Agios (AGIO) Q4 2025 Earnings Call Transcript

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DATE

Thursday, Feb. 12, 2026 at 8:00 a.m. ET

CALL PARTICIPANTS

• Chief Executive Officer — Brian Goff
• Chief Financial Officer — Cecilia Jones
• Chief Commercial Officer — Tsveta Milanova
• Chief Medical Officer — Sarah Gheuens

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TAKEAWAYS

• PYRUKYND Net Revenue -- $20,000,000 for the fourth quarter, an 86% increase year over year and a 55% sequential increase over $13,000,000 in the prior quarter.
• Full-Year Revenue -- $54,000,000 for 2025, attributed to higher demand and launch execution.
• U.S. PYRUKYND Revenue -- $16,000,000 in the fourth quarter, supported by ongoing commercial efforts, an additional ordering week, and favorable gross-to-net adjustments.
• Non-U.S. Revenue -- $4,000,000 in the fourth quarter, mainly from European inventory stocking as patients transition to commercial supply.
• 2026 U.S. PK Deficiency Revenue Guidance -- $45,000,000 to $50,000,000 anticipated in the U.S.
• Cost of Sales -- $1,900,000 in the fourth quarter.
• R&D Expense -- $88,100,000 in the fourth quarter, up $5,300,000 year over year, reflecting early-stage pipeline advancement.
• SG&A Expense -- $51,600,000 in the fourth quarter, remaining roughly flat compared to 2024.
• Year-End Liquidity -- Approximately $1,200,000,000 in cash, cash equivalents, and marketable securities were reported, providing financial flexibility for launches and pipeline progress.
• Afesni (Afesme) FDA Approval -- The company received U.S. FDA approval for its thalassemia therapy just before year-end, initiating the commercial launch with 44 prescriptions written by Jan. 30, all from REMS-certified U.S. physicians.
• Prescription Conversion Timeline -- The average time from Afesme prescription to treatment initiation is estimated at 10 to 12 weeks, affected by insurance authorization and required baseline liver tests.
• Patient Segment in Early Launch -- Initial U.S. prescriptions for Afesme predominantly came from transfusion-dependent patients, alongside engaged, symptomatic non-transfusion-dependent patients.
• REMS Program Impact -- Management stated, "We are not seeing the ramp as a barrier to prescribing," with certification described as a "very, quick process."
• Key Upcoming Catalysts -- 2026 pipeline events include Phase IIb top-line data for tebipivat in lower-risk myelodysplastic syndrome (MDS) in the first half, and Phase II top-line data in sickle cell disease in the second half.
• Mitapivat Sickle Cell Regulatory Path -- The company is holding a pre-sNDA meeting with the FDA this quarter for mitapivat in sickle cell disease, seeking clarity on approval pathways.
• Global Thalassemia Commercialization -- Afesme is distributed under different names in several regions, with commercialization agreements in Europe and the GCC (via partners), as well as patient-by-patient distribution in Saudi Arabia.
• Gross-to-Net Assumptions for Thalassemia -- Management reiterated gross-to-net assumptions for thalassemia consistent with PK deficiency, in the 10%-20% range.
• Operating Expense Guidance -- The company expects 2026 operating expenses to be roughly flat versus 2025, with investments prioritized for the U.S. thalassemia launch and gated for sickle cell disease.
• Profitability Outlook -- Management presented a "clear path" to profitability based on the current commercial runway in PK deficiency and thalassemia, though no specific timeline or breakeven revenue was provided.

SUMMARY

Agios Pharmaceuticals (NASDAQ:AGIO) closed the year with accelerated revenue growth for PYRUKYND and established notable early traction in the U.S. launch of Afesme for thalassemia, underscored by strong prescription numbers and breadth of prescriber participation. Management highlighted major pipeline milestones for 2026, including imminent regulatory dialogue with the FDA for mitapivat in sickle cell disease and multiple high-value data readouts for tebipivat across hematologic indications. The company emphasized ample liquidity and operational discipline to support these strategic priorities, while signaling readiness to scale infrastructure for additional launches as regulatory clarity emerges.

• Management made clear that PYRUKYND’s ex-U.S. fourth quarter revenue surge was largely attributable to European inventory stocking and not end-user demand pull-through.
• A majority of initial Afesme prescribers were community-based hematologists, with broad geographic distribution and minimal overlap with previous PK deficiency physician writers.
• The payer mix for the thalassemia launch closely mirrors that of PK deficiency, with most patients covered by commercial insurance and medical exceptions expected to bridge access until full formulary inclusion in six to nine months.
• Enrollment is now complete for the Phase II sickle cell trial of tebipivat, and management cited "Enthusiasm for PK activation," in this patient population following the recent positive data from the RISE UP study.
• Payer hurdles in the early Afesme launch were reported as minimal, with the gross-to-net impact for thalassemia not expected to materially diverge from prior experience in PK deficiency.
• Commercial and distribution arrangements outside the United States are focused on partnerships and named patient approaches, with Europe regulatory decisions pending after October’s positive CHMP opinion.
• The leadership underscored that sickle cell disease commercial readiness spending will be gated and aligned with regulatory progress, diverging from the up-front investment approach taken in thalassemia.
• In discussion of potential regulatory outcomes, management referenced the possibility of both full and accelerated approval paths for mitapivat in sickle cell disease, contingent on FDA guidance and evolving surrogate endpoints.

