Equity Research
`Health Care
`
`Therapeutic Categories Outlook
`Comprehensive Study
`
`February 2017
`
`Alzheimer’s Disease
`Bone Diseases
`Cardiovascular
`Central Nervous System
`Dermatology
`Diabetes/Obesity
`Epilepsy
`Gastrointestinal/Ulcer
`Hepatitis
`Infectious Diseases
`Liver Disease
`Multiple Sclerosis
`Non-Malignant Hematology
`Oncology/Hematology
`Ophthalmology
`Orphan Diseases
`Pain Management
`Respiratory
`Rheumatology
`Women’s Health
`
`
`
`www.cowen.com
`
`
`
` @CowenResearch
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 1 of 10
`
`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`much worse than it used to be. As community physicians have grown more
`comfortable treating mild patients with oral therapies, patients are increasingly being
`referred to expert centers only after their disease has become more severe.
`
`Chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary hypertension
`that occurs secondary to a blood clot. Our consultants note that there are not great
`incidence or prevalence figures for CTEPH. However, in their experience there are
`about five times more PAH patients in their practices than there are CTEPH patients,
`suggesting that there may be about 5,000 treatable CTEPH patients in the U.S.
`
`Despite the relatively small number of patients afflicted, the market for pulmonary
`hypertension therapies is actually quite large in dollar terms. Infused and inhaled
`prostanoids can demand $100,000+ per patient per year for treatment. With
`approximately 110,000 patients worldwide, and perhaps 50,000+ patients in the U.S.
`itself, worldwide sales for major PAH drugs surpassed $5B in 2016.
`
`Major PAH Drugs - Worldwide Sales And Consensus Estimates
`
`Source: Cowen and Company, Consensus estimate from Thomson
`
`
`
`
`
`There are currently 13 drugs indicated for the treatment of PAH in the U.S., and these
`can be broadly categorized based on their route of administration. Oral therapies
`include Adempas (riociguat) from Bayer, Revatio (sildenafil) from Pfizer, Adcirca
`(tadalafil) and Orenitram (treprostinil) from United Therapeutics, Tracleer (bosentan),
`Opsumit (macitentan), and Uptravi (selexipag) from Actelion, and Letairis
`(ambrisentan) from Gilead. These therapies tend to be used in newly presenting, less
`severe patients. There are three branded infused (intravenous and subQ) prostacyclins
`on the U.S. market including Remodulin (treprostinil) from United Therapeutics, Flolan
`(epoprostenol) from GlaxoSmithKline, and Veletri (epoprostenol) from Actelion. In
`addition, in 2008 Teva launched a generic version of Flolan. These therapies are
`considered the most potent, and are used in the most severe patients (WHO FC-III and
`IV). There are currently two inhaled options, Actelion’s Ventavis (iloprost), and United
`Therapeutics’ Tyvaso (treprostinil), and these therapies are typically positioned for use
`in patients who require treatment benefit beyond oral therapies, but whose condition
`is not considered severe enough to warrant infused prostanoids.
`
`2248
`
`www.cowen.com
`
`Brand
`
`Drug
`
`Mechanism of Action
`
`Company
`
`Reported sales ($MM)
`
`Consensus estimate ($MM)
`
`2010A 2011A 2012A 2013A 2014A 2015A 2016A↓ 2017E 2018E 2019E 2020E
`
`Letairis/Volibris
`
`ambrisentan (oral)
`
`ET-A antagonist (Endothelin pathway)
`
`GILD/GSK
`
`$311
`
`$449
`
`$611
`
`$750
`
`$855
`
`$932 $1,036 $1,142
`
`$956
`
`$793
`
`$629
`
`Tracleer
`
`Opsumit
`
`bosentan (oral)
`
`ET-A, ET-B antagonist (Endothelin pathway)
`
`macitentan (oral)
`
`ET-A, ET-B antagonist (Endothelin pathway)
`
`ATLN
`
`ATLN
`
`UTHR
`
`$1,573 $1,722 $1,600 $1,653 $1,620 $1,260 $1,020
`
`$582
`
`$332
`
`$226
`
`$165
`
`$0
`
`$0
`
`$0
`
`$5
`
`$197
`
`$537
`
`$831 $1,005 $1,303 $1,567 $1,827
`
`$404
`
`$430
`
`$458
`
`$491
`
`$554
`
`$573
`
`$602
`
`$605
`
`$543
`
`$471
`
`$395
`
`Remodulin
`
`treprostinil (i.v., s.c.)
