AGIO - NASDAQ

Good morning and welcome to Agios Pharmaceuticals, Inc. Fourth Quarter and Full Year 2025 Conference Call. At this time, participants are in a listen-only mode. There will be a question and answer session at the end. Please be advised that this call is being recorded at Agios Pharmaceuticals, Inc.'s request. I would now like to turn the call over to Morgan Sanford, Head of Investor Relations at Agios Pharmaceuticals, Inc. Please go ahead.

Thank you, operator. Good morning, everyone. Thank you for joining us to discuss Agios Pharmaceuticals, Inc. Fourth Quarter and full year 2025 financial results and business highlights. You can access the slides for today's call by going to the Investors section of our website agios.com. Please note, we will be making certain forward-looking statements today. Actual events and results could differ materially from those expressed or implied by any forward-looking statements because of various risks, uncertainties, and other factors, including those set forth in our most recent filings with the SEC and any other future filings that we may make with the SEC. On the call with me today from Agios Pharmaceuticals, Inc. are Brian Goff, Chief Executive Officer; Cecilia Jones, Chief Financial Officer; Tsveta Milanova, Chief Commercial Officer; and Dr. Sarah Gheuens, Chief Medical Officer and Head of Research and Development. Following prepared remarks, we will open the call for questions. With that, I am pleased to turn the call over to Brian. Thanks, Morgan. Good morning, everyone, and thank you for joining us on today's call. Next slide, please. Just last month, we outlined our 2026 strategic priorities, which are focused on delivering long-term shareholder value. First, we are focused on executing a high-impact launch of Afesmi for the treatment of thalassemia in the U.S.

Second,

We see meaningful opportunity to expand our PK activation franchise into additional high-value indications including sickle cell disease, and lower-risk myelodysplastic syndrome, with key catalysts this year for both opportunities. Third, through the advancement of our early-stage pipeline with AG-236 and AG-181, we have the potential to unlock future value in hematologic and other rare diseases. And finally, we remain committed to long-term sustainability, supported by disciplined capital allocation and continued operational efficiency. Building on those priorities, the next slide marks key pipeline catalysts in 2026 across multiple high-value indication opportunities. The Afesmi launch in thalassemia is underway in the U.S., and we look forward to the potential to expand our PK activation franchise into sickle cell disease and lower-risk MDS. These milestones and continued progress in our early-stage pipeline position the portfolio for growth and long-term value creation. Next slide, please. We exited 2025 with solid momentum across the business, commercial execution, pipeline progress, and continued focus on financial discipline, which together provide a strong foundation to deliver on our 2026 strategic priorities. Starting with commercial performance, Pyrukynd delivered $20 million in net revenue in the fourth quarter, bringing full year 2025 revenue to $54 million reflecting robust year-on-year growth. In the fourth quarter, we reported top-line data from the RISE UP Phase III trial and will meet with the FDA this quarter as anticipated for our pre-sNDA meeting to determine the regulatory path forward. Importantly, just before the end of the year, we received FDA approval for Afesmi in the U.S. Thalassemia launch is underway. Finally, we recently completed enrollment in the Phase II sickle cell disease trial of tebipivat with top-line results expected in the second half of this year. Importantly, we continue to operate from a position of strength, ending the year with approximately $1,200,000,000 in cash, providing flexibility to maximize the Afesmi thalassemia U.S. launch, pursue the path forward for mitapivat in sickle cell disease, and continue to advance our pipeline programs. Please move to the next slide, and I will turn the call over to Cecilia to provide additional details on our 2025 fourth quarter and full year performance as well as our 2026 outlook.

Thank you, Brian. Next slide, please. Our fourth quarter and full year 2025 financial results

