Milestone Pharmaceuticals (MIST) 10-Q13 May 242024 Q1 Quarterly reportFinancial data

Company Profile

Document and Entity Information

Document and Entity Information - shares	3 Months Ended
Document and Entity Information - shares	Mar. 31, 2024	May 13, 2024
Document and Entity Information
Document Type	10-Q
Document Quarterly Report	true
Document Period End Date	Mar. 31, 2024
Document Transition Report	false
Entity File Number	001-38899
Entity Registrant Name	Milestone Pharmaceuticals Inc.
Entity Incorporation, State or Country Code	A8
Entity Tax Identification Number	00-0000000
Entity Address, Address Line One	1111 Dr. Frederik-Philips Boulevard
Entity Address, Address Line Two	Suite 420
Entity Address, City or Town	Montréal
Entity Address, State or Province	QC
Entity Address, Country	CA
Entity Address, Postal Zip Code	H4M 2X6
City Area Code	514
Local Phone Number	336-0444
Title of 12(b) Security	Common Shares
Trading Symbol	MIST
Security Exchange Name	NASDAQ
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Non-accelerated Filer
Entity Small Business	true
Entity Emerging Growth Company	true
Entity Ex Transition Period	true
Entity Shell Company	false
Entity Common Stock, Shares Outstanding		53,260,467
Entity Central Index Key	0001408443
Current Fiscal Year End Date	--12-31
Document Fiscal Year Focus	2024
Document Fiscal Period Focus	Q1
Amendment Flag	false

Consolidated Balance Sheets

Consolidated Balance Sheets - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Current assets
Cash and cash equivalents	$ 10,131	$ 13,760
Short-term investments	79,350	52,243
Research and development tax credits receivable	711	643
Prepaid expenses	2,362	3,178
Other receivables	1,413	3,208
Total current assets	93,967	73,032
Operating lease right-of-use assets	1,785	1,917
Property and equipment	249	277
Total assets	96,001	75,226
Current liabilities
Accounts payable and accrued liabilities	3,575	6,680
Operating lease liabilities	555	546
Total current liabilities	4,130	7,226
Operating lease liabilities, net of current portion	1,306	1,457
Senior secured convertible notes	50,644	49,772
Total liabilities	56,080	58,455
Shareholders' Equity
Common shares, no par value, unlimited shares authorized 33,483,111 shares issued and outstanding as of December 31, 2023, 34,286,002 shares issued and outstanding as of December 31, 2022	287,879	260,504
Pre-funded warrants - 9,577,257 issued and outstanding as of December 31, 2023 and 8,518,257 as of December 31, 2022	53,076	48,459
Additional paid-in capital	35,346	33,834
Accumulated deficit	(336,380)	(326,026)
Total shareholders' equity	39,921	16,771
Total liabilities and shareholders' equity	$ 96,001	$ 75,226

Consolidated Balance Sheets (Pa

Consolidated Balance Sheets (Parenthetical) - $ / shares	3 Months Ended	12 Months Ended
Consolidated Balance Sheets (Parenthetical) - $ / shares	Mar. 31, 2024	Dec. 31, 2023
Consolidated Balance Sheets
Common shares, par value (in dollars per share)	$ 0	$ 0
Common shares, Shares authorized (in shares)	Unlimited	Unlimited
Common shares, Shares issued (in shares)	53,245,165	33,483,111
Common shares, Shares outstanding (in shares)	53,245,165	33,483,111
Pre-funded warrants, Warrants issued (in shares)	12,910,590	9,577,257
Pre-funded warrants, Warrants outstanding (in shares)	12,910,590	9,577,257

Consolidated Statements of Loss

Consolidated Statements of Loss - USD ($) $ in Thousands	3 Months Ended
Consolidated Statements of Loss - USD ($) $ in Thousands	Mar. 31, 2024	Mar. 31, 2023
Consolidated Statements of Loss
Revenue	$ 0	$ 1,000
Operating expenses
Research and development, net of tax credits	3,639	10,257
General and administrative	3,953	3,889
Commercial	2,884	2,356
Loss from operations	(10,476)	(15,502)
Interest income	994	585
Interest expense	(872)	(33)
Net loss and comprehensive loss	$ (10,354)	$ (14,950)
Weighted average number of shares and pre-funded warrants outstanding, basic (in shares)	50,155,111	42,853,275
Weighted average number of shares and pre-funded warrants outstanding, diluted (in shares)	50,155,111	42,853,275
Net loss per share, basic (in dollars per share)	$ (0.21)	$ (0.35)
Net loss per share, diluted (in dollars per share)	$ (0.21)	$ (0.35)

Consolidated Statements of Shar

Consolidated Statements of Shareholders' Equity - USD ($) $ in Thousands	Common Shares	Pre-funded warrants	Additional paid-in capital	Accumulated deficit	Total
Opening balance at Dec. 31, 2022	$ 273,900	$ 34,352	$ 24,437	$ (266,341)	$ 66,348
Beginning Balance (in shares) at Dec. 31, 2022	34,286,002	8,518,257
Increase (Decrease) in Stockholders' Equity
Net loss				(14,950)	(14,950)
Exercise of stock options	$ 213		(89)		124
Exercise of stock options (in shares)	67,224
Share-based compensation			2,293		2,293
Exchange of common shares	$ (14,115)				(14,115)
Pre-funded warrants - Private Placement, net of issuance costs		$ 14,107			14,107
Pre-funded warrants - Private Placement, net of issuance costs (in shares)		1,059,000
Employee stock purchase plan purchases	$ 128				128
Employee stock purchase plan purchases (in shares)	42,988
Closing balance at Mar. 31, 2023	$ 260,126	$ 48,459	26,641	(281,291)	53,935
Ending Balance (in shares) at Mar. 31, 2023	33,337,214	9,577,257
Increase (Decrease) in Stockholders' Equity
Exchange of common shares (in shares)	(1,059,000)
Opening balance at Dec. 31, 2023	$ 260,504	$ 48,459	33,834	(326,026)	$ 16,771
Beginning Balance (in shares) at Dec. 31, 2023	33,483,111	9,577,257			33,483,111
Beginning Balance, warrants (in shares) at Dec. 31, 2023					9,577,257
Increase (Decrease) in Stockholders' Equity
Net loss				(10,354)	$ (10,354)
Share-based compensation			1,512		1,512
Issuance of common shares, net of issuance costs	$ 27,258				27,258
Issuance of common shares, net of issuance costs (shares)	19,666,667
Pre-funded warrants - Private Placement, net of issuance costs		$ 4,617			4,617
Pre-funded warrants - Private Placement, net of issuance costs (in shares)		3,333,333
Employee stock purchase plan purchases	$ 117				117
Employee stock purchase plan purchases (in shares)	95,387
Closing balance at Mar. 31, 2024	$ 287,879	$ 53,076	$ 35,346	$ (336,380)	$ 39,921
Ending Balance (in shares) at Mar. 31, 2024	53,245,165	12,910,590			53,245,165
Ending Balance, warrants (in shares) at Mar. 31, 2024					12,910,590

