Fulcrum Therapeutics, Inc. Q1 FY2026 Earnings Call

Good morning, and welcome to Fulcrum Therapeutics First Quarter 2026 Financial Results and Business Update Conference Call. This call is being webcast live and can be accessed on the Investors section of Fulcrum's website at www.fulcrumtx.com and is being recorded. Please be reminded that remarks during this call may contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995 and may include statements about the company's future expectations and plans, clinical development timelines and financial projections. While these forward-looking statements represent Fulcrum's views as of today, they should not be relied upon as representing the company's views in the future. Fulcrum may update these statements in the future, but is not taking on an obligation to do so. Please refer to Fulcrum's most recent filings with the Securities and Exchange Commission for a discussion of certain risks and uncertainties associated with the company's business. Leading the call today will be Alex Sapir, CEO and President of Fulcrum. Joining Alex on the call are Alan Musso, Chief Financial Officer; and Dr. Iain Fraser, Senior Vice President, Clinical Development. After providing updates on the company's key programs, there will be a brief Q&A in which the full management team will be available for questions. With that, it's my pleasure to turn the call over to Alex.

That's great. Thanks, Shannon, and good morning, everyone. We appreciate you all joining us today. The first quarter of 2026 was an important and exciting period for Fulcrum highlighted by the positive clinical data we reported from the Phase Ib PIONEER trial of pociredir in sickle cell disease. Now as a reminder, sickle cell disease is a serious genetic blood disorder with a significant unmet need, affecting approximately 120,000 patients in the United States and millions more globally. Patients with sickle cell disease face a substantial disease burden, including chronic pain and fatigue as well as serious complications, such as vaso-occlusive crises, stroke and progressive end organ damage, all of which result in a substantial reduction in life expectancy of over 20 years. Now we have known for decades that increasing levels of fetal hemoglobin, or HbF, in patients with sickle cell disease leads to improvements in anemia and reductions in vaso-occlusive pain crises. And so it was for that reason that we were so pleased with the data that we reported in February, demonstrating that after only 12 weeks of treatment, 20 milligrams of pociredir taken once daily demonstrated a robust and clinically meaningful increase in HbF from 7.1% at baseline to 19.3% at week 12, along with improvements in markers of hemolysis and improvements in anemia. We also observed continued progression toward pancellular expression of HbF, which we believe is critical for achieving meaningful clinical benefit. And importantly, we saw a reduction in the number of VOCs we would have expected in this severe patient population with 7 of the 12 patients experiencing no VOCs during the 12-week treatment period. And importantly, pociredir has continued to be generally well tolerated with no treatment-related serious adverse events reported to date. And so taken together, these data reinforce our conviction in pociredir's potential to address the underlying biology of sickle cell disease and support our belief that pociredir has the potential to represent a differentiated, once-daily oral treatment option for patients. Now during the quarter, we also initiated an open-label, long-term dosing trial for patients in the PIONEER study, and we recently enrolled our first patient in this new study. All patients in this long-term dosing study previously completed 12 weeks of treatment as part of the PIONEER trial. Therefore, we expect this study to provide a distinct data set offering important insights into long-term safety, durability of response and the effects of reinitiating treatment with pociredir. We also continue to support initiatives aimed at improving the care journey for people living with sickle cell disease, including our recent collaboration with Medical Alert and the Sickle Cell Disease Association of America, or SCDAA, to help improve access to patient-specific care information in the emergency department setting. Looking ahead, we are now focused on the next stage of clinical development for pociredir, and we expect to provide an update in the design of our next trial later this quarter following our upcoming end-of-phase meeting with the FDA and receipt of the final meeting minutes. Pending FDA feedback from that end-of-phase meeting, we plan to initiate a potential registration-enabling trial in the second half of 2026. And so with a strong balance sheet that provides cash runway into 2029, we are well positioned to advance pociredir through the next phase of clinical development. Now before turning it over to Alan, I want to cover the two other important corporate updates. First, I want to welcome Josh Lehrer to our Board of Directors. Josh brings to Fulcrum deep experience and passion for sickle cell disease as well as a strong track record in advancing transformative therapies in this space, including his role in the development and approval of Oxbryta. We are honored to have Josh join Fulcrum at this important stage. And secondly, I would also like to thank Alan for his years of dedication and leadership as he looks towards retirement later in the year. Alan has played a critical role in strengthening our balance sheet and instilling financial discipline across the organization, and we are grateful for his continued commitment to Fulcrum as he remains in his role until a successor is named to ensure a smooth transition. And so with that, let me now turn it over to Alan to review our financial results and again, I want to thanks...