Be found in the press release issued earlier this morning and additional details can be found in our 10-K which will be filed later today. Fourth quarter worldwide Pyrukynd revenue was $20,000,000, an increase of 86% compared to 2024, and a sequential increase of 55% compared to $13,000,000 in 2025. In the U.S., fourth quarter revenues of $16,000,000 were driven by continued commercial focus in PK deficiency ahead of FDA approval for Afesmi, an additional ordering week in the fourth quarter, and favorable gross-to-net adjustments. In 2026, we expect U.S. PK deficiency revenue to be in the range of $45,000,000 to $50,000,000. Outside of the U.S., revenue of $4,000,000 in the fourth quarter primarily reflects inventory stocking ahead of demand driven by PK deficiency patients in Europe transitioning from our global managed access program where Pyrukynd was provided free of charge to commercial supply. We anticipate a sequential decline in U.S. revenues into 2026. Cost of sales for the fourth quarter was $1,900,000. R&D expenses were $88,100,000, an increase of $5,300,000 compared to 2024, associated with the advancement of our earlier-stage pipeline program. SG&A expenses were $51,600,000 in the fourth quarter and roughly flat year-on-year. We ended the fourth quarter with cash, cash equivalents, and marketable securities of approximately $1,200,000,000. As a reminder, in future quarters, we will report mitapivat revenue as a whole, breaking out U.S. and ex-U.S. performance. Next slide, please. We remain committed to financial discipline as we work toward our goal of becoming a sustainable rare disease company. We anticipate operating expenses in 2026 to be roughly flat with 2025. This guidance assumes investment to maximize launch of Afesmi in thalassemia in the U.S., gated investment for sickle cell disease, and operating model refinement. Importantly, we see a clear path to profitability through our existing commercial presence in thalassemia and PK deficiency. Please advance to the next slide, and I will turn the call over to Tsveta to share commercial highlights for the quarter. Thank you, Cecilia. Next slide, please. As Cecilia noted, in the fourth quarter, Pyrukynd delivered $16,000,000 in net revenue in the U.S., up 50% year-over-year, driven by continued demand in PK deficiency, an additional ordering week in the quarter

And

Certain gross-to-net adjustments

Fourth quarter ex-U.S. was roughly $4,000,000 which primarily reflects supply ahead of demand pull-through as PK deficiency patients in Europe transition onto commercial supply. We expect this ordering to moderate in coming quarters. As expected, we continue to see quarterly variability driven by ordering patterns,

Inventory dynamics and gross-to-net adjustments.

Fourth quarter performance underscores the strength of our commercial model and the foundation we are building for future growth. Starting with the recent U.S. approval of Afesmi for the treatment of anemia in adults with alpha- and beta-thalassemia, regardless of transfusion burden.

Please move to the next slide.

I am pleased to share that as planned, the final implementation of the Afesmi REMS was completed in late January to align with the approved FDA label.

And

Have already begun dispensing products. As of January 30, we have seen 44 prescriptions written by a REMS-certified physician in the U.S.

Which reflects strong early recognition

Of Afesmi’s clinical value and excellent execution by our field team.

Is especially encouraging is the healthy breadth

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

We are very encouraged by the early market

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

We are not seeing the REMS as a barrier to prescribing,

With early experience suggesting the certification process has been straightforward. We have also seen strong engagement with our patient support program. Initial experience indicates that patients do not view the REMS as burdensome given the potential for meaningful clinical benefit, including reduction in transfusion burden and improvement in fatigue. Taken together, this early feedback reinforces both the significant unmet need in thalassemia and the value proposition of Afesmi. It also reflects the strength of our prelaunch planning. On the next slide, I will take a few moments to discuss how we anticipate this demand will convert into treatment initiation and ultimately revenues in the first few quarters of launch. There are three key steps in the Afesmi REMS certification process. One of those steps, pharmacy education, is already completed as we use a single specialty pharmacy to dispense prescriptions and coordinate on delivery. Additionally, physicians are required to be educated and certified on the Afesmi REMS. In parallel, once a prescription has been written, patients need to receive insurance authorization and complete a baseline liver test prior to initiating treatment. Our comprehensive patient support service, MyAgios, has a strong track record assisting patients with the insurance authorization process for PK deficiency, which we expect to continue with thalassemia. Once these three components are completed, the pharmacy is authorized to dispense the prescription. Patients will then complete monthly liver tests for the first six months and as clinically indicated thereafter. Initially, we expect the time from first prescription to treatment initiation to be on average 10 to 12 weeks. As physicians are onboarded and access expands, we see opportunity to shorten this timeline as launch progresses.

Turning to the next slide.

The thalassemia opportunity presents a major potential growth inflection for Agios Pharmaceuticals, Inc. Today, we have received approval of mitapivat for thalassemia in two regions, marketed as Afesmi in the U.S. and

Pyrukynd in Saudi Arabia.

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

Reviews remain underway.

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

In October 2025.

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

I will hand the call over to Sarah to cover key R&D highlights from the

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

And as you heard from Tsveta, the U.S. launch is underway with strong reception from

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

Pipeline to important decision points this year and are on track to initiate a Phase 1b proof-of-mechanism trial of AG-181, our phenylalanine hydroxylase stabilizer, in PKU patients in the coming months and report top-line data from the Phase I healthy volunteer

Study of AG-236, our siRNA targeting TMPRSS6 for polycythemia vera, in the first half. Please move to the next slide. Turning to tebipivat, we look forward to understanding more about the potential role of this more potent PK activator in low-risk MDS and sickle cell disease this year. We remain on track in low-risk MDS where top-line data from the Phase IIb trial are expected in the first half of this year. This study will provide important insights into dose optimization as well as the potential role of tebipivat in different patient subgroups, including low- and high-transfusion burden patients as well as potential applications in later lines of treatment. In sickle cell disease, enrollment in the Phase

II trial is now complete, an important milestone that reflects the growing

Enthusiasm for PK activation following the RISE UP Phase III results of mitapivat in this debilitating and deadly disease.