Consolidated Statements of Cash

Consolidated Statements of Cash Flows - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Cash flows used in operating activities
Net loss	$ (10,354)	$ (14,950)
Adjustments to reconcile net loss to net cash used in operating activities:
Depreciation of property and equipment	28	18
Amortization of debt costs	87
Accretion of investment discount	(93)	(50)
Non-cash interest expense related to debt	785
Share-based compensation expense	1,512	2,293
Changes in operating assets and liabilities:
License receivable		(1,000)
Other receivables	1,795	188
Research and development tax credits receivable	(68)	(83)
Prepaid expenses	816	558
Operating lease assets and liabilities	(10)	1
Accounts payable and accrued liabilities	(3,432)	(912)
Interest Payable		33
Net cash used in operating activities	(8,934)	(13,904)
Cash provided by (used in) investing activities
Acquisition of property and equipment		(32)
Acquisition of short-term investments	(52,514)	(15,000)
Redemption of short-term investments	25,500	45,000
Net cash used in investing activities	(27,014)	29,968
Cash provided by financing activities
Proceeds from exercise of options		124
Proceeds from issuance of senior secured convertible debt		50,000
Issuance of common shares, net of issuance costs	27,538
Pre-funded warrant issuance costs	4,664
Proceeds from employee stock purchase plan	117	129
Cash provided by financing activities	32,319	50,253
Net increase (decrease) in cash and cash equivalents	(3,629)	66,317
Cash and cash equivalents - Beginning of period	13,760	7,636
Cash and cash equivalents - End of period	$ 10,131	$ 73,953

Organization and Nature of Oper

Organization and Nature of Operations	3 Months Ended
Organization and Nature of Operations	Mar. 31, 2024
Organization and Nature of Operations
Organization and Nature of Operations	1 Organization and Nature of Operations Milestone Pharmaceuticals Inc. (Milestone or the Company) is a biopharmaceutical company incorporated under the Business Corporations Act

Summary of Significant Accounti

Summary of Significant Accounting Policies	3 Months Ended
Summary of Significant Accounting Policies	Mar. 31, 2024
Summary of Significant Accounting Policies
Summary of Significant Accounting Policies	2 Summary of Significant Accounting Policies a) Basis of Consolidation The condensed consolidated financial statements include the accounts of the Company and Milestone Pharmaceuticals USA, Inc. All intercompany transactions and balances have been eliminated. b) Basis of Presentation and Use of Accounting Estimates and Significant Accounting Policies These unaudited interim condensed consolidated financial statements have been prepared in accordance with accounting principles generally accepted in the United States of America, or “U.S. GAAP”, and on a basis consistent with those accounting principles followed by the Company and disclosed in Note 2 of its most recent annual consolidated financial statements. Certain information, in particular the accompanying notes normally included in the annual financial statements prepared in accordance with U.S. GAAP have been omitted or condensed. Accordingly, these unaudited interim condensed consolidated financial statements do not include all the information required for full annual financial statements, and therefore, should be read in conjunction with the annual consolidated financial statements and the notes thereto for the year ended December 31, 2023. In the opinion of the Company's management, the accompanying unaudited interim condensed consolidated financial statements contain all adjustments, consisting of only normal recurring adjustments, necessary for a fair statement of its balance sheet as of March 31, 2024, and its statements of loss, shareholders’ equity and cash flows for the three months ended March 31, 2024 and 2023. The condensed consolidated balance sheet as of December 31, 2023, was derived from audited annual consolidated financial statements, but does not contain all the footnote disclosures required by accounting principles generally accepted in the United States of America. These unaudited interim condensed consolidated financial statements are presented in US dollars, which is the Company’s functional currency. The preparation of unaudited interim condensed consolidated financial statements in conformity with U.S. GAAP requires the Company to make estimates and judgments that affect certain reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the consolidated financial statements and the reported amounts of revenue and expenses during the period. The Company bases its estimates and assumptions on current facts, historical experience and various other factors that it believes are reasonable under the circumstances, to determine the carrying values of assets and liabilities that are not readily apparent from other sources. Significant estimates and judgments include, but are not limited to, ● Estimates of the percentage of work completed of the total work over the life of the individual trial in accordance with agreements established with clinical research organizations, or CROs, contract manufacturing organizations, or CMOs, and clinical trial sites which in turn impact the research & development expenses. ● Estimate of the grant date fair value share options granted to employees, consultants and directors, and the resulting share-based compensation expense, using the Black-Scholes option-pricing model. c) Significant Risks and Uncertainties The Company is subject to challenges and risks specific to its business and its ability to execute on its strategy, as well as risks and uncertainties common to companies in the pharmaceutical industry, including, without limitation, risks and uncertainties associated with: obtaining regulatory approval of its product candidate; delays or problems in the supply of its study drug or failure to comply with manufacturing regulations; identifying, acquiring or in-licensing product candidates; pharmaceutical product development and the inherent uncertainty of clinical success; and the challenges of protecting and enhancing its intellectual property rights; and complying with applicable regulatory requirements. Further, the Company may be impacted by general economic, political, and market conditions, including deteriorating market conditions due to investor concerns regarding inflation, armed conflicts, and overall fluctuations in the financial markets in the U.S. and abroad. d) Recent Accounting Pronouncements In November 2023, the Financial Accounting Standards Board (“FASB”) issued Accounting Standard Update (“ASU”) 2023-07, Segment Reporting (Topic 280): Improvements to Reportable Segment Disclosures (“ASU 2023-07”), which requires public entities to disclose information about their reportable segments’ significant expenses on an interim and annual basis. ASU 2023-07 is effective for fiscal years beginning after December 15, 2023, and interim periods within fiscal years beginning after December 15, 2024. Early adoption is permitted. The Company is evaluating the effect of adopting this new accounting guidance on its financial statements, but does not intend to early adopt. In December 2023, the FASB issued ASU 2023-09, Income Taxes (Topic 740): Improvements to Income Tax Disclosures (“ASU 2023-09”). The amendments in this update require that public business entities on an annual basis (1) disclose specific categories in the rate reconciliation and (2) provide additional information for reconciling items that meet a quantitative threshold (if the effect of those reconciling items is equal to or greater than 5 percent of the amount computed by multiplying pretax income [or loss] by the applicable statutory income tax rate). The amendments also require entities on an annual basis to disclose disaggregated amounts of income taxes paid. ASU 2023-09 is effective for annual periods beginning after December 15, 2024. Early adoption is permitted for annual financial statements that have not yet been issued or made available for issuance. The Company is evaluating the effect of adopting this new accounting guidance on its financial statements, but does not intend to early adopt. e) Sources of Liquidity and Funding Requirements The Company incurred operating losses and has experienced negative operating cash flows since its inception and anticipates continuing to incur losses for at least the next several years. Further, in connection with the revised timeline for our NDA submission, we have undertaken certain cash conservation measures to reduce spending through program deferrals and team restructuring. These cash conservation measures were substantially completed during the first quarter of 2024. These cash conservation measures were partially offset by $1.1 million in termination benefits paid as a result of the team restructuring. As of March 31, 2024, the Company had cash, cash equivalents and short-term investments of $89.5 million and an accumulated deficit of $336.4 million. Management has evaluated the Company’s operating plan, including the previously mentioned cash conservation measures, against its existing cash and cash equivalents and short-term investments and determined that the Company expects to be able to support its operations for at least the next 12 months from the date of issuance of these unaudited interim consolidated financial statements.

