BioMarin Pharmaceutical - Earnings Call - Q1 2021
April 29, 2021
Transcript
Operator (participant)
Welcome to the BioMarin First Quarter 2021 Financial Results Conference Call. Hosting the conference call today from BioMarin is Traci McCarty, Vice President of Investor Relations. Please go ahead, Traci.
Traci McCarty (VP of Investor Relations)
Thank you, Grace. Thank you all for joining us today. To remind you, this non-confidential presentation contains forward-looking statements about the business prospects of BioMarin Pharmaceutical Inc., including expectations regarding BioMarin's financial performance, commercial products, and potential future products in different areas of therapeutic research and development. Results may differ materially depending on the progress of BioMarin's product programs, actions of regulatory authorities, availability of capital, future actions in the pharmaceutical market, and developments by competitors, and those factors detailed in BioMarin's filings with the Securities and Exchange Commission, such as 10-Q, 10-K, and 8-K reports. On the call remotely from BioMarin Management today are J.J. Bienaimé, Chairman and Chief Executive Officer, Jeff Ajer, Executive Vice President, Chief Commercial Officer, Hank Fuchs, President, Worldwide Research and Development, Greg Guyer, Executive Vice President, Chief Technical Officer, and Brian Mueller, Executive Vice President, Chief Financial Officer.
I will now turn the call over to BioMarin's Chairman and CEO, J.J. Bienaimé.
J.J. Bienaimé (Chairman and CEO)
Thank you, Traci, and good afternoon, everyone. We hope you and your families are well and enjoying the return to normal day-to-day activities as access to COVID-19 vaccines increases and the U.S. continues to open up, so we had a very strong start to 2021, recording $486 million of total revenues and GAAP net income of $17 million in the first quarter, and $114 million of cash flow from operations, an important achievement. We have also reaffirmed previously released financial guidance for the full year. This takes into consideration both the typical uneven ordering patterns in some of our ex-U.S. regions, as well as continued uncertainty outside of the U.S. due to COVID-19. It is not by chance that BioMarin has successfully managed through the challenges caused by the global pandemic. Our business is built to weather uncertainty, given the essential nature of our products.
The underlying strength of our business is quantifiable across a number of metrics. BioMarin's five-year non-GAAP income compounded annual growth rate, or CAGR, of 62% far exceeds the 12% average of biotech companies with at least $1 billion of revenues in the last five years. Our five-year revenue CAGR of 16% is better than 10 of the 15 biotech companies with at least $1 billion of revenues over the last five years. With the approval of vosoritide in Europe in sight and the EMA marketing authorization representing an opportunity that's roughly three times the size of the U.S., we are poised to deliver meaningful growth beginning in 2022.
On the heels of potential vosoritide approvals this year in the U.S. and Europe, and with the European filing of Roctavian, which is targeted for this June, we could potentially receive a second significant product approval in Europe in the second quarter of next year. Similar to the achondroplasia market opportunity in the EMA, we believe that there are three times as many severe hemophilia patients in that region as compared to North America, representing transformational growth opportunities with vosoritide and Roctavian approvals and commercialization. Assuming favorable results with Roctavian at year two, we will target a biologics license application, or BLA, with submission in the U.S. in the second quarter of 2022, followed by an expected six-month review procedure, and then potential U.S. approval at the end of 2022, next year.
Based on the cumulative data to date with Roctavian, with both the 6 x 10^13 and the 4 x 10^13 doses, we believe it is reasonable to expect durable bleeding control at year two in the phase III study. Also, that's based on the first 17 patients that we communicated that reached also the two-year goalpost. If the data are supportive of the efficacy and safety data from our extensive program, it would represent significant cost savings to global healthcare providers. It should be a very momentous 2021 and 2022 with this exciting catalyst on the horizon. Thank you all for your continued support, and I would like to turn the call over to Jeff to discuss the commercial business update. Jeff?
Jeff Ajer (EVP, Chief Commercial Officer)
Thank you, J.J. As we begin 2021, I am very pleased with the team's performance across all brands and all regions during the quarter. As J.J. mentioned, we achieved total revenues of $486 million in the first quarter. Excluding Kuvan contributions, total revenues grew 9% in the first quarter 2021 compared to first quarter 2020. Before discussing commercial results, I'd like to introduce the brand name for vosoritide. As we are currently in label negotiations in the EU and with ample product supply ready for launch, we are pleased to introduce Voxzogo to the investment community. The name is as unique as our company and our product, and we look forward to spreading the word once it's go time with Voxzogo, spelled V-O-X-Z-O-G-O. Turning to results in the quarter, I begin with a reminder of the dynamics of large irregular order patterns specific to our enzyme replacement therapy brands.
I want to emphasize that we received large orders during the first quarter from such markets as Turkey, Brazil, Egypt, Russia, and Saudi Arabia that are gratifying and good for our business, and which we expect will cause the first half of 2021 to have some concentration of our annual revenues for both Naglazyme and Vimizim relative to the second half of 2021. We reaffirm our annual guidance for total revenues and for each of the commercial brands and ask that you consider that guidance when modeling your expectations for the balance of 2021. Relative to my comment of gratifying and good for our business, having inventory in these markets helps maintain continuity of supply, the lack of which can occasionally present a challenge in these and other markets, and which can have a negative impact on compliance and demand generation.
For Brineura, we experienced a different impact from order patterns. In this case, inventory purchases late in Q4 2020 were followed by drawing down of inventory in Q1 2021, which contributed to a decrease in revenue quarter-to-quarter for Brineura. A few more details on our products for lysosomal storage disorders: Naglazyme, Vimizim, and Brineura. All three products have maintained strong patient compliance despite the persistence of COVID-19 globally, and our mitigation tactics across the most pandemic-impacted markets continue to successfully support patient access and adherence to therapy. Of note, patient demand for both Naglazyme and Vimizim increased approximately 10% year-over-year, underscoring the essential nature of these important therapies for the people who rely on them.
We expect that Brineura, in particular, will resume a trend of modest quarterly growth following the normalization of customer inventory levels in Q1 and driven by roughly a 30% increase year-over-year in patients on commercial therapy. Moving now to Palynziq, where year-over-year growth of 56% translated to $54 million in first quarter revenue, the U.S. continued to be the main contributor of growth in the quarter, driven by U.S. patient increases of more than 20% year-over-year. While we are still experiencing net patient growth, new patient starts in the U.S. have continued to be impacted by COVID-19 in the quarter. We are optimistic about the growth prospects for Palynziq for the balance of 2021, with an expectation that PKU clinics that have been operating at partial capacity are able to increase capacity over the coming quarters.
