Cara Therapeutics Inc (NASDAQ: CARA) Q4 2019 Earnings Conference Call
Final Transcript
Corporate participants:
Jack Hildick-Smith — Investor Relations
Derek Chalmers — President, Director and Chief Executive Officer
Richard Makara — Vice President, Head of Accounting and Controller
Analysts:
Chris Howerton — Jefferies — Analyst
David Amsellem — Piper Sandler — Analyst
Annabel Samimy — Stifel — Analyst
Chi Meng Fong — Bank of America Merrill Lynch — Analyst
Pete Stavropoulos — Cantor Fitzgerald — Analyst
Joey — Needham & Co. — Analyst
Ben Shim — Canaccord — Analyst
Esther Hong — Janney — Analyst
Presentation:
Operator
Good afternoon, and welcome to Cara Therapeutics Fourth Quarter and Full Year 2019 Financial Results Conference Call. [Operator Instructions] There will be a question-and-answer session at the end. Please be advised that this call is being recorded at Cara’s request.
I would now like to turn the call over to the Cara team. Please proceed.
Jack Hildick-Smith — Investor Relations
Good afternoon. This is Jack Hildick-Smith with Stern Investor Relations, and welcome to Cara Therapeutics fourth quarter and full year 2019 financial results and update conference call. The news release became available just after 4:00 PM today and can be found on our website at www.caratherapeutics.com. You may also listen to a live webcast and replay of today’s call on the Investors section of the website.
Before we begin, let me remind you that statements made on today’s call regarding matters that are not historical facts are forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. Examples of these forward-looking statements include statements concerning the expected timing of the data readouts from the company’s ongoing clinical trials, the potential results of ongoing clinical trials, timing of future regulatory and development milestones for the company’s product candidates including the company’s projected time line for the submission of its first NDA, the potential for the company’s product candidates to be alternative in the therapeutic areas investigated and the company’s expected cash reach.
Because such statements are subject to risks and uncertainties, actual results may differ materially from those expressed or implied by such forward-looking statements. Risks are described more fully in Cara Therapeutics’ filings with the Securities and Exchange Commission including the Risk Factors section of the company’s most recent Annual Report on Form 10-K and its other documents subsequently filed with or furnished to the Securities and Exchange Commission.
All forward-looking statements made in today’s call speak only as of the date on which they were made. Cara Therapeutics undertakes no obligation to update such statements to reflect events that occur or circumstances that exist after the date on which they were made.
Participating on this call are Dr. Derek Chalmers, Cara’s President and CEO; and Mr. Rick Makara, VP and Head of Accounting. I’ll now turn the call over to Dr. Chalmers.
Derek Chalmers — President, Director and Chief Executive Officer
Thank you, Jack. Good afternoon, everybody and thanks for joining us on the call today. 2019 was certainly a very significant and productive year for Cara as we advanced the late-stage clinical development of our lead candidate KORSUVA across a range of pruritic clinical populations.
In May of last year, we announced positive topline results from our KALM-1 pivotal Phase 3 trial of KORSUVA injection in hemodialysis patients with moderate to severe chronic kidney disease associated pruritus or CKD-aP. The full results from this trial were published in the New England Journal of Medicine in November of last year.
In December of last year, we identified the appropriate tablet strength of oral KORSUVA to bring forward into a Phase 3 registrational program in non-hemodialysis patients with CKD associated pruritus following positive topline results from our dose ranging Phase 2 trial in this patient population. We also expanded our oral KORSUVA clinical development program into two new pruritic indications with high unmet need atopic dermatitis and chronic liver disease associated pruritus. And we initiated both of those Phase 2 trials in the middle of 2019.
Lastly, we made important corporate advances in 2019. We strengthened our financial position with a public follow-on offering of approximately $136 million. We also entered into a commercial license agreement with Enteris BioPharma for oral formulation rights to its Peptelligence Technology to develop and commercialize oral KORSUVA in any indication. Building on this momentum from 2019, we expect multiple major clinical data readouts and regulatory advancements in 2020. And on the call, I’ll provide an update on each of our programs and what we expect for the rest of this year.
Before we dive into those programs, as a quick reminder on KORSUVA’s broad anti-pruritic mechanism of action, which is in contrast to other modalities that focus on blocking one specific pruritogen such as MK1 antagonist, which have been in the news this week. The action of KORSUVA on dermal and epidermal immune cells blocks the release of a range of nerve sensitizing molecules of pruritogens and KORSUVA directly diminishes the stimulation of dermal sensory fibers, principally C fibers downstream from the action of the pruritogens. And this has dual neuronal and anti-inflammatory effect that we believe provides for antipruritic activity regardless of the initiating pathophysiology whether that’s chronic kidney disease, chronic liver disease, or some type of dermatological condition.
