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MannKind Corporation (NASDAQ: MNKD)
Q1 2019 Earnings Call
May. 07, 2019, 9:00 a.m. ET


  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Welcome to the MannKind Corporation first-quarter 2019 earnings call. As a reminder, this call is being recorded on May 7, 2019, and will be available for playback on the MannKind Corporation website, shortly after the conclusion of this call until May 21, 2019. [Operator instructions] Joining us today from MannKind are Chief Executive Officer Michael Castagna; Chief Financial Officer Steven Binder; and Rose Alinaya, investor relations. I would now like to turn the conference over to Rose Alinaya.

Please go ahead.

Rose Alinaya -- Investor Relations

Good morning, and thank you for joining us on today's call. As indicated on Slide 2, I need to advise you that this call will contain forward-looking statements. Such forward-looking statements are subject to risks and uncertainties, which could cause actual results to differ materially from these stated expectations. For further information on our risk factors, please see the 10-Q report filed with the Securities and Exchange Commission, the earnings release and the slides prepared for this presentation.

I will now turn the call over to our CEO, Michael Castagna. Mike?

Michael Castagna -- Chief Executive Officer

Thank you, Rose. Today, I'm going to go through Q1 highlights and give you some perspective on how we see the year shaping up. No. 1, we are focused on enhancing shareholder value on the four key pillars outlined on this slide that we laid out, over the past 24 months.

Overall, we looking to implement a cohesive strategy to transform the company with an entrepreneurial spirit that drives innovative solutions. The first pillar in this is our partnerships, and as you've seen us continue to announce United Therapeutics updates as recently with the $12.5 million milestone received. Cipla, I was -- had the pleasure to be in India recently to go and help secure the pathway for regulatory approval. Biomm, where we expect, hopefully, approval, surely in Brazil.

And Receptor Life Sciences in the cannabinoid space that looks to hopefully launch in Canada and beyond. When we bridge over to the Technosphere platform, United Therapeutics was one of the molecules that we announced last year with Treprostinil. We continue to have a very strong partnership and move together as we think about BluHale connected care and manufacturing facility capabilities. The next milestones related to United Therapeutics are things that we control.

I'm very proud to announce that during Q2 we started to build out the factory to make high-potency molecules, which establishes a new capability within MannKind. Additionally, BluHale continues to help integrate our platform with other pipeline molecules and Afrezza, as we think about how to get into connected care in the future. Next is Afrezza. Afrezza, as we all know, was approved back in 2014 and launched by MannKind in Q1 of 2017.

We continue to highlight new scientific data that articulates the profile of the product, as I'll show you in a second, with the One Drop study that was released at ATTD, continue to highlight the ultra-rapid-acting profile that was recently presented at AACE, as well Levin Type II study, which really focused on fixed dosing that was recently accepted as a late-breaker at ADA. And what you'll see is in -- 2018 and 2017, we laid out the foundation on the focus of how do you properly dose Afrezza in Type I patients, and in this year, you'll start to see what happens when you use Afrezza in Type II patients based on what we know today. Additionally, we launched a cash program in January and a global program to help patients outside the U.S. with Tanner Group.

Both of those programs continue to enroll new patients day by day. From a financial position, the company is in the best shape it's been in a long time. Q1 revenues were $17.4 million versus 2018, our second quarterly gross profit of Afrezza in our history. We started the quarter with $59.8 million in cash and short-term investments.

We used $11.6 million in cash in our operating activities and we paid down $2.5 million in our Deerfield debt that was due today -- yesterday. Our demand sales were $6 million, which is in line with analysts' expectations. The capital raise in December enable us to fund our growth plan into mid-2020 or longer, depending on what happens with our warrants, Afrezza sales, as well as our BD efforts. Our cash balance is the third highest it's been in three years, with December being the highest.

We continue to make trade-offs to manage our expenses as we believe Afrezza will continue to transform diabetes care. This data set I've shared with you on our last earnings call, but I wanted to reinforce what we see in the Type II market. We continue to hear people understand the profile of Afrezza and have appreciation for how quickly it works and how it works differently. This data set was presented as an ePoster at AACE and I can tell you is one of the more well attended sessions in the posters with lots of discussion with Dr.

David Kendall. The feedback there was very positive from the multiple customer interactions we've had, the traffic at our booth, as well as the several dinner events we put on. We continue to highlight the differentiation of Afrezza in the Type II space, as well as injectable insulins. The next study you see here is One Drop.

This study was presented also at ATTD where it showed you a consistent reduction in A1C just by switching your injectable insulin to Afrezza. In this particular trial, you can see where you start at a high baseline or a low baseline A1C, across all A1Cs you saw an improvement by switching to Afrezza, and nearly overall in the trials, almost 1% A1C improvement. The reason -- these two studies back-to-back show you in Type II patients Afrezza gives you a very quick onset with an immediate post-prandial response change versus injectable insulin, which ultimately will provide a better reduction now come in A1C. These two studies, plus the additional data we have coming out at ADA will start to show how Afrezza can differentiate in the Type II space and drive better patient outcomes as you think about the challenges people face managing their sugar.