`
`Prostacyclin agonist
`
`Tyvaso
`
`Adcirca
`
`Revatio
`
`treprostinil (inhaled)
`
`Prostacyclin analogues
`
`tadalafil (oral)
`
`PDE 5 inhibitor (NO pathway)
`
`sildenafil (oral)
`
`PDE 5 inhibitor (NO pathway)
`
`UTHR
`
`UTHR
`
`PFE
`
`$152
`
`$240
`
`$326
`
`$439
`
`$463
`
`$470
`
`$405
`
`$441
`
`$460
`
`$412
`
`$369
`
`$36
`
`$71
`
`$123
`
`$177
`
`$222
`
`$279
`
`$372
`
`$355
`
`$200
`
`$132
`
`$43
`
`$481
`
`$535
`
`$534
`
`$307
`
`$276
`
`$260
`
`$285
`
`$203
`
`$181
`
`$174
`
`$161
`
`$502
`
`$575
`
`$624
`
`Adempas
`
`Uptravi
`
`Orenitram
`
`riociguat (oral)
`
`Guanylate cyclase stimulator (NO pathway)
`
`selexipag (oral)
`
`IP prostanoid receptor agonist
`
`treprostinil (oral)
`
`Prostacyclin analogues
`
`BAYN
`
`ATLN
`
`UTHR
`
`ATLN
`
`$0
`
`$0
`
`$0
`
`$3
`
`$0
`
`$0
`
`$0
`
`$0
`
`$0
`
`$0
`
`$4
`
`$0
`
`$0
`
`$17
`
`$26
`
`$40
`
`$118
`
`$201
`
`$263
`
`$375
`
`$0
`
`$41
`
`$70
`
`$0
`
`$245
`
`$882 $1,312 $1,818 $2,322
`
`$118
`
`$157
`
`$214
`
`$277
`
`$336
`
`$388
`
`$86
`
`$97
`
`$246
`
`$268
`
`$289
`
`$311
`
`Veletri
`
`Ventavis
`
`Flolan
`
`epoprostenol (i.v.)
`
`Prostacyclin analogues
`
`iloprost (inhaled )
`
`Prostacyclin analogues
`
`epoprostenol (i.v.)
`
`Prostacyclin analogues
`
`ATLN
`
`GSK
`
`Total
`
`$114
`
`$120
`
`$117
`
`$119
`
`$123
`
`$109
`
`$302
`
`$287
`
`$214
`
`$230
`
`$119
`
`$89
`
`$73
`
`$70
`
`$53
`
`$45
`
`$38
`
`$34
`
`$115
`
`$136
`
`$158
`
`$179
`
`$3,376 $3,872 $4,009 $4,215 $4,657 $4,915 $5,456 $6,217 $6,515 $6,990 $7,449
`
`Prostacyclin pathway
`
`$974 $1,095 $1,140 $1,319 $1,369 $1,445 $1,649 $2,556 $3,041 $3,522 $4,000
`
`Endothelin pathway
`
`$1,884 $2,171 $2,212 $2,408 $2,672 $2,729 $2,887 $2,729 $2,590 $2,587 $2,622
`
`Nitric Oxide pathway
`
`$517
`
`$606
`
`$657
`
`$488
`
`$616
`
`$740
`
`$920
`
`$933
`
`$883
`
`$881
`
`$828
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 2 of 10
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`

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`Cowen and Company
`Equity Research
`
`February 2017
`
`Pathways And Molecular Targets Associated With PAH
`
`There are three major biochemical pathways that have been shown to be associated
`with PAH: the endothelin pathway, nitric oxide pathway and prostacyclin pathway.
`These pathways play a critical role in the regulation of vascular tone, and their
`dysregulation results in vasoconstriction and pulmonary smooth muscle cell
`proliferation.
`
`Endothelin (ET-1) is an endogenous peptide formed by proteolytic processing of
`preproendothelin-1. ET-1 signaling through the endothelin receptors ETA and ETB,
`present in the pulmonary vascular smooth muscle cells, maintains vascular tone. In
`PAH patients, ET-1 levels are elevated in the blood stream and the ability to clear ET-1
`from the systemic circulation is reduced. Elevated signaling of the endothelin pathway
`in smooth muscle cells, from increased levels of ET-1 and endothelin receptors,
`produces pronounced vasoconstriction and smooth muscle proliferation effects.