Okay, so let’s begin with our lead program for KORSUVA injection in hemodialysis patients with CKD associated pruritus. This pivotal program includes four Phase 3 studies. KALM-1, a US efficacy trial which we read a positive topline data last year. KALM-2, our global efficacy trial which we expect topline data from in the second quarter of this year, and two open-label safety trials.
In KALM-1, we observed a robust sustained antipruritic effect of KORSUVA over the three-month treatment period. KORSUVA injection met the primary endpoint, significantly reducing itch intensity with 51% of subjects achieving at least a three-point improvement in worse itch intensity or NRS compared to 29% of subjects in the placebo group. The trial also met all secondary endpoints. And in addition, KORSUVA was generally well-tolerated with a safety profile consistent with prior clinical trials.
Like KALM-1, our ongoing global KALM-2 trial was designed to investigate the efficacy of KORSUVA injection at a dose of 0.5 micrograms per kilo versus placebo and this is administered three times per week after scheduled dialysis sessions over the 12-week treatment period. In October of last year, we announced an increase in target enrollment for KALM-2 to 430 patients, about a 20% increase from the original target of 350 based on the recommendation of the independent data monitoring committee to maintain our pre-specified conservative statistical power for the primary endpoint.
KALM-2 was fully enrolled to this level in December of last year and we expect topline data from this trial in the second quarter followed by the submission of our first new drug application for KORSUVA injection in the second half of this year. In terms of safety exposures, we currently have a safety database in line with ICH guidelines for NDA submission with over 1,500 total patient exposures with more than 600 patients completing six months of treatment and over 300 patients completing one year of continuous treatment.
As you know from these calls, CKD associated pruritus is an area of high unmet need with no therapies currently approved in the US or Europe. Per the National Kidney Foundation there are over 500,000 dialysis patients in the US with 60% of these patients reporting some level of pruritus, 40% to 50% in the moderate to severe range. So, clearly a significant unmet need. We do intend to commercialize KORSUVA injection in the US and we’ve established commercial license agreements in the other major commercial markets including Japan, South Korea, and the European Union.
In the EU, we have a collaboration with Vifor Fresenius, which allows us to leverage the broad reach of Fresenius to dialysis patients across Europe. And we also believe this collaboration positions us well for commercial success in the US where we’ve established a co-promotion and profit sharing agreement with Vifor Fresenius specifically within Fresenius clinics in this country. That allows us to utilize the nephrology-focused expertise of Fresenius and we expect help build momentum for the adoption of KORSUVA injection upon launch.
So, as we advance KORSUVA injections to an NDA filing in the second half of this year pending our positive KALM-2 results, we have also initiated key pre-commercial activities across functional groups at Cara including medical affairs, commercial, and CMC where we’ve already established a supply agreement for commercial scale manufacturing.
So, that’s where we stand in terms of KORSUVA injection development and we’ll continue to update you on our commercial preparations as we approach the NDA filing and beyond. Near term, of course, we’re very much looking forward to KALM-2 Phase 3 results in the next couple of months.
So let’s move on to our pipeline programs focused on oral KORSUVA and start with our lead program in pre-dialysis CKD patients with moderate to severe pruritus. Based on pruritus-related drug prescription data of the approximately 7.3 million people diagnosed with CKD here in the US about 33% are currently receiving some sort of treatment for pruritus. These treatments typically include generic antihistamines or corticosteroids, neither of which effectively alleviate the pruritus burden long-term. So this is a large again patient population with significant unmet need.
In December of last year, we reported positive topline results from our 12-week Phase 2 trial, evaluating the safety and efficacy of 3-tablet strands of oral KORSUVA 0.25 milligrams, 0.5 and 1 milligram once daily. Based on the data we identified the 1 milligram tablet strength of oral KORSUVA as a dose level to take forward into Phase 3. And we’re pleased with the clinically meaningful responses we observed in patients treated with oral KORSUVA.
Patients treated with this dose achieved the primary endpoint of a statistically significant reduction in the weekly mean of the daily worse itch intensity scores at week 12. In terms of responder analysis, we also observed 72% of patients in the 1 milligram dose achieved a three point or greater improvement from baseline and the weakening of the worse itch intensity scores and this was compared to 58% of patients on placebo barely missing statistical significance.
Looking at the higher threshold complete responder level, this is a proportion of patients exhibiting worst itch NRS values of one or zero in the final week of treatment. All three tablets strengths of KORSUVA exhibited dose-dependent statistically significant improvements over placebo with approximately 40% of patients at the 1 milligram level exhibiting a complete response versus 14% on placebo.
Lastly and of course importantly, oral KORSUVA was generally well tolerated with a safety profile consistent with that seen in our earlier KORSUVA clinical trials. So, having successfully identified the tablet strength to take forward for this indication, we plan to hold an end of Phase 2 meeting with the FDA to enable the initiation of a pivotal Phase 3 program in the second half of this year.