The next slide here shows you our demand. So since we launched our efforts in Q1 of 2017, we've seen consistent growth in our base, as our base business builds and we get new [Inaudible] patients. Yes, we want faster growth and we're doing everything we can, but at the same time, we have to remember, we are changing 97 years of habit and training by physicians. Any doctor who graduated in the last 5 to 7 years was not trained on Afrezza and a doctor who graduated over 10 years ago was probably trained on the old product Abzurba.

These are things that we are currently undoing. We continue to focus our profile in helping type IIs and type Is and as we evolve this year into children and other areas that we look to serve continued unmet needs. When you look at our demand number on WACC, which is that SYMPHONY data, you see in Q1 we started with the $2 million in sales, and in Q1 of ' '19 we're at $9.6 million in sales. When you apply the gross to net percentages in each of those quarters, you can see we've had a nice consistent growth over the past nine quarters.

And if you go back two quarters before then, you also will see growth. So we continue to -- we don't see anything that will tell us we're not going to continue to grow this company into a successful company in the future. As we entered 2019 we believe -- we believed we'd have some positive gross to net impacts versus second half of 2018, because we walked away from two contracts and renegotiated the other existing contracts,. In Q2, this was 38% and we expect this will continue into -- I'm sorry, in Q1 it was 38% and we expect that to continue in the same range in Q2.

Our net growth was impacted, unfortunately, in Q1 by channel inventory reduction. So you can see our demand year over year was 71% growth in Q1 ' 18 over Q1 of ' 19, and when you look at net revenue, according to GAAP, 49% growth from $3.4 million to $5.1 million. The difference between the demand at WACC and the net revenue, was related to $900,000 reduction in supply chain inventory. The last few weeks, we've seen a consistent order pattern and a stabilization of this decline.

It's also important that we're showing here with some transparency is our growth with and without vouchers, because we know we had a special program last year to help get people started on Afrezza. Unfortunate that didn't result in refills as much as we would anticipated. So when we look now, we want to continue to try to show you highlights in the business with and without vouchers, because we believe vouchers mask the underlying growth that we see in the business. So you can see TRx is on the left side, which is what's reported in SYMPHONY, 28% growth, on the right side without vouchers, you see 37% growth.

Again, our base business continues to grow as we go forward. The next slide here is important to continue to show you differences in cartridge growth. This is important. No.

1, because as you see, prescriptions will grow 37% and revenue grows close to 58%. Part of the reason for this compound effect is not just gross to net, but also mix. And so when you think about the percentage of 12-U cartridges being shipped into various new packaging configurations, that's part of the execution of our strategy. And here you can see, year over year, 82% growth in 12-units and 32% overall in cartridge growth.

This is important as we think about dosing and efficacy and retention of patients. We know one of the main challenges at launch was really around under-dosing the product. I'm really proud to continue to see a eight and 12s grow in unit cartridges, because that's a signal that we're continuing to execute our strategy of proper dosing and proper titration. And I can tell you, we know this is working, because we've seen a decline in the number of phone calls, a decline in the number of adverse events around reporting of lack of effect and efficacy.

We remain excited as we enter Q2. We continue to feel very good about the plans we have in place and the execution of our strategy. I'll circle back on some additional comments at the end. And for now, I'm going to turn it over to Steve.

Steve Binder -- Chief Financial Officer

Thanks, Mike, and good morning. It's my pleasure to discuss and highlight our first-quarter 2019 results, which show a five times growth in total revenues over first quarter of 2018, $12.4 million in revenue recognized from our collaboration and services agreements with United Therapeutics, a 49% growth in Afrezza net revenue versus first quarter of 2018, the achievement of consecutive quarterly Afrezza gross profit and net cash used in operating activities of only $11.6 million. I'll be discussing select financial highlights and urge you to read the condensed consolidated financial statements and MD&A contained in our 10-Q, which is filed with the SEC this morning. First, let's review our sources of revenue for the first quarter of 2019.

Starting with the left-hand table, total revenues for the first quarter were $17.4 million versus $3.5 million for the corresponding first quarter of 2018. A 404% increase comes from both the recognition of revenue related to the United Therapeutics license and research agreements of $12.4 million, as well as growth of 49% in Afrezza net revenue to $5.1 million for the first quarter of 2019. The Afrezza net revenue increase was favorably impacted by volume, cartridge mix, as Mike showed earlier, and price. Afrezza gross to net of 38% was 3% higher than the first quarter of 2018.

