TITLE PAGE...2012N132812_08 CONFIDENTIAL The GlaxoSmithKline group of companies SAP115570 2 Revision Chronology GlaxoSmithKline Document Number Date Version 2012N132812_00 2012-SEP-04

2012N132812_08 CONFIDENTIALThe GlaxoSmithKline group of companies SAP115570

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TITLE PAGE

Division: Worldwide DevelopmentInformation Type: Protocol Amendment

Title: A single dose first in human study of GSK2398852 co-administered with GSK2315698 in patients with systemic amyloidosis

Compound Number: GSK2398852 + GSK2315698

Development Phase: I

Effective Date: 04-AUG-2015

Protocol Amendment Number: 05

Author (s):

(Academic DPU); (Safety Assessment); (Clinical Statistics); (PTS DMPK); (Clinical PharmacologySciences and Study Operations); (Clinical Pharmacology Sciences and Study Operations); (CPMS); (UCL Wolfson Drug Discovery Unit, London); (National Amyloidosis Centre, London);

(Global Health Outcomes).

Copyright 2015 the GlaxoSmithKline group of companies. All rights reserved. Unauthorised copying or use of this information is prohibited.


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Revision Chronology

GlaxoSmithKline Document Number

Date Version

2012N132812_00 2012-SEP-04 Original

2012N132812_01 2012-DEC-17 Amendment No.: 01

Additional regulatory required changes to exclusion criterion, QTc criterion and dose interval plus minor clarifications to Time and Events table

2012N132812_02 2013-MAY-21 Amendment No.: 02

Change to radiation level quoted for fluoroscopy, 48hr shelf life for GSK2315698 extended to 72hrs, increase in maximum age of patients from 65 to 70 years and other minor clarifications and consistencies.

2012N132812_03 2013-MAY-30 Amenndment No. 02 (Republished):

Change in Section 4.2.2 exclusion criteria 8

2012N132812_04 2013-MAY-30 Amendment No. 02 (Republished):

Change in Section 4.2.2 exclusion criteria 8

2012N132812_05 2014-MAR-26 Amendment No. 03:

Increase in study population for Part A, increase in duration of infusion of GSK2398852, Clarifications in Time and events Table to reflect emerging data and information on assessments to be performed for extended stay. Minor clarifications

2012N132812_06 2014-APR-08 Amendment No. 03 (Republished):

Minor typographical errors corrected

2012N132812_07 2014-JUL-30 Amendment No. 04

Updated to reflect amended design for Part B of the study based on observations from Part A.

2012N132812_08 2015-AUG-04 Amendment No. 05

Increase in the maximum age of participants (TTR only) from 70 to 75 years and allowance of anticoagulant therapy in these participants. Addition of patients with AL


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amyloidosis receiving chemotherapy for plasma cell dyscrasia. Increase in threshold level of GSK2398852 in the blood to inform cessation of GSK2315698. Clarifications to Time and Events table.

2012N132812_08 CONFIDENTIALSAP115570

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SPONSOR/MEDICAL MONITOR INFORMATION PAGE

Medical Monitor and Sponsor Contact Information:

Role Name Day Time Phone Number

After-hours Phone/Cell/Pager Number

Fax Number GSK Address

Primary Medical Monitor

Dr.

GlaxoSmithKline, Clinical Unit Cambridge Addenbrooke’s Hospital, Box 128, Hills Rd, Cambridge CB2 2GG, UK

Secondary Medical Monitor

Dr.

GlaxoSmithKline, Medicines Research Centre,Gunnels Wood Rd,Stevenage SG1 2NY, UK

Sponsor Registered Address:

GlaxoSmithKline Research & Development Limited980 Great West RoadBrentfordMiddlesex, TW8 9GSUK

In some countries, the clinical trial sponsor may be the local GlaxoSmithKline affiliate company (or designee). If applicable, the details of the alternative Sponsor and contact person in the territory will be provided to the relevant regulatory authority as part of the clinical trial application.

Regulatory Agency Identifying Number(s): 2012-00334-515


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PROTOCOL AGREEMENT PAGE

For protocol number SAP115570

I confirm agreement to conduct the study in compliance with the protocol, as amended by this protocol amendment.

I acknowledge that I am responsible for overall study conduct. I agree to personally conduct or supervise the described study.

I agree to ensure that all associates, colleagues and employees assisting in the conduct of the study are informed about their obligations. Mechanisms are in place to ensure that site staff receives the appropriate information throughout the study.

Investigator Name:

Investigator Address:

Investigator Phone Number:

Investigator Signature Date


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TABLE OF CONTENTS

PAGE

ABBREVIATIONS .........................................................................................................11

1. INTRODUCTION....................................................................................................141.1. Background ................................................................................................141.2. Rationale ....................................................................................................15

1.2.1. Overview of therapeutic intervention ............................................151.2.2. Summary of information available for GSK2315698 (SAP

depleter) ......................................................................................171.2.3. Current PKPD model for GSK2315698 and SAP .........................181.2.4. Summary of information available for anti-SAP mAb

(GSK2398852).............................................................................191.3. Study Design and Rationale........................................................................20

1.3.1. Notes on pharmacodynamic assessments...................................231.3.2. Dose Rationale ............................................................................25

1.4. Summary of Risk Management...................................................................291.4.1. Potential risks associated with administration of SAP

depleter GSK2315698 .................................................................291.4.2. Potential risks associated with administration of

GSK2398852 ...............................................................................301.4.3. Potential risks associated with study procedures .........................331.4.4. Part B chemotherapy regimen .....................................................34

2. OBJECTIVE(S) AND ENDPOINTS.........................................................................36

3. INVESTIGATIONAL PLAN.....................................................................................393.1. Study Design/Schematic.............................................................................39

3.1.1. Outline of study assessments ......................................................423.2. Treatment Assignment................................................................................423.3. Investigational Product and Other Study Treatment

Dosage/Administration................................................................................433.4. Dose Adjustment/Stopping Criteria .............................................................43

3.4.1. Dose Adjustment/Stopping Safety Criteria ...................................443.4.1.1. Liver Chemistry Stopping Criteria ...............................443.4.1.2. QTc Withdrawal Criteria .............................................443.4.1.3. Other Dose Adjustment/Stopping Safety

Criteria........................................................................453.5. Time and Events Tables (Part A, and Part B) .............................................46

4. STUDY POPULATION ...........................................................................................554.1. Number of Subjects ....................................................................................554.2. Eligibility Criteria .........................................................................................55

4.2.1. Inclusion Criteria ..........................................................................554.2.2. Exclusion Criteria.........................................................................56

4.3. Screen and Baseline Failures .....................................................................57

5. DATA ANALYSIS AND STATISTICAL CONSIDERATIONS...................................585.1. Hypotheses and Treatment Comparisons...................................................585.2. Sample Size Considerations.......................................................................58


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5.2.1. Sample Size Assumptions ...........................................................585.2.1.1. Part A and B...............................................................58

5.2.2. Sample Size Sensitivity................................................................605.2.2.1. Part A and B...............................................................60

5.2.3. Sample Size Re-estimation..........................................................605.3. Data Analysis Considerations .....................................................................60

5.3.1. Interim Analysis ...........................................................................605.3.2. Final Analyses .............................................................................60

5.3.2.1. Analysis Populations ..................................................605.3.2.2. Safety Analyses..........................................................615.3.2.3. Non-Compartmental Pharmacokinetic Analyses.........615.3.2.4. Pharmacodynamic Analyses ......................................62

5.3.2.4.1. Liver Histology........................................625.3.2.5. Pharmacokinetic/Pharmacodynamic Modelling...........625.3.2.6. Novel Biomarker(s) Analyses .....................................635.3.2.7. Health Outcomes Analyses ........................................63

6. STUDY ASSESSMENTS AND PROCEDURES .....................................................646.1. Demographic/Medical History Assessments ...............................................646.2. Safety .........................................................................................................646.3. Pregnancy ..................................................................................................66

6.3.1. Time period for collecting pregnancy information .........................666.3.2. Action to be taken if pregnancy occurs ........................................676.3.3. Action to be taken if pregnancy occurs in a female partner

of a male study subject ................................................................676.4. Pharmacokinetics .......................................................................................67

6.4.1. Blood Sample Collection..............................................................676.4.2. Sample Analysis ..........................................................................68

6.5. Biomarker(s)/Pharmacodynamic Markers ...................................................686.5.1. Pharmacodynamic markers in plasma .........................................686.5.2. EqMRI assessment......................................................................686.5.3. SAP scan.....................................................................................686.5.4. Liver Elastography .......................................................................696.5.5. Exploratory Biomarkers................................................................69

6.5.5.1. Blood biomarkers .......................................................696.5.5.2. Urine biomarkers ........................................................696.5.5.3. Histological assessment of liver biopsy.......................696.5.5.4. Bone scan ..................................................................69

6.6. Immunogenicity...........................................................................................706.7. Efficacy.......................................................................................................706.8. Health Outcomes........................................................................................70

6.8.1. Questionnaire Administration .......................................................706.8.2. Recording of Data........................................................................716.8.3. Collection and Storage of Subject Questionnaires .......................71

7. LIFESTYLE AND/OR DIETARY RESTRICTIONS..................................................717.1. Contraception Requirements ......................................................................71

7.1.1. Female Subjects ..........................................................................717.1.2. Male Subjects ..............................................................................72

7.2. Meals and Dietary Restrictions ...................................................................727.2.1. Caffeine, Alcohol, and Tobacco ...................................................72


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8. CONCOMITANT MEDICATIONS AND NON-DRUG THERAPIES .........................728.1. Permitted Medications ................................................................................728.2. Prohibited Medications................................................................................738.3. Non-Drug Therapies ...................................................................................738.4. Subject Completion.....................................................................................738.5. Subject Withdrawal Criteria.........................................................................738.6. Subject Withdrawal Procedures ..................................................................74

8.6.1. Subject Withdrawal from Study ....................................................748.6.2. Subject Withdrawal from Study Treatment ...................................74

8.7. Treatment After the End of the Study..........................................................748.8. Follow-on Study..........................................................................................75

9. STUDY TREATMENT ............................................................................................759.1. Blinding.......................................................................................................759.2. Packaging and Labelling.............................................................................759.3. Preparation/Handling/Storage/Accountability ..............................................75

9.3.1. GSK2315698 and GSK2398852 solution.....................................769.4. Assessment of Compliance ........................................................................769.5. Treatment of Study Treatment Overdose....................................................76

10. ADVERSE EVENTS (AE) AND SERIOUS ADVERSE EVENTS (SAE) ..................7610.1. Definition of Adverse Events.......................................................................7710.2. Definition of Serious Adverse Events ..........................................................7810.3. Method of Detecting AEs and SAEs............................................................7910.4. Recording of AEs and SAEs .......................................................................7910.5. Evaluating AEs and SAEs...........................................................................80

10.5.1. Assessment of Intensity ...............................................................8010.5.2. Assessment of Causality..............................................................80

10.6. Follow-up of AEs and SAEs........................................................................8010.7. Prompt Reporting of SAEs to GSK..............................................................8110.8. Regulatory Reporting Requirements For SAEs...........................................82

11. LIVER CHEMISTRY FOLLOW-UP PROCEDURES...............................................8211.1. Restarting Investigational Product ..............................................................84

12. STUDY CONDUCT CONSIDERATIONS ...............................................................8512.1. Posting of Information on Publicly Available Clinical Trial Registers............8512.2. Regulatory and Ethical Considerations, Including the Informed

Consent Process ........................................................................................8512.2.1. Urgent Safety Measures ..............................................................85

12.3. Quality Control (Study Monitoring) ..............................................................8512.4. Quality Assurance.......................................................................................8612.5. Study and Site Closure ...............................................................................8612.6. Records Retention ......................................................................................8612.7. Provision of Study Results to Investigators, Posting of Information

on Publically Available Clinical Trials Registers and Publication .................8712.8. Data Management ......................................................................................8712.9. External Safety Advisory Committee (ESAC)..............................................88

13. REFERENCES.......................................................................................................89

14. APPENDICES ........................................................................................................93


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14.1. Appendix 1: Liver Safety Algorithms ...........................................................9314.2. Appendix 2: Liver Safety Drug Restart Guidelines ......................................9414.3. Appendix 3: Preparation of dosing solutions ...............................................9714.4. Appendix 4: MDRD Equation ....................................................................10014.5. Appendix 5: Protocol Amendment Changes..............................................101


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ABBREVIATIONS

99mTc-DPD 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid

g Micrograms

-HCG Beta-Human Chorionic Gonadotropin

µg MicrogramµL MicrolitreAE Adverse EventALT Alanine aminotransferase (SGPT)APTT Activated Partial Thromboplastin Time AST Aspartate aminotransferase (SGOT)AUC Area under concentration-time curve

AUC(0-) Area under the concentration-time curve over the dosing interval

AUC(0-)AUC(0-inf)

Area under the concentration-time curve from time zero (pre-dose) extrapolated to infinite time

BP Blood pressureBUN Blood urea nitrogenCmax Maximum observed concentration CO2 Carbon dioxideCPHPC Carboxy Pyrrolidine Hexanoyl Pyrrolidine CarboxylateCPK Creatine phosphokinaseCPSSO Clinical Science and Study OperationsCRF Case Report FormCRP C Reactive ProteinCUC Clinical Unit CambridgeDa DaltonsDDX Doctors and Dentists ExemptionDMPK Drug Metabolism and PharmacokineticsDPU Discovery Performance UnitEC50 Plasma concentration of drug associated with 50% of drug effectECG ElectrocardiogramEmax Maximum drug effectEqMRI Equilibrium contrast Magnetic Resonance ImagingEudraCT European Union Drug Regulatory Authorities Clinical TrialsFDA Food and Drug AdministrationFSH Follicle Stimulating Hormoneg GramsGCP Good Clinical PracticeGFR Glomerular Filtration RateGGT Gamma glutamyltransferaseGLP Good Laboratory PracticeGSK GlaxoSmithKlineh/hr Hour(s)Hb HaemoglobinHBsAg Hepatitis B surface antigenHR Heart rate


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HuSAP Human Serum Amyloid P componantIB Investigator’s BrochureICH International Conference on Harmonization of Technical Requirements

for Registration of Pharmaceuticals for Human UseIEC Independent Ethics CommitteeIHC ImmunohistochemistryINR International Normalized RatioIP Investigational ProductIRB Institutional Review BoardIV IntravenousKg KilogramL LitreLDH Lactate dehydrogenaseLFTs Liver function testsmAb Monoclonal antibodyMCH Mean corpuscular haemoglobinMCHC Mean corpuscular haemoglobin concentrationMCV Mean corpuscular volumeMDRD Modification of Diet in Renal DiseaseMg/mg MilligramsmL MillilitreMRI Magnetic Resonance ImagingMSDS Material Safety Data Sheetmsec/ms MillisecondsmSv MillisievertsNAC National Amyloidosis CentreNOAEL No observed adverse effect levelPD Pharmacodynamicpg PicogramsPI Principal InvestigatorPK PharmacokineticPSRI Periodic Safety Reports for InvestigatorsPT Prothrombin TimeQTcB QT duration corrected for heart rate by Bazett’s formulaQTcF QT duration corrected for heart rate by Fridericia’s formulaRAP Reporting and Analysis PlanRBC Red blood cellsRNA Ribonucleic acidSAA Serum Amyloid A proteinSAE Serious adverse event(s)SAP Serum amyloid P componentSC SubcutaneousSD Standard deviationSGOT Serum glutamic-oxaloacetic transaminaseSGPT Serum glutamic pyruvic transaminaseSOP Standard Operating Procedure


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SPM Study Procedures ManualTAP Normal Tissue SAPtds Ter Die Sumendum (3 times daily)tmax Time of occurrence of CmaxTTR TransthyretinUK United KingdomULN Upper limit of normalUSA United States of AmericaWBC White blood cells

Trademark Information

Trademarks of the GlaxoSmithKline group of companies

Trademarks not owned by the GlaxoSmithKline group of companies

NONE Chiron RIBADotaremWinNonlin


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1. INTRODUCTION

1.1. Background

Amyloid and Amyloidosis

Amyloidosis is a clinical disorder caused by extracellular deposition of amyloid in visceral parenchyma, connective tissues and blood vessel walls damaging their structure and function [Pepys, 2006]. In systemic amyloidosis any tissue or organ may be affected except the cerebral parenchyma. In local amyloidosis the deposits are confined to a single organ or tissue type.

Amyloid deposits are largely composed of amyloid fibrils, which are abnormal, insoluble fibrous structures, composed of normally soluble autologous proteins which have undergone misfolding, losing their stable native structure and/or assembly and then aggregating as stable fibres with a characteristic cross- core [Sunde, 1997].

The amyloid fibril precursor proteins in systemic amyloidosis are derived from the circulation while in local amyloidosis the fibril protein may be produced locally. Although more than 25 different proteins have been identified as forming amyloid fibrils in different types of amyloidosis and amyloid deposits, the fibrils always share the common cross- core structure and similar ultrastructural fibrillar morphology.

All amyloid deposits are rich in heparin and dermatan sulphate proteoglycans and glycosaminoglycan chains, tightly associated with the fibrils [Nelson, 1991]. Also all amyloid deposits always contain the normal plasma glycoprotein, serum amyloid P component (SAP), as a result of its specific calcium dependent binding to all types of amyloid fibrils [Pepys, 1979] including synthetic fibrils created in vitro from isolated pure fibril precursor proteins [Pepys, 1997].

In systemic amyloidosis, progressive amyloid deposition leads inexorably to organ dysfunction, failure and is almost always fatal. In the most common type of systemic amyloidosis, monoclonal immunoglobulin light chain (AL) disease (sometimes previously referred to as primary amyloidosis), median survival is about 12-15 months without treatment. In reactive systemic (AA) amyloidosis (sometimes previously referred to as secondary amyloidosis), a complication of chronic inflammatory diseases, and in most forms of hereditary amyloidosis, patients may survive for 5-10 years. Treatments to reduce the abundance of the respective fibril precursor proteins can prolong survival for several years but these may not be available in all types of amyloidosis, are often toxic, and rarely cure the primary disease. Although these interventions may arrest amyloid deposition and in some patients regression of the deposits then ensues, no treatments currently exist which specifically target amyloid for elimination [Pepys, 2006].

Serum amyloid P component (SAP)

Human SAP, is a normal, non-fibrillar, constitutive plasma glycoprotein circulating at ~20-40 mg/L which, together with C-reactive protein (CRP) forms the pentraxin family


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of proteins [Pepys, 1997]. Although SAP is an acute phase protein in mice [Pepys, 1979] and some other rodents [Pepys, 1997], its circulating concentration is stable in man in health and disease, including amyloidosis, except in individuals with liver failure since SAP is uniquely synthesised by hepatocytes [Pepys, 1978; Nelson, 1991]. A total of about 50-100 mg of SAP is present in the combined plasma and extravascular compartments both of normal individuals and patients with diseases other than amyloidosis [Hawkins, 1990]. SAP is also a normal constituent of the extracellular matrix located on the microfibrillar mantle of elastic fibres throughout the body [Breathnach, 1981] and in the lamina rara interna of the glomerular basement membrane [Dyck, 1980]. However the amounts of SAP in these normal tissue sites are extremely small compared to the quantity of fluid phase SAP. In patients with amyloidosis, SAP is also specifically concentrated in the amyloid deposits, and in an individual with extensive systemic amyloidosis there may be as much as 20,000 mg of SAP in the amyloid deposits, reversibly bound to the fibrils and in equilibrium with the fluid phase SAP pool.

The pentraxins are phylogenetically ancient proteins and their sequences, native fold, molecular assembly and capacity for calcium dependent ligand binding are highly conserved across species. However, their circulating concentration, behaviour as acute phase proteins, glycosylation, fine ligand specificity and capacity for secondary effects after ligand binding, including precipitation, aggregation and complement activation, vary widely, even between closely related species [Baltz, 1982; Pepys, 1983]. Their normal physiological roles are therefore not clearly defined and their biological properties are controversial.

The most robust observations on the function of SAP are that its binding to various ligands, including amyloid fibrils, stabilises them substantially and protects them from proteolytic cleavage [Tennent, 1995]. SAP binding also promotes amyloid fibrillogenesis in vitro [Hamazaki, 1995; Myers, 2006]. Although mouse SAP binds much more weakly to amyloid fibrils than does human SAP [Baltz, 1986; Hawkins, 1988; Herbert, 2002], SAP knockout mice show delayed and reduced formation of amyloid deposits [Botto, 1997] and SAP thus seems to contribute to pathogenesis and/persistence of amyloid in vivo.

1.2. Rationale

1.2.1. Overview of therapeutic intervention

Based on the validation of SAP as a therapeutic target in amyloidosis, the novel small molecule palindromic bis-D-proline compound (R)-1-[6-[(R)-2-carboxy-pyrrolidin-1-yl]-6-oxo-hexanoyl]pyrrolidine-2-carboxylic acid (abbreviated as Carboxy Pyrrolidine Hexanoyl Pyrrolidine Carboxylate, CPHPC, GSK2315698) was developed as a tool to remove SAP from amyloid deposits and thus potentially enable and promote physiological clearance of the amyloid fibrils [Pepys, 2002]. However, despite high affinity binding of SAP to CPHPC [Pepys, 2002], the avidity of binding of SAP to the solid phase ligands on amyloid fibrils is so great that CPHPC does not displace all the bound SAP [Gillmore, 2010]. Unexpectedly, CPHPC was found, in academic clinical studies, to greatly accelerate clearance of SAP from circulation, leading to almost complete depletion of SAP from the blood, and increased SAP clearance from amyloid


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deposits [Pepys, 2002],although, some SAP remains in the amyloid deposits [Gillmore, 2010].