INDUSTRY GLOSSARY

• REMS: Risk Evaluation and Mitigation Strategy, an FDA-mandated safety program for managing specific drug safety risks.
• Gross-to-Net Adjustment: The difference between a product's gross sales and the net amount received after discounts, rebates, chargebacks, and other deductions.
• CHMP: Committee for Medicinal Products for Human Use, the body in the European Medicines Agency responsible for preparing opinions on medicines for human use.
• Pre-sNDA Meeting: A meeting with FDA prior to submitting a supplemental New Drug Application seeking approval for a new indication or patient population.
• PK Activation: Pharmacological activation of pyruvate kinase enzymes, pursued as a therapeutic strategy for hemolytic anemias and related disorders.

Full Conference Call Transcript

Brian Goff: We see meaningful opportunity to expand our PK activation franchise into additional high value indications including sickle cell disease, and lower risk myelodysplastic syndrome, with key catalyst this year for both opportunities. Third, through the advancement of our early stage pipeline with AG 236 and AG 181, we have the potential to unlock future value in hematologic and other rare diseases. And finally, we remain committed to long term sustainability, supported by disciplined capital allocation and continued operational efficiency. Building on those priorities, the next slide masks key pipeline catalyst in 2026 across multiple high value indication opportunities.

The Afesni launch in thalassemia is underway in the U.S., and we look forward to the potential to expand our PK activation franchise into sickle cell disease and lower risk MDS. These milestones and continued progress in our early stage pipeline position the portfolio for growth and long term value creation. Next slide, please. We exited 2025 with solid momentum across the business, commercial execution, pipeline progress, and continued focus on financial discipline, which together provide a strong foundation to deliver on our 2026 strategic priorities. Starting with commercial performance, PyroTime delivered $20,000,000 in net revenue in the fourth quarter, bringing full year 2025 revenue to $54,000,000 reflecting robust year on year growth.

In the fourth quarter, we reported top line data from the RISE UP Phase III trial and will meet with the FDA this quarter as anticipated for our pre-sNDA meeting to determine the regulatory path forward. Importantly, just before the end of the year, we received FDA approval for Afdesi in the U.S. Thalassemia launch is underway. Finally, we recently completed enrollment in the Phase II sickle cell disease trial of tebipivat with top line results expected in the second half of this year.

Importantly, we continue to operate from a position of strength, ending the year with approximately $1,200,000,000 in cash, providing flexibility to maximize the Igbezi, thalassemia and U.S. launch, pursue the path forward for mitapivat in sickle cell disease, and continue to advance our pipeline programs. Please move to the next slide, and I will turn the call over to Cecilia to provide additional details on our 2025 fourth quarter and full year performance as well as our 2026 outlook.

Cecilia Jones: Thank you, Brian. Next slide, please. Our fourth quarter and full year 2025 financial results be found in the press release issued earlier this morning and additional details can be found in our 10-K which will be filed later today. Fourth quarter worldwide kyrosine revenue was $20,000,000, an increase of 86% compared to 2024, and a sequential increase of 55% compared to $13,000,000 in 2025. In the U.S., fourth quarter revenues of $16,000,000 were driven by continued commercial focus in CKD deficiency ahead of FDA approval for a vaccine, an additional ordering week in the fourth quarter, and favorable gross to net adjustment. In 2026, we expect U.S. PK deficiency revenue to be in the range of $45,000,000 to $50,000,000.

Outside of the U.S., revenue of $4,000,000 in the fourth quarter primarily reflects inventory stocking ahead of demand driven by fatigue deficiency patients in Europe, transitioning from our global managed access program where Pyrogyne was provided free of charge to commercial supply. We anticipate a sequential decline in U.S. revenues into 2026. Cost of sales for the fourth quarter was $1,900,000. R&D expenses were $88,100,000, an increase of $5,300,000 compared to 2024, associated with the advancement of our earlier stage pipeline program. SG&A expenses were $51,600,000 in the fourth quarter and roughly flat year on year. We ended the fourth quarter with cash, cash equivalents and marketable securities of approximately $1,200,000,000.

As a reminder, in future quarters, we will report mitapivat revenue as a whole, breaking out U.S., and ex-U.S. performance. Next slide, please. We remain committed to financial discipline as we work toward our goal of becoming a sustainable rare disease company. We anticipate operating expenses in 2026 to be roughly flat with 2025. This guidance assumes investment to maximize launch of Avvectomy in thalassemia in the U.S., gated investment for sickle cell disease, and operating model refinement. Importantly, we see a clear path profitability through our existing commercial presence in thalassemia and PK deficiency. Please advance to the next slide, and I will turn the call over to Tsveta to share commercial highlights for the quarter. Thank you, Cecilia.

