Key Investment Conclusions
In this report, I have made projections for sales, earnings and cash flow for A.P. Pharma (APPA.OB) through 2016. The underlying assumptions and calculations are explained within this report. However, let's start with the conclusions. My base investment case is that A.P. Pharma will gain approval for its first commercial product APF530 in early 2013, will launch the product in the US with its own sales force in mid-2013 and will partner the product in the rest of the world. Here are my key projections.
|Key Investment Projections|
|FY 2012||FY 2013||FY 2014||FY 2015||FY 2016|
|APF530 US Sales (millions)||$0.0||$45.5||$199.6||$184.9||$182.3|
|Fully diluted shares (millions)||200.0||284.4||450.4||459.5||468.8|
|Cash at year end ($millions)||$36.9||$62.6||$201.1||$343.0||$477.7|
|Cash per share at year end||$0.18||$0.22||$0.45||$0.75||$1.02|
If these projections are realized, I think that in 2015 the company could be valued at about 20 plus times estimated 2016 EPS; this results in a 2015 price target of $5.40+. I recommend this stock for sophisticated biotechnology investors who understand the risks of investing in emerging biotechnology companies. There is execution risk for this small company and if my assumptions on approvability of APF530 and the potential for APPA to successfully commercialize it are wrong, the investor could lose most or all of their investment. This risk is counterbalanced by the significant upside opportunity that I have just outlined. Please carefully read the investment risk section that follows. As with other pre-commercial companies in this sector, if you do not understand and are unwilling to accept these risks, this stock is not a suitable investment for you.
A.P. Pharma's lead product, APF30, is being developed for the prevention of chemotherapy induced nausea and vomiting or CINV. It is an injectable drug that uses the company's Biochronomer™ polymer-based, sustained-release delivery technology to deliver the widely used generic drug granisetron. It increases the time of effectiveness for granisetron from one to five days, which provides important therapeutic advantages.
The company is in the process of responding to a Complete Response Letter or CRL on APF530 which it received in March, 2010. In that CRL, the FDA expressed no concerns on clinical efficacy and safety of APF530 in its pivotal trial or the statistical analysis used. The FDA asked the company to address a number of CMC issues that were fairly straightforward. Of more concern was a request to conduct a study to rule out the possibility that APF 530 might cause QTc prolongation, a condition which was recently detected with Anzemet, a drug of the same chemical class. On March 26, 2012, APPA announced that it had successfully completed that study which showed no QTc prolongation; this appears to take away the major uncertainty in regard to approval. The other issues in the CRL were less serious and the company believes that it has actions that should successfully address these issues.
The company is on track to refile the NDA in mid-year and assuming a Class II response the PDUFA date would be in early 2013. It has been a routine practice for the FDA to issue CRLs for new drugs at their first PDUFA date with CMC issues being a frequent reason. The second PDUFA date has become the "new" PDUFA date. It now seems prudent for investors to assume that almost every drug will receive a CRL on its first PDUFA date. A.P. Pharma has already been through this vetting process and appears to have successfully addressed the issues raised by the FDA. This significantly increases the potential for approval in early 2013.
After approval, biotechnology investors are not home free. One of the most troubling situations that has developed over the last few years is the slow launch phenomenon; this has occurred with Avanir's (AVNR) Nudexta, Human Genome Sciences (HGSI) Benlysta, Auxilium's (AUXL) Xiaflex and Cadence's (CADX) Ofirmev. These slow takeoffs reflect physicians' increased level of concern with safety of new drugs and the slow process involved in getting drugs accepted on formulary. Investors now routinely expect slow launches and hedge funds often short stocks during the launch period. However, I think that APF530 could be the exception to this trend and surprise investors with how quickly it takes off.
The active ingredient of APF530 is granisetron, a product with a long history of safe usage in CINV that is trusted by physicians so that there should be minimal concern about safety and efficacy. There is also a compelling clinical reason to use this drug when the market leading product Aloxi fails to completely halt emesis (vomiting), which is about 30% to 60% of the time. A 1,341 patient Phase III trial showed that APF530 is as effective as Aloxi and offers the physician an alternative when Aloxi fails to establish complete control. Thirdly, there is a compelling economic reason to use APF530. Both Aloxi and APF530 are reimbursed as Medicare part B drugs. The physician currently receives about $31 per Aloxi injection. However, the peculiarities of reimbursement are such that if APF530 is priced at the same wholesale price as Aloxi, for a period of around 6 to 9 months following introduction, the physician could make $78 for an APF530 injection. This is a significant economic inducement which I will explain in more detail later.