In early academic clinical studies, at the National Amyloidosis Centre under the former Doctors and Dentists Exemption (DDX) scheme, CPHPC (GSK2315698) and plasma SAP depletion were well tolerated, and there was some evidence of clinical benefit: no demonstrable accumulation of amyloid was observed during treatment, however no regression of existing deposits was seen [Gillmore, 2010]. An alternative approach to the elimination of existing amyloid was therefore required and is the subject of the present intervention [Bodin, 2010].

The key element is the use of GSK2315698 to deplete circulating SAP leaving some SAP in the amyloid deposits. This allows for the administration of the anti-SAP antibody (GSK2398852) without their consumption by the abundant SAP that is normally present in the blood, thereby allowing the antibodies to reach the SAP bound in amyloid deposits. In animal studies, binding of antibodies to the amyloid-associated SAP triggers complement activation which in turn attracts macrophages, activates them and opsonises the deposits for engulfment and destruction [Bodin, 2010].

The anti-SAP antibody approach exploits the fact that SAP is universally present in all deposits of all types. SAP therefore serves as an amyloid specific target for the physiological function of IgG antibodies in clearing ‘foreign’ or abnormal materials from the tissues via the ‘normal’ complement and macrophage dependent mechanisms of tissue repair.

The critically important, fundamental point about the present combined approach of GSK2315698 plus anti-SAP mAb (GSK2398852) is that SAP is simply and solely a passive target which happens to be specific for amyloid deposits. The therapy has nothing to do with any physiological or pathophysiological role of SAP itself, other than the fact it is specifically bound to amyloid fibrils.

Figure 1 Overview of intervention


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This study will be the first time that GSK2398852 (anti-SAP mAb) is administered to humans (co-administered with GSK2315698). Administration of GSK2398852 without depletion of SAP by GSK2315698 is not proposed because the presence of such large amounts of antigen (SAP) in the blood would mean little if any mAb would be available to target SAP on amyloid deposits.

1.2.2. Summary of information available for GSK2315698 (SAP depleter)

Please refer to the Investigator’s Brochure for detailed information [GlaxoSmithKline Document Number 2012N141587_01]. The findings from the completed nonclinical studies following co-administration of GSK2315698 and GSK2398852, or GSK2315698 alone support planned IV (infusion) clinical dosing. The proposed clinical investigation may also include subcutaneous dosing of GSK2315698 supported by previous dosing in patients by this route; the justification for this is outlined in detail in Section 1.4.1.

Previous clinical experience in academic sponsored clinical investigations and published in peer-reviewed journals is summarised in the Investigator’s Brochure [GlaxoSmithKline Document Number 2012N141587_01]. Briefly, the highest daily dose administered was 6 mg/kg and the most common daily dose during long term treatment was approximately 1 mg/kg. Treatment with CPHPC (GSK2315698) was reported to be well tolerated and no treatment-related safety findings were identified. Long term (52-104 weeks) subcutaneous administration of CPHPC at doses of 1 mg/kg (in two divided doses; dose concentration 200 mg/mL) was generally well tolerated in patients with systemic amyloidosis. Subcutaneous CPHPC injection produced transient minor local stinging at the injection site, causing two patients (out of 31) to leave the study [Gillmore, 2010]. Patients with Alzheimer's disease tolerated up to 3 mg/kg in three divided doses daily for 12 weeks with no adverse effects other than transient local discomfort [Kolstoe, 2009].

A PK/PD study in healthy volunteers CPH113776 [GlaxoSmithKline Document Number 2011N118597_01] is complete. Short term (24 hours or less) intravenous administration of a range of doses including one associated with exposure at approximate parity with the NOAEL, was well tolerated. The data from this study were used to inform the preliminary PK/PD model for use in patients.

An open label PK/PD study in patients with systemic amyloidosis CPH114527 is complete [GlaxoSmithKline Document Number 2012N142777_00] exploring short term (48 hours) IV administration followed by up to three SC doses. Plasma SAP profiles show consistent characteristics with healthy volunteers and baseline plasma SAP levels were not significantly different. The data show that depletion of circulating SAP to <0.5 mg/L can be achieved within 48 hours by iv infusion of GSK2315698 in subjects with small- moderate amyloid loads. Subjects with large amyloid loads, especially those with liver involvement, will achieve a circulating SAP concentration of <2mg/L with a similar dosing regimen over the same time period. Limited studies of SAP concentrations following cessation of GSK2315698 suggest that SAP recovery is dependent on amyloid loads, being slower with larger amyloid loads. Because GSK2315698 is renally cleared the administered dose is corrected for renal function. Furthermore administration of a three times daily regimen of subcutaneous GSK2315698 is capable of maintaining the


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depletion of circulating SAP at low concentrations in patients with systemic amyloidosis. To date treatment with all the proposed dosing regimens of GSK2315698 have been well tolerated. It is important to note that SAP profiles within each patient are very consistent, indicating a small intra-subject variability.

Please see Investigators Brochure [GlaxoSmithKline Document Number 2012N141587_01] for full details.

1.2.3. Current PKPD model for GSK2315698 and SAP

PKPD modelling work based on the observed data from CPH113776 [GlaxoSmithKline Document Number 2011N118597_01] and CPH114527 [GlaxoSmithKline Document Number 2012N142777_00], together with radiolabelled SAP studies from literature [Hawkins, 1990; Jager, 1998] is on-going. To date, the model described in Figure 2 has been selected and allows for the predictions of GSK2315698 and SAP concentration-time profiles in plasma and in tissue for healthy volunteers and amyloid patients. The model is being used to inform GSK2315698 dose selection in the study (Section 1.3.2). It is a mechanistic model and includes the following components:

- GSK2315698 disposition, characterised by a two-compartment model with rapid first order elimination (major elimination pathway) and target mediated clearance

- SAP kinetics, characterised by a turnover model with binding to GSK2315698 in plasma, transfer/binding to non-amyloid ligands in a peripheral compartment, and transfer/binding to amyloid ligands in second peripheral compartment present in patients only.

The current model includes the relationship between renal function and GSK2315698 clearance. The influence of amyloid load/type/location on SAP turnover and distribution is currently ongoing.


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Figure 2 Schematic representation of the current PKPD model for GSK2315698 and SAP

a. kiin is the SAP production constant,b. kout is the SAP degradation rate constant,c. Q1 is the passive GSK2315698 transfer d. KelGSK2315698 is the elimination rate constant of free GSK2315698 e. KintGSK2315698 is the elimination rate constant of the complex GSK2315698-SAP f. F: free, B: bound, NA: Non Amyloid, A: Amyloid

1.2.4. Summary of information available for anti-SAP mAb (GSK2398852)

Co administration of GSK2315698 (SAP depleter) and GSK2398852 (anti-SAP mAb) was evaluated in a transgenic mouse model for human SAP (C57BL/6J hSAP (transgenic)) as GSK2398852 was shown not to bind to SAP from the standard preclinical species (rat, mouse, dog, rhesus or cynomolgus monkey. The mouse has physiologically relevant concentrations of circulating SAP (approximately 20 mg/L) and widespread tissue SAP, principally associated with connective tissue. The mice did not have systemic amyloidosis. The study was therefore designed to address two potential risks associated with administration of GSK2398852: formation of SAP/ anti-SAP complexes in the circulation and targeting non amyloid-associated SAP. GSK2315698 was also administered in this study to be consistent with the proposed co-administration in humans. Of note constraints in the dosing of GSK2315698 meant that circulating SAP concentrations when GSK2398852 was administered were close to baseline. Administration of GSK2398852 was well tolerated and there was no evidence of toxicity


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resulting from immune complex formation or of an inflammatory response in tissues with normal SAP [GlaxoSmithKline Document Number 2012N141587_01]. The limitations of these types of study are acknowledged but the available information supports the progression to human studies. These potential risks will be closely monitored in the proposed study. An in vitro assessment of potential binding of GSK2398852 to a panel of human tissues using immunohistochemistry demonstrated no off target specific or non specific binding.

1.3. Study Design and Rationale

The primary purpose of this study is to evaluate the safety of GSK2398852 in humans when co-administered with GSK2315698 (a small molecule SAP depleter ). In addition, pharmacokinetics (of GSK2398852 and GSK2315698), and circulating SAP concentrations will be assessed. Although clinical efficacy is not the primary objective of this study, measures of pharmacodynamic activity and clinical status will be made.

The study will be conducted in two parts [Figure 3]. The first (Part A) will be an open label single dose escalation based primarily on safety. Because of the rarity of the disease and the intensity of the protocol it is anticipated that escalation will take place based on data from two subjects at each dose level. The predictions of the likely clinical dose suggest that it will be relatively high (owing to the amount of the target and mechanism of action) and therefore exposure of large numbers of subjects to low doses is not considered appropriate. Because of the prognosis of systemic amyloidosis and the complexity of this intervention, exposure of subjects to placebo treatment is also not considered appropriate. Dose escalation in Part A will continue to the highest well tolerated dose or the highest allowable dose. Although safety is the primary objective of this part pharmacodynamic activity will be assessed by methods including EqMRI(including organ volume) [Flett, 2010] ,elastography, SAP scan, and biochemistry.

The liver, (commonly affected in most forms of systemic amyloidosis), is expected to be readily accessible to GSK2398852 (good blood supply and fenestrated capillary endothelium), and can be readily biopsied. The presence of macrophages and macrophage-derived giant cells (and evidence of amyloid clearance) as assessed on liver biopsy is considered the gold standard assessment of pharmacology in this intervention. A liver biopsy may be performed on a small number of subjects in Part B if required to validate PD responses.

Part B will have an open label dose adaptive design. The objective will be to further evaluate the safety, tolerability, PK, and PD of GSK2398852. Part A has shown that in subjects with a large amyloid load including the liver substantial reduction in liver amyloid load can be achieved with the a single dose of GSK2399852 but that more than one dose may be required to target amyloid in other organs. Part B will focus on evaluation of the PD response to a second dose. Subjects from part A will be invited to participate and new subjects will be recruited. In the event that a second dose shows PD response only in the liver then a third dose will be considered on a case by case basis. Doses will be administered at least 2 months apart to allow for completion of follow up and evaluation of the response before another dose is considered. A small number of


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subjects in Part B may be asked to undergo liver biopsy to validate PD findings observed on other measures. In future clinical studies the AntiSAP treatment may be administered to patients prior to or during chemotherapy treatment (for plasma cell dyscrasia in AL amyloidosis) and, due to the nature of that chemotherapy, there may be an effect on the PD response to AntiSAP therapy. In this study a small number of subjects (AL amyloid only) may be recruited into Part B to investigate the impact of on-going chemotherapy treatment on a subject's response to GSK2315698 and GSK2398852. Subjects who have achieved a complete response (CR) or very good partial response (VGPR) during chemotherapy will be eligible to receive the treatment at their next cycle of chemotherapy.

Safety oversight. Because of the complex patient population and the limited number of subjects to be studied in Part A, an external safety advisory committee will review safety data at key points in the study and in response to any safety signals (Section 12.8).


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Figure 3 Study outline and decision tree


23

1.3.1. Notes on pharmacodynamic assessments

EqMRI

This non-invasive MRI technique estimates the extracellular space (volume of distribution of gadolinium) in key organs (liver, spleen and heart) and data from an ongoing enabling study (CRT114645) shows that it is able to distinguish those with small, medium and large amyloid loads in organs of interest [Figure 4]. Its ability to measure changes in amyloid load has not been established as there are no current interventions that reliably reduce amyloid load. It will be used in Part A and B of this study in an exploratory mannerIndeed, based on preliminary results shown in Figure 4, in which amyloid load was scored by SAP scintigraphy, the volume of distribution in the spleen seems to be the most informative in terms of EqMRI assessment. This investigation will include an assessment of organ volume as this may also be a measure of pharmacodynamic activity.

Figure 4 EqMRI assessment of organ extracellular space (volume of distribution of gadolinium)

Liver volume of distribution (Vd) by SAP score

Note: Normal subjects (n=36); SAP score: 0= none (n=29), 1 = small (n=0), 2= moderate (n=5), 3= large (n=5)


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Spleen volume of distribution (Vd) by SAP score

Note: Normal subjects (n=32); SAP score: 0= none (n=22), 1 = small (n=7), 2= moderate (n=7), 3= large (n=5)

Liver biopsy. A review of the literature and archive material from the National Amyloidosis Centre shows that macrophages are not an uncommon feature in liver biopsies in systemic amyloidosis but macrophage giant cells are very uncommon (present in ~2% of biopsies). The appearance of macrophage giant cells is a cardinal feature of the inflammatory response induced by anti-SAP antibodies, leading to elimination of amyloid deposits in mouse studies, and will be interpreted in this study as evidence of engagement of pharmacology [Bodin, 2010]. Biopsies will be further examined for evidence of macrophage activity and clearance of amyloid. These pieces of information may be combined in a numerical score as an assessment of dose response. The proposed timing of the post treatment biopsy is based on the time course observed in animal studies and it is considered unlikely that a response will be missed by assessment around this time. Because this is an invasive intervention it will be applied judiciously in the smallest number of subjects to provide the maximum information [Figure 3].

SAP scan. The radiolabelled SAP scan is considered the gold standard for assessment of amyloid load and distribution in systemic amyloidosis. It is however only semi-quantitative and is not informative about amyloid in the heart. The present intervention involves both SAP depletion and administration of anti-SAP antibodies, and scintigraphy with radiolabelled SAP therefore cannot be used for early assessment of amyloid load. Thus subjects will undergo a SAP scan at the beginning of the study and after it has finished, with a sufficient interval to enable re-equilibration of the plasma and amyloid pools of SAP. The examination will involve volumetric quantification of labelled SAP localisation in SPECT-CT, which greatly improves both the quantitative information from the scan and the anatomical definition of the amyloid deposits.


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DPD- Bone scan. For patients with cardiac TTR systemic amyloidosis

Recently it has been shown that 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) which has been in routine clinical use for many years as a bone scan agent can also be used to image cardiac amyloid in patients with ATTR. If any patients with ATTR are recruited they may undergo this investigation instead of SAP scintigraphy.

Elastography. This is a non invasive ultrasound based technique measuring the speed of propagation of elastic waves. The velocity of these waves is directly correlated with liver or other organ stiffness. This technique may be used as an exploratory endpoint in this study.

1.3.2. Dose Rationale

Dose rationale for GSK2315698 (SAP depleter)

Prior detailed PK/PD exploration in both healthy volunteers and patients with systemic amyloidosis (summarised in the IB and Section 1.2.2) has shown that a dose of 20 mg/hr by intravenous infusion is well tolerated and is capable of depleting SAP to <0.5 mg/L within 48 hrs in patients with small/moderate amyloid loads and normal renal function. Subjects with large amyloid loads are expected to achieve a concentration <2 mg/L with a similar dosing regimen. Subjects in this second group will only be enrolled providing that an external safety committee review of data from those with small/moderate loads supports this. The existing PK/PD model includes a dose adjustment (reduction) based on subjects’ renal function as GSK2315698 is renally cleared.

Prior data shows that depletion of SAP can be generally maintained by a three times daily subcutaneous regimen (GSK2315698 maximum dose 60 mg tds in patients with normal renal function) [GlaxoSmithKline Document Number 2012N141587_01] and this route may be used to maintain depletion of SAP.

The SAP concentration will be measured prior to administration of GSK2398852 and if not within the target range dosing may be prolonged and/or the dosing regimen of GSK2315698 adjusted.

The existing PK/PD model provides a robust estimate of the dose but it will be updated throughout this study as more data emerge. The dose for a subject will be adjusted based on the latest information available.

Following administration of GSK2398852 administration of GSK2315698 will continue in order to maintain depletion of circulating SAP. Administration of GSK2315698 will continue until at least Day 7 and will continue until the inferred concentration of free GSK2398852 has fallen to below 5000 ng/mL or below the LLQ. The SC route of administration might be considered instead of an infusion if a prolonged administration of GSK2398852 becomes necessary. At these concentrations the amount of circulating mAb is predicted to be ~1.5 mg (based on a plasma volume of 3L). This small amount of antibody is considered unlikely to cause substantial adverse effects if it were to form complexes with circulating SAP.


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All doses administered will have a predicted exposure that is below a mean AUC0-24 of 145 µg*h/mL and Cmax of 6.05 µg/mL. These limits are defined by the NOAEL in the rat 28 day intravenous repeat dose studies. The maximum subcutaneous dose will be 60 mg tds as this was generally well tolerated in the long term academic study [Kolstoe, 2009; Gillmore, 2010].

Dose rationale for GSK2398852 (Anti SAP mAb)

In animal studies, anti-SAP mAbs act as opsonins which stimulate a macrophage giant cell reaction. Because of this mechanism of action and because the amount of target amyloid in patients with systemic amyloidosis is large, the effective dose of GSK2398852 is expected to be relatively high. The complement system in humans is more efficient than in mice and may reduce the effective antibody dose somewhat. Systemic amyloidosis is a very heterogeneous condition with wide variations in the amount and distribution of amyloid deposit which may also affect the clinical response. Because SAP is universally present in amyloid deposits this intervention is expected to have potential utility in all forms of amyloidosis.

In animal studies a dose response was observed associated with administration of the murine version of GSK2398852 [IB]. The lowest tested dose associated with what would be considered a significant biological effect was 0.5 mg per mouse (approximately 20 mg/kg) showing little effect in the spleen but a modest and statistically significant effect in the liver. For the reasons outlined above, direct extrapolation of doses from the mouse studies is considered potentially misleading but a 20 mg/kg dose would be considered a biologically active dose. In humans 20 mg/kg would be a 1.4g dose in a 70 kg adult.

Starting dose

The starting dose is proposed to be 5 mg (approximately equivalent to 0.1 mg/kg).

The mechanism of action of GSK2398852 is such that the definition of a Minimum Anticipated. Biological Effect Level (MABEL) is difficult to define. The elimination of amyloid deposits by anti-SAP antibody is complement dependent and two adjacent IgG antibody molecules are required to activate the classical complement pathway. Thus each pair of anti SAP mAb molecules that binds has the potential to initiate some amyloid clearance by macrophages but our ability to detect this may be limited by the sensitivity assessments available. Although circulating SAP will be depleted to low levels by administration of GSK23156998, a small amount of soluble SAP will remain because it is being continuously synthesised and secreted by hepatocytes.

Available information regarding immune complex disease indicates that immune complexes formed in antibody excess are generally rapidly cleared without toxic effects [Cochrane, 1969; Dixon, 1972; Carter, 1973]. Administration of doses of antibody in the presence of excess antigen, in this case the circulating SAP, may lead to formation of small soluble immune complexes which are potentially toxic .

The first subjects to be enrolled will be those with a moderate amyloid load without liver involvement. An enabling study [CPH114527] has shown that SAP can be reliably


27

depleted to <0.5 mg/L in these subjects (and this will be checked prior to administration of the anti-SAP mAb).

Taking the worst-case scenario that the residual free SAP is 0.5 mg/L (target is <0.5 mg/L) and assuming a plasma volume of 3L this will mean up to 1.5 mg circulating SAP remain. This is equivalent to 0.01 micromoles (mw SAP = 127 310 Da). After its planned intravenous administration the anti-SAP mAb will first presumably bind to this circulating SAP and will form immune complexes. GSK2398852 is an IgG1 (mw 150 000 Da); 0.01 micromoles would be 1.5 mg. Aiming for at least a 3-fold excess of mAb over antigen (SAP) this would indicate that the starting dose would be 5 mg . On a mg/kg basis this is approximately 0.1 mg/kg (70kg adult).

In animal studies the pharmacological action of an anti-SAP mAb was not associated with a systemic inflammatory response. Similarly the resorption of extracellular protein for example a haematoma in man, which is thought to involve a similar mechanism, is not associated with a systemic response. For the proposed starting dose the uncomplexed antibody that would be free to target amyloid would be between 1.5 and 3 mg. This provides an approximate 200-fold difference compared with a dose (on a mg/kg basis) associated with a measurable response in the animal model.

Dose escalation in Part A

In Part A it is planned that two or more subjects will be studied at each dose but only one subject will be dosed at a time.

The risk from targeting the normal tissue SAP (TAP), which is present in everybody and unlikely to be related to amyloid, might increase with administration of anti-SAP mAb. However the abundance of TAP is extremely low compared to the thousands of mg of SAP which may be present in systemic amyloid deposits. The absence of any adverse effects from administration of the largest doses of anti-SAP antibody to human SAP transgenic mice without any amyloid, but which have human TAP is reassuring and suggests that TAP may not be readily or rapidly accessible to antibodies from the circulation. (cf. Section 1.2.4).

An outline dose escalation plan is provided in Table 1.