In 2019, we also initiated Phase 2 trials for the treatment of pruritus in two additional patient populations, atopic dermatitis and primary biliary cholangitis or PBC. And we do aim to see topline data from both of these trials later in 2020. In January of this year, we expanded our Phase 2 trial in atopic dermatitis patients to include approximately 320 adult patients with moderate to severe pruritus from 240. And we incorporated an interim conditional power assessment and to the design to be conducted again after approximately 50% of the targeted patient number completely designated 12-week treatment period.
Based on that current sample size and our ongoing enrollment rates, we do expect to complete the interim statistical analysis for this trial in the second quarter of this year. In this trial, in terms of design, subjects were randomized to three tablet strengths of oral KORSUVA 0.25, 0.5 and 1 milligram taken twice daily versus placebo. The primary efficacy endpoint is the change from baseline and the weekly mean of the daily 24 itch worst NRS score at week 12 of the treatment period and secondary endpoints include the proportion of patients achieving an improvement of — from baseline of at least four points as well as change from baseline in each itch related quality of life scores at the end of week 12.
So overall, our progress in 2019 has laid the foundation for a very significant year ahead at Cara. We expect several important clinical and regulatory milestones in the year ahead, starting in the next quarter with topline data from our pivotal KALM-2 Phase 3 trial, which of course is going to enable filing of our first NDA in the second half of this year. So we do look forward to updating you on all the progress across all these programs in the coming quarters.
And with that, I’ll turn the call over to Rick to cover the financial results for the quarter and also for the full year.
Richard Makara — Vice President, Head of Accounting and Controller
Thanks, Derek. As a reminder, the full financial results for the fourth quarter and full year 2019 can be found in our press release issued today after the market closed. For the year ended December 31, 2019, we reported a net loss of $106.4 million or $2.49 per basic and diluted share compared to a net loss of $74 million or $2.06 per basic and diluted share for 2018.
For the fourth quarter of 2019, we reported a net loss of $28.6 million or $0.61 per basic and diluted share compared to a net loss of $20.7 million or $0.52 per basic and diluted share for the same quarter of 2018. Revenues for the year ended December 31, 2019 were $19.9 million compared to $13.5 million in 2018. Revenues in 2019 and 2018 were primarily related to our license agreement with Vifor Fresenius. Revenues in 2019 and 2018 also included $140,000 and $33,000 respectively from the sale of clinical compound to Maruishi.
In the fourth quarter of 2019, we recognized revenue of $4.5 million related to the Vifor Fresenius collaboration agreement compared to $5.5 million during the same quarter in 2018. Research and development expenses were $113.8 million for the year ended December 31, 2019 compared to $75.5 million in 2018. The higher R&D expense in 2019 were principally due to net increases in clinical trial costs, increases in stock compensation expense, payroll and related costs as well as expense in connection with the Enteris license agreement in 2019.
For the fourth quarter, we reported R&D expense of $29.9 million compared to $22.8 million in the same period of 2018. The higher R&D expenses in 2019 were principally due to a net increase in cost associated with clinical trials as well as increases in payroll and related costs. G&A expenses were $17.7 million for the year ended December 31, 2019 compared to $15.3 million in 2018. The increase was primarily due to increases in stock compensation expense, payroll and related costs, consultant costs, legal and accounting fees, insurance costs and franchise taxes. Those increases were partially offset by decreased rent and utilities.
G&A expenses were relatively consistent at $4.6 million during the fourth quarter of 2019 compared to $4.7 million in the same period of 2018. Other income was $4.5 million for the full year 2019 compared to $3 million in 2018. The increase was primarily due to higher average balance of our portfolio of investments in 2019. Other income was $1.2 million in the fourth quarter of both 2019 and 2018.
As of December 31, 2019, our cash, cash equivalents and marketable securities totaled $218.2 million compared to $182.8 million at the end of 2018. The increase primarily resulted from $136.5 million of cash raised in the follow-in offering of our common stock in July 2019 and $6.1 million received from the exercise of stock options, partially offset by $109.2 million of cash used in operating activities.
Turning to our financial guidance. Based on the projected costs for our clinical development plans and timing expectations, we expect that our current cash, cash equivalents and marketable securities as of December 31, 2019 will be sufficient to fund our operations into the second half of 2021 not accounting for any potential milestone payments under existing collaborations.
I’ll now turn the call back over to the operator for Q&A.
Questions and Answers:
Operator
Thank you. [Operator Instructions] Our first question comes from the line of Chris Howerton with Jefferies. Your line is open.