Revenues

Revenues	3 Months Ended
Revenues	Mar. 31, 2024
Revenues
Revenues	3 Revenues The Company recorded no revenue for the three months ended March 31, 2024. The Company recorded $1.0 million in revenue for the three months ended March 31, 2023. This revenue was the result of having reached a milestone pursuant to our License and Collaboration Agreement, dated May 15, 2021, with Ji Xing Pharmaceuticals Limited (such party “Ji Xing” and , such agreement, the “Ji Xing License Agreement”) due upon the successful initiation of a Phase 1 Clinical Trial of a pharmaceutical product that uses a device to deliver etripamil by nasal spray by or on behalf of Ji Xing for the treatment of PSVT in the People’s Republic of China, or the Territory, including mainland China, Hong Kong Special Administrative Region, Macau Special Administrative Region and Taiwan. For details on the arrangement with Ji Xing, see Note 3 to our audited consolidated financial statements for the year ended December 31, 2023, filed on Form 10-K.

Short-term Investments

Short-term Investments	3 Months Ended
Short-term Investments	Mar. 31, 2024
Short-term Investments
Short-term Investments	4 Short-term Investments Short-term investments are classified as held-to-maturity, are initially recognized at fair value and are subsequently accounted for at amortized cost. They are comprised of guaranteed investment certificates with a maturity greater than 90 days but less than one year and, as such, are classified as current assets. As of March 31, 2024, $0.5 million in short-term investments were pledged as collateral for a letter of credit.

Debt

Debt	3 Months Ended
Debt	Mar. 31, 2024
Debt
Debt	5 Debt On March 29, 2023, we closed the transactions contemplated by a note purchase agreement, or the “Note Purchase Agreement”, with RTW Investments LP and certain of its affiliates, or collectively, RTW The 2029 Convertible Notes are senior secured obligations and are guaranteed on a senior secured basis by our wholly owned subsidiary, Milestone Pharmaceuticals USA, Inc. Interest at the annual rate of 6.0% is payable quarterly in cash or, at our option, payable in kind for the first three years. The maturity date for the 2029 Convertible Notes is March 31, 2029, the “Maturity Date”. The obligations under the 2029 Convertible Notes are secured by substantially all of our and our subsidiary guarantor’s assets. Each $1,000 of principal of the 2029 Convertible Notes (including any interest added thereto as payment in kind) is convertible into 191.0548 shares of our common shares, equivalent to an initial conversion price of approximately $5.23 per share, subject to customary anti-dilution and other adjustments. In addition, following a notice of redemption or certain corporate events that occur prior to the Maturity Date, we will, in certain circumstances, increase the conversion rate for a holder who elects to convert its 2029 Convertible Notes in connection with such notice of redemption or corporate event. On or after March 27, 2027, the 2029 Convertible Notes are redeemable by us, subject to certain conditions, if the closing sale price of the common shares exceeds 150% of the conversion price then in effect for at least 20 trading days (whether or not consecutive), including the trading day immediately preceding the date on which we provide notice of redemption, during any 30 consecutive trading day period ending on, and including, the trading day immediately preceding the date on which we provide notice of redemption, at a redemption price equal to 100% of the principal amount of the 2029 Convertible Notes to be redeemed, plus accrued and unpaid interest to, but excluding, the redemption date. In accounting for the issuance of the Convertible Notes, the Company determined there were no embedded features, which require bifurcation between debt and equity components. As a result, the Convertible Notes are accounted for as a liability. As of March 31, 2024, the estimated fair value of the Convertible Notes was approximately $47.5 million based on level 2 inputs. The net carrying amount of the Convertible Note were as follows: March 31, 2024 December 31, 2023 Original principal $ 50,000 $ 50,000 Paid in kind (PIK) interest 3,094 2,310 Unamortized debt discount (528) (547) Unamortized debt issuance costs (1,922) (1,991) Total $ 50,644 $ 49,772 The following table presents the total amount of interest cost recognized relating to the 2029 Convertible Notes: Three months ended March 31, 2024 2023 Contractual interest expense $ 785 $ 30 Amortization of debt discount 18 1 Amortization of debt issuance costs 69 2 Total interest expense $ 872 $ 33

Accounts Payable and Accrued Li

Accounts Payable and Accrued Liabilities	3 Months Ended
Accounts Payable and Accrued Liabilities	Mar. 31, 2024
Accounts Payable and Accrued Liabilities
Accounts Payable and Accrued Liabilities	6 Accounts Payable and Accrued Liabilities Accounts payable and accrued liabilities are comprised of the following: March 31, 2024 December 31, 2023 Trade accounts payable $ 1,727 $ 3,981 Accrued compensation and benefits payable 824 712 Accrued research and development liabilities 518 894 Accrued commercial liabilities 40 710 Other accrued liabilities 466 383 Total $ 3,575 $ 6,680

Shareholders' Equity

Shareholders' Equity	3 Months Ended
Shareholders' Equity	Mar. 31, 2024
Shareholders' Equity
Shareholders' Equity	7 Shareholders’ Equity Authorized Share Capital The Company has authorized and issued common shares, voting and participating, without par value, of which unlimited shares were authorized and 53,245,165 shares were issued and outstanding As of March 31, 2024, there were 1,798,766 common shares available for issuance under the Employee Stock Purchase Plan, or the ESPP, of which 1,561,373 are available for future purchases. On February 28, 2024, we entered into an underwriting agreement, or the Underwriting Agreement, related to an underwritten public offering, or the Offering, of 16,666,667 of our common shares, without par value, at a public offering price of $1.50 per share and, in lieu of common shares to certain investors, pre-funded warrants to purchase 3,333,333 Shares at a public offering price of $1.499 per pre-funded warrant. Each pre-funded warrant has an exercise price of $0.001 per share. The pre-funded warrants were exercisable immediately upon issuance, subject to certain beneficial ownership limitations. Under the terms of the Underwriting Agreement, we granted the underwriters party thereto, or the Underwriters, an option to purchase up to an additional 3,000,000 common shares at the same price per share as the other common shares sold in the Offering, which was exercised by the Underwriters in full on February 29, 2024. On March 22, 2023, the Company entered into an exchange agreement, or the Exchange Agreement, with entities affiliated with RTW, or the Exchanging Stockholders, pursuant to which the Company exchanged an aggregate of 1,059,000 shares of the Company’s common shares owned by the Exchanging Stockholders for pre-funded warrants, or the Exchange Warrants, to purchase an aggregate of 1,059,000 common shares, with an exercise price of $0.001 per share and no expiration date. The Exchange Warrants are exercisable immediately and no additional cash consideration was rendered in exchange for the warrants. A holder of the Exchange Warrants (together with its affiliates and other attribution parties) may not exercise any portion of an Exchange Warrant to the extent that immediately prior to or after giving effect to such exercise the holder, together with its affiliates, would beneficially own more than 9.99% of the Company’s outstanding common shares immediately after exercise, which percentage may be increased or decreased to any other percentage specified not in excess of 9.99% at the holder's election upon 61 days ' notice to the Company subject to the terms of the Exchange Warrants.