`Endothelin receptor antagonists target ETA and/or ETB receptors to attenuate ET-1
`signaling in the smooth muscle cells. There are currently three approved endothelin
`receptor antagonist drugs: bosentan (Tracleer from Actelion), ambrisentan (Letairis in
`US from Gilead and Volibris in ex-US from GSK), and macitentan (Opsumit from
`Actelion). Tracleer and Opsumit target both the ETA and ETB receptor whereas
`Letairis/Volibris target only the ETA receptor. Drugs targeting the endothelin pathway
`(Tracleer, Letairis/Volibris, and Opsumit) had worldwide sales of ~$2.9B in 2016. The
`cumulative sales from these drugs are expected to marginally decline over the next
`four years. Tracleer and Letairis/Volibris are expected to see heavy generic erosion
`during this time period, whereas Opsumit, launched in 2013 (and not anticipated to be
`subject to generic competition during this time period) is expected to grow strongly.
`
`Nitric oxide (NO) is a vasodilator and plays a major role in smooth muscle cell
`signaling. NO is normally produced continuously by the endothelial cells from the
`conversion of L-arginine to L-citrulline aided by the enzyme NO synthase. NO diffuses
`into the vascular smooth muscle cells and binds to Guanylate Cyclase to stimulate the
`synthesis of cGMP, a second messenger that inhibits cell proliferation and produces
`muscle relaxation. In PAH patients there is decreased bioavailability of NO, resulting in
`reduced cGMP in smooth muscle cells. In addition, cGMP levels are also affected by
`the phosphodiesterase 5 (PDE-5) enzyme, which inactivates cGMP in smooth muscle
`cells. There are two class of approved drugs that target the NO pathway in PAH
`patients – soluble guanylate cyclase stimulators (GCS) and PDE-5 inhibitors. GCS
`directly bind to guanylate cyclase and mediates the synthesis of cGMP. Riociguat
`(Adempas from Bayer) is the only drug approved in this category. PDE-5 inhibitors
`preserve cGMP levels by blocking the inactivation of cGMP by the PDE-5 enzyme.
`Tadalafil (Adcirca from United Therapeutics) and sildenafil (Revatio) are the two major
`PDE-5 inhibitors approved for PAH. Drugs targeting the nitric oxide pathway (Adcirca,
`Revatio, and Adempas) reported worldwide sales of ≈$920MM in 2016. Cumulative
`sales from these drugs are expected to marginally increase for the next four years.
`Revatio sales have eroded due to generic entry and Adcirca is also expected to see
`competition from generic entry at the end of 2017. Adempas, launched in 2013, is
`expected to grow strongly during this time period.
`
`www.cowen.com
`
`2249
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 3 of 10
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`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`Mechanism Of PAH Drugs
`
`
`
`
`
`
`
`
`
`2250
`
`Source: Cowen and Company
`
`Prostacyclin is the major arachidonic acid metabolite of vascular endothelial and
`smooth muscle cells. Prostacyclin binds to the prostaglandin IP receptor on the
`smooth muscle cells to promote vasodilation and inhibit smooth muscle proliferation
`through the activation of cAMP. Prostacyclin levels are reduced in PAH patients
`thereby leading to reduced dilatory and anti-proliferative effects. Prostacyclin
`analogues and IP receptor agonists have been approved to target the prostacyclin
`
`www.cowen.com
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 4 of 10
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`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`pathway in PAH patients. Epoprostenol (Flolan from GSK and Veletri from Actelion),
`iloprost (Ventavis from Actelion) and treprostinil (Remodulin, Tyvaso and Orenitram
`from United Therapeutics) are prostacyclin analogues approved to treat PAH.
`Selexipag (Uptravi from Actelion) is the only approved prostaglandin IP receptor
`agonist in the market. Drugs targeting the prostacyclin pathway (Remodulin, Tyvaso,
`Uptravi, Orenitram, Flolan, Veletri and Ventavis) reported a worldwide sales of ≈ $1.6B
`in 2016. Cumulative sales from these drugs are expected to grow sharply for the next
`four years, primarily due to the growth expected in oral prostacyclin agent (Uptravi
`and Orenitram).
`
`Worldwide Sales (Reported And Consensus) From PAH Drugs Targeting Major Pathways
`
`
`
`Source: Cowen and Company
`
`
`
`In 2016, drugs targeting the prostacyclin, endothelin and nitric oxide pathways
`contributed 30%, 53%, and 17% to the worldwide PAH sales, respectively. In 2020,
`prostacyclin drugs are expected to contribute a majority share of 54%, whereas
`endothelin drugs are predicted to decline to a 35% market share. Nitric oxide pathway
`drugs market share are also expected to decline to 11% by 2021.