Chris Howerton — Jefferies — Analyst
Excellent. Thanks for taking the questions. And of course, congratulations on quite a year last year. So for me Derek, I think just a couple of questions, primarily related to the pipeline. So the CKD, oral CKD program and the results are what they are. What do you hope to get in terms of alignment with the FDA? And have you kind of thought any more about, what the ultimate primary endpoint you think would be either received by the investment and clinician community that will get the best reaction?
Derek Chalmers — President, Director and Chief Executive Officer
Okay, Chris thanks. I thought you were going to have an additional question. Was that one question, one long question? Or do you have — was that?
Chris Howerton — Jefferies — Analyst
That was one long question. I like to hear myself talk, as you know.
Derek Chalmers — President, Director and Chief Executive Officer
Yeah. Yeah. I like those mellifluous tones, as well. So, on the CKD oral, as you know we were pleased with that data. We had our primary endpoint. It was a study designed to identify the optimal dose strengths to take forward. And we did so. And in terms of endpoint definition, as you know, we spent a long time on this, in terms of our hemodialysis patient analysis, essentially end-stage CKD. And when we looked at that actually in consultation with the FDA, as we discuss the designation of breakthrough for KORSUVA, we actually empirically took our data. And looked at clinical meaningfulness, in terms of reduction in what’s the itch NRS score for that patient class.
And that number as you know is a little less than three points. And we were nice enough with our FDA plans went that up to three points. And that certainly is a clinically meaningful reduction for CKD patient with NRS scores. So, that would be our proposal, as a primary endpoint going forward, with the CKD oral study. Now we also, as you know, have a range of secondary endpoints. We’re interested in there. And we would look at, most likely, higher threshold responder analysis there perhaps in the other ways in fleet. But as far as we have determined, again, empirically and part of our consultation with the FDA a three point responder, analysis does — is the threshold for clinical meaningfulness there.
Chris Howerton — Jefferies — Analyst
Sure. And so then, outside of perhaps, the primary endpoint are there other — and I’m not, I guess, I’m putting words in your mouth. But what — what would you like to gain alignment with on the FDA, during that meeting? Or what are the things that you think, need to be worked out?
Derek Chalmers — President, Director and Chief Executive Officer
You’ve had the nail on the head right, Chris. We won agreement on our registration endpoint. And our proposal based again, on our analysis for CKD patients would be a 3-point responder. And we would most likely look at, four point beyond that as well as our usual quality of life measures. And that’s the main goal, at least, in the clinical portion of our end of Phase II, meeting with the FDA.
Chris Howerton — Jefferies — Analyst
Got it, okay. And is there. The other topic of discussion with respect to the oral CKD program has been the perhaps higher than expected placebo response, have you given any additional thought in terms of how you expect to control that in further trials.
Derek Chalmers — President, Director and Chief Executive Officer
Yes, we have. You’ll not be surprised to hear Chris, we have thought about that. On more than one occasion, we’ve thought about that sure. So — but let me say, outright. The aim of this Phase 2 trial of course is to be able to obtain, empirical data and the patient population we want to examine in Phase 3. And actually based on our proposed endpoint use that data to power the Phase 3 appropriately, even to overcome which we think, based on our past experience in this patient population is an unusual anomalous placebo response.
So that’s the first thing to say. We have the data now that we can power that trial appropriately. And even if we are off the mark, in our proposed measures to reduce that placebo response, we still will have an appropriately powered trial. And as you know, we’re very fond of running interim analysis to make sure we’re on track in our larger trials. So that is our overall approach. So that’s how we’re going to solve this if you like to view it as a problem.
But again, we have thought about this in terms of other elements, we could adopt into that Phase III that should help, the placebo response we believe. And we’ve mentioned this, before we do believe, there certainly was a potential for some expectation bias in these patients. A lot of the sites we use, the clinical sites we used in our oral KORSUVA trial were sites that had previously participated in KORSUVA injection trials for hemodialysis patients.
So there was experience with the drug albeit in a different formulation, and in the end stage if you like for that particular patient population. But certainly, that could have been a possibility. And the solution there is, somewhat obvious we’re going to use de novo sites that haven’t had the previous experience with the drug. So that’s one thing we can easily adopt. We’re also looking at the possibility of using a longer run in periods. It’s possible that these earlier stage CKD patients perhaps they have more labile pruritus that may wax and wane a little more than end-stage patients and so to identify the more consistent predications we can incorporate a longer run in period, which is easily incorporated.
And then finally, by nature of the very design of the Phase 3 looking at one optimum dose versus placebo on one-to-one randomization that alone should reduce the placebo response from the designed 3:1 randomization we used in that Phase 2 trial. So certainly we’re going to have that as part of our design. So those are all easy elements we can change that should help the placebo. Again ultimately we now have the data to power that trial and we’ll make sure we do so. And then we’ll confirm that we’ve maintained the power we desire there with interim analysis when we do run that trial.