Share Based Compensation

Share Based Compensation	3 Months Ended
Share Based Compensation	Mar. 31, 2024
Share Based Compensation
Share Based Compensation	8 Share Based Compensation Stock Options Under the Company’s 2019 Equity Incentive Plan, or the 2019 Plan, and the Company’s Stock Option Plan, or the 2011 Plan, unless otherwise decided by the Board of Directors, options vest and are exercisable as follows: 25% vest one thirty-sixth th remaining anniversary On January 1, 2024, the number of the Company’s common shares reserved for issuance under the 2019 Plan automatically increased by 1,339,324 common shares. In addition, 125,323 options have been forfeited under the 2011 Plan since the adoption of the 2019 Plan and have become available for issuance under the 2019 Plan. Further, since the adoption of the plan, 561,000 of previously issued options were cancelled and were made available for future grants. As of March 31, 2024, there were 9,522,270 common shares available for issuance under the 2019 Plan, of which 3,399,059 common shares were available for future grants. On November 10, 2021, the Company established a 2021 Inducement Plan, or the Inducement Plan, through the granting of awards. This 2021 Inducement Plan is intended to help the Company provide an inducement material for certain individuals to enter into employment with the Company, incentives for such persons to exert maximum efforts for the success of the Company and provide a means by which employees may benefit from increases in value of the common shares. As of March 31, 2024, there were 1,000,000 shares available for issuance under the 2021 Inducement Plan, of which 473,250 shares were available for future grants. The total outstanding and exercisable options from the 2011 Plan, 2019 Plan and Inducement Plan as of March 31 were as follows: 2024 Weighted Number average of shares exercise 2019 Plan Inducement Plan 2011 Plan Total price Outstanding at beginning of year - 2011 Plan — — 1,694,233 1,694,233 $ 2.09 Outstanding at beginning of year - 2019 Plan 6,406,897 — — 6,406,897 5.82 Outstanding at beginning of year - Inducement Plan — 625,000 — 625,000 5.74 Granted - 2019 Plan 45,000 — — 45,000 1.45 Forfeited - Inducement Plan — (98,250) — (98,250) 4.33 Forfeited - 2019 Plan (386,053) — — (386,053) 4.42 Expired - 2019 Plan (13,722) — — (13,722) 6.36 Outstanding at end of period 6,052,122 526,750 1,694,233 8,273,105 $ 5.11 Outstanding at end of period - Weighted average exercise price $ 5.88 $ 6.00 $ 2.09 Exercisable at end of period 3,819,413 250,271 1,694,233 5,763,917 $ 5.24 Exercisable at end of period - Weighted average exercise price $ 6.56 $ 6.42 $ 2.09 2023 Weighted Number average of shares exercise 2019 Plan Inducement Plan 2011 Plan Total price Outstanding at beginning of year - 2011 Plan — — 1,802,672 1,802,672 $ 2.05 Outstanding at beginning of year - 2019 Plan 5,314,312 — — 5,314,312 8.35 Outstanding at beginning of year - Inducement Plan — 503,000 — 503,000 6.41 Granted - 2019 Plan 1,487,400 — — 1,487,400 3.59 Granted - Inducement Plan — — — — — Exercised - 2019 Plan (7,000) — — (7,000) 3.74 Exercised - 2011 Plan — — (60,224) (60,224) 1.63 Forfeited - Inducement Plan — — — — — Forfeited - 2019 Plan (5,323) — — (5,323) 7.45 Forfeited - 2011 Plan — — — — — Expired - 2019 Plan (24,617) — — (24,617) 17.80 Expired - 2011 Plan — — — — — Outstanding at end of period 6,764,772 503,000 1,742,448 9,010,220 $ 6.22 Outstanding at end of period - Weighted average exercise price $ 7.28 $ 6.41 $ 2.07 Exercisable at end of period 2,896,996 89,375 1,742,448 4,728,819 $ 6.62 Exercisable at end of period - Weighted average exercise price $ 9.36 6.47 $ 2.07 The weighted average remaining contractual life was 6.7 and 7.7 years for outstanding options as of March 31, 2024 and 2023, respectively. The weighted average remaining contractual life was 5.9 and 6.6 years for vested options, as of March 31, 2024 and 2023, respectively. There was $8.6 million and $17.7 million of total unrecognized compensation cost related to non-vested share options as of March 31, 2024 and 2023, respectively. The share options are expected to be recognized over a remaining weighted average vesting period of 2.3 years and 2.6 years as of March 31, 2024 and 2023, respectively. Options granted are valued using the Black-Scholes option pricing model. This model also requires assumptions, including expected option life, volatility, risk-free interest rate and dividend yield, which greatly affect the calculated values. Amortization of the fair value of the options over vesting years has been expensed and credited to additional paid-in capital in shareholders’ equity. The non-vested options as of March 31 were as follows: 2024 Number Weighted of options average 2019 Plan Inducement Plan 2011 Plan Total fair value Non-vested share options at beginning of year - 2019 Plan 3,178,475 — — 3,178,475 3.64 Non-vested share options at beginning of year - Inducement Plan — 403,167 — 403,167 4.07 Granted - 2019 Plan 45,000 — — 45,000 1.12 Vested, outstanding 2019 Plan (604,713) — — (604,713) 3.54 Vested, outstanding Inducement Plan — (28,438) — (28,438) 4.85 Forfeited - Inducement Plan — (98,250) — (98,250) 3.31 Forfeited - 2019 Plan (386,053) — — (386,053) 3.47 Non-vested share options at end of period 2,232,709 276,479 — 2,509,188 $ 3.71 Non-vested share options at end of period - Weighted average fair value $ 3.64 $ 4.26 $ — 2023 Number Weighted of options average 2019 Plan Inducement Plan 2011 Plan Total fair value Non-vested share options at beginning of year - 2011 Plan — — 2,126 2,126 $ 6.64 Non-vested share options at beginning of year - 2019 Plan 2,923,763 — — 2,923,763 5.30 Non-vested share options at beginning of year - Inducement Plan — 503,000 — 503,000 4.84 Granted - 2019 Plan 1,487,400 — — 1,487,400 2.86 Vested, outstanding 2011 Plan — — (2,126) (2,126) 6.64 Vested, outstanding 2019 Plan (538,064) — — (538,064) 5.37 Vested, outstanding Inducement Plan — (89,375) — (89,375) 4.88 Forfeited - 2019 Plan (5,323) — — (5,323) 5.69 Non-vested share options at end of period 3,867,776 413,625 — 4,281,401 $ 4.40 Non-vested share options at end of period - Weighted average fair value $ 4.35 $ 4.83 $ — The fair value of options granted for the 2011 Plan, 2019 Plan and Inducement Plan were estimated using the Black-Scholes option pricing model, resulting in the following weighted average assumptions for the options granted: Three months ended March 31, 2024 2023 Exercise price $ 1.45 $ 3.59 Share price $ 1.45 $ 3.59 Volatility 91 % 97 % Risk-free interest rate 4.26 % 3.95 % Expected life 6.08 years 6.08 years Dividend 0 % 0 % Expected volatility is determined using comparable companies for which the information is publicly available. The risk-free interest rate is determined based on the U.S. sovereign rates benchmark in effect at the time of grant with a remaining term equal to the expected life of the option. Expected option life is determined based on the simplified method as the Company does not have sufficient historical exercise data to provide a reasonable basis upon which to estimate expected term. The simplified method is an average of the contractual term of the options and its ordinary vesting period. Dividend yield is based on the share option’s exercise price and expected annual dividend rate at the time of grant. Employee Stock Purchase Plan On July 15, 2022, the Company offered an ESPP, in which participation is available to our employees in the United States and Canada who meet certain service eligibility requirements. Eligible employees may authorize an amount up to 15% of their salary to purchase common stock at the lower of a 15% discount to the beginning price of the participation period or a 15% discount to the ending price of each six-month purchase interval. The ESPP also provides for an automatic reset feature to start participants on a new twelve-month participation period in the event that the common stock market value on a purchase date is less than the common stock value on the first day of the twelve-month offering period. On January 1, 2024, the number of common shares reserved for issuance under the ESPP automatically increased by 334,831 shares. As of March 31, 2024, the Company has 1,797,766 common shares available for issuance under the ESPP, of which 237,393 shares of common stock have been issued. Compensation expense for purchase rights under the ESPP related to the purchase discount and the “look-back” option were determined using a Black-Scholes option pricing model. The Company recognized total share-based compensation expense for all plans as follows: Three months ended March 31, 2024 2023 Administration $ 910 $ 1,201 Research and development 471 786 Commercial activities 131 306 Total $ 1,512 $ 2,293