The pandemic impact on Palynziq has been more severe in the EMEA region, where we continue to experience delays in price and reimbursement approvals and very little new patient activity. In spite of that, we are making incremental progress, and I continue to expect that we will see more material Palynziq revenue from this region when PKU clinics have more freedom to operate and start additional patients. Continuing with the PKU franchise, Kuvan contributed $71 million in revenues in the quarter. Kuvan net product revenues decreased by $51 million year-over-year, primarily due to the loss of market exclusivity in the U.S. in October 2020, resulting from generic competition and as anticipated. Circling back to our next potential commercial product, Voxzogo, launch readiness in key EU markets and the U.S. are quite advanced.
Sales, brand, and market access teams are in place and working on finalizing details of the launch. Released, labeled, finished goods are expected to be available in key markets, including Germany, France, Italy, and the U.S., and ready to ship to customers within four-to-eight weeks of an approval. We have been able to leverage existing teams that are well experienced from recent launches of Palynziq and Brineura and expect to be well prepared for what could be BioMarin's largest brand yet. In conclusion, it was a strong start to the year from a revenue perspective, and I'm very pleased with the continued commitment and resilience of our teams globally. Thank you for your attention, and I will now turn the call over to Hank to provide an R&D update. Hank?
Hank Fuchs (President, Worldwide Research and Development)
Thank you, Jeff. As J.J. conveyed, we look forward to a number of important events on the horizon in 2021. Accumulating data on the durability of both Voxzogo and Roctavian suggests meaningful clinical benefits will be maintained, and therefore we remain optimistic about the potential of these two innovative therapies to be transformative to the people who need them. In Europe, and beginning with Voxzogo in the quarter, our dialogue with European health authorities has been quite positive, and we look forward to a CHMP opinion in June, followed by European Commission decision in late summer. With labeling discussions well underway in Europe, we feel that the Voxzogo path forward is significantly de-risked. Turning to Roctavian in the European Union, in the quarter, we held a very productive pre-submission discussion meetings with the European health authorities and remain on track to submit the marketing authorization application in June.
Of particular note, the rapporteur and co-rapporteur are fully aware of the coming five-year phase II and two-year phase III Roctavian data cuts and are not requiring those data to support submission, giving us added confidence in our ability to meet the June submission goal. Assuming we remain on the anticipated timelines in Europe, therefore, we could potentially receive a CHMP opinion on Roctavian in the second quarter of 2022. Turning to the U.S. and Voxzogo, in the quarter, we provided the Food and Drug Administration with the two-year results from the phase III extension study to supplement the new drug application already under review. As anticipated, they designated this submission a major amendment to the application to provide the time for a full review of the submission, thus extending the PDUFA target action date by three months to November 20th, 2021.
We are pleased that the pre-approval inspection of our Novato facility for the manufacturing of Voxzogo was completed, checking off another milestone for regulatory review. Special congratulations to our technical operations team and our compliance teams for that accomplishment. We are also happy to report the phase II study with zero to five-year-olds completed enrollment in the quarter. The importance of starting treatment with Voxzogo as early as possible cannot be overstated, and we are hopeful that the output of our zero to five-year study will provide support to regulators to enable the youngest children to benefit from the first potential therapeutic option to treat the underlying cause of achondroplasia. Developing Voxzogo has been a 15-year journey, and I want to extend my deep appreciation for the team at BioMarin, our investigators, and the generous families who have dedicated themselves to advancing the standard of care in achondroplasia. Thank you.
Moving to Roctavian in the U.S., following discussions with the FDA this quarter, we have aligned on the previously communicated base case scenario of resubmission with two-year follow-up safety and efficacy data on all phase III subjects in the second quarter of 2022. FDA remains committed to this path forward with Roctavian to support their final benefit risk assessment. Based on the consistent and dramatic bleed control observed to date across our phase II program, not just with the 6e13 dose, but also with the 4e13 dose through three years and the 6e13 dose through four years, as well as the phase III data to date, now out to two years, we are encouraged that the combined dossier will provide ample evidence of clinical benefit with Roctavian.
We remain on track to share the phase II five-year update with the 6e13 dose, as well as the four-year update on the 4e13 dose later this year, and plan to also include those data in the U.S. BLA resubmission in 2Q 2022, assuming favorable results, followed by an expected six-month review procedure by the FDA upon resubmission. Briefly, on the earlier stage pipeline, dose escalation has commenced with BMN 307, our investigational gene therapy for PKU, and the program continues based on the encouraging Phe lowering observed with the lower dose that's been tested so far.
In our IND enabling studies for BMN 351 for the treatment of Duchenne muscular dystrophy, this antisense oligonucleotide therapy demonstrated dystrophin protein expression levels of between 30% and 50% of normal levels in the quadriceps in a DMD mouse model treated for at least 13 weeks and who possess the human skippable mutation. The familiar chemistry and novel biology of BMN 351 position us uniquely in this context. Levels of antisense oligonucleotide that are known to be achievable in muscles with this class of molecule are expected to produce enough protein in humans to transform lives. While it is early days, we are very encouraged by these data, as we shared at the World Muscle Meeting last fall, because this may represent the potential of another important new therapeutic to address the unmet need in this population.
With BMN 331 gene therapy for the treatment of hereditary angioedema, we're conducting IND enabling studies and expect to file an IND in the middle of the year. Our collaboration with DiNAQOR on hypertrophic cardiomyopathy, which we announced in May of last year, is progressing well. Preclinical studies are underway, and we plan to select our candidate vector in 2021 for this program. We look forward to sharing a deep dive on all of these next-generation products at our upcoming R&D day, tentatively planned for this coming November. The R&D organization is energized and very busy as we advance multiple early to late-stage programs this year to deliver on our goal of bringing transformative therapies to patients with rare genetic diseases. Thanks for your support, and a special thanks to the worldwide R&D and the team and the organization for driving as hard as they can on behalf of our patients.
I'll now turn the call over to Brian to update the financial results in the quarter. Brian?
Brian Mueller (EVP and CFO)
Thank you, Hank. Please refer to today's press release summarizing our financial results for full details on the first quarter of 2021. As usual, our comprehensive report on the quarter will be available in our upcoming Form 10-Q, which we're on track to file tomorrow. As J.J. mentioned, the anticipated timing of revenue and expenses over the course of 2021 resulted in a strong start to the year with our financial performance in the first quarter. With respect to revenues, Jeff mentioned some of the specific markets that placed large orders in the first quarter. While we don't expect that pattern to repeat this year, and future quarterly revenues in 2021 may be lower, we are pleased to be able to supply the market earlier rather than later, and we continue to emphasize our full-year guidance and our annual business cycle as the best metrics to measure our performance.
Moving to operating expenses, while R&D expense in the first quarter of 2021 was largely flat compared to the first quarter of 2020, the program mix of our R&D spend is starting to shift to our earlier stage pipeline. As we advance these early-stage assets, we expect R&D expense to increase over the course of the year, which is a key timing element driving the quarterly financials this year. Likewise, as we hope to be launching Voxzogo in the second half of the year, SG&A expenses are also weighted towards the back half of the year. Timing aside, SG&A expense for the first quarter of 2021 was slightly lower than Q1 last year, primarily due to lower foreign currency exchange losses and slightly reduced operating activity in Q1 2021 due to the pandemic.