We benefited from a favorable adjustment related to estimating our gross to net liabilities. In addition, both gross and net Afrezza revenues in the first quarter of 2019 improved due to a lower level of free goods or vouchers received by patients versus 2018. The table to the right of the arrow shows how Afrezza net revenue for the first quarter compared to demand TRx at WACC, adjusted for gross to net, as Mike just showed you, was unfavorably impacted by $0.9 million due to the use of inventory in the wholesale and retail channels to meet Afrezza Rx demand. In other words, no to supply chain destocking.

Returning to the table on the left, the recognition of first-quarter 2019 collaboration and services revenue of $12.4 million is broken down as follows. United Therapeutics license agreement of $7.6 million. United Therapeutics research agreement of $4.7 million and ROS of $0.1 million. We expect to recognize revenue from the United Therapeutics license agreement to the estimated date of when our performance obligations will be substantially completed, which is expected to be December 31, 2021.

For the United Therapeutics research agreement, we recognize revenue based upon attainment of performance obligations, which were largely complete by March 31 of 2019. Since the contract inception, we recognized $8.5 million of the $10 million upfront payment. First-quarter 2019 was the second and consecutive quarter that we've had a gross profit for Afrezza. Our cost of goods sold remained flat at $4 million, our net revenue increased by $1.7 million, yielding a gross profit of $1.1 million.

We did not have any significant inventory write-offs in the first quarter of 2019. As long as we continue to grow our Afrezza net sales, and have a low volume of inventory write-offs in 2019, I would expect to report a gross profit from Afrezza in all four quarters of 2019. We have been strengthening our balance sheet over the last year and a half and the result is a significant decrease in net interest expense from $2.8 million in the first quarter of 2018 to $1.4 million in the first quarter of 2019. With our interest in the Mann Group paid in kind, the favorable cash impact of net interest expense is 84% lower than the first quarter of 2018.

Our interest income from our cash and short-term investments tripled from the prior year, due to a higher balance of cash and short-term investments, as well as our decision to vest about $25 million in higher yielding short-term U.S. Treasury securities. Interest expense decreased by 43%, primarily due to our reduced outstanding balance with Deerfield, as we work to remove this debt from our balance sheet. Recapping other key financial highlights.

We ended the first quarter with $59.8 million in cash, cash equivalents and short-term investments, decreasing from $71.7 million at December 31, 2018. We continue to carefully and deliberately spend our cash behind our priorities, having used $11.6 million of net cash in operating activities for the quarter. This includes spending $9.3 million on direct to consumer TV advertising for Afrezza and benefiting from the receipt of $12.5 million from United Therapeutics for achieving our first milestone in the Treprostinil Technosphere license in collaboration agreement. In early April, $14 million warrants associated with the April 2018 capital raise expired unused.

Also in early April, we filed a new S-3 shelf registration statement with the SEC, which is now effective, due to our previous shelf expiring after the three-year regulatory time limit in late April. Because of the new effective shelf registration statement, this morning we filed a prospective supplement with the SEC for our ATM agreement with Cantor Fitzgerald. This is a formality to enable our ATM to remain functional. And lastly, we paid Deerfield $2.5 million yesterday, as our tranche B notes were maturing.

We have $9 million of Deerfield debt remaining outstanding, which matures at the beginning of the third quarter. The security interest granted by MannKind to Deerfield in substantially all of our assets will terminate upon repayment of the debt. Thank you. And let me turn it back over to Mike for some concluding comments.

Michael Castagna -- Chief Executive Officer

Thank you, Steve. And as you can see, we continue to be very prudent with our capital allocation and the cash on hand that we have, as you think about our Q1 burn with TV included, and that was due to the resources and choices we made coming into the new year with restructuring our sales force and a different focused commercial effort. I am going to bridge over to talk about some of the Q2 initiatives you can see. So, in Q1, we focused an effort on DTC, to try to enhance patient demand and request.

While we didn't see maybe as much upside as people had expected in our prescriptions, we did get a lot of [Inaudible] evidence of getting into places that we've never been in, such as academic centers. I can tell you from my own dinner events, I've traveled the country, met customers. When I used to go to dinners, five, 10 people would show up, I had packed rooms everywhere I went during Q1, of over 20 people each time. These events enable us to continue to educate others, so if you can get 20 endocrinologists in a room, they typically have another three or four partners, that's how you start to impact 15, 80 people at a time.

So we're very excited that we continue to get in, educate customers and help them learn how to choose and adopt Afrezza and understand the clinical knowledge that exists and the data we presented recently. In Q2, you may have seen or heard about our non-branded campaign. We are now starting to move into Phase II of change in behavior and this ad on the left side is really the first of many as we expect to produce. This one you'll continue to see during Q2 throughout multiple diabetes journals.

This is targeted toward the physicians. In addition to this, we have a direct mail campaign, talking about Afrezza. And the journal, as we expect, you'll also see mentions of Afrezza as well, but due to FDA compliance we have to stick to unbranded ads when we talk about things like we are here. On the right side, we are very excited to sponsor Conor Daly, who as you know is a Type 1 driver, recently started taking Afrezza, and you can see our partnership here with the U.S.