Net Loss Per Share

Net Loss Per Share	3 Months Ended
Net Loss Per Share	Mar. 31, 2024
Net Loss Per Share
Net Loss Per Share	9 Net Loss Per Share Basic and diluted net loss per common share is determined by dividing net loss applicable to common shareholders by the weighted average number of common shares and pre-funded warrants outstanding during the period. In addition to the conversion feature on the 2029 Convertible Notes described above, which the Company reviewed and concluded that if-converted would be anti-dilutive due to the facts surrounding the feature, the following potentially dilutive securities have also been excluded from the computation of diluted weighted average shares outstanding as of March 31, as they would be anti-dilutive: 2024 2023 Share options 8,273,105 9,010,220 Amounts above reflect the common share equivalents of the noted instruments.

Royalty Purchase Agreement

Royalty Purchase Agreement	3 Months Ended
Royalty Purchase Agreement	Mar. 31, 2024
Royalty Purchase Agreement
Royalty Purchase Agreement	10 Royalty Purchase Agreement On March 27, 2023, we entered into a purchase and sale agreement, or the “Royalty Purchase Agreement”, with RTW. Pursuant to the Royalty Purchase Agreement, RTW agreed to purchase, following the U.S. Food and Drug Administration approval of etripamil (subject to certain conditions), in exchange for a purchase price of $75.0 million, the right to receive a tiered quarterly royalty payments, or the “Royalty Interest”, on the annual net product sales of etripamil in the United States in an amount equal to: (i) 7%, or the “Initial Tier Royalty”, of annual net sales up to $500 million, (ii) 4% of annual net sales greater Based on the Company’s assessment of the terms and conditions under the Royalty Purchase Agreement, there is no accounting recognition required in these interim financial statements.

Other receivables

Other receivables	3 Months Ended
Other receivables	Mar. 31, 2024
Other receivables
Other receivables	11 Other receivables Other receivables comprised of the following: March 31, 2024 December 31, 2023 Interest receivable $ 813 $ 528 Sales tax receivable 218 264 Clinical receivable 381 2,400 Other current receivable 1 16 $ 1,413 $ 3,208 As of March 31, 2024, the Company recognized $0.4 million in clinical receivables for clinical upfront payments made to CROs. For the year ended December 31, 2023, the Company recognized a clinical receivable of $2.4 million for clinical upfront payments made to CROs.

Summary of Significant Accoun_2

Summary of Significant Accounting Policies (Policies)	3 Months Ended
Summary of Significant Accounting Policies (Policies)	Mar. 31, 2024
Summary of Significant Accounting Policies
Basis of Consolidation	a) Basis of Consolidation The condensed consolidated financial statements include the accounts of the Company and Milestone Pharmaceuticals USA, Inc. All intercompany transactions and balances have been eliminated.
Basis of Presentation and Use of Accounting Estimates and Significant Accounting Policies	b) Basis of Presentation and Use of Accounting Estimates and Significant Accounting Policies These unaudited interim condensed consolidated financial statements have been prepared in accordance with accounting principles generally accepted in the United States of America, or “U.S. GAAP”, and on a basis consistent with those accounting principles followed by the Company and disclosed in Note 2 of its most recent annual consolidated financial statements. Certain information, in particular the accompanying notes normally included in the annual financial statements prepared in accordance with U.S. GAAP have been omitted or condensed. Accordingly, these unaudited interim condensed consolidated financial statements do not include all the information required for full annual financial statements, and therefore, should be read in conjunction with the annual consolidated financial statements and the notes thereto for the year ended December 31, 2023. In the opinion of the Company's management, the accompanying unaudited interim condensed consolidated financial statements contain all adjustments, consisting of only normal recurring adjustments, necessary for a fair statement of its balance sheet as of March 31, 2024, and its statements of loss, shareholders’ equity and cash flows for the three months ended March 31, 2024 and 2023. The condensed consolidated balance sheet as of December 31, 2023, was derived from audited annual consolidated financial statements, but does not contain all the footnote disclosures required by accounting principles generally accepted in the United States of America. These unaudited interim condensed consolidated financial statements are presented in US dollars, which is the Company’s functional currency. The preparation of unaudited interim condensed consolidated financial statements in conformity with U.S. GAAP requires the Company to make estimates and judgments that affect certain reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the consolidated financial statements and the reported amounts of revenue and expenses during the period. The Company bases its estimates and assumptions on current facts, historical experience and various other factors that it believes are reasonable under the circumstances, to determine the carrying values of assets and liabilities that are not readily apparent from other sources. Significant estimates and judgments include, but are not limited to, ● Estimates of the percentage of work completed of the total work over the life of the individual trial in accordance with agreements established with clinical research organizations, or CROs, contract manufacturing organizations, or CMOs, and clinical trial sites which in turn impact the research & development expenses. ● Estimate of the grant date fair value share options granted to employees, consultants and directors, and the resulting share-based compensation expense, using the Black-Scholes option-pricing model.
Recently Adopted Accounting Pronouncements	d) Recent Accounting Pronouncements In November 2023, the Financial Accounting Standards Board (“FASB”) issued Accounting Standard Update (“ASU”) 2023-07, Segment Reporting (Topic 280): Improvements to Reportable Segment Disclosures (“ASU 2023-07”), which requires public entities to disclose information about their reportable segments’ significant expenses on an interim and annual basis. ASU 2023-07 is effective for fiscal years beginning after December 15, 2023, and interim periods within fiscal years beginning after December 15, 2024. Early adoption is permitted. The Company is evaluating the effect of adopting this new accounting guidance on its financial statements, but does not intend to early adopt. In December 2023, the FASB issued ASU 2023-09, Income Taxes (Topic 740): Improvements to Income Tax Disclosures (“ASU 2023-09”). The amendments in this update require that public business entities on an annual basis (1) disclose specific categories in the rate reconciliation and (2) provide additional information for reconciling items that meet a quantitative threshold (if the effect of those reconciling items is equal to or greater than 5 percent of the amount computed by multiplying pretax income [or loss] by the applicable statutory income tax rate). The amendments also require entities on an annual basis to disclose disaggregated amounts of income taxes paid. ASU 2023-09 is effective for annual periods beginning after December 15, 2024. Early adoption is permitted for annual financial statements that have not yet been issued or made available for issuance. The Company is evaluating the effect of adopting this new accounting guidance on its financial statements, but does not intend to early adopt.
Significant Risks and Uncertainties	c) Significant Risks and Uncertainties The Company is subject to challenges and risks specific to its business and its ability to execute on its strategy, as well as risks and uncertainties common to companies in the pharmaceutical industry, including, without limitation, risks and uncertainties associated with: obtaining regulatory approval of its product candidate; delays or problems in the supply of its study drug or failure to comply with manufacturing regulations; identifying, acquiring or in-licensing product candidates; pharmaceutical product development and the inherent uncertainty of clinical success; and the challenges of protecting and enhancing its intellectual property rights; and complying with applicable regulatory requirements. Further, the Company may be impacted by general economic, political, and market conditions, including deteriorating market conditions due to investor concerns regarding inflation, armed conflicts, and overall fluctuations in the financial markets in the U.S. and abroad.
Sources of Liquidity and Funding Requirements	e) Sources of Liquidity and Funding Requirements The Company incurred operating losses and has experienced negative operating cash flows since its inception and anticipates continuing to incur losses for at least the next several years. Further, in connection with the revised timeline for our NDA submission, we have undertaken certain cash conservation measures to reduce spending through program deferrals and team restructuring. These cash conservation measures were substantially completed during the first quarter of 2024. These cash conservation measures were partially offset by $1.1 million in termination benefits paid as a result of the team restructuring. As of March 31, 2024, the Company had cash, cash equivalents and short-term investments of $89.5 million and an accumulated deficit of $336.4 million. Management has evaluated the Company’s operating plan, including the previously mentioned cash conservation measures, against its existing cash and cash equivalents and short-term investments and determined that the Company expects to be able to support its operations for at least the next 12 months from the date of issuance of these unaudited interim consolidated financial statements.

