even if our product
candidates receive regulatory approval, they may still face future development and regulatory difficulties.
Any regulatory approval that we receive
may also contain requirements for potentially costly post-marketing testing, including Phase 4 clinical trials, and surveillance
to monitor the safety and efficacy of the approved product. Once a product is approved, the manufacturing processes, labeling,
packaging, distribution, adverse event reporting, storage, advertising, promotion, import, export and recordkeeping for the product
will be subject to extensive and ongoing regulatory requirements. For any clinical trials that we conduct post-approval, these
requirements include submission of safety and other post-marketing information and reports, registration and continued compliance
with cGMP. Although the manufacturing facilities of the third parties from whom we order are cGMP-certified, they may face difficulties
in maintaining regulatory approval for the manufacturing and quality control process of our product candidates.
We may not benefit
from the regulatory data protection and/or market exclusivity period afforded to our underlying drug substances in the European
Union.
There is no formal “grant”
of regulatory data exclusivity under EU law. The rules are complex and are constantly evolving. For example, the issue of regulatory
data protection and market exclusivity for combination products is the subject of litigation involving Teva Pharmaceutical Industries
Ltd., or Teva, before the Court of Justice of the European Union, or CJEU. The outcome of this case or other cases or changes in
policy may impact the regulatory data exclusivity period of combination drugs that rely on the standard “8+2(+1)” marketing
and regulatory data exclusivity protection of their underlying components under EU law. The standard “8+2(+1)” exclusivity
protection provides that data exclusivity applies during the first eight years from the grant of the innovator company’s
marketing authorization. After the eight years have expired, a generic company can make use of the preclinical and clinical trial
data of the originator in its regulatory applications but still cannot market its product until the end of 10 years. Additional
market exclusivity of one further year can be obtained if during the first eight of those 10 years, the marketing approval holder
obtains approval for one or more new therapeutic indications which, during the scientific evaluation prior to their approval, are
determined to bring a significant clinical benefit in comparison with existing therapies. Our product candidates may be negatively
impacted by a decision of the CJEU or a change in policy that precludes combination drugs from benefitting from such a period of
market and/or regulatory data exclusivity beyond that of their component parts.
Products developed and approved based
on a complete, free-standing marketing authorization dossier may benefit from the standard “8+2(+1)” period of regulatory
data exclusivity protection notwithstanding that products containing the same active substances have existed in the European Union
for some time. Even where products benefit from regulatory data exclusivity, however, the exclusivity will only attach to the novel
data that the company generates. For example, one possible regulatory route in the European Union is to compile a complete “mixed
data” application dossier comprising a mixture of the company’s own data and data compiled from peer-reviewed literature.
The company may benefit from exclusivity in respect of the dossier it submits, but it may be relatively easy for a competitor to
repeat the study or studies that the company has done and compile the same additional data from peer-reviewed literature, as well.
Approvals based on a hybrid generic application
(e.g., using an oral or gastrointestinal LD/CD product as the reference, supplemented by bridging data for subcutaneous or transdermal
administration) are currently not valid reference products for the purpose of generic applications. However, potential generic
competitors could seek to rely on data for the LD/CD reference product, supplemented with their own bridging data for subcutaneous
or transdermal administration.
The medical devices
associated with our product candidates are subject to extensive governmental regulation, and failure to comply with applicable
requirements could cause delay or prevent approval of our product candidates.
The medical device industry is regulated
extensively by governmental authorities. The regulations are complex and are subject to rapid change and varying interpretations.
Regulatory restrictions or changes could limit our ability to carry on or expand our operations or result in higher than anticipated
costs or lower than anticipated sales. We intend to submit an NDA for the administration of our product candidate ND0612 for use
with the CRONO Twin ND and CRONO ND devices. While such clearance is not required in order for us to receive marketing authorization
for our product candidates, any delay in such process may delay the approval process for our product candidates.
Additionally, the FDA and other regulatory
authorities have broad enforcement powers. Regulatory enforcement or inquiries, or other increased scrutiny on us, could dissuade
some customers from using our products and adversely affect our reputation and the perceived safety and efficacy of our products
and the devices we use to administer them.
Furthermore, in light of the stated policies
of the incoming U.S. presidential administration, there is uncertainty with respect to the impact, if any, on the regulatory initiatives
affecting us. While any legislative and regulatory changes will likely take time to develop, and may or may not have an impact
on the regulatory regime to which we are subject, we cannot predict the ultimate content, timing or effect of any healthcare reform
legislation or the impact of potential legislation on us.
Regulatory approval
for our product candidates would be limited to specific indications and conditions for which clinical safety and efficacy have
been demonstrated, and the prescription or promotion of off-label uses could adversely affect our business.
Any regulatory approval of our product
candidates would be limited to those specific indications for which such product candidates had been deemed safe and effective
by the FDA, the EMA or other regulatory authority. Additionally, labeling restrictions may also limit the manner in which a product
is approved to be used. It is not, however, unusual for physicians to prescribe medication or use medical devices for unapproved,
or “off-label,” uses or in a manner that is inconsistent with the manufacturer’s labeling. To the extent such
off-label uses are pervasive and produce results such as reduced efficacy or other adverse effects, the reputation of our products
in the marketplace may suffer. In addition, should any of our future products have a significant price difference and if they are
used interchangeably, off-label uses may cause a decline in our revenues or potential revenues.
Furthermore, while physicians may choose
to prescribe treatments for uses that are not described in the products’ labeling and for uses that differ from those approved
by regulatory authorities, our ability to promote the products is limited to those indications that are specifically approved by
the FDA, the EMA or other regulatory authorities. Although regulatory authorities generally do not regulate the behavior of physicians,
they do restrict communications by companies on the subject of off-label use. If our promotional activities fail to comply with
these regulations or guidelines, we may be subject to warnings from, or enforcement action by, these authorities. In the United
States, “off-label promotion” by pharmaceutical companies has resulted in significant litigation under the federal
False Claims Act, violations of which may result in substantial civil penalties and fines. More generally, failure to follow the
rules and guidelines of regulatory agencies relating to promotion and advertising, such that promotional materials are not false
or misleading, can result in refusal to approve a product, the suspension or withdrawal of an approved product from the market,
product recalls, fines, disgorgement of money, operating restrictions, injunctions or criminal prosecution.
Certain of our business
practices could become subject to scrutiny by regulatory authorities, as well as to lawsuits brought by private citizens.
The laws governing our conduct in the
United States are enforceable by criminal, civil and administrative penalties. Violations of laws such as the Federal Food, Drug
and Cosmetic Act, or the FDCA, the Public Health Service Act, the federal False Claims Act, provisions of the U.S. Social Security
Act, including the provision known as the “Anti-Kickback Law,” or any regulations promulgated under their authority,
may result in various administrative, civil and criminal sanctions, jail sentences, fines or exclusion from federal and state programs,
as may be determined by Medicare, Medicaid, other regulatory authorities and the courts. There can be no assurance that our activities
will not come under the scrutiny of regulators and other government authorities or that our practices will not be found to violate
applicable laws, rules and regulations or prompt lawsuits by private citizen “relators” under federal or state false
claims laws.
For example, under the Anti-Kickback Law,
and similar state laws and regulations, even common business arrangements, such as discounted terms and volume incentives for customers
in a position to recommend or choose drugs and devices for patients, such as physicians and hospitals, can result in substantial
legal penalties, including, among others, exclusion from Medicare and Medicaid programs. As a result, arrangements with potential
referral sources must be structured with care to comply with applicable requirements. Also, certain business practices, such as
payment of consulting fees to healthcare providers, sponsorship of educational or research grants, charitable donations, interactions
with healthcare providers and financial support for continuing medical education programs, must be conducted within narrowly prescribed
and controlled limits to avoid any possibility of wrongfully influencing healthcare providers to prescribe or purchase particular
products or of rewarding past prescribing.
In addition, significant enforcement activity
has taken place under federal and state false claims act statutes and violations of the federal False Claims Act can result in
treble damages, and penalties of up to $11,000 for each false claim submitted for payment. The federal False Claims Act, as well
as certain state false claims acts, permit relators to file complaints in the name of the United States (and if applicable, particular
states). These relators may be entitled to receive up to 30% of total recoveries and have been active in pursuing cases against
pharmaceutical companies. Where practices have been found to involve improper incentives to use products, the submission of false
claims, or other improper conduct, government investigations and assessments of penalties against manufacturers have resulted in
substantial damages and fines. In addition, to avoid exclusion from participation in federal healthcare programs, many manufacturers
have been required to enter into Corporate Integrity Agreements that prescribe allowable corporate conduct. Failure to satisfy
requirements under the FDCA can also result in a variety of administrative, civil and criminal penalties, including injunctions
or consent decrees that prescribe allowable corporate conduct.
To enhance compliance with applicable
healthcare laws, and mitigate potential liability in the event of noncompliance, regulatory authorities, such as the Office of
Inspector General of the U.S. Department of Health and Human Services, or OIG, have recommended the adoption and implementation
of a comprehensive health care compliance program that generally contains the elements of an effective compliance and ethics program
described in Section 8B2.1 of the U.S. Sentencing Commission Guidelines Manual. Increasing numbers of U.S.-based pharmaceutical
companies have such programs. As our product candidates are not yet approved for marketing in the United States, we have not adopted
U.S. healthcare compliance and ethics programs that generally incorporate the OIG’s recommendations, but even if we do, having
such a program can be no assurance that we will avoid any compliance issues.
In addition, we are subject to analogous
state and foreign laws and regulations, such as state anti-kickback and false claims laws, which may apply to sales or marketing
arrangements and claims involving healthcare items or services reimbursed by non-governmental third-party payors, including private
insurers; state and foreign laws that require pharmaceutical companies to comply with the pharmaceutical industry’s voluntary
compliance guidelines and the relevant compliance guidance promulgated by the federal government or otherwise restrict payments
that may be made to healthcare providers; state and foreign laws that require drug manufacturers to report information related
to payments and other transfers of value to physicians and other healthcare providers or marketing expenditures; and state and
foreign laws governing the privacy and security of health information in certain circumstances. Many of these laws differ from
each other in significant ways and often are not preempted by the U.S. Health Insurance Portability and Accountability Act of 1996
thus complicating compliance efforts.
Efforts to ensure that our business arrangements
with third parties will comply with applicable healthcare laws and regulations may involve substantial costs. It is possible that
governmental authorities will conclude that our business practices may not comply with current or future statutes, regulations
or case law involving applicable fraud and abuse or other healthcare laws and regulations. If our operations are found to be in
violation of any of these laws or any other governmental regulations that may apply to us, we may be subject to significant civil,
criminal and administrative penalties, including, damages, fines, imprisonment, exclusion from participation in government healthcare
programs, such as Medicare and Medicaid, and the curtailment or restructuring of our operations, which could have a material adverse
effect on our business. If any of the physicians or other healthcare providers or entities with whom we expect to do business is
found not to be in compliance with applicable laws, it may be subject to criminal, civil or administrative sanctions, including
exclusions from participation in government healthcare programs, which could also materially affect our business.
As a public company with securities registered
under the Exchange Act, we are subject to the U.S. Foreign Corrupt Practices Act, or FCPA. The FCPA and similar worldwide anti-bribery
laws generally prohibit companies and their intermediaries from making improper payments to officials for the purpose of obtaining
or retaining business. We have adopted an Anti-Corruption Compliance Policy in furtherance of our compliance with the FCPA and
such other similar worldwide laws. However, we may operate in parts of the world that have experienced governmental corruption
to some degree and in certain circumstances, strict compliance with anti-bribery laws may conflict with local customs and practices
or may require us to interact with doctors and hospitals, some of which may be state-controlled, in a manner that is different
than in the United States. Our internal control policies and procedures may not be sufficient to effectively protect us against
reckless or criminal acts committed by our employees or agents. Violations of these laws, or allegations of such violations, could
disrupt our business and result in a material adverse effect on our financial condition, results of operations and cash flows.
We could be subject
to product liability lawsuits, which could result in costly and time-consuming litigation and significant liabilities.
The development of pharmaceutical products
involves an inherent risk of product liability claims and associated adverse publicity. Our product candidates may be found to
be harmful or to contain harmful substances. This exposes us to substantial risk of litigation and liability or may force us to
discontinue production of certain product candidates. Although we usually obtain approximately $10.0 million in clinical trial
liability insurance, this coverage may not adequately cover all liabilities that we may incur. Such insurance is costly and often
limited in scope. There can be no assurance that we will be able to obtain or maintain insurance on reasonable terms or to otherwise
protect ourselves against potential product liability claims that could impede or prevent commercialization of our product candidates.
Furthermore, a product liability claim could damage our reputation, whether or not such claims are covered by insurance or are
with or without merit. A product liability claim against us or the withdrawal of a product from the market could have a material
adverse effect on our business or financial condition. Additionally, product liability lawsuits, regardless of their success, would
likely be time-consuming and expensive to resolve and would divert management’s time and attention, which could seriously
harm our business.
We are subject to
extensive environmental, health and safety, and other laws and regulations.
Our business involves the controlled use
of chemicals. The risk of accidental contamination or injury from these materials cannot be eliminated. If an accident, spill or
release of any such chemicals or substances occurs, we could be held liable for resulting damages, including for investigation,
remediation and monitoring of the contamination, including natural resource damages, the costs of which could be substantial. We
are also subject to numerous environmental, health and workplace safety laws and regulations, including those governing laboratory
procedures. Although we maintain workers’ compensation insurance to cover the costs and expenses that may be incurred because
of injuries to our employees resulting from the use of these materials, this insurance may not provide adequate coverage against
potential liabilities. Additional or more stringent laws and regulations affecting our operations may be adopted in the future.
We may incur substantial capital costs and operating expenses and may be required to obtain consents to comply with any of these
or certain other laws or regulations and the terms and conditions of any permits required pursuant to such laws and regulations,
including costs to install new or updated pollution control equipment, modify our operations or perform other corrective actions
at our respective facilities. In addition, fines and penalties may be imposed for noncompliance with environmental, health and
safety and other laws and regulations or for the failure to have, or comply with the terms and conditions of, required environmental
or other permits or consents.
Risks Related to Our Intellectual
Property
Our success depends
in part on our ability to obtain and maintain protection for the intellectual property relating to or incorporated into our technology
and products.
Our commercial success depends in part
on our ability to obtain and maintain patent protection and trade secret protection for our intellectual property and proprietary
technologies, our products and their uses, as well as our ability to operate without infringing upon the proprietary rights of
others. We rely on a combination of patent, trademark and trade secret laws, non-disclosure and confidentiality agreements, licenses,
assignments of invention agreements and other restrictions on disclosure and use to protect our intellectual property rights.
However, any party with whom we have executed
such an agreement may breach that agreement and disclose our proprietary information and we may not be able to obtain adequate
remedies for such breaches. If we do not adequately protect our intellectual property, competitors may be able to use our technologies
and erode or negate any competitive advantage we may have, which could harm our business and financial condition.
We have 38 issued patents, including in
Australia, Canada, Chile, China, Japan, Israel, Mexico, New Zealand, Russia, Singapore, South Africa and the United States, and
have over 70 pending patent applications worldwide, including nine national phase international applications filed under the Patent
Cooperation Treaty, or PCT. However, there can be no assurance that patent applications relating to our product candidates, processes
or technologies will result in patents being issued, or that any patents that have been issued will be adequate to protect our
intellectual property or that we will enjoy patent protection for any significant period of time. Additionally, any issued patents
may be challenged by third parties, and patents that we hold may be found by a judicial authority to be invalid or unenforceable.
Other parties may independently develop similar or competing technology or design around any patents that may be issued to or held
by us. Our current patents will expire or they may otherwise cease to provide meaningful competitive advantage, and we may be unable
to adequately develop new technologies and obtain future patent protection to preserve our competitive advantage or avoid adverse
effects on our business.
Patents that claim specific molecules
or active ingredients are generally considered to be the strongest form of intellectual property protection. However, as our product
candidates are formulations based on existing drugs, those types of claims are limited for our products. Instead, our main patents
and patent applications underlying our product candidates cover specific compositions and methods of use of the active drug substance
in ND0612H, ND0612L, ND0701, ND680 and ND0801. If our patents or pending applications in various jurisdictions were subject to
a successful challenge or failed to issue, or if our competitors were able to design around the claims of our issued patents, our
business and competitive advantage could be significantly affected.
In addition, we may fail to apply for
or be unable to obtain patents necessary to protect our technology or products or enforce our patents due to lack of information
about the exact use of our process by third parties. Even if patents are issued to us, they may be challenged, narrowed, invalidated,
held to be unenforceable or circumvented, which could limit our ability to prevent competitors from using similar technology or
marketing similar products, or limit the length of time our technologies and products have patent protection.
Unauthorized use of our intellectual property
may have occurred or may occur in the future. Any reported adverse events involving counterfeit products that purport to be our
products could harm our reputation and the sale of our products. Moreover, if we are required to commence litigation related to
unauthorized use, whether as a plaintiff or defendant, such litigation would be time-consuming, force us to incur significant costs
and divert our attention and the efforts of our management and other employees, which could, in turn, result in lower revenue and
higher expenses. Lawsuits may ultimately be unsuccessful and may also subject us to counterclaims and cause our intellectual property
rights to be challenged, narrowed, invalidated or held to be unenforceable. Any failure to identify unauthorized use of, and otherwise
adequately protect, our intellectual property could adversely affect our business, including by reducing the demand for our products.
Significant disruptions
of our information technology systems or breaches of our data security could adversely affect our business.
A
significant invasion, interruption, destruction or breakdown of our information technology systems and/or infrastructure by persons
with authorized or unauthorized access could negatively impact our business and operations. We could also experience business interruption,
information theft and/or reputational damage from cyber attacks, which may compromise our systems and lead to data leakage either
internally or at our third-party providers. Our systems may be the target of malware and other cyber attacks. Although we have
invested in measures to reduce these risks, we cannot assure you that these measures will be successful in preventing compromise
and/or disruption of our information technology systems and related data.
Our material patents
also may not afford us adequate protection against competitors with similar technology.
Patent applications in the United States
and many other jurisdictions are typically not published until 18 months after their filing, if at all, and because publications
of discoveries in scientific literature often lag behind actual discoveries, neither we nor our licensors can be certain that we
or they were the first to make the inventions claimed in our or their issued patents or pending patent applications, or that we
or they were the first to file for protection of the inventions set forth in such patent applications. As a result, our patents
may be invalidated in the future, and our patent applications may not be granted. For example, if a third party has also filed
a patent application covering an invention similar to one covered in one of our patent applications, we may be required to participate
in an adversarial proceeding known as an “interference proceeding,” declared by the U.S. Patent and Trademark Office,
or the USPTO, or its foreign counterparts, to determine priority of invention. The costs of these proceedings could be substantial
and our efforts in them could be unsuccessful, resulting in a loss of our anticipated patent position. In addition, if a third
party prevails in such a proceeding and obtains an issued patent, we may be prevented from practicing technology or marketing products
covered by that patent without obtaining a license from such third party, which we may not be able to obtain on commercially reasonable
terms. Additionally, patents and patent applications owned by third parties may prevent us from pursuing certain opportunities
such as entering into specific markets or developing certain products. Finally, we may choose to enter into markets where certain
competitors have patents or patent protection over technology that may impede our ability to compete effectively.