Thanks, Alex, and thank you for the kind words. It's been a privilege to be part of Fulcrum's progress, and I'm proud of what we've accomplished together. With the impressive results from the PIONEER trial, a talented and motivated team and a strong capital base, the company is well positioned to deliver transformative therapy for sickle cell patients. I look forward to continuing to work with the team over the coming months and ensuring a successful transition. And with that, I will now go over our results for the first quarter ended March 31, 2026. Research and development expenses were $14.1 million for the first quarter of 2026 compared to $13.4 million for the first quarter of 2025. The increase of $700,000 was primarily driven by higher employee compensation costs, including $400,000 of increased stock-based compensation expense. General and administrative expenses were $8.1 million for the first quarter of 2026 compared to $7.0 million for the first quarter of 2025. The increase of $1.1 million was primarily driven by higher employee compensation costs, including $300,000 of increased stock-based compensation expense as well as higher professional services costs. The net loss was $22.2 million for the first quarter of 2026 compared to a net loss of $20.4 million for the first quarter of 2025. Now turning to the balance sheet. We ended the first quarter of 2026 with cash, cash equivalents and marketable securities of $333.3 million compared to $352.3 million as of December 31, 2025. The $19.0 million decrease was primarily due to cash used to fund our operating activities. And based on our current plans, we expect our existing cash, cash equivalents and marketable securities will be sufficient to fund our operating requirements into 2029, providing runway to advance pociredir through the next phase of clinical development. And with that, I'll turn it back over to you, Alex.

That's great. Thanks so much, Alan. So Fulcrum has reached an important inflection point with the positive clinical data from our PIONEER trial, reinforcing our conviction in pociredir's potential in sickle cell disease. We are focused on the next stage of development and look forward to providing an update on our plans following our upcoming end-of-phase meeting with the FDA. And with a strong balance sheet and a dedicated team, we believe we are well positioned to advance pociredir through the next phase of clinical development. And so with those brief remarks, Shannon, why don't we go ahead and open up the line for questions.

Our first question comes from the line of Joe Schwartz with Leerink Partners.

Alan, congrats on your upcoming retirement, and thanks for your excellent stewardship of the company over the years. Alex, as you reflect on the experience gained through PIONEER, what are the most important things you've learned that you might not have fully appreciated going in? And how will those lessons shape your Phase III design and execution?

Yes. It's a great question, Joe. And I may turn it over to Iain to see who wants to add anything. I mean, I think the one thing that I've really learned from PIONEER and talking with a lot of the investigators and hearing from those investigators, the conversations that they've had with their patients is that there continues to be continued high, high, high unmet need in this patient population, especially in the severe patient population that we studied in the PIONEER trial and in the severe patient population that we would expect to continue in our next phase of clinical development. I would say that's learning number one. I would say learning number two is that there is such a strong connection between fetal hemoglobin and reduction of VOCs. And we've known this for a long time, but spending time as much as I have with people like Martin Steinberg, who has spent decades researching the underlying biology of fetal hemoglobin, he said that just so succinctly and so simple in his explanation that if you can increase fetal hemoglobin you're going to see a reduction in VOCs, you're going to see an improvement in anemia because of an increase in total hemoglobin because you're seeing less hemolysis. And so I think it's really to me, Joe, it's those two things taken together: one related to the unmet need of the patient population, and secondarily is what we think is a very, very profound and robust induction of fetal hemoglobin that's really, I think, what continues to motivate me and make me excited for the next phase of this asset's journey along the clinical development timeline. Iain, you've obviously been pretty deeply involved with PIONEER as well. Anything you would want to add to that?

I think you captured it very well, Alex. It's the severity of the disease and the manifestations experienced by these patients coupled with the really high unmet need in terms of available therapies for the patients. And I think on a daily basis, we continue to be reminded of that.

Okay. Great. And then as you approach discussions with the FDA, what level of evidence do you think they might require in order to consider HbF as a reasonably likely surrogate endpoint for accelerated approval? And how do you plan to position what you've seen efficacy and safety-wise for pociredir so far in terms of that clinical profile to support your case?

Yes, it's a great question, Joe. And obviously, Iain has been very, very deep in those preparations for our upcoming meeting. So I think to answer that, let me turn that one over to Iain.