`
`Treatment Algorithm For PAH Patients
`
`Right-sided heart catheterization (RHC) is generally used to establish the
`hemodynamic criteria to arrive at a diagnosis for PAH. If PAH is confirmed at an expert
`center, then an acute vasoreactivity test is conducted to identify a small number of
`PAH patients (< 15%) that are vasoreactive and can be successfully treated with high-
`dose calcium channel blockers like nifedipine, diltiazem and amlodipine. All of these
`drugs are available as generics. A majority of diagnosed PAH patients, however, are
`non-vasoreactive and thus their treatment sequence is determined by their WHO
`functional classification.
`
`Low-risk WHO FC II and intermediate-risk WHO FC III patients start treatment with
`either a single agent or a combination of agents. ERA, PDE-5i, GCS, IP agonists drugs
`are used in the monotherapy setting, and ERA+PDE-5i is commonly used in the
`combination setting. For WHO FC III patients, due to their higher risk profile, can also
`start with a prostacyclin as a monotherapy. A prostacyclin is then added to the ERA or
`
`www.cowen.com
`
`2251
`
`Reported Sales (2010A to 2016A) and Consensus Estimates (2017E to 2020E)
`
`$4,500
`
`$4,000
`
`$3,500
`
`$3,000
`
`$2,500
`
`$2,000
`
`$1,500
`
`$1,000
`
`$500
`
`$0
`
`Worldwide Sales ($MM)
`
`2010A
`
`2011A
`
`2012A
`
`2013A
`
`2014A
`
`2015A
`
`2016A
`
`2017E
`
`2018E
`
`2019E
`
`2020E
`
`Prostacyclin pathway
`
`Endothelin pathway
`
`Nitric Oxide pathway
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 5 of 10
`
`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`ERA+PDE-5i in the combination setting. High risk WHO FC IV patients can be initiated
`with a prostacyclin or prostacyclin in combination with ERA or ERA+PDE-5i. Given
`that PAH is a chronically progressive disease, initial treatment regimens tend to
`produce less adequate clinical responses over time. In such scenarios, double or triple
`drug combinations therapies have become increasingly employed.
`
`Treatment Algorithm For PAH Patients
`
`Source: Cowen and Company, 2015 ESC/ERS Guidelines
`
`
`Physicians Start Patients On Monotherapy or Combination, And Add More As The
`Disease Progresses
`
`
`
`The latest treatment guidelines from the European Society of Cardiology and the
`European Respiratory Society, presented in 2015, provides a hierarchy of
`recommendations for the use of approved drugs in patients with PH based on the
`level of available evidence, general consensus, efficacy and safety. Drugs are
`classified as class I (recommended), class IIa (should be considered), class IIb (may be
`considered), and class III (not recommended) for WHO functional class II, III and IV.
`The table below provides the hierarchy for drugs for use as monotherapy, initial
`combination and sequential combination.
`
`Monotherapy: All three approved drugs (ambrisentan, bosentan, and macitentan) in
`the ERA class and the GCS class drug riociguat are recommended for use as
`monotherapy in WHO-FC II and III patients. In the PDE-5i drug class, sildenafil and
`tadalafil are recommended over vardenafil. Selexipag is the only drug targeting the
`prostacyclin pathway recommended for WHO-FC II patients. Prostacyclins are
`generally recommended as monotherapy for WHO-FC III patients. Epoprostenol i.v. is
`the only prostacyclin recommended as monotherapy in WHO-FC IV patients.
`
`2252
`
`www.cowen.com
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 6 of 10
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`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`Combination: For initial combinations in WHO-FC II and III patients, ambrisentan +
`Tadalafil is the recommended ERA + PDE-5i combination. For sequential
`combinations in WHO-FC II and III patients, ERA (macitentan) added to PDE-5i
`(sildenafil), GCS (riociguat) added to ERA (bosentan) and Prostacyclin (selexipag)
`added to ERA and/or PDE-5i are recommended. In addition, for WHO-FC III patients,
`PDE-5i (selexipag) added to Prostacyclin (epoprostenol i.v.) is also recommended. For
`WHO-FC IV patients, initial and sequential combinations are restricted to a lower level
`of recommendation (class II). GCS class drug riociguat added to PDE-5i is the only
`sequential combination that is not recommended (class III) for PAH patients.