Absent patent-term extensions, our existing
patents for our product candidates will expire between 2028 and 2033. However, because of the extensive time required for development,
testing and regulatory review of a potential product, and although such delays may entitle patent term extensions, it is possible
that, before our product candidates can be commercialized, any related patent may expire or remain in force for only a short period
following commercial launch, thereby reducing any advantages of the patent. Our pending and future patent applications may not
lead to the issuance of patents or, if issued, the patents may not be issued in a form that will provide us with any competitive
advantage. We also cannot guarantee that:
|
■
|
any of our present or future patents or patent claims or other intellectual property rights will not lapse or be invalidated, circumvented, challenged or abandoned;
|
|
■
|
our intellectual property rights will provide competitive advantages or prevent competitors from making or selling competing products;
|
|
■
|
our ability to assert our intellectual property rights against potential competitors or to settle current or future disputes will not be limited by our agreements with third parties;
|
|
■
|
any of our pending or future patent applications will be issued or have the coverage originally sought;
|
|
■
|
our intellectual property rights will be enforced in jurisdictions where competition may be intense or where legal protection may be weak; or
|
|
■
|
we will not lose the ability to assert our intellectual property rights against, or to license our technology to, others and collect royalties or other payments.
|
Effective protection
of our intellectual property rights may be unavailable or limited in some countries.
The patent landscape in the pharmaceutical
and biotechnology fields is highly uncertain and involves complex legal, factual and scientific questions, and changes in either
patent laws or in the interpretation of patent laws in the United States and other countries may diminish the value and strength
of our intellectual property or narrow the scope of our patent protection. Effective protection of our intellectual property rights
may also be unavailable or limited in some countries, and even if available, we may fail to pursue or obtain necessary intellectual
property protection in such countries because filing, prosecuting, maintaining and defending patents on product candidates in all
countries throughout the world would be prohibitively expensive. In addition, the legal systems of certain countries, particularly
of certain developing countries, do not favor the aggressive enforcement of patents and other intellectual property rights, and
the laws of foreign countries do not protect our rights to the same extent as the laws of the United States. As a result, our intellectual
property may not provide us with sufficient rights to exclude others from commercializing products similar or identical to ours.
Competitors may use our technologies in jurisdictions where we have not obtained patent protection to develop their own products,
and we may be unable to prevent those competitors from importing those infringing products into territories where we have patent
protection but enforcement is not as strong as in the United States or into jurisdictions in which we do not have patent protection.
These products may compete with our product candidates and our patents and other intellectual property rights may not be effective
or sufficient to prevent them from competing in those jurisdictions. Moreover, competitors or others in the chain of commerce may
raise legal challenges against our intellectual property rights or may infringe upon our intellectual property rights, including
through means that may be difficult to prevent or detect.
Proceedings to enforce our patent rights
in the United States or foreign jurisdictions could result in substantial costs and divert our efforts and attention from other
aspects of our business, could put our patents at risk of being invalidated or interpreted narrowly and our patent applications
at risk of not issuing and could provoke third parties to assert patent infringement or other claims against us. We may not prevail
in any lawsuits that we initiate and the damages or other remedies awarded, if any, may not be commercially meaningful. Accordingly,
our efforts to enforce our intellectual property rights around the world may be inadequate to obtain a significant commercial advantage
from the intellectual property that we develop or license from third parties.
In addition to patents,
we rely on our unpatented proprietary technology, trade secrets, processes and know-how.
We rely on proprietary information (such
as trade secrets, know-how and confidential information) to protect intellectual property that may not be patentable, or that we
believe is best protected by means that do not require public disclosure. We generally seek to protect this proprietary information
by entering into confidentiality agreements, or consulting, services or employment agreements that contain non-disclosure and non-use
provisions with our employees, consultants, contractors, scientific advisors and third parties. However, we may fail to enter into
the necessary agreements, and even if entered into, these agreements may be breached or otherwise fail to prevent disclosure, third-party
infringement or misappropriation of our proprietary information, may be limited as to their term and may not provide an adequate
remedy in the event of unauthorized disclosure or use of proprietary information. We have limited control over the protection of
trade secrets used by our suppliers, manufacturers and service providers and could lose future trade secret protection if any unauthorized
disclosure of such information occurs. In addition, our proprietary information may otherwise become known or be independently
developed by our competitors or other third parties. To the extent that our employees, consultants, contractors, scientific advisors
and other third parties use intellectual property owned by others in their work for us, disputes may arise as to the rights in
related or resulting know-how and inventions. Costly and time-consuming litigation could be necessary to enforce and determine
the scope of our and relevant third parties’ proprietary rights, failure to obtain or maintain protection for our proprietary
information could adversely affect our competitive business position and if third parties are able to establish that we are using
their proprietary information without their permission, we may be required to obtain a license to that information, or if such
a license is not available, re-design our products to avoid any such unauthorized use or temporarily delay or permanently stop
manufacturing or sales of the affected products. Furthermore, laws regarding trade secret rights in certain markets where we operate
may afford little or no protection to our trade secrets.
We also rely on physical and electronic
security measures to protect our proprietary information, but we cannot provide assurance that these security measures will not
be breached or provide adequate protection for our property. There is a risk that third parties may obtain and improperly utilize
our proprietary information to our competitive disadvantage. We may not be able to detect or prevent the unauthorized use of such
information or take appropriate and timely steps to enforce our intellectual property rights.
Some of our employees were previously
employed at universities or other biotechnology or pharmaceutical companies, including potential competitors. While we take steps
to prevent our employees from using the proprietary information or know-how of others in their work for us, we may be subject to
claims that we or these employees have inadvertently or otherwise used or disclosed intellectual property, trade secrets or other
proprietary information of any such employee’s former employer. Litigation may be necessary to defend against these claims
and, even if we are successful in defending ourselves, could result in substantial costs to us or be distracting to our management.
If we fail to defend any such claims successfully, in addition to paying monetary damages, we may lose valuable intellectual property
rights or personnel.
We are in the process
of registering our trademarks. Failure to secure those registrations could adversely affect our business.
We have registered our trademarks in the
United States and Israel, and we are in the process of obtaining trademark registrations, including for the trademark “NeuroDerm,”
in certain jurisdictions that we consider material to the marketing of our product candidates. While we intend for our applications
to mature into registrations, we cannot be certain that we will obtain such registrations or that the permissible use of those
marks will not be limited in scope. For example, the USPTO has informed us that a third party has a prior trademark registration
for “neuroderm” classified in the same class of goods as our product candidates. While we believe that our product
candidates under this trademark are different from the products of such third party and unlikely to cause any confusion, we cannot
guarantee the USPTO will withdraw the citation of such prior trademark. Consequently, we might not be able to secure trademark
registration for “NeuroDerm” in the United States. In addition, in the USPTO or its foreign counterparts, third parties
are given an opportunity to oppose pending trademark applications and to seek to cancel registered trademarks. Opposition or cancellation
proceedings may be filed against our trademarks, and our trademarks may not survive such proceedings. If we do not secure registrations
for each of our trademarks, we may not be able to use such trademarks in conducting our business (including forfeiting any goodwill
we have built-up related to such trademarks), and if we are able to use them, then we may encounter more difficulty in enforcing
them against third parties than we otherwise would, each of which could adversely affect our business.
We may be subject
to claims that we infringe, misappropriate or otherwise violate the intellectual property rights of third parties.
Our development, manufacturing, marketing
or sale of our product candidates may infringe or be accused of infringing one or more claims of an issued patent or may fall within
the scope of one or more claims in a published patent application that may be subsequently issued and to which we do not hold a
license or other rights. Our product candidates are reformulated versions of existing approved drugs, and we may be subject to
claims that such reformulations, our proposed uses or label claims, violate the intellectual property rights of others relating
to the underlying drugs. In such case, we may not be able to design around such third party intellectual property rights or obtain
licenses to use such intellectual property on acceptable terms, or at all, especially if our reformulated version is perceived
to be a competitive threat to the pre-existing product. We may also be subject to claims that we are infringing, misappropriating
or otherwise violating other intellectual property rights, such as trademarks, copyrights or trade secrets. Third parties could
therefore bring claims against us or our third-party manufacturers or partners that would cause us to incur substantial expenses,
including litigation costs or costs associated with settlement, and, if successful against us, could cause us to pay substantial
damages. Further, if such a claim were brought against us, we could be forced to temporarily delay or permanently stop manufacturing
or sales of our product candidates that is the subject of the suit.
If we are found to be infringing, misappropriating
or otherwise violating the patent or other intellectual property rights of a third party, or in order to avoid or settle claims,
we may choose or be required to seek a license from a third party and be required to pay license fees or royalties or both, which
could be substantial. These licenses may not be available on terms acceptable to us, or at all. Even if we were able to obtain
a license, the rights may be nonexclusive, which could result in our competitors gaining access to the same intellectual property.
Ultimately, we could be prevented from commercializing a product, or be forced to cease some aspect of our business operations,
if, as a result of actual or threatened claims, we or our partners are unable to enter into licenses on acceptable terms. If we
cannot operate without infringing on the proprietary rights of others, we will not earn revenues on our product candidates and
our business would be materially adversely affected.
There have been substantial litigation
and other proceedings regarding patent and other intellectual property rights in the pharmaceutical and biotechnology industries.
In addition, to the extent that we gain greater visibility and market exposure as a public company in the United States, we face
a greater risk of being involved in such litigation. In addition to infringement claims against us, we may become a party to other
patent litigation and other proceedings, including interference, opposition, re-examination and similar proceedings, such as the
America Invents Act post grant proceedings, before the USPTO and its foreign counterparts, regarding intellectual property rights
with respect to our product candidates. The cost to us of any patent litigation or other proceeding, even if resolved in our favor,
could be substantial. A negative outcome could result in liability for monetary damages, including treble damages and attorneys’
fees if, for example, we are found to have willfully infringed a patent. A finding of infringement could prevent us or our collaborators
from developing, marketing or selling a product or force us to cease some or all of our business operations. Some of our competitors
may be able to sustain the costs of such litigation or proceedings more effectively than we can because of their substantially
greater financial resources. Uncertainties resulting from the initiation and continuation of patent litigation or other proceedings
could have a material adverse effect on our ability to compete in the marketplace, and patent litigation and other proceedings
may also absorb significant management time.
Risks Related to Our Management
and Employees
We depend on our
executive officers and key clinical and technical personnel to operate our business effectively, and we must attract and retain
highly skilled employees in order to succeed.
Our success depends upon the continued
service and performance of our executive officers who are essential to our growth and development. The loss of one or more of our
executive officers could delay or prevent the continued successful implementation of our growth strategy, could affect our ability
to manage our company effectively and to carry out our business plan, or could otherwise be detrimental to us. As of December 31,
2016, we had 55 full-time employees. Therefore, knowledge of our product candidates and clinical trials is concentrated among a
small number of individuals. Members of our executive team as well as key clinical, scientific and technical personnel may resign
at any time and there can be no assurance that we will be able to continue to retain such personnel. If we cannot recruit suitable
replacements in a timely manner, our business will be adversely impacted.
Our growth and continued success will
also depend on our ability to attract and retain additional highly qualified and skilled research and development, operational,
managerial and finance personnel. However, we face significant competition for experienced personnel in the pharmaceutical field.
Many of the other pharmaceutical companies that we compete against for qualified personnel have greater financial and other resources,
different risk profiles and a longer history in the industry than we do. They also may provide more diverse opportunities and better
chances for career advancement. Some of these characteristics may be more appealing to quality candidates than what we have to
offer. If we cannot retain our existing skilled scientific and operational personnel and attract and retain sufficiently-skilled
additional scientific and operational personnel, as required, for our research and development and manufacturing operations on
acceptable terms, we may not be able to continue to develop and commercialize our existing product candidates or new products.
Further, any failure to effectively integrate new personnel could prevent us from successfully growing our company.
Under applicable
employment laws, we may not be able to enforce covenants not to compete.
We generally enter into non-competition
agreements with our employees. These agreements prohibit our employees, if they cease working for us, from competing directly with
us or working for our competitors or clients for a limited period. We may be unable to enforce these agreements under the laws
of the jurisdictions in which our employees work and it may be difficult for us to restrict our competitors from benefitting from
the expertise our former employees or consultants developed while working for us. For example, Israeli labor courts have required
employers seeking to enforce non-compete undertakings of a former employee to demonstrate that the competitive activities of the
former employee will harm one of a limited number of material interests of the employer which have been recognized by the courts,
such as the protection of a company’s trade secrets or other intellectual property.
If we fail to manage
our growth effectively, our business could be disrupted.
Our future financial performance and ability
to successfully commercialize our product candidates and to compete effectively will depend, in part, on our ability to manage
any future growth effectively. We have made and expect to continue to make significant investments to enable our future growth
through, among other things, new product development and clinical trials for new indications. We may acquire or make investments
in businesses, technologies or products, whether complementary or otherwise, as a means to expand our business, if appropriate
opportunities arise. We cannot give assurances that we will be able to identify future suitable acquisition or investment candidates,
or, if we do identify suitable candidates, that we will be able to make the acquisitions or investments on reasonable terms or
at all. In addition, we have no prior experience in integrating acquisitions and we could experience difficulties incorporating
an acquired company’s personnel, operations, technology or product offerings into our own or in retaining and motivating
key personnel from these businesses. We may also incur unanticipated liabilities. The financing of any such acquisition or investment,
or of a significant general expansion of our business, may not be readily available on favorable terms. Any significant acquisition
or investment, or major expansion of our business, may require us to explore external financing sources, such as an offering of
our equity or debt securities. We cannot be certain that these financing sources will be available to us or that we will be able
to negotiate commercially reasonable terms for any such financing, or that our actual cash requirements for an acquisition, investment
or expansion will not be greater than anticipated. In addition, any indebtedness that we may incur in such a financing may inhibit
our operational freedom, while any equity securities that we may issue in connection with such a financing would dilute our shareholders.
We must also be prepared to expand our
work force and train, motivate and manage additional employees as the need for additional personnel arises. Even following expansion,
our facilities, personnel, systems, procedures and controls may not be adequate to support our future operations, or we may expand,
but then fail to grow our sales of our product candidates sufficiently to support such operational growth. Any failure to manage
future growth effectively could have a material adverse effect on our business and results of operations.
Our results of operations
may be adversely affected by fluctuations in currency exchange rates and we may not adequately hedge against them.
Through December 31, 2015, our functional
currency was the NIS but our presentation currency was and remains the U.S. dollar. Even after we transitioned to the U.S. dollar
as our functional currency effective as of January 1, 2016, a significant portion of our operating expenses have continued to be
incurred in NIS. The portion of our expenses that have been denominated in U.S. dollars has accounted for 16.0%, 45.0% and 55%
of our expenses in the years ended December 31, 2014, 2015 and 2016, respectively. As a result, we are exposed to the risks that
the shekel may appreciate relative to the dollar, or, if the shekel instead devalues relative to the dollar, that the inflation
rate in Israel may exceed such rate of devaluation of the shekel, or that the timing of such devaluation may lag behind inflation
in Israel. In any such event, the dollar cost of our operations in Israel would increase and our dollar-denominated results of
operations would be adversely affected. We cannot predict any future trends in the rate of inflation in Israel or the rate of devaluation
(if any) of the shekel against the dollar. For example, the dollar appreciated relative to the shekel by 12.0% in 2014 and 0.3%
in 2015, respectively, eclipsing the 0.5% rate of inflation in 2014 and compounding the negative rate of inflation (-1.0%) in Israel
in 2015. In 2016, however, the shekel appreciated relative to the dollar by 1.5%, and the inflation rate was neutral (0%), thereby
increasing our dollar-denominated costs slightly. If the dollar cost of our operations in Israel increases, our dollar-measured
results of operations will be adversely affected. Our operations also could be adversely affected if we are unable to effectively
hedge against currency fluctuations in the future.
Changes in laws, regulations or governmental policies
in jurisdictions in which we operate or where our products are sold may impact our business.
We may depend on distributors and agents
outside of Israel for compliance and adherence to local laws and regulations. Significant political or regulatory developments,
such as those
stemming from the recent change of
the presidential administration in the U.S. or the U.K.’s “Brexit” referendum could have a material adverse effect
on us.
In
the United States, the new presidential administration has
expressed support for and may implement greater restrictions
on free trade and increases tariffs on goods imported into the United States, as well as a comprehensive tax reform, including
in corporate and income taxation. We cannot predict whether quotas, duties, tariffs, taxes or other similar restrictions will be
imposed by the United States or other countries upon the import or export of our products in the future. However, given our significant
sales, distribution, import and manufacturing operations in the U.S., changes in U.S. political, regulatory and economic conditions
or in its policies governing international trade and foreign manufacturing and investment in the U.S. could adversely affect our
business.
In the United Kingdom, a recent referendum
was held in which voters approved an exit from the European Union (“E.U.”), commonly referred to as “Brexit.”
On February 8, 2017, the U.K.’s House of Commons approved a bill authorizing the government to start exit talks with the
E.U. The impact on us from Brexit will depend, in part, on the outcome of tariff, trade, regulatory and other negotiations. As
a result of the referendum, the global markets and certain currencies have been adversely impacted, including a sharp decline in
the value of the British pound as compared to the U.S. dollar, which led to decrease in our revenues generated from sales in the
U.K. A potential devaluation of the local currencies of our buyers in the U.K. and the E.U. relative to the U.S. dollar may impair
the purchasing power of our international buyers and could cause international buyers to decrease their participation in our marketplaces
or use of our services.
Volatility in the foregoing exchange rates
resulting from Brexit may continue as the U.K. negotiates its exit from the E.U. We translate sales and other results denominated
in foreign currency into U.S. dollars for our financial statements. During periods of a strengthening U.S. dollar, our reported
international sales and earnings would be reduced because these currencies would translate into fewer U.S. dollars. Furthermore,
brexit could also lead to legal uncertainty and potentially divergent national laws and regulations as the U.K. determines which
E.U. laws to replace or replicate, any of which could adversely affect our business, financial condition, operating results and
cash flows. Any of these effects of Brexit, among other factors, could adversely affect our business, financial condition, operating
results and cash flows.
Risks Related to Our Ordinary
Shares
Our share price
has been, and may continue to be, volatile, and you may lose all or part of your investment.