There are difficult challenges. The rapid takeoff I am projecting stems from a pricing aberration under Medicare part B that creates a great economic incentive for physicians to use a new drug. It is imperative that APPA stages an aggressive launch for APF530 to maximize its market position during this economic window of opportunity. However, A.P. Pharma has no commercial experience, limited infrastructure and a weak balance sheet with only $18 million of cash at yearend 2011. Usually this would rule out a small company like APPA even thinking about marketing a new drug on its own. However, the CINV market is relatively small and can be covered with about 40 reps. I estimate that putting a sales force in place and then launching APF530 would cost about $15 to $20 million and this is within APPA's reach, even with its limited resources.
Investors must also be aware that there are a very large number of shares outstanding with this company. Because of the CRL, the commercial timing was delayed and the company was forced into some highly dilutive financings. The company reported 200.0 million shares outstanding in its 2011 10-K. However, the highly probable conversion of "in the money" convertible notes, warrants and stock options could increase the share count to 446.7 million by the end of 1Q, 2014.
There are two wildcards that I think are possible for A.P. Pharma that could create significant value for shareholders. The company might be acquired outright. I am not sure, however, how much of a premium it could command over its current price if this were to happen before approval. There is also the possibility that an ongoing study will show that Zofran, a long established market leading drug in CINV, is linked to QTc interval prolongation. It accounts for 29% of the unit market and a warning about this risk could lead to a sharp drop in its usage and significantly enlarge the market potential for APF530. I would note that each 10% of current ondansetron usage that is shifted toward APF530 and Aloxi would increase use and sales of APF530 by 5% according to my assumptions.
The numbers that I present in this report give the appearance of greater precision than is actually the case. They should be looked at as indicators for trend and magnitude of corporate results, not numbers that are etched in stone. Eventual results could vary significantly from my projections.
FDA regulatory action can be unpredictable and the greatest risk is that APF530 receives another CRL and is delayed. This could delay partnering discussions and create a cash squeeze. The company in this event might have to finance at depressed valuations to keep operations ongoing. This could result in severe dilution to shareholders.
I have assumed partnering deals for APF530 in 4Q, 2012 for parts of Asia and Europe produce milestone payments of $15 million for each market. My thinking is influenced by the $26 million partnering deal that Prostrakan received with its transdermal granisetron patch, Sancuso, for rights to Southeast Asia. My judgment is that APF530 is a superior product. These potential partnering deals would obviate the need for the company to raise capital from the capital markets to launch APF530 in the US. However, the projection of a fourth quarter partnering deal would be prior to the projected approval date for APF530 and potential partners might elect to wait and make sure the product is approved. My projection for cash at the end of 2012 of $36.8 million is dependent on consummating these partnerships. If they are delayed my year end cash balance projection would drop to $6.8 million. This might force the company to raise perhaps $10 million through a small equity offering or bridge loan.
I am assuming that A.P. Pharma launches APF530 on its own in the U.S. This is a formidable undertaking for a company that has little commercial infrastructure and no prior experience in selling a drug. There is substantial risk that they may encounter execution problems during the roll out.
APF530 uses APPA's Biochronomer drug delivery technology to deliver the generic drug granisetron. The intellectual property position is based on patents related to Biochronomer that protect this technology through 2020. I assume that there will be no generic competition until these patents expires. I acknowledge that competitive long acting granisetron products could come to the market though the 505 (B) 2 approval pathways, but they would not be substitutable for APF530 under current FDA practices.
Aloxi's key composition of matter patent expires in 2015. Recently additional patents covering stability and shelf life were issued which I believe extends the exclusivity of Aloxi through 2024. Generic companies will certainly challenge these new patents and if they prevail, there is a possibility of generic competition to Aloxi in 2015 or years thereafter which might negatively impact the pricing of APF530.
CINV Market Overview
APF530 is targeted at a very promising niche in the market for drugs that treat chemotherapy induced nausea and vomiting (CINV). The efficacy of chemotherapy drugs is based on their ability to target and destroy rapidly dividing cancer cells. However, normal cells that divide rapidly such as those lining the stomach and intestinal tract suffer collateral damage in the process. The induced stress causes the release of the chemical messenger 5-HT3 serotonin in the brain inducing nausea and a signal to vomit (emesis). The understanding of this mechanism of action led to the development of a class of drugs that block the receptor for 5-HT3 serotonin (5-HT3 serotonin antagonists); they have become the mainstay of therapy to prevent CINV.