Air Force. And representing MannKind diabetes we thought was important to highlight, not just to MannKind Corporation, but our focus on diabetes and supporting Conor. The car is running really well, and we look forward to seeing Conor race in the Indianapolis 500. Our anticipated milestones for the first half that I previously talked about.

The first milestone from United Therapeutics was paid. We expect the second milestone in the second half of 2019, of $12.5 million as we complete the build-out of our factory. Multiple data publications focused on hypoglycemia, safety and efficacy, as well as lung function will be presented and published in various journals throughout this year. We were excited to finally nail down a pathway for India, as we went over hoping to get an exception, but knowing that was a very low probability.

We now have a study design that we are presenting this month that will hopefully get accepted and start that trial very quickly to help patients in India. Additionally, we got interim results on our Phil Levin study. I'm very excited to share that as a late-breaker at ADA, Phil has been working on the study for a little while. I mean, it is slow to enroll and as it continues to pick up, you're seeing faster enrollment and now we're seeing some of the data, which really will generate some excitement post-ADA.

We are near completion of our cohort 2 of the pediatric program and we're about to start enrollment, hopefully, shortly on cohort 3. So far we've analyzed the dosing of the patients who've come in to-date and feel very good about continuing to move this program forward. As for Brazil, we submitted our responses back in December to some questions they've had. We continue to await feedback from them.

From our perspective, we receive our GMP certificate from our factory, which enables us to ship product to Brazil. And we've done shipping stability studies to know that it will be safe and consistent throughout the transportation process. We have additional pursuit of more international agreements and we continue to complete formulation work for an unnamed compound for United Therapeutics. So overall, when we think about the future, we continue to see Technosphere platform in the pipeline, as I'll give you some updates during Q2, to focus the pipeline on things that we believe will make a difference in patients.

Afrezza, we'll continue to build here in the U.S. as we also continue to see international expansion start to kick in. Very excited to get down to Brazil, India and other markets to start to help patients outside the U.S. We continue to look for pipeline opportunities to bring in, as well as in-license opportunities to fulfill our sales force capacity.

And Afrezza pediatric program we believe will help set the standard for diabetes over the next 20 years. As we look out, we continue to see growth over the past nine quarters and we expect to continue to see growth as we go forward. I want to thank everyone for their patience as we continue to complete our transformation into a growth company. And for those of you that will be attending our shareholder meeting next Tuesday in New York City, we will be there at 10 o'clock on May 14 and look forward to seeing you in person.

I want to say thank you and we'll open up to questions.

Questions & Answers:


[Operator instructions] We'll take our first question from Oren Livnat with H.C. Wainwright.

Oren Livnat -- H. C. Wainwright and Company -- Analyst

Hi, guys. Thanks for taking the question. I think we saw prescription, at lease in IQVIA down quarter-over-quarter in Q1. And can you just talk a little bit about what that's from, how much of that's just seasonal, I guess, copay, assistance, disruption and insurance and also what are your leading indicators telling you about prescriptions in Q2 and going forward? Thanks.

Michael Castagna -- Chief Executive Officer

Oren, great question. Thank you. So when you look Q4 to Q1, there was about an 11% decline in TRxs, and if you look across the industry, specifically within diabetes, but I think you'll see among other companies. Outside of diabetes the high-deductible health plans definitely showed an impact in Q1 across the industry, where people obviously usually try to squeeze in one last three fill in December and we know that typically creates some softness, as we go into January and February and we start to pull out in March.

That's no different than the last couple of years. We were hoping to overcome some of that decline with the DTC. We are continuing to see that decline, unfortunately, and I think the change in the air, I'll tell you, from my industry colleagues is really is -- high deductible plans, people are delaying filling their medicines unfortunately and trying to use up maybe their overstocked supply they have in safety or stretching out their meds as a pay by month. So nothing unusual in our business.

We saw a recovery through March and April and we continue to see prescription trends look positive as we look at our copay card downloads, our copay card utilization, all of our indicators are back in the right direction at this point.

Oren Livnat -- H. C. Wainwright and Company -- Analyst

All right. And [Inaudible] cash a little bit. So obviously you guys are pretty well stocked up, at least historically speaking. Excluding that United Therapeutics milestone, I think my math says it was about a $24 million burn, obviously including that hefty DTC spend.

So where should we expect spending I guess to go in Q2 and beyond? And I guess, bigger picture. I mean obviously scripts are slowly and steadily growing, not as much as you'd like, but I have no doubt they should continue to grow long term. But is there any way to right size the business realistically around the overall magnitude of this product?

Michael Castagna -- Chief Executive Officer

Yeah, I think there's two comments I'll make on that Oren. The first is, cash, cash flow. So yes, you can see there's $24 million, including a $9.3 million in DTC and we were able to offset some of the expense with the restructuring of our sales force and holding our expenses tightly. So as you think about the next 12 months, we expect $12.5 million from United Therapeutics in the second half and we expect another $12.5 million in the first half of 2020.