Our ordinary shares were first offered
publicly in our initial public offering in November 2014, at a price of $10.00 per share, and our ordinary shares have subsequently
traded as high as $30.45 per share and as low as $5.67 per share through March 15, 2017. In addition, the market price of our ordinary
shares could be highly volatile and may fluctuate substantially as a result of many factors, including:
|
■
|
actual or anticipated fluctuations in our results of operations;
|
|
■
|
variance in our financial performance from the expectations of market analysts;
|
|
■
|
announcements by us or our competitors of significant business developments, changes in service provider relationships, acquisitions or expansion plans;
|
|
|
|
|
■
|
changes in the prices of our products and services;
|
|
■
|
our involvement in litigation;
|
|
■
|
our sale of ordinary shares or other securities in the future;
|
|
■
|
market conditions in our industry;
|
|
■
|
changes in key personnel;
|
|
■
|
changes in the estimation of the future size and growth rate of our markets; and
|
|
■
|
general economic and market conditions.
|
In addition, the stock markets have experienced
extreme price and volume fluctuations. Broad market and industry factors may materially harm the market price of our ordinary shares,
regardless of our operating performance. In the past, following periods of volatility in the market price of a company’s
securities, securities class action litigation has often been instituted against that company. If we were involved in any similar
litigation we could incur substantial costs and our management’s attention and resources could be diverted.
If we do not meet
the expectations of equity research analysts, if they do not publish research or reports about our business or if they issue unfavorable
commentary or downgrade our ordinary shares, the price of our ordinary shares could decline.
The trading market for our ordinary shares
relies in part on the research and reports that equity research analysts publish about us and our business. The analysts’
estimates are based upon their own opinions and are often different from our estimates or expectations. If our results of operations
are below the estimates or expectations of public market analysts and investors, our stock price could decline. Moreover, the price
of our ordinary shares could decline if one or more securities analysts downgrade our ordinary shares or if those analysts issue
other unfavorable commentary or cease publishing reports about us or our business.
A small number of
significant beneficial owners of our shares, if acting together, would possess a controlling influence over matters requiring shareholder
approval, which could delay or prevent a change of control.
Three of our directors beneficially own
approximately 33.7% of our ordinary shares. As a result, these shareholders, acting together, could exercise a controlling influence
over our operations and business strategy and will have sufficient voting power to control the outcome of various matters requiring
shareholder approval. These matters may include:
|
■
|
the composition of our board of directors which has the authority to direct our business and to appoint and remove our officers;
|
|
■
|
approving or rejecting a merger, consolidation or other business combination;
|
|
|
|
|
■
|
raising future capital; and
|
|
■
|
amending our articles of association which govern the rights attached to our ordinary shares.
|
This concentration of ownership of our
ordinary shares could delay or prevent proxy contests, mergers, tender offers, open-market purchase programs or other purchases
of our ordinary shares that might otherwise give you the opportunity to realize a premium over the then-prevailing market price
of our ordinary shares. This concentration of ownership may also adversely affect our share price.
As a foreign private
issuer, we are permitted to follow, and have been following, certain home country corporate governance practices instead of otherwise
applicable SEC and NASDAQ requirements, which may result in less protection than is accorded to investors under rules applicable
to domestic U.S. issuers.
As a foreign private issuer, we are permitted
to follow, and have been following, certain home country corporate governance practices instead of those otherwise required under
the Listing Rules of NASDAQ, for domestic U.S. issuers. For instance, we follow home country practice in Israel with regard to
the quorum requirement for shareholder meetings. As permitted under the Companies Law, our articles of association provide that
the quorum for any meeting of shareholders is the presence of at least two shareholders present in person, by proxy or by a voting
instrument, who hold at least 25% of the voting power of our shares instead of 33 1/3% of the issued share capital, as required
under the Listing Rules of NASDAQ. We may in the future elect to follow home country practices in Israel with regard to other matters,
including the formation and composition of the compensation committee and nominating and governance committee, separate executive
sessions of independent directors and the requirement to obtain shareholder approval for certain dilutive events (such as for the
establishment or amendment of certain equity-based compensation plans, issuances that will result in a change of control of the
company, certain transactions other than a public offering involving issuances of a 20% or more interest in the company and certain
acquisitions of the stock or assets of another company). Following our home country governance practices as opposed to the requirements
that would otherwise apply to a U.S. company listed on the NASDAQ Global Market may provide less protection to you than what is
accorded to investors under the Listing Rules of NASDAQ applicable to domestic U.S. issuers. See “ITEM 16G. Corporate Governance.”
As a foreign private
issuer, we are not subject to the provisions of Regulation FD or U.S. proxy rules and are exempt from filing certain Exchange Act
reports, which reduces the frequency and scope of information and protections to which you are entitled as an investor.
In addition, as a foreign private issuer,
we are exempt from a number of requirements under U.S. securities laws that apply to public companies that are not foreign private
issuers. In particular, we are exempt from the rules and regulations under the Exchange Act related to the furnishing and content
of proxy statements, and our officers, directors and principal shareholders are exempt from the reporting and short-swing profit
recovery provisions contained in Section 16 of the Exchange Act. In addition, we are not required under the Exchange Act to file
annual and current reports and financial statements with the SEC as frequently or as promptly as U.S. domestic companies whose
securities are registered under the Exchange Act and are generally exempt from filing quarterly reports with the SEC under the
Exchange Act. We are also exempt from the provisions of Regulation FD, which prohibits the selective disclosure of material nonpublic
information to, among others, broker-dealers and holders of a company’s securities under circumstances in which it is reasonably
foreseeable that the holder will trade in the company’s securities on the basis of the information. Even though we intend
to comply voluntarily with Regulation FD, these exemptions and leniencies reduce the frequency and scope of information and protections
to which you are entitled as an investor.
If we lose our status
as a foreign private issuer under the SEC’s rules, that will increase our compliance costs.
We would lose our foreign private issuer
status if (i) a majority of our shares are held of record by U.S. residents, and either (ii)(A) a majority of our directors or
executive officers are U.S. citizens or residents or (ii)(B) we fail to meet additional requirements necessary to avoid loss of
foreign private issuer status. Although we have elected to comply with certain U.S. regulatory provisions, our loss of foreign
private issuer status would make such provisions mandatory. The regulatory and compliance costs to us under U.S. securities laws
as a U.S. domestic issuer may be significantly higher. If we are not a foreign private issuer, we will be required to file periodic
reports and registration statements on U.S. domestic issuer forms with the SEC, which are more detailed and extensive than the
forms available to a foreign private issuer. We would also be required to follow U.S. proxy disclosure requirements, including
the requirement to disclose more detailed information about the compensation of our senior executive officers on an individual
basis. We may also be required to modify certain of our policies to comply with good governance practices associated with U.S.
domestic issuers. Such conversion and modifications will involve additional costs. In addition, we may lose our ability to rely
upon exemptions from certain corporate governance requirements on U.S. stock exchanges that are available to foreign private issuers.
We are an “emerging
growth company” and we cannot be certain whether the reduced requirements applicable to emerging growth companies will make
our ordinary shares less attractive to investors.
We are an “emerging growth company,”
as defined in the Jumpstart Our Business Startups Act of 2012 effective on April 5, 2012, or the JOBS Act, and we may take advantage
of certain exemptions from various requirements that are applicable to other public companies that are not “emerging growth
companies.” Most of such requirements relate to disclosures that we would only be required to make if we cease to be a foreign
private issuer in the future. Nevertheless, as a foreign private issuer that is an emerging growth company, we will not be required
to comply with the auditor attestation requirements of Section 404(b) of the Sarbanes-Oxley Act of 2002, or the Sarbanes-Oxley
Act, for up to five fiscal years after the date of our initial public offering. We will remain an emerging growth company until
the earliest of: (a) the last day of our fiscal year during which we have total annual gross revenues of at least $1.0 billion;
(b) the last day of our fiscal year following the fifth anniversary of the completion of our initial public offering; (c) the date
on which we have, during the previous three-year period, issued more than $1.0 billion in non-convertible debt; or (d) the date
on which we are deemed to be a “large accelerated filer” under the Exchange Act. When we are no longer deemed to be
an emerging growth company, we will not be entitled to the exemptions provided in the JOBS Act discussed above. We cannot predict
if investors will find our ordinary shares less attractive as a result of our reliance on exemptions under the JOBS Act. If some
investors find our ordinary shares less attractive as a result, there may be a less active trading market for our ordinary shares
and our share price may be more volatile.
The market price
of our ordinary shares could be negatively affected by future sales of our ordinary shares.
As of March 15, 2017, there were 26,338,138
of our ordinary shares outstanding. Sales by us or our shareholders of a substantial number of ordinary shares in the public market,
or the perception that these sales might occur, could cause the market price of our ordinary shares to decline or could impair
our ability to raise capital through a future sale of, or pay for acquisitions using, our equity securities. Shares held by our
pre-IPO shareholders are now eligible for sale under Rule 144 of the Securities Act, which could facilitate additional downward
pressure on the market price of our ordinary shares.
The holders of 8,057,760 of our ordinary
shares are entitled to require that we register under the Securities Act the resale of their shares into the public markets. All
shares sold pursuant to an offering covered by such registration statement will be freely transferable. See “ITEM 7.B — Related
Party Transactions — Registration Rights”.
In addition to these registration rights,
approximately 3.1 million ordinary shares are subject to outstanding options granted to employes and office holders under our equity
incentive plans, including approximately 1.5 million ordinary shares issuable under currently exercisable share options as of March
15, 2017. Upon issuance, such shares may be freely sold in the public market, except for shares held by affiliates who have certain
restrictions on their ability to sell.
We believe we were a passive foreign investment company,
or PFIC, for the taxable year ending December 31, 2016 and expect to be classified as a PFIC for the taxable year ending December
31, 2017.
A non-U.S. corporation will be classified
as a PFIC for federal income tax purposes in any taxable year in which, after applying certain look-through rules with respect
to the income and assets of subsidiaries, either at least 75% of its gross income is “passive income,” or at least
50% of the average quarterly value of its total gross assets (which, in our case, may be determined in part by the market value
of our ordinary shares, which is subject to change) is attributable to assets that produce “passive income” or are
held for the production of passive income. Based on certain estimates of our gross income and gross assets and the nature of our
business, we believe, and you should assume, that we were classified as a PFIC for the taxable year ending December 31, 2016. We
furthermore expect to be classified as a PFIC for the 2017 tax year. Because we must determine our PFIC status annually based on
tests, which are factual in nature, our status in 2017 and future years will depend on our income, assets and activities in those
years. There can be no assurance that we will not be considered a PFIC for any taxable year.
Our classification as a PFIC may result
in material adverse consequences for you if you are a U.S. taxable investor, including having gains realized on the sale of the
ordinary shares treated as ordinary income, rather than capital gains, having potentially punitive interest charges apply to those
gains, and the denial of the taxation of certain dividends we pay at the lower rates applicable to long-term capital gains. If
we are classified as a PFIC, a U.S. investor may be able to mitigate some of the adverse U.S. federal income tax consequences described
above with respect to owning our ordinary shares, provided that such U.S. investor is eligible to make, and successfully makes,
a “mark-to-market” election. U.S. investors could also mitigate some of the adverse U.S. federal income tax consequences
of us being classified as a PFIC by making a “qualified electing fund” election, provided that we provide the information
necessary for a U.S. investor to make such an election. We intend to make available to U.S. investors upon request the information
necessary for U.S. holders to make qualified electing fund elections if we are classified as a PFIC. Prospective U.S. investors
should consult their own tax advisers regarding the potential application of the PFIC rules to them. For more information related
to classification as a PFIC, see “ITEM 10.E Taxation and Government Programs—U.S. Federal Income Taxation—Passive
Foreign Investment Company Considerations.”
As a public company we may become subject to further compliance
obligations, which may strain our resources and divert management's attention.
Changes in the laws and regulations affecting
public companies would result in increased costs to us as we respond to their requirements. These laws and regulations could make
it more difficult or more costly for us to obtain certain types of insurance, including director and officer liability insurance,
and we may be forced to accept reduced policy limits and coverage or incur substantially higher costs to obtain the same or similar
coverage. The impact of these requirements could also make it more difficult for us to attract and retain qualified persons to
serve on our board of directors, our board committees or as executive officers. If our efforts to comply with new laws and regulations
differ from the activities intended by regulatory or governing bodies due to ambiguities related to practice, regulatory authorities
may initiate legal proceedings against us and our business may be harmed. Being a publicly traded company in the United States
and being subject to U.S. rules and regulations make it more expensive for us to obtain director and officer liability insurance,
and we may be required to accept reduced coverage or incur substantially higher costs to obtain coverage.We cannot predict or estimate
the amount or timing of additional costs we may incur in order to comply with such requirements.
We have never paid
cash dividends on our share capital, and we do not anticipate paying any cash dividends in the foreseeable future.
We have never declared or paid cash dividends
on our share capital, nor do we anticipate paying any cash dividends on our share capital in the foreseeable future. We currently
intend to retain all available funds and any future earnings to fund the development and growth of our business. As a result, capital
appreciation, if any, of our ordinary shares will be an investor’s sole source of gain for the foreseeable future. In addition,
Israeli law limits our ability to declare and pay dividends, and may subject our dividends to Israeli withholding taxes, and our
payment of dividends (out of tax-exempt income) may subject us to certain Israeli taxes, to which we would not otherwise be subject
(see “ITEM 8. FINANCIAL INFORMATION—A. Consolidated Statements and Other Financial Information—Dividend Distribution
Policy,” “ITEM 10.
Additional Information
—B. Articles of Association—Dividend and Liquidation Rights” and “ITEM 5. OPERATING AND FINANCIAL REVIEW AND PROSPECTS—A. Operating Results—Israeli
Tax Structure and Tax Programs That May Become Applicable to Our Company”).
If we are unable
to satisfy the requirements of Section 404 of the Sarbanes-Oxley Act, or if our internal controls over financial reporting are
not effective, investors may lose confidence in the accuracy and the completeness of our financial report,s the reliabiliyt of
our financial statements may be questioned and our share price may suffer.
We are required to comply with the internal
control, evaluation and certification requirements of Section 404 of the Sarbanes-Oxley Act as of this annual report. Pursuant
to Section 404(a) of the Sarbanes-Oxley Act, we are required to furnish a report by management on the effectiveness of our internal
control over financial reporting. Pursuant to Section 404(b) of the Sarbanes-Oxley Act, unless we lose our status as an “emerging
growth company” under the JOBS Act prior to the end of the fiscal year in which the fifth anniversary of our initial public
offering occurred, we will not be required to obtain an auditor attestation under Section 404 of the Sarbanes-Oxley Act until the
year ended December 31, 2019.
To maintain the effectiveness of our disclosure
controls and procedures and our internal control over financial reporting, we expect that we will need to continue enhancing existing,
and implement new, financial reporting and management systems, procedures and controls to manage our business effectively and support
our growth in the future. The process of evaluating our internal control over financial reporting requires an investment of substantial
time and resources, including by our Chief Financial Officer and other members of our senior management. The determination and
any remedial actions required could divert internal resources and take a significant amount of time and effort to complete and
could result in us incurring additional costs that we did not anticipate, including the hiring of outside consultants.
Irrespective of compliance with Section
404, any failure of our internal controls could have a material adverse effect on our stated results of operations and harm our
reputation. As a result, we may experience higher than anticipated operating expenses, as well as higher independent auditor fees
during and after the implementation of these changes. If we are unable to implement any of the required changes to our internal
control over financial reporting effectively or efficiently, it could adversely affect our operations, financial reporting or results
of operations and could result in an adverse opinion on internal controls from our independent auditors. Further, if our internal
controls over financial reporting are not effective, the reliability of our financial statements may be questioned and our share
price may suffer.
Risks Relating to Our Incorporation
and Location in Israel
Our headquarters
and other significant operations are located in Israel and, therefore, our results may be adversely affected by political, economic
and military instability in Israel.
Our headquarters and principal research
and development facilities are located in Rehovot, Israel. In addition, the majority of our key employees, officers and directors
are residents of Israel. Accordingly, political, economic and military conditions in Israel may directly affect our business. Since
the establishment of the State of Israel in 1948, a number of armed conflicts have taken place between Israel and its neighboring
countries. Although Israel is a party to peace agreements with Egypt and Jordan and agreements with the Palestinian Authority,
it is unclear whether any negotiations that may occur between Israel and the Palestinian Authority will result in any additional
agreements. Any hostilities involving Israel or the interruption or curtailment of trade between Israel and its trading partners
could adversely affect our operations and results of operations.
During the Second Lebanon War of 2006,
between Israel and Hezbollah, a militant Islamic movement, rockets were fired from Lebanon into Israel causing casualties and major
disruption of economic activities in northern Israel. An escalation in tension and violence between Israel and the militant Hamas
movement (which controls the Gaza Strip) and other Palestinian Arab groups, has led to Israeli military campaigns in Gaza in December
2008, in November 2012 and from July through August 2014, in an endeavor to prevent continued rocket attacks in Israel’s
southern and central regions. In addition, Israel faces threats from more distant neighbors, in particular, Iran, an ally of Hezbollah
and Hamas, which has threatened to attack Israel and is believed to be developing nuclear weapons. Iran is also believed to have
a strong influence among parties hostile to Israel, such as the Syrian government, Hamas in Gaza and Hezbollah in Lebanon.
Recent political uprisings, social unrest
and violence in various countries in the Middle East and North Africa, including Israel’s neighbors Egypt and Syria are affecting
the political stability of those countries. This instability may lead to deterioration in the political and trade relationships
that exist between the State of Israel and these countries and have raised concerns regarding security in the region and the potential
for armed conflict. Furthermore, several countries, principally in the Middle East, restrict doing business with Israel and Israeli
companies, and additional countries may impose restrictions on doing business with Israel and Israeli companies if hostilities
in the region continue or intensify. Such restrictions may seriously limit our ability to sell our products to customers in those
countries. Any hostilities involving Israel or the interruption or curtailment of trade between Israel and its present trading
partners, or significant downturns in the economic or financial condition of Israel, could materially and adversely affect our
operations and product development, detrimentally affect our potential to generate revenues and adversely affect the share price
of publicly traded companies having operations in Israel, such as us. Similarly, Israeli corporations are limited in conducting
business with entities from several countries. For example, in 2008, an Israeli law was enacted forbidding any investments in entities
engaged in business with Iran.
Although Israeli legislation requires
the Israeli government to cover the reinstatement value of direct damages that are caused by terrorist attacks or acts of war,
we cannot assure you that this government coverage will be maintained, or if maintained, will be sufficient to compensate us fully
for damages incurred. Any losses or damages incurred by us could have a material adverse effect on our business. Any armed conflicts,
terrorist activities or political instability in the region would likely negatively affect business conditions generally and could
harm our results of operations.
Several countries, principally in the
Middle East, restrict doing business with Israel and Israeli companies, and additional countries may impose restrictions on doing
business with Israel and Israeli companies whether as a result of hostilities in the region or otherwise. In addition, there have
been increased efforts by activists to cause companies and consumers to boycott Israeli goods based on Israeli government policies.
Such actions, particularly if they become more widespread, may adversely impact our ability to conduct business.
Certain Israeli
governmental grants that we received for certain of our research and development activities in Israel may restrict our ability
to transfer manufacturing operations or technology outside of Israel without obtaining a pre-approval from the relevant authorities
and, in certain circumstances, payment of significant amounts to the authorities.