This 12-week double-blind trial is designed to further explore tebipivat’s

Potential to deliver meaningful improvements in hemoglobin,

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

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

Thank you, Sarah. Next slide. In closing, we have another pivotal catalyst-rich year ahead of us. In line with our 2026 strategic priorities, we are focused on executing a high-value Afesmi U.S. launch in thalassemia. In sickle cell disease, we are preparing for our pre-sNDA meeting for mitapivat this quarter, an important step towards defining our regulatory path. We also expect Phase II top-line data for tebipivat in sickle cell disease later this year, which will give us deeper insight into the potential of higher potency PK activation in this population. In lower-risk MDS, Phase IIb top-line data for tebipivat remain on track for 2026 and will be a key readout as we assess its ability to drive transfusion independence and broader improvements in anemia. We also anticipate Phase I top-line data for AG-236 in polycythemia vera and Phase Ib proof-of-mechanism data for AG-181 in PKU, two important early-stage programs that expand our reach across hematologic and other rare diseases. Please move to the next slide. As we look beyond 2026, our opportunity set continues to expand. The combined global market potential across our current pipeline indications is $10,000,000,000 reflecting both the breadth of unmet need and potential to deliver transformative medicines to patients. Beginning in 2026, we are focused on delivering a high-impact U.S. launch of Afesmi in thalassemia, which we believe has the potential to establish a strong foundation for our leadership more broadly in rare hematology. Our combination of near-term catalysts, disciplined investment, and a maturing pipeline creates a clear pathway to deliver long-term value. Agios Pharmaceuticals, Inc. is well positioned for the next chapter of growth while advancing the next wave of innovation across our rare disease portfolio. Before we move into Q&A, I would like to acknowledge the dedication of our employees whose unwavering focus and commitment continue to make a meaningful difference for patients with rare disease. With that, I would like to open the call for questions. Operator, please open the line.

Thank you. To be announced. To withdraw your question, please press 11 again. And our first question comes from Gregory Renza with Truist. Your line is open. Great. Thanks. Good morning, Brian and team. Congrats on the quarter and, of course, another eventful year. Maybe two questions from us on Afesmi and then on sickle cell. First, just on the Afesmi launch, we appreciate all the color you are sharing early and getting patients engaged and prescriptions written. Just on that translation perhaps, on the prescription updates that we are seeing, how do you see that not only translating to treatment initiation but also to revenue recognition, maybe not asking for guidance on early quarters, but any color you can provide on the first quarter and even subsequent early days of the launch with respect to how it holsters to revenue? And then I have a follow-up. Thanks.

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

Absolutely. Definitely excited. And Greg, as I mentioned in my prepared remarks, we are really encouraged by the early demand that we are seeing with Afesmi. As you mentioned, we reported that we had 44 prescriptions from REMS-certified physicians up to January 30, which is the first five weeks of the launch, and that is fantastic to see. With regards to your questions, what we expect is to see in the initial quarters prescriptions and demand

To grow ahead of revenues. And the main reason for that is that it takes about 10 to 12 weeks for us to convert

Prescriptions to treatment initiation and ultimately revenues. So, we anticipate, in Q1, the majority of the prescriptions to turn into treatment initiation. And as the year progresses,

We will expect to see revenues and demand start tracking more

Closely?

We get a lot of questions about potential analogs. So when I think about another product which also has a liver REMS, that is Truseltiq, so that is a good analog

For you to look at of how the actual revenue

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

Great. Thank you. That is very helpful. And maybe just moving on to sickle cell and tebipivat. And of course, not to overlook the MDS readout in the first half, but with enrollment complete in the Phase II in sickle cell and Sarah, the color that you have provided, maybe if I may just ask a bit about how you are pegging expectations for what you want to see to get excited about the Phase II data in sickle cell coming later this year. You had spoken about the potency and the higher hemoglobin response potential. Any color that would help to get you excited and how that kind of fits into the larger portfolio relative to mitapivat and the larger sickle cell space even. Thanks so much and congrats again, guys.