So there's $25 million more in cash coming in the company, we expect there. And we believe Afrezza will continue to serve growth quarter-over-quarter for the rest of this year, and just depending on that trend, we'll drive the decisions you just asked about, which is, is there a way to manage our overall cash burn, consistent with the revenue expectations, and I think we continue to believe there will be an inflection at some point beyond the trends we've seen, but it's really a question of when and we'll continue to monitor our cash. But at this point, I think it's important, as I stated earlier, the financing plans we laid out and what we put in place, and with the United Therapeutics milestones, we expect to be able to get to mid-2020. And the only reason I'll give further guidance is, is we just want to see what that Afrezza trend is.

So we obviously have some flexibility on managing our expense base. And I think that we always keep our optionality around that and I think that's where we have choices around, do we start the Ped study early or late. We have to start at some point, but we do have some flexibility on certain things, depending on how sales trends are going. And I think that's really our real focus, is to continue to invest to grow faster, but at some point we can burn the type of cash we are, if we don't see this becoming a very meaningful growth driver in the future.

Oren Livnat -- H. C. Wainwright and Company -- Analyst

And you just mentioned that Ped steady. Can you help us understand exactly what this plan is with these cohorts, and where this development program is going and just ultimately what kind of timing should we look for on this becoming an actual incremental opportunity?

Michael Castagna -- Chief Executive Officer

Yeah. So the first phase took us a little longer than we'd like, which was good and bad unfortunately for us as a company overall, because we, at the time when we started, we probably couldn't have started Phase III when we wanted to. So the fact that this took a little longer in cohorts 1 through 3, I think the timing works out better overall for the company. But when you think about each cohort, it's dosing by age group, so it's a single PK study followed for 30 days.

And so cohort 1 was 13 to 17 year-olds, cohort 2 is eight to 12 year-olds and cohort 3 is four to seven year-olds. So we have to keep dosing down to prove that Afrezza absorption in kids is consistent with that of adults. And so the good news is, one thing we hear often from doctors who've never used the drug is I need a two-unit cartridge, because doctors think they are dosing so accurately and I remind them how many patients use three units of insulin a day, because it's basically what you're getting with a two-unit cartridge. And they recognize it's not a lot.And so with kids, so far down to the eight year-olds, we can safely say four units dosing is working fine and in fact we see kids going up to eight in the four to 12 and 13 and beyond.

So we feel good about our dosing so far down the eight years-old. The next cohort 3, which we'll open up, will continue to look at is the four-unit cartridge appropriate or not. And then once we get cohort 3 opened, we will go ahead, submit a protocol to the FDA for a Phase III trial design. And that's really what we're in the middle of right now, is what should that Phase III trial design look like to accelerate enrollment.

And so, for example, if you go against MDI, one of our challenges with these dosing study is you can't be on an insulin pump. And for you to come into the trial, you have to come off your pump, get on injectable and then switch over to Afrezza, that's a multi-month process and not easy for many parents and patients to want to do.So that's the lead enrollment. And then we have some -- IRBs take a little longer to open up, but we're basically at 12 sites and we expect cohort 3 to go a lot faster than cohorts 1 and 2. And so, we're just literally on the cusp of talking with the chairman of the program today actually and hopefully opening up cohort 3, which will get this study moving and closed out where we can start to move to the large Phase III study.

Oren Livnat -- H. C. Wainwright and Company -- Analyst

All right. Thanks.


And we'll take our next question from Pasha Sarraf with SVB Leerink.

Unknown speaker

This is [Inaudible] sitting in for Pasha. So two quick questions. First of all, what kind of footprint did you see in your DTC campaign evenly across the market in terms of demand? And then No. 2, if you can give an update on what did growth look like in terms of the prescriber base? Thank you.

Michael Castagna -- Chief Executive Officer

I'm sorry, what looks like in the prescriber base?

Unknown speaker

What your growth from the prescriber base looked like over the quarter?

Michael Castagna -- Chief Executive Officer

OK, great. Sorry. So on the DTC, I think we're waiting, because SYMPHONY had some data issues in the quarter, and so we're waiting for that restatement, which we actually get tomorrow. And once we get that restatement, we'll be able to start to analyze the DTC by district, by area.

So for example, we kept 10 markets on throughout the entire campaign and then there are other markets where you flight in for two, three weeks and you take a break and then you flight in. And so we'll be able to see the level of investment by market and what happened to drive demand in terms of new writers, NBRx, total prescriptions, refills etc. So those analytics will take place. It's one of the reasons we stopped DTC at the end of March was to give it time to see what happens, A, when you stop the copay card downloads -- copay card redemption, but also allow some time to measure, because it was a big investment and you don't want to continue to burn at that rate, if you don't think you're going to anticipate that's a huge return on that investment.