Next slide, please. As Cecilia noted, in the fourth quarter, ViralKinds delivered $16,000,000 in net revenue in the U.S., up 50% year over year, driven by continued demand in PK deficiency, an additional ordering week in the quarter and certain gross to net adjustments. Fourth quarter ex-U.S. was roughly $4,000,000 which primarily reflects supply ahead of demand pull through at PK deficiency patients in Europe transition onto commercial supply. We expect this ordering to moderate in coming quarters. As expected, we continue to see quarterly variability driven by ordering patterns, inventory dynamics and gross to net adjustment. Fourth quarter performance underscores the strength of our commercial model and the foundation we are building for future growth.

Starting with the recent U.S. approval of a CME for the treatment of anemia, in adults with alpha and beta thalassemia, regardless of transfusion burden.

Operator: Please move to the next slide.

Tsveta Milanova: I am pleased to share that as planned, the final implementation of a phase new ramp was completed in late January to align with the approved FDA label, and have already begun dispensing products. As of January 30, we have seen 44 prescriptions written by a REM certified physician in the U.S., which reflects strong early recognition of Afesme's clinical value and excellent execution by our field team.

Morgan Sanford: Is especially encouraging is the healthy bread

Tsveta Milanova: Of early prescribers at this stage of the launch. With this strong geographic distribution, and, as expected, predominance of community physicians at early prescribers. We are also seeing in this early days of launch, emergence of the patient profile we anticipated, largely transfusion dependent patients along with a group of highly engaged non transfusion dependent patients. These early signals speak not only to our launch readiness, but importantly to our deep understanding of this patient community, and their unmet needs. Please move to the next slide.

Morgan Sanford: We are very encouraged by the early market

Tsveta Milanova: Response at Fresnius. Physicians consistently view its profile as addressing meaningful gaps in the current treatment landscape for thalassemia. Importantly, this aligns with what we heard ahead of FDA approval.

Operator: We are not seeing the ramp as a barrier to prescribing,

Tsveta Milanova: With early experience suggesting certification process has been straightforward. We have also seen strong engagement with our patient support program, initial experience indicates that patients do not view the ramps as burdensome given the potential for meaningful clinical benefit including reduction in transfusion burden and improvement in fatigue. Taken together, this early feedback reinforces both the significant unmagnetic lymphedema and the value proposition of a PSME. It also reflects the strength of our prelaunch planning. On the next slide, I will take a few moments to discuss how we anticipate this demand will convert into treatment initiation and ultimately revenues in the first few quarters of launch. There are three key steps in the QASMINE REMS certification process.

One of those steps, pharmacy education and is already completed as we use a single specialty pharmacy to discuss prescriptions and coordinate on delivery. Additionally, physicians are required to be educated and certified on the SPEDNI RAN. In parallel, once a prescription has been written, patients need to receive insurance authorization and complete a baseline liver test prior to initiating treatment. Our comprehensive patient support service might add you has a strong track record assisting patients with the insurance authorization process for PK deficiency, which we expect to continue with thalassemia. Once these three components are completed, the pharmacy is authorized to dispense the prescription.

Patients will then complete monthly liver tests for the first six months and is clinically indicated thereafter. Initially, we expect decline from first prescription to treatment initiation to be on average 10 to 12 weeks. As physicians are onboarded and access expands, we see opportunity to shorten this line timeline as launch progresses.

Operator: Turning to the next slide.

Tsveta Milanova: The thalassemia opportunity presents a major potential growth inflection for Adju. Today, we have received approval of Micipiva for thalassemia in two regions, marketed as Expensin in the U.S. and

Operator: Pyrokine in Saudi Arabia.

Tsveta Milanova: Our capital efficient global commercial model enables us to focus our investments on the U.S. which presents the most significant revenue opportunity. Outside of the U.S., we have executed commercialization and distribution agreements with Avandomite Bioscience in Europe and Newbridge Pharmaceuticals in the GCC. Given access dynamics, we currently distribute pyrokines in Saudi Arabia on a patient by patient basis, with potential to expand access following national procurement agreement. In Europe and UAE, regulatory

Morgan Sanford: Reviews remain underway.

Tsveta Milanova: We anticipate a potential EC decision in the coming months following the positive CHMP opinion received

Morgan Sanford: In October 2025.

Tsveta Milanova: Across these regions, we see real potential to expand access and deliver meaningful growth as we scale the launch globally. Please move to the next slide. And with that,

Morgan Sanford: I will hand the call over to Sarah to cover key R and D highlights from the

Tsveta Milanova: Quarter. Thank you, Sarah. Next slide, please. Since we reported third quarter results, we have continued to make progress advancing our robust rare disease pipeline. We received the FDA approval of Afesne for alpha and beta thalassemia regardless of transfusion burden on December 23,

Morgan Sanford: And as you heard from Sveta, the U.S. launch is underway with strong reception from

Tsveta Milanova: Physicians. Following the rise of phase three top line data of mitapivat in sickle cell disease, we will have our pre-sNDA meeting this quarter to inform the regulatory path forward. We continue to advance our more potent PK activator, Tevaptiva, in two Phase II trials and anticipate results in lower risk MDS in the first half of this year and in sickle cell disease in the second half. We continue to advance our early stage

Morgan Sanford: Pipeline to important decision points this year and are on track to initiate a phase 1b proof of mechanism trial of HA-one hundred eighty one our phenylalanine hydroxylase stabilizer in PKU patients in the coming months and report top line data from the phase one healthy volunteer

Tsveta Milanova: Study of AG two three six our siRNA targeting TMPRSS six for polycythemia vera in the first half. Please move to the next slide. Turning to tebapivat, we look forward to understanding more about the potential role of this more potent PK activator in low risk MDS and sickle cell disease this year. We remain on track in low risk MDS where top line data from the Phase IIb trial are expected in the first half of this year. This study will provide important insights into dose optimization as well as the potential role of tebapivat in different patient subgroups, including low and high transfusion burden patients as well as potential applications in later lines of treatment.