Decisions about the next dose level will be made following safety review of the prior subjects’ data; dose levels may be changed (increased and lowered) and dose levels may be repeated depending on the observed safety and PD. For each subject the precise dose to be administered will be defined as an absolute dose level (mg) for the avoidance of doubt.

Highest dose in Part A

The highest anticipated dose level is 30 mg/kg. This is at approximate parity with the administered highest dose in the mouse toxicology study (33.3.mg/kg). The administered dose has been used (as opposed to exposure) because the toxicology study was a model system to address specific questions (hazard identification). Disposition in humans with amyloidosis is expected to be very different from the HuSAP transgenic mouse without


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amyloidosis. In addition, circulating SAP in human at the time of GSK2398852 administration is expected to be very low due to the co-administration of GSK2315698, which was not the case in the mouse toxicology study (Section 1.2.4). Of note doses of (murine) anti-SAP mAb approximately equivalent to 200 mg/kg (5 mg in a 25 g mouse) have been well tolerated in mice with amyloidosis [GlaxoSmithKline Document Number 2012N141587_01].

The total dose of GSK2398852 will not exceed 3000 mg (equivalent to 30 mg/kg in a 100 kg individual).

Subjects with large amyloid loads

Information from study CPH114527 shows that subjects with large amyloid loads undergo substantial circulating SAP depletion when treated with GSK2315698 but not to the same extent as those with small or moderate loads. This reflects the large pool of SAP reversibly associated with the amyloid deposits, which is in equilibrium with the circulating SAP pool and replenishes it as the circulating SAP is depleted by GSK2315698 In subjects with a large load, especially when this involves the liver this effect can be substantial. Subjects with large amyloid loads achieve circulating SAP concentrations of between 1 and 2 mg/L after 48 hours treatment with GSK2315698. This would represent 0.04 micromoles of SAP and therefore a 5-fold excess of GSK2398852 would be a dose of 0.4 mg/kg. Subjects with a large liver load will not be enrolled until anticipated doses are in excess of this and after review with the external safety advisory committee as outlined in Section 1.4. Additional patients may be studied at any dose level in order to add scientific clarity where necessary e.g. to optimise the rate of antibody infusion in terms of tolerability and PD effect, or to define variation attributable to varying anatomic distribution of amyloid load.

Table 1 Outline dose escalation plan for GSK2398852 Part A [2 subjects per dose level]

Dose level 1

Dose level 2

Dose level 3

Dose level 4

Dose level 5

Dose (mg/kg)GSK2398852

-a 1 3 10 30b

Illustrative dose for 70 kg adult (mg) 5a 70 210 700 2100b

a. This dose is fixed at 5 mg as it is determined by the concentration of circulating SAP (approximately equivalent to 0.1 mg/kg).

b. Highest dose will not exceed 3000 mg (100 kg individual.

Dose escalation is subject to a safety review of previous dose(s). Dose levels may be reduced and repeated as well as increased.

Part B

The purpose of Part B is to provide a preliminary assessment of dose response in relation to amyloid load. The precise selection of numbers of subjects and dose levels will be informed by the results from Part A and available data from the ongoing review of Part B


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data, including PD assessments. Information from part A has shown that doses of GSK2398852 should be individualised based on amount and location of amyloid. More than one dose may be required to target amyloid in organs other than the liver. Decisions about dose levels will be based on an individual subject's disease profile and prior subjects’ data; dose levels may be changed (increased and lowered) and dose levels may be repeated depending on the observed safety, PK and PD. For each subject the precise dose to be administered will be defined as an absolute dose level (mg) for the avoidance of doubt.

The dose of GSK2398852 given on a single occasion will not exceed 3000 mg (equivalent to 30 mg/kg in a 100 kg individual).

1.4. Summary of Risk Management

This is a complex intervention in a complex patient population. A number of potential risks have been identified but pre-clinical studies indicate that these are likely to be manageable in the clinic. Subjects will be studied one at a time in Part A with intensive monitoring. For each of the potential risks, signals have been identified that would trigger more detailed specific investigations, and potential treatments have been identified. In this way the study has been designed to maximize the information obtained while minimizing the overall risks. Additional safety oversight is provided by an external safety advisory committee who will review data at key points of the study and if emergent issues arise (Section 12.8).

1.4.1. Potential risks associated with administration of SAP depleter GSK2315698

GSK2315698 has been administered to patients with systemic amyloidosis in a GSK-sponsored study and in a long term academic-sponsored investigation. The published literature reports approximately 54 patient years of exposure at doses up to 6 mg/kg of GSK2315698 which were generally well tolerated

There were no findings in safety pharmacology or genetic toxicity studies that would preclude the IV or oral administration of GSK2315698 to humans.

In toxicology studies, minor reductions in red cell parameters were observed in female dogs given high doses (200mg/kg/day) of GSK2315698. Some trends (haemoglobin increased; white cells and platelets decreased) within the reference range were observed in a single dose study in healthy volunteers. The clinical significance of these observations is not clear, and similar changes have not been observed in patients with systemic amyloidosis in study CPH114527. Haematological parameters will be measured in the clinic.

Small volume nose bleeds have been noted in a few patients in study CPH114527 which have been self-limited and not associated with any evidence of thrombocytopenia or coagulopathy. Subjects should be closely monitored for bleeding.

In one study in male rats (but not in another similar study), testicular changes were observed at the highest dose tested (400mg/kg/day). Given the lack of reproducibility of


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these findings, their significance to humans is unclear. The proposed doses of GSK2315698 are considerably below the NOAEL for this effect and therefore the potential risk to humans during short term dosing is considered very low.

The normal physiological function of circulating SAP is not fully understood, but neither mice with deletion of the SAP gene nor a small number of humans receiving CPHPC (GSK2315698) continuously for up to 2 years have shown any adverse effects attributable to SAP depletion. [Investigator’s Brochure [GlaxoSmithKline Document Number 2012N141587_01]. The autoimmune phenotype in SAP knockout C57BL/6 mice was not present in 129sv mice and was later shown not to be caused by SAP deficiency but by damage to the adjacent sle locus on chromosome 1 combined with the C57BL/6 strain background [Botto, 1997; Gillmore, 2004]. Short-term depletion of SAP in patients is therefore unlikely to be associated with adverse consequences.

Safety data from each subject will be reviewed after each dosing session. Stopping criteria are defined in Section 3.4.

The poor tolerability of SC administration of GSK2315698 in rats and dogs is noted. Notwithstanding these observations, administration of GSK2315698 by this route has been generally well tolerated in patients with systemic amyloidosis for up to 2 years, in a few individuals for longer periods of up to 7 years, and at a higher dose (60 mg) given three times daily for 12 weeks in 5 patients with Alzheimer's disease [Gillmore, 2010; Kolstoe, 2009]. Subcutaneous GSK2315698 injection produced transient minor local stinging at the injection site, causing two patients (out of 31) to leave the study. Administration of subcutaneous GSK2315698 in Study CPH114527 has also been generally well tolerated. Given this prior experience, administration of GSK2315698 by the subcutaneous route is considered an appropriate means to maintain SAP depletion especially in the event that prolonged administration of GSK2315698 becomes necessary. Subjects will be closely monitored for skin-related adverse events.

1.4.2. Potential risks associated with administration of GSK2398852

In vitro peripheral blood flow cytometry analyses demonstrated no specific binding in human peripheral blood cells (leukocytes, red blood cells or platelets). Specific binding to CD45+/high Side Scatter (SS)/CD14+ granulocytes was observed. Any potential changes in granulocyte counts can be monitored in the clinic. An immunohistochemistry (IHC) study assessing specific and non-specific binding of GSK2398852 with human tissues demonstrated specific positive staining with blood vessels and/or connective tissue where SAP staining was anticipated.

Co-administration of GSK2315698 and GSK2398852 was evaluated in the C57BL/6 human SAP transgenic mouse model human SAP circulating at concentrations comparable to the normal human reference range. These mice were not induced to have amyloidosis and no amyloid deposits were detected on histological examiniation. Co-administration of GSK2315698/GSK2398852 was well tolerated at doses of 150/33.3 mg/kg (highest doses tested). No microscopic changes indicative of damage resulting from immune complex formation were noted. When co-administered, the no observed adverse effect level (NOAEL) was 150/33.3 mg/kg of GSK2315698 and GSK2398852, respectively.


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The following potential risks have been identified based on current understanding of the biology of the anti SAP mechanism. None of these potential risks have been observed in preclinical studies but the limitation of pre clinical models is acknowledged.

Formation of complexes of SAP and anti-SAP mAb

GSK2398852 targets SAP which is a normal plasma protein. Pre-treatment with GSK2315698 will deplete SAP in the blood to low concentrations but some will remain. Administration of GSK2398852 will therefore lead to formation of some immune complexes. Immune complexes vary greatly in their propensity to cause toxicity and many are cleared without toxic effect. Toxicity is less common when the antibody is in substantial excess; this risk is mitigated by depletion of circulating SAP [Cochrane, 1969; Dixon, 1972; Carter, 1973]. This has been taken into account in dose selection [Section 1.3.2]. If the formed complexes do have toxic effects these are most likely to manifest as urticaria, erythema and other cutaneous rashes. In the worst case there may be signs and symptoms of systemic vasculitis. Subjects will be carefully monitored for evidence of these. Immune complex vasculitis generally responds well to systemic glucocorticoids. If necessary, circulating immune complexes, especially those produced by passive antibody administration, can be rapidly and completely removed by plasma exchange.

Following administration of GSK2398852, GSK2315698 will continue to be administered for at least 7 days and until the concentration of unbound GSK2398852 has fallen to 5000 ng/mL or below LLQ. Refer to Section.1.3.2

Targeting non amyloid-associated SAP

In addition to the substantial quantities present in the blood, very small quantities of SAP are also present in the tissues. This is known as normal tissue amyloid P component (TAP) and is present in the lamina rara interna of the glomerular basement membrane and with the peripheral microfibrillar mantle of elastic fibres in connective tissues and blood vessels throughout the body [Breathnach, 1981]. The quantities in these tissues are very small (estimated to be at most a few milligrammes in the whole body). By contrast the amounts of SAP decorating amyloid deposits in those with systemic amyloidosis are large, and known by direct measurements at autopsy to be as much as 20,000 mg. Furthermore the SAP in amyloid deposits is more directly accessible to antibodies from the circulation, since the SAP itself all arrives by this route, whereas TAP is tightly bound, covalently and non-covalently to connective tissue matrix structures which are less directly accessible to circulating plasma proteins. Consideration of both the microanatomy and the amount of SAP in amyloid vs TAP indicate that in patients with systemic amyloidosis GSK2398852 will overwhelmingly bind to SAP in amyloid deposits rather than TAP. If GSK2398852 were to bind to TAP it could potentially cause glomerulonephritis or vasculitis. Subjects will be closely monitored for evidence of these conditions. Glucocorticoid and additional anti-inflammatory therapy would generally suppress any reaction but if necessary plasma exchange could be included.

Alzheimer’s disease is characterized by the presence of intracerebral and cerebrovascular amyloid deposits composed of Aβ fibrils. Patients with cerebral amyloid angiopathy, an important cause of cerebral microbleeds and haemorrhagic stroke, also have


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cerebrovascular Aβ amyloid deposits. All these amyloid deposits always contain SAP. Patients with cerebral amyloid angiopathy (CAA) may rarely develop cerebral inflammation which has been speculated to result from formation of anti-Aβ antibodies [Greenberg, 2011], and a similar clinical syndrome, termed vasogenic oedema, was observed in approximately 10% of patients treated with bapineuzumab, an anti-Aβ antibody [Salloway, 2009]. The clinical presentation included subacute confusion, headaches or seizures. MRI findings were reversible focal subcortical or cortical T2-hyperintensities. Most cases responded to treatment with steroids. A more severe clinical syndrome of meningoencephalitis occurred following active immunisation with an Aβ42 vaccine (AN1792) but this unlikely to be relevant here since it was apparently caused by a T cell response [Orgogozo, 2003]. There is no known mechanism by which passive administration of an antibody induces T cells reactive with the cognate antigen. Subjects known to have CAA or Alzheimer’s disease will be excluded from this study.

Inflammatory response associated with targeting of SAP in systemic amyloid deposits

Based on the mechanism of action of the anti-SAP mAb in mouse models of systemic amyloidosis, binding of the anti-SAP mAb to SAP decorating amyloid deposits is expected to result in a complement dependent macrophage giant cell response that clears amyloid. In the mouse models studied this was well tolerated. The mechanism is presumed to correspond to that normally involved in the clinically silent resolution of haematomas and other non-infected tissue damage. Nevertheless, subjects will be monitored for evidence of systemic inflammation and systemic complement activation.

GSK2398852 is not expected to trigger cytokine production and/or release by human peripheral blood mononuclear cells either alone or in the presence of human endothelial cells. An in vitro study conducted at the National Institute for Biological Standards and Control, UK (NIBSC) showed that GSK2398852 stimulated the release of TNFα and IL-6 but not IL-2 and IFNγ when immobilised onto polypropylene (by air-drying or wet-coating). While mAb immobilisation onto plastic proved to be a useful procedure for mimicking the in vivo toxicity of TGN1412, this was likely because the immobilisation procedure mimicked the formation of the immunological synapse believed to be necessary for the superagonist mAb TGN1412 to stimulate CD28 receptors. For other mAbs, e.g. the anti-SAP mAb GSK2398852, such immobilisation has no obvious in vivo analogue in the blood. The magnitude of the cytokine release observed under these condition was similar to that observed with other Fc-enabled therapeutic mAbs (Avastin, Campath) and was considerably lower than that observed with TGN1412.

GSK2398852 in aqueous phase, i.e. the most physiologically relevant presentation of the mAb (in the blood), did not stimulate TNFα, IL-6, IL-2 and IFNγ responses above background levels. This was the case when anti-SAP mAb was incubated with PBMC alone (from 8 donors) or with PBMC (from 4 donors) cultured over a monolayer of endothelial cells. Consequently, the results from this evaluation, suggest that GSK2398852 is unlikely to significantly stimulate cytokine release by mechanisms unrelated to its therapeutic effect. Cytokines and other systemic markers of inflammation will be carefully monitored in this proposed clinical study.


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Symptoms associated with the infusion of anti-SAP mAb (GSK2398852)

Symptoms include but are not limited to: warm feelings, flushing, headache, increases and decreases in heart rate and blood pressure, diarrhoea/loose stools, nausea, abdominal discomfort. Symptoms are self limiting and mainly occurred during infusion and the first 12 hours after the commencement of dosing with GSK2398852. The available evidence is that these symptoms are related to engagement of the target mechanism and may be mitigated by slowing the rate of infusion of GSK2399852 (including splitting the dose during the day). Additionally the administration of a non-selective antihistamine and corticosteroid prior to administration of GSK2398852 may also mitigate the symptoms associated with the infusion.

1.4.3. Potential risks associated with study procedures

SAP scan (with SPECT/CT) and 99mTc-DPD Bone scan (TTR subjects only)

Subjects will be exposed to additional doses of ionising radiation due to their participation in this study. The ionising radiation exposure from SAP scanning comes from the administered radioligand and CT examination. The total radiation burden per subject is calculated as 8 mSv per SAP scan; total 16 mSv for two scans. Subjects with TTR amyloid will undergo a DPD bone scan and will be exposed to 6.7mSv per scan, total 13.4 mSv. Subjects will receive either an SAP scan or a DPD scan, not both.

A baseline SAP/DPD scan at session 2/3 will only be performed if it has been greater than 3 months since the previous scan. If subjects do receive a second (or third) dose of GSK2398852 and a baseline scan is performed this will involve additional exposure to radiation.

The International Commission on Radiological Protection (ICRP) Publication 60 has recommended a maximum occupational adult effective dose limit of 20 mSv per year, averaged over a defined period of 5 years (not exceeding 50 mSv in a single year) [ICRP60, 1990].

It is recognised that if subjects receive more than one dose of GSK2398852 the 20mSv limit may be exceeded but this is considered justified because (i) data from part A show that GSK2398852 can lead to substantial amyloid clearance which may be of benefit to the subject (ii) subjects will only be given a second dose if there is evidence from the first dose that they may benefit (iii) systemic amyloidosis has a poor prognosis and no currently available treatments directly target amyloid clearance (iv) the SAP scan provides vital evidence of the PD effect of GSK2398852.

SAP scanning is considered the gold standard assessment to measure amyloid distribution and the UK National Amyloidosis Centre has conducted over 15 000 of these investigations.


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EqMRI

There are no known risks to subjects associated with MRI scanning, provided subjects have no contraindications to MRI. Subjects with exclusions to MRI scanning (including claustrophobia) will not undergo this investigation. Eligibility for MRI scanning will be checked at screening and re-checked immediately pre-scan. EqMRI involves infusion of gadolinium. This is used routinely as a contrast agent in MRI scanning. Some preparations of gadolinium have been associated with rare cases of nephrogenic systemic fibrosis (NSF). According to CHMP Dotarem is considered to be associated with a low risk of NSF. The guidance provided by CHMP has been taken account in the design of this study: precaution in severe renal impairment and hepatic transplanted patients: use the minimum diagnostic dose and allow a minimum 7 days between administrations.

Liver biopsy (Part B only)

Liver biopsies may be conducted in the minimum number of subjects in order to provide robust pharmacodynamic information as outlined in Section 1.3.

In those subjects in whom liver biopsies are planned, two liver biopsies, one pre-dose and one post dose are required as part of this study. This will be conducted via the transjugular liver route. The site for this investigation (Royal Free Hospital) has pioneered the use of transjugular biopsy in the management of liver disease and performs more than 250 procedures/year. The investigation will be carried out by a specified consultant experienced in the technique.

The transjugular approach is considered a safer technique than the standard percutaneous approach as the biopsy is taken from within the liver itself through the wall of the hepatic vein which is accessed under radiographic control. The radiation dose associated with fluoroscopic screening is approximately 2mSv per biopsy. The (maximum) total dose for 2 biopsies will therefore be approximately 4 mSv.

Pain is less common after a transjugular biopsy than percutaneous biopsy and is usually around the puncture site as the local anaesthetic wears off and usually responds to paracetamol. Bleeding is the most important complication; the risk of bleeding is greatest immediately after the liver biopsy when intraperitoneal bleeding can occur. Subjects will be monitored according to the Royal Free Hospital’s usual post-biopsy care protocol. Severe bleeding is estimated to occur following 1 in 2500 to 1 in 10,000 biopsies [Rockey, 2009].

1.4.4. Part B chemotherapy regimen

Chemotherapy treatment for the plasma cell dyscrasia in patients with AL amyloidosis is varied but commonly consists of intermittent, repeated cycles of a combination of proteasome inhibitor, high dose corticosteroid and immunosuppressant.


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Table 2 Example of chemotherapy cycle

Day 1 Day 8 Day 15 Day 22 Day 29

Bortezomib 1.3mg/m2 SC

Cyclophosphamide 350mg/m2 PO (max 500mg

Dexamethosone 20mg PO/IV

The cycle is repeated every 35 days

Patients who have demonstrated a complete response (CR) or a very good partial response (VGPR) in terms of free light chain levels as part of their clinical care, defined by their haematologist consultant, will be eligible to take part in the study. The administration of the AntiSAP treatment is not expected to interfere with the action of the chemotherapy medication. However, to minimise the impact of any interaction, dosing with GSK2398852 will occur immediately prior to or immediately after the final dose (e.g. Day 22 in the above example) of the cycle following confirmation of CR or VGPR.

The mechanism of action of the high dose corticosteroid and /or the immunosuppressant may interfere with the PD response to GSK2398852.

Other procedures

Other study procedures are routine and are not expected to be associated with a clinical risk to subjects.


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2. OBJECTIVE(S) AND ENDPOINTS

Objectives Endpoints

Primary (Part A)

Evaluate safety and tolerability of single doses of GSK2398852 when co-administered with GSK2315698

Safety and tolerability: Adverse events, laboratory measurements, ECGs, vital signs.

Evaluate pharmacokinetics of single doses of GSK2398852 and GSK2315698 when co-administered

Pharmacokinetic profile of GSK2315698 and GSK2398852

Primary (Part B)

Evaluate safety and tolerability after doses of GSK2398852 when co-administered with GSK2315698


Evaluate pharmacokinetics after doses of GSK2398852 and GSK2315698 when co-administered


Preliminary evaluation of dose response after doses of GSK2398852 when co-administered with GSK2315698

The main measures of PD response may include:

-Volume of distribution of gadolinium in the spleen as a measure of amyloid load (EqMRI)

-SAP scan assessment of amyloid load before and after treatment

- Liver elastography

-

Secondary (Both parts

Evaluate SAP concentrations in blood during administration of doses of GSK2398852 when co-administered with GSK2315698

-SAP concentrations using Hycult ELISA assay before administration of GSK2398852

-SAP concentrations measured by GSK assay after administration of GSK2398852

Assess the immunogenicity of GSK2398852 when co-administered with GSK2315698.