Turning to bottom line results, we reported GAAP net income of $17 million in the first quarter of 2021, compared to GAAP net income of $81 million in the first quarter of 2020. The decrease in income was primarily due to the absence of the $60 million gain on the sale of the Firdapse commercial assets in the first quarter of 2020 and the impact of the U.S. Kuvan generic competition in 2021. Non-GAAP income decreased to $104 million in the first quarter of 2021, compared to Q1 2020 non-GAAP income of $117 million, also primarily due to the Kuvan U.S. generic entry late last year. Based on the expected timing dynamics of both revenue and expenses from quarter-to-quarter in 2021 and our business plans for the remainder of the year, we reaffirm full-year 2021 R&D expense, SG&A expense, and bottom line guidance.
Lastly, with respect to total cash and investment, we ended the first quarter of 2021 with $1.4 billion, compared to $1.35 billion at the end of 2020. We set a goal of earning positive operating cash flow in 2021, and while the aforementioned timing dynamics also impact cash flow, the business is off to a strong start in 2021 with $114 million of positive cash flow from operations in the first quarter. This solid cash position, coupled with BioMarin's business fundamentals, as shown with our stable operating financial performance, put us in good standing to manage through this year when our rapid growth is on pause in anticipation of the potential launches of Voxzogo and Roctavian, and beyond our late-stage pipeline, our increasing investment in the early-stage pipeline sets up the advancement of the next generation of transformative BioMarin products.
Thank you for your support, and we'll now open up the call to your questions. Operator?
Operator (participant)
All right. So as a reminder, to ask a question, you will need to press star one on your telephone. To resolve your question, press the pound key. Again, that is star one on your telephone. We do have a question from Joseph Schwartz from SVB Leerink. You are now live.
Joori Park (VP of Equity Research)
Hi, I'm Joori dialing for Joe. Thanks for taking our question. I was curious about your Roctavian program first. How satisfied are you with your pricing discussions and the EU health authorities, given that another gene therapy manufacturer recently decided to forgo offering their gene therapy product in Germany after they didn't get a lot of traction for their premium price?
J.J. Bienaimé (Chairman and CEO)
Jeff, do you want to answer that? I have some comments.
Jeff Ajer (EVP, Chief Commercial Officer)
Sure. Thank you. So I think the first thing to recognize is Roctavian is a very different situation with respect to value proposition compared to Zynteglo, the product and the situation that you referenced. I'll remind you that ICER in the U.S. recently reviewed Roctavian and Hemlibra against standard of care prophylaxis. With respect to Roctavian, their determination was that Roctavian would be a superior choice at a presumed cost of $2.5 million. And so thinking about that and the situation of Germany, the Zynteglo situation relies on cost offsets indeed, but cost offsets of transfusions, which are relatively lower cost than the cost offsets due to the ability to reduce or eliminate Factor VIII replacement therapy. That's the main situation.
In addition, when we price Roctavian, we intend to capture the full value of that product, which includes in part cost offsets, but also potentially superior clinical outcomes and quality of life benefits. So I think you've really got an apples-to-oranges comparison here that needs to be thoughtfully considered.
J.J. Bienaimé (Chairman and CEO)
If I may add, also, I think the price that they turned down wasn't that low. It was around close to $900,000 per treatment. I think the issue they were facing is that I understand that the market in Germany for the indication that Zynteglo was looking for is very small compared to Southern Europe. The disease is mainly prevalent in Southern Europe, and it was just not worth the effort, which is a very different situation for us. Germany is a pretty large market for us in Europe for Roctavian.
Joori Park (VP of Equity Research)
Okay, great. Thanks for that. And then my second question is on Voxzogo. You said that this program could be your strongest launch in the company's history. So what is the driving factor that makes you believe that this could be the largest brand? Are you detecting high demand from younger patients, older patients, parents, advocacy groups? I guess I'm curious to know, one, what gives you confidence, and two, how you're thinking about the adoption pattern, assuming approval? Thanks.
J.J. Bienaimé (Chairman and CEO)
Jeff, do you want to start again?
Jeff Ajer (EVP, Chief Commercial Officer)
Sure. Happy to. Yeah, we're really excited about Voxzogo. I'll start with the fact that we've got a really comprehensive clinical package that is supporting the potential approval and launch. So we've got a very large and multi-year effort behind defining the natural history and burden of illness behind achondroplasia, which hadn't been really well characterized before BioMarin started working, and which is foundational to our value proposition. We've got many years of durability expressed in the phase II. We've got a very robust phase III study that's augmented by the crossover arm from year one to year two and the full two years in that phase III from the active participants. In addition, we have another study that we'll read out in the not-too-distant future, studying Voxzogo in 0-4 year-olds, and we have additional work ongoing.
So very robust clinical program with very robust results to support that and a relatively large patient population to go after. We mentioned that our EMEA operating region, which includes the EU and Europe outside of the EU, Middle East, Africa, unlocks a patient population roughly three times the size of the U.S. market. So there's a lot of patients. There's a really powerful value proposition. And yes, we know that our investigators are excited about this program. And to the extent that we've been able to communicate about this program in advance of launch without promoting it, we're getting very good signals of enthusiasm back from the market.
J.J. Bienaimé (Chairman and CEO)
Just would add, Jeff said, it's a large opportunity. We have estimated in the EMEA region of about 11,000 eligible patients. There is no approved therapy for achondroplasia. So competition in some of those countries, over 80% of the patients undergo limb lengthening surgery, which is very painful and potentially risky. So that's the illustration of the unmet medical need in that region and in the world for achondroplasia patients.
Operator (participant)
All right. So next one on the queue is Cory Kasimov from J.P. Morgan. You are now live.
Coming on for Cory. Thanks for taking our question. I guess we just had a follow-up on vosoritide. You spoke to the 3X greater patient population. I just want to get the sense of initial uptake in geographies comparing EMEA and U.S. What are your expectations there? And then just how should we look at this, the commercial opportunity at peak, the split between these geographies?
J.J. Bienaimé (Chairman and CEO)
Jeff?
Jeff Ajer (EVP, Chief Commercial Officer)
Yeah. Thanks for the question. And I'll refer you also to the transcript from our earnings call for the fourth quarter of 2020, where I addressed this question in some level of detail. So we always anticipate that payer coverage for BioMarin drugs comes fastest. We get the best pricing and the most rapid uptake in the U.S. Relative to that, the EMEA region is a 3X, as you noted, larger opportunity. Those price and reimbursement approvals take a little bit longer to navigate. We have to go market by market to do that. That can take some time. And then typically, the patient uptake comes a little bit slower. In spite of that, it's exactly the EMEA operating region and other international markets that become kind of the long-term engine of growth for our brands.