`
`Physicians’ choice of an initial agent depends largely on the severity of a patient’s
`disease. Our consultants treat the majority of Class II or III patients initially with either
`a PDE5 inhibitor (Revatio or Adcirca) or an endothelin receptor antagonist (Opsumit,
`Tracleer or Letairis). Our consultants note that there is no scientific data that makes
`any one of the oral therapies an overwhelming favorite for treatment naïve patients.
`Some use an endothelin receptor antagonist (either Letairis or Opsumit) first, while
`others use a PDE5 inhibitor, most specifically Adcirca.
`
`Physicians traditionally did not consider that there was sufficient data to support the
`use of combination therapy in treatment naïve patients. However, in 2015 Gilead/GSK
`reported that the AMBITION trial of first-line Letairis + Adcirca, compared to either
`agent as a monotherapy, demonstrated a significant reduction in the risk of clinical
`failure. This was not an expected result and the findings from the AMBITION study are
`considered paradigm changing, and has prompted the standard of care to include the
`use of combinations earlier in the course of treatment in the first-line setting. Data
`from AMBITION was added to the Letairis label in October 2015.
`
`If a patient has not improved within 6-8 weeks, or if a patient progresses through their
`first-line therapy, a second agent is typically added. For patients on a PDE-5 inhibitor,
`an endothelin receptor antagonist (ERA) such as Actelion’s Opsumit, Actelion’s
`Tracleer or Gilead’s Letairis, is then added. For those patients already on an ERA, then
`UTHR’s Adcirca is typically added.
`
`Within the PDE-5 class Adcirca is the physicians’ first choice therapy as it is dosed
`once per day, which is more convenient than Revatio, which is dosed three times per
`day. Physicians also note that the labeled dose of Adcirca is considered more effective
`than the labeled dose of Revatio, which is lower than the optimal dose in Revatio’s
`clinical trials. Although Revatio generics are available, thus far physicians do not
`report being forced by payors to use them ahead of Adcirca.
`
`Our consultants suggest each ERA has certain benefits and drawbacks. Which agent
`they choose for any particular patient depends on the etiology of the patient’s PAH,
`and on the data that has been generated for each agent in the specific patient
`population. Physicians generally prefer either Letairis or Opsumit over Tracleer, as the
`former are dosed once per day (while Tracleer is dosed twice per day), and Tracleer is
`associated with a higher rate of liver toxicity (~10% of Tracleer patients develop
`elevated liver enzyme levels, while few patients on either Opsumit or Letairis do).
`
`Patients whose disease deteriorates further are prescribed an oral, inhaled or infused
`(for very severe disease) prostacyclin. For their infused option, our consultants prefer
`subcutaneous Remodulin, and will switch a patient to intravenous Remodulin if
`injection site pain becomes a problem. They typically do not use much epoprostenol.
`
`www.cowen.com
`
`2253
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 7 of 10
`
`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`Classes Of Recommendation For Approved Drugs
`
`Source: Cowen and Company, 2015 ESC/ERS Guidelines
`
`
`
`PAH Clinical Trials
`
`
`
`Drugs for PAH are typically approved based on randomized clinical trials comparing
`the drug to placebo. Head-to-head trials are seen in the combination setting and are
`generally not required to gain approval as a single agent. Single agent trials have been
`historically performed with no background therapy or on top of an ERA and/or a PDE-
`5i. For the primary endpoint, 6-minute walk distance (6MWD) is the historically
`preferred endpoint for regulatory approval. However, this is changing with the advent
`
`2254
`
`www.cowen.com
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 8 of 10
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`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`of drugs like Uptravi, which was approved based on what is increasingly viewed as a
`more clinically relevant TTCW (time to clinical worsening) endpoint.
`
`6MWD: The 6-minute walk distance test, a submaximal exercise test, has been the
`preferred primary endpoint used in clinical trials to demonstrate efficacy. The test is
`generally reproducible, safe, not complicated to perform, and familiar to patients.
`Results of the 6MWD test, however, have been shown to be influenced by several
`factors: age, sex, body habitus, learning curve, coaching and motivation, hence
`making it a less than ideal clinical endpoint. Superiority in 6MWD over placebo
`results in a label indicating that the drug has been shown to improve exercise
`capability in PAH patients.
`
`TTCW: A new primary endpoint is emerging in the form of an event driven endpoint
`denoted by Time To Clinical Worsening. This composite endpoint takes into account
`key morbidity outcomes as well as mortality. TTCW is now favored over 6WMD as it is
`less subjective and considered a more clinically relevant measure of therapeutic
`efficacy. Three recent trials (SERAPHIN, AMBITION, and GRIPHON) have successfully
`used this endpoint and results have had a major influence on treatment selection in
`PAH.