Measurement of anti-drug antibodies before and after treatment with GSK2398852


37


Exploratory (Both parts)

Assess effect after doses of GSK2398852 when co-administered with GSK2315698 on amyloid load, both overall and in affected organs

-Volume of distribution of gadolinium in organs of interest as a measure of amyloid load (EqMRI of spleen, liver, heart)

-Volume of organs of interest measured by MRI (spleen, heart and liver)

-Elastography assessment of liver (Part A)

-SAP scan assessment of amyloid load before and after treatment (Part A)

-DPD scan (TTR subjects in Part B only)

-If liver biopsy conducted: Liver histology examination for presence of giant cells, activation of macrophages, and amyloid clearance

Assess effect after doses of GSK2398852 when co-administered with GSK2315698 on organ function in organs affected by amyloid deposition

Biomarkers of organ function in amyloid affected organs .e.g.: protein excretion, creatinine; creatinine clearance; Pro NT-BNP, KIM-1, NGAL, liver function tests

Assess individual patient quality of life, as measured by the MOS Short Form 36 (MOS SF-36) of patients prior to and following a dose of GSK2398852

Explore the impact of single doses of GSK2398852 on individual patient quality of life compared to individual quality of life at baseline (prior to receiving a dose of GSK2398852), as measured by the MOS SF-36.

Construct a PK PD model for GSK2315698 and GSK2398852

-Exploratory histological examination of liver biopsies to inform on PK/PD and/or mechanistic aspects of drug effect

- Exploratory PK/PD analysis of SAP concentrations following administration of GSK2398852

Exploratory analyses to evaluate mechanism of action of GSK2398852

-Biomarkers to inform on the mechanism of action of GSK2398852 e.g. granulocyte counts, monocyte counts, complement assays, TNF, IL-6, IL-8


38


Assess effect of chemotherapy standard of care on pharmacodynamic response in a subset of subjects (AL only)


-Volume of distribution of gadolinium in organs of interest as a measure of amyloid load (EqMRI of spleen, liver, heart)




39

3. INVESTIGATIONAL PLAN

3.1. Study Design/Schematic

See Figure 3 for an overview of the study and decision tree.

Protocol waivers or exemptions are not allowed with the exception of immediate safety concerns. Therefore, adherence to the study design requirements, including those specified in the Time and Events Table, are essential and required for study conduct.


40

Table 3 Overview of study flow for a single subject in Part A

Day ~D-30 to D8 D-26 to D-6 D-4 to D-1 Day 1 Days 2-~14 (approx)`

If discharged before D14

D14-42 Long term follow up

Setting Outpatient Inpatient (Quintiles Clinical Research Unit, London) Outpatient but resident in London area

Outpatient

Activity Screening

Patient identification (NAC)

Potential subjects referred to Quintiles for assessment

Consent procedures and safety screening (Qn)

Baseline procedures

SAP scan (NAC)

EqMRI (HHL)

Administration of MOS SF-36 (Qn)

Elastography (RFH)

Liver Biopsy if required (RFH)

Assessment of organ function in key target organs (only affected or suspected to be affected organs) will be assessed.

Depletion of SAP

Administration of GSK2315698 (to deplete circulating SAP)

Estimated 48-72 hours

Circulating SAP concentration will be checked before GSK2398852 is dosed.

Administration of anti-SAP mAb

Infusion of GSK2398852 (anti-SAP mAb) over up to a maximum 8 hours

Only one subject will be a dosed at any time in Part A

Administration of GSK2315698 continuesuntil the concentration of the unbound mAb has fallen below 100 ng/mL or below the LLQ.

Subjects will be closely monitored. Samples to measure concentrations of GSK2315698, GSK2398852 and SAP will be measured.

Subjects will be discharged once GSK2315698 has been stopped for at least 12 hours.

Inpatient safety follow up

Ongoing infusion of GSK2315698 until mAb concentration <100ng/mL or below the LLQ.

Estimated 2-14 days

Subject discharged from Quintiles

Safety follow up

Follow up assessments (Qn)

Subjects will be contacted daily by telephone for the next 7 days following discharge from the clinical unit.

Clinical follow up

Follow up safety assessments (Qn)

SAP scan (NAC) ~6 weeks post dose

EqMRI (HHL)~D14 and D42


Elastography (RFH)- D14 and D42

Measurement of anti drug antibodies

Assessment of organ function in key target organs (to mirror those conducted at baseline)

Long term follow up

Subjects will be invited to enroll in SAP115970, a long term follow up observational study.

EqMRI (HHL) (D6-9)


Elastography (RFH) (D6-9)

Liver Biopsy if required (RFH)

NAC - National Amyloidosis Centre, Qn - Quintiles London, HHL - Heart Hospital London, RFH - Royal Free Hospital


41

Table 4 Overview of study flow for a single subject in Part B

Session 1, 2 and 3

Day D-4 to D-1 Day 1 Days 2-~10 (approx)` D14 Day 21 Day 42

Setting Inpatient (Clinical Research Unit) Outpatient but resident in London area

Outpatient Out patient

Activity Depletion of SAP

Administration of GSK2315698

Estimated 76 hours IV

Circulating SAP concentration will be

checked before GSK2398852 is dosed.

Administration of anti-SAP mAb

Infusion of GSK2398852 (anti-SAP mAb) over up

to 8 hour

Administration of GSK2315698 continues

SC

Subjects will be closely monitored.

Inpatient safety follow up

Administration of GSK2315698 continues until concentration of the unbound mAb has fallen

below threshold in Section 1.3.2.

Estimated in-patient stay 2-10 days

Subject will be discharged from Unit

once GSK2315698 has been stopped for at least

12 hours. In some circumstances subjects may be allowed to self

administer subcutaneous CPHPC in an outpatient

setting at the investigators discretion and in agreement with the medical monitor.

Safety follow up

Follow up assessments (CRU)

Subjects will be contacted daily by

telephone for the next 7 days following discharge

from the unit.

PD assessments

Elastography (RFH)

Administration of MOS SF-36 (CRU)

Liver Biopsy (in subset of subjects)

Safety follow up


Safety follow up


PD assessments

EqMRI (HHL)Administration of MOS

SF-36 (CRU)Elastography (RFH)

SAP scan (RFH)aDPD scan (RFH)

CRU – Clinical Research Unit (Quintiles London or Clinical Unit Cambridge), NAC - National Amyloidosis Centre, HHL - Heart Hospital London, RFH - Royal Free Hospitala - only in TTR subjectsSee Table 7 for screening and baselines assessments


42

3.1.1. Outline of study assessments

Details of the study assessments are given in Section 6. A brief outline is provided here and in Table 3 and Table 4. The schedule of assessments is the same for all parts of the study however the precise timing of assessments will be refined based on the experience in Part A. The timings given here are for guidance and may be altered.

Potential subjects will be identified by the National Amyloidosis Centre (Royal Free Hospital) and if they express an interest, invited to attend for consent and screening which will be conducted byone of the Clinical Research Units; Quintiles , London, or Clinical Unit Cambridge

Following successful screening subjects will undergo a baseline assessment of their disease in the month prior to the study drug administration, followed by an inpatient phase based at one of the clinical research units where they will receive the study treatment (approx 14 days), and an outpatient phase where they will have various safety assessments and study follow up. [Table 3 and Table 4].

Organ function will be assessed using the following measures:

Kidney- protein excretion; Estimated GFR will be derived from measured creatinine clearance. If this is not available it will be calculated using the MDRD equation [Appendix 4]

Heart- Troponin, ProNT-BNP

Liver function tests

Spleen size (from MRI)

Inpatient dosing

The dosing will be open label in part A and Part B Unlike many other mAbs, clearance of GSK2398852 from the blood is expected to be rapid owing to the large excess of target antigen in the tissues.

3.2. Treatment Assignment

In Part A doses will be administered sequentially as detailed in Section 1.3.2.

In Part B, doses will administered based on the subject's disease profile and safety review of prior subjects’ data.


43

3.3. Investigational Product and Other Study Treatment Dosage/Administration

Study TreatmentProduct name: GSK2315698 GSK2398852Dosage form: Solution in 0.9% w/v saline,

pH 5.0GSK2398852 Concentrate for Solution for Infusion, 100 mg/mL

Unit dose strength(s)/Dosage level(s):

Unit dose strength: 200mg/mL stock to be dilutedDosage levels: variable

Unit dose strength: 100 mg/mL provided as 1 mL solution per vial. Dosage levels variable

Route/Administration/Duration:

Intravenous infusion Subcutaneous injection

Intravenous infusion up to maximum permitted by expiry of dose so up to 8 hour infusion duration (based on total dose to be administered).

Dosing instructions:

Study medication will be administered by intravenous infusion and subcutaneous injection by study personnel following specified regimens

Study medication will be diluted in 0.9% w/v sodium chloride and administered by intravenous infusion by study personnel following specified regimens

Manufacturer/source of procurement:

Supplied by GSK Study medication supplied by GSK, 0.9% w/v sodium chloride sourced locally by site

3.4. Dose Adjustment/Stopping Criteria

GSK2398852

This is an exploratory study, the starting and highest dose to be administered are given in Section 1.3.2. The proposed dose escalation regimen is given in Table 1.

The decision to proceed to the next dose level of GSK2398852, will be made by the GSK Study Team and the investigator based on safety, tolerability with all available preliminary pharmacokinetic and pharmacodynamic data obtained at prior dose levels. The actual doses to be administered may be adjusted based on the available information and may involve either a repeat, increase or decrease in the planned dose.

In Part A the interval between subjects starting dosing will be a minimum of 14 days and the decision on dosing the next subject will be made after a minimum of 7 days of follow up after dosing with GSK2398852.

GSK2315698

The dose of GSK2315698 to be administered will be informed by the PK/PD model derived from enabling studies CPH113776 and CPH114527. The model will be continually updated with information from this study and dosing regimens adjusted based on the latest information. The limits of the predicted exposure are outlined in Section 1.3.2.


44

If after 4 days administration of GSK2315698 the concentration of SAP is not within the target for the subject’s patient group, the subject will be withdrawn and the anti SAP mAb not dosed.

GSK2315698 will be continued after the administration of GSK2398852 for a minimum of 7 days and until the concentration of unbound GSK2398852 has fallen below 5000 ng/mL or below LLQ. Refer to Section 1.3.2.

3.4.1. Dose Adjustment/Stopping Safety Criteria

3.4.1.1. Liver Chemistry Stopping Criteria

Liver chemistry threshold stopping criteria have been designed to assure subject safety and to evaluate liver event etiology (in alignment with the FDA premarketing clinical liver safety guidance).

If a subject has an:

ALT 3xULN during treatment with SAP depleter GSK2315698 alone, study treatment will be stopped and the subject withdrawn. They will not be dosed with GSK2398852.

If ALT 3xULN is observed following administration of GSK2398852 and administration of GSK2315698 is continuing the potential risk benefit of continuing GSK2315698 will be considered with a view to stopping this as soon as possible.

Refer to Section 11, Liver Chemistry Follow-up Procedures, for details of the required assessments if a subject meets the above criteria.

3.4.1.2. QTc Withdrawal Criteria

A subject that meets the criteria below during treatment with GSK2315698 alone will be withdrawn from the study and GSK2398852 will not be dosed. If these criteria are observed following administration of GSK2398852 and during administration of GSK2315698 the potential risk benefit of continuing GSK2315698 will be considered with a view to stopping this as soon as possible. The QT correction formula used to determine discontinuation should be the same one used throughout the study.

QTcF > 500 msec or uncorrected QT >600 msec

Change (increase) from baseline: QTc >60 ms

If subject has underlying bundle branch block then the QTc withdrawal criteria depends on the baseline value:

Baseline QTc value (with underlying bundle branch block)

QTc withdrawal criteria

<450 ms >500 ms

450-480 ms 530 ms


45

Withdrawal decisions are to be based on an average QTc value of triplicate ECGs. If an ECG demonstrates a prolonged QT interval, obtain 2 more ECGs over a brief period, and then use the averaged QTc values of the 3 ECGs to determine whether the subject should be discontinued from the study.

3.4.1.3. Other Dose Adjustment/Stopping Safety Criteria

The available data from all previous subjects will be reviewed prior to dosing the next subject. The following observations will lead to a safety review before any more subjects are dosed:

Evidence of toxicity from immune complex formation (e.g. active urinary sediment suggesting glomerulonephritis; inflammatory skin lesions)

Evidence of toxicity from targeting of non-amyloid SAP (e.g. evidence of systemic inflammation)

Evidence of a systemic inflammatory response associated with poor tolerability (headache of CTCAE ≥Grade 3 severity, or a fever or hypotension of CTCAE ≥Grade 2 in severity; elevated CRP/SAA). If this occurs Cytokine concentrations will be analysed before any additional subjects are dosed

Other safety concerns at discretion of study team in conjunction with Investigator

The safety review will involve in the first instance the GSK study team, advisors from the National Amyloidosis Centre, and the investigator. Additional experts including the external safety advisory committee may be involved depending on the nature of the issue (Section 12.8).


46

3.5. Time and Events Tables (Part A, and Part B)

Timings are subject to change dependent on emerging data. The changes will be reviewed by GSK study team with the Investigator but will not constitute a protocol amendment.

Table 5 Part A - Overview (for details of inpatient stay see Table 5)

Day: Screening Baseline

assessments (outpatient)7

Inpatient phase(up to approx 14 days)9 D610 D1410 D21

Follow-upD427

Visit Window -30 to -8 days

D-26 to D-6 -48 to Day 10+5 days9

2 days

2 days 4 days

Inpatient stay at Quintiles Unit X (X)9

Outpatient visit to Quintiles Unit X

See separate schedule (Table 6) for

details of assessments

X X X XOutpatient visit to Heart Hospital (EqMRI) X X5 X5 XOutpatient visit to Royal Free Hospital (National Amyloidosis Centre) for SAP scan

X X

Outpatient visit to Royal Free Hospital (National Amyloidosis Centre) for elastography

X X X X

Informed Consent XTelephone contact X2 X2

Medical/medication/ history Cardiovascular medical history/risk factors

X

Demographics and complete physical XHeight/Weight/BMI XMOS SF-36 Questionnaire X X XStudy Treatment Dosing XBrief physical XFSH/E2 X12-lead ECG X X X XVital signs X X X X XSerum or urine -hCG (women) X X XHaem/Clin Chem/Urinalysis tests1 X X X X X


47



Inpatient phase(up to approx 14 days)9 D610 D1410 D21

Follow-upD427


D-26 to D-6 -48 to Day 10+5 days9

2 days

2 days 4 days

Hep B/ Hep C X

See separate schedule (Table 6) for

details of assessments

Urine Collection for protein excretion4 X X XBlood biomarker samples XUrine biomarkers- KIM-1/ NGAL/Creatinine X X XAE assessment X X X X XCon.Medication Review X X XGSK2398852 PK blood sample X X X3 XSAP concentration (blood sample) GSK assay X X X XSAP concentration (blood sample) Hycult ELISA assay

X

GSK2398852 Immunogenicity blood sample X XLiver biopsy (If required) X XClotting assessment X X6 X6

Discharge from Quintiles unit X1. Routine clin chem.; haem; urinalysis, Urine may undergo renal microscopy if indicated2. Daily for 7 days following discharge3. If data permit4. Collection over 24 hours. To be performed before the SAP scan on D6 and D42. A 3.5ml serum biochemistry sample should be taken for creatinine measurements at time points

when there are no corresponding Clinical Chemistry samples i.e. at Baseline.5. These assessments will be at least 7 days apart6. To be performed here only on subjects undergoing a liver biopsy prior to each liver biopsy assessment (Day -26 to -6 and Day 6 to 12).7. Assessments may be more than one day and on separate days8. Day of GSK2398852 dose is designated Day 1. GSK2315698 may be administered for up to 5 days before Day 19. The inpatient phase may be longer or shorter depending on PK and safety data.10. Assessments make take place as inpatient assessment if subject has not yet been discharged.


48

Table 6 Part A - Details of inpatient stay (Example Scenario)

Procedure

Study Day8

Day -4

Day-3

Day-2

Day-1

Day 1

Day2

Day3

Day 4

Day 5

Pre

-dos

e

0-24

h

0-24

h

0.-

24 h

Pre

-dos

e

1 h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

60 h

72 h

Dis

char

ge5

Admission to Unit XBrief Physical Exam XMedical/medicationreview

X

12-lead ECG X X X X X X X X X X XHolter tape X X XVital signs X X X X X X X X X X X X X X X X XTemperature X X X X X X X X X X X XTelemetry -------------------------------

Serum or urine -hCG (women)

X

Haem/clin chem./Urinalysis X X X X XC3/C4/CRP/ CH50/SAA X X X X X X X XUrine collection for protein1 X X X XUrine microscopy2 X X X X X X XBlood Biomarkers – IL-6/ IL-8/ TNF

X X X X X X

Urine Biomarkers- KIM-1/ NGAL/creatinine

X X X X

Troponin T/ proNT BNP X X X X X X XImmunogenicity Sampling for GSK23988527

X

Administration of GSK23156988 ----------------------------------------------------------------------------------------X-----------------------------------------------------------------

Administration of GSK2398852 (iv infusion)3 -----------------------X---------------------


49

Procedure

Study Day8

Day -4

Day-3

Day-2

Day-1

Day 1

Day2

Day3

Day 4

Day 5

Pre

-dos

e

0-24

h

0-24

h

0.-

24 h

Pre

-dos

e

1 h

2 h

3 h

4 h

6 h

8 h

10 h

12 h

15 h

24 h

36 h

48 h

60 h

72 h

Dis

char

ge5

SAP concentration (blood sample) Hycult ELISA assay

X4 X4 X4

Pharmacokinetic Sampling for GSK2315698

X9 X X X X X X X X X X

Pharmacokinetic Sampling for GSK23988526 X X X X X X X X X X

SAP concentration (blood sample) GSK assay

X X X X X X X X X X

Adverse Event Review X X X X X X X X X X X X X XConcomitant Medication Review

X =========================================================================== X X X

Discharge X1. 24 hour collection A 3.5ml serum biochemistry sample should be taken for creatinine measurements at time points when there are no corresponding Clinical Chemistry samples

i.e. on Day -2.2. ‘renal’ examination of urine (ie not just dipstick and culture)3. Over a maximum of 8 hours (dependent on total dose to be administered) following pre-dose assessments.4. Sample to be taken at end of dosing period. Rapid turnaround to ensure SAP depleted to target prior to dosing mAb5. 12 hours post end of GSK2315698 administration- PK sampling schedule can be modified according to emerging data throughout the study.6. Rapid turnaround so can make decision whether GSK2315698 can be switched off. The timing of the PK sampling regimen may be adjusted within the inpatient stay period based

on emergent data.7. Particular attention will be paid to cutaneous manifestations of immune complex disease8. Day of GSK2398852 dose is designated Day 1. GSK2315698 may be administered for up to 5 days before Day 1.9. To be taken at approximately 48hrs after the start of GSK2315698 administration.