Yes. Thanks, Alex. Thanks, Joe. I think there's really substantial published literature that demonstrates the association between higher HbF levels and improved clinical outcomes in sickle cell disease. And as we've discussed previously and again today, that biological relationship is really a key part of the underlying rationale for our program overall. Of course, the role that HbF could play in terms of the regulatory framework is one that is going to be a topic of discussion with regulators to understand their perspective on the appropriate path forward. Our focus remains on designing a robust study that can meaningfully demonstrate clinical benefit, and we hope to align with the regulators on the optimal strategy around that.

Our next question comes from the line of Anupam Rama with JPMorgan.

Thanks and Alan best wishes on the retirement. So at the sickle cell disease research symposium, will there be any new analysis that will be presented relative to the first-quarter corporate update for PIONEER? And I know second question, I know that the first patients have been dosed in the OLE portion of the Phase I. What portion of the patients from PIONEER went to the OLE? And could we see that update maybe around ASH?

Yes. Maybe let me — I'll answer the second question, and then Iain, I can turn it over to you to answer the first question. Yes. So we have enrolled our first patient in this open-label long-term dosing for pociredir. Right now, Anupam, we're targeting the 17 U.S.-based patients that were enrolled in either Cohort 3b, which was the 12-milligram cohort, or Cohort 4, which was the 20-milligram cohort. And so right now, really, our focus has really been on getting those sites activated. Unfortunately, this is not your sort of traditional OLE study where patients roll right over; this is considered a new study. And so it has to go through the same mechanics of any new protocol that gets introduced to an institution. So that obviously takes a bit of time. I think it's a little difficult to project when we would have patients of those 17 patients enrolled in this open-label long-term dosing for pociredir. We don't think we'll get all of them. Some may be lost to follow-up, some may be in other clinical trials. But I think given what we've heard from investigators in terms of the interest level in going back on therapy, we should expect to see a decent number of those 17 patients. If you ask me to try to predict as a possible timeline, I'd say it's probably going to be sometime in 2027 before we would have a critical mass of patients enrolled in order to be able to see a duration of therapy that is going to be a meaningful, interesting and new data point. We've seen what happens to this therapy when patients are dosed for 12 weeks. I think what's going to be really interesting is what happens when patients go for longer — 24 weeks or six months. And so that would probably be the first data set that we would share with folks. And so more than likely, that probably would happen sometime in 2027 as opposed to ASH 2026.

There is a second question.

Yes, yes. This is Iain. I can handle that one. So we've indicated that we expect to provide a full, separate presentation of the entire PIONEER study at a medical conference later this year. We have not provided details on that as yet. As we indicated in the press release, the FSCDR symposium oral abstract will include previously disclosed clinical data.

Our next question comes from the line of Kristen Kluska with Cantor.

And let me also add my congrats to Alan for a great career in biotech and pharma, including the accomplishments at Fulcrum. The first question I had for you was just on broadly understanding the latest views coming from FDA. I know there's been several workshops, including at ASH. I know the team has met with some thought leaders in Washington, D.C. So bigger picture without specifically honing in on Fulcrum's path forward, what's the latest you've been hearing from these thought leaders about how they're thinking about sickle cell disease as an indication, the unmet need and just receptiveness to hearing about new drug classes?

Yes, it's a great question, Kristen. And I'll start, and Iain, you may want to add some thoughts as well. I'll break the question up into two pieces: what are we hearing and what are we doing with folks on the Hill — and then what are we hearing and seeing at the FDA. I personally have been spending a lot of time in Washington, D.C. Kristen is referencing a very interesting program that she attended in which we provided a congressional briefing to staffers of senators and congressmen just several weeks ago in Washington, D.C., where we really talked about the unmet need. We had a couple of patients talk about their journey and it was standing room only and toward certain parts of the meeting, there were very few dry eyes in the house. And so I think that what the politicians understand is that sickle cell continues to be a disease with very high unmet need with shortened life expectancy of 20 years, not to mention during their time here experiencing very debilitating pain crises and organ damage, leg ulcers — I could go on and on. And so I think that it's important that the senators and congressmen on the sickle cell disease caucus and the rare disease caucus and others understand that and can help lend their support in terms of how high the unmet need is in this patient population. So I'd say that's more on the Hill side. I think on the FDA side, I would point you to Agios' recent press release that showed that they will be moving forward with filing an NDA in the coming months for sickle cell disease with mitapivat. And we think that what that shows is an understanding of how high the unmet need is and potentially some regulatory flexibility to try to get drugs to patients as quickly as we can. These drugs obviously have to be not only effective, but they need to be safe. And so we're obviously very excited and looking forward to engaging with the FDA in our upcoming end-of-phase meeting. Iain, anything you would want to add to that?