There are currently four 5-HT3 drugs on the market: Zofran (ondansetron), Kytril (granisetron), Anzemet (dolasetron) and Aloxi (palonosetron). Zofran and Kytril were the pioneers in the market and dominated it for many years. Zofran became generic in 2006 and Kytril in 2008. It is usually the case that when the leaders in a drug category go generic the market shifts to generic competitors, leading to declines in usage and pressure on pricing of the remaining branded competitors in the category. This has not been as true for the 5-HT3 category. To understand why and to understand the potential of APF530, one has to understand some things about market dynamics.
CINV occurs in about 75% of patients given chemotherapy with different regimens causing more or less nausea and vomiting. It usually appears on the first day a few hours after the chemotherapy is administered and can last for five days. There are two phases of CINV, the acute onset during the first 24 hours and delayed onset that occurs over the next four days. Zofran and Kytril are effective in the acute phase, but much less so in the delayed phase because of their short half-lives.
On the first day, CINV drugs are almost always given intravenously in order to achieve effective blood levels at the time the chemo is administered. On subsequent days, it is usually not practical to administer the drugs intravenously as the patient most likely has gone home. This means that for short acting drugs like Zofran and Kytril, an oral dosage form is required for days two through five. For patients who have some nausea and vomiting, they may be unable to swallow the pills and compliance may be a problem. Well controlled studies indicate that Zofran and Kytril are effective in about 42% of patients receiving moderately emetogenic chemotherapy and in 39% of patients on highly emetogenic chemotherapy therapy. Effectiveness or complete response is defined as a patient having no emesis and not requiring rescue medication. A CINV drug can offer some relief without meeting these criteria.
When only Zofran and Kytril were available there was often difficulty in controlling nausea and vomiting in the delayed phase. In 2004, MGI Pharma introduced Aloxi into the market. The advantage of Aloxi is that it has a very long half-life so that with one IV course of therapy, it retains its efficacy through the delayed phase. After Zofran and then Kytril went generic, they were available for about $5 to $10 per injection versus $175 for Aloxi. Nevertheless, the long acting advantage of Aloxi has allowed it to become the market leader with 49% of the unit market.
While Aloxi is the leading drug in the CINV market, it has shortcomings that APF530 can capitalize on. Clinical studies have suggested that Aloxi has a complete response of 46% to 69% in moderately emetogenic chemotherapy and 41% to 62% in highly emetogenic chemotherapy. Hence, there are large numbers of patients who don't obtain full relief with Aloxi, somewhere in the range of 30% to 60%. When Aloxi doesn't work, doctors may add corticosteroids or Merck's Emend to the regimen on the next cycle. Emend works through a different mechanism, blockage of substance P, to control CINV.
There is now an unmet medical need for a long acting drug that has the potential to work when Aloxi falls short. This is one of the market segments that APF530 is targeting. It is long acting like Aloxi in that it can be injected on the first day and lasts five days. Head to head studies in a large phase III involving 1,341 patients showed that it is statistically non-inferior to Aloxi which indicates equivalency. The hope is that many patients who are not treated effectively with Aloxi may be switched to APF530 and controlled in subsequent chemotherapy cycles. It is often the case that drugs of the same chemical class will produce different effects on the same patient. Even though, the large phase III trial comparing Aloxi and APF530 showed equivalent efficacy, physicians could hypothesize that they might have different effects on different patients.
There is another potential advantage for APF530 that was hinted at in the clinical trials. Most cancer patients go through 5 to 15 cycles of treatment during the course of the disease. Aloxi seems to lose some effectiveness as the number of cycles increase, while complete response appears to increase with APF530. More studies are needed to confirm this observation, but it is worth noting and watching. If proven in clinical studies, this would be a huge advantage versus Aloxi.
I have published a more detailed report on my website that explains the unusual pricing situation under Medicare Part B that is so important to my projection for a dynamic launch for APF530. It also has detailed tables that show the sales and earnings estimates that were used to make my projections. For those who want to understand the basis for my estimates, I would suggest that you click on the above link.
Disclosure: I am long CADX.