Chris Howerton — Jefferies — Analyst
Right. Right. So I think my phone cut out there for a minute, but that will make sense to me. And I guess just one maybe quick question would be what was the rationale for increasing the size of the atopic dermatitis trial?
Derek Chalmers — President, Director and Chief Executive Officer
Yeah. Again that was based on maintaining a high level of power to see a statistical difference. And when we started that trial, we really didn’t have any oral KORSUVA data with pruritus endpoints. And of course as we’ve just discussed we know — and we did at the end of last year achieved the primary endpoint for oral KORSUVA in CKD-aP patients. And with that data in hand, we could model based on some assumptions related to placebo rates, a powering analysis. And based on that, we decided it made sense to increase the sample size just to make sure we have the appropriate power.
And again with the increased sample size, we also incorporated an interim conditional power analysis just to make sure that we were on track again. So that’s really two new adaptations for AD. And that trial is recruiting very well and we do expect to complete the interim analysis next quarter.
Chris Howerton — Jefferies — Analyst
Okay. Well, I have some more questions, but I’ll hop back in the queue to give other people a chance. I appreciate it. Thank you.
Derek Chalmers — President, Director and Chief Executive Officer
Thank you, Chris.
Operator
Thank you. Our next question comes from the line of David Amsellem of Piper Sandler. Your line is open.
David Amsellem — Piper Sandler — Analyst
Thanks. So, Derek you may have addressed this, but I wanted to just drill down in more detail. Can you talk about the Phase 3 for oral KORSUVA and CKD in the context of backgrounds medications? And what are your thoughts on which background medications could be part of the inclusion criteria, and which would be excluded? And what did you learn from the Phase 2 study regarding the use of background medications? That’s number one.
And then number two is just a bigger picture question to the extent that you do have positive data in atopic dermatitis. That’s obviously a different call point, a different physician vertical if you will. And is that something that you would plow ahead with in a Phase 3 on your own? Or is that something that you’d look to partner? And I guess the broader question is beyond CKD, what would you look to commercialize on your own? And what would you look to partner? Thanks.
Derek Chalmers — President, Director and Chief Executive Officer
Great. Thanks, David. So, on the first question we have looked, I think we’ve mentioned this before we did look at the background meds in our Phase 2 trial for the pre-dialysis CKD patients. And there was some difference there between those patients and what we’d seen in hemodialysis patients. So a higher percentage of patients using centrally acting drugs such as gabapentin or pregablin. That doesn’t seem to have heavily skewed our data however. But going forward, we’re optimized that if we can eliminate these variables relatively easily and it doesn’t interfere with recruitment than we would. Most likely we may leave patients with their antihistamines, which is a relatively small percentage in that patient population because that tends to help them sleep. But it’s most likely we try to eliminate as much as possible in the Phase 3 design. So that’s what we would do there.
In terms of atopic derm, yeah, that’s a different call point and it’s a large population, of course, also ultimately from a commercial standpoint. I think we are perfectly capable of running a late-stage trial in atopic derm. As you know, we spent some time recruiting experienced development personnel into the company, so that we can handle that beyond the registration level trial. It’s true that that would require some effort commercially and it’s most likely at that point we’d look to partner that particular indication with a larger partner. But running late-stage trials is basically what we’re designed to do here, as you know David, and I think we could easily accommodate a late-stage trial and atopic derm.
David Amsellem — Piper Sandler — Analyst
Okay. And I would imagine Derek that the logic would apply to the liver disease setting as well as you run the late-stage study, but may explore a partnership there?
Derek Chalmers — President, Director and Chief Executive Officer
Yes. Yes. And just to reiterate and I think you and I have had this discussion I think on this call previously. Our strategy here in terms of ultimate label for the oral formulation of KORSUVA is of course a broad one, and the strategy, we’re following is there are if you like various pathophysiologies that lead to pruritus. And they have definitive and separate if you like pathophysiologies. And we’re looking to see activity in these different patient populations as evidenced if you like ultimately. That this is a mechanism and we talked about the mechanism earlier that should have broad applicability.
And so it’s unlikely we’d run registration programs in every patient population, we’re looking at here. We will be selective on the first patient populations we take forward. But ultimately all of this data is going to be useful when we have that discussion related to getting a broader label for moderate to severe pruritus.
David Amsellem — Piper Sandler — Analyst
Okay that’s great. Thank you.
Derek Chalmers — President, Director and Chief Executive Officer
Thanks, David.
Operator
Thank you. Our next question comes from the line of Annabel Samimy with Stifel. Your line is open.
Annabel Samimy — Stifel — Analyst
Hi. Thanks for taking my questions. And I like your use of the word, mellifluous. I hope I can live up to those expectations. So, just going back to the placebo gate for a minute. Can you tell us, I guess, hopefully at this point you’ve consulted with a number of physicians or consultants. Do you still feel that the AD population is less variable and that it’s, you’re not going to see as much of a placebo response in that population?