No, I think you covered the key points really well, Alex. Given the severity of the disease and the unmet need, I think the recent progress in the sickle cell disease landscape is very encouraging for the field, and we look forward to moving our program with pociredir forward.

Yes. And then my other question is just focusing in a little bit more on the open-label extension. Obviously, you want to understand the longer-term impacts on both safety and efficacy. But I'm curious if there are any endpoints in particular you're really trying to understand for longer-term efficacy. So are there certain endpoints that maybe take a little bit longer for the benefits to occur where a trial longer than 12 weeks potentially might give you some insight?

Yes, Kristen, that's a great question. I think to answer that, I will turn that one over to Iain, who has been deeply involved in the design as well as the execution of the open-label long-term dosing study for which we've enrolled our first patient. Iain?

Yes. Thanks, Alex, and thanks, Kristen. So as we've indicated before, at the 12-week treatment duration with pociredir the HbF levels are starting to flatten out, but we don't believe they've reached their peak level at that point. And so one of the outcomes of the study that we'll be very much interested in is to see the progression beyond that 12-week mark. And then downstream of the HbF, as we've seen with other hematologic markers, there are improvements in markers of hemolysis in particular, but also the increase in total hemoglobin that we've seen. Those are probably not maxed out either at that point and with a longer duration of increased HbF, we would expect to see further improvements in those markers. So I think it's looking at how that response plays out over a longer treatment period. Having said that, I think it is important and Alex alluded to this earlier, that these patients have been off pociredir for some time. So it's not the traditional open-label extension where they roll over immediately into that. So that will be starting from a new baseline, but it's the extended dosing duration in particular that we're interested in tracking.

Our next question comes from the line of Corinne Jenkins with Goldman Sachs.

Congratulations to Alan as well from all of us in terms of the retirement. Maybe a question for us and just kind of the competitive landscape and evolving treatment landscape in sickle cell disease. I guess, could you help us think through the role you expect pociredir to play, particularly if there's more kind of oral medications that come to market over the next couple of years?

Sure, absolutely. I'll start, and then Iain, you may want to add some additional points that I maybe leave off. So yes, I think the way we think about this is there's sort of — and it's interesting. This market is one that I think will grow exponentially over the next 5 to 10 years. If you look at just the sheer number of drugs in development for the treatment of sickle cell disease. This is a very large market that has been underserved for years and years. And so I think the way that we see this market evolving is very much towards oral treatment options. And there's really — to us, we think about this as sort of two different approaches. One is operating downstream on the mature red blood cells like the PKR activators and the second is operating more upstream when those red blood cells are being formed in the bone marrow and ensuring that those red blood cells have enough fetal hemoglobin as they're being formed because once those red blood cells have enough fetal hemoglobin as they form and are released from the bone marrow, those red blood cells cannot and will not sickle. They maintain their soft flexible shape, thereby preventing vaso-occlusive crises; they have a lifespan of about 120 days versus a roughly 30-day lifespan for a sickled red blood cell. And so for us, we think that really attacking the upstream underlying cause of the disease as we're doing with pociredir — we believe that that will ultimately be the treatment of choice as we look over the next 5 to 10 years as this market evolves. Now where we are in relation to some of those other fetal hemoglobin inducers: conservatively, we believe that we have about a 24-month head start over the next closest competitor in the oral HbF inducer class, which would be BMS-986, which targets mechanisms including ZBTB7A (LRF). They are currently in the clinic in a Phase I study, and they expect to announce the results of that Phase I study sometime in the first half of 2027. So we'll be well underway, we believe, with our Phase III study while the next closest competitor, BMS, is reporting out their Phase I study results in 2027. And so maintaining that roughly two-year head start, so that when we come to market, we can have this market essentially without other oral HbF competitors, we believe that that's an important consideration that we want to make sure that we maintain.

I think you mentioned the key point, Alex. I think the focus of the PKR activators is on the increases in total hemoglobin resulting from a decrease in hemolysis, and I agree that the HbF mechanism has emerged as a more central, more upstream mechanism to address a broader range of manifestations of sickle cell disease. I think we're seeing that reflected in the interest in the clinic in sponsors that are bringing forward oral HbF inducers.

Our next question comes from the line of James Condulis with Stifel.

And I'll add my congrats as well, Alan. Maybe just one sort of on the competitive landscape and all these regulatory dynamics. Novo recently hit on a VOC endpoint. Just curious if you think that changes anything at all as it relates to the potential regulatory path for you? And if a drug were to be approved on VOC, does that sort of change what the FDA may be open to approving as it relates to the endpoints that are not a VOC endpoint? Just curious your perspectives there.