Thanks, Greg. Thanks, yes, thanks for the question, Greg. So the

Phase II tebipivat trial that we have just indeed announced full enrollment is a dose-finding trial. So we are looking indeed to explore the doses. We are looking at the hemoglobin.

It is a standalone Phase II trial, so VOCs are included as

Safety assessments, which is different than how the Phase

II/III seamless operational design was for RISE UP. But, obviously, we are now in a position that we can leverage data across the PK activation franchise, basically. And we are able to use the RISE UP data to also model what we anticipate a hemoglobin response can lead to for clinical benefit. So we are very excited about the trial. We think actually the fact that we can announce the enrollment completion also reflects the excitement of the community. You know, the RISE UP data announcement really led to a faster enrollment in the tebipivat Phase II trial, so we are very excited about that. Thank you.

Our next question comes from Samantha Semanko with Citi. Your line is open.

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

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

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

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

Absolutely, Sam. And a reminder, we started basically engaging and educating physicians and generating demand as soon as the product was approved. So within the first five weeks of the launch, we have been educating physicians on the value proposition of Afesmi and the REMS itself. So, we are very encouraged with what we see in terms of demand in these early stages of the launch. A lot of the things that are happening, and I am really, really pleased with the execution of the team, are happening as we expected. So we are seeing prescriptions coming from the transfusion-dependent patients and the very engaged symptomatic non–transfusion-dependent patients who have frequent interactions with the health care system, which is fantastic. And we see a very healthy dynamics of the launch in terms of the physicians. We see prescriptions coming from across the country. And a lot of them are in the community setting where the majority of the patients are treated, and I am really pleased with the progress that the team is making.

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

Yes. Thanks, Sam. So we have guided to the

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

Full approval based on the data that was generated in RISE UP with the strong anti-hemolytic profile that is now

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

And, once we have that meeting, we

Are planning to give an update

Once we have the meeting minutes to you guys.

Great. Thanks very much.

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

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

Of the emerging PK data, or is this maybe more likely at the 15 and the 20 mg doses? Thank you.

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

Two things. The first aspect is the insurance authorization, which is very standard for any specialty rare disease drug. That is not unique to Afesmi. And most of the patients would need to go to prior authorization, which can take on average a month. And for some patients, it happens faster. For some patients, it takes longer, but that is one of the main drivers. The second aspect is the requirement for a liver test ahead of the treatment initiation. So when we combine both of these factors, we anticipate the conversion from prescription to treatment initiation to be on average 10 to 12 weeks. As I said, we will see patients falling on either end of that time frame. And over time, we will, of course, look to shorten the time from prescription to treatment initiation on both fronts. We have an excellent market access team that will be engaging with payers. So as some of the payers actually put the product on formulary, that can be an opportunity for us to move faster through some of the prior authorizations, and supporting patients as well as we will be learning throughout the launch and identify areas to support to have efficiency in their liver testing initially as well.

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

Yeah. Thanks, Alec. And so to your point, we indeed are testing higher doses than the dose that we tested in the Phase IIa. So we have a 10 milligram, a 15 milligram, and a 20 milligram dose. So, indeed, we are looking

To explore the doses here in this Phase II to see which dose would be best. And then in addition, we are, because it is a heterogeneous

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

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

Yeah. It is going to be an exciting year for tebipivat in 2026. We have two catalysts, as we noted. We have the MDS Phase IIb trial in the first half of the year, and then as we have already discussed, for sickle cell disease, the second half of this year, we look forward to that Phase II result.

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

Thank you.

Thank you. And our next question will come from Marc Frahm with TD Cowen. Your line is open.

Questions. Maybe to start on Afesmi with the REMS-certified physicians. Just

Can you maybe talk about kind of where that is from a quantitative perspective,

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

Okay. So I can start. Yeah. When it comes

To the REMS, for in this initial stage of the launch, I am really pleased with what we are seeing, and things are happening exactly as we anticipated. Physicians do not see the REMS as a barrier to prescribing and the patients that we have engaged with they basically do not see it as burdensome given the strong value proposition of Afesmi and their willingness to consider and initiate therapy. What is happening with the REMS? Initially, a lot of the bigger academic centers and KOLs are getting certified. And when it comes to the community physicians, actual certification happens almost simultaneous with the first prescription. And we will see in a way the certification and REMS progressing simultaneously over time. But as I said, REMS has not been a reason for not to prescribe. It is the opposite. When physicians have patients that they want to initiate, they are more than willing to complete the REMS, which can actually take one visit. It is a very quick process.