In sickle cell disease, enrollment in the phase

Morgan Sanford: Two trial is now complete, an important milestone that reflects the growing

Tsveta Milanova: Enthusiasm for PK activation, following the rise of phase three results of mitapivat in this debilitating and deadly disease.

Morgan Sanford: This twelve week double blind trial is designed to further explore tebapivat's

Tsveta Milanova: Potential to deliver meaningful improvements in hemoglobin,

Morgan Sanford: As well as broader markers of hemolysis. In turn, we see potential for higher hemoglobin response building on the

Tsveta Milanova: Strength of the data established with mitapivat. Together, these programs underscore the potential for tebapivat to expand our leadership in hematology and address multiple high value populations where unmet need remains significant. We have an exciting year ahead of us, and we look forward to updating you on our pipeline progress throughout the year. With that, please move to the next slide, and I will hand the call back to Brian for closing remarks.

Brian Goff: Thank you, Sarah. Next slide. In closing, we have another pivotal catalyst rich year ahead of us. In line with our 2026 strategic priorities, we are focused on executing a high value Ecbezni U.S. launch in thalassemia. In sickle cell disease, we are preparing for our pre-sNDA meeting mitapivat this quarter, an important step towards defining our regulatory path. We also expect Phase II top line data for tebipivat is sickle cell disease later this year, which will give us deeper insight into the potential of higher potency PK activation in this population.

In lower risk MDS Phase 2b top line data for tebipivat remain on track for the 2026, and will be a key readout as we assess its ability to drive transfusion independence and broader improvements in anemia. We also anticipate Phase I top line data for AG two thirty six in polycythemia vera and Phase 1b proof of mechanism data for a g one a one in PKU, two important early stage programs that expand our reach across hematologic and other rare diseases. Please move to the next slide. As we look beyond 2026, our opportunity set continues to expand.

The combined global market potential across our current pipeline indications $10,000,000,000 reflecting both the breadth of unmet need and potential to deliver transformative medicines to patients. Beginning in 2026, we are focused on delivering high impact U.S. launch of Acasti in thalassemia, which we believe has the potential to establish a strong foundation for our leadership more broadly in rare hematology. Our combination of near term catalysts, disciplined investment, and a maturing pipeline creates a clear pathway to deliver long term value. Agios Pharmaceuticals, Inc. is well positioned for the next chapter of growth while advancing the next wave of innovation across our rare disease portfolio.

Before we move into Q&A, I would like to acknowledge the dedication of our employees whose unwavering focus and commitment continue to make a meaningful difference for patients with rare disease. With that, I would like to open the call for questions. Operator, please open the line.

Operator: Thank you. To be announced. To withdraw your question, please press 11 again. We will now open for questions. Our first question comes from Gregory Renza with Truist. Your line is open. Great. Thanks. Good morning, Brian and team. Congrats on the quarter and, of course, another eventful year. Maybe two questions from us on the Quesme and then on sickle cell. First, just on the AQUESMY launch, we appreciate all the color you are sharing early and getting patients engaged and prescriptions written.

Just on that translation perhaps, on the prescription updates that we are seeing, how do you see that not only translating to treatment initiation but also to revenue recognition, maybe not asking for guidance on early quarters, but any color you can provide on the first quarter and even subsequent early days of the launch with respect to how it holstered to revenue? And then I have a follow-up. Thanks.

Brian Goff: Yeah. Thanks, Greg. Very happy to talk about the launch. And before Sveta gets going here, I just want to say I am really proud of the way the team has executed. It is early days but, Sveta is excited to finally have a chance to begin talking about the AgBesmi launch.

Tsveta Milanova: Absolutely. Definitely excited. And Greg is as I mentioned in my prepared remarks, we are really encouraged by the early demand that we are seeing with AccessMe. As you mentioned, we reported that we had 44 prescriptions from REM certified physicians, up to January 30, which is the first five weeks, of the launch, and that is fantastic to see. With regards to your questions, what do we expect is to see in the initial quarters prescriptions and demand to grow ahead of revenues. And the main reason for that is that it takes about 10 to 12 weeks for us to convert prescriptions to treatment initiation and ultimately revenues.

So, we anticipate, in Q1, the majority of the prescriptions to turn into treatment initiation. And as the year progresses, we will expect to see revenues and demands to start tracking more closely?

Morgan Sanford: We get a lot of questions about potential analogs So when I think about another product which also has a liver ramp, that is still sparring, so that is a good analog

Operator: For you to look at of how the actual revenue

Sarah Gheuens: Trajectory throughout the first year of the launch, actually evolved. It is a very different disease, of course, but from a shape of the curve of the revenue, I think it is a good one to look at.