Second, when you upsize the trial, did you assume the placebo assumptions of the CKD population? Or when you brought it to 320 and then did you have a set amount to upsize it to if necessary beyond — at your interim analysis? Or is it just something that’s calculated by the IDSMV or IDSM, ID, whatever…
Derek Chalmers — President, Director and Chief Executive Officer
IDMC, yeah.
Annabel Samimy — Stifel — Analyst
Right, IDMC at that moment based on their specific calculations. So that’s my first long-winded question. I have a couple more.
Derek Chalmers — President, Director and Chief Executive Officer
Yeah. No, that’s a great question. And so in AD population in terms of looking at placebo, there’s a lot of data out there. As you know from a lot of different drug classes looking at particularly disease alterations in terms of endpoint, but also looking at pruritus. And so there’s a lot of available information. So when we look at that and chelate that and look at the normal placebo rates we see and then we looked at the variability we had within our CKD-aP oral trial. Those were really the two factors we thought about in terms of looking at what would be the sample size to maintain a high statistical power to see a specific treatment effect. And that’s how we modeled it.
So it was modeled based on if you like historical placebo rates that had been seen in the atopic population as well as the treatment effects we’ve seen with oral and to a certain extent the variability we’d seen in there. So that was the idea of OP-ing emphasize to accommodate the possibility of an increased placebo response essentially. And again, you’re right with introduced in the interim conditional power assessment we can actually if you like confirm those assumptions when we have 50% of our patients complete. And, again, you’re correct, based on the IDMC recommendation, we can then alter that sample size to make sure we’re going to maintain our conservative power level to see a statistical difference.
We’re also interested in this particular trial and not only looking at mean NRS change. We’re also going to be looking at responder analysis with that. So that was really the whole rationale. We had kind of historical data versus, if you like, in conjunction with data we generated with oral KORSUVA. That was the basis of upsizing that sample size there for atopic.
Annabel Samimy — Stifel — Analyst
Okay. And if I understand correctly, you are now powered sufficiently to see statistical significance on the secondary endpoint for atopic dermatitis or…
Derek Chalmers — President, Director and Chief Executive Officer
Well, I wouldn’t say, we are not — well we’re — that’s our aim is to maintain sufficient power to see a response on that secondary endpoint as well. And again, that will have some advice on that from the IDMC, as you pointed out, when we have the analysis of 50% of the patients completing the treatment period.
Annabel Samimy — Stifel — Analyst
Okay. And then just curious about the PBC trial. You didn’t upsize that one. So are you treating that one differently? Is there something different about that trial?
Derek Chalmers — President, Director and Chief Executive Officer
Well, again, I think we’ve discussed this before and that we truly see as a proof-of-concept trial for liver disease. As you know, PBC is an orphan indication that’s quite difficult to recruit in the patient population where, in fact, expanding beyond the US and to the UK at this point, to gather more patients for that. So there we want to make sure we can get enough patients to see a signal, but that’s a much more challenging populations. And that gets back to the discussion I had with David, we hope to see data there that’s going to be supportive ultimately of getting a broader label for oral KORSUVA in pruritus.
Annabel Samimy — Stifel — Analyst
Okay, all right. Great, thank you.
Derek Chalmers — President, Director and Chief Executive Officer
Thanks Annabel.
Operator
Thank you. Your next question comes from the line of Jason Gerberry with Bank of America. Your line is open.
Chi Meng Fong — Bank of America Merrill Lynch — Analyst
Hi. Good afternoon, good evening, everyone. This is Chi on for Jason. I guess, first question is, piggyback to your earlier question about alignment with the FDA at the end of Phase II meeting for the oral CKD. Just curious, Derek. Given there are several hundred, if not thousand patients have exposed to the IV formulation of CKD. Curious on thoughts on whether there could be potential additional conversation with the FDA on the alignment of whether that could be a smaller trial to be run for Phase 3, or maybe a smaller safety database, given you already have wealthy amount of safety database from the IV dose already? And then, I have a follow-up after that. Thank you.
Derek Chalmers — President, Director and Chief Executive Officer
Yes. Thanks, Chi. Yes, I think, we’ve also discussed that possibility previously here and that has been in our thought for oral CKD. We do have, as you pointed out, several thousand patient exposures with IV KORSUVA in CKD, if you like, end-stage patients. Actually, at a higher exposure level than that we obtained with our oral tablet formulation. So we do think it’s a reasonable case that we should be able to reference those safety exposures as part of our Phase 3 program for oral CKD and pre-dialysis patients.