Our research and development efforts were
and are financed in part through grants from the National Technological Innovation Authority, or the Innovation Authority (formerly
operating as Office of the Chief Scientist of the Ministry of Economy of the State of Israel, or the OCS). As of December 31, 2014,
2015 and 2016, we had received, cumulatively, $1.9 million, $2.8 million and $2.8 million, respectively, from the OCS and/or the
Innovation Authority for our research and development programs. As of December 31, 2016, we had not paid any royalties to the OCS
and/or the Innovation Authority.
We must comply with
the requirements of the Israeli Encouragement of Research, Development and Technological Innovation Law, 5744-1984, or the Innovation
Law (formerly known as the Encouragement of Industrial Research and Development Law, 5744-1984, or the Research Law), and related
regulations, with respect to those grants.
When a company develops
know-how, technology or products using grants provided by the Innovation Authority, the terms of those grants and the Innovation
Law restrict the transfer of such know-how, and the transfer of manufacturing or manufacturing rights of such products, technologies
or know-how outside of Israel. Even after the repayment of such grants in full, we will remain subject to the restrictions set
forth under the Innovation Law, including:
|
·
|
Transfer of know-how outside of Israel
. Any transfer of the know-how that was developed with the funding of the Innovation
Authority, outside of Israel, requires prior approval of the Innovation Authority, and the payment of a redemption fee.
|
|
·
|
Local manufacturing obligation
. The terms of the grants under the Innovation Law require that the manufacturing of products
resulting from Innovation Authority-funded programs be carried out in Israel, unless a prior written approval of the Innovation
Authority is obtained (except for a transfer of up to 10% of the production rights, for which a notification to the Innovation
Authority is sufficient).
|
|
·
|
Certain reporting obligations
. We, as any recipient of a grant or a benefit under the Innovation Law, are required to
file reports on the progress of activities for which the grant was provided as well as on our revenues from know-how and products
funded by the Innovation Authority. In addition, we are required to notify the Innovation Authority of certain events detailed
in the Innovation Law.
|
Therefore, if aspects
of our technologies are deemed to have been developed with Innovation Authority funding, the discretionary approval of an Innovation
Authority committee would be required for any transfer to third parties outside of Israel of know-how or manufacturing or manufacturing
rights related to those aspects of such technologies. We may not receive those approvals. Furthermore, the Innovation Authority
may impose certain conditions on any arrangement under which it permits us to transfer technology or development out of Israel.
The transfer of Innovation
Authority -supported technology or know-how outside of Israel may involve the payment of significant amounts, depending upon the
value of the transferred technology or know-how, the amount of Innovation Authority support, the time of completion of the Innovation
Authority -supported research project and other factors. Furthermore, the consideration available to our shareholders in a transaction
involving the transfer outside of Israel of technology or know-how developed with Innovation Authority funding (such as a merger
or similar transaction) may be reduced by any amounts that we are required to pay to the Innovation Authority.
An extensive amendment
to the Innovation Law came into effect as of January 1, 2016, or the Amendment, which may also affect the terms of existing grants.
The Amendment provides for an interim transition period (which has not yet expired), after which time our grants will be subject
to terms of the Amendment. Under the Innovation Law, as amended by the Amendment, the Innovation Authority is provided with a power
to modify the terms of existing grants. Such changes, if introduced by the Innovation Authority in the future, may impact the terms
governing our grants.
We may not be eligible
for tax benefits that may be available to us under Israeli law and such benefits may be terminated or reduced in the future.
We may be eligible for certain tax benefits
provided to “Preferred Enterprises” under the Israeli Law for the Encouragement of Capital Investments, 1959, referred
to as the Investment Law. In order to be eligible for the tax benefits for “Preferred Enterprises,” we must meet certain
conditions stipulated in the Investment Law and its regulations, as amended. If we do not satisfy these conditions, our Israeli
taxable income would be subject to regular Israeli corporate tax rates, which in 2017 is set at 24% and as of 2018 will be 23%
(the corporate tax rate was 26.5% and 25% in 2015 and 2016, respectively). Even if we were to become eligible for these tax benefits,
they may be reduced, cancelled or discontinued. See “ITEM 5.A Operating Results—Israeli Tax Structure and Tax Programs
That May Become Applicable to Our Company—Law for the Encouragement of Capital Investments, 5719-1959.”
We may be required to pay monetary remuneration
to employees for their service inventions, even if the rights to such inventions have been assigned to us.
We
enter into assignment-of-invention agreements with our employees pursuant to which such individuals agree to assign to us all rights
to any inventions created in the scope of their employment or engagement with us. A significant portion of our intellectual property
has been developed by our employees during the course of their employment by us. Under the Israeli Patent Law, 5727-1967, or the
Patent Law, inventions conceived by an employee during the scope of his or her employment with a company are regarded as “service
inventions,” which belong to the employer, absent a specific agreement between the employee and employer giving the employee
service invention rights. Although our employees have agreed to assign to us service invention rights, as a result of uncertainty
under Israeli law with respect to the efficacy of waivers of service invention rights, we may face claims demanding remuneration
in consideration for assigned inventions. As a consequence of such claims, we could be required to pay additional remuneration
or royalties to our current and/or former employees, or be forced to litigate such claims, which could negatively affect our business.
Provisions of Israeli
law and/or our articles of association may delay, prevent or otherwise impede a merger with, or an acquisition of, us, even when
the terms of such a transaction are favorable to us and our shareholders.
Israeli corporate law regulates mergers,
requires tender offers for acquisitions of shares and voting rights above specified thresholds, requires special approvals for
certain transactions involving directors, officers or significant shareholders and regulates other matters that may be relevant
to such types of transactions. For example, a tender offer for all of a company’s issued and outstanding shares can only
be completed if the acquirer receives positive responses from the holders of at least 95% of the issued share capital. Completion
of the tender offer also requires approval of a majority of the offerees that do not have a personal interest in the tender offer,
unless at least 98% of the company’s outstanding shares are tendered. Furthermore, the shareholders, including those who
indicated their acceptance of the tender offer (unless the acquirer stipulated in its tender offer that a shareholder that accepts
the offer may not seek appraisal rights), may, at any time within six months following the completion of the tender offer, petition
an Israeli court to alter the consideration for the acquisition. See “ITEM 10
Additional
Information
—B. Articles of Association—Acquisitions under Israeli Law” for additional information.
Our articles of association provide that
our directors (other than external directors) are elected on a staggered basis, such that a potential acquiror cannot readily replace
our entire board of directors at a single annual general shareholder meeting. This could prevent a potential acquiror from receiving
board approval for an acquisition proposal that our board of directors opposes.
Furthermore, Israeli tax considerations
may make potential transactions unappealing to us or to our shareholders whose country of residence does not have a tax treaty
with Israel exempting such shareholders from Israeli tax. For example, Israeli tax law does not recognize tax-free share exchanges
to the same extent as U.S. tax law. With respect to mergers, Israeli tax law allows for tax deferral in certain circumstances but
makes the deferral contingent on the fulfillment of a number of conditions, including, in some cases, a holding period of two years
from the date of the transaction during which sales and dispositions of shares of the participating companies are subject to certain
restrictions. Moreover, with respect to certain share swap transactions, the tax deferral is limited in time, and when such time
expires, the tax becomes payable even if no disposition of the shares has occurred. These provisions could delay, prevent or impede
an acquisition of us or our merger with another company, even if such an acquisition or merger would be beneficial to us or to
our shareholders.
It may be difficult
to enforce a judgment of a U.S. court against us or our officers and directors in Israel or the United States, to assert U.S. securities
laws claims in Israel or to serve process on our officers and directors.
We are incorporated in Israel. The majority
of our directors and executive officers reside outside of the United States, and most of our assets and most of the assets of these
persons are located outside of the United States. Therefore, a judgment obtained against us, or any of these persons, including
a judgment based on the civil liability provisions of the U.S. federal securities laws, may not be collectible in the United States
and may not be enforced by an Israeli court. It also may be difficult for you to effect service of process on these persons in
the United States or to assert U.S. securities law claims in original actions instituted in Israel. Israeli courts may refuse to
hear a claim based on an alleged violation of U.S. securities laws reasoning that Israel is not the most appropriate forum in which
to bring such a claim. In addition, even if an Israeli court agrees to hear a claim, it may determine that Israeli law and not
U.S. law is applicable to the claim. If U.S. law is found to be applicable, the content of applicable U.S. law must be proven as
a fact by expert witnesses, which can be a time consuming and costly process. Certain matters of procedure will also be governed
by Israeli law. There is little binding case law in Israel that addresses the matters described above. As a result of the difficulty
associated with enforcing a judgment against us in Israel, you may not be able to collect any damages awarded by either a U.S.
or foreign court.
Your rights and
responsibilities as a shareholder are governed by Israeli law, which differs in some material respects from the rights and responsibilities
of shareholders of U.S. companies.
The rights and responsibilities of the
holders of our ordinary shares are governed by our articles of association and by Israeli law. These rights and responsibilities
differ in some material respects from the rights and responsibilities of shareholders in U.S.-based corporations. In particular,
a shareholder of an Israeli company has a duty to act in good faith and in a customary manner in exercising its rights and performing
its obligations towards the company and other shareholders, and to refrain from abusing its power in the company, including, among
other things, in voting at a general meeting of shareholders on matters such as amendments to a company’s articles of association,
increases in a company’s authorized share capital, mergers and related party transactions requiring shareholder approval.
In addition, a shareholder who is aware that it possesses the power to determine the outcome of a shareholder vote or to appoint
or prevent the appointment of a director or executive officer in the company has a duty of fairness toward the company. There is
limited case law available to assist us in understanding the nature of this duty or the implications of these provisions. These
provisions may be interpreted to impose additional obligations and liabilities on holders of our ordinary shares that are not typically
imposed on shareholders of U.S. corporations.
ITEM 4
.
|
Information on the Company
.
|
|
A.
|
History and Development of the Company
|
Our full, legal name
is NeuroDerm Ltd. and we were incorporated under Israeli law as a limited liability company in March 2003. We are a clinical-stage
pharmaceutical company developing next-generation, drug-device combinationsfor central nervous system, or CNS, disorders through
proprietary formulations based on existing drugs that are intended to make a significant difference in patients’ lives. Product
candidates in our pipeline are designed to overcome major deficiencies of current treatments and achieve enhanced clinical efficacy
through continuous, controlled administration, primarily subcutaneously or transdermally. Additionally, because our product candidates
are based on reformulations of leading, approved drugs, we believe that most of them qualify for an accelerated, lower risk regulatory
pathway to marketing approval.
In November 2014, we completed
our IPO, pursuant to which we sold 4.5 million ordinary shares, generating net proceeds (after underwriting discounts, commissions
and expenses) of $40.7 million. Upon the consummation of our IPO, our ordinary shares began trading on the NASDAQ Global Market,
under the symbol “NDRM”.
In July 2015, we consummated
a follow-on offering, pursuant to which we sold approximately 4.5 million ordinary shares, generating aggregate net proceeds (after
underwriting discounts, commissions and expenses) of $71.9 million.
In December 2015, we
incorporated our Delaware subsidiary, Neuroderm, Inc., which currently constitutes our sole subsidiary.
In December 2016, we
consummated a follow-on offering, pursuant to which we sold 4.6 million ordinary shares, generating aggregate net proceeds (after
underwriting discounts, commissions and expenses) of $80.8 million.
We are subject to the
provisions of the Israeli Companies Law, 5759-1999, or the Companies Law. Our corporate headquarters are located at Ruhrberg Science
Building, 3 Pekeris St., Rehovot 7670212, Israel. Our telephone number is +972 (8) 946-2729 and our web site is located at www.neuroderm.com
(the information contained therein or linked thereto shall not be considered incorporated by reference in this annual report).
Our agent for service of process in the United States is Puglisi & Associates, located at 850 Library Avenue, Suite 204, Newark,
Delaware 19711.
We are a clinical-stage
pharmaceutical company developing next-generation drug-device combinations for CNS disorders through proprietary formulations based
on existing drugs that are intended to make a significant difference in patients’ lives. Product candidates in our pipeline
are designed to overcome major deficiencies of current treatments and achieve enhanced clinical efficacy through continuous, controlled
administration, primarily subcutaneously or transdermally. Additionally, because our product candidates are based on reformulations
of leading, approved drugs, we believe that most of them qualify for an accelerated, lower risk regulatory pathway to marketing
approval.
For moderate to severe
Parkinson’s disease, our product candidates are aimed at overcoming the most significant limitations of current levodopa-carbidopa,
or LD/CD, therapy. For over 30 years, oral administration of LD/CD has been the standard of care for Parkinson’s disease.
However, despite its widespread acceptance, oral LD/CD has significant limitations, primarily short duration in the blood, or half-life,
as well as low absorption and availability in the body. As a result, plasma levodopa concentrations fluctuate sharply, contributing
to patients’ motor complications. At the advanced stages of the disease, patients do not respond to oral administration of
LD/CD, motor complications are exacerbated and patients are left with limited treatment options that are highly invasive and/or
burdensome. We have developed liquid formulations, such as our product candidates ND0612H and ND0612L, that for the first time
enable 24-hour, continuous subcutaneous administration of LD/CD to overcome these limitations, maintain steady levodopa levels
and offer patients a better quality of life without the need for surgery.
There are three main stages
to Parkinson’s disease: mild, moderate and severe, each associated with increasing levels of motor complications and requiring
different treatments. We are developing a pipeline of product candidates for the growing population of moderate and severe Parkinson’s
disease patients that address the deficiencies of current treatments. These product candidates are designed to administer continuous,
controlled doses of LD/CD or apomorphine, utilizing customized versions of off-the-shelf, belt pump devices. We are also developing
a product candidate for patients suffering from cognition disorders associated with CNS diseases. These diseases include Attention
Deficit Disorder/Attention Deficit Hyperactivity Disorder, or ADD/ADHD, Parkinson’s disease, Alzheimer’s disease and
schizophrenia. Our cognition product candidate is based on a combination of reformulated approved drugs allowing for continuous
administration via transdermal patches.
In a recently completed
28-day multicenter, international (U.S., EU and Israel), parallel-group, blinded rater, randomized Phase II study (trial 006),
we investigated the efficacy, safety, tolerability and pharmacokinetics of two dosing regimens (R1 and R2) of ND0612H and compared
them to the baseline of standard optimized oral therapy. Preliminary results demonstrate that the R1 dosing regimen significantly
reduced OFF-time and significanty increased ON-time with no or mild dyskinesia. A substantial percentage of subjects experienced
complete resolution of OFF-time.
In a previously completed
Phase IIa dose-finding trial, we examined the plasma levodopa concentrations achieved in individual Parkinson’s disease patients
treated with ND0612H and ND0612L for eight hours. The high average plasma levodopa concentrations achieved with ND0612H in this
trial indicate that ND0612H may offer a viable nonsurgical alternative to more nvasive surgical procedures for advanced Parkinson’s
Disease.
In addition, in our completed
Phase II trial with ND0612L, we examined plasma levodopa concentrations of individual Parkinson’s disease patients treated
with optimized, current standard of care and either ND0612L or a placebo as an add-on for 14 days. In this trial, treatment with
ND0612L demonstrated major clinical benefits over the placebo in all objective, in-clinic, pre-specified, exploratory efficacy
end points, including OFF-time reduction, which was not accompanied by an increase in troublesome dyskinesia.
Clinical Status of Product Candidates
Our expectations
below regarding the timing of our clinical trials for our product candidates are estimates, which may change as we progress
through the clinical trials and engage in discussions with regulatory agencies since we have not yet some of the
pivotal trials or have not opened yet all study sites. The following chart provides a summary of our development
pipeline:
Product
Candidate
|
|
Active Drug
Compound
|
|
Administration
|
|
Indication
|
|
Clinical Status
|
ND0612*
|
|
LD/CD
|
|
Subcutaneous
|
|
Patients with Parkinson’s Disease and motor fluctuations / advanced PD patients
|
|
·
Completed
Phase II trials and preliminary results announced in March 2017
·
Completed
PK Pilot Dose Finding Trial and results announced in June 2016
·
Ongoing
Long-Term Safety Trial (BeyoND)
·
Ongoing
Phase III Efficacy Trial (iNDiGO)
·
Anticipated
comparative pharmacokinetic (PK) trials
|
|
|
|
|
|
|
|
|
|
ND0701
|
|
Apomorphine
|
|
Subcutaneous
|
|
Severe Parkinson’s Disease**
|
|
·
Completed
pilot study comparing PK of ND0701 with commercial apomorphine
·
Planned
follow-up comparison PK study in 2017
·
Planned
meeting with EU authorities to discuss regulatory requirements for submission
|
|
|
|
|
|
|
|
|
|
ND0801
|
|
Opipramol and nicotine
|
|
Transdermal
|
|
Cognition disorders associated with CNS diseases
|
|
·
Ongoing
open-label, Phase IIa, proof-of-concept dose escalation
trial
·
Interim
results received for Phase IIa proof-of-concept study with patients suffering from ADD/ADHD at two centers in Israel; awaiting
final results
|
|
*
|
Includes the low and high doses of ND0612.
|
|
**
|
Primarily for patients who suffer from high motor fluctuations
and who do not respond well to LD/CD.
|
Parkinson’s Disease and Current Treatment Limitations
Parkinson’s disease
is a progressive neurodegenerative illness characterized by reduced dopamine levels in the brain, resulting in a debilitating decrease
in the patient’s motor and non-motor functions. Its symptoms, such as trembling in the extremities and face, slowness of
movement and impaired balance and coordination, worsen over time and gravely impact the patient’s quality of life. As the
disease progresses, these symptoms become more severe and complications of treatment become more pronounced, resulting in debilitating
periods of decreased motor and non-motor functions, also referred to as “off” time. In addition, patients experience
dyskinesia, which is typically associated with excessive levodopa doses. The “off” time and dyskinesia affect the majority
of Parkinson’s disease patients and interfere with day-to-day functions, causing patients to become severely disabled. Two
to five years from disease diagnosis, patients can go from “on” to “off” in a rapid and sometimes erratic
manner and experience an average of six hours of “off” time at various and unpredictable times throughout the day.
In the most severe stage of the disease, patients may become bedridden or require a wheelchair, as oral therapy becomes mostly
ineffective.
The EPDA estimates that
6.3 million people worldwide suffer from Parkinson’s disease. The Michael Jay Fox Foundation, or MJFF, estimates that
at least one million people who suffer from Parkinson’s disease live in the United States, representing an estimated one
in one hundred people over age 60. According to the International Parkinson and Movement Disorder Society, the prevalence of diagnosed
patients with the disease will likely double from 2010 to 2040 due to increased life expectancy. Additionally, it estimates that
Parkinson’s disease patients in the United States spent over $14 billion on medical expenses in 2010. According to GlobalData
Ltd., the global Parkinson’s disease drug market was approximately $3.3 billion in 2010. According to the Michael Stern
Parkinson’s Research Foundation, drugs used to treat Parkinson’s disease patients can cost up to $6,000 a year in the
United States. First year surgery and devices for more severe patients can cost up to $100,000, with Duodopa costing approximately
$70,000 a year, outside of the United States.