`
`PAH Drugs Randomized Clinical Trials Summary
`
`Source: Cowen and Company
`
`
`
`
`
`Actelion’s Tracleer Was The First Oral Therapy For PAH; Its Final Orange Book Listed
`Patent Has Expired
`
`Actelion’s Tracleer (bosentan) is an oral endothelin-1 antagonist. Endothelin-1 is a
`potent vasoconstrictive peptide that also plays a role in vascular remodeling. Tracleer
`binds to both the ETA and ETB endothelin receptors, resulting in vasodilation of the
`pulmonary arterial system. Tracleer may also ameliorate vascular remodeling. With a
`half-life of roughly five hours, Tracleer is administered twice per day.
`
`www.cowen.com
`
`2255
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 9 of 10
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`

`

`Cowen and Company
`Equity Research
`
`February 2017
`
`United Therapeutics PAH Worldwide Revenue Model ($000)
`
`Source: Cowen and Company
`
`
`
`
`Orenitram’s Clinical Program Yielded Mixed Results
`
`Dosing Issues Tripped Up FREEDOM-C In 2008
`
`The first Phase III trial produced top-line data in November 2008. FREEDOM-C was a
`300-patient combination study with other oral agents including Revatio and/or
`Tracleer in PAH patients failing oral regimens. In its primary endpoint of 6MWD at
`week 16, Orenitram produced a median change of 11m, p=0.072, just missing
`statistical significance.
`
`As initially designed, patients in FREEDOM-C were started on 1mg Orenitram BID, and
`patients were to be up-titrated by 1mg BID every week. Not only was 1mg the starting
`dose, and expected dose increment, but the drug was available only in a 1mg pill size,
`meaning lower doses or smaller dosing increments were not possible. This dosing
`paradigm was problematic. Prostacyclins like treprostinil have relatively harsh side
`effects such as nausea, vomiting, and flushing that are dose-related. To minimize the
`side effects, patients are typically started at low doses, and as the patients acclimate,
`the dose is increased to get the patient into the therapeutic range gradually, over
`weeks. Unfortunately, Orenitram was somewhat more bioavailable than United
`Therapeutics had originally thought, meaning that patients were being started on and
`up-dosed by too large of a dose. Many patients experienced harsh prostacyclin-like
`side effects. United Therapeutics realized its mistake, and worked to introduce smaller
`Orenitram pill sizes that would permit both a lower starting dose and smaller dose
`increments. A 0.5mg pill was introduced in July 2007 when the trial had enrolled about
`
`2278
`
`www.cowen.com
`
`Remodulin
`
`2014A
`
`2015A
`
`Q1:16A
`
`Q2:16A
`
`Q3:16A
`
`Q4:16A
`
`2016A
`
`Q1:17E
`
`Q2:17E
`
`Q3:17E
`
`Q4:17E
`
`2017E
`
`2018E
`
`2019E
`
`2020E
`
`2021E
`
`Avg # s.c. Remodulin patients, US
`
`# s.c. Remodulin patients, ROW
`
`# s.c. Remodulin patients, W/W
`
`1706
`
`394
`
`2100
`
`1843
`
`325
`
`2168
`