50

Table 7 Part B – Overview (for details of inpatient stay see Table 8)



Baseline assessments

sessions 2 and 3

Inpatient phase(up to approx 14

days)9

D1410 D21Follow-up

D427


D-26 to D-6 -48 to Day 9 2 days

2 days

4 days

Inpatient stay In Unit XOutpatient visit to Unit X

See separate schedule (Table 8) for details of assessments

X X XOutpatient visit to Heart Hospital (EqMRI) X X XOutpatient visit to Royal Free Hospital (National Amyloidosis Centre) for SAP scan/DPD scan

X11 X11X

Outpatient visit to Royal Free Hospital (National Amyloidosis Centre) for elastography

X12 X X X

Informed Consent XTelephone contact X2

Medical/medication/ history Cardiovascular medical history/risk factors

(X)

Demographics and complete physical (X)Height/Weight/BMI (X)MOS SF-36 Questionnaire X X X XStudy Treatment Dosing XBrief physical XFSH/E2 (X)12-lead ECG X X X X XVital signs X X X X XSerum or urine -hCG (women) (X) XHaem/Clin Chem/Urinalysis tests1 X X X X XHep B/ Hep C (X)Troponin T/ proNT BNP (X) X X13

Urine microscopy XUrine Collection for protein excretion4 X X X X


51



Baseline assessments

sessions 2 and 3

Inpatient phase(up to approx 14

days)9

D1410 D21Follow-up

D427


D-26 to D-6 -48 to Day 9 2 days

2 days

4 days

Blood biomarker samples (C3/C4/CRP/CH50/SAA) See separate

schedule (Table 8) for details of assessments

X

Urine biomarkers- KIM-1/ NGAL/Creatinine X X XAE assessment X X X X XCon.Medication Review X XGSK2398852 PK blood sample X X3 XSAP concentration (blood sample) GSK assay X X XSAP concentration (blood sample) Hycult ELISA assay

X X

GSK2398852 Immunogenicity blood sample X XLiver biopsy (If required) X X XClotting assessment (X) X6 XDischarge from Clinical Research unit X(X) – For subjects who did not participate in or complete Part A.1. Routine clin chem.; haem; urinalysis, Urine may undergo renal microscopy if indicated2. Daily for 7 days following discharge3. If data permit4. Collection over 24 hours. To be performed before the SAP scan on D6 and D42. A 3.5ml serum biochemistry sample should be taken for creatinine measurements at time points

when there are no corresponding Clinical Chemistry samples i.e. at Baseline.5. These assessments will be at least 7 days apart6. To be performed here only on subjects undergoing a liver biopsy prior to each liver biopsy assessment (Day -26 to -6 and Day 6 to 12).7. Assessments may be more than one day and on separate days8. Day of GSK2398852 dose is designated Day 1. GSK2315698 may be administered for up to 5 days before Day 19. The inpatient phase may be longer or shorter depending on PK and safety data. Subjects will need to attend the clinical unit for dosing and safety assessments but may leave the

unit in between at the principal investigator’s discretion.10. Assessments make take place as inpatient assessment if subject has not yet been discharged.11. SAP scan for subjects who did not participate in or complete Part A or it has been greater than 3 months since the previous scan. DPD scan for TTR subjects only12. Two baseline elastography assessments where feasible.13. Only for patients with cardiac amyloid


52

Table 8 Part B - Details of Inpatient stay (Example scenario)

Procedure

Study Day8

Day -4

Day-3

Day-2

Day-1

Day 1

Day 2 Day3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Pre

-dos

e

0-24

h

0-24

h

0-24

h

Pre

-dos

e

0.5

h

1 h

2 h

3 h

4 h

6 h

7 hr

8 h

12h

24 h

36 h

48 h

60 h

Admission to Unit XBrief Physical Exam XMedical/medication review X12-lead ECG X X X X X X X X X X X X X X XHolter tape X X XVital signs X X X X X X X X X X X X X X X X X X X X X X XTemperature X X X X X X X X X X X X X X X X XTelemetry12 -------------------------------------------------

Serum or urine -hCG (women)

X

Haem/clin chem./Urinalysis X X X X X X X X X XC3/C4/CRP/ CH50/SAA X X X X X X XUrine collection for protein1 X X X XUrine microscopy2 X X X X X X X X X X X X XBlood Biomarkers – IL-6/ IL-8/ TNF

X X X X X X X X X

Urine Biomarkers- KIM-1/ NGAL/creatinine

X X X X X X

Troponin T/ proNT BNP12 X X X X X X XImmunogenicity Sampling for GSK23988527

X

Administration of GSK23156988

----------------------------------------------------------------------------------------X-------------------------------------------------------------------------------------------

Administration of GSK2398852 (iv infusion)3 ---------------X--------------------------


53

Procedure

Study Day8

Day -4

Day-3

Day-2

Day-1

Day 1

Day 2 Day3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Pre

-dos

e

0-24

h

0-24

h

0-24

h

Pre

-dos

e

0.5

h

1 h

2 h

3 h

4 h

6 h

7 hr

8 h

12h

24 h

36 h

48 h

60 h

SAP concentration (blood sample) Hycult ELISA assay

X4 X4 X4

Pharmacokinetic Sampling for GSK2315698

X9 X X X X X X11 X X X X X10 X X X X X

Pharmacokinetic Sampling for GSK23988526 X X X X X X11 X X X X X10 X X X X X

SAP concentration (blood sample) GSK assay

X X X X X X11 X X X X X10 X X X X X

Adverse Event Review X X X X X X X X X X X X X X X X X X XConcomitant Medication Review

X =========================================================X=================================================

Discharge (X) (X) (X)

(X) – Subjects can only be discharged once levels of GSK2398852 have fallen below specified level in Section 1.3.21. 24 hour collection A 3.5ml serum biochemistry sample should be taken for creatinine measurements at time points when there are no corresponding Clinical Chemistry samples

i.e. on Day -2.2. ‘renal’ examination of urine (ie not just dipstick and culture)3. Over a maximum of 8 hours (dependent on total dose to be administered) following pre-dose assessments. Dosing may be split over Day 1 and Day 2 if necessary e.g. in

subjects with cardiac amyloid.4. Sample to be taken at end of dosing period. Rapid turnaround to ensure SAP depleted to target prior to dosing mAb5. 12 hours post end of GSK2315698 administration- PK sampling schedule can be modified according to emerging data throughout the study.6. Rapid turnaround so can make decision whether GSK2315698 can be switched off. The timing of the PK sampling regimen may be adjusted within the inpatient stay period based

on emergent data.7. Particular attention will be paid to cutaneous manifestations of immune complex disease8. Day of GSK2398852 dose is designated Day 1. GSK2315698 may be administered for up to 5 days before Day 1.9. To be taken at approximately 48hrs after the start of GSK2315698 administration.10. PK sample at 72 hours post GSK2398852 dose11. PK sample to be taken at the end of infusion, immediately before the infusion is stopped (at 6hr if infusion as planned or at a time point earlier or later if the infusion has been

shortened or has been interrupted)12. Telemetry monitoring and Troponin T/ proNT BNP samples may be increased at the investigators discretion e.g. in subjects with cardiac amyloid.


54

Table 9 Parts A & B - Extended inpatient stay assessments (where subject is not discharged on Day 9)

ProcedureStudy Day

Day 10 Day 11 Day 12 Day 13

12-lead ECG X X X X

Vital signs X X X X

Temperature X X X X

Haem/clin chem./Urinalysis X X X X

C3/C4/CRP X X

CH50/SAA4 X X

Urine microscopy1 X X

Urine Biomarkers- KIM-1/ NGAL/creatinine X X

Troponin T/ proNT BNP4 X

Administration of GSK2315698 X X X X

Pharmacokinetic Sampling for GSK2315698 X X X X

Pharmacokinetic Sampling for GSK23988523 X X X X

SAP concentration (blood sample) GSK assay X X X X

Adverse Event Review ====================================X==========================

Concomitant Medication Review ====================================X==========================

Discharge2 (X) (X) (X) (X)

1. ‘renal’ examination of urine (ie not just dipstick and culture).2. Subject may be discharged based on PK and safety data. If subject cannot be discharged, assessments as listed for Day 13 should continue until discharge.3. Rapid turnaround so can make decision whether GSK2315698 can be switched off. The timing of the PK sampling regimen may be adjusted within the inpatient stay period

based on emergent data.4. For Troponin T/proNT BNP and CH50/SAA sample time points falling on a weekend day, samples should be collected on the nearest weekday either before or after the

scheduled day.


55

4. STUDY POPULATION

4.1. Number of Subjects

Approximately 16 subjects will be enrolled in to Part A. The number of subjects in Part B is proposed to be up to approximately 30.

Subjects from Part A may enrol in Part B. For both parts of the study additional subjects may be enrolled to allow for evaluation of additional dose levels or to add scientific clarity within one dose level.

If subjects prematurely discontinue the study, additional subjects may be enrolled as replacement subjects at the discretion of the Sponsor in consultation with the investigator.

4.2. Eligibility Criteria

4.2.1. Inclusion Criteria

Deviations from inclusion criteria are not allowed because they can potentially jeopardize the scientific integrity of the study, regulatory acceptability or subject safety. Therefore, adherence to the criteria as specified in the protocol is essential.

A subject will be eligible for inclusion in this study only if all of the following criteria apply:

1. Subject has been medically diagnosed with systemic amyloidosis and falls into one of the following patient groups:

Part A (first dose levels) Small to moderate amyloid load involving the spleen

Part A (following agreement from external safety committee)

Moderate to large amyloid load involving the spleen (to a moderate/large extent)

Part B Subjects from Part A

Subjects who did not participate in Part A with:

Moderate to large amyloid load)

And/or Mild cardiac involvement in a subset of subjects


56

2. ALT < 3xULN and bilirubin <1.5x ULN (isolated bilirubin >1.5xULN is acceptable if bilirubin is fractionated and direct bilirubin <35%).

3. Male or female between 18 and 70 years (upper limit of 75 years for ATTR patients)of age inclusive, at the time of signing the informed consent. Subject is ambulant and capable of attending for the study visit schedule.

4. Capable of giving written informed consent, which includes compliance with the requirements and restrictions listed in the consent form.

5. A female subject is eligible to participate if she is of:

Non-childbearing potential defined as pre-menopausal females with a documented tubal ligation or hysterectomy; or postmenopausal defined as 12 months of spontaneous amenorrhea [in questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) > 40 MlU/ml and estradiol < 40 pg/ml (<147 pmol/L) is confirmatory]. Females on hormone replacement therapy (HRT) and whose menopausal status is in doubt will be required to use one of the contraception methods in Section 7.1 if they wish to continue their HRT during the study. Otherwise, they must discontinue HRT to allow confirmation of post-menopausal status prior to study enrollment. For most forms of HRT, at least 2-4 weeks will elapse between the cessation of therapy and the blood draw; this interval depends on the type and dosage of HRT. Following confirmation of their post-menopausal status, they can resume use of HRT during the study without use of a contraceptive method.]

6. Male subjects with female partners of child-bearing potential must agree to use one of the contraception methods listed in Section 7.1. This criterion must be followed from the time of the first dose of study medication until 85 days post-last dose.

7. Smokers (<10 /day) are permitted but must be willing to abstain for the duration of residential study sessions

4.2.2. Exclusion Criteria

Deviations from exclusion criteria are not allowed because they can potentially jeopardize the scientific integrity of the study, regulatory acceptability or subject safety. Therefore, adherence to the criteria as specified in the protocol is essential.

A subject will not be eligible for inclusion in this study if any of the following criteria apply:

1. A positive pre-study Hepatitis B surface antigen or positive Hepatitis C antibody result within 3 months of screening

2. The subject has participated in a clinical trial and has received an investigational therapeutic product (unlicensed) within the following time period prior to the first dosing day in the current study: 3 months, 5 half-lives or twice the duration of the biological effect of the investigational product (whichever is longer). This timeframe will not apply to short term administration of GSK2315698 in study CPH114527.


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3. Pregnant females as determined by positive serum or urine hCG test at screening or prior to dosing.

4. Lactating females.

5. Estimated GFR<30 mL/min [<60 mL/min for the first 4 subjects to be enrolled]

6. Evidence of an active urinary sediment on microscopy as evidenced by the presence of red cell casts at screening

7. Decompensated cardiac failure or a recent history of syncope or pre--syncope associated with cardiac disease.

8. In a subject in whom there is a clinical suspicion of cardiac amyloid: an echocardiogram shows significantly impaired systolic function, whether symptomatic or not, presence of symptoms consistent with NYHA functional class III or IV, NT-pro BNP >212 pMol/L (AL patients only)

9. Clinically significant anaemia- Hb <9 g/dL.

10. Use of prohibited medications (see Section 8.2).

11. Poor or unsuitable venous access.

12. Subjects with a QTcF of >480ms or other ECG abnormalities which, in the opinion of the investigator is clinically significant in that they may increase safety risk.

13. Uncontrolled hypertension with systolic BP > 170 mmHg and /or diastolic > 100 mmHg

14. Presence of any co-morbid condition (e.g. severe or unstable coronary artery disease; moderate-severe chronic obstructive pulmonary disease) which in the opinion of the investigator would increase the potential risk to the subject.

15. Subjects with active vasculitis

16. Subjects with dementia or a diagnosis of cerebral amyloid angiopathy

17. Exclusions from EqMRI scanning

Contraindications to MRI scanning including, but not limited to:Intracranial aneurism clips (except Sugita);History of intra-orbital metal fragments that have not been removed by an MD (as confirmed by orbital X-Ray);Pacemakers and non-MR compatible heart valves;Inner ear implants;History of claustrophobia

Estimated GFR < 30 mL/min (gadolinium exclusion)

NB Subjects who have contraindication to MRI scanning may still enter the study but will not undergo the EqMRI scan

4.3. Screen and Baseline Failures

Data for screen and baseline failures will be collected in source documentation at the site but will not be transmitted to GSK.


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5. DATA ANALYSIS AND STATISTICAL CONSIDERATIONS

5.1. Hypotheses and Treatment Comparisons

In Part A and B, no formal hypotheses will be tested.

5.2. Sample Size Considerations

The planned sample size for part A and B is based primarily on feasibility. Assumptions for the evaluaton of sample size are based on data from the EqMRI enabling study CRT114645 (see Section 1.3, Figure 4).

5.2.1. Sample Size Assumptions

5.2.1.1. Part A and B

Assuming a true response (i.e. change from baseline in log10 Vd) of -0.15 at the highest well-tolerated dose and a standard deviation of 0.04, a total of 100,000 trial simulations were performed, based on a log-normal distribution for Vd and various sample sizes from n=2 to 8 The probability of observing no subjects with a change in log10 Vd of -0.15 at a given dose or higher is low for an n ≥ 4 (≤ 6%), assuming a true effect of -0.15, and hence there is only a low risk that a true signal based on EqMRI will be missed entirely. Further details regarding the probability of 1 or more subjects having a change in log10 Vd of -0.15 or better under these assumptions are given below.

Table 10 Probability of observing 1 or more subjects with change in log10 Vd of -0.15 or better for various sample sizes

n=2 n=3 n=4 n=6 n=8No. of

pts with strong signal*

% simulated

trials

No. of pts with strong signal*

% simulated trials


% simulated trials


% simulated trials


% simulated trials

0 25% 0 13% 0 6% 0 2% 0 <1%1 50% 1 37% 1 25% 1 9% 1 3%2 25% 2 37% 2 38% 2 23% 2 11%

3 13% 3 25% 3 31% 3 22%4 6% 4 24% 4 27%

5 9% 5 22%6 2% 6 11%

7 3%8 <1%

* No. of subjects with change from baseline in log10(volume of distribution) = -0.15 or better. Assuming true effect=-0.15.

Note, in any given simulated trial, the number of subjects with a strong signal, i.e. a change from baseline in log10 Vd ≤ -0.15 (our assumed mean), will follow a binomial distribution where the probability of observing a strong signal in an individual subject = 0.5. As such, the percentages of simulated trials with a given number of ‘responders’, as presented in Table 10, equate to the binomial probabilities for a given number of ‘responders’ (within 1%) assuming the probability of ‘response’ for an individual


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subject = 0.5. These probabilities are therefore equivalent irrespective of the assumed standard deviation for the trial simulations.

Assuming we were to observe no responders at all in a total of n subjects, i.e. 0 out of n subjects had an observed change from baseline in log10Vd of ≤ -0.15, then the following are given in Table 11 for various n:

i) 95% credible intervals for response rate

ii) probability of response rate > 0.5,

derived within a Bayesian framework with a non-informative conjugate prior distribution, Beta(1,1), for the response rate.

Table 11 95% credible intervals for response rate and probability of response rate > 0.5, if we were to observe no responders

n Observed number of responders

95% credible interval for response rate, given observed

data

Prob. of response rate > 0.5, given observed

data

2 0 (0.01, 0.71) 0.13

3 0 (0.01, 0.60) 0.06

4 0 (0.01, 0.52) 0.03

5 0 (0.00, 0.46) 0.02

6 0 (0.00, 0.41) 0.01

7 0 (0.00, 0.37) <0.01

8 0 (0.00, 0.34) <0.01

‘Response‘ equates to a change in log10(Vd) ≤ -0.15

Note, if we were to observe zero subjects with a response at a given dose or higher, the probability, of the response rate being greater than 0.5 would be low for any sample size (eg 13% for n=2, <10% for n ≥ 3, <=1% for n ≥ 6). . A further 100,000 trial simulations were also performed to assess the probability of observing a false positive, assuming no treatment effect at a given dose (i.e. a change from baseline in log10 Vd of zero), and a standard deviation of 0.04, based on various sample sizes from n=2 to8 A change of -0.15 or better in log10 Vd (i.e. a false positive) was observed in < 1% of the simulated trials and for no more than one subject within any given simulated trial, i.e. there is a negligible risk of observing a strong signal (a false positive) based on EqMRI in any one subject at a given dose (i.e. a change from baseline of -0.15 or better in log10 Vd) if there is truly no treatment effect.


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5.2.2. Sample Size Sensitivity

5.2.2.1. Part A and B

To further assess the probability of observing a false positive, an additional 100,000 trial simulations were performed assuming no treatment effect at a given dose and a larger standard deviation of 0.06, based on various sample sizes from n=2 to 8 The probability of observing a strong signal (a false positive) in one or more subject, i.e. a change of -0.15 or better in log10 Vd if there is truly no treatment effect, increases with increasing n but is no more than 5% for up to n=8 at a given dose. Probabilities were 1%, 2%, 2%, 4% and 5% for n=2, 3, 4, 6 and 8 respectively.

5.2.3. Sample Size Re-estimation

Sample size is based primarily on feasibility. However, the precise selection of numbers of subjects and dose levels in Part B will be informed by the results from Part A and available data from the ongoing review of Part B data including PD assessments As such, there will be no formal sample size re-estimation.

5.3. Data Analysis Considerations

5.3.1. Interim Analysis

Data will be reviewed by the study team on an ongoing basis during Part A and B. Dose escalation decisions will be based on safety data (including AEs, clinical laboratory data, vital signs, ECGs), PK (GSK2315698 and GSK2398852 concentrations), PD (EqMRI (volume of distribution), liver elastography, SAP scan data,biochemistry and biomarker data. A subset of data displays will also be produced based on an interim data cut off to inform internal decision making.

5.3.2. Final Analyses

5.3.2.1. Analysis Populations

Safety Population:

This population is defined as all subjects who received at least one dose of study medication. This will be the primary population for assessing safety.

PK (GSK2315698) Population:

This population is defined as all subjects administered at least one dose of GSK2315698 and who have at least one GSK2315698 PK sample taken and analysed. This will be the primary population for assessing GSK2315698 PK.


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PK (GSK2398852) Population:

This population is defined as all subjects administered at least one dose of GSK2398852 and who have at least one GSK2398852 PK sample taken and analysed. This will be the primary population for assessing GSK2398852 PK.

PD Population:

This population is defined as all subjects who received at least one dose of study medication and who also have both a baseline and at least one post-treatment PD measure. This will be the primary population for assessing PD.

PK/PD Population:

This population is defined as all subjects included in either PK population and the PD population. This will be the primary population for PK/PD modelling.

5.3.2.2. Safety Analyses

Safety data from Part A and B will be listed and summarized as appropriate

5.3.2.3. Non-Compartmental Pharmacokinetic Analyses

Pharmacokinetic analysis will be the responsibility of the Clinical Pharmacokinetics Modeling & Simulation department within GlaxoSmithKline.

For both compounds (GSK2315698 and GSK2398852), plasma concentration-time data will be analyzed by non-compartmental methods with WinNonlin, version 6 or higher. Calculations will be based on the actual sampling times recorded during the study. From the plasma concentration-time data, the pharmacokinetic parameters shown in Table 12will be determined for GSK2315698 and for GSK2398852.

Table 12 PK parameter derived from non-compartment analysis per drug

Drugs PK parameter name PK parameter description

GSK2315698

Cmax Maximum observed plasma concentration

tmax Time to Cmax

AUC(0-x)Area under the plasma-concentration time curve from zero time (pre-dose) to the end of GSK2315698 infusion (x)

GSK2398852

Cmax Maximum observed plasma concentrationtmax Time to Cmax

AUC(0-t)Area under the plasma-concentration time curve from zero time (pre-dose) to the time of last quantifiable concentration

t1/2 Terminal half-life


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Pharmacokinetic data will be presented in graphical and/or tabular form and summarized descriptively as appropriate. All pharmacokinetic data will be stored in the Archives, GlaxoSmithKline Pharmaceuticals, R&D.

An assessment of dose proportionality may be explored for AUC and Cmax values for the two compounds using summary statistics and graphical presentations as appropriate.

5.3.2.4. Pharmacodynamic Analyses

PD measures of interest may be presented graphically by subject, by dose and by baseline amyloid load/organ involvement for a preliminary assessment of dose response.

If data permit an Emax model may be used to further evaluate the relationship between the change from baseline in log10-transformed Vd (and/or other PD measure) and dose,. Baseline PD measures may be included in the model as a covariate as appropriate and a slope parameter may also be incorporated.

If data permit, the following will be estimated from the analysis model as appropriate and presented together with associated 95% confidence intervals:

Maximum reduction from baseline in log10-transformed Vd (and/or other PD measure), attributable to drug (Emax)

Dose which induces half maximum reduction from baseline in log10-transformed Vd

(and/or other PD measure),attributable to drug (ED50)

Slope factor, as appropriate.

If data permit, at each of the dose levels studied, the model-predicted reduction from baseline in log10-transformed Vd (and/or other PD measure) will be presented together with associated 95% confidence intervals.

An alternative data transformation may be used as appropriate. Alternative dose-response models may also be explored as appropriate, and if data permit.

Further details regarding the analysis of EqMRI data and other PD measures will be provided in the RAP.

5.3.2.4.1. Liver Histology

Available liver histology data will be listed together with EqMRI and/or other PD measures of interest for comparison.

Further details will be provided in the RAP as applicable.

5.3.2.5. Pharmacokinetic/Pharmacodynamic Modelling

A PK/PD model including the effects of both compounds on SAP in plasma and in tissues (including amyloid tissues) will be investigated, using the plasma concentration data of GSK2315698, GSK2398852 and SAP. The existing PK/PD model of GSK2315698 developed in previous studies in healthy volunteers (CPH113776) and


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amyloidosis patients (CPH114527) will be used as the initial model. The PK parameters of both GSK2315698 and GSK2398852, will be estimated from the model together with the SAP turn-over parameters.