Oral administration of
LD/CD is regarded as the “gold standard” treatment for patients suffering from Parkinson’s disease. Levodopa
is a therapy that complements dopamine levels in the brain that decrease due to degeneration of dopamine producing brain cells.
Whenever complementation therapy is possible, it often becomes a “gold standard” therapy. Virtually all patients diagnosed
with Parkinson’s disease will require levodopa at some point over the course of their treatment for the disease, and 70%
to 80% of patients receive the drug at any given point in time. When LD/CD is taken orally, levodopa crosses into the brain through
the “blood-brain barrier” and is converted into dopamine. The resulting increase in the brain’s dopamine concentration
improves nerve conductivity and helps control the motor symptoms associated with Parkinson’s disease. The addition of carbidopa
allows lower doses of levodopa to be used by preventing the breakdown of levodopa into dopamine before levodopa crosses into the
brain.
One major limitation of
oral administration of LD/CD is that it results in highly variable and fluctuating levels of levodopa in the plasma. When LD/CD
is administered orally, levodopa is absorbed actively through amino acid receptors in the gastrointestinal tract and competes for
necessary receptors with amino acids from food and from carbidopa. Therefore, the absorption of levodopa is erratic and its bioavailability
is relatively low. Only 30% of it enters the blood stream; thus, by the time the levodopa reaches the brain, it has a significantly
reduced drug concentration than when it was administered. In addition, levodopa is also known for its short half-life of approximately
50 to 90 minutes, which means that approximately three to four hours after a single dose, almost none of the drug remains in the
plasma. Due to the short half-life, patients are required to take multiple LD/CD doses daily. This results in sharp fluctuations
in levodopa levels, which in turn causes concomitant sharp fluctuations in brain-dopamine levels shortly after oral levodopa ingestion.
When brain-dopamine levels are excessive, motor complications, such as dyskinesia, occur. Such motor complications occur at increasing
levels as the disease progresses: 20% of Parkinson’s disease patients develop motor complications and “off time”
within six months of diagnosis, 50% after 18 months and almost all patients suffer from motor complications, with up to six
hours of “off” time within two to five years. The fluctuations in brain-dopamine levels due to the oral administration
of levodopa result in the erratic “off” and “on” periods shown in the figure below. This figure also demonstrates
the narrowing of the therapeutic window over time, i.e. higher doses are needed to turn a patient “on” but may also
cause dyskinesia.
There are three main stages
of Parkinson’s disease: mild, moderate and severe. According to MEDACorp, Inc., Ltd., patients suffering from moderate to
severe Parkinson’s disease constituted approximately 60% of all Parkinson’s disease patients in 2011.
Mild Parkinson’s disease
Early-stage patients who
suffer from mild Parkinson’s disease may experience shaking in the hands or fingers, slowness in movement and stiffness in
the muscles. In this stage of Parkinson’s disease, the brain still produces some base level of dopamine. Such patients are
generally treated with one or more of these forms of treatment: oral drugs (delivered in the form of pills) such as MAO inhibitors,
which help block the breakdown of dopamine in the brain; dopamine agonists (most of which are oral drugs), which activate dopamine
receptors; or relatively low-dose LD/CD complementation therapy. Oral drugs are effective in reducing motor symptoms associated
with mild Parkinson’s disease. However, as the disease progresses, such drugs provide only modest symptomatic improvements
and additional therapeutic approaches are needed, mainly consisting of higher doses of LD/CD.
Moderate Parkinson’s disease
Within two to five years
from the diagnosis of Parkinson’s disease, the disease progresses to the moderate stage when, despite optimized LD/CD therapy,
patients develop motor complications, i.e., more frequent daily “off” time causing limited mobility. At this stage
of the disease, performing normal physical tasks becomes more difficult for such patients due to increased “off” time
and dyskinesia. In addition, patients at this stage begin to suffer from morning akinesia. Patients with moderate Parkinson’s
disease are dependent on, and typically treated with, high doses of LD/CD. For example, patients may receive extended-release tablets
of dopamine agonists in order to treat the symptoms of Parkinson’s disease. One such extended-release tablet, Mirapex ER,
had annual peak sales of $810 million worldwide in 2010.
Severe Parkinson’s disease
As the Parkinson’s
disease progresses to the severe stage, patients’ therapeutic window narrows. Patients in this stage experience extended
“off” time and, as a result of frequent doses of LD/CD, frequent and severe dyskinesia, causing a small subset of these
patients to become bedridden or require a wheelchair. Over time, patients who have not adequately responded to oral LD/CD therapy
must either live with such conditions or undergo invasive surgical procedures to try to control or minimize motor complications.
The primary existing treatments for patients who suffer from severe Parkinson’s disease require surgical intervention. These
include deep brain stimulation, or DBS, which involves inserting electrodes into the brain, or LCIG, which requires gastrointestinal
surgery. We estimate that approximately 700,000 patients who suffer from severe Parkinson’s disease globally do not receive
such advanced Parkinson’s disease treatments.
According to Transparency Market Research,
the 2012 global DBS device market size for Parkinson’s disease, excluding surgical costs, was approximately $500 million.
DBS is a highly invasive procedure that involves open-brain surgery with local anesthesia applied to numb the scalp, during which
electrodes are implanted into the brain and connected to a small electrical pulse generator that can be externally programmed.
Once in place, electrical impulses are sent from the device to the brain. These impulses block the electrical signals that cause
tremors and other Parkinson’s disease symptoms. Studies have shown that DBS is effective in reducing tremors, stiffness,
some walking problems and other movement-interfering symptoms in patients who undergo the DBS procedure. Nonetheless, DBS involves
extreme risks, including coma, seizures, speech loss, cognitive deficits, infection and bleeding in the brain, which can cause
stroke-like symptoms. Patients who undergo DBS are also required to have additional surgeries every three to five years in order
to replace the battery. The complexity and related risks of this invasive procedure preclude physicians from referring older patients,
and nearly 52% of Parkinson’s disease patients who receive referrals to undergo this procedure are turned down. According
to a 2012 study by the Association of American Medical Colleges, there are approximately 14,000 neurologists and geriatricians
in the United States and, based on a an article titled “Neurology Residency Training in Europe—the Current Situation”
in the April 2011 issue of the European Journal of Neurology along with publicly available data from the British Geriatrics Society,
we estimate that there are approximately 35,000 neurologists and geriatricians in Europe, in each case, that we believe may treat
patients who suffer from moderate Parkinson’s disease. We further believe, based on information from leading physicians,
that there are an estimated 1,500 physicians in each of the United States and Europe that may treat patients who suffer from severe
Parkinson’s disease.
Similarly, Duodopa, which
had sales of $293 million for the year ended December 31, 2016, is a high dose LCIG product that was recently approved in the United
States under the name Duopa. Duodopa is administered into the duodenum via a permanent tube that is surgically inserted into the
duodenum. Surgery for treatment with Duodopa involves general anesthesia and significant costs requiring gastrointestinal surgery.
Patients receiving this form of treatment face potential complications, such as connector leakage, dislocation or movement of the
intestinal tube, wound infection or peritonitis. In addition, patients must continuously carry a large, bulky shoulder-worn pump
attached to their duodenum during the day. Duodopa is designed for continuous 16-hour administration of a gel form of high-dose
LD/CD. Patients usually remove the pump at night, which affects quality of sleep and results in morning akinesia. Such complications
and restrictions acutely limit the patients’ day-to-day activities and prevent many of the patients from having this treatment.
Our Solutions for Parkinson’s Disease
We believe we are the
first company to develop liquid formulations of LD/CD, enabling continuous subcutaneous administration to more effectively treat
Parkinson’s disease. Our formulations, based on existing drugs enable the administration of drugs, which are currently either
delivered orally and have low bioavailability, or through routes requiring surgical intervention, to be administered continuously
and subcutaneously. Our Parkinson’s disease product candidates are designed to provide a steady state therapeutic level of
levodopa or apomorphine via continuous 24-hour administration. We expect these product candidates to reduce the debilitating “off”
time that Parkinson’s disease patients typically experience and to improve patients’ quality of life by significantly
ameliorating motor and non-motor complications, while also giving patients who suffer from severe Parkinson’s disease an
alternative to surgery.
Our Parkinson’s
disease product candidates are drug-device combination products, with distinct devices and varying LD/CD or apomorphine concentrations
and dosages that are tailored to treat certain populations of Parkinson’s disease patients. See “— Our Solutions
for Parkinson’s Disease — Delivery devices.” To further the clinical development of our product candidates,
the MJFF awarded us $1.0 million grants in each of 2010 and 2013.
Advanced Parkinson’s Disease:
ND0612H
We
are developing ND0612H for the treatment of patients suffering from advanced Parkinson’s disease and for whom oral drugs
are no longer effective. ND0612H is designed to be more effective therapy than oral LD/CD, and we believe it will offer a safe
and effective alternative to surgery and other highly invasive and complicated treatments such as DBS and LCIG. ND0612H is designed
to provide continuous subcutaneous delivery of an adjustable dose LD/CD formulation in order to reduce the motor complications
associated with orally administered LD/CD by maintaining controlled and steady plasma levodopa concentration levels between 1,500
and 2,000 ng/ml, which are currently achieved only with Duodopa. Like ND0612H, ND0612L is designed to continuously administer
LD/CD over night to avoid morning “off” time and improve sleep quality. Furthermore, unlike Duodopa’s 16-hour,
duodenal administration by way of a large shoulder-worn pump, ND0612H’s 24-hour, subcutaneous administration by way of the
CRONO Twin ND, a more convenient and smaller belt-pump (described below) that resembles the administration of insulin to diabetic
patients. Depending on the results of our clinical trials and the regulatory approval process, we expect to submit applications
for marketing approval in Europe and the United States for ND0612H in
the second half of 2018.
Moderate Parkinson’s Disease:
ND0612L
We are developing ND0612L
for the treatment of patients at the moderate stage of Parkinson’s disease that can no longer effectively control motor complications
with oral levodopa. Each dose of ND0612L is designed to be continuously administered subcutaneously to such patients for a 24-hour
period via the CRONO ND belt pump (described below). ND0612L is designed to administer approximately 40% of the maximum daily levodopa
dosage delivered by ND0612H. By maintaining a steady plasma levodopa concentration between 700 and 1,000 ng/ml, we aim to
reduce dyskinesia and “off” periods and to improve sleep quality. In addition, we are designing ND0612L to allow patients
to receive LD/CD overnight. We expect that ND0612L will serve as a second-line therapy for patients suffering from moderate Parkinson’s
disease and may be used as an adjunct or mono-therapy. Depending on the results of our clinical trials and the regulatory approval
process, we expect to submit applications for marketing approval in the United States and Europe for ND0612L in 2018.We are also
developing with third-party medical device designers and manufacturers a smaller, next-generation patch-pump device for use with
ND0612L in the future.
Moderate to Severe Parkinson’s
Disease: ND0701
In addition to our LD/CD Parkinson’s
Disease product candidates, we have also developed ND0701, an apomorphine-based product candidate designed to offer a next-generation
alternative to the continuously administered apomorphine product currently approved and sold outside the United States in order
to significantly improve local tolerability and allow a much lower daily administration volume. ND0701, for patients who suffer
from Parkinson’s disease, may be used mostly by patients who suffer from high motor fluctuations and who do not respond well
to LD/CD. ND0701 is administered via CRONO ND belt pump (as described below). See “— Our Solutions for Parkinson’s
Disease — Clinical trials of ND0701.”
Our Cognition Disorder Product Candidate
We are also developing a product candidate,
ND0801, to treat cognition disorders associated with CNS diseases, such as ADD/ADHD, Alzheimer’s disease and schizophrenia.
ND0801’s reformulation is designed to be a tansdermal patch of opipramol and nicotine, intended to become a safe and non-addictive
nicotine-based treatment administered via a transdermal patch. See “— Cognition and our ND0801 Product Candidate.”
Delivery devices
Both the CRONO ND and
CRONO Twin ND belt pumps are manufactured by a cGMP-certified, third-party medical device manufacturer. The CRONO ND belt pump
has been “CE” marked in accordance with EU law and will be submitted for regulatory approval in the United States as
the device component of the ND0612L drug-device combination product. Similarly, the CRONO Twin ND belt pump’s design has
been “CE” marked in accordance with EU law and will undergo a drug-device combination approval process in the United
States. See “ITEM 4. Information on the Company—B. Business Overview—Government Regulation.”
|
·
|
CRONO ND.
CRONO ND is a simple-to-operate, fixed-dose belt pump that operates 24 hours a day and can be preprogrammed
to the desired delivery profile of LD/CD. This device is used to administer our ND0612L and ND0701 drug formulations. CRONO ND
consists of two parts: a preprogrammed pump device that regulates the delivery rate of the drug, and a single-use, disposable cartridge,
which holds our liquid reformulation of LD/CD and which is connected to an infusion tube. For ND0612L, the CRONO ND infusion tube
is attached to a small disposable cannula, or flexible needle, positioned to subcutaneously deliver 4.5ml of LD/CD to the patient
per day. The disposable cartridge and the infusion set are discarded and replaced by the patient daily.
|
|
·
|
CRONO Twin ND.
CRONO Twin ND is also a simple-to-operate, adjustable belt pump. The durable belt pump fits into a case
that can be attached to a patient’s belt and shares the same characteristics of the CRONO ND, in that it is preprogrammed
to pump up to 12ml of LD/CD subcutaneously for 24 hours a day through a small tube connected to the disposable cartridge. However,
the CRONO Twin ND belt-pump delivers LD/CD subcutaneously through two insertion points, allowing administration of up to 2.6 times
more levodopa than CRONO ND.
|
|
·
|
Second-Generation Patch Pump.
We have engaged third-party firms to design and eventually manufacture a patch pump that
will be used for the administration of ND0612L and ND0701. The patch pump would be worn directly on the skin underneath a patient’s
clothing and preprogrammed to subcutaneously deliver our reformulated drugs 24 hours a day without requiring further attention
from the patient. The patch pump will be a smaller and even more convenient device than CRONO ND, with similar characteristics:
a single-use portion, from which the cannula is placed under the skin, and a durable portion, which controls and regulates the
administration of the drug. We currently expect that the patch pump will be utilized in our ND0612L and ND0701 product candidates.
|
Preclinical trials
Our preclinical trials
for ND0612L have shown a positive, linear, correlation between the subcutaneous doses of LD/CD and plasma levodopa concentrations.
The variability of plasma concentrations attained by subcutaneous administration is significantly less than that obtained with
oral LD/CD administration, providing more reliable, predictive and constant plasma levodopa concentration. Preclinical trials demonstrated
a dose-response correlation between ND0612L and plasma levodopa concentrations. We have also conducted a nonclinical study of ND0612L
for 28 consecutive days on pigs. The study was carried out on 18 pigs divided into three equal groups of three male and three female
pigs. Group one acted as control and received the placebo, while groups two and three received two different doses of ND0612L.
The primary endpoint was ND0612L’s local and systemic toxicity when administered by continuous subcutaneous infusion. No
signs of systemic toxicity were observed during the study and local reactions at the administration site were rare, minimal and
sporadic.
We also completed a
90-day, local tolerability and toxicity study in mini-pigs to evaluate potential local and systemic reactions to long-term exposure
to ND0612H and ND0612L. No systemic adverse effects were observed after 13 weeks of continuous subcutaneous infusion with either
ND0612H or ND0612L. Treatment-related findings included minimal to moderate reactions at the injection sites, which correlated
to the frequency of administration at those sites and was less evident at sites when administered with longer intervals between
treatments (≥15 days). All sites displayed a significant degree of recovery within 30 days. Drug absorption was not affected
by such local reactions and levodopa blood levels were similar throughout the study period. In our pre-IND meeting with the FDA,
it was agreed that this would serve as the preclinical requirement for an NDA submission.
We have conducted multiple
preclinical studies with ND0701. Based on such studies, the pharmacokinetics of ND0701 was found to be equivalent to that of the
commercial apomorphine-HCl solution, Apo-Go. We have also completed a 28 days local tolerability study to support further clinical
study. Based on histological and MRI evaluation, ND0701 was found to have favorable local safety, even when administered at concentrations
five times higher than Apo-Go.
Completed clinical trials
To date, we have completed
the following clinical studies for ND0612 using the CRONO ND belt-pump device design:
Phase I and Phase Ib —ND0612L—Israel.
We
conducted a Phase I, single dose, 24-hour continuous administration, single-center, randomized, double-blind, placebo-controlled
dose escalation study to evaluate the safety, tolerability and plasma levodopa concentration following continuous subcutaneous
delivery of LD/CD in 36 healthy subjects for one day. The subjects were divided into six equal groups, receiving LD/CD at a rate
of (i) 80 µl/h; (ii) 120µl/h; (iii) 160 µl/h; (iv) 200 µl/h; (v) 200µl/h
using a shorter cannula infusion; or (vi) 240 µl/h. The primary endpoint was the drug’s safety and tolerability
and its pharmacokinetic attributes under each rate of infusion. Data showed that the plasma levodopa levels increased linearly
with the dose. The following chart shows mean plasma levodopa concentrations at varied doses of LD/CD from 15 to 24 hours after
infusion. Pursuant to the design of the study, the infusion occurred at hour zero but the plasma sampling commenced at hour 15.
For the purposes of this chart, we combined the two groups of patients who received LD/CD at the rate 200 µl/h and 200µl/h
using a shorter cannula infusion as there was no statistical difference in the mean LD plasma concentrations of these patients.
A continuation study of the Phase I trial
was subsequently conducted as a Phase Ib study on an additional 18 healthy male volunteers to evaluate three additional doses.
The subjects were divided into three equal groups of six patients, receiving either (i) 5%/1.25% LD/CD at a rate of 240 µl/h
for 24 hours; (ii) 6%/1.5% LD/CD at rates of 240 µl/h for 16 hours and 80 µl/h for eight hours;
or (iii) 6%/1.5% LD/CD at a rate of 240 µl/h for 24 hours with oral entacapone administered every two hours for
10 hours. The primary endpoint was the drug’s safety and tolerability and the pharmacokinetic attributes of a specific
dose and rate of infusion. ND0612L demonstrated good tolerability and safety at each tested rate. Additionally, adverse local response
was minor, typical to other continuously subcutaneously administered drugs.
Phase IIa —ND0612L—Israel.