`1768
`
`350
`
`2118
`
`2058
`
`350
`
`2408
`
`1950
`
`350
`
`2309
`
`1941
`
`350
`
`2291
`
`1929
`
`350
`
`2282
`
`132
`
`1873
`
`400
`
`2273
`
`33
`
`1873
`
`400
`
`2273
`
`33
`
`1910
`
`400
`
`2310
`
`33
`
`1910
`
`400
`
`2310
`
`33
`
`1891
`
`400
`
`2291
`
`132
`
`1790
`
`400
`
`2190
`
`140
`
`1550
`
`400
`
`1950
`
`140
`
`1390
`
`400
`
`1790
`
`140
`
`1250
`
`400
`
`1650
`
`140
`
`Revenue/patient (000s)
`
`132
`
`132
`
`33
`
`33
`
`33
`
`33
`
`S.C. Remodulin revenue (000s)
`
`$277,218
`
`$286,110
`
`$69,894
`
`$79,464
`
`$76,197
`
`$75,603
`
`$301,158
`
`$75,000
`
`$75,000
`
`$76,230
`
`$76,230
`
`$302,460
`
`$306,600
`
`$273,000
`
`$250,600 $231,000
`
`Avg # i.v. Remodulin patients, US
`
`# i.v. Remodulin patients, ROW
`
`# i.v. Remodulin patients, W/W
`
`2015
`
`80
`
`2095
`
`1847
`
`325
`
`2172
`
`1768
`
`350
`
`2118
`
`2057
`
`350
`
`2407
`
`1950
`
`350
`
`2309
`
`1941
`
`350
`
`2291
`
`1929
`
`350
`
`2281
`
`1873
`
`400
`
`2273
`
`1873
`
`400
`
`2273
`
`1910
`
`400
`
`2310
`
`1910
`
`400
`
`2310
`
`1891
`
`400
`
`2291
`
`1790
`
`400
`
`2190
`
`140
`
`1550
`
`400
`
`1950
`
`140
`
`1390
`
`400
`
`1790
`
`140
`
`1250
`
`400
`
`1650
`
`140
`
`Revenue/patient (000s)
`
`132
`
`132
`
`33
`
`33
`
`33
`
`33
`
`132
`
`33
`
`33
`
`33
`
`33
`
`132
`
`I.V. Remodulin revenue (000s)
`
`$276,508
`
`$286,727
`
`$69,906
`
`$79,431
`
`$76,197
`
`$75,603
`
`$301,137
`
`$75,000
`
`$75,000
`
`$76,230
`
`$76,230
`
`$302,460
`
`$306,600
`
`$273,000
`
`$250,600 $231,000
`
`Infus e d Re modulin re v e nue (0 0 0 s )
`
`$553,726
`
`$572,837
`
`$139,800
`
`$158,895
`
`$152,394
`
`$151,206
`
`$602,295
`
`$150,000
`
`$150,000
`
`$152,460
`
`$152,460
`
`$604,920
`
`$613,200
`
`$546,000
`
`$501,200 $462,000
`
`Tyvaso
`
`2014A
`
`2015A
`
`Q1:16A
`
`Q2:16A
`
`Q3:16A
`
`Q4:16A
`
`2016A
`
`Q1:17E
`
`Q2:17E
`
`Q3:17E
`
`Q4:17E
`
`4500
`
`5000
`
`5100
`
`5100
`
`5100
`
`5100
`
`5100
`
`5100
`
`5100
`
`5100
`
`5100
`
`2017E
`
`5100
`
`2018E
`
`5100
`
`2019E
`
`5100
`
`2020E
`
`2021E
`
`5100
`
`5100
`
`Avg # inhaled prostacyclins patients, US
`
`Revenue/patient (000s)
`
`# patients on Tyvaso
`
`U.S. Tyvaso revenue
`
`126
`
`3675
`
`126
`
`3731
`
`32
`
`3244
`
`32
`
`3397
`
`32
`
`3232
`
`32
`
`2971
`
`126
`
`3211
`
`32
`
`3200
`
`32
`
`3200
`
`32
`
`3200
`
`32
`
`3200
`
`126
`
`3200
`
`126
`
`3300
`
`126
`
`3200
`
`126
`
`2976
`
`126
`
`2556
`
`$463,068
`
`$470,067
`
`$102,200
`
`$107,006
`
`$101,808
`
`$93,587
`
`$404,600
`
`$100,800
`
`$100,800
`
`$100,800
`
`$100,800
`
`$403,200
`
`$415,800
`
`$403,200
`
`$375,000 $322,000
`
`# inhaled prostacyclin patients, ROW
`
`2000
`
`2000
`
`2600
`
`2700
`
`2800
`
`2900
`
`2750
`
`2800
`
`32
`
`2800
`
`32
`
`2800
`
`32
`
`2800
`
`32
`
`2750
`
`126
`
`2800
`
`126
`
`2800
`
`126
`
`2800
`
`126
`
`2800
`
`126
`
`Revenue/patient (000s)
`
`# patients on Tyvaso
`
`ROW Tyvaso revenue
`
`126
`
`0
`
`$0
`
`126
`
`0
`
`$0
`
`32
`
`0
`
`$0
`
`32
`
`0