So we're measuring it and we will give you updates once we have that data in-house, but we need to wait for the restatement of SYMPHONY, which again is coming tomorrow.On the prescriber growth, one of the interesting details I was looking at was, we're up to 2% market share, a little above 2% through April on the doctors that we target who are actually writing Afrezza. So when you look at our target list and we had a little over 2,400 prescribers, I think, last I looked, through the first four months of this year. And so we're continuing to see that growth on prescribers. But then there were some docs who have never written that weren't on our target list that were within our territories and you saw almost 3% market share and that was growing month-over-month during the DTC campaign.

So there are some new writers starting to grow, and you're seeing that business and we'll add those to our target list as we go forward. So that's just some data we'll start to show in Q2, but we kind of want to let another quarter go before we start looking at these types of things. I hope that answers your question, but we're continuing to see new writers growing and existing writers writing more.


We'll take our next question from Anita Dushyanth with Zacks Small Cap Research.

Anita Dushyanth -- Zacks Small Cap Research -- Analyst

Good morning. Thanks for taking my questions. Just a couple here. Could you just throw some color on your strategy for the DTC? And I know you just mentioned that you have turned it on for 10 markets and the others you probably add on for a couple of weeks. So after you get the analysis data from SYMPHONY, would you plan to sort of keep it on for the 10 markets, or how would that -- how would you change that?

Michael Castagna -- Chief Executive Officer

I think we have a budget that we're running the company against and had DTC gotten above our trend that we expected internally, we would evaluate additional spend and investment opportunities. But I think until we can see that data start to really come in above trend that we expect internally, I'm always going to be prudent with the cash allocation. So I don't want to speculate we will return it back on, do we need to do a new TV ad, I think all those things are on the table. I think it's really measuring what we did first before we continue to spend at the rates we were.

And so just to clarify, we basically ran TV for about 11, 12 weeks and during that time frame we took a break every two or three weeks, depending on the market, but in general pretty much ran at a full national campaign for Q1, all the way through the end of Q1, and then we had about 10 sub-markets that we kept it going throughout. And I can tell you we've heard very positive feedback from doctors, from our sales force, from our patients. So it's not that it wasn't a good investment at this point, we just want to see how many writers came in white space that we don't cover, how many writers came inside of our targets within our reps. We're actually fully staffed with the exception of one position in North Carolina, I believe.

And so, we have only one opening right now on the sales force. So as people think about Q1, we had about 15 openings in the quarter and now we're fully staffed up. We just had our first Phase II training class. So from a sales force focus and execution energy, the two manager positions have been filled and we're very excited about.

We got three quarters now in front of us with a full team. And so, I think that plus the DTC opening up doors, should give us a nice, hopefully, trend as we continue to look for the next two, three quarters.

Anita Dushyanth -- Zacks Small Cap Research -- Analyst

Great. Tank you. And the other question was, are we expecting the large trial in India to begin before end of the year?

Michael Castagna -- Chief Executive Officer

Yes. We believe it will be a few hundred patients, type II, and we're literally discussing as we speak. We're trying to get to better dosing in type II. We know from our Phil Levin study that will be coming out that the dosing in that was a way to standardize insulin titration and that's a big focus for us, is to make it very easy for prescribers to titrate patients who are naive to insulin or switching over to insulin.

And I think that's the beauty of the Indian trials, we will be able to do a study probably the way we wish we could have done six, seven years ago on our last study with proper dosing and proper titration, because we know in that particular original pivotal trial, it took docs about 12 weeks to titrate up to the effective dose and even then we'd say it wasn't effective, because they had to stop titrating at the end of that period. We're trying to not repeat those mistakes in the Indian design and so far, we feel very good with our partner Cipla in that trial design and execution. We will be ready to start that trial.

Anita Dushyanth -- Zacks Small Cap Research -- Analyst

Thank you again.


And we'll take our next question from Bert Hazlett with BTIG.

Bert Hazlett -- BTIG -- Analyst

Thank you for taking the question. I actually have two. In general terms, Mike, could you discuss the overall strategy regarding publications surrounding Afrezza data? Again, the Phil Levin study looks very intriguing. If you could just discuss maybe what the general characteristics about what drove the oral presentation slot for that?

Michael Castagna -- Chief Executive Officer

Yes. I think the late-breaker will be -- I think late-breaker as I recall at ADA are only posters. So as much as I would like an oral presentation, I'm not sure late-breakers are accepted as orals, but I could be wrong on that, Bert. But I think what we saw there was for the first time using a fixed-dose titration along with lead rate, looking at baseline timing range, baseline A1C and end of treatment timing range and A1C, and we can see with a fixed-dose titration what the average dose was per patient, percent A1C reduction, time and range.