Debt (Tables)

Debt (Tables)	3 Months Ended
Debt (Tables)	Mar. 31, 2024
Debt
Schedule of Convertible Note	March 31, 2024 December 31, 2023 Original principal $ 50,000 $ 50,000 Paid in kind (PIK) interest 3,094 2,310 Unamortized debt discount (528) (547) Unamortized debt issuance costs (1,922) (1,991) Total $ 50,644 $ 49,772
Schedule of total amount of interest cost	The following table presents the total amount of interest cost recognized relating to the 2029 Convertible Notes: Three months ended March 31, 2024 2023 Contractual interest expense $ 785 $ 30 Amortization of debt discount 18 1 Amortization of debt issuance costs 69 2 Total interest expense $ 872 $ 33

Accounts Payable and Accrued _2

Accounts Payable and Accrued Liabilities (Tables)	3 Months Ended
Accounts Payable and Accrued Liabilities (Tables)	Mar. 31, 2024
Accounts Payable and Accrued Liabilities
Schedule of accounts payable and accrued liabilities	March 31, 2024 December 31, 2023 Trade accounts payable $ 1,727 $ 3,981 Accrued compensation and benefits payable 824 712 Accrued research and development liabilities 518 894 Accrued commercial liabilities 40 710 Other accrued liabilities 466 383 Total $ 3,575 $ 6,680

Share Based Compensation (Table

Share Based Compensation (Tables)	3 Months Ended
Share Based Compensation (Tables)	Mar. 31, 2024
Share Based Compensation
Schedule of outstanding and exercisable options	2024 Weighted Number average of shares exercise 2019 Plan Inducement Plan 2011 Plan Total price Outstanding at beginning of year - 2011 Plan — — 1,694,233 1,694,233 $ 2.09 Outstanding at beginning of year - 2019 Plan 6,406,897 — — 6,406,897 5.82 Outstanding at beginning of year - Inducement Plan — 625,000 — 625,000 5.74 Granted - 2019 Plan 45,000 — — 45,000 1.45 Forfeited - Inducement Plan — (98,250) — (98,250) 4.33 Forfeited - 2019 Plan (386,053) — — (386,053) 4.42 Expired - 2019 Plan (13,722) — — (13,722) 6.36 Outstanding at end of period 6,052,122 526,750 1,694,233 8,273,105 $ 5.11 Outstanding at end of period - Weighted average exercise price $ 5.88 $ 6.00 $ 2.09 Exercisable at end of period 3,819,413 250,271 1,694,233 5,763,917 $ 5.24 Exercisable at end of period - Weighted average exercise price $ 6.56 $ 6.42 $ 2.09 2023 Weighted Number average of shares exercise 2019 Plan Inducement Plan 2011 Plan Total price Outstanding at beginning of year - 2011 Plan — — 1,802,672 1,802,672 $ 2.05 Outstanding at beginning of year - 2019 Plan 5,314,312 — — 5,314,312 8.35 Outstanding at beginning of year - Inducement Plan — 503,000 — 503,000 6.41 Granted - 2019 Plan 1,487,400 — — 1,487,400 3.59 Granted - Inducement Plan — — — — — Exercised - 2019 Plan (7,000) — — (7,000) 3.74 Exercised - 2011 Plan — — (60,224) (60,224) 1.63 Forfeited - Inducement Plan — — — — — Forfeited - 2019 Plan (5,323) — — (5,323) 7.45 Forfeited - 2011 Plan — — — — — Expired - 2019 Plan (24,617) — — (24,617) 17.80 Expired - 2011 Plan — — — — — Outstanding at end of period 6,764,772 503,000 1,742,448 9,010,220 $ 6.22 Outstanding at end of period - Weighted average exercise price $ 7.28 $ 6.41 $ 2.07 Exercisable at end of period 2,896,996 89,375 1,742,448 4,728,819 $ 6.62 Exercisable at end of period - Weighted average exercise price $ 9.36 6.47 $ 2.07
Schedule of non-vested share options activity	2024 Number Weighted of options average 2019 Plan Inducement Plan 2011 Plan Total fair value Non-vested share options at beginning of year - 2019 Plan 3,178,475 — — 3,178,475 3.64 Non-vested share options at beginning of year - Inducement Plan — 403,167 — 403,167 4.07 Granted - 2019 Plan 45,000 — — 45,000 1.12 Vested, outstanding 2019 Plan (604,713) — — (604,713) 3.54 Vested, outstanding Inducement Plan — (28,438) — (28,438) 4.85 Forfeited - Inducement Plan — (98,250) — (98,250) 3.31 Forfeited - 2019 Plan (386,053) — — (386,053) 3.47 Non-vested share options at end of period 2,232,709 276,479 — 2,509,188 $ 3.71 Non-vested share options at end of period - Weighted average fair value $ 3.64 $ 4.26 $ — 2023 Number Weighted of options average 2019 Plan Inducement Plan 2011 Plan Total fair value Non-vested share options at beginning of year - 2011 Plan — — 2,126 2,126 $ 6.64 Non-vested share options at beginning of year - 2019 Plan 2,923,763 — — 2,923,763 5.30 Non-vested share options at beginning of year - Inducement Plan — 503,000 — 503,000 4.84 Granted - 2019 Plan 1,487,400 — — 1,487,400 2.86 Vested, outstanding 2011 Plan — — (2,126) (2,126) 6.64 Vested, outstanding 2019 Plan (538,064) — — (538,064) 5.37 Vested, outstanding Inducement Plan — (89,375) — (89,375) 4.88 Forfeited - 2019 Plan (5,323) — — (5,323) 5.69 Non-vested share options at end of period 3,867,776 413,625 — 4,281,401 $ 4.40 Non-vested share options at end of period - Weighted average fair value $ 4.35 $ 4.83 $ —
Schedule of weighted average assumptions for the options granted	Three months ended March 31, 2024 2023 Exercise price $ 1.45 $ 3.59 Share price $ 1.45 $ 3.59 Volatility 91 % 97 % Risk-free interest rate 4.26 % 3.95 % Expected life 6.08 years 6.08 years Dividend 0 % 0 %
Schedule of share-based compensation expense	Three months ended March 31, 2024 2023 Administration $ 910 $ 1,201 Research and development 471 786 Commercial activities 131 306 Total $ 1,512 $ 2,293