`
`$0
`
`32
`
`0
`
`$0
`
`32
`
`0
`
`$0
`
`126
`
`0
`
`$0
`
`0
`
`$0
`
`0
`
`$0
`
`0
`
`$0
`
`0
`
`$0
`
`0
`
`$0
`
`0
`
`$0
`
`198
`
`397
`
`476
`
`$25,000
`
`$50,000
`
`$60,000
`
`T y v a s o Inha le d Re modulin re v e nue (0 0 0 s )
`
`$463,068
`
`$470,067
`
`$102,200
`
`$107,006
`
`$101,808
`
`$93,587
`
`$404,600
`
`$100,800
`
`$100,800
`
`$100,800
`
`$100,800
`
`$403,200
`
`$415,800
`
`$428,200
`
`$425,000 $382,000
`
`Adcirca
`
`2014A
`
`2015A
`
`Q1:16A
`
`Q2:16A
`
`Q3:16A
`
`Q4:16A
`
`2016A
`
`Q1:17E
`
`Q2:17E
`
`Q3:17E
`
`Q4:17E
`
`2017E
`
`2018E
`
`2019E
`
`32579
`
`2020E
`
`34208
`
`2021E
`
`35920
`
`Diagnosed PAH Patients, US
`
`Avg # Adcirca patients, US
`
`Revenue/patient (000s)
`
`25526
`
`14520
`
`15
`
`26803
`
`17734
`
`16
`
`27500
`
`18284
`
`4
`
`27950
`
`22666
`
`4
`
`28350
`
`23700
`
`4
`
`28772
`
`27550
`
`4
`
`28143
`
`23050
`
`16
`
`29550
`
`20000
`
`4
`
`29550
`
`22000
`
`4
`
`29550
`
`24000
`
`4
`
`29550
`
`14583
`
`4
`
`29550
`
`20146
`
`17
`
`31028
`
`2015
`
`17
`
`1007
`
`18
`
`907
`
`18
`
`889
`
`18
`
`U.S. Adc irc a Re v e nue (0 0 0 s )
`
`$221,472
`
`$278,832
`
`$72,601
`
`$90,901
`
`$95,998
`
`$112,708
`
`$372,207
`
`$83,048
`
`$91,352
`
`$99,657
`
`$60,556
`
`$334,613
`
`$34,465
`
`$17,750
`
`$16,454
`
`$16,000
`
`Q3:16A
`
`Q4:16A
`
`2016A
`
`Q1:17E
`
`Q2:17E
`
`Q3:17E
`
`Q4:17E
`
`2017E
`
`2018E
`
`2019E
`
`2020E
`
`2021E
`
`Orenitram
`
`Diagnosed PAH Patients, US
`
`Revenue/patient (000s)
`
`# patients on Orenitram
`
`U.S. Orenitram revenue
`
`2014A
`
`25526
`
`200
`
`206
`
`2015A
`
`Q1:16A
`
`Q2:16A
`
`26803
`
`27500
`
`27950
`
`28350
`
`28772
`
`28143
`
`29550
`
`29550
`
`29550
`
`29550
`
`29550
`
`31028
`
`32579
`
`34208
`
`35920
`
`155
`
`801
`
`35
`
`1149
`
`35
`
`1086
`
`35
`
`1163
`
`35
`
`1094
`
`140
`
`1123
`
`38
`
`1075
`
`38
`
`1100
`
`38
`
`1150
`
`38
`
`1200
`
`150
`
`1131
`
`160
`
`1300
`
`170
`
`1450
`
`170
`
`1600
`
`170
`
`1765
`
`$41,266
`
`$118,450
`
`$40,200
`
`$38,010
`
`$40,705
`
`$38,290
`
`$157,205
`
`$40,313
`
`$41,250
`
`$43,125
`
`$45,000
`
`$169,688
`
`$208,000
`
`$246,500
`
`$272,000 $300,050
`
`29550
`
`29550
`
`31028
`
`32579
`
`34208
`
`35920
`
`Diagnosed PAH Patients, ROW
`
`25526
`
`26803
`
`27500
`
`27950
`
`28350
`
`28772
`
`28143
`
`29550
`
`29550
`
`29550
`
`Revenue/patient (000s)
`
`# patients on Orenitram
`
`ROW Orenitram revenue
`
`100
`
`0
`
`$0
`
`100
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`100
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`25
`
`0
`
`$0
`
`100
`
`0
`
`$0
`
`100
`
`150
`
`100
`
`500
`
`100
`
`700
`
`100
`
`1000
`
`$15,000
`
`$50,000
`
`$70,000 $100,000
`
`Ore nitra m re v e nue (0 0 0 s )
`
`$41,266
`
`$118,450
`
`$40,200
`
`$38,010
`
`$40,705
`
`$38,290
`
`$157,205
`
`$40,313
`
`$41,250
`
`$43,125
`
`$45,000
`
`$169,688
`
`$223,000
`
`$296,500
`
`$342,000 $400,050
`
`WATSON LABORATORIES, INC. , IPR2017-01621, Ex. 1083, p. 10 of 10
`
`