EqMRI data and/or other PD data of interest may be integrated in to the model to enrich the information at the tissue level, mainly in terms of in-situ degradation of GSK2398852 -SAP complexes.

The PK/PD modeling will be the responsibility of the Clinical PharmacokineticsModeling & Simulation department within GlaxoSmithKline and will be performed using the non-linear mixed effects approach implemented in NONMEM version VII. Further details will be provided in the RAP.

5.3.2.6. Novel Biomarker(s) Analyses

Novel biomarkers of interest may be presented graphically by subject, by dose and by baseline amyloid load/organ involvement for a preliminary assessment of dose response.

The results of some biomarker investigations may be reported separately from the main clinical study report. All endpoints of interest from all comparisons will be descriptively and/or graphically summarized as appropriate to the data.

Additional exploratory analyses may be performed to further characterize the novel biomarker.

5.3.2.7. Health Outcomes Analyses

The MOS SF-36 has 36 questions evaluating the patients’ quality of life over a 1 week period. All questions are scored using normative based scoring. Software is available that assists in the scoring of the MOS SF-36 (QualityMetric Health Outcomes Scoring Software 2.0, Saris-Baglama, 2007), and details on scoring can be found in the SF-36v2 user manual.

MOS SF-36 data will be listed and summarized as appropriate by domain score (physical health and mental health) and dose group.

Individual subject scores may also be interpreted, for example, using content-referenced interpretation, criterion-based interpretation and/or norm-referenced interpretation, as described below:

Content-referenced interpretation - subject’s scores are referenced to a specific content of different response levels (i.e. at the question level) and to the percentage of individuals from a normative sample who have responded at these response levels.

Criterion-based interpretation - subject’s scores are related to the percentage of people who report a specific criterion, such as inability to work or frequency of utilization of various services.


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Norm-referenced interpretation - subject’s total scores (for mental & physical health) are compared to mean scores and designated percentile rankings for various demographic and disease specific groups.

Further details of analyses of MOS SF-36 will be provided in the RAP.

6. STUDY ASSESSMENTS AND PROCEDURES

This section lists the parameters of each planned study assessment. The exact timing of each assessment is listed in the Time and Events Table (Section 3.5). Detailed procedures for obtaining each assessment are provided in the Study Procedures Manual (SPM). Whenever vital signs, 12-lead ECGs and blood sampling are scheduled for the same nominal time, the assessments should occur in the following order: 12-lead ECG, vital signs, blood draws. The timing of the assessments should allow the blood draw to occur at the exact nominal time when applicable.

The timing and number of planned study assessments, including safety, pharmacokinetic, pharmacodynamic/biomarker may be altered during the course of the study based on newly available data (e.g. to obtain data closer to the time of peak plasma concentrations) to ensure appropriate monitoring. The change in timing or addition of time points for any planned study assessments must be approved and documented by GSK, but this will not constitute a protocol amendment. The IRB/IEC will be informed of any safety issues that require alteration of the safety monitoring scheme. No more than 500 mL of blood will be taken for each dose of GSK2398852 administered.

6.1. Demographic/Medical History Assessments

The following demographic parameters will be captured: year of birth, gender, race and ethnicity.

Medical/medication/alcohol history will be assessed as related to the eligibility criteria listed in Section 4.2. Cardiovascular medical history/risk factors will also be assessed at screening.

6.2. Safety

Planned timepoints for all safety assessments are listed in the Time and Events Tables (Section 3.5). Additional time points for safety tests such as vital signs, physical exams and laboratory safety tests may be added during the course of the study based on newly available data to ensure appropriate safety monitoring.

Physical Exams

A complete physical examination will include assessments of the head, eyes, ears, nose, throat, skin, thyroid, neurological, lungs, cardiovascular, abdomen (liver and spleen), lymph nodes and extremities. Height and weight will also be measured and recorded.

A brief physical examination will include assessments of the skin, lungs, cardiovascular system, and abdomen (liver and spleen).


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Vital Signs

Vital sign measurements will include semi supine systolic and diastolic blood pressure, pulse rate and temperature (measured orally).

Electrocardiogram (ECG)

Single 12-lead ECGs will be obtained at each timepoint during the study using an ECG machine that automatically calculates the heart rate and measures PR, QRS, QT, and QTc intervals. Refer to Section 3.4.1.2 for QTc withdrawal criteria and additional QTc readings that may be necessary.

Continuous cardiac telemetry will be performed as outlined in the Time and Events table (Section 3.5). Full disclosures will be maintained as part of the subject’s source documents and will be reviewed in detail.

3 Lead Holter capture with standard arrhythmia analysis will be performed as outlined in the Time and Events tables (Section 3.5).


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Clinical Laboratory Assessments

Haematology, clinical chemistry, urinalysis and additional parameters to be tested are listed below:

HaematologyPlatelet Count RBC Indices: Automated WBC Differential:RBC Count MCV NeutrophilsWBC Count (absolute) MCH LymphocytesReticulocyte Count MCHC MonocytesHaemoglobin EosinophilsHaematocrit Basophils

Clinical ChemistryBUN Potassium AST (SGOT) Total and direct bilirubinCreatinine Chloride ALT (SGPT) Uric AcidGlucose Total CO2 GGT AlbuminSodium Calcium Alkaline phosphatase Total ProteinLDH CK

Immunology/Complement activityC3 C4 CH50CRP SAA

Renal UrinalysisUrine Microscopy (not dipstick and culture)Urine creatinine, albumin and protein from 24 hour collections

Routine UrinalysisSpecific gravitypH, glucose, protein, blood and ketones by dipstickMicrobiology-Microscopic examination (if blood or protein is abnormal)

Other AssessmentsHepatitis B (HBsAg)Hepatitis C (Hep C antibody -- if second generation Hepatitis C antibody positive, a hepatitis C antibody Chiron RIBA immunoblot assay (or other third generation immunoassay) should be reflexively performed on the same sample to confirm the result)FSH and oestradiol (women only)Clotting tests- PT and APTT

6.3. Pregnancy

6.3.1. Time period for collecting pregnancy information

All pregnancies in female subjects and female partners of male subjects will be collected after the start of dosing and until follow up.


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6.3.2. Action to be taken if pregnancy occurs

The investigator will collect pregnancy information on any female subject, who becomes pregnant while participating in this study. The investigator will record pregnancy information on the appropriate form and submit it to GSK within 2 weeks of learning of a subject's pregnancy. The subject will also be followed to determine the outcome of the pregnancy. Information on the status of the mother and child will be forwarded to GSK. Generally, follow-up will be no longer than 6 to 8 weeks following the estimated delivery date. Any premature termination of the pregnancy will be reported.

While pregnancy itself is not considered to be an AE or SAE, any pregnancy complication or elective termination of a pregnancy for medical reasons will be recorded as an AE or SAE.

A spontaneous abortion is always considered to be an SAE and will be reported as such. Furthermore, any SAE occurring as a result of a post-study pregnancy and is considered reasonably related to the study treatment by the investigator, will be reported to GSK as described in Section 10. While the investigator is not obligated to actively seek this information in former study participants, he or she may learn of an SAE through spontaneous reporting.

Any female subject who becomes pregnant while participating will be withdrawn from the study but will undergo appropriate safety follow up.

6.3.3. Action to be taken if pregnancy occurs in a female partner of a male study subject

The investigator will attempt to collect pregnancy information on any female partner of a male study subject who becomes pregnant while participating in this study. The investigator will record pregnancy information on the appropriate form and submit it to GSK within 2 weeks of learning of the partner’s pregnancy. The partner will also be followed to determine the outcome of the pregnancy. Information on the status of the mother and child will be forwarded to GSK. Generally, follow-up will be no longer than 6 to 8 weeks following the estimated delivery date. Any premature termination of the pregnancy will be reported.

6.4. Pharmacokinetics

6.4.1. Blood Sample Collection

Blood samples for pharmacokinetic analysis of GSK2315698 and GSK2398852 will be collected at the time points indicated in Section 3.5, Time and Events Tables. The actual date and time of each blood sample collection will be recorded. The timing of PK samples may be altered and/or PK samples may be obtained at additional time points to ensure thorough PK monitoring.

Details of PK blood sample collection (including volume to be collected), processing, storage and shipping procedures are provided in the Study Procedures Manual (SPM).


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6.4.2. Sample Analysis

Plasma analysis will be performed under the management of Bioanalytical Sciences & Toxicokinetics, PTS DMPK, GlaxoSmithKline. Concentrations of GSK2315698 and GSK2398852 will be determined in plasma samples using the currently approved analytical methodology. Raw data will be stored in the GLP Archives, GlaxoSmithKline.

6.5. Biomarker(s)/Pharmacodynamic Markers

6.5.1. Pharmacodynamic markers in plasma

Blood samples for pharmacodynamic analysis of the following parameters will be collected at the time points indicated in Section 3.5, Time and Events Tables. The actual date and time of each blood sample collection will be recorded.

The timing of PD samples may be altered as information is obtained. Details of PD blood sample collection (including volume to be collected), processing, storage and shipping procedures are provided in the Study Procedures Manual (SPM).

SAP concentration

A small blood sample for plasma SAP and analysed using the Hycult assay prior to treatment with GSK2398852

Plasma samples used for the determination of GSK2315698 and GSK2398852 will be analysed for concentrations of SAP levels following treatment with GSK2398852

Renal Function and Liver function tests (also collected as safety measures)

6.5.2. EqMRI assessment

EqMRI will be used to measure the extracellular space in key organs involved in systemic amyloiosis and used to determine any changes in amyloid load. This technique involves the infusion of gadolinium contrast agent. This is routinely used in MRI scanning. This study will use gadoteric acid (Dotarem) which is considered to be associated with a low risk of nephrogenic systemic fibrosis according to CHMP. Subjects will be in the MRI scanner for approximately 40-45 minutes with approximately 30 minutes break in-between for gadolinium infusion. A cannula will need to be inserted for the duration of the scan and a blood sample may be required.

6.5.3. SAP scan

SAP scintigraphy will be conducted and used as a PD marker. SAP scintigraphy will be used to evaluate amyloid load in liver, spleen, kidney, bone marrow and other involved organs. A qualitative and if possible quantitative assessment of amyloid load pre and post treatment will be made.


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6.5.4. Liver Elastography

A liver elastography assessment will be performed and may be used as a PD marker measuring changes in the stiffness of the organ in response to drug treatment

6.5.5. Exploratory Biomarkers

With the subject’s consent, serum, urine and possibly liver samples will be collected during this study and may be used for the purposes of measuring novel biomarkers to identify factors that may influence amyloidosis and/or medically related conditions, as well as the biological and clinical responses to GSK2398852. If relevant, this approach will be extended to include the identification of biomarkers associated with adverse events.

Samples will be collected at the timepoints indicated in Section 3.5. The timing of the collections may be adjusted on the basis of emerging PK or PD data from this study or other new information in order to ensure optimal evaluation of the PD endpoints. Analysis of these samples may not take place if other information from the study would indicate that they will not provide useful additional information.

For further instructions on the collection and handling of samples refer to the Study Procedures Manual.

6.5.5.1. Blood biomarkers

Serum samples will be collected for the purposes of measuring biomarkers of immune function in serum. These may include but are not limited to TNFα, IL-8 and IL-6.

Blood samples will be collected to measure exploratory measures of efficacy including but not limited to: Pro-NT BNP and troponin.

6.5.5.2. Urine biomarkers

Urine samples will be collected for assessment of exploratory markers of renal function including but not limited to KIM-1 and NGAL.

6.5.5.3. Histological assessment of liver biopsy

If liver biopsy samples are collected they will be processed for histological and immunohistological assessment. These samples may be used to assess markers of mechanistic response to drug treatment and/or response such as the number and activation state of macrophages, the number of macrophage giant cells, and the amount of amyloid present.

6.5.5.4. Bone scan

DPD scanning may be used in patients with ATTR cardiac amyloidosis to evaluate PD response.[Rapezzi, 2011] A qualitative and if possible quantitative assessment of cardiac amyloid load pre and post treatment will be made.


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6.6. Immunogenicity

Blood samples for determination of anti-GSK2398852 antibodies will be taken from all subjects in this study as a safety measurement at the time-points specified in the Time and Events Tables. Timing of the assessments may be adjusted based on emerging data.

Samples will be analysed for the presence of anti-GSK2398852 antibodies using an analytically validated screening assay. If sera contain anti-GSK2398852 antibodies in the screening assay, they will be further analysed for specificity and titres of antibodies.Samples will be retained for further characterisation of neutralising activity if required and reported separately. The immunogenicity assessment report will include the incidence and titres of anti-GSK2398852 binding antibodies.

For further instructions on the collection and handling of samples refer to the Study Procedures Manual.

6.7. Efficacy

Some of the samples taken primarily for assessment of safety (e.g. renal protein excretion) and some exploratory biomarkers (e.g. Pro-NT BNP) may also provide some insight into efficacy.

6.8. Health Outcomes

The MOS SF-36 has 36 questions. All questions are scored using normative based scoring. Software is available that assists in the scoring of the MOS SF-36 (QualityMetric Health Outcomes Scoring Software 2.0, Saris-Baglama, 2007), and details on scoring can be found in the SF-36v2 user manual.

6.8.1. Questionnaire Administration

Subjects will complete the MOS SF-36 at the time-points specified in the Time and Events Tables,

The investigator or designee will ask the subject to complete the questionnaire during the clinical visit separately from the medical history and the standard AE and concomitant medication questions.

Questionnaires should be completed in a quiet place (preferably the same place each time, if possible) and at as consistent a time during the study visits as possible. To avoid biasing responses, subjects should not be told the results of diagnostic tests prior to completing the questionnaire. Regardless of when the questionnaire is completed, the subject should be given adequate time to complete all items. No stated or implied time limit for completing the questionnaire items will be given.

The subject should be asked to complete the questionnaire completely and accurately. If the subject requests help or clarification of any question, he should be asked to read the instructions again and to give the best answer possible to each question. Subjects should be encouraged to report their own experiences and opinions. The investigator will not


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provide the subject with an answer to any question nor interpret any portion of the question.

6.8.2. Recording of Data

The use of black ink is required for subject-completed questionnaires. If any changes are necessary, subjects must be instructed to make changes by drawing a line through the undesired response, initialling the change, and then recording the desired response. Once a subject returns the completed questionnaire, no changes will be allowed.

6.8.3. Collection and Storage of Subject Questionnaires

Upon completion of the questionnaire, the investigator will retrieve the questionnaire from the subject, ensure all questions have been answered, and check that the header section (Subject Number, Visit Date, etc) is complete. A copy of the completed questionnaire will stay with the subject’s source documents. A completed questionnaire should not be given back to the subject once it has been returned to the source documents.

7. LIFESTYLE AND/OR DIETARY RESTRICTIONS

7.1. Contraception Requirements

7.1.1. Female Subjects

This study will enrol women who are not of childbearing potential. Any subjects wishing to continue HRT during this study will also be required to use one of the methods of contraception outlined below.

Abstinence

Abstinence from penile-vaginal intercourse must be consistent with the preferred and usual lifestyle of the subject. Periodic abstinence (e.g. calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception.

Contraceptive Methods with a Failure Rate of < 1%

Oral contraceptive, either combined or progestogen alone

Injectable progestogen

Implants of etonogestrel or levonorgestrel

Estrogenic vaginal ring

Percutaneous contraceptive patches

Intrauterine device (IUD) or intrauterine system (IUS) that meets the <1% failure rate as stated in the product label


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Male partner sterilization (vasectomy with documentation of azoospermia) prior to the female subject's entry into the study, and this male is the sole partner for that subject. For this definition, “documented” refers to the outcome of the investigator's/designee’s medical examination of the subject or review of the subject's medical history for study eligibility, as obtained via a verbal interview with the subject or from the subject’s medical records.

Male condom combined with a female diaphragm, either with or without a vaginal spermicide (foam, gel, cream or suppository).

These allowed methods of contraception are only effective when used consistently, correctly and in accordance with the product label. The investigator is responsible for ensuring subjects understand how to properly use these methods of contraception.

7.1.2. Male Subjects

Male subjects with female partners of child-bearing potential must use one of the following contraceptive methods after the first dose of study treatment and until the follow-up contact. :

Condom plus partner use of a highly effective contraceptive (see list in Section 7.1.1).

Abstinence, defined as sexual inactivity consistent with the preferred and usual lifestyle of the subject. Periodic abstinence (e.g. calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception

7.2. Meals and Dietary Restrictions

7.2.1. Caffeine, Alcohol, and Tobacco

During each resident dosing session, subjects will abstain from alcohol and tobacco for 12 hours prior to admission and until discharge.

8. CONCOMITANT MEDICATIONS AND NON-DRUG THERAPIES

8.1. Permitted Medications

Subjects usual medication can be continued during this study with the exception of those listed in Section 8.2.

Paracetamol at doses of 2 grams/day is permitted. Other new concomitant medication may be considered on a case by case basis in discussion with the GSK Medical Monitor.

The following information is provided as a general guide. Specific cases should be discussed with the Medical Monitor

Stable (>3 months) treatment with cytokine modulator drugs will be allowed.


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Stable doses (>3 months) of disease-modifying anti-rheumatic drugs (DMARDs) will be allowed.

Maintenance therapy with corticosteroids will be allowed but patients requiring high dose pulsed therapy (e.g. 1g methyprednisolone) will be excluded.

Non selective antihistamine (e.g. Chlorphenamine 10-20 mg) and hydrocortisone are permitted prior to GSK2398852 dosing to prevent/alleviate GSK2398852 infusion reactions (see Section 1.4.2). Additional administrations of either or both medications are permitted at discretion of Investigator or designee if symptoms require this.

8.2. Prohibited Medications

The following medications are not permitted in the study. If use is medically required then the subject will be withdrawn

Induction or parenteral cytotoxic chemotherapy with the exception of the subjects enrolled to assess interaction with chemotherapy regimen.Stable maintenance chemotherapy (e.g. oral cyclophosphamide) will be allowed providing this has been stable for at least 2 months

Use of anti-coagulant drugs (except patients with TTR amyloidosis - Use of anti-coagulant drugs will be permitted in TTR patients only).

8.3. Non-Drug Therapies

Subjects must abstain from taking any herbal treatments or other supplements not directed by a physician within 7 days (or 14 days if the drug is a potential enzyme inducer) or 5 half-lives (whichever is longer) prior to the first dose of study medication until completion of the follow-up visit, unless in the opinion of the Investigator and sponsor the medication will not interfere with the study.

8.4. Subject Completion

A completed subject is one who has completed all phases of the study including the follow-up visit for Part A and/or Part B as applicable.

The end of the study is defined as the last subject’s last visit.

8.5. Subject Withdrawal Criteria

Refer to Section 3.4 for dose adjustment/stopping criteria based on safety/PK/PD criteria.

A subject may withdraw from study treatment at any time at his/her own request, or may be withdrawn at any time at the discretion of the investigator for safety, behavioural or administrative reasons.


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8.6. Subject Withdrawal Procedures

8.6.1. Subject Withdrawal from Study

A subject may voluntarily discontinue participation at any time and is not obliged to state a reason for withdrawal. However, the reasons for withdrawal, or failure to provide a reason, must be documented in the CRF by the site staff. The Investigator may also, at his/her discretion; withdraw a subject from this study at any time.

Where possible, if a subject decides to withdraw or is withdrawn through a study day, all scheduled assessments will be taken as planned. The investigator must also make every effort to perform the following evaluations if not already scheduled for that day:

12-lead ECG

Supine vital signs

Clinical laboratory tests (clinical chemistry, haematology and urinalysis)

Adverse events assessment

If a subject prematurely withdraws or is withdrawn on a non-study visit day, then the investigator must make every attempt to conduct the above evaluations. These data should be recorded in the CRF, as they comprise an essential evaluation that should be performed before discharging any subject from the study.

Subjects who withdraw due to adverse events will not be replaced and the AE must be followed as indicated in the SPM. Subjects who withdraw for other reasons will not be replaced however additional subjects may be enrolled to provide further information.

8.6.2. Subject Withdrawal from Study Treatment

A subject will be considered to have prematurely withdrawn from the study drug if the infusion of study drug is permanently stopped. Temporary interruptions in the infusion administration, e.g. due to issues with the intravenous line, will not constitute a withdrawal of the subject, PK and PD analysts will be advised of the details of any temporary interruptions.

Once a subject has discontinued study drug, the subject may not re-enter the study. Dosing of the subjects with investigational product may be stopped at any time, at the request of the subject, or at the discretion of the Principal Investigator (i.e. if clinically significant adverse events should occur). Withdrawal due to adverse events will be distinguished from withdrawal for other reasons. The reasons for withdrawal and the results of any relevant tests will be recorded in the CRF and the planned follow-up procedures will be performed, where possible.

8.7. Treatment After the End of the Study

Subjects will not receive any additional treatment from GSK after completion of the study


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The investigator is responsible for ensuring that consideration has been given to the post-study care of the patient’s medical condition, whether or not GSK is providing specific post-study treatment.

8.8. Follow-on Study

All subjects who receive a dose of GSK2398852 will be asked to enrol into a long-term follow-on assessment study (SAP115970).

9. STUDY TREATMENT

Study treatment dosage and administration details are listed in Section 3.3.