I think all the key things that everyone are talking about. Remember, we did this STAT study last year, which we remain excited about and continue to -- most people still, unfortunately -- when I talk -- I just met a doctor last night and just learned about the STAT study last week. So we know the data is still out there, we know people are still learning it and as they start to see that the pool of data build up, they always ask questions, but we kind of point -- we have multiple studies showing you head to head Afrezza works. And then now we're building these small studies to show you how to actually get even better results than we saw in our development program.So I think when you think about the publication strategy, it's really trying to nail down the objections that we hear from customers.

Do you really have less hypoglycemia, are lungs really safe and effective delivery route, how do you probably titrate the drug? These are all the things that we hear that we have lots of data on that we think are really important to highlight out there. And the good news is the investigators on those articles are well known thought leaders throughout the world and I think that's the other part, is bringing credibility of the scientific agenda back to MannKind. And surprisingly, these people weren't aware of our data six, seven years ago or even three years ago. So we're getting really well-known people, familiar with the company, familiar with the data set.

And I would say that's going to continue to elevate when we think about guidelines and committees and speaking at the stage of conferences, Afrezza traditionally has been highlighted here, everything about artificial pancreas and CGM and I think that's really what we continue to change, the noise, and hopefully get Afrezza highlighted. Just as an example, one of the things we hear is my sugar has dropped in the first hour on Afrezza. People aren't used to seeing on CGM their sugars go down in the first hour, because they're used to seeing them go up. That's a mind shift for people, right.

And that's one that if you've practiced diabetes for 20, 30 years, you've never seen someone's sugar respond so quickly. That to us is a benefit, right, is maintaining good real-time control, but to providers and patients who never had that type of control, it's scary at first and that's building their comfort. And we continue to look at ways to get this data out there and get that experience and continue to fund small trials that will articulate proper niche areas that we're looking at to make sure people understand. So I hope that answers your question there Bert?


We'll go to our next question, follow-up from Oren Livnat with H.C. Wainwright.

Oren Livnat -- H. C. Wainwright and Company -- Analyst

Thanks for the follow up. Yes. You mentioned earlier that you have some docs that, let's say, 2% share. Why isn't that higher for the docs you've already broken through with? Obviously, awareness and that breakthrough is a huge challenge at scale. And I'm just wondering if they're seeing the same, at least anecdotally the same successes that I'm hearing about with regards to their glucose control and A1C reductions.

Why aren't these guys much higher than 2%? Is insurance really not a roadblock? Are you hearing any negative feedback from them on certain patients not having good experiences with the product? Thanks.

Michael Castagna -- Chief Executive Officer

Oren, great question. Let me clarify that statement. So what we do is, we look at the overall number of rapid-acting analogs and their current market share of Afrezza. Remember, 90% of patients in most doctors' offices are the base stations they've been seeing and maybe they see 10%, 20% new.

So you're always fighting for the new patient and/or an existing patient, and we know doctors generally don't change treatments, they just add on to it. And so when you think about, I'll call it, for rough simplicity, you take 2,500 prescribers all of the rapid-acting analogs, including Afrezza, we continue to see share penetration grow in that market. So I don't have it right in front of me, but I think we went from 1.2% to 2.07% just in the last 12 months. So we're continuing to see that growth in share among 2,500 prescribers.Now remember, some of those prescribers may have just started prescribing recently and some may have been prescribing for two, 3 years.

So as that base of prescribers builds and patients build that share will continue to build. And I'm sure if I looked at NBRx or NRx, we'd see it be a lot higher, probably in the 5%, 6%, 7% range. So we expect that 2% to continue to grow as we go forward. But to your other comment, we have doctors where we have 90% market share and 70% market share, because they -- and they just use on other type IIs that are appropriate.

And so we do see docs and when the people ask me why do I continue to remain very optimistic and excited, is because what we see in certain micro markets, I'll pick on New York and Texas is, you see doctors starting to adopt it, you see patients starting to use it and then they're telling their friends and then you see a compound effect across the market, where you have two or three great reps, a base of prescribers, who are educating the peers and then you start to see that groundswell of uptake in certain markets. And so that's what we're trying to get to, is a lot of times, we're just getting started in probably half of our markets, but the other half are continuing to see penetration of prescribers and patients.So we do have high market share in people that have been using the drug. And when you ask why do we not get 100% everybody, it's really change is hard. I mean, diabetes is a condition that it's been documented numerous times that there is a delay to intensification of seven to 10 years and I think that's the problem and we tell people, we'll tweak this, lose a few pounds, come back in three to six months and it's a multi-year process, unfortunately.

It's not one that we are satisfied with. We think people shouldn't have to wait to get better A1C control, but we love where CGM is going, we love where our data is starting to shape up and we think that will be really a pump for doctors. And so far we just held an advisory board sharing some of the strategies we're working on and we continue to remain very optimistic and trying to streamline, I'll say, perceived hospital factors, whether it's reimbursement, it's dosing and titration, packet selection. Those are all things that doctors just need to understand.