Net Loss Per Share (Tables)

Net Loss Per Share (Tables)	3 Months Ended
Net Loss Per Share (Tables)	Mar. 31, 2024
Net Loss Per Share
Schedule of potentially dilutive securities excluded from the computation of diluted weighted average shares	2024 2023 Share options 8,273,105 9,010,220

Other receivables (Tables)

Other receivables (Tables)	3 Months Ended
Other receivables (Tables)	Mar. 31, 2024
Other receivables
Schedule of other receivables	March 31, 2024 December 31, 2023 Interest receivable $ 813 $ 528 Sales tax receivable 218 264 Clinical receivable 381 2,400 Other current receivable 1 16 $ 1,413 $ 3,208

Summary of Significant Accoun_3

Summary of Significant Accounting Policies - Sources of Liquidity and Funding Requirements (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Dec. 31, 2023
Summary of Significant Accounting Policies
Cash, cash equivalents and short-term investments	$ 89,500
Accumulated deficit	(336,380)	$ (326,026)
Termination benefits	$ 1,100

Revenues (Details)

Revenues (Details) - USD ($) $ in Thousands	3 Months Ended
Revenues (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Mar. 31, 2023	Dec. 31, 2023
Revenues
Revenue	$ 0	$ 1,000
Warrants	$ 53,076		$ 48,459

Short-term Investments (Details

Short-term Investments (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Short-term Investments
Short-term investments	$ 79,350	$ 52,243
Pledged collateral	$ 500

Debt (Details)

Debt (Details)		3 Months Ended
Debt (Details)	Mar. 29, 2023 USD ($) item $ / shares shares	Mar. 31, 2023 USD ($)	Mar. 31, 2024 USD ($)
Debt Instruments
Proceeds from convertible notes		$ 50,000,000
RTW Investments, LP \| Senior Secured Convertible Notes \| Strategic Financing Agreements
Debt Instruments
Proceeds from convertible notes	$ 50,000,000
Coupon rate (as a percent)	6%
Paid in kind, term	3 years
Principal amount denomination for conversion	$ 1,000
Convertible shares issuable \| shares	191.0548
Conversion price \| $ / shares	$ 5.23
Threshold Percentage of stock price	150%
Threshold trading days \| item	20
Threshold consecutive trading days \| item	30
Redemption price percentage	100%
Estimated Fair Value			$ 47,500,000

Debt - Convertible Note (Detail

Debt - Convertible Note (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Debt Instruments
Total	$ 50,644	$ 49,772
Senior Secured Convertible Notes \| RTW Investments, LP \| Strategic Financing Agreements
Debt Instruments
Original principal	50,000	50,000
Paid in kind (PIK) interest	3,094	2,310
Unamortized debt discount	(528)	(547)
Unamortized debt issuance costs	(1,922)	(1,991)
Total	$ 50,644	$ 49,772

Debt - Total amount of interest

Debt - Total amount of interest cost (Details) - Senior Secured Convertible Notes - RTW Investments, LP - Strategic Financing Agreements - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Debt Instruments
Contractual interest expense	$ 785	$ 30
Amortization of debt discount	18	1
Amortization of debt issuance costs	69	2
Total interest expense	$ 872	$ 33

Accounts Payable and Accrued _3

Accounts Payable and Accrued Liabilities (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Accounts Payable and Accrued Liabilities
Trade accounts payable	$ 1,727	$ 3,981
Accrued compensation and benefits payable	824	712
Accrued research and development liabilities	518	894
Accrued commercial liabilities	40	710
Other accrued liabilities	466	383
Total	$ 3,575	$ 6,680

Shareholders' Equity - Authoriz

Shareholders' Equity - Authorized share capital (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Dec. 31, 2023
Authorized share capital
Common shares, Shares issued (in shares)	53,245,165	33,483,111
Common shares, Shares outstanding (in shares)	53,245,165	33,483,111
Net proceeds	$ 27,538
Employee Stock Purchase Plan
Authorized share capital
Number of common shares available for issuance	1,798,766
Additional shares reserved for issuance	1,561,373

Shareholders' Equity - Addition

Shareholders' Equity - Additional authorized share capital (Details) - USD ($) $ / shares in Units, $ in Thousands		3 Months Ended
	Feb. 28, 2024	Mar. 31, 2024
Authorized share capital
Net proceeds		$ 27,538
Pre-funded warrants \| Strategic Financing Agreements
Authorized share capital
Share price (in dollar per share)	$ 1.499
Warrants issued to purchase shares	3,333,333
Warrants exercise price	$ 0.001
Pre-funded warrants \| Strategic Financing Agreements \| Maximum
Authorized share capital
Number of shares issued during the period	3,000,000
Underwriters \| Strategic Financing Agreements
Authorized share capital
Number of shares issued during the period	16,666,667
Share price (in dollar per share)	$ 1.50

Shareholders' Equity - Open Mar

Shareholders' Equity - Open Market Sale Agreement and Public Offering (Details) - USD ($)		3 Months Ended
	Mar. 22, 2023	Mar. 31, 2024	Mar. 31, 2023
Class of Warrant or Right
Offering price		$ 27,258,000
RTW Investments, LP
Class of Warrant or Right
Common shares exchanged for pre-funded warrants	1,059,000
Purchase price	$ 0.001
Proceeds from exercise of warrants	$ 0
Maximum ownership after exercise of exchange agreement	9.99%
Required notice (in days)	61 days
Common Shares
Class of Warrant or Right
Common shares exchanged for pre-funded warrants			1,059,000
Offering price		$ 27,258,000
Number of shares issued during the period		19,666,667

Share Based Compensation (Detai

Share Based Compensation (Details) - $ / shares			3 Months Ended
Share Based Compensation (Details) - $ / shares	Jan. 01, 2024	Jul. 15, 2022	Mar. 31, 2024	Mar. 31, 2023	Dec. 31, 2023	Dec. 31, 2022
2011 Plan
Share-based compensation
Number of options forfeited after termination of one plan	125,323
Number of options, Options outstanding			1,694,233	1,742,448	1,694,233	1,802,672
2019 Plan
Share-based compensation
Shares reserved for issuance	1,339,324		9,522,270
Shares available for future grants			3,399,059
Options granted			45,000	1,487,400
Cancelled			561,000
Number of options, Options outstanding			6,052,122	6,764,772	6,406,897	5,314,312
Weighted average exercise price			$ 1.45	$ 3.59
2021 Inducement Plan
Share-based compensation
Shares reserved for issuance			1,000,000
Shares available for future grants			473,250
Number of options, Options outstanding			526,750	503,000	625,000	503,000
ESPP
Share-based compensation
Shares reserved for issuance	334,831		1,797,766
Shares issued			237,393
Percentage of wages eligible employees may authorize of their salary to purchase common stock		15%
Percentage of discount at which an eligible employee may purchase common stock of each purchase interval		15%
Duration of of each purchase interval		6 months
Automatic reset period		12 months
Options \| 2011 Plan
Share-based compensation
Vesting period			4 years
Options \| 2011 Plan \| Share-based Compensation Award, Tranche One
Share-based compensation
Percentage of shares to vest			25%
Options \| 2011 Plan \| Share-based Compensation Award, Tranche Two
Share-based compensation
Percentage of shares to vest			2.78%
Options \| 2019 Plan
Share-based compensation
Vesting period			4 years
Options \| 2019 Plan \| Share-based Compensation Award, Tranche One
Share-based compensation
Percentage of shares to vest			25%
Options \| 2019 Plan \| Share-based Compensation Award, Tranche Two
Share-based compensation
Percentage of shares to vest			2.78%