And you can see that embodied in the continued growth in patient demand for Brineura and Vimizim and even Naglazyme, which has been on the market now for almost 16 years. So that's how we think about the uptake from the EMEA region relative to the U.S. opportunity.
J.J. Bienaimé (Chairman and CEO)
And if I may add, so again, the market size is eligible patients. I'd say about 11,000 in the EU or EMEA. That does not include Latin America, Asia, and other regions, but still, and 3,100 patients or so in the U.S. So let's say ballpark that we get an average reimbursement price of $150,000 in Europe and $200,000 in the U.S. So that would be $1.6 billion market in EU, in EMEA, and about $600 million market, adding to $2.2 billion market between the two regions combined. And the market is wide open. There's no competition. And we don't anticipate any competition for at least five to six years.
Great. Thank you.
Operator (participant)
Next one on the queue is Salveen Richter from Goldman Sachs. You are now live.
Elizabeth Burton (Managing Director)
This is Elizabeth on for Salveen. How have your discussions with the FDA been progressing with respect to their willingness to allow you to submit Roctavian ahead of having the full two-year data set? Thank you.
J.J. Bienaimé (Chairman and CEO)
Next.
The FDA has reiterated their request to see the two-year data. They said that before the one-year data, and they repeated it after the one-year data without looking at the one-year data. So that's why we have reiterated our working case to file Q2 2022.
Elizabeth Burton (Managing Director)
Thank you.
Operator (participant)
Chris Hender, you are now live.
Chris Raymond (Senior Research Analyst)
Hi. It's Chris Raymond here. Yeah, thanks. Just a couple of pipeline questions. I guess first on BMN 307, I know you guys said last month you were moving to the higher dose, I think the 6e13 dose, if I remember, and that you'd share an update in the second half. Just on timing, Hank, are we to wait until your R&D day for that, or could we get maybe something sooner? And can you maybe just confirm if you've actually treated a patient at that higher dose yet on that one? And then maybe similar question on 255, BMN 255. Again, I know you've been a little quiet in terms of what the target is. Is this another November reveal, or could we get something from you guys earlier? Thanks.
Hank Fuchs (President, Worldwide Research and Development)
Hi, Real Chris. Yes, I can confirm it's the 6e13 dose. Yes, I can confirm that we've already treated that patient. I want to reiterate that our plan for data sharing more concretely and specifically will be when we pick the dose to take into the registration enabling program, and I unfortunately want to confirm that as regards 255 and ongoing data availability later this year for 307, that we're going to remain somewhat quiet about that for competitive reasons until we have much more clarity about next steps.
Chris Raymond (Senior Research Analyst)
Great. Thank you. Thank you.
Hank Fuchs (President, Worldwide Research and Development)
But all that said, we're very excited. The PKU market is not, in spite of Jeff's fantastic work and in spite of how good Palynziq is, there's plenty of opportunity to expand the PKU market. And 255 fits into our model of genetically validated and potentially transformative interventions. So we're very excited about the programs. We're just being a little bit quiet for competitive reasons.
Chris Raymond (Senior Research Analyst)
Thanks.
Operator (participant)
Next one on the line is Phil Nadeau from Cowen and Company. You are now live.
Ernie Rodriguez (VP of Biotech Equity Research)
Hi. This is Ernie Rodriguez for Phil. Thank you for taking my call. I'm curious, do you have any concerns of the effects from shortening the lead time that you have against competitors with Roctavian now being delayed up to 2022, or any commercial potential that harm the results from the delay?
Hank Fuchs (President, Worldwide Research and Development)
I might start, maybe hand it over to Jeff. It's hard for me to imagine how the commercial competitors won't end up having to do what we end up doing. It's pretty apparent from Pfizer Sangamo's product that there's attrition in factor activity from year one to year two. And that was the agency's question of Roctavian. And frankly, they've got to enroll a larger trial and potentially follow for longer than they're currently planning to. And I don't have visibility into where they are with their commercial manufacturing. So in spite of our delay, if anything, it feels like the spacing is either maintained or growing. And the one thing I'd say before turning it over to Jeff for his commercial interpretation of things is that as time goes by, the Roctavian data package just gets stronger and stronger and stronger. Maybe Jeff, you want to comment?
J.J. Bienaimé (Chairman and CEO)
Okay. Before Jeff, let me see here. Also, if you look at the most recent update, the Pfizer-Sangamo update, it was actually with phase II product. There is no data yet, as far as I know, on the phase III product. Their variability of response was even greater than with Roctavian, and the drop in Factor levels at 31 was greater than with Roctavian. So I would say some fear as to what competitive advantage they will have, if any, against that. Jeff?
Jeff Ajer (EVP, Chief Commercial Officer)
Yeah. Well stated, Hank and JJ. I guess I would just add that with an expectation that lead in the marketplace is likely not diminished by the moves that we're taking. I am super excited about the potential to go to the marketplace with five years or greater durability from our phase II studies and the largest phase III of any gene therapy completed with two years of data coming out from that. Never mind the significant life cycle management work that we're already into that the competitors aren't. I wouldn't say that we're at a competitive disadvantage at all. I would say the opposite. Our position got stronger, not weaker.
Ernie Rodriguez (VP of Biotech Equity Research)
Thank you. That's helpful. Another question regarding Palynziq. You mentioned that you still see the impact of COVID on new starts. And I was wondering if you have seen any sort of recovery reflected with the vaccine rollout. Has the vaccine rollout basically accelerated this process at all of getting the patients into the clinic?
J.J. Bienaimé (Chairman and CEO)
Jeff, you want to ask?
Jeff Ajer (EVP, Chief Commercial Officer)
Yeah, so in the U.S., where we know that the vaccine uptake is way, way further along than it is in Europe, we haven't seen an explicit effect yet on the operations of our PKU clinics, but in my remarks, when I said we're optimistic that PKU clinics will be able to increase their capacity as we go through the year, it's exactly that vaccine uptake in the U.S. that grounds our expectations of increased capacity later in 2021. What I would say is, by and large, there's a lot of variability by clinic, but by and large, the clinics in the U.S. have been operating at partial capacity since around Q2 of last year. That's what has allowed us to continue the growth that we've achieved over the last year with Palynziq, particularly in the U.S.
So we are getting growth, just not as rapid as we would hope or expect. And so as conditions improve in the U.S., we do expect that our business uptake will pick up here.
Ernie Rodriguez (VP of Biotech Equity Research)
Okay. Thanks again for taking my question.
Operator (participant)
All right. Next one on the line is Geoff Meacham from Bank of America. You are now live.