Gregory Renza: Great. Thank you. That is very helpful. And maybe just moving on to sickle cell and tebipivin. And of course, not to overlook the MDS readout in the first half, but with enrollment complete in the Phase II in sickle cell and Sarah, the color that you have provided, maybe if I may just ask a bit about how you are pegging expectations for what you want to see to get excited about the Phase II data in sickle cell coming later this year. You had spoken about the potency and the higher hemoglobin response potential.

Any color that would help to get you excited and how that kind of fits into the larger portfolio relative to mitapivat and the larger sickle cell space even. Thanks so much and congrats again guys.

Brian Goff: Thanks, Greg. Thanks, yes, thanks for the question, Greg. So the

Sarah Gheuens: Phase two sebapiva trial that, we have just indeed announced full enrollment, is a dose finding trial. So we are looking indeed to explore the doses. We are looking at the hemoglobin. It is a standalone phase two trial so our VOCs are included as safety assessments, which is different than how the phase two, three seamless operational design was for Rise Up. But, obviously, we are now in a position that we can leverage data across PK activation franchise, basically. And we are able to use the rise of data to also, model what we anticipate a hemoglobin response can lead to. For clinical benefit. So we are very excited about the trial.

We think actually the fact that we can announce the enrollment completion also reflects the excitement of the community. You know, the rise of data announcement really led to a faster enrollment in the tebapivat phase two trial, so we are very excited about that. Thank you.

Operator: Our next question comes from Samantha Simenko with Citi. Your line is open.

Morgan Sanford: Hi, good morning, and thanks very much for taking the questions, and congratulations on all the commercial progress.

Tsveta Milanova: Just one follow-up on ExVes May. I am wondering if you could speak to a bit of the cadence of scripts that have come in since approval. And particularly, are you seeing an increase

Emily Bodnar: In the scripts written, since January 30 after the REMS has become fully operational. And then just a second question. I am wondering if you could speak to the potential outcomes from the planned sNDA meeting with FDA on the sickle cell disease. What are the outcomes that could come out of that meeting? Thanks very much.

Brian Goff: Thanks, Sam. So we are going to stick with the 44 that we have so far for ACT VESMI, but I think Sveta could continue to provide color on the early days of the launch. And so I will have Sveta start on that and then Sarah can speak to the pre-sNDA meeting.

Sarah Gheuens: Absolutely, Sam. And a reminder, we started basically, engaging and educating physicians and generating demand as soon as the product was approved. So within the first five weeks of the launch, we have been educating, physicians on the value proposition of a and the REMS itself. So, the we are very encouraged with what we see in terms of demand, in this early stages of the launch. A lot of the things that are happening, and I am really, really pleased with the execution of the team, are happening as we expected.

So we are seeing prescriptions coming from the transfusion dependent patients and the very engaged symptomatic non transfusion dependent patients who have frequent interactions with the health care system, which is fantastic. And we see a very healthy dynamics of the launch in terms of the physician's We see prescriptions coming from across the country. And a lot of them are in the community setting where the majority of the patients are treated, and I am really pleased with the progress that the team is making.

Brian Goff: Great. And then, Sarah, the pre-sNDA meeting and Sam's question about the potential outcomes.

Tsveta Milanova: Yes. Thanks, Sam. So we have guided to the

Morgan Sanford: Pre-sNDA meeting in the first quarter of, this year. The goal for that meeting is, of course, to gain insights in the regulatory pathways that we can use for mitapivat. As stated, we are, of course, going in with a data package that we can that we would like to present for

Sarah Gheuens: Full approval based on the data that was generated in Ryzep with the strong anti hemolytic profile that is now

Morgan Sanford: Confirming again the anti hemolytic profile of mitapivat now in a in a third hemolytic anemia, with additional strong clinical benefit observed in those hemoglobin responders.

Sarah Gheuens: And, once we have that meeting, like we

Morgan Sanford: Are planning to, give it an update

Sarah Gheuens: We have the meeting minutes to you guys.

Emily Bodnar: Great. Thanks very much.

Operator: Thank you. And our next question comes from Stranahan with Bank of America. Your line is open.

Brian Goff: Great to see the continued progress for both the commercial and the clinical stage portfolios. Two questions from us. I guess, first, is sort of the main bottleneck informing that 10 to 12 week prescription to treatment initiation? Is it getting the patient in for their baseline liver test or maybe something else and how do you anticipate this shortening over the course of this year? And then second, for teprotivat in MDS, what does good look like on transfusion independence in this lower risk population? And I guess given what you learned from the phase two a do you expect you could see activity at the ten mg dose based on

Alec Stranahan: Of the emerging PK data, or is this maybe more likely at the fifteen and the twenty mg doses? Thank you.

Brian Goff: Thanks, Alex. So we are going to follow the same sequence here. Stade gets to talk about the eCVESB launch and then Sarah thankfully we have a robust pipeline so she can discuss the MDS trial with tebipivat. Absolutely. So the 10 to 12 weeks is driven by

Sarah Gheuens: Two things. The first aspect is the insurance authorization. Which is very standard for any specialty rare disease drug that is not unique to QESMI. And the a lot most of the patients would need to go to prioritization, which can take know, an average a month. And for some patients, it happens faster. For some patients, it takes longer, but that is one of the main drivers. The second aspect is the requirement for a liver test ahead of the treatment initiation. So when we combine both of these factors, we anticipate, the conversion from prescription to treatment initiation to be on average 10 to 12 weeks.