We
conducted a Phase IIa, single dose, 24-hour continuous administration, single-center, randomized, double-blind, placebo-controlled,
cross-over study on eight subjects with moderate Parkinson’s disease. The eight subjects were randomly treated with either
placebo or ND0612L continuously for twenty-four hours. One week later, the same eight subjects switched to the other treatment
(e.g., patients who had previously received placebo were treated with ND0612L) and received such treatment continuously for
twenty-four hours. The primary endpoint was the pharmacokinetic attributes of the plasma concentrations of levodopa following subcutaneous
delivery of ND0612L, and the secondary endpoint was the safety and tolerability of ND0612L compared to saline. The preliminary
data showed that subcutaneous delivery of ND0612L achieved steady-state plasma levodopa concentrations ranging from 700-1,000 ng/ml
(which is estimated to be within the typical therapeutic range). Additionally, fluctuations in plasma levodopa concentration were
significantly reduced. The chart below compares the mean plasma levodopa concentrations in subjects treated either with ND0612L
or a saline solution. All patients received Stalevo, an orally administered triple combination drug that includes levodopa, carbidopa
and entacapone. The addition of carbidopa and entacapone extends the half life of levodopa. Continuous administration of ND0612L
resulted in subjects having a higher mean plasma levodopa concentration than the control group.
Phase II —ND0612L— Israel.
In October 2014, we successfully completed a randomized, placebo-controlled, double-blind clinical study of ND0612L of 30 subjects
with moderate to severe Parkinson’s disease. The purpose of this study was to examine the safety, tolerability, LD/CD plasma
levels (pharmacokinetics) and exploratory efficacy end points following subcutaneous delivery of ND0612L.
Study design
The study included two
treatment periods. In the first period, all patients received optimized, current oral standard of care and were then randomized
(in a 2:1 ratio) to receive as an add-on a subcutaneous infusion of either ND0612L or placebo for 14 days. After 14 days,
according to the protocol, 16 patients were offered an additional week of treatment, in which they were randomized to receive either
ND0612L alone or ND0612L with oral entacapone, in each case, without the patient’s standard of care.
All parameters, including
safety, tolerability and pharmacokinetics, were compared to the patients’ original baseline standard of care and between
groups. Additionally, exploratory efficacy end points, including daily duration of “off” time, “on” time
(with and without troublesome dyskinesia), quality of sleep, quality of life and disease improvement were assessed in the clinic
and reported in subjective home diaries. Eligible patients included male or female individuals with Parkinson’s disease,
experiencing motor fluctuations averaging more than two hours of “off” time per day on optimized levodopa treatment
and, if necessary, additional Parkinson’s disease drugs. Patients treated with controlled-release levodopa formulations who
had undergone neurosurgical intervention for Parkinson’s disease or who suffered from severe disabling dyskinesia were excluded.
Topline results of this study are presented below:
Safety and tolerability results
We believe that ND0612L
was generally well tolerated and safe, causing only minimal and transient local reactions at the infusion site and no particular
systemic adverse events, which corroborates the results obtained in our previous Phase I and Phase IIa studies. No adverse
events, local or systemic, caused treatment discontinuation or withdrawal from the study, and the 16 patients chose to continue
to the second phase of the study. Additionally, all patients complied with treatment protocol and successfully operated the pump,
with some patients being assisted by a caregiver or a nurse.
Pharmacokinetics results
Treatment with ND0612L
resulted in a clinically significant reduction in fluctuations of plasma levodopa concentrations when compared to the placebo.
In the group treated with ND0612L, plasma levodopa concentrations were relatively stable and were maintained above an average minimum
of approximately 800ng/ml, avoiding the low trough concentrations observed in the placebo group (approximately 180ng/ml), as shown
in the chart below. Compared to the placebo, ND0612L also demonstrated a markedly reduced peak-to-trough ratio, which measures
the maximum concentration relative to the minimum, and fluctuation index, which measures the concentration fluctuations relative
to the average level of levodopa, as shown in the table below.
In order to determine
the effect of ND0612L without the standard of care, following the first period, 16 patients, as planned pursuant to the protocol,
volunteered for an additional week of open label study with treatment of ND0612L alone or with entacapone. The chart below shows
that an average steady plasma levodopa concentration of 550ng/ml was maintained when ND0612L was administered alone, and an approximately
800ng/ml plasma levodopa concentration was maintained when ND0612L was administered together with thrice-daily oral entacapone.
* Includes 10 out of 16 patients, who did not require
additional oral levodopa to control their disease during the assessment period.
Futility analysis
ND0612L successfully met the primary end
point of the exploratory efficacy futility analysis, pre-specified in the statistical plan, a reduction in “off” time
greater than a threshold of at least 1.6 hours, by demonstrating an average reduction of 2.1 hours in “off”
time based on home diaries. Therefore, we intend to proceed to pivotal clinical studies of ND0612L.
First period clinical efficacy results
Treatment with ND0612L
demonstrated significant clinical benefits over the placebo in all objective, in-clinic, pre-specified, exploratory efficacy end
points, in spite of being a low-powered study, including only 30 patients, that was not designed to achieve statistical significance
of an efficacy endpoint. Accordingly, statistically significant values (p-values) are not presented.
·
Off-time:
A
mean reduction of two hours versus placebo was observed in the ND0612L treated group in spite of a marked reduction in oral levodopa
dose. Moreover, the reduction in “off” time was not accompanied by an increase in troublesome dyskinesia.
1
___________________________________
1
Data was only available from 29 patients for “off” time reduction and troublesome dyskinesia, as one in-clinic diary
was lost at the clinical center.
As compared to in-clinic results,
a smaller reduction in “off” time versus placebo was observed in the home diaries due to the strong placebo-effect
common to Parkinson’s disease studies.
·
Sleep
quality:
ND0612L improved quality of sleep by 30.3% compared to 0.9% in the placebo group, expressed by reduction
in the Parkinson’s Disease Sleep Scale, or PDSS. This highlights the fact that, unlike current Parkinson’s drug therapies,
ND0612L demonstrates the ability to treat patients throughout the night.
·
Quality
of life:
ND0612L improved quality of life score by 17.1% compared to 4.8% in the placebo group as determined
by the Parkinson’s Disease Questionnaire, or PDQ-39.
·
Global
disease improvement (CGI-C):
ND0612L patients showed clinical improvement in 89.5% of patients compared with
only 36.0% of patients in the placebo group. This improvement was determined by physician’s assessment based on a seven-point
scale, the Clinical Global Impression, or CGI-C.
Second period clinical efficacy
results
Similar trends were also observed in the
second period of the study. All patients markedly reduced their oral levodopa intake during the second period by a median of 80%,
with 19% of the patients discontinuing oral levodopa treatment completely.
Phase IIa
—
ND0612H and ND0612L
—
Israel.
In December 2014, we successfully completed a multicenter, open-label,
dose-finding Phase IIa study of 16 subjects with motor complications caused by Parkinson’s disease. The primary endpoints
of this study were to assess the safety, tolerability and pharmacokinetics of six dose regimens of ND0612H and ND0612L compared
to the patient’s standard oral doses of LD/CD, including high and low concentrations of carbidopa and the concomitant administration
of oral entacapone. Sixteen advanced Parkinson’s disease patients (all of whom completed the study), with motor fluctuations,
chronically treated with standard oral LD/CD, were enrolled in the study and were treated with ND0612L (n=9) or ND0612H (n=7) for
eight hours per day, for three consecutive days, with high and low doses of CD, and with adjunct oral entacapone.
Final results of the
study showed that plasma levodopa levels were proportionate to dose, with ND0612H achieving approximately three times higher plasma
levels than ND0612L. ND0612H achieved maximum average daytime concentrations of 1,454ng/ml when administered alone and 1,844ng/ml
when combined with two administrations of oral entacapone during eight hours of infusion. ND0612L achieved maximum daytime concentrations
of 487ng/ml and 604ng/ml with adjunct dosing of oral entacapone.
Both ND0612H and ND0612L regimens maintained
steady, therapeutic plasma concentrations of levodopa. Fluctuations in levodopa plasma levels were significantly reduced with ND0612
regimens in comparison to oral LDCD. The primary pharmacokinetic endpoint of this study, the fluctuation index of levodopa (mixed
measures repeated model (MMRM) analysis of Models root mean square estimate (MSE)), was significantly reduced with ND0612 regimens
when compared to oral LDCD (p < 0.0001). In addition, ND0612H and ND0612L administration achieved high levodopa plasma concentrations,
irrespective of the dose of carbidopa provided.
The chart below presents
the plasma levodopa concentrations obtained with ND0612H and ND0612L, with and without entacapone.
Treatment with ND0612L and ND0612H did
not raise safety and tolerability concerns, causing only minimal and transient local reactions at the infusion site and no particular
systemic adverse events, which corroborates the results obtained in previous studies. We believe these results suggest that ND0612H
could provide an effective treatment option for the majority of advanced Parkinson’s disease patients that are considering
or are currently treated with DBS or Duodopa.
Pharmacokinetic(PK) Pilot Study —ND0612H
We have commenced bioequivalence clinical
trials that compare the level of ND0612 in plasma to existing forms of treatment that require surgical intervention. Our initial
such trial was an open-label, pharmacokinetic, or PK, pilot dose study on 36 healthy volunteers. The primary endpoint was to define
the bioequivalent dose of the LD/CD plasma concentrations of ND0612H compared to Duodopa.
In
June 2016, we announced topline results of this study. The results demonstrated, among other findings, that ND0612H levodopa exposure
levels had lower inter-subject variability, or CV%, than DUODOPA and that administration of comparable levodopa doses resulted
in higher total plasma exposure, or AUC, from ND0612H than from DUODOPA, suggesting a higher bioavailability for ND0612H. Although
not an objective of this trial, the 90% confidence interval of the geometric mean ratios of the two drugs in both parameters were
found to lie within the bio-equivalence range, a finding that is statistically significant (p<0.001 for AUC, p=0.015 for Cmax)
and lies within regulatory authorities’ bioequivalence acceptance criteria.
Phase II — ND0612H — United
States, Europe and Israel.
In December 2016, we completed patient enrollment and treatment in a 28-day, multicenter,
parallel-group, single blind (rater-blinded), randomized pilot Phase II study
of
38 subjects, with advanced Parkinson’s disease, who experience at least 2.5 hours of “off” time per day and whose
symptoms are not adequately controlled with oral medications.
Trial 006 Design
Trial 006 was a 28-day
multicenter, international (US, EU and Israel), parallel-group, blinded rater, randomized Phase II study that investigated the
efficacy, safety, tolerability and pharmacokinetics of two dosing regimens (R1 and R2) of ND0612H and compared them to the baseline
of standard optimized oral therapy:
|
·
|
R1: 24 hour administration of ND0612H (720/90mg LD/CD) at a high day rate for
18 hours and a low night rate for 6 hours.
|
|
·
|
R2: 14 hour administration of ND0612H during the waking hours (538/68mg LD/CD)
complemented by a morning dose of 150/15mg oral LD/CD.
|
In addition, all patients
could add oral LD/CD therapy at any time as needed. The 38 enrolled subjects had typical characteristics for patients with advanced
Parkinson’s disease including: an average age of 63.5 years, 11.5 years since diagnosis and an average baseline OFF-time
of 5.3 hours per day.
Trial 006 Preliminary
Results
OFF-time
(primary endpoint):
The primary endpoint
was met in R1. From 5.5 hours at baseline, the OFF-time was reduced by 2.8 hours (p equals 0.004). There was a smaller, non-statistically
significant reduction of 1.3 hours in OFF-time in R2.
“ON”
by 8:00am and 9:00am (key secondary endpoint):
In R1, the proportion
of patients who achieved the first “ON” by 8:00am (as reported by the patient) increased from 11% at baseline to 50%
by day 28 (p equals 0.020), and, by 9:00am, from 26% at baseline to 75% (p equals 0.004). In R2, dosing began in the morning and
there was therefore no improvement from baseline at either timepoint.
Complete
reduction of OFF-time (post-hoc analysis):
As demonstrated
in the chart below, in R1, 42% of patients had a complete reduction in OFF-time to zero hours (in R2, 11% experienced complete
resolution of OFF-time). Patients who experienced reduction in OFF-time (greater than 0 hours change) during the trial were defined
as “Responders” and constituted 68% of all patients (12 patients in R1 and 14 patients in R2). Eight (66%) of the Responders
in R1 (and two (14%) of the Responders in R2) experienced a complete reduction of their OFF-time to zero hours; all Responders
in R1 experienced a reduction of more than 50% in their OFF-time.
“Good” ON (secondary
endpoint):
Good ON (defined
as “ON” with no or mild dyskinesia, as assessed by the blinded rater) increased in R1 from 9.2 hours by 3.7 hours (p
less than 0.001), and in R2 from 8.5 hours by 2.8 hours (p equals 0.003).
Unified Parkinson’s Disease
Rating Scale (UPDRS) III by 8:00am (post-hoc analysis):
UPDRS III score
by 8:00am decreased in R1 from 37.4 at baseline by 19.1 points (p less than 0.001) and from 37.3 at baseline by 10.7 points in
R2 (p equals 0.001).
Troublesome Dyskinesia (post
hoc analysis):
Troublesome dyskinesia
(defined as “ON” with moderate or severe dyskinesia as assessed by the blinded rater) decreased from 5.1 hours at baseline
by 3.5 hours (p equals 0.011) in the subgroup of all patients who had at least 1 hour of troublesome dyskinesia at baseline (N
equals 14, R1 and R2 combined).
Oral LD Dosing and Frequency
(post hoc analysis):
Average dosing
frequency of oral levodopa decreased in all patients from 6.6 times at baseline to 2.3 times per day by day 28. The average dose
of oral LD decreased from approximately1100mg at baseline to approximately 330mg.
Safety and Tolerability:
33 subjects (87%)
out of 38 completed the study with 5 who did not complete the study, two of which were due to adverse events: one due to an infection
at the infusion site and the other due to worsening of symptoms. Infusion site reactions (nodules, bruising and erythema) were
common yet generally well tolerated. These results corroborate the safety and tolerability data obtained in previous studies and
did not raise new safety or tolerability concerns.
Preliminary trial
006 results demonstrate that the R1 dosing regimen provides a significant reduction in OFF-time and a significant increase in ON-time
with no or mild dyskinesia and together with a reduction in LD avarage dose and frequncy. A substantial percentage of subjects
experienced complete resolution of OFF-time.
Benefits were
also seen with the R2 regimen in spite of the study design whereby patients started levodopa therapy later in the morning. ND0612H
devices were generally found to be reliable with only few minor, correctable malfunctions reported. No inconvenience related to
the wearing of the device was reported for either day or night administration.
Current and future clinical trials with ND0612H and ND0612L
Our ongoing and currently-planned
clinical trials are a function of our regulatory pathway strategies for obtaining approval of ND0612 from the FDA and EMA.
In late October 2016,
we held an End-of-Phase 2 meeting with the FDA, during which we discussed the regulatory development strategy for ND0162H and ND0612L.
Based on such discussions and responses from the FDA, we have amended our clinical development strategy for these product candidates.
Instead of conducting large Phase 3 clinical efficacy trials, we intend to pursue marketing approval in the United States for ND0612L
and ND0612H via a comparative bioavailability 505(b)(2) regulatory pathway. In order to submit an 505(b)(2)-based NDA, we plan
on conducting several comparative PK studies against Duodopa/Duopa, an FDA-approved drug for the treatment of “late stage”
and “advanced” Parkinson’s disease.
In January 2017, we held
a meeting with EMA’s Scientific Advice Working Party to discuss ND0612. Based on this meeting and on the preliminary results
of our phase II trial (006), we have modified our EU clinical and regulatory development path. Upon the completion of our ongoing
trials, we plan to submit a marketing application based on the results of an amended iNDiGO phase III efficacy study and the ongoing
BeyoND (trial 012) long-term safety trial, seeking to obtain a broader label for ND0612 than the label that could have been granted
under a PK regulatory route in the EU.
The following table
summarizes ongoing and/or currently-planned clinical trials and studies with respect to our pipeline product candidates, which
reflects our updated strategy based on our most recent discussions with the FDA and the EMA:
Study
|
|
Actual or
Estimated
Start Date
|
|
Population Type**
|
|
Design*
|
|
No.
Patients
|
|
Primary
Endpoint
|
|
Treatment
Duration
|
Clinical Development of ND0612
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
iNDiGO Phase III Effiacy Trial
|
|
Ongoing*
|
|
PD
|
|
Double blind
|
|
240
|
|
Efficacy
|
|
16 weeks (optional 1 yr extension)
|
PK Trials
|
|
2017
|
|
PD
|
|
PK
|
|
70-80
|
|
Bioequivalence†
|
|
Approximetly 1 week
|
BeyoND Safety Trial (Safety follow-up)
|
|
Ongoing
|
|
PD
|
|
Open
|
|
~150
|
|
Local safety
|
|
12 months (optional 1 yr extension)
|
|
*
|
“PK” stands for pharmacokinetic.
|
|
**
|
“PD” stands for patients suffering from Parkinson’s disease.
|
Ongoing and Planned Studies
|
·
|
BeyoND Safety
Follow-up— ND0612H — International.
We initiated in 2016 a multicenter, open
extension study of ND0612H, to follow approximately 100 patients in order to assess the long-term safety, particularly dermal
safety, of continuous subcutaneous infusion of ND0612H. Following our meeting with the FDA in October 2016,
we
decided to add approximately 50 patients to this safety trial. These additional patients will be subject to a different
dosing regimen that is in line with our above-described PK trials. We expect results from this trial in 2018.
|
|
·
|
iNDiGO Phase III Efficacy Study
— ND0612— International
.
We plan to amend and restart the iNDiGo trial to support a broad label claim in the EU for ND0612. iNDiGO is a 16-week, international,
multicenter, randomized, double-blind, placebo controlled, parallel group study designed to compare the efficacy, safety and tolerability
of continuous subcutaneous infusion of adjunct ND0612 therapy with oral standard-of-care and placebo in patients who suffer from
motor fluctuations despite optimized standard-of-care therapy. The trial will enroll 240 patients, who will be randomized
to receive either continuous subcutaneous infusion of ND0612H, ND0612L or a placebo replaced every 24 hours during the 16-week
treatment period. The primary endpoint is the change from baseline to week 16 in the mean percentage of “OFF” time,
defined as periods of motor fluctuations that result in decreased mobility during waking hours, based on patients’ home diary
assessments and will include a responder analysis.
|
|
·
|
PK Trial — ND0612 — United States and
Europe.
We plan to initiate open-label, bioequivalence studies with ND0612 with approximately 70-80 patients
suffering from Parkinson’s disease. We expect to commence these studies in 2017. The purpose of these studies is to
obtain comparative PK data concerning ND0612 relative to Duopa/Duopdopa. The primary endpoint is to obtain bioequivalence
data in furtherance of our U.S. regulatory strategy.
|
Clinical development and overall safety assessment of ND0612
Based on our clinical
trials to date, there was no increased pattern in the type, severity or frequency of adverse events, with patients primarily experiencing
mild and transient side effects. Examination of the skin at the application site revealed temporary, circumscribed, firm areas
under the skin, varying in size from a pinhead to one square centimeter, which were noted only upon deep palpation and were not
associated with pain or discomfort. Our phase II trial (006) safety data was consistent with prior trials and did not raise new
safety or tolerability concerns. Other safety parameters, including physical examination, vital signs and electrocardiograms did
not reveal any notable issues or differences between study groups.
Clinical trials of ND0701.