Aspen Mori (Biopharma Research Analyst)
Hey, guys. It's Aspen on for Geoff. Thanks for taking our questions. Just two from us. First on Roctavian and then one quick one on vosoritide. On Roctavian, so we have the five-year and four-year data coming up. I think the last time we spoke, you mentioned that the low dose is going to be kind of the focus here for the readout. Maybe you can walk us through again your thought process there and how you think that low dose could be an arbiter for the phase III longer-term data.
J.J. Bienaimé (Chairman and CEO)
Hank?
Hank?
Hank Fuchs (President, Worldwide Research and Development)
I don't have the numbers.
Yeah, yeah, yeah. I'm here. I don't have the numbers as encyclopedic as I did maybe a quarter ago. But the framework that I think we carry is that it's like we just talked about chromogenic and median because these are the lowest numbers on the board, and everything else is kind of upside. The median Factor VIII expression in the N=17 after two years in the 301 study was on the order of like 14 IU per deciliter, and at the end of two years after transduction in the 4E group, Factor VIII expression median was a little bit lower, closer to around 10. In the ensuing year after that point for the low dose group in the third year, Factor VIII expressions remained in the seven, eight, nine IU per deciliter range.
That was accompanied by extremely good hemostatic efficacy with an ABR that was around one or lower. Assuming that the decline in year three from 14 IU per deciliter is not worse than the decline was in the 201 study, then the expectation would be that the ABR in year three after the 301 dose was administered would be similarly close to zero. That gives us a lot of confidence. If the same thing is observed in the fourth year after transduction, it would augur well for maintained durability of Roctavian through three and four years after dose with the to-be commercialized material.
We see that in spite of having launched, if you will, a little lower, that is to say, achieved a slightly lower peak Factor VIII expression with the to-be commercialized material, the patterns of trajectory are starting to emerge with much greater clarity. And namely, what that clarity is, is that following peak Factor VIII expression, there's a little bit of decline in the first year after that peak, but that decline decelerates as time goes by. And also, that decline is dependent on the initial height. So all that together says, if we did well in year three after 4E, that augurs well for Roctavian, the to-be commercialized material. And with the four-year data, that will augur well for the fourth year after the Roctavian administration. Hopefully, that.
J.J. Bienaimé (Chairman and CEO)
And if I may add also, if you look at the Factor VIII levels observed so far in the phase III trial at one year with all the patients and at two years with the 17 patients, they're always tracking above the low dose phase II. So consequently, in a sense, if you believe in a case that Factor VIII is representative of what's going to happen, that's why the 4E data at year four that we're going to see in a few weeks is kind of potentially the worst case scenario.
Aspen Mori (Biopharma Research Analyst)
Got it. Got it. That's helpful, J.J. and Hank. I appreciate that. And just two really quick ones on the vosoritide. So I just want to confirm that when the FDA provided their extension of the PDUFA, that there was nothing else they brought up that they wanted to look at in the data package. It was just that they wanted the two-year data. And then I think you mentioned that there's a four to eight-week turnaround from the potential approval to shipping orders. Just want to confirm that that means that we're going to see very low or negligible vosoritide revenues this year. Thanks.
J.J. Bienaimé (Chairman and CEO)
So maybe I'll start with the answer to the last question. And then Hank can answer the other question. So obviously, the U.S. with the PDUFA extension approval will be late. If it happens, hopefully, it will be late November. So indeed, we're not going to see any revenues in the US for Voxzogo this year. But hopefully, you will see some revenues from Europe this year for Voxzogo since we anticipate final approval in the mid to late summer. So Hank, do you want to answer the first question? Or is that for you?
Hank Fuchs (President, Worldwide Research and Development)
Yeah, yeah. So first of all, the process of review at the FDA is they can send the information requests really at any time. And that has continued. That was before, and that's true after the submission of the two-year data. I think what's important about the submission of the two-year data is they got right on it. And they started asking a lot of questions about the two-year data, which means they're fairly deep into the review of it. And so the fact that they're deeply reviewing the two-year data, they're continuing to ask questions about the application in general. They've conducted their site inspection. This is feeling like they are working towards their PDUFA action date.
Aspen Mori (Biopharma Research Analyst)
Helpful guys. Really appreciate it. Thanks.
Operator (participant)
Next one on the queue is Robyn Karnauskas from Truist Securities. You are now live.
Kripa Devarakonda (VP of Biotechnology Equity Research)
Hey, guys. Thank you so much for taking our questions. This is Kripa on for Robyn. You mentioned that the FDA did not even really look at the one-year Roctavian data. It would be great to get any additional color you can give us and what sort of conversations you had around Roctavian. Any idea of what they were thinking? And also, given that they've been set on the two-year data for a while now, have they conveyed if there is a bar for what would be acceptable two-year data? And finally, is there any concern that there could be a moving target? Could they want three-year data?
Hank Fuchs (President, Worldwide Research and Development)
On that last piece, I would say one's getting quite shy, meaning they make the rules, and we didn't exactly know that they were going to shift the goalposts until they shifted the goalposts, and I think the agency would say about themselves that their communication ability is maybe not the best that it's ever been right now, and back to any further color on the why, I think it all is as described in the CRL. That is to say, they saw a decline. They saw a decline in Factor VIII activity between year one and year two, and they want to make sure that Factor VIII activity decline between year one and year two is not consequential using the to-be commercialized material in the steroid regimen that we used, given that launch was a little bit lower, and everybody's well aware.
We are well aware of the N=17 that did great. But their attitude before the data was even looked at was, "We want the N=134 for the two-year population." And I don't think there's really that much more insight to be had other than when they see the data, they'll have a lot more information. Now, at the two-year mark with an N=134, if things go as they're expected to go, we should see a clinical outcome that's really fabulous. Side effect profile at that point will be well defined. All patients will be off of steroids. All of the ALT rises will have calmed down, etc., etc. And we'll be looking at Factor VIII trajectories. And if what has happened basically already three different times continues to happen, that is to say, and it's a complicated kind of concept to get across, but the rate of decline is decelerating.
As long as the rate of decline is decelerating as it did in all prior years for the other doses, then I think that they're going to be looking at what we just talked about in terms of how does this augur for a third year of protection. And I want to remind about the magnitude of clinical benefit because it's sometimes getting lost from the argument. It took people. It's not just that we compared ourselves to nothing. We took people off a marginally effective standard of care. We took people off an enormously effective standard of care prophylactic Factor VIII therapy. If you give somebody 150 infusions a year of this stuff, they'll reduce their bleeding from 30 times a year to like four times a year, five times a year.
We took that away. These people would have bled 30 times a year, and they bled less than or around one time a year. In the second year, they bled around one time a year. Even with those lower factor levels that J.J. mentioned from the lower dose, they didn't bleed in their third year. The treatment benefit here is large. I think if we just corroborate that in a much larger sample size, that will really carry the day.
Kripa Devarakonda (VP of Biotechnology Equity Research)
Very helpful. Thank you so much.