As I said, we will see kind of patients falling on either end of that time frame. And over time, we will, of course, look to shorten the time from prescription to treatment initiation on both fronts. We have an excellent market access team that will be engaging with payers. So as some of the payers actually put the product on formulary, that can be an opportunity for us to move fast faster through some of the prior authorizations, and supporting patients as well as we will be learning, throughout the launch and identify areas to support to, have an efficiency in their liver testing initially as well.

Brian Goff: Great. And, Sarah, for, tebipivat and MDS, just some of the you know, what are we expecting and then the different dosing

Tsveta Milanova: Yeah. Thanks, Alex. And so to your point, we indeed are testing higher doses than the dose that we tested in the phase 2a. So we have a 10 milligram, a 15 milligram, and a 20 milligram dose. So, indeed, we are looking

Sarah Gheuens: To explore the doses here in this phase two to see which dose would be best. And then in addition, we are, because it is a heterogeneous

Morgan Sanford: Patient population, this trial will also allow us to further define patient populations. So we have low and high transfusion burden, plus additional lines of therapy that have been used. So it will really give us a lot of insights on where this drug can play a role. Obviously, it is an oral therapy, which

Sarah Gheuens: Of course, can be very meaningful for a patient population like this because if patients would have treatment response, it allows them to be really untethered of the clinic.

Brian Goff: Yeah. It is going to be it is an exciting year for teprotivat in 2026. We have two catalysts, as we noted. We have the MDS Phase 2b trial in the first half of the year, and then as we have already discussed, for sickle cell disease, the second half of this year, we look forward to that phase two result.

Alec Stranahan: Great. Thanks for the color, and congrats on the continued progress, guys.

Brian Goff: Thank you.

Operator: Thank you. And our next question will come from Mark Fromm with TD Cowen. Your line is open.

Gregory Renza: Questions. Maybe to start on ekvezmi with the REMS certified physicians. Just

Brian Goff: Can you maybe talk about kind of where that is from a quantitative perspective? You know,

Marc Alan Frahm: Within these first few months? And kind of what do you look think that trajectory looks like in terms of number and breadth of certified physicians over the next, you know, quarter or two as the as that part of the ramp really happens. And then I will, I will have a follow-up on the pipeline.

Brian Goff: Okay. So I can start. Yeah. When it comes

Tsveta Milanova: To the REMS, for in this initial stage of the launch, I am really pleased with what we are seeing, and things are happening exactly as we anticipated. Physicians do not see the ramps as barrier to prescribing and the patients that we have engaged with they basically they do not see it as burdensome given the strong value proposition of aquezmia and their willingness to consider and initiate therapy What is happening with the rams? Initially, a lot of the bigger academic centers and KOLs are getting certified. And when it is comes to the community physicians, actual certification happens almost simultaneous with the first prescription.

And we will see in a way the certification and brands, progressing simultaneously over time. But as I said, REMS has not been a reason or a reason for not to prescribe is the opposite When physicians have patients that they want to initiate, they are more than willing to start to complete the REMS, which can actually take, one visit is a very, quick process.

Marc Alan Frahm: Okay. Thanks. That is helpful. And then maybe just following up on Sarah's comments about the pre-sNDA meeting and that the package is really aimed for supporting full approval. I think at other times, you have also mentioned possibilities of an outcome of accelerated approval. Is that still something you think is a reasonable outcome, or are you know, more confident in a full approval than maybe you have been as you gotten a little deeper into the data and conversations? And then assuming Accelerate is on the table, what is your latest thoughts on kinda what a confirmatory trial might look like under that scenario?

Tsveta Milanova: Yeah. So thanks, Mark. So for us, the data package

Sarah Gheuens: Really the benefit risk profile generated in RISE confirms a strong anti hemolytic profile, as I mentioned. And we really see those clinically meaningful changes in the hemoglobin responders. So our view is that benefit risk here is you know, seen in this trial, and it is a supplemental, NDA. Now as you also know, at ASH recently, the FDA highlighted that hemoglobin can be a surrogate endpoint for sickle cell disease. So either one of those pathways for us allows us to discuss the data, and have that meaningful conversation with the agency under any of those circumstances, then there is always the normal filing procedure that, yeah, one would have to go through.

But we are very, very excited about the data as it stands. Then in regards to your question on confirmatory trials, obviously, we have, several options

Tsveta Milanova: That we can discuss in which

Sarah Gheuens: Some of these options have endpoints that have been used before. Some of them are novel endpoints as well. So we are ready to discuss, as needed.

Tsveta Milanova: K. Thank you.

Operator: Thank you. And our next question will come from Eric Schmidt with Cantor. Your line is open.

Brian Goff: Hey, guys. Sorry for any background noise, but Cecilia mentioned a direct path or clear path to profitability. I was hoping you get a little bit more detail on thinking or around the breakeven point of revenue needed to hit that and maybe timelines to profitability. And then were there any sales at all in the GCC countries in Q4? Thank you.