Of course, ultimately that’s a decision for the FDA, but I think it’s reasonable that we could propose that as a path forward there. And perhaps, as an upside, as you indicate and that may result in a reduced number of registration trials for that particular program. Again, we can’t guarantee that. It’s certainly something we thought about and something we’ll investigate when we have our FDA interactions.
Chi Meng Fong — Bank of America Merrill Lynch — Analyst
Got it. And maybe, if I can clarify on the expanding the trial sites for other trial numbers for the — I’m sorry, the subject size for AD. When you said you are modeling based on the historical AD response rates, based on available data and also the effect that you see in your own CKD trial. Are you taking into account the placebo response on the CKD or not? I wasn’t sure about that. So I just want to confirm whether that is a factor on whether the — factor into the trial size increase. Thank you.
Derek Chalmers — President, Director and Chief Executive Officer
Yes. Thanks, Chi. We’re looking at the treatment effect we achieved with CKD oral, but predominantly we’re looking at historical placebo rates in the atopic population and we realize these are completely different patient populations and it’s much more likely that AD patients have had their condition for much, much longer than early stage CKD. So we do expect different placebo response rates from AD than we see in CKD, but with the benefit of the treatment effect, we’ve seen with oral that’s something we can incorporate into those models. And that again in combination with what we expect in the AD population was the basis for increasing the sample size there.
Chi Meng Fong — Bank of America Merrill Lynch — Analyst
Got it. And maybe if I can ask a quick follow-up, if you can provide any incremental color or guidance on how we should think about for in this year versus last year. Thank you.
Derek Chalmers — President, Director and Chief Executive Officer
Yes, well as Rick pointed out overall, we do expect our cash position to carry us through this year and into the second half of 2021 and that’s obviously executing in all the programs we’ve been discussing. The quarterly burn as you know, we don’t guide from quarter-to-quarter, it’s going to be a little lumpy through this year. And Rick, do you want to add anything to that?
Richard Makara — Vice President, Head of Accounting and Controller
Yeah. No, I mean I think with the higher level of trial activity, it would be expected that it will be higher in 2020 than it was in 2019.
Derek Chalmers — President, Director and Chief Executive Officer
As we complete our Phase 3 trials Chi and then file the NDA in the second half of the year.
Chi Meng Fong — Bank of America Merrill Lynch — Analyst
Awesome. Thank you so much.
Derek Chalmers — President, Director and Chief Executive Officer
Thanks, Chi.
Operator
Thank you. Our next question comes from the line of Charles Duncan with Cantor Fitzgerald. Your line is open.
Pete Stavropoulos — Cantor Fitzgerald — Analyst
Hi. This is Pete Stavropoulos on for Charles. Congratulations on 2019. So for the Oral KORSUVA, atopic dermatitis study, are you including or excluding any patients on a particular medication or refractory to any particular medication including dupilumab?
Derek Chalmers — President, Director and Chief Executive Officer
Well, hi, Pete. Yes we are. We’re watching patients that have all their medications. So they’re going to come clean into that trial no medications.
Pete Stavropoulos — Cantor Fitzgerald — Analyst
Okay. And for the KALM-2 study, when you increase the sample size in order to maintain statistical significance or I mean not powering. Is there any particular geography that you grab the new patients from? Or was it dispersed among all the centers?
Derek Chalmers — President, Director and Chief Executive Officer
Well, when we increase the sample it is about approximately 20% increase in sample size there. Most of those patients in fact almost all of those patients came from US sites, the additional 20%. And overall the vast majority of patients in KALM-2 are indeed from US clinical sites.
Pete Stavropoulos — Cantor Fitzgerald — Analyst
Okay. And how many of the clinical sites actually overlap between the first study and the second study?
Derek Chalmers — President, Director and Chief Executive Officer
Virtually none, so those were separate sites in KALM-2 than from KALM-1.
Pete Stavropoulos — Cantor Fitzgerald — Analyst
All right. Thank you and again congratulations on the quarter.
Derek Chalmers — President, Director and Chief Executive Officer
Great. Thanks, Pete.
Operator
Thank you. Our next question comes from the line of Alan Carr with Needham & Company. Your line is open.
Joey — Needham & Co. — Analyst
Hi. This is Joey [Phonetic] on for Alan. Thanks for taking our question. A quick one on the AD upcoming results Phase 2. Maybe you can help us frame expectations potentially around maybe response rates or improvements in NRS. You mentioned, there’s a number of oral and even some injectable data out there. But in terms of Phase 2 comparison what would be one or two in your view as best comparators?