We
currently expect to meet with the European regulatory authorities in the first half of 2017 to discuss the development strategy
of ND0701.
In the United States, we are evaluating the development of ND0701.
Below, we outline our current regulatory strategy
with respect to ND0701.
|
·
|
Pharmacokinetic Bioequivalence- Pilot Study.
In December 2016, we announced
the results of a pilot study, trial 101, in 18 healthy subjects comparing the PK of ND0701, our proprietary
continuous, subcutaneously delivered apomorphine liquid formulation, to commercial apomorphine in a pilot
crossover, randomized, two-sequence, 12-hour study. The study results demonstrated that ND0701 produced PK results that were comparable to
those produced by the referenced drug. Based on those results, we plan to pursue a
PK similarity regulatory development route in the EU for ND0701 and plan to conduct a follow-up comparison PK study in 2017
(as described below).
|
|
·
|
Pharmacokinetic Bioequivalence Definitive Study — Europe.
In
2017, we plan to conduct an open-label, bioequivalence study of 20 to 40 healthy volunteers. The purpose of the study is to compare
the bioequivalence of ND0701 with that of commercial apomorphine.
|
|
·
|
Local
Safety Follow-up Studies — Europe.
We
will plan eventual safety follow up studies based on the outcome of a planned meeting with EU authorities in the first half of
2017.
|
Cognition and our ND0801 Product
Candidate
We are also developing a product candidate,
ND0801, to treat cognition disorders associated with CNS diseases, such as ADD/ADHD, Alzheimer’s disease and schizophrenia.
Cognition refers to mental processes and brain functions that involve one’s ability to learn, understand and remember information;
to organize, plan and problem-solve; to focus, maintain and shift attention; and to understand and use language. The therapeutic
drugs most commonly used to treat the symptoms associated with ADD/ADHD are stimulants, such as Ritalin and Adderall, which have
significant abuse and misuse potential because their use is associated with severe psychological or physical dependence. Non-stimulant
drugs may also be prescribed to treat the symptoms associated with ADD/ADHD, although the significant side effects of such drugs,
including fatigue, decreased appetite, sexual problems, palpitations, increased heart rate and high blood pressure, have limited
their use.
To treat cognition disorders
associated with CNS diseases, we are developing ND0801, a non-addictive combination of nicotine and opripramol to be administered via a transdermal patch. We are
currently developing ND0801 for the treatment of ADD/ADHD, but we may consider treating other cognition disorders associated
with Alzheimer’s disease, schizophrenia or Parkinson’s disease with this product candidate, as well.
For ADD/ADHD, we believe our ND0801 drug candidate will eliminate the side effects associated with the current standard of
care, which are addiction and toxicity.
Preclinical
studies and development
We have conducted preclinical studies
to examine the effect of opipramol on nicotine addiction in animals. In one such study, we tested the effect of opripramol on the
withdrawal symptoms associated with nicotine in animal models. This study consisted of eight separate groups with either six or
seven subjects per group: group 1 received a saline solution for nine days and served as the control group; group 2 received nicotine
for seven days; groups 3 and 4 received opripramol for ten days; groups 5 and 6 received opripramol and nicotine for seven days
and just opripramol one day prior and one day after co-administration with nicotine; and groups 7 and 8 received nicotine for seven
days and opripramol on the eighth day. Per our examination of the subjects following the end of nicotine administration, we determined
that daily oral administration of opipramol with nicotine materially reduces the occurrence of nicotine withdrawal symptoms 23 – 24
hours after ceasing nicotine administration. In another preclinical study, we injected nicotine into rats, which produced a typical
1.5 degree reduction in the rats’ body temperature. Following controlled, repeated injections, the effect of nicotine on
the rats’ body temperature was significantly reduced overtime. In contrast, repeated injections of a combination of nicotine
and opipramol maintained nicotine’s effect on body temperature.
Clinical
trials
We are also conducting an open-label Phase
IIa proof-of-concept study with 60 patients suffering from ADD/ADHD at two centers in Israel. The study is designed to examine
the safety, tolerability and optimal therapeutic doses of opipramol and nicotine, within the approved range, and to evaluate the
cognitive improvement in the subjects following treatment with escalating doses of both drugs using standard cognition scale tests
and computerized tests. Study completion is expected in 2017. Based on the results of the Phase IIa study, we will examine what
specific cognition indications to pursue and develop a more detailed clinical plan for ND0801.
Research and Development
Our research and development
strategy is centered on continuing the clinical development of our product candidates and developing additional formulations based
on well-established drugs for high-value indications. Our research and development team, located at our facilities in Rehovot,
Israel, consisted of 55 full-time employees as of December 31, 2016 and is supported by highly experienced consultants, comprised
of our clinical guidance committee and scientific advisory board, in various research and development disciplines.
Our clinical guidance committee and scientific
advisory board are comprised of:
|
·
|
Warren Olanow, MD
—Dr. Olanow is a Professor and the Chairman Emeritus of the Department of Neurology
at the Mount Sinai School of Medicine in New York City, New York. His clinical and basic science research efforts are directed
toward defining more effective therapies for Parkinson’s disease and other neurodegenerative disorders. He is a member of
the executive committee of the Michael J. Fox Foundation Scientific Advisory Board and is presently Co-Editor-in-Chief
of the journal Movement Disorders.
|
|
·
|
Olivier Rascol, MD
—Dr. Rascol is a Professor of Clinical Pharmacology at Toulouse University Hospital
in Toulouse, France. Dr. Rascol has been actively involved in the development of several marketed anti-Parkinsonian medications.
|
|
·
|
Karl Kieburtz, MD, MPH
—Dr. Kieburtz is the Director of the Clinical and Translational Science Institute
in Rochester, New York and a Professor and Senior Associate Dean at the University of Rochester in Rochester, New York. He has
led numerous multi-site projects in neurodegenerative diseases and has served on and chaired various research groups related to
Parkinson’s disease research and other neurological conditions. He has served as the Chair of the Executive Committee of
the Parkinson Study Group and has served on the International Executive Committee of the Movement Disorders Society, the Executive
Council of the American Neurological Association, and the Chair of the Peripheral and Central Nervous System Advisory Committee
of the FDA.
|
|
·
|
Peter A. LeWitt, MD
—Dr. LeWitt is a Professor of Neurology at Wayne State University School of Medicine
in Detroit, Michigan and directs the Parkinson’s Disease and Movement Disorders Program at Henry Ford Hospital in West Bloomfield,
Michigan. Dr. LeWitt has directed laboratory research investigating neurochemical mechanisms and diagnostic markers in Parkinson’s
and Alzheimer’s diseases.
|
|
·
|
Nir Giladi, MD
—Dr. Giladi is the Chairman and a Professor at the Department of Neurology in the Tel
Aviv Medical Center in Tel Aviv, Israel, Director of the Department of Neurology Sackler School of Medicine in Tel Aviv University
and Chairman of the Medical Advisory Board to the Israeli Parkinson Association. Dr. Giladi specializes in movement disorders
and is past treasurer of the International Society for Parkinson’s disease and other movement disorders.
|
|
·
|
John Nutt, MD
—Dr. Nutt is a Professor of Neurology and Physiology & Pharmacology, Co-Founder
and Emeritus Director of the OHSU Parkinson Center of Oregon and Movement Disorders Program in Portland, Oregon and Emeritus Director
of the Portland VAMC Parkinson’s Disease Research, Education and Clinical Center in Portland, Oregon. Dr. Nutt conducts
innovative research in movement disorders.
|
|
·
|
Werner Poewe, MD
—Dr. Poewe is Professor of Neurology and Director of the Department of Neurology at
Innsbruck Medical University in Innsbruck, Austria. Dr. Poewe’s main research interests are in the field of movement
disorders with particular emphasis on the clinical pharmacology of Parkinson’s disease and dystonia. He served as President
of the International Movement Disorder Society as well as the past Chair of the Movement Disorders Society/European Section. He
has authored and co-authored numerous original articles and reviews in the field of movement disorders.
|
We received government
grants (subject to the payment of royalties) as part of our research and development programs that had been approved by the Innovation
Authority (formerly the OCS). As of December 31, 2014, 2015 and 2016, we had received, cumulatively, $1.9 million, $2.8 million
and $2.8 million, respectively, from the Innovation Authority for our research and development programs. Additionally, we receive
funding for our clinical trials through private offerings, convertible loans and third-party grants.
For example, the MJFF
awarded us one grant totaling $1.0 million to support our Phase I trial for ND0612L, or the 2010 Grant, and a second 18-month grant
totaling $1.0 million to support our Phase II clinical study of ND0612L, or the 2013 Grant. We have performed all of our obligations
under the 2010 Grant and have ongoing reporting and royalty obligations under the 2013 Grant. Pursuant to the 2013 Grant, we are
obligated to pay the MJFF royalties of 10% of the revenue received from the option, license, sale, transfer or use of ND0612L,
its derivative product candidates or any new invention arising from the project or any product incorporating such invention after
approval for marketing. We are obligated to pay a maximum of $2.0 million in such royalty payments to MJFF, after which no future
royalty obligation exists. On August 27, 2014, we received the final installment of approximately $0.3 million.
We incurred approximately
$8.1 million, $12.8 million and $27.0 million in research and development expenses, net, in the years ended December 31, 2014,
2015 and 2016, respectively. See “Item 5. Operating and Financial Review and Prospects—Components of Statement of Operations—Operating
expenses—Research and development expenses.”
We engage third-party
research organizations to conduct clinical tests and preclinical studies to support the efficacy and safety of our products and
their ingredients and to extend and validate their benefits for human health. Preclinical studies allow us to substantiate the
safety of our products and obtain preliminary indications of their pharmacological profile. As of December 31, 2016, third-party
research organizations had conducted more than three preclinical studies, according to the principles of Good Laboratory Practices,
or GLP, and more than seven clinical studies, according to the principles of GCP, for our product candidates.
Manufacturing, Supply and Production
The manufacturing of our product candidates
is subject to strict safety requirements and compliance with cGMP. As we seek regulatory approval in the United States and other
jurisdictions for our product candidates, the FDA or other applicable agencies may inspect the manufacturing plant in which our
products are manufactured to confirm it meets all regulatory requirements. Any changes in the production processes for our product
candidates for advanced clinical trials under an IND must be approved by regulatory authorities in these jurisdictions.
The active ingredients in our ND0612H
and ND0612L are LD/CD, which are approved for use in several jurisdictions, including the United States and Europe. We currently
acquire LD/CD for use in our clinical trials from accredited U.S. and European suppliers. We work with a reputable U.S. cGMP drug
product manufacturer in order to ensure we have sufficient amounts of the drug product for our planned clinical trials and for
marketing ND0612H and ND0612L if and when they are approved.
In addition, we are in the process of
qualifing an additional EU cGMP manufacturer to serve as an alternative source for our drug developments.
Additionally, we engage a third-party
supplier to provide the CRONO ND and CRONO Twin ND medical devices for the administration of our Parkinson’s disease product
candidates. We currently acquire the majority of our medical devices from an Italian manufacturer on a purchase order basis. While
we have not entered into supply agreements with our suppliers, we are in discussions with suppliers to establish long-term supply
agreements. Moreover, our suppliers are currently developing new medical devices related to the administration of our product candidates.
In order to continue enhancing our product candidates, we may participate in funding certain activities of such suppliers for the
development of new medical devices. We are also working with a third-party manufacturer with respect to the design of a next-generation
patch pump device for use with our ND0612L and ND0701 product candidates.
The active ingredient in ND0701 is apomorphine,
which is approved for continuous administration in the European Union and for acute administration for rescue purposes in the United
States and the European Union. We currently acquire the apomorphine used in our clinical trials on a purchase order basis from
a U.S.-based DMF holder. We entered into an agreement with an EU cGMP CMO for the manufacturing of the product candidate for future
clinical studies and, upon marketing approval, commercial use.
The active drug substances in ND0801are
opipramol and nicotine . Nicotine is approved in the United States for smoking cessation, as an over-the-counter drug, as skin
patches, chewing gum or lozenges, and with a prescription, as a nasal spray or an oral inhaler. Opipramol is approved for the treatment
of anxiety disorder and depression in several jurisdictions, including Germany, Israel, Switzerland and Turkey. We purchase both
the active drug substances for use in our clinical trials of ND0801 and the transdermal patch for ND0801 from local pharmacies
in Israel. We are in the process of identifying appropriate suppliers and CMOs for the optimization and scale up of this product.
Marketing, Sales and Distribution
A company-sponsored third-party market
research report of 12 neurologists in the United States demonstrated that physicians perceive a significant unmet need for longer
acting therapies aimed at better controlling motor fluctuations. The physicians expressed their belief that ND0612L and ND0612H
would be very useful for patients with moderate and severe Parkinson’s disease, who need continuous dopaminergic stimulation
to reduce off time or who have difficulties with motor fluctuations on their current oral regimen. Almost all physicians interviewed
expect to use both ND0612H and ND0612L, if regulatory approval is obtained, instead of Duodopa or before referring patients to
DBS.
We have also conducted third-party sponsored
research in the United States, Germany, France and United Kingdom. In the United States, the majority of the 19 payers interviewed
believed that our product candidates fulfill an unmet need for Parkinson’s patients and that ND0612H and ND0612L, if regulatory
approval is obtained, would likely be covered by both public and private payers. Similarly, a company-sponsored third-party report
of 15 payers from Germany, France and United Kingdom concluded that the likelihood of access and reimbursement of ND0612H and ND0612L
are high.
We currently do not have any sales, marketing
or distribution infrastructure. In the event we receive regulatory approval for our product candidates, we intend, where appropriate,
to pursue commercialization relationships with pharmaceutical companies and other strategic partners in order to gain access to
global markets. In the long term, we may build an internal commercial infrastructure.
Intellectual Property
Our intellectual property and proprietary
technology are important to the development, manufacture and future sale of our product candidates. We seek to protect our intellectual
property, core technologies and other know-how through a combination of patents, trademarks, trade secrets, non-disclosure and
confidentiality agreements, assignments of invention and other contractual arrangements with our employees, consultants, partners,
suppliers, customers and others. We submit patent applications under the PCT, which is an international patent law treaty that
provides a unified procedure for filing a single initial patent application to further seek patent protection for an invention
simultaneously in each of the member states. Although a PCT application cannot issue as a patent, it allows the applicant to seek
protection in any of the member states through national-phase applications.
Our patents and patent
applications underlying our product candidates cover specific compositions and methods of use of the active drug substances for
the ND0612H, ND0612L, and ND0801 product candidate programs. For the ND0612H and ND0612L product candidate programs, we have 27
issued patents, including issued patents in the United States, Japan, South Africa, Canada, China, Chile, Russia and New Zealand,
and have more than 53 pending patent applications worldwide, including four national phase international applications filed under
the PCT. Absent patent-term extensions, these patents will expire between 2030 and 2031. Additional patent applications we have
filed in this family, if approved, will expire in 2035. In addition, we have an issues U.S. patent and two pending international
PCT application for the composition of ND0701. In relation to the composition and method of use related to ND0801, we have 9 issued
patents, including issued patents in Australia, Canada, China, Mexico, Japan and the United States and have more than 9 pending
patent applications worldwide pursuant to one national phase international application filed under the PCT. Such patents will expire
between 2028 and 2031 absent patent-term extensions.
While our policy is
to obtain patents by application, license or otherwise, to maintain trade secrets and to seek to operate without infringing on
the intellectual property rights of third parties, technologies related to our business have been rapidly developing in recent
years. Loss or invalidation of certain of our patents, or a finding of unenforceability or limited scope of certain of our intellectual
property, could have a material adverse effect on us. Additionally, patent applications that we may file or license from third
parties may not result in the issuance of patents, and our issued patents and any issued patents that we may receive in the future
may be challenged, invalidated or circumvented. For example, we cannot predict the extent of claims that may be allowed or enforced
upon our patents nor be certain of the priority of inventions covered by pending third-party patent applications. If third parties
prepare and file patent applications that also claim technology or therapeutics to which we have rights, we may have to partake
in proceedings to determine priority of invention, which could result in substantial costs to us, even if the eventual outcome
is favorable to us. Moreover, because of the extensive time required for clinical development and regulatory review of a product
we may develop, it is possible that, before any of our product candidates can be commercialized, related patents will have expired
or will expire a short period following commercial launch, thereby reducing the advantage of such patent. Loss or invalidation
of certain of our patents, or a finding of unenforceability or limited scope of certain of our intellectual property, could have
a material adverse effect on us. See “ITEM 3.D Risk Factors—Risks Related to Our Intellectual Property—Our success
depends in part on our ability to obtain and maintain protection for the intellectual property relating to or incorporated into
our technology and products.”
In addition to patent
protection, we also rely on trade secrets, including unpatented know-how, technology innovation, drawings, technical specifications
and other proprietary information in attempting to develop and maintain our competitive position. We also rely on protection available
under trademark laws, and we are currently in the process of registering the trademark for “NeuroDerm,” in various
jurisdictions, including the United States, the European Union and Israel.
Competition
The medical, biotechnology and pharmaceutical
industries are intensely competitive and subject to significant technological change and changes in practice. While we believe
that our innovative technology, knowledge, experience and scientific resources provide us with competitive advantages, we may face
competition from many different sources with respect to our product candidates that we may seek to develop or commercialize in
the future. Academic institutions, governmental agencies and other public and private research organizations are also conducting
research activities and seeking patent protection and may commercialize products on their own or through joint ventures. Smaller
or other early-stage companies may also prove to be significant competitors, particularly through collaborative arrangements with
large, established companies.
Additionally, many of our potential competitors
have substantially greater financial, technical and human resources than we do and significantly greater experience in the discovery
and development of drug candidates, obtaining FDA and other regulatory approvals of products and the commercialization of those
products.
Accordingly, our competitors may be more
successful than we may be in obtaining FDA and other marketing approvals for drugs and achieving widespread market acceptance.
Our competitors’ drugs may be more effective, or more effectively marketed and sold, than any drug we may commercialize and
may render our product candidates obsolete or non-competitive before we can recover the expenses of developing and commercializing
the product.
Parkinson’s
Disease
Our commercial opportunity could be reduced
or eliminated if our competitors develop and commercialize products, treatments or procedures that are safer, more effective, have
fewer or less severe side effects, are more convenient or are less expensive than any product that we may develop. Specifically,
we may compete with companies that attempt to decrease the sharp fluctuations and improve the bioavailability and short-half life
associated with orally administered LD/CD, such as Impax Laboratories Inc., XenoPort, Inc., Intec Pharma Ltd. and Depomed, Inc.,
which have deloped or are developing oral LD/CD drugs that include a controlled release or gastric retention attribute in order
to decrease the gastronomical tract’s impact on the concentration of levodopa. Similarly, Synagile Corporation is developing
a new intra-oral semi-contionus delivery device for the administration of a liquid formulation of LD/CD ester, and Abbvie is developing
a liquid levodopa formaultion for continuous subcutaneous administration. If such products are approved and successfully improve
the bioavailability of LD/CD or an alternative drug, the demand for our Parkinson’s disease product candidates may be significantly
reduced.