9.1. Blinding

Part A and Part B will be open-label. .

9.2. Packaging and Labelling

The contents of the label will be in accordance with all applicable regulatory requirements.

9.3. Preparation/Handling/Storage/Accountability

Investigational product must be dispensed or administered according to procedures described herein. Only subjects enrolled in the study may receive investigational product. Only authorised site staff may supply or administer investigational product. All investigational products must be stored in a secure area with access limited to the investigator and authorised site staff. Investigational products are to be stored as described in the Technical agreement and SPM.

The investigator, institution, or the head of the medical institution (where applicable) is responsible for investigational product accountability, reconciliation, and record maintenance. The investigator or the head of the medical institution (where applicable), or designated site staff (e.g., storage manager, where applicable) must maintain investigational product accountability records throughout the course of the study. The responsible person(s) will document the amount of investigational product received from GSK and destroyed at end of study and the amount administered to subjects. The required accountability unit for this study will be vial. Discrepancies are to be reconciled or resolved. Procedures for final disposition of unused investigational product are listed in the Technical agreement and SPM.

Investigational product is not expected to pose significant occupational safety risk to site staff under normal conditions of use and administration. A Material Safety Data Sheet (MSDS)/equivalent document describing occupational hazards and recommended handling precautions either will be provided to the investigator, where this is required by local laws, or is available upon request from GSK.


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However, precautions are to be taken to avoid direct skin contact, eye contact, and generating aerosols or mists. In the case of unintentional occupational exposure notify the monitor, medical monitor and/or study manager.

9.3.1. GSK2315698 and GSK2398852 solution

GSK2315698 may be administered via both IV infusions and as a sub cutaneous injection. GSK2398852 will be administered via IV infusion. A description of the methods and materials required for preparation of dosing solutions of GSK2315698 and GSK2398852 are provided in Appendix 3 and in the SPM and technical agreement PI_TP_QP001.

9.4. Assessment of Compliance

When the individual dose for a subject is prepared from a bulk supply, the preparation of the dose will be confirmed by a second member of the study site staff.

All subjects are dosed at the study site, they will receive investigational product directly from the investigator or designee, under medical supervision. The date and time of each dose administered in the clinic will be recorded in the source documents. The dose of investigational product(s) and study participant identification will be confirmed at the time of dosing by a member of the study site staff other than the person administering the investigational product.

9.5. Treatment of Study Treatment Overdose

For this study, any dose of GSK2315698 or GSK2398852 greater than the intended dose within the scheduled dosing period will be considered an overdose.

GSK does not recommend specific treatment for an overdose. The investigator will use clinical judgment to treat any overdose.

10. ADVERSE EVENTS (AE) AND SERIOUS ADVERSE EVENTS (SAE)

The investigator or site staff is responsible for detecting, documenting and reporting events that meet the definition of an AE or SAE.

AEs will be collected from the baseline visit and until the follow-up contact. SAEs will be collected over the same time period as stated above for AEs. However, any SAEs assessed as related to study participation (e.g. study treatment, protocol-mandated procedures, invasive tests, or change in existing therapy) or related to a GSK product will be recorded from the time a subject consents to participate in the study up to and including any follow-up contact. All SAEs will be recorded and reported to GSK within 24 hours, as indicated in Section 10.6.

Investigators are not obligated to actively seek AEs or SAEs in former study participants. However, if the investigator learns of any SAE, including a death, at any time after a subject has been discharged from the study, and he/she considers the event reasonably


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related to the study treatment or study participation, the investigator would promptly notify GSK.

10.1. Definition of Adverse Events

An AE is any untoward medical occurrence in a patient or clinical investigation subject, temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product.

Note: An AE can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally associated with the use of a medicinal product.

Events meeting the definition of an AE include:

Any abnormal laboratory test results (haematology, clinical chemistry, or urinalysis) or other safety assessments (e.g., ECGs, radiological scans, vital signs measurements), including those that worsen from baseline, and felt to be clinically significant in the medical and scientific judgement of the investigator.

Exacerbation of a chronic or intermittent pre-existing condition including either an increase in frequency and/or intensity of the condition.

New conditions detected or diagnosed after study treatment administration even though it may have been present prior to the start of the study.

Signs, symptoms, or the clinical sequelae of a suspected interaction.

Signs, symptoms, or the clinical sequelae of a suspected overdose of either study treatment or a concomitant medication (overdose per se will not be reported as an AE/SAE ).

Events that do not meet the definition of an AE include:

Any clinically significant abnormal laboratory findings or other abnormal safety assessments that are associated with the underlying disease, unless judged by the investigator to be more severe than expected for the subject’s condition.

The disease/disorder being studied, or expected progression, signs, or symptoms of the disease/disorder being studied, unless more severe than expected for the subject’s condition.

Medical or surgical procedure (e.g., endoscopy, appendectomy); the condition that leads to the procedure is an AE.

Situations where an untoward medical occurrence did not occur (social and/or convenience admission to a hospital).

Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present or detected at the start of the study that do not worsen.


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10.2. Definition of Serious Adverse Events

If an event is not an AE per Section 10.1, then it cannot be an SAE even if serious conditions are met (e.g., hospitalization for signs/symptoms of the disease under study, death due to progression of disease, etc).

An SAE is any untoward medical occurrence that, at any dose:

a. Results in death

b. Is life-threatening

NOTE: The term 'life-threatening' in the definition of 'serious' refers to an event in which the subject was at risk of death at the time of the event. It does not refer to an event, which hypothetically might have caused death, if it were more severe.

c. Requires hospitalization or prolongation of existing hospitalization

NOTE: In general, hospitalization signifies that the subject has been detained (usually involving at least an overnight stay) at the hospital or emergency ward for observation and/or treatment that would not have been appropriate in the physician’s office or out-patient setting. Complications that occur during hospitalization are AEs. If a complication prolongs hospitalization or fulfills any other serious criteria, the event is serious. When in doubt as to whether “hospitalization” occurred or was necessary, the AE should be considered serious.

Hospitalization for elective treatment of a pre-existing condition that did not worsen from baseline is not considered an AE.

d. Results in disability/incapacity, or

NOTE: The term disability means a substantial disruption of a person’s ability to conduct normal life functions. This definition is not intended to include experiences of relatively minor medical significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life functions but do not constitute a substantial disruption.

e. Is a congenital anomaly/birth defect

f. Medical or scientific judgment should be exercised in deciding whether reporting is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but may jeopardize the subject or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. These should also be considered serious. Examples of such events are invasive or malignant cancers, intensive treatment in an emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalization, or development of drug dependency or drug abuse.

g. Is associated with liver injury and impaired liver function defined as:

ALT 3xULN and total bilirubin* 2xULN (>35% direct), or

ALT 3xULN and INR** > 1.5.


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* Serum bilirubin fractionation should be performed if testing is available; if unavailable, measure urinary bilirubin via dipstick. If fractionation is unavailable and ALT 3xULN and total bilirubin 2xULN, then the event is still to be reported as an SAE.

** INR testing not required per protocol and the threshold value does not apply to subjects receiving anticoagulants. If INR measurement is obtained, the value is to be recorded on the SAE form.

10.3. Method of Detecting AEs and SAEs

Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended and non-leading verbal questioning of the subject is the preferred method to inquire about AE occurrence. Appropriate questions include:

“How are you feeling?”

“Have you had any (other) medical problems since your last visit/contact?”

“Have you taken any new medicines, other than those provided in this study, since your last visit/contact?”

10.4. Recording of AEs and SAEs

When an AE/SAE occurs, it is the responsibility of the investigator to review all documentation (e.g., hospital progress notes, laboratory, and diagnostics reports) relative to the event. The investigator will then record all relevant information regarding an AE/SAE in the appropriate data collection tool.

It is not acceptable for the investigator to send photocopies of the subject’s medical records to GSK in lieu of completion of the GSK, AE/SAE data collection tool. However, there may be instances when copies of medical records for certain cases are requested by GSK. In this instance, all subject identifiers, with the exception of the subject number, will be blinded on the copies of the medical records prior to submission of to GSK.

The investigator will attempt to establish a diagnosis of the event based on signs, symptoms, and/or other clinical information. In such cases, the diagnosis will be documented as the AE/SAE and not the individual signs/symptoms.


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10.5. Evaluating AEs and SAEs

10.5.1. Assessment of Intensity

The investigator will make an assessment of intensity for each AE and SAE reported during the study and will assign it to one of the following categories:

Mild: An event that is easily tolerated by the subject, causing minimal discomfort and not interfering with everyday activities.

Moderate: An event that is sufficiently discomforting to interfere with normal everyday activities.

Severe: An event that prevents normal everyday activities.

An AE that is assessed as severe will not be confused with an SAE. Severity is a category utilized for rating the intensity of an event; and both AEs and SAEs can be assessed as severe. An event is defined as ‘serious’ when it meets at least one of the pre-defined outcomes as described in the definition of an SAE.

10.5.2. Assessment of Causality

The investigator is obligated to assess the relationship between study treatment and the occurrence of each AE/SAE. A "reasonable possibility" is meant to convey that there are facts/evidence or arguments to suggest a causal relationship, rather than a relationship cannot be ruled out. The investigator will use clinical judgment to determine the relationship. Alternative causes, such as natural history of the underlying diseases, concomitant therapy, other risk factors, and the temporal relationship of the event to the study treatment will be considered and investigated. The investigator will also consult the Investigator Brochure (IB) and/or Product Information, for marketed products, in the determination of his/her assessment.

For each AE/SAE the investigator must document in the medical notes that he/she has reviewed the AE/SAE and has provided an assessment of causality.

10.6. Follow-up of AEs and SAEs

After the initial AE/SAE report, the investigator is required to proactively follow each subject at subsequent visits/contacts. All AEs and SAEs will be followed until resolution, until the condition stabilizes, until the event is otherwise explained, or until the subject is lost to follow-up.

The investigator is obligated to perform or arrange for the conduct of supplemental measurements and/or evaluations as may be indicated or as requested by GSK to elucidate as fully as possible the nature and/or causality of the AE or SAE. The investigator is obligated to assist. This may include additional laboratory tests or investigations, histopathological examinations or consultation with other health care professionals. If a subject dies during participation in the study or during a recognized


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follow-up period, the investigator will provide GSK with a copy of any post-mortem findings, including histopathology.

New or updated information will be recorded in the originally completed data collection tool. The investigator will submit any updated SAE data to GSK within the designated reporting time frames.

10.7. Prompt Reporting of SAEs to GSK

Once the investigator determines that an event meets the protocol definition of an SAE, the SAE will be reported to GSK within 24 hours. Any follow-up information on a previously reported SAE will also be reported to GSK within 24 hours.

If the investigator does not have all information regarding an SAE, he/she will not wait to receive additional information before notifying GSK of the event and completing the appropriate data collection tool. The investigator will always provide an assessment of causality at the time of the initial report as described in Section 10.5.2, Assessment of Causality.

The primary mechanism for reporting SAEs to GSK will be the electronic data collection tool.. If the electronic system is unavailable for greater than 24 hours, the site will use the paper SAE data collection tool and fax it to the GSK Medical Monitor or protocol contact. Then the site will enter the serious adverse event data into the electronic system as soon as it becomes available.

After the study is completed at a given site, the electronic data collection tool will be taken off-line to prevent the entry of new data or changes to existing data. If a site receives a report of a new SAE from a study participant or receives updated data on a previously reported SAE after the electronic data collection tool has been taken off-line, the site can report this information on a paper SAE form or to their GSK protocol contact by telephone.

GSK contacts for SAE receipt can be found at the beginning of this protocol on the Sponsor/Medical Monitor Contact Information page.

Facsimile transmission of the SAE data collection tool is the preferred method to transmit this information to the project contact for SAE receipt. In rare circumstances and in the absence of facsimile equipment, notification by telephone is acceptable, with a copy of the SAE data collection tool sent by overnight mail. Initial notification via the telephone does not replace the need for the investigator to complete and sign the SAE data collection tool within the designated reporting time frames.

GSK contacts for SAE receipt can be found at the beginning of this protocol on the Sponsor/Medical Monitor Contact Information page.


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10.8. Regulatory Reporting Requirements For SAEs

Prompt notification of SAEs by the investigator to GSK is essential so that legal obligations and ethical responsibilities towards the safety of subjects are met.

GSK has a legal responsibility to notify both the local regulatory authority and other regulatory agencies about the safety of a product under clinical investigation. GSK will comply with country specific regulatory requirements relating to safety reporting to regulatory authorities, IRBs/IECs and investigators.

Investigator safety reports are prepared for suspected unexpected serious adverse reactions according to local regulatory requirements and GSK policy and are forwarded to investigators as necessary. An investigator who receives an investigator safety report describing an SAE(s) or other specific safety information (e.g., summary or listing of SAEs) from GSK will file it with the IB and will notify the IRB/IEC, if appropriate according to local requirements.

11. LIVER CHEMISTRY FOLLOW-UP PROCEDURES

Refer to the diagram in Appendix 1 for a visual presentation of the procedures listed below.

The procedures listed below are to be followed if a subject meets the liver chemistry stopping criteria defined in Section 3.4.1.1:

Immediately withdraw the subject from study treatment

Notify the GSK medical monitor within 24 hours of learning of the abnormality to confirm the subject’s study treatment cessation and follow-up.

Complete the “Safety Follow-Up Procedures” listed below.

Complete the liver event case report forms. If the event also meets the criteria of an SAE (see Section 10.2), the SAE data collection tool will be completed separately with the relevant details.

Upon completion of the safety follow-up withdraw the subject from the study unless further safety follow up is required or GSK Medical Governance approval of drug restart is granted (see Section 11.1).

Do not restart investigational product unless written approval is granted by GSK Medical Governance (see Section 11.1), whereupon the subject continues in the study after completion of the liver chemistry monitoring.

Safety Follow-Up Procedures for subjects with ALT 3xULN:

Monitor subjects weekly until liver chemistries (ALT, AST, alkaline phosphatase, bilirubin) resolve, stabilize or return to within baseline values.


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Safety Follow-Up Procedures for subjects with ALT 3xULN and total bilirubin 2xULN (>35% direct bilirubin); or ALT 3xULN and INR1 > 1.5:

This event is considered an SAE (see Section 10.2). Serum bilirubin fractionation should be performed if testing is available. If fractionation is unavailable, urinary bilirubin is to be measured via dipstick (a measurement of direct bilirubin, which would suggest liver injury).

Make every reasonable attempt to have subjects return to the clinic within 24 hours for repeat liver chemistries, additional testing, and close monitoring (with specialist or hepatology consultation recommended).

Monitor subjects twice weekly until liver chemistries (ALT, AST, alkaline phosphatase, bilirubin) resolve, stabilize or return to within baseline values.

In addition, for all subjects with ALT 3xULN, every attempt must be made to also obtain the following:

Viral hepatitis serology including:

Hepatitis A IgM antibody.

Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM).

Hepatitis C RNA.

Cytomegalovirus IgM antibody.

Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain heterophile antibody or monospot testing).

Hepatitis E IgM antibody.

Blood sample for pharmacokinetic (PK) analysis, obtained within 12h of last dose. Record the date/time of the PK blood sample draw and the date/time of the last dose of study treatment prior to blood sample draw on the CRF. If the date or time of the last dose is unclear, provide the subject’s best approximation. If the date/time of the last dose can not be approximated OR a PK sample can not be collected in the time period indicated above, do not obtain a PK sample. Instructions for sample handling and shipping are included in the SPM.

Serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH).

Fractionate bilirubin, if total bilirubin 2xULN.

Assess eosinophilia

Record the appearance or worsening of clinical symptoms of hepatitis (fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash or eosinophilia) on the AE CRF.

1 INR testing not required per protocol and the threshold value does not apply to subjects receiving

anticoagulants.


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Record use of concomitant medications, acetaminophen, herbal remedies, other over the counter medications, or putative hepatotoxins on the Concomitant Medications CRF.

Record alcohol use on the Liver Events CRF.

The following are required for subjects with ALT 3xULN and bilirubin 2xULN (>35% direct) but are optional for other abnormal liver chemistries:

Anti-nuclear antibody, anti-smooth muscle antibody, and Type 1 anti-liver kidney microsomal antibodies.

Serum acetaminophen (paracetamol) adduct HPLC assay (quantifies potential acetaminophen contribution to liver injury in subjects with definite or likely acetaminophen use in the preceding week.

Liver imaging (ultrasound, magnetic resonance, or computerized tomography) to evaluate liver disease.

The Liver Imaging and/or Liver Biopsy CRFs are also to be completed if these tests are performed.

11.1. Restarting Investigational Product

Following a Liver Event that is possibly related to investigational product, GSK will consider drug rechallenge where:

the subject is receiving compelling benefit,

the benefit of drug restart exceeds risk, and

no effective alternative therapy is available

See Appendix 2 for the drug restart/rechallenge process.


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12. STUDY CONDUCT CONSIDERATIONS

12.1. Posting of Information on Publicly Available Clinical Trial Registers

Study information from this protocol will be posted on publicly available clinical trial registers before enrolment of subjects begins.

12.2. Regulatory and Ethical Considerations, Including the Informed Consent Process

The study will be conducted in accordance with all applicable regulatory requirements.

The study will also be conducted in accordance with ICH Good Clinical Practice (GCP), all applicable subject privacy requirements, and, the guiding principles of the 2008 Declaration of Helsinki. This includes, but is not limited to, the following:

IRB/IEC review and favourable opinion/approval to conduct the study and of any subsequent relevant amended documents

Written informed consent (and any amendments) to be obtained for each subject before participation in the study

Investigator reporting requirements (e.g. reporting of AEs/SAEs/protocol deviations to IRB/IEC)

12.2.1. Urgent Safety Measures

If an event occurs that is related to the conduct of the study or the development of the study treatment, and this new event is likely to affect the safety of subjects, the sponsor and the investigator will take appropriate urgent safety measures to protect subjects against any immediate hazard.

The sponsor will work with the investigator to ensure the IEC/IRB is notified.

12.3. Quality Control (Study Monitoring)

In accordance with applicable regulations including GCP, and GSK procedures, GSK monitors will contact the site prior to the start of the study to review with the site staff the protocol, study requirements, and their responsibilities to satisfy regulatory, ethical, and GSK requirements. When reviewing data collection procedures, the discussion will also include identification, agreement and documentation of data items for which the CRFwill serve as the source document.

GSK will monitor the study and site activity to verify that the:

Data are authentic, accurate, and complete.

Safety and rights of subjects are being protected.


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Study is conducted in accordance with the currently approved protocol and any other study agreements, GCP, and all applicable regulatory requirements.

The investigator and the head of the medical institution (where applicable) agrees to allow the monitor direct access to all relevant documents

12.4. Quality Assurance

To ensure compliance with GCP and all applicable regulatory requirements, GSK may conduct a quality assurance assessment and/or audit of the site records, and the regulatory agencies may conduct a regulatory inspection at any time during or after completion of the study. In the event of an assessment, audit or inspection, the investigator (and institution) must agree to grant the advisor(s), auditor(s) and inspector(s) direct access to all relevant documents and to allocate their time and the time of their staff to discuss the conduct of the study, any findings/relevant issues and to implement any corrective and/or preventative actions to address any findings/issues identified.

12.5. Study and Site Closure

Upon completion or premature discontinuation of the study, the monitor will conduct site closure activities with the investigator or site staff, as appropriate, in accordance with applicable regulations including GCP, and GSK procedures.

In addition, GSK reserves the right to temporarily suspend or prematurely discontinue this study at any time for reasons including, but not limited to, safety or ethical issues or severe non-compliance. If GSK determines such action is needed, GSK will discuss this with the investigator or the head of the medical institution (where applicable), including the reasons for taking such action. When feasible, GSK will provide advance notification to the investigator or the head of the medical institution, where applicable, of the impending action prior to it taking effect.

If the study is suspended or prematurely discontinued for safety reasons, GSK will promptly inform investigators or the head of the medical institution (where applicable) and the regulatory authorities of the suspension or premature discontinuation of the study and the reason(s) for the action. If required by applicable regulations, the investigator or the head of the medical institution (where applicable) must inform the IRB/IEC promptly and provide the reason for the suspension or premature discontinuation.

12.6. Records Retention

Following closure of the study, the investigator or the head of the medical institution (where applicable) must maintain all site study records, except for those required by local regulations to be maintained by someone else, in a safe and secure location. The records must be maintained to allow easy and timely retrieval, when needed (e.g., audit or inspection), and, whenever feasible, to allow any subsequent review of data in conjunction with assessment of the facility, supporting systems, and staff. Where permitted by local laws/regulations or institutional policy, some or all of these records can be maintained in a format other than hard copy (e.g., microfiche, scanned, electronic); however, caution needs to be exercised before such action is taken. The


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investigator must assure that all reproductions are legible and are a true and accurate copy of the original, and meet accessibility and retrieval standards, including re-generating a hard copy, if required. Furthermore, the investigator must ensure there is an acceptable back-up of these reproductions and that an acceptable quality control process exists for making these reproductions.

GSK will inform the investigator of the time period for retaining these records to comply with all applicable regulatory requirements. The minimum retention time will meet the strictest standard applicable to that site for the study, as dictated by any institutional requirements or local laws or regulations, or GSK standards/procedures; otherwise, the retention period will default to 15 years.