Derek Chalmers — President, Director and Chief Executive Officer
Yeah. Thanks, Joe. I mean, it’s hard to come up with a comparator, because as you know we are really the only company that is investigating this modality. There’s not a lot of prior data using this approach other than with non-selective, if you like medications that are being used there. So there is a standard the FDA likes for derm conditions and that’s a four point responder analysis and that’s what we’re looking at as our main secondary analysis here. Again, the reason we have used mean NRS as a primary and have done so consistently in all our Phase 2s is that continuous variable is much more sensitive to identify an appropriate dose. And as you know, it’s a dose-ranging trial, but we will be looking at the four point responder analysis. And again that was one of the reasons that we adjusted sample size in that trial.
Joey — Needham & Co. — Analyst
Great. Thanks.
Derek Chalmers — President, Director and Chief Executive Officer
Thanks, Joe.
Operator
Thank you. Our next question comes from the line of Arlinda Lee with Canaccord. Your line is open.
Ben Shim — Canaccord — Analyst
Hi guys. It’s Ben Shim on for Arlinda. Many of my questions have been answered. And I’d just like to maybe ask one thing. As we get closer to data and then to ultimately filing for the IV pruritus. Maybe could you provide us a little bit more detail on the cadence and magnitude of upcoming milestones that you may potentially earn from [indecipherable] this year? And will they be accounted for in any special way or are they going to be just straight revenue? Thanks.
Derek Chalmers — President, Director and Chief Executive Officer
Great. Thanks, Ben. In terms of milestones with the four specifically, I think we’ve guided before and the total amount there and divided that in terms of regulatory and commercial. So, there is $30 million in regulatory milestones that will be coming to us via that particular arrangement. We haven’t actually guided as to particular quarter. We expect to see these Ben. But that’s the level of milestones that is part of that license agreement. Beyond that, there’s another $430 million in commercial milestones through sales out west the US.
But as we go forward and we file the NDA and we have more visibility on the time line for launch and approval, then we will guide us to when we expect those milestones. But again to reiterate and Rick said all the guidance we’ve given in terms of financial and runway here is excluding any projected milestones from Vifor Fresenius R&D, Maruishi or CKD Pharma.
Ben Shim — Canaccord — Analyst
Okay, great. Well, congrats on another great year and keep up the good work. Good luck to you.
Derek Chalmers — President, Director and Chief Executive Officer
Great. Thanks, Ben.
Operator
Thank you. Our next question comes from the line of Esther Hong with Janney. Your line is open.
Esther Hong — Janney — Analyst
Hi. I’ve got two questions. So, the first one regarding the interim statistical analysis next quarter for atopic dermatitis, what’s the range lower and upper end of the increase in sample size if it’s required? And then I’ve got a follow-up.
Derek Chalmers — President, Director and Chief Executive Officer
Hi, Esther. Thanks for that. So, we haven’t actually divested publicly at the upper range of what we would increase the sample size. One thing I can say is that, we’re going to look at that on a curve. So we’ll have an ability for the IDMC to guide us to a specific patient number. And also that will be directed towards if you like the most active dose that we see. Again, this is a dose-ranging trial. So, that’s what we’re most interested in. But we haven’t actually guided as to what the upper limit of that would be at this point.
Esther Hong — Janney — Analyst
Okay. And then my follow-up is so as we get closer to KALM-2 data potentially launched. Can you remind us of your launch strategy, any additional details on how Vifor Fresenius plans to rollout KORSUVA? Will you initially focus on Fresenius clinics together leave that to Fresenius, any details? Thanks.
Derek Chalmers — President, Director and Chief Executive Officer
Yes. Unfortunately, I can’t give you much detail on that. That’s confidential at this point Esther. We are of course working with Vifor Fresenius to coordinate that. We have undertaken a whole range of activities and preparation for launch pre-commercial activities really across the company. We’ve established and we are expanding an MSL team here at Cara. We’re working to broaden our KOL universe, increase awareness of CKD associated pruritus. We’ve established regional national advisory boards. We’re sponsoring strategic education opportunities including CME Symposia at the appropriate meetings. And we’re trying real hard to increase our KORSUVA publication footprint and that you’re going to see that throughout this year.
And then of course, on our commercial side, we will be hiring some senior level people in sales and marketing in market access later in 2020. So, there is an integrated cross-functional plan in place to accommodate the launch and we’re also coordinating as you indicate with Vifor Fresenius specifically in relation to our co-promotion arrangement here in the US.
Esther Hong — Janney — Analyst
Okay. Thank you.
Derek Chalmers — President, Director and Chief Executive Officer
Thanks, Esther.
Operator
Thank you. Ladies and gentlemen, that concludes our Q&A session. I would now like to turn the call over to Derek Chalmers for closing remarks.
Derek Chalmers — President, Director and Chief Executive Officer
Yes, thank you everybody for participating on the call today. I’d also like to thank our hard-working Cara team, our study investigators and all the patients who continue to participate in our clinical trials. And we’re very much looking forward to updating you real soon and throughout the year. So, thank you very much. Have a great night.
Operator
[Operator Closing Remarks]
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