Yes, James, great question. Maybe just to orient everybody, they did have co-primary endpoints: total hemoglobin and VOCs and they hit on that. It was a 27% reduction in vaso-occlusive crises. So very similar to the percent reduction in VOC that we saw with another product that's currently approved and generally not widely used, a product called L-glutamine, which had about a 25% reduction in VOC. So I wanted just to make sure that everybody on the call was oriented to specifically what James was talking about. Iain, maybe I'll have you sort of take the heart of James' question, which is really around if there's any potential sort of read-through with pociredir and our path forward. Iain?

Yes, I think the fact that VOCs is an important clinical endpoint remains the case. I don't think there's any change in that. I think as we've discussed before, the literature associating increases in fetal hemoglobin with reductions in VOCs certainly remains the case. And given the magnitude of HbF induction that we've seen in the PIONEER study to date, both at the 12 and the 20-milligram doses, we would expect that that would translate into a VOC benefit. And I think that remains an important clinical endpoint.

Our next question comes from the line of Matthew Biegler with Opco.

Congrats to you, Alan as well. Maybe just piggybacking on some of an earlier comment that you made, Alex. I'm thinking about maybe potential future combination strategies here. And you mentioned PKR activators and some of the other downstream treatments where you guys are more upstream and maybe that makes logical sense. So it sounds to me like maybe there might be a better partner for you than hydroxyurea. Have you given any thoughts to that?

Yes. It's a really good question, Matt. Iain, I may turn this over to you, but I think just a couple of initial thoughts. So hydroxyurea has been approved now for coming on 40 years. It is clearly the mainstay. I think that patients at times aren't crazy about it. It doesn't have great adherence because of some of the side effects associated with it. But despite that, it is very much the mainstay. So I think our long-term development strategy has always been to figure out a path forward for us to be used in combination with hydroxyurea. We don't believe that that will be part of the design that we will reach agreement on with the FDA as part of our upcoming end-of-phase meeting with them. But we do see that as an important part of the ongoing clinical development program for pociredir. Iain, maybe if you want to take just beyond hydroxyurea, is there the idea of possibly combining an HbF inducer with potentially a PKR activator or operating on different mechanisms and potentially seeing greater efficacy than either one could achieve on their own?

Yes, absolutely. We've certainly seen combination strategies work in other fields, and that remains a potential in this disease, which has so many severe manifestations. However, our primary objective at the moment really is to generate an interpretable data set with pociredir that will support its registration. Understanding the drug in the context of monotherapy is really the first step in that journey so that we have a full understanding and can then give serious consideration to how we evaluate potential combination therapies down the road.

Yes, I think that's well said, Iain.

Our next question comes from the line of Gregory Renza with Truth Securities.

My congratulations to Alan on his service at Fulcrum and in the industry. I know, of course, the focus is on pociredir, but I'm just curious when you see the time being right to potentially advance or nominate some of the discovery programs and think about the novel HbF inducers that you may have in the library. And then maybe secondarily, as we think about the FDA meetings upcoming, can you just give us an update on the engagement plans with respect to EMA and the global development?

Sure. I'll take the first question and Iain, I'll turn the second question over — actually, Iain, why don't you — if you want, do you want to take the second question first?

Yes. Happy to do that. Thanks, Greg. So as we've indicated before, the context of a registrational sickle cell disease study is likely to be a global study and we've indicated that we will be interacting with EMA later this year as part of that process. So that's certainly the first step on looking more globally and getting additional feedback on the program.

Yes, it's great. And then in terms of your first question about our discovery efforts, we're a company of about 60 to 65 people, we've got 20 to 25 people focused entirely on discovery. Within discovery, they are focused on developing second-, third- and fourth-generation oral HbF inducers. That has really been our key area of focus because, again, going back to something I said earlier, we do believe that this is a market that ultimately will be dominated by oral fetal hemoglobin inducers. We're thinking about how we can develop a product that potentially could be an improvement on pociredir once it eventually hits the market. At this point, it's a little bit premature to estimate when we would start seeing things coming out of our discovery efforts and conducting IND-enabling studies. But I will say that in the coming years, we believe we will see a number of new INDs almost entirely focused on trying to come out with an even better oral HbF inducer than what we currently have with pociredir given how we see this market evolving over the next 5 to 10 years.

And I'm currently showing no further questions at this time. Thank you, everyone, for your participation on today's call. This does conclude the conference. Thank you, and you may now disconnect.