Companies may also develop
and market products that address other aspects of Parkinson’s disease, such as Acorda Therapeutics, Inc., which is developing
a rescue, or on demand, levodopa product to address acute “off” episodes commonly associated with levodopa therapy,
Sunovion , which is developing an apomorphine sublinguial strip to address acute “off” episodes and Britannia Pharmaceuticals
Ltd. that markets in collaboration with U.S. World Med Apokine apomorphine injection. While such products would not directly compete
with our Parkinson’s’ product candidates, as they address specific effects of Parkinson’s disease, such treatment
may reduce the demand of our Parkinson’s disease product candidates.
Moreover, if one of our
Parkinson’s disease product candidates obtains approval in the future, we believe that we would compete with
traditional surgery and existing drug treatments of Parkinson’s disease, including the “gold standard” of
treatment for the past 30 years, oral administration of levodopa. Additionally, we may directly compete with DBS and AbbVie
Inc.’s product, Duodopa (EU and ROW), Duopa (U.S.), a LD/CD drug solution that comes in a gel form and is approved in
the United States and in several jurisdictions including Europe, Canada and Australia. Additionally, Duodopa,which marketed
in the United States under the name Duopa, has received orphan drug status in the United States for the treatment of severe
stage Parkinson’s disease. Accordingly, we may not be permitted to market a product that competes with Duopa for such
indications until the expiration of its orphan drug market exclusivity period, which will occur seven years after such
approval.
In addition, if approved, our apomorphine-based
product candidate, ND0701, would directly compete with other non-LD/CD treatments. For example, in Europe Britannia Pharmaceuticals
Limited (part of the STADA Arzneimittel AG group of companies) currently markets a Parkinson’s disease therapy that administers
apomorphine, Apo-Go, via a belt pump. However, patients that use Apo-Go may suffer from painful local reactions at the injection
site, necessitating auxiliary treatments.
Based on our clinical trials, we believe
that our Parkinson’s disease product candidates will have a sustainable competitive advantage over non-surgical alternatives
and a clear advantage over surgery. See “— Our Solutions for Parkinson’s Disease — Completed
clinical trials ” above in this ITEM 4 for the results of our clinical trials.
Other
Cognitive Disorders
Similarly, although we are in the clinical
phase of ND0801 for the treatment of other cognitive disorders, such as ADD/ADHD, if ND0801 obtains approval in the future, we
would compete with current treatments. For example, we are aware that a number of existing treatments for ADD/ADHD are currently
on the market and are marketed by pharmaceutical companies that may be far larger and more experienced than us. Current competitor
drugs to ND0801 for the treatment of ADD/ADHD include stimulants such as Ritalin and Adderall, as well as the non-stimulant drugs
Strattera, Intuniv and Kapvay. Further, we recognize that patients and doctors are often unwilling to change medications, and this
factor may make it difficult for ND0801 to penetrate the market, even if it receives FDA approval. However, based on our clinical
trials, we believe that ND0801 will have a sustainable competitive advantage over the current alternatives, and at the very least
offer an alternative mode of administration. See “— Cognition and our ND0801 Product Candidate” above for
the results of our clinical trials.
Government Regulation
Our business is subject to extensive government
regulation. Regulation by governmental authorities in the United States, the European Union and other jurisdictions is a significant
factor in the development, manufacture and marketing of our product candidates and in ongoing research and development activities.
On April 10, 2012, we held a pre-IND meeting with the DNP. In this meeting, the DNP stated that ND0612L would be eligible for the
submission of a 505(b)(2) regulatory pathway application, which allows expedited regulatory development with reduced clinical trials,
see — “United States — Section 505(b)(2) NDAs.” The DNP also provided a clinical trials
framework that would allow for a 505(b)(2) submission. We therefore seek to submit an NDA pursuant to section 505(b)(2) of the
FDCA. Following our October 2016 end-of-Phase II meeting with the FDA, based upon which we have amended our clinical development
strategy, we preliminarily estimate that we will submit our 505(b)(2) NDA in the second half of 2018. As to European regulatoy
approval, on May 22, 2014, the EMA confirmed that our product candidate, ND0612H, was eligible for a European Union marketing authorization
application via a centralized procedure, which allows ND0612H to be able to benefit from more streamlined access to the EU market.
United
States
Review
and Approval of Drug Products
In the United States, the FDA regulates
drugs under the FDCA and related regulations and other laws. Drug products require the submission of a NDA and approval by the
FDA prior to being marketed in the United States. The process of obtaining regulatory approvals and the subsequent compliance with
appropriate federal, state, local and foreign statutes and regulations requires the expenditure of substantial time and financial
resources. Failure to comply with the applicable U.S. requirements at any time during the product development process, approval
process or after approval may subject an applicant to a variety of administrative or judicial sanctions, and enforcement actions
brought by the FDA, the Department of Justice or other governmental entities. Possible sanctions may include the FDA’s refusal
to approve pending NDAs, withdrawal of an approval, imposition of a clinical hold, issuance of warning letters, product recalls,
product seizures, total or partial suspension of production or distribution, injunctions, fines, refusals of government contracts,
restitution, disgorgement and civil or criminal penalties.
The process required by the FDA prior
to marketing and distributing a drug product in the United States generally involves the following:
|
■
|
completion of laboratory tests, animal studies and formulation studies in compliance with the FDA’s GLP or GMP regulations, as applicable;
|
|
|
|
|
■
|
submission to the FDA of an IND, which must become effective before clinical trials may begin;
|
|
|
|
|
■
|
approval by an IRB at each clinical site before each trial may be initiated;
|
|
|
|
|
■
|
performance of adequate and well-controlled clinical trials in accordance with GCP to establish the safety and efficacy of the product for each indication;
|
|
|
|
|
■
|
preparation and submission to the FDA of a NDA or supplemental NDA;
|
|
|
|
|
■
|
satisfactory completion of an FDA advisory committee review, if applicable;
|
|
|
|
|
■
|
satisfactory completion of one or more FDA inspections of the manufacturing facility or facilities at which the product, or components thereof, are produced to assess compliance with cGMP requirements, and to assure that the facilities, methods and controls are adequate to preserve the product’s identity, strength, quality and purity; and
|
|
|
|
|
■
|
payment of user fees and FDA review and approval of the NDA.
|
Preclinical Studies
Preclinical studies include
laboratory evaluation, as well as animal studies to assess the potential safety and efficacy of the product candidate. Preclinical
safety tests must be conducted in compliance with FDA regulations regarding good laboratory practices. The results of the preclinical
tests, together with manufacturing information and analytical data, are submitted to the FDA as part of an IND, which must become
effective before clinical trials may be commenced.
Clinical Trials in Support of an NDA
Clinical trials involve
the administration of an investigational product to human subjects under the supervision of qualified investigators in accordance
with GCP requirements, which include, among other things, the requirement that all research subjects provide their informed consent
in writing before their participation in any clinical trial. Clinical trials are conducted under written study protocols detailing,
among other things, the objectives of the study, the parameters to be used in monitoring safety and the effectiveness criteria
to be evaluated. A protocol for each clinical trial and any subsequent protocol amendments must be submitted to the FDA as part
of the IND. An IND automatically becomes effective 30 days after receipt by the FDA, unless, before that time, the FDA raises concerns
or questions related to a proposed clinical trial and places the trial on clinical hold. In such a case, the IND sponsor and the
FDA must resolve any outstanding concerns before the clinical trial can begin.
In addition, an IRB representing
each institution participating in the clinical trial must review and approve the plan for any clinical trial before it commences
at that institution, and the IRB must conduct continuing review and reapprove the study at least annually. The IRB must review
and approve, among other things, the study protocol and informed consent information to be provided to study subjects. An IRB must
operate in compliance with FDA regulations. Information about certain clinical trials must be submitted within specific timeframes
to the National Institutes of Health for public dissemination on their ClinicalTrials.gov website.
Clinical trials are typically
conducted in three sequential phases, which may overlap or be combined:
|
·
|
Phase 1: The drug is initially introduced into healthy human subjects or patients with the target disease or condition and
tested for safety, dosage tolerance, absorption, metabolism, distribution, excretion and, if possible, to gain an early indication
of its effectiveness and to determine optimal dosage.
|
|
·
|
Phase 2: The drug is administered to a limited patient population to identify possible adverse effects and safety risks, to
preliminarily evaluate the efficacy of the product for specific targeted diseases and to determine dosage tolerance and optimal
dosage.
|
|
·
|
Phase 3: The drug is administered to an expanded patient population, generally at geographically dispersed clinical trial sites,
in well-controlled clinical trials to generate enough data to statistically evaluate the efficacy and safety of the product for
approval, to establish the overall risk-benefit profile of the product, and to provide adequate information for the labeling of
the product.
|
Section 505(b)(2) NDAs
NDAs for most new drug
products are based on two full clinical studies, which must contain substantial evidence of the safety and efficacy of the proposed
new product. These applications are submitted under Section 505(b)(1) of the FDCA. However, the FDA is authorized to approve an
alternative type of NDA under Section 505(b)(2) of the FDCA. This type of application allows the applicant to rely, in part, on
the FDA’s previous findings of safety and efficacy for a similar product, or published literature. Specifically, Section
505(b)(2) applies to NDAs for a drug for which the investigations made to show whether or not the drug is safe for use and effective
in use and relied upon by the applicant for approval of the application “were not conducted by or for the applicant and for
which the applicant has not obtained a right of reference or use from the person by or for whom the investigations were conducted.”
Thus, Section 505(b)(2)
authorizes the FDA to approve an NDA based on safety and effectiveness data that were not developed by the applicant. NDAs filed
under Section 505(b)(2) may provide an alternate and potentially more expeditious pathway to FDA approval for new or improved formulations
or new uses of previously approved products. If the 505(b)(2) applicant can establish that reliance on the FDA’s previous
approval is scientifically appropriate, the applicant may eliminate the need to conduct certain preclinical or clinical studies
of the new product. The FDA may also require companies to perform additional studies or measurements to support the change from
the approved product. The FDA may then approve the new drug candidate for all or some of the label indications for which the referenced
product has been approved, as well as for any new indication sought by the Section 505(b)(2) applicant.
As our Parkinson’s
disease product candidates are based on reformulations of FDA-approved drugs, levodopa and carbidopa, we intend to submit an NDA
under Section 505(b)(2), which may result in an expedited FDA approval.
Submission of an NDA to the FDA
In the United States,
we intend to rely upon our Phase II studies as well as additional data from several comparative PK studies against FDA-approved
drugs, to support a Section 505(b)(2) NDA submission to the FDA. The results of the preclinical studies and clinical trials, together
with other detailed information, including information on the manufacture, control and composition of the product, are submitted
to the FDA as part of an NDA requesting approval to market the product candidate for a proposed indication. Under federal law,
the submission of most NDAs is additionally subject to an application user fee, currently exceeding $2.1 million, and the sponsor
of an approved NDA is also subject to annual product and establishment user fees, currently exceeding $104,000 per product and
$554,600 per establishment. These fees are typically increased annually. Each NDA submitted to the FDA for approval is typically
reviewed for administrative completeness and reviewability within 45 to 60 days following submission of the application. If found
complete, the FDA will “file” the NDA, thus triggering a full review of the application. The FDA may refuse to file
any NDA that it deems incomplete or not properly reviewable at the time of submission. The FDA’s established goal is to review
90% of NDA applications and original efficacy supplements given “Priority” status within six months and 90% of applications
and original efficacy supplements given “Standard” status within ten months, whereupon a review decision is to be made.
The FDA, however, may not approve a drug within these established goals, and its review goals are subject to change from time to
time. Further, the outcome of the review, even if generally favorable, may not be an actual approval but rather an “action
letter” that describes additional work that must be completed before the application can be approved.
Before approving an NDA,
the FDA generally inspects the facilities at which the product is manufactured or facilities that are significantly involved in
the product development and distribution process, and will not approve the product unless cGMP compliance is satisfactory. The
FDA may deny approval of a NDA if applicable statutory or regulatory criteria are not satisfied, or may require additional testing
or information, which can delay the approval process. FDA approval of any application may include many delays or may never be granted.
If a product is approved, the approval will impose limitations on the indicated uses for which the product may be marketed, may
require that warning statements be included in the product labeling, may require that additional studies be conducted following
approval as a condition of the approval, may impose restrictions and conditions on product distribution, prescribing or dispensing
in the form of a risk management plan, or may impose other limitations.
Once a product is approved,
marketing the product for other indicated uses or making certain manufacturing or other changes requires FDA review and approval
of a supplemental NDA or a new NDA, which may require additional clinical data. In addition, further post-marketing testing and
surveillance to monitor the safety or efficacy of a product may be required. Also, product approvals may be withdrawn if compliance
with regulatory standards is not maintained or if safety or manufacturing problems occur following initial marketing. In addition,
new government requirements may be established that could delay or prevent regulatory approval of our product candidates under
development.
Post-Approval Requirements
Any drug product for which
we receive FDA approvals is subject to continuing regulation by the FDA. Certain requirements include, among other things, record-keeping
requirements, reporting of adverse experiences with the product, providing the FDA with updated safety and efficacy information
on an annual basis or more frequently for specific events, product sampling and distribution requirements, complying with certain
electronic records and signature requirements and complying with FDA promotion and advertising requirements. These promotion and
advertising requirements include, among others, standards for direct-to-consumer advertising, prohibitions against promoting drugs
for uses or in patient populations that are not described in the drug’s approved labeling, known as “off-label use,”
and other promotional activities, such as those considered to be false or misleading. Failure to comply with FDA requirements can
have negative consequences, including the immediate discontinuation of noncomplying materials, adverse publicity, enforcement letters
from the FDA, mandated corrective advertising or communications with doctors, and civil or criminal penalties. Such enforcement
may also lead to scrutiny and enforcement by other government and regulatory bodies. Although physicians may prescribe legally
available drugs for off-label uses, manufacturers may not encourage, market or promote such off-label uses. As a result, “off-label
promotion” has formed the basis for litigation under the federal False Claims Act, violations of which are subject to significant
civil fines and penalties.
The manufacturing of our
product candidates is and will be required to comply with applicable FDA manufacturing requirements contained in the FDA’s
cGMP regulations. Our product candidates are manufactured at third-party facilities, which are cGMP certified. The FDA’s
cGMP regulations require, among other things, quality control and quality assurance, as well as the corresponding maintenance of
comprehensive records and documentation. Drug manufacturers and other entities involved in the manufacture and distribution of
approved drugs are also required to register their establishments and list any products they make with the FDA and to comply with
related requirements in certain states. These entities are further subject to periodic unannounced inspections by the FDA and certain
state agencies for compliance with cGMP and other laws. Accordingly, manufacturers must continue to expend time, money and effort
in the area of production and quality control to maintain cGMP compliance. Discovery of problems with a product after approval
may result in serious and extensive restrictions on a product, manufacturer or holder of an approved NDA, as well as lead to potential
market disruptions. These restrictions may include recalls, suspension of a product until the FDA is assured that quality standards
can be met, and continuing oversight of manufacturing by the FDA under a “consent decree,” which frequently includes
the imposition of costs and continuing inspections over a period of many years, as well as possible withdrawal of the product from
the market. In addition, changes to the manufacturing process generally require prior FDA approval before being implemented. Other
types of changes to the approved product, such as adding new indications and additional labeling claims, are also subject to further
FDA review and approval.
The FDA also may require
post-marketing testing, or Phase IV testing, as well as risk minimization action plans and surveillance to monitor the effects
of an approved product or place conditions on an approval that could otherwise restrict the distribution or use of any of our product
candidates.
Orphan Drug Designation and Exclusivity
Under the Orphan Drug
Act, the FDA may designate a drug product as an “orphan drug” if it is intended to treat a rare disease or condition
(generally meaning that it affects fewer than 200,000 individuals in the United States, or more in cases in which there is no reasonable
expectation that the cost of developing and making a drug product available in the United States for treatment of the disease or
condition will be recovered from sales of the product). A company must request orphan product designation before submitting a NDA.
If the request is granted, the FDA will disclose the identity of the therapeutic agent and its potential use. Orphan drug designation
entitles a party to seven years of market exclusivity following drug product approval, but does not convey any advantage in or
shorten the duration of the regulatory review and approval process.
If a product with orphan
status receives the first FDA approval for the disease or condition for which it has such designation, the product will be entitled
to orphan product exclusivity. Orphan product exclusivity means that the FDA may not approve any other applications for the same
product for the same indication for seven years, except in certain limited circumstances. Competitors may receive approval of different
products for the indication for which the orphan product has exclusivity and may obtain approval for the same product but for a
different indication. If a drug or drug product designated as an orphan product ultimately receives marketing approval for an indication
broader than that designated in its orphan product application, it may not be entitled to exclusivity.
Abbreviated New Drug Applications for Generic Drugs
In 1984, with passage
of the Drug Price Competition and Patent Term Restoration Act of 1984, commonly referred to as the “Hatch-Waxman Act,”
Congress authorized the FDA to approve generic drugs that are the same as drugs previously approved by the FDA under the NDA provisions
of the statute. To obtain approval of a generic drug, an applicant must submit an abbreviated new drug application, or ANDA, to
the agency. In support of such applications, a generic manufacturer may rely on the preclinical and clinical testing previously
conducted for a drug product previously approved under a NDA, known as the reference listed drug, or RLD.
Specifically, in order
for an ANDA to be approved, the FDA must find that the generic version is identical to the RLD with respect to the active ingredients,
the route of administration, the dosage form, and the strength of the drug. At the same time, the FDA must also determine that
the generic drug is “bioequivalent” to the innovator drug. Under the statute, a generic drug is bioequivalent to a
RLD if “the rate and extent of absorption of the drug do not show a significant difference from the rate and extent of absorption
of the listed drug. . . .”
Upon approval of an ANDA,
the FDA indicates that the generic product is “therapeutically equivalent” to the RLD and it assigns a therapeutic
equivalence rating to the approved generic drug in its publication “Approved Drug Products with Therapeutic Equivalence Evaluations,”
also referred to as the “Orange Book.” Physicians and pharmacists consider an “AB” therapeutic equivalence
rating to mean that a generic drug is fully substitutable for the RLD. In addition, by operation of certain state laws and numerous
health insurance programs, the FDA’s designation of an “AB” rating often results in substitution of the generic
drug without the knowledge or consent of either the prescribing physician or patient.
The FDCA provides a period
of five years of non-patent data exclusivity for a new drug containing a new chemical entity. In cases where such exclusivity has
been granted, an ANDA may not be filed with the FDA until the expiration of five years unless the submission is accompanied by
a Paragraph IV certification, in which case the applicant may submit its application four years following the original product
approval. The FDCA also provides for a period of three years of exclusivity if the NDA includes reports of one or more new clinical
investigations, other than bioavailability or bioequivalence studies, that were conducted by or for the applicant and are essential
to the approval of the application. This three-year exclusivity period often protects changes to a previously approved drug product,
such as a new dosage form, route of administration, combination or indication.