Tsveta Milanova: So we have thanks, Eric. We gave the guidance on profitability with PKD and thalassemia regarding

Sarah Gheuens: Of the path forward for sickle cell? Anovacar base case there. We have not given a specific timing of when that will happen. We believe

Tsveta Milanova: You know, thalassemia is a meaningful opportunity. We are excited about the initial stages of the launch. We also have, as you mentioned, ex-U.S.

Sarah Gheuens: Being part of that opportunity as well. And then part of that profitability path also requires us to proactively manage our

Tsveta Milanova: OpEx as we navigate the multiple catalysts on the but we also have other earlier programs. So we have not given specific timing

Sarah Gheuens: On that

Tsveta Milanova: My god. Second time. GCC? And then for GCC, what we have seen, the ex-U.S. revenue we saw in Q4 is mostly driven by

Sarah Gheuens: Europe, and that is in anticipation of demand. So that is why we guided to

Tsveta Milanova: An expected decrease, Q4 to Q1. GCC, as a reminder, today is on a equivalent of a named patient, like, case by case. So you see some consistency quarter over quarter until we get to the point where we have more broad access negotiated over the next 12 to 18 months or so.

Brian Goff: Yeah. And, Eric, I will just add. We are we are pleased with the partner we have in place in GCC with Newbridge. Tsveta and I spent some time in Saudi Arabia late last year and really got a kind of a street level sense about how the team is doing, the enthusiasm from clinicians, as well as, even at the minister of health level and you know, that is going to take some time to build traction, but I think in the early days, feel quite good about the opportunity. Thank you. You bet.

Operator: And our next question comes from Emily Bodnar with H. C. Wainwright. Your line is open.

Tsveta Milanova: Hi. Good morning. Thanks for taking questions, and congrats on all the progress. I guess for the first one, can you give some

Morgan Sanford: Color on the type of physicians who are initially prescribing Aquesti? And whether they are mainly physicians who have used pyrokine in the past or you are getting physicians who are more new to drug? And then on sickle cell disease, assuming you achieve alignment with the FDA, are you expecting potential approval in 2026 And can you maybe discuss some of the launch preps that you are planning to do this year ahead of approval? Thanks.

Brian Goff: Thanks, Emily. Scott, you want to start with ACFSB and the types of physicians in the early days?

Sarah Gheuens: Absolutely. As I said, a lot of the early launch dynamics are playing as expected. The team did a fantastic job ahead of the launch. Profiling and prioritizing accounts on the initial prescriptions are actually coming from the physicians we anticipated to see prescribing. As I mentioned, Emily, they are primarily the community hemangs, where majority of the patients are, and these are physicians we have engaged with previously. We do not see, that much overlap between PK deficiency and thalassemia, and that is because PK deficiency is an ultra rare disease. So there are very few physicians who have experience with pyrucarin tropic deficiency.

And as I said, I am very pleased with the with the start of the launch. It is it is a very healthy breath of prescribing that we see. Across the country. Different physicians, are engaged and really, trying the product in the patients that they would think will benefit the most initially.

Brian Goff: Great. And, Sarah, for sickle cell disease and potential timing. Yes. So, Emily, we have not guided

Tsveta Milanova: To potential approval dates

Sarah Gheuens: Yet. We are now the first guidance we have given in process is our pre-sNDA meeting anti anticipated Q1. And then, in regards to the launch prep, I will ask Cecilia to comment.

Tsveta Milanova: Yeah. So as a reminder, we did not very similar to how we did thalassemia, we did not build for sickle cell until we saw the data.

Sarah Gheuens: That is what we refer to when we talk about the gated sickle cell investments. We will look into that timeline and understand the path to start building investment there accordingly. Thank you.

Operator: And our next question will come from Salveen Richter with Goldman Sachs. Your line is open.

Lydia Erdman: Good morning. This is Lydia on for Salveen. Thanks so much for taking our questions and congrats on the update. Is there any additional color you can provide on the split between the transfusion and transfusion dependent patients amongst these 44 scripts that have been written. And then given scripts will be the key metric to watch Do you anticipate third party services like IQVIA to accurately capture these scripts? Thanks so much. Yep. So the initial prescriptions, as I said, very much as we anticipated, come from a combination of transfusion dependent patients

Tsveta Milanova: Obviously, a large proportion is transfusion dependent patients. And very engaged symptomatic nontransfusion dependent patients who are in a active interaction with the health care system. So when you think about the kind of the evolution over time, as anticipated, I think we will see initially more transfusion dependent patients, but the scale up of the launch will come from the nontransfusion dependent patients. Later on. When you think about IQVIA, we have a single specialty pharmacy that distributes the product. So IQVIA will not be the right source for you for you to look at.

It is just the information will not be available And this is the reason that we are looking to provide you initially with prescriptions revenue, as well as we gave you the guidance on taking the fish so you can see where the growth of thalassemia will be coming throughout the year. So much.

Operator: Thank you. And our next question will come from Tess Romero with JPMorgan. Your line is open.