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

Yeah. So thanks, Marc. So for us, the data package

Really the benefit-risk profile generated in RISE confirms a strong anti-hemolytic profile, as I mentioned. And we really see those clinically meaningful changes in the hemoglobin responders. So our view is that benefit-risk here is seen in this trial, and it is a supplemental NDA. Now as you also know, at ASH recently, the FDA highlighted that hemoglobin can be a surrogate endpoint for sickle cell disease. So either one of those pathways for us allows us to discuss the data, and have that meaningful conversation with the agency. Under any of those circumstances, then there is always the normal filing procedure that one would have to go through. But we are very, very excited about the data as it stands. Then in regards to your question on confirmatory trials, obviously, we have several options

That we can discuss in which

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

K. Thank you.

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

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

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

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

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

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

OpEx as we navigate the multiple catalysts on the horizon. But we also have other earlier programs. So we have not given specific timing

On that

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

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

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

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

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

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

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

Thanks, Emily. Tsveta, you want to start with Afesmi and the types of physicians in the early days?

Absolutely. As I said, a lot of the early launch dynamics are playing as expected. The team did a fantastic job ahead of the launch profiling and prioritizing accounts, and the initial prescriptions are actually coming from the physicians we anticipated to see prescribing. As I mentioned, Emily, they are primarily the community heme-oncs, where majority of the patients are, and these are physicians we have engaged with previously. We do not see that much overlap between PK deficiency and thalassemia, and that is because PK deficiency is an ultra-rare disease. So there are very few physicians who have experience with Pyrukynd in PK deficiency. And as I said, I am very pleased with the start of the launch. It is a very healthy breadth of prescribing that we see across the country. Different physicians are engaged and really trying the product in the patients that they would think will benefit the most initially.

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

To potential approval dates

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

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

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

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

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

Obviously, a large proportion is transfusion-dependent patients. And very engaged symptomatic non–transfusion-dependent patients who are in active interaction with the health care system. So when you think about the evolution over time, as anticipated, I think we will see initially more transfusion-dependent patients, but the scale-up of the launch will come from the non–transfusion-dependent patients later on. When you think about IQVIA, we have a single specialty pharmacy that distributes the product. So IQVIA will not be the right source for you to look at. It is just the information will not be available. And this is the reason that we are looking to provide you initially with prescriptions and revenue, as well as we gave you the guidance on PK deficiency so you can see where the growth of thalassemia will be coming throughout the year. So much.

Thank you. And our next question will come from Tessa Thomas Romero with JPMorgan. Your line is open.

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

Afesmi. Just can you just quickly touch on initial payer dynamics over the first couple of quarters here and

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

Thanks so much.

Okay. Thanks, Tessa. And, Tsveta can start on payer aspects, and maybe we could also just remind our gross-to-net assumptions too. Think we

Yep. Would be good. Answering Tessa, I will start here. So the payer mix in thalassemia is similar to PK deficiency with majority of the patients being under the commercial payer bucket. Very similar to PK deficiency and any other drug initially, the actual market access and payer authorization route will happen through medical exceptions because payers would take time, about six months, six to nine months, to actually start putting the product on formulary. We have a very experienced market access team that is very familiar with how to navigate the medical exceptions process. And so far, in these early stages of the launch, I must say, as expected, we have not seen any payer hurdles at all. I think the value proposition of Afesmi speaks for itself, and the team is doing a great job in terms of those interactions. Brian asked to comment on the gross-to-net assumptions. Given that we do not expect that to be a managed category, very similar payer mix to PK deficiency, our gross-to-net assumptions for thalassemia are similar to PK deficiency, 10% to 20%. And then on the SG&A question, Tessa, as we think about it,

We are going to update and manage our spend based on the regulatory discussions and the timing. But if you want to think about it,

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

Leverage, but the scale of sickle is much bigger. So we will have to scale up those functions that we built, but we have a really nice foundation to build from. Thank you.

Thank you. Thank you. And our last question will come from Hiro Nagayumi with RBC Capital Markets. Your line is open.

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

Versus the Phase II for sickle cell disease?

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

Any color is much appreciated. Thanks.

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

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

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

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

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

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

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

Yes.

Okay. Then

I will go ahead and close it down. First, I just want to thank everyone for joining us this morning. It is an exciting time for Agios Pharmaceuticals, Inc. As you heard throughout the call, we are entering 2026 with quite strong momentum and really pleased that we are already seeing strong initial progress with the Afesmi launch in the U.S. We have meaningful clinical and regulatory catalysts ahead, as we have talked about, and we will continue to operate with financial discipline. These near-term drivers combined with our advancing pipeline position Agios Pharmaceuticals, Inc. to deliver sustained growth and long-term value, and we very much appreciate your continued engagement and look forward to updating you on our progress throughout the year. Thanks a lot.