Share Based Compensation - Outs

Share Based Compensation - Outstanding and exercisable options (Details) - USD ($) $ / shares in Units, $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Outstanding and exercisable options, weighted average exercise price
Weighted average remaining contractual life (in years)	6 years 8 months 12 days	7 years 8 months 12 days
Weighted average remaining contractual life for vested options (in years)	5 years 10 months 24 days	6 years 7 months 6 days
Unrecognized compensation cost	$ 8,600	$ 17,700
Expected period for recognition	2 years 3 months 18 days	2 years 7 months 6 days
Share-based compensation expense	$ 1,512	$ 2,293
Plans 2011 and 2019 and 2021 Inducement [Member]
Outstanding and exercisable options, number of shares
Outstanding at end of period	8,273,105	9,010,220
Exercisable at end of period	5,763,917	4,728,819
Outstanding and exercisable options, weighted average exercise price
Outstanding at end of period	$ 5.11	$ 6.22
Exercisable at end of period	$ 5.24	$ 6.62
2011 Plan
Outstanding and exercisable options, number of shares
Outstanding at beginning of period	1,694,233	1,802,672
Exercised		(60,224)
Outstanding at end of period	1,694,233	1,742,448
Exercisable at end of period	1,694,233	1,742,448
Outstanding and exercisable options, weighted average exercise price
Outstanding at beginning of period	$ 2.09	$ 2.05
Exercised		1.63
Outstanding at end of period	2.09	2.07
Exercisable at end of period	$ 2.09	$ 2.07
2019 Plan
Outstanding and exercisable options, number of shares
Outstanding at beginning of period	6,406,897	5,314,312
Granted	45,000	1,487,400
Expired	(13,722)	(24,617)
Exercised		(7,000)
Forfeited	(386,053)	(5,323)
Cancelled	(561,000)
Outstanding at end of period	6,052,122	6,764,772
Exercisable at end of period	3,819,413	2,896,996
Outstanding and exercisable options, weighted average exercise price
Outstanding at beginning of period	$ 5.82	$ 8.35
Granted	1.45	3.59
Exercised		3.74
Forfeited	4.42	7.45
Expired	6.36	17.80
Outstanding at end of period	5.88	7.28
Exercisable at end of period	$ 6.56	$ 9.36
2021 Inducement Plan
Outstanding and exercisable options, number of shares
Outstanding at beginning of period	625,000	503,000
Forfeited	(98,250)
Outstanding at end of period	526,750	503,000
Exercisable at end of period	250,271	89,375
Outstanding and exercisable options, weighted average exercise price
Outstanding at beginning of period	$ 5.74	$ 6.41
Forfeited	4.33
Outstanding at end of period	6	6.41
Exercisable at end of period	$ 6.42	$ 6.47

Share Based Compensation - Non-

Share Based Compensation - Non-vested share options (Details) - $ / shares	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Plans 2011 and 2019 and 2021 Inducement
Number of options
Non-vested share options at end of period	2,509,188	4,281,401
Weighted average fair value
Non-vested at end of period	$ 3.71	$ 4.40
2011 Plan
Number of options
Non-vested at beginning of period		2,126
Vested, outstanding		(2,126)
Weighted average fair value
Non-vested at beginning of period		$ 6.64
Vested, outstanding		$ 6.64
2019 Plan
Number of options
Non-vested at beginning of period	3,178,475	2,923,763
Granted	45,000	1,487,400
Vested, outstanding	(604,713)	(538,064)
Forfeited	(386,053)	(5,323)
Non-vested share options at end of period	2,232,709	3,867,776
Weighted average fair value
Non-vested at beginning of period	$ 3.64	$ 5.30
Granted	1.12	2.86
Vested, outstanding	3.54	5.37
Forfeited	3.47	5.69
Non-vested at end of period	$ 3.64	$ 4.35
2021 Inducement Plan
Number of options
Non-vested at beginning of period	403,167	503,000
Vested, outstanding	(28,438)	(89,375)
Forfeited	(98,250)
Non-vested share options at end of period	276,479	413,625
Weighted average fair value
Non-vested at beginning of period	$ 4.07	$ 4.84
Vested, outstanding	4.85	4.88
Forfeited	3.31
Non-vested at end of period	$ 4.26	$ 4.83

Share Based Compensation - Weig

Share Based Compensation - Weighted average assumptions for the options granted (Details) - Options - USD ($)	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Share-based compensation
Exercise price	$ 1.45	$ 3.59
Share price (in dollars per share)	$ 1.45	$ 3.59
Volatility (as a percent)	91%	97%
Risk-free interest rate (as a percent)	4.26%	3.95%
Expected life (in years)	6 years 29 days	6 years 29 days
Dividend (as a percent)	0%	0%

Share Based Compensation - Reco

Share Based Compensation - Recognized share-based compensation expense (Details) - USD ($) $ in Thousands	3 Months Ended
	Mar. 31, 2024	Mar. 31, 2023
Share-based compensation
Share-based compensation expense	$ 1,512	$ 2,293
Administration
Share-based compensation
Share-based compensation expense	910	1,201
Research and development
Share-based compensation
Share-based compensation expense	471	786
Commercial activities
Share-based compensation
Share-based compensation expense	$ 131	$ 306

Net loss per share (Details)

Net loss per share (Details) - shares	3 Months Ended
Net loss per share (Details) - shares	Mar. 31, 2024	Mar. 31, 2023
Share options
Net income (loss) per share
Share options	8,273,105	9,010,220

Royalty Purchase Agreement (Det

Royalty Purchase Agreement (Details) - RTW Investments, LP - Strategic Financing Agreements $ in Millions	Mar. 27, 2023 USD ($)
Royalty Purchase Agreement
Funding received from sale of product rights	$ 75
Up to $500 million
Royalty Purchase Agreement
Future payment as a percentage of aggregate net sales	7%
Threshold amount of annual aggregate net sales	$ 500
Additional future payment as a percentage of aggregate net sales	9.50%
Above $800 million
Royalty Purchase Agreement
Future payment as a percentage of aggregate net sales	1%
Threshold amount of annual aggregate net sales	$ 800
Minimum \| Above $500 million
Royalty Purchase Agreement
Future payment as a percentage of aggregate net sales	4%
Threshold amount of annual aggregate net sales	$ 500
Maximum \| Up to $800 million
Royalty Purchase Agreement
Future payment as a percentage of aggregate net sales	4%
Threshold amount of annual aggregate net sales	$ 800

Other receivables (Details)

Other receivables (Details) - USD ($) $ in Thousands	Mar. 31, 2024	Dec. 31, 2023
Other receivables
Interest receivable	$ 813	$ 528
Sales tax receivable	218	264
Clinical receivable	381	2,400
Other current receivable	1	16
Other receivables	$ 1,413	$ 3,208