Lydia Erdman: Hey, guys. Thanks so much for taking our questions this morning. So first one is just on

Tsveta Milanova: Agvezny. Just can you just quickly touch on initial payer dynamics? Over the first couple of quarters here and

Lydia Erdman: Remind us of payer mix. Just want to make sure that we are thinking about potential free drug the right way. And then second question, a bit of a housekeeping question. Here. If you are indeed approved in sickle cell disease, how does your SG&A line change Just trying to think through what you might need to successfully launch a drug in sickle cell from an expense perspective.

Tsveta Milanova: Thanks so much.

Brian Goff: Okay. Thanks, Tess. And, Sveta, can start on payer aspects, and maybe we could also just remind our gross to net assumptions too. Think we

Sarah Gheuens: Yep. Would be good. Answer the Tessa, I will start here. So the payer mix in the lesseemias was to begin deficiency with majority of the patients. Being, under the commercial payer bucket. Very similar to PK deficiency in any other drug initially, the actual market access and payer authorization through it will happen through medical exceptions because payers would take time about six months, six to nine months, to actually start putting the product on formulary. We have a very experienced market access team that is very familiar of how to navigate the medical exceptions process.

And so far, this early stages of the launch, I must say, as expected, we have not seen any payer further hurdles at all. I think the value proposition of a Fresmis speaks to itself, and the team is doing a great job, in terms of, those interactions Brian asked to kind of to comment on the gross to net assumptions. Given that we do not expect that to be a managed category, very similar payer mix to pick in deficiency or gross to net assumptions for thalassemia similar to PK deficiency 10% to 20%.

And then on the SG&A question, test, as we think about it, So as I mentioned, we are going to update and manage our spend, based on the regulatory discussions and the timing. But if you want to think about it is

Tsveta Milanova: We have an infrastructure that we have paid for PKD and thalassemia that we would

Sarah Gheuens: Leverage, but the scale of signal is much bigger. So we will have to scale up those functions that we built, but we have a really nice foundation to, bid from. Thank you.

Operator: Thank you. Thank you. And our last question it will come from Luca Izzi with RBC Capital Markets. Your line is open.

Morgan Sanford: Oh, great. Hi, team. This is Shelby on for Luca, and thanks for taking the question. Could you remind us what is the rationale for dosing higher and lower risk MDS

Sarah Gheuens: Versus the phase two for sickle cell disease?

Morgan Sanford: And then maybe one more. Now that we have the label and REMS program for thalassemia, do you expect any read through to sickle cell, and has it changed any internal expectations on the commercial opportunity there?

Lydia Erdman: Any color is much appreciated. Thanks.

Brian Goff: Yeah. I think well, so we could start with MDS and the rationale for the all of all three of the doses, being higher than what we tested in the 2A. And then we will talk a little bit about REMS and sickle. Yes. So for the rationale of higher doses, so we originally had a

Morgan Sanford: Phase 2a with the five milligram dose based on modeling from the healthy volunteer trials, but we learned in that trial that MDS patients metabolize it faster, the drug, and so we pushed the dose higher in the phase 2b, to do further dose exploration. Versus sickle cell disease patients who are exactly the same as healthy volunteers. So that is why we have those differences between those two, two indications.

Brian Goff: And then and, Sarah, you could start on the sickle cell the question about REMS. And read through, and Sveta can certainly comment on how we see it commercially.

Sarah Gheuens: Yes. So as you know, in the sickle cell disease program, we did not have the same observations as we had in thalassemia. So

Morgan Sanford: It is it is much more like the pyruvate kinase deficiency program where we do not have a REMS, as you know, versus thalassemia where we do have a REMS. So all of this actually does give us optionality. So our going in position based on the data observed is that would not be needed, and we and we would propose something more like the pyruvate kinase deficiency path. Now a read through, if it would turn out to be a REMS, I will hand that one over

Sarah Gheuens: To Sarah. Absolutely, obviously, sickle cell disease is a devastating disease with high morbidity and mortality. No treatment options. So we see a meaningful commercial opportunity assuming we have a label in the U.S. And the team will be ready to execute on it. We have we have got ready and executing successfully on the ramp for thalassemia gives us a very solid foundation to continue to execute if we were to have something similar in sickle cell disease as well.

Brian Goff: Yeah. And I will I will just take a moment to say. So Tsveta's team has continued to navigate through PKD as a launch, which is ultra rare and certainly not the easiest of launches that began back in 2022. And now we have ACBESME and off to, you know, really good start in the first month, of January. So I feel very confident the team in any scenario will be very well prepared. So I think that is our last question.

Lydia Erdman: Yes.

Sarah Gheuens: Okay. Then

Brian Goff: I will go ahead and close it down. I first, I just want to thank everyone for joining us morning. It is an exciting time for Agios Pharmaceuticals, Inc. As you heard throughout the call, we are entering 2026 with quite strong momentum and really pleased that we are already seeing strong initial progress with the ACBESBI launch in the U.S. We have meaningful clinical and regulatory catalyst ahead, as we have talked about, and we will continue to operate with financial discipline.

These near term drivers combined with our advancing pipeline position Agios Pharmaceuticals, Inc. to deliver sustained growth and long term value, and we very much appreciate your continued engagement and look forward to updating you on our progress throughout the year. Thanks a lot.

Operator: Thank you. This does conclude today's conference call. Thank you for participating and you may now disconnect.

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