Operator (participant)
Next question comes from Akash Tewari from Wolfe Research. You are now live.
Neil Howland (Equity Research Assistant)
Hi. This is Neil for Akash. Thank you for taking our question. According to your market analysis, how big is the addressable market of Roctavian for severe hemophilia A patients in the U.S. and the EU respectively? For example, based on our math, there are about like 2,000-3,000 patients eligible for Roctavian in the U.S. after taking into account like AAV5, HIV, HBV, and inhibitor status. And also, among those patients who are eligible, how many of them do you think are interested in receiving gene therapies? Thank you.
J.J. Bienaimé (Chairman and CEO)
Yeah. And again, I think unless Jeff answered that question again, just want to emphasize also that in the U.S., there's a lot of emphasis on the U.S. market. The European market is three times or more the size of the U.S. market. So eligible 9,000 patients. And the eligibility criteria you mentioned were just at launch, not in the future. We have late-cycle management projects to actually expand the eligible population. But that being said, Jeff, we'll answer your question. Thank you.
Jeff Ajer (EVP, Chief Commercial Officer)
Yeah, thanks, JJ. So just to sharpen the pencil a little bit, when we quote 3X larger patient population, we're talking about our EMEA operating region, which includes the EU or Europe beyond the EU, Russia, Turkey, Middle East, Africa, that sort of thing. And our logic on that is that an EU approval begins to substantially unlock the market, not just for those countries in the EU, but for those other markets, many of which key their actions off of an EU approval. So as you're doing your market analysis, we would note that there's 112,000 hemophilia A patients around the world. 50%-60% of those are severe.
When you take a cut for patients that are less than 18 years old, which we presume will be our initial but not final label, and you take a cut largely for mild and moderate, that's how you get down to an addressable patient population, and we'll be working on lifecycle management activities that would allow us potentially in the future to start to unlock part of that age-limited segment, 0-18, and mild and moderate population, perhaps over time.
Neil Howland (Equity Research Assistant)
Thank you.
Operator (participant)
Next one on the line is Kennen MacKay from RBC Capital Markets. You are now live.
Kennen MacKay (Managing Director)
Hi. Thanks for taking the question. And congrats on the quarter. Maybe one for Hank, another one for Hank. From where we're sitting, it seems like BMN 307 is kind of staying upside to valuation. And I think this is maybe partially because some of the competitive PKU gene therapy data out there aren't super encouraging. Can you maybe sort of help us with what you see as the key differences between 307 and the competition that's out there as it relates to the expression cassette or construct or even the vector itself to really help add some confidence in the potential there? Thanks.
Hank Fuchs (President, Worldwide Research and Development)
AAV5 is a little bit better known to us than any other AAV might be to almost any other company just because of having a large amount of both clinical experience but also manufacturing experience. We have an enormous amount of preclinical data on almost every single nucleotide in the cassette. I mean, every single thing has kind of been tested for specific reasons when it comes to matters like codon optimizations or spacers or tails or those sorts of things. We leveraged a lot of the knowledge that was gained in the building of Roctavian to build an even more potent phenylalanine hydroxylase.
I think if you don't have just as much experience as our group has in terms of designing vectors, testing them in mice, testing them in non-human primates, and then ultimately bringing them to humans and being able to iterate what you've learned, if you don't have all that experience, then you're just sort of flying blind. I think that they can be encouraged that they got some expression of phenylalanine hydroxylase, but they're pulling back from that dose rather than leaning into a dose that's even more effective. Because of our confidence in the safety profile of Roctavian and what we've seen so far, we're very confident that the dose level that we're at is going to produce extremely meaningful Phe reduction levels.
So I think at the end of the day, the real answer to your question is our view of the competition is that we're going to end up being more effective by virtue of having a better vector design, the details of which are kind of inside the guts of the vector.
J.J. Bienaimé (Chairman and CEO)
If I may add also, we are testing these patients with the anticipated manufacturing process and scale that will be used for commercial products.
Kennen MacKay (Managing Director)
Got it. Thanks again.
Operator (participant)
Next one on the line is Gena Wang from Barclays. You are now live.
Gena Wang (Managing Director)
Thank you for taking my questions. I have two. One is regarding Roctavian. Hank, you mentioned that FDA did not see the one-year data. Are you planning to have additional discussion with the FDA regarding the possibility of early submission with more data? So that's the first question. And also, same Roctavian, I think you mentioned that 2.5 million. Would that be the benchmark price in Europe? And if you can give a little bit more color regarding the installment, how many years you are thinking? And I have a quick question regarding the Voxzogo. When you submit the five-year data from phase I/II study to the FDA, would that be—and we saw five-year data had some decline—would there be any concern there?
J.J. Bienaimé (Chairman and CEO)
Hank, would you answer the question one and question three? And if not, I will do question two.
Hank Fuchs (President, Worldwide Research and Development)
Sure. We press released the one-year data. So when I say the FDA didn't do the one-year data, what I mean is we didn't submit. We didn't make a submission. There was a press release. You're asking about additional discussions. We're in fairly regular dialogue with the division on all sorts of matters. If you're asking me, would I say no if the FDA said, "We rethought this, and we really would like to take" - never mind the 27 times that you've asked us and the times that we've communicated to you that we want to see the two-year data. If they changed their mind and said, "Would you submit the one-year data?" I would say, "Hell, yeah." If you're asking me if I have stopped bringing it up, no, I haven't stopped bringing it up.
I think I'm trying to reflect to you that not as a result of an evaluation of the data themselves, the agency has recapitulated their request for the two-year data to form the basis of the submission. That request was made before the one-year data even existed and was carried through without any change. So our will remains high. Our confidence in Roctavian is enormously high. We're dealing with an agency that they're busy, and they make the rules, and this is the edict they've issued. On Voxzogo, as you point out, as the kids get older, of course, the relative increase in growth velocity is not going to be as great, which is, of course, what animates the desire to treat younger and younger children. And I do suspect this will be potentially some discussion around, for example, labeling considerations.
Next up clearly is going to be in the European Union. Like I said, we're in labeling discussions. And you too will know shortly the resolution of how at least the first health authority is viewing long-term durability.
J.J. Bienaimé (Chairman and CEO)
I mean, I think in the most recent updates, some patients in the data set on the phase II that reached five years, they are getting close to their final adult height. Some of them are basically there. And as you know, as you get closer to your final adult height, even when you're unaffected by achondroplasia, your growth velocity goes down substantially. On the pricing in Europe, I'll start and have Jeff then answer more details. But your question, I think, was $2.5 million by ICER in the U.S. to be cost-effective. They have not done an analysis on the U.S. market. They haven't done it on the European market. The prices of comparable agents of Factor VIII gene therapy are lower in Europe in some countries, not that much lower in other countries.