When you never write a drug, it's almost like trying to switch from a gas car to a Tesla or flip phone to an iPhone, it just takes a while for populations to get there, but when they do get there, they don't go backwards and I think that's -- that's the beauty in what we're doing. We don't see any major competition coming in the next seven to 10 years and I think that's -- we'll continue to change that paradigm and get patients started and keep our patients. I guess, one last closing comment I'll make is, we just analyzed our data against another analog that recently launched and we don't see higher dropout rates than other drugs who are [Inaudible]. So I think that's one of the misconceptions we hear is, are we losing a lot of patients? We always lose patients on new products and you start to build your base business.

And I think if you look at our refills over the last quarter, you're starting to see that base business grow and build and the refills starting to come in, as we continue to gather new patients and build that up.And so really getting good doctor experience, good patient experience. I just met with probably 20 payers over the last quarter, between advisory board and one-on-ones, and I feel good about our position as a premium priced product. Despite all the noise on informed pricing, we talk to payers all the time and our formulary position seemed that they're stable, and if not, well, we can enhance them as we go throughout this year, but that's not -- the payers are not what's slowing us down, doctors will use that excuse, but it's really not what's slowing us down right now.

Oren Livnat -- H. C. Wainwright and Company -- Analyst



And we'll go back to Bert Hazlett with BTIG.

Bert Hazlett -- BTIG -- Analyst

Sorry, I had some phone problems. Just asking, you may have made some comments early on in the call, but would really like to understand, has there been any progress or additional thinking with regarding to expanding the Technosphere pipeline? And in particular, is there any movement on the Receptor Life Sciences collaboration with the cannabinoids?

Michael Castagna -- Chief Executive Officer

Yes. No, great question, Bert. I think when we get to our Q2 earnings call, by then I should have an update on the pipeline. we are going through our strategic review for the company, in terms of where do we see ourselves over the next three to five years, what's really important to drive growth for shareholder value, and that includes how do we accelerate Afrezza, how do we maximize international, there's lots of ideas we've had over time.

Some we've executed, some we've held off, but the pipeline is one that is a major focus in terms of bringing in new talent in the company to accelerate the development program and focus on those programs, as well as potential partnerships. And then -- so you'll hear more about the pipeline, I think, probably as the quarter rolls out into Q2 results.On Receptor Life Sciences, we've been meeting with them really to figure out where is this market going. We remain very excited about that particular opportunity. So, for example, in Canada, we know that you can launch a Receptor product there in the cannabinoid space, that would be exported to the rest of the world, and as well as kind Canada, with the exception of the U.S.

And in the U.S. market, while you can potentially cross state lines with CBD, I think the government is stepping in a little more in that space and our real focus there is can we get a prescription-based U.S. FDA product of an FTKP cannabinoid and which ratio and which combination should that look like, the real discussion we have with them, and where should we -- we believe we can be the manufacturer of that. But we look at like GW Pharma, you just saw their Epidiolex sales in Q1 of over $30 million.

So I think that gives you some hint that this is going to be a real market in the U.S. on the prescription side, and so we're excited to continue to partner with Receptor to identify those opportunities and move it along as quickly as possible. So I don't know, anything else I should -- OK. So I hope that gives you some clarity there, Bert.

Bert Hazlett -- BTIG -- Analyst

Thank you. Should we get visibility on any of those movements in -- with Receptor, specifically, in 2019, or is that something that's a little further out?

Michael Castagna -- Chief Executive Officer

I think you'll see updates this year on that. I mean we're talking to them. It's been a multi-year partnership and it's one that now they have a team in place, they have capital in place, we are now more focused here from a survival mode to a growth mode. And I think that you'll continue to see how can we work together, so that one plus one is three and not one plus one is 1.5.

And I think that's really our focus with Receptor, is moving this particular class of drugs faster, to get the patients and drive an unmet need and I think the more we see that space evolve, the more exciting it will be for our shareholders to know that we'll get some benefit from that in terms of milestones and royalties in that agreement.

Bert Hazlett -- BTIG -- Analyst

Terrific. Thank you.


And that concludes today's question-and-answer session. At this time, I will turn the conference back to you for any additional or closing remarks.

Michael Castagna -- Chief Executive Officer

OK. Thank you, everyone, for your time today. Appreciate you dialing in so early on the West Coast as well as the East Coast and international markets. We will continue to hopefully demonstrate continued growth of Afrezza, give you some clarity on the pipeline as we move forward in international expansion.

So look forward to seeing our shareholders there in May, next week in New York City and hope we'll take additional questions there. Thank you again.


[Operator signoff]

Duration: 48 minutes

Call participants:

Rose Alinaya -- Investor Relations

Michael Castagna -- Chief Executive Officer

Steve Binder -- Chief Financial Officer

Oren Livnat -- H. C. Wainwright and Company -- Analyst

Unknown speaker

Anita Dushyanth -- Zacks Small Cap Research -- Analyst

Bert Hazlett -- BTIG -- Analyst

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