So obviously, if you use those metrics, the price might probably be a little lower than $2.5 million. But it's still going to be pretty significant here. I mean, Jeff, you want to add your perspective?
Jeff Ajer (EVP, Chief Commercial Officer)
Yeah, I think that's very well stated, JJ. And Gena, I think you also inquired about installments. So I might address that part of the question. And of course, we've heard about other companies talking about installment payments for their programs. I'm not sure what drives that. We've had extensive interaction with European payers, and we have established relationships to facilitate that. And when we talk about European markets, we're not talking about a monolithic viewpoint, of course. Every country, particularly the major ones, has a different viewpoint. Some of them have different models upon which they review products like Roctavian and Voxzogo to come to their pricing decisions. What we have heard is an appetite for risk-based agreements. Not everywhere, but in a number of key markets. So we won't be focusing on installments. There's been no signal of a desire for installments that I'm aware of.
We will be focusing, at least in certain markets, on having a risk-based agreement. What I like about the risk-based agreements, both in Europe where they can be used and also in the U.S. with payers that would be willing to do that, is that allows us the possibility of maximizing the potential value that we capture for Roctavian with the offset that we're at risk. BioMarin is at risk to cover if a patient or patients don't achieve the maximum benefit. And I'm personally and professionally okay with that trade-off. I think it's a good one.
Gena Wang (Managing Director)
Great. Thank you.
Operator (participant)
Next one on the queue is Debjit Chattopadhyay from Guggenheim Securities. You are now live.
Aaron Welch (Equity Research Associate)
Hi guys. Thanks for taking all the questions. This is Aaron on for Debjit. I just wanted to ask about BMN 307. What Phe levels do you think would be commercially viable? Do you need to get down to 120, 360, or 600? And can you say anything about any immune response? Is it looking like it's going to be similar to Roctavian? Thanks.
J.J. Bienaimé (Chairman and CEO)
Hank, do you want to start?
Hank Fuchs (President, Worldwide Research and Development)
Yeah. Well, let me just start by saying that Phe can get people under 600. Phe can get people under 360. Phe can get a fraction of patients to normal. What would be really cool for gene therapy to do would be to get everybody normal on a normal diet. And that's the working direction. Now, whether that ends up being actually 100% or we'll let the data tell that story. But we're looking for the profile of the product to be normal Phe, normal diet. And we believe that even at the dose that we're now testing, that that's within striking distance. How low it has to go is a matter of medicine and science that are still a little bit undefined.
I think the easiest thing for us to do is to get people in the normal range, and then we don't have to argue about how low matters. Jeff, did you want to add anything?
J.J. Bienaimé (Chairman and CEO)
Or, if I may, before.
Yes?
Yeah. So based on what we observed with the 2e13 dose, the low dose, and based on the experience with Roctavian that we observed going from 2e13 to 6e13, where there was a very steep response curve, we believe there is a good chance that with the 6e13 dose, we'll get to normal FVIII levels. That is the objective. Obviously, in that case, measure our commercial opportunity. But it's a good question you're asking there. Even if we couldn't quite get there, if we could get to something similar to FVIII, we believe there is still an opportunity, but that is not our objective. Jeff, do you have anything to add?
Jeff Ajer (EVP, Chief Commercial Officer)
Nothing to add. Well stated. Thank you.
Operator (participant)
Next one on the line is Matthew Harrison from Morgan Stanley. You are now live.
Kostas Biliouris (VP of Biotech Equity Research)
Hello, this is Kostas on for Matthew. I have a quick question on 331. Would you be able to provide some color around the design of this trial, and how do you plan to differentiate from current therapeutics on the market? Thank you.
Hank Fuchs (President, Worldwide Research and Development)
It's a little early. We're planning to file the IND, and oftentimes you get a little bit of IND feedback that could inform. I think the main competitive advantage is natural replacement as opposed to bioengineered molecules that require compliance. I think one of the things that makes gene therapy special is the sort of persistent presence of what you're trying to replace, combined with resulting therefore in complete disease control without having to chronically take a medicine or modify dosing or safety, etc., so when we talk to patients in these communities for our gene therapy products, their drive is to be free of their condition, and we see these things as potentially market expansion opportunities.
So you asked about 331, but just again to illustrate with 307, the problem with phenylketonuria for decades has been there's been only one approach to management, and that's to eat food that is completely free of phenylalanine. And some people trivialize that and say, "Well, it's a convenience or it's a diet thing." And it's not. I mean, these alternative therapies are not without side effects. They're not without challenges. And patients take drug holidays, and they get sick as a consequence of that. And therefore, their dream is to be done with their condition. And any number of years that we can provide that as an alternative to their current therapy is being viewed very highly in our patient communities. So on 331, stay tuned for more specifics on trial designs, and we'll keep you abuzz.
Kostas Biliouris (VP of Biotech Equity Research)
Thank you.
Operator (participant)
Next one on the queue is Paul Matteis from Stifel. You are now live.
Alex Thompson (Biotech Equity Research)
Hey there. This is Alex on the call. Thanks for taking the question. I think apologies if I missed this earlier, but just wondering with this PDUFA extension for Roctavian, is there any indication that there may now be an AdCom from the FDA? Thanks.
Hank Fuchs (President, Worldwide Research and Development)
They have communicated that specifically. Whether the submission changes that, we haven't had any indication that that's the case. But so far, they have said to us, "No AdCom expected." And you should remember that they had an AdCom in 2018, and that substantially our program follows entirely the specification of that AdCom. And the only difference between the AdCom now and the FDA's articulation is the AdCom was a little bit more divided on the necessity of a two-year placebo-controlled trial, citing considerations like pediatric ethics, prospects for benefit, withholding therapies from pediatric patients for two years, not one year. That preclinical data could, or long-term clinical data or biomarkers could substantiate durability claims. That was the 2018 AdCom. Since then, we've actually provided the FDA the second year of that contemporaneously controlled trial anyway.
So at this point, they'd be going back to an AdCom that has already basically answered all these questions too in our favor. So don't anticipate an AdCom, but don't know.
Alex Thompson (Biotech Equity Research)
Great. Thank you.
Operator (participant)
Next question comes from Mohit Bansal from Citigroup. You are now live.
J.J. Bienaimé (Chairman and CEO)
We lost Mohit.
Operator (participant)
All right. So for the next one, we do have Tim Lugo from William Blair. You are now live.
Tim Lugo (Head of Biotechnology Equity Research)
Thanks for taking the question. And digging into the early-stage pipeline, you gave us a little color on six of the early-stage assets in the press release. Do any of these assets have kind of a Brineura-like fast-to-market development path potential? And I also believe you have a partnership with Deep Genomics up in Toronto covering, I think, four products. When do you expect we start to see some candidates roll out of that partnership?
Hank Fuchs (President, Worldwide Research and Development)
Hi, real Tim. And I'm really glad that the operator pronounced BioMarin right. Poor guy did. I have to say that all of the assets that we consider, we aspire to be fast-to-market. Now, we haven't always been able to. Vimizim took us a little longer. Voxzogo has taken us a little longer. And sometimes the biology of these things turns out to be a little more complicated in humans than you'd like. But we are sticking with the fundamental model of BioMarin for discovery and development has been genetic, precisely understood etiologies, targeted therapeutics, discernible effects rapidly with transformative results. The collaborations that we're doing that have just been announced all neatly fit into having that potential. I think part of the pipeline pivot at BioMarin is to really institutionalize what we did with Brineura. I'm really pleased to report that you see J.J. a lot.
You see Hank a lot. You see Jeff Ajer a lot. Behind the scenes, there are these incredibly clever people. So Kevin Eggan, for example, who is our new head of research, just a phenomenal cell and molecular biologist. Dave Jacobi, who led the clinical development program for Brineura. By the way, both these guys are Harvard-trained guys, so they're also getting along for that reason. And that Dave Jacobi did it clinically for Brineura. He wanted to do it again. We recruited Kevin. That's what Kevin wants to do over and over and over and again. So I don't think that part of BioMarin is going to change.
I think the part that's going to evolve is looking at both bigger assets, potentially looking at assets that can be extendable into other locations, or really leveraging our platform technology even more than what we were just talking about with 307, where we built a better vector faster for 307 by virtue of our expertise. And we want to do that across the advanced medicine space. So short answer is yes, Tim. Everything we are about is looking for these medical conditions that we can transform quickly through genetic insights.
Tim Lugo (Head of Biotechnology Equity Research)
Good to hear. And the Deep Genomics partnership up in Toronto, I think you have four compounds up there.
Hank Fuchs (President, Worldwide Research and Development)
Yeah. Same basic concepts in that we learned in our antisense oligos program for Duchenne that the first target you find of effect may not be the best. We went about that through a much more manual process of tiling and then sort of tweaking chemistry, retiling, tweaking chemistry, retiling. Once we mashed through all that, we realized that we had come upon a much better biological approach. I've talked before about the nature of the genetic condition and the targeted therapy. It needs to fit in like a key fits in a lock. And the keys in these conditions can be highly, highly refined and specific. And this is another area, by the way, that Kevin is phenomenally interested in, subject to RNA metabolism.
The concept is that as you learn from how genes are structured, you'll learn more and more about the regulation of RNA metabolism, which will give you insights into how to more quickly design. And this is a setup now that's really quite right for machine-based learning, artificial intelligence, just because there's so much massive amount of genetic information. Reminder that the coding sequence in a human is vastly smaller than you would have otherwise expected. And all that, they used to call that other DNA junk. It's not junk. It's regulatory elements. So Kevin is really intent on leveraging the Deep Genomics collaboration to figure out how to power through the identification of regulatory targets in the genome that are going to be transformative as therapeutics.
Tim Lugo (Head of Biotechnology Equity Research)
That's very interesting. Thank you for the color.
Hank Fuchs (President, Worldwide Research and Development)
Yep.
Operator (participant)
Next question comes from Mohit Bansal from Citigroup. You are now live.
Mohit Bansal (Director)
Great. Thanks for taking my question and sorry about the mishap earlier. Maybe a bigger picture question. Gene therapy space appears to be facing some challenges lately. Obviously, you faced the regulatory one, but there are safety issues coming up, and some of these agents have both those safety issues. Some of them are tissue-related. Some of them are gene-related, gene therapy-related. Any thoughts, any updated view on what is happening around in the gene therapy world? And how do you think about going forward, picking up areas to go after, given this backdrop, in terms of prioritizing which targets to go after, as well as which diseases to go after in terms of if there's existing therapy versus there's no existing therapy, those kind of things? Thank you.
Hank Fuchs (President, Worldwide Research and Development)
I guess I'll start, JJ. Mohit, it's good to hear your voice. I'm glad you're alive. Sounds like the operator did CPR or something, so what we experience with OTAT is obviously not new. I'm sorry, not novel in the context of we see a lot of this happening with them. Now, we were fortunate. Brad Glascock, who's our head of regulatory, was an influential partner in PDUFA negotiations, and so I think we have an opportunity to have some insight on what's going on in OTAT, and this is all public information. OTAT is basically understaffed, and CBER also happens to be doing a lion's share of the work on COVID, obviously, due to vaccines, so you're talking about an understaffed and otherwise incredibly busy group.
I previously commented that conservatism is not an unusual reaction to that sort of thing from a regulatory perspective, and we've seen that before. I think also that the field is just so novel that the nature of the kinds of questions that get asked are being asked to me. You only get one shot at these things for the most part. If there are alternatives to therapy, people ask about questions about durability more than they would otherwise ask when there are alternatives to therapy. That's created a lot more to be thought about by a group that is also relatively thinly staffed. Does it have impact on how we pick and how we develop? You bet it does.
Clearly, if you can offer a patient something where they have no other choice, it's going to be a little bit clearer to be able to develop that. And if they have choices, you're going to have to have a bit more robust of a program. Now, I think Valrox is a good exemplification of that. Maybe if there was no such thing as factor replacement therapy, and we take people who are taking nothing and bled 30 times a year and put them on gene therapy, and they stop bleeding, we might be talking about Roctavian second commercial year. But the fact is that there is Factor VIII replacement therapy. So what we did there was we did a proper comparison of factor replacement therapy to Roctavian gene therapy in the absence of Factor VIII gene therapy replacement.
So we had to do a bigger, more robust program because of the availability of the alternative therapy. So these considerations, they're not the OTAT understaffing thing has just come to light more recently, but the evolution of requirement of conservativeness as you go in with very innovative things in spaces where there is available therapy but a remaining unmet need is, I think, the complexity that you're seeing the agency deal with. And I think as we accumulate more data, more mass, more experience, comfort level with benefit-risk decisions will improve. And it's great that BioMarin is the sponsor of a lot of that stuff because we're leveraging all of that learning for the rest of our pipeline.
Mohit Bansal (Director)
Super helpful. Thank you very much, Hank.
Operator (participant)
If there are no further questions at this time, I will now turn the call over to J.J. Bienaimé.
J.J. Bienaimé (Chairman and CEO)
Thank you all for your continued support. I would say we have so many opportunities ahead for BioMarin. The momentum towards our next significant phase of growth is building. Again, I want to reiterate, we had positive operating cash flows of $114 million in the first quarter, which is a major growth compared to last year's first quarter. It represents the strength of our underlying business, and with our next two larger product opportunities in Voxzogo and Roctavian within sight, we expect 2022 to be a financially transformational year for BioMarin. Thank you, and have a nice afternoon.
Operator (participant)
Thank you, everyone, for joining. You may now disconnect. Have a great day.