The investigator must notify GSK of any changes in the archival arrangements, including, but not limited to, archival at an off-site facility or transfer of ownership of the records in the event the investigator leaves the site.

12.7. Provision of Study Results to Investigators, Posting of Information on Publically Available Clinical Trials Registers and Publication

Where required by applicable regulatory requirements, an investigator signatory will be identified for the approval of the clinical study report. Investigators will be provided reasonable access to statistical tables, figures, and relevant reports and will have the opportunity to review the complete study results at a GSK site or other mutually-agreeable location.

GSK will also provide investigators with the full summary of the study results. Investigators are encouraged to share the summary results with the study subjects, as appropriate.

GSK aims to post a results summary to the GSK Clinical Study Register and other publicly available registers no later than 8 months after the last subject’s last visit (LSLV) [this applies to each data analysis phase for studies with multiple phases, e.g., primary analysis, follow up analysis etc]. In addition, the aim is to submit a manuscript to a peer-reviewed journal for publication within 18 months of LSLV. GSK also aims to publish the full study protocol on the GSK Clinical Study Register at the time the results of the study are published as a manuscript in the scientific literature.

When manuscript publication in a peer-reviewed journal is not feasible, further study information will be posted to the GSK Clinical Study Register to supplement the results summary.

12.8. Data Management

For this study subject data will be entered into electronic case report forms (eCRFs), combined with data provided from other sources in a validated data system and transmitted electronically to GSK.


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Management of clinical data will be performed in accordance with applicable GSK standards and data cleaning procedures to ensure the integrity of the data, e.g., removing errors and inconsistencies in the data. Adverse events and concomitant medications terms will be coded using MedDRA (Medical Dictionary for Regulatory Activities) and an internal validated medication dictionary, GSKDrug. Electronic versions of the eCRFs (including queries and audit trails) will be retained by GSK and the investigator. Subject initials will not be collected or transmitted to GSK according to GSK policy

12.9. External Safety Advisory Committee (ESAC)

Patients with systemic amyloidosis have a complex medical history. The number of subjects studied in Part A of the study is limited and therefore an external safety advisory committee (ESAC) will provide oversight at key points in the study and in response to any emergent safety signals.

Scheduled data review meetings will be held:

1. After administration of dose levels 1 and 2 (4 subjects) to discuss whether subjects with a large amyloid load (and hence a target SAP concentration <2 mg/L) can be enrolled.

2. At the end of Part A to approve progression to Part B as appropriate

Serious adverse events will be reviewed by the ESAC members.

In addition to the scheduled reviews above an ad hoc meeting of the ESAC may be held at the request of GSK to review any emergent safety data of potential clinical concern.

Progression of the study will not take place against the majority advice of the ESAC members.

The study team will only progress proposals that are different from the majority opinion of ESAC members following review by GSK Global Safety Board


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13. REFERENCES

Baltz ML, Caspi D, Evans DJ, Rowe IF, Hind CRK, Pepys MB. Circulating serum amyloid P component is the precursor of amyloid P component in tissue amyloid deposits. Clin. Exp. Immunol. 1986;66:691-700.

Baltz ML, de Beer FC, Feinstein A, Munn EA, Milstein CP, Fletcher TC, March JF, Taylor J, Bruton C, Clamp JR, Davies AJS and Pepys MB. Phylogenetic aspects of C-reactive protein and related proteins. Ann. N.Y. Acad. Sci., 1982;389:49-75.

Bodin K, Ellmerich S, Kahan MC, Tennent GA, Loesch A, Gilbertson JA, Hutchinson WL, Mangione PP, Gallimore JR, Millar DJ, Minogue S, Dhillon AP, Taylor GW, Bradwell AR, Petrie A, Gillmore JD, Bellotti V, Botto M, Hawkins PN and Pepys MB. Antibodies to human serum amyloid P component eliminate visceral amyloid deposits. Nature. 2010;468:93-97.

Botto M, Hawkins PN, Bickerstaff MC, Herbert J, Bygrave AE, McBride A, Hutchinson WL, Tennent GA, Walport MJ, Pepys MB. Amyloid deposition is delayed in mice with targeted deletion of the serum amyloid P component gene. Nat Med. 1997;3(8):855-9.

Breathnach SM, Melrose SM, Bhogal B, de Beer FC, Dyck RF, Tennent G, Black MM, Pepys MB. Amyloid P component is located on elastic fibre microfibrils in normal human tissue. Nature. 1981;293(5834):652-4.

Carter PM. Immune complex disease. Ann Rheum Dis. 1973;32(3):265-71.

Cochrane CG, Dixon FJ. Cell and tissue damage through antigen-antibody complexes. Calif Med. 1969;111(2):99-112.

Dixon FJ. Immune complex diseases. J Invest Dermatol. 1972;59(6):413-5.

Dyck RF, Evans DJ, Lockwood CM, Rees AJ, Turner D, Pepys MB. Amyloid P-component in human glomerular basement membrane. Abnormal patterns of immunofluorescent staining in glomerular disease. Lancet. 1980;2(8195 pt 1):606-9.

Flett AS, Hayward MP, Ashworth MT, Hansen MS, Taylor AM, Elliott PM, McGregor C, Moon JC. Equilibrium contrast cardiovascular magnetic resonance for the measurement of diffuse myocardial fibrosis: preliminary validation in humans. Circulation. 2010;122(2):138-44.

Gillmore JD, Tennent GA, Hutchinson WL, Gallimore JR, Lachmann HJ, Goodman HJ, Offer M, Millar DJ, Petrie A, Hawkins PN, Pepys MB. Sustained pharmacological depletion of serum amyloid P component in patients with systemic amyloidosis. Br J Haematol. 2010;148(5):760-7.

Gillmore, J.D., Hutchinson, W.L., Herbert, J., Bybee, A., Mitchell, D.A., Hasserjian, R.P., Yamamura, K., Suzuki, M., Sabin, C.A. and Pepys, M.B. Autoimmunity and glomerulonephritis in mice with targeted deletion of the serum amyloid P component gene: SAP deficiency or strain combination? Immunology, 2004; 112: 255-264


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GlaxoSmithKline Document Number 2010N110988_01 Technical Memorandum: GSK2398852 clinical in-use stability study to support intravenous administration Report Date 30-May-2013.

GlaxoSmithKline Document Number 2011N118597_01 Study ID CPH113776. A Phase I dose escalation study to investigate the pharmacokinetics, pharmacodynamics, safety, and tolerability of single intravenous doses of GSK2315698A in healthy volunteers. Report Date 25-JAN-2014.

GlaxoSmithKline Document Number 2012N141587_01. GSK2398852 + GSK2315698 Investigator's Brochure (IB) Effective 25-NOV-2013.

GlaxoSmithKline Document Number 2012N142777_00 Study ID CPH114527. A Phase I, open label, dose characteristic study to investigate the pharmacokinetics, pharmacodynamics, safety, and tolerability of intravenous and subcutaneous doses of GSK2315698A patients with systemic amyloidosis. Effective date14-OCT-2013.

Greenberg SM, Frosch MP. Life imitates art: anti-amyloid antibodies and inflammatory cerebral amyloid angiopathy. Neurology. 2011 1;76(9):772-3.

Hamazaki H. Amyloid P component promotes aggregation of Alzheimer's -amyloid peptide. Biochem. Biophys. Res. Commun., 1995;211:349-353.

Hawkins PN, Myers MJ, Epenetos AA, Caspi D, Pepys MB. Specific localization and imaging of amyloid deposits in vivo using 123I-labeled serum amyloid P component. J. Exp. Med. 1988;167:903-913.

Hawkins PN, Wootton R, Pepys MB. Metabolic studies of radioiodinated serum amyloid P component in normal subjects and patients with systemic amyloidosis. J Clin Invest. 1990;86(6):1862-9.

Herbert J, Hutchinson WL, Carr J, et al. Influenza virus infection is not affected by serum amyloid P component. Mol. Med. 2002;8:9-15.

ICRP, 1991. 1990 Recommendations of the International Commission on Radiological Protection. ICRP Publication 60. Ann. ICRP 21 (1-3).

Jager PL, Hazenberg BPC, Franssen EJF, Limburg MH, Rijswijk MH, Piers. Kinetic Studies with Iodine-123-Labeled Serum Amyloid P Component in Patients with Systemic AA and AL Amyloidosis and Assessment of Clinical Value A. J Nucl Med 1998; 39;699-706

Kolstoe SE, Ridha BH, Bellotti V, Wang N, Robinson CV, Crutch SJ, Keir G, Kukkastenvehmas R, Gallimore JR, Hutchinson WL, Hawkins PN, Wood SP, Rossor MN, Pepys MB. Molecular dissection of Alzheimer's disease neuropathology by depletion of serum amyloid P component. Proc Natl Acad Sci U S A. 2009;106(18):7619-23.


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Myers SL, Jones S, Jahn TR, Morten IJ, Tennent GA, Hewitt EW and Radford SE. A systematic study of the effect of physiological factors on 2-microglobulin amyloid formation at neutral pH. Biochemistry. 2006;45:2311-2321.

Nelson SR, Lyon M, Gallagher JT, Johnson EA and Pepys MB. Isolation and characterization of the integral glycosaminoglycan constituents of human amyloid A and monoclonal light-chain amyloid fibrils. Biochem. J.,1991;275:67-73.

Nelson SR, Tennent GA, Sethi D, Gower PE, Ballardie FW, Amatayakul-Chantler S, Pepys MB. Serum amyloid P component in chronic renal failure and dialysis. Clin Chim Acta. 1991 Aug 30;200(2-3):191-9.

Orgogozo JM, Gilman S, Dartigues JF, Laurent B, Puel M, Kirby LC, Jouanny P, Dubois B, Eisner L, Flitman S, Michel BF, Boada M, Frank A, Hock C.Subacute meningoencephalitis in a subset of patients with AD after Abeta42 immunization. Neurology. 2003 Jul 8;61(1):46-54.

Pepys MB and Baltz ML. Acute phase proteins with special reference to C-reactive protein and related proteins (pentaxins) and serum amyloid A protein. Adv. Immunol. 1983;34:141-212.

Pepys MB, Baltz M, Gomer K, Davies AJ, Doenhoff M. Serum amyloid P-component is an acute-phase reactant in the mouse. Nature. 1979;278(5701):259-61.

Pepys MB, Booth DR, Hutchinson WL, Gallimore JR, Collins PM and Hohenester E. Amyloid P component. A critical review. Amyloid: Int. J. Exp. Clin. Invest. 1997;4:274-295.

Pepys MB, Dash AC, Markham RE, Thomas HC, Williams BD, Petrie A. Comparative clinical study of protein SAP (amyloid P component) and C-reactive protein in serum. Clin Exp Immunol 1978;32:119-124.

Pepys MB, Dyck RF, de Beer FC, Skinner M and Cohen AS. Binding of serum amyloid P component (SAP) by amyloid fibrils. Clin. Exp. Immunol. 1979;38: 284-293.

Pepys MB, Herbert J, Hutchinson WL, Tennent GA, Lachmann HJ, Gallimore JR, Lovat LB, Bartfai T, Alanine A, Hertel C, Hoffmann T, Jakob-Roetne R, Norcross RD, Kemp JA, Yamamura K, Suzuki M, Taylor GW, Murray S, Thompson D, Purvis A, Kolstoe S, Wood SP, Hawkins PN. Targeted pharmacological depletion of serum amyloid P component for treatment of human amyloidosis. Nature. 2002;417(6886):254-9.

Pepys MB, Rademacher TW, Amatayakul-Chantler S, Williams P, Noble GE, Hutchinson WL, Hawkins PN, Nelson SR, Gallimore JR, Herbert J, et al. Human serum amyloid P component is an invariant constituent of amyloid deposits and has a uniquely homogeneous glycostructure. Proc Natl Acad Sci U S A. 1994;91(12):5602-6.

Pepys MB. Amyloidosis. Annu. Rev. Med. 2006;57:223-241.


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Rapezzi C, Quarta. C.C, Guidalotti. P.L, Longhi. S, Pettinato. C, Leone. O, Alessandra. F, Salava. F, Gallo. P, Gagliasdi. C, Branzi. A. Usefulness and limitations of 99mTc-3,3-diphosphono-1, 2-propanodicarboxylic acid scintigraphy in the aetiological diagnosis of amyloidotic cardiomyopathy. Eur J Nucl Med Mol Imaging. 2011;38:470-478.

Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD; Liver biopsy. Hepatology. 2009 Mar;49(3):1017-44.

Salloway S, Sperling R, Gilman S, Fox NC, Blennow K, Raskind M, Sabbagh M, Honig LS, Doody R, van Dyck CH, Mulnard R, Barakos J, Gregg KM, Liu E, Lieberburg I, Schenk D, Black R, Grundman M; Bapineuzumab 201 Clinical Trial Investigators.A phase 2 multiple ascending dose trial of bapineuzumab in mild to moderate Alzheimer disease. Neurology. 2009;73(24):2061-70.

Saris-Baglama, R., C. Dewey, G. Chisholm, B. Chisholm, E. Plumb, J. King, M. Kosinski, J. B. Bjorner, and J. E. Ware. "SF-8 Health Survey." QualityMetric Inc (2007).

Sharma A, Jusko WJ. Characterization of four basic models of indirect pharmacodynamic responses. J. Pharmacokinet. Biopharm. 1996;24:611-635

Sunde M, Serpell LC, Bartlam M, Fraser PE, Pepys MB and Blake CCF. Common core structure of amyloid fibrils by synchrotron X-ray diffraction. J. Mol. Biol. 1997; 273:729-739.

Tennent GA, Lovat LB and Pepys MB. Serum amyloid P component prevents proteolysis of the amyloid fibrils of Alzheimer's disease and systemic amyloidosis. Proc. Natl. Acad. Sci. USA. 1995;92:4299-4303.


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14. APPENDICES

14.1. Appendix 1: Liver Safety Algorithms

ALT≥3xULN ?

Bilirubin ≥ 2xULN

(>35% direct) or INR > 1.5 (if measured)* ?

No

No

Yes

Yes

Continue investigational product (IP)

Instruct subject to stop IP Notify GSK within 24 hrs Obtain weekly liver chemistries until resolved, stabilized or returned

to baseline values Perform liver event follow up assessments (serology, PK sample, etc

as in protocol) Complete liver event CRF Withdraw subject from study after liver chemistry monitoring

complete (unless protocol offers option to restart drug).

Instruct subject to stop IP Notify GSK and arrange clinical followup within 24 hrs Perform liver event follow up assessments (serology, PK sample etc

as in protocol) Report as SAE (excl. hepatic impairment or cirrhosis studies);

complete SAE & liver event CRF + liver imaging and biopsy CRFs (if these tests are performed)

Obtain twice weekly liver chemistries until resolved, stabilized or returned to baseline values

Consultation with hepatologist/specialist recommended Withdraw subject from study after liver chemistry monitoring

complete (unless protocol offers option to restart drug).*INR threshold does not apply to subjects receiving anticoagulants.


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14.2. Appendix 2: Liver Safety Drug Restart Guidelines

Drug restart may be considered for a subject exhibiting compelling benefit for a critical medicine following drug-induced liver injury, if there is favourable benefit: risk ratio and no alternative medicine available.

Background Information on Drug Restart/Rechallenge

Following drug-induced liver injury, drug restart or rechallenge is associated with a 13% mortality across all drugs in prospective studies.1 Clinical outcomes vary by drug, with nearly 50% fatality with halothane readministered in one month of initial injury. However, some drugs seldom result in recurrent liver injury or fatality. Risk factors for a fatal drug restart/rechallenge outcome include: hypersensitivity1 with initial liver injury (e.g. fever, rash, eosinophilia), jaundice or bilirubin2xULN or INR>1.5 suggesting severe liver injury, prior IP-related severe or fatal drug restart/rechallenge2,3 or evidence of drug-related preclinical liability / mitochondrial impairment3.

Drug Restart/Rechallenge Process (also see Figure 5)

1. Principal Investigator (PI) requests consideration of drug restart for a subject receiving compelling benefit from a critical or life-saving drug, who exhibits liver chemistry elevation meeting subject stopping criteria, with no alternative treatment.

2. GSK Medical Monitor & Clinical Safety Physician.to review the subject’s restart/rechallenge risk factors & complete checklist (Table 13).

Table 13 Checklist for drug restart/rechallenge for critical medicine (Following drug-induced liver injury, drug rechallenge is associated with 13% mortality across all drugs in prospective studies)

Yes No

Compelling benefit of the investigational product (IP) for this subject and no alternative therapy. Provide brief explanation:

Relative benefit-risk favorable for drug restart/rechallenge, after considering the following high risk factors:

• Initial liver injury event included:

– fever, rash, eosinophilia, or hypersensitivity

– or bilirubin 2xULN (direct bilirubin >35% of total)

• Subject currently exhibits ALT 3xULN, bilirubin 2xULN (direct

bilirubin >35% of total, if available), or INR1.5

• Severe or fatal restart/rechallenge has earlier been observed

with IP If yes, please provide brief explanation:


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Yes No

• IP associated with known preclinical #hepatic liability/ injury

3. If GSK provides written approval for restart/rechallenge following the above review, the Principal Investigator (PI) must ensure the following:

The PI is to obtain Ethics Committee or Institutional Review Board review of drug reinitiation, as required.

PI must discuss the possible benefits and risks of drug reinitiation with the subject.

The subject must sign informed consent with a clear description of possible benefits and risks of drug administration, including recurrent liver injury or death. Consent specifically for the IP restart must be recorded in the study chart.

The drug must be reinitiated at GSK approved dose(s). Subjects approved by GSK for restart of IP must return to the clinic twice a week

for liver chemistry tests until stable, liver chemistries have been demonstrated and then laboratory monitoring may resume as per protocol. If protocol defined stopping criteria for liver chemistry elevations are met, study drug must be stopped.

The Ethics Committee or Institutional Review Board is to be informed of the subject’s outcome, as required.

GSK is to be notified of any adverse events, as per Section 10


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Figure 5 Drug Restart/Rechallenge Process

References:

1. Andrade RJ. Expert Opin Drug Saf 2009;8:709-714.2. Papay JI. Regul Tox Pharm 2009;54:84-90.3. Hunt CM. Hepatol 2010;52:2216-2222.


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14.3. Appendix 3: Preparation of dosing solutions

GSK2315698

Preparation of dosing syringes

Refer to technical memo [GlaxoSmithKline Document Number 2010N110988_01] and technical agreement PI_TP_QP001.

A sample of each prepared solution will be taken into a NUNC tube and stored refrigerated until notified that the sample can be destroyed.

Whenever possible 1 vial of GSK2315698 stock solution (200mg/mL) will be used to prepare all dosing solutions for dispensing in that day (IV and subcut).

Unused vials of GSK2315698 will be destroyed at site on confirmation of end of study by GSK. Individual dosing syringes will be destroyed following completion of the dosing session.

Intravenous administration

Solutions for IV administration will be made up in Baxter Sodium Chloride 0.9% Viaflo infusion bags (50, 100, 250, 500 or 1000mL). The required volume for dosing will be drawn up into suitable sized syringe (maximum of 50mL in 60mL syringe) and administered over up to approximately 24 hours.

Expiry of solutions following preparation is 72hours including administration over a maximum of 24 hours at up to 25°C. The solutions should be stored prior to use at 2-8°C.

Sub-cutaneous administration

The required volume for dosing will be drawn up into suitable sized syringe (BD micro-fine 0.3 to 1mL) either from the stock solution (200mg/mL) or from solutions made up in Baxter Sodium Chloride 0.9% Viaflo infusion bags (50, 250, 500 and 1000mL).

GSK2398852

Preparation of dosing syringes

Refer to technical memo RPT_00000188183 and technical agreement PI_TP_QP001.

GSK2398852 Concentrate for Solution for Infusion, 100 mg/mL is provided as a 100 mg/mL solution that must be diluted in sterile, isotonic 0.9% (w/v) Sodium Chloride prior to intravenous (IV) administration to provide a GSK2398852 Solution for Infusion. Solutions for IV administration will be prepared in a Type I glass bottle at the clinical siteby the dilution of GSK2398852 Concentrate for Solution for Infusion, 100 mg/mL, withsterile 0.9% w/v sodium chloride solution, to provide GSK2398852 Solution for Infusion,in concentrations ranging from 5 to 30 mg/mL of GSK2398852. The required volume for Solution for Infusion must be withdrawn from the Type I glass bottle within 2 hours of


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preparation into suitable sized polypropylene syringe (maximum of 55 mL in 60mL syringe).

GSK2398852 Solution for Infusion is stable for up to 2 hours at room temperature in Type I glass vials and up to 6 hours in a polypropylene syringe at concentrations ranging from 5 mg/mL to 30 mg/mL. Refer to Technical Agreement for further details.

Intravenous administration

The required volume for dosing of GSK2398852 Solutions for Infusion is withdrawn into a polypropylene syringe of suitable size and secured to a syringe pump. The GSK2398852 Solutions for Infusion must be administered over up to a maximum 8 hour duration using a infusion giving set with a infusion line, 3 way extension set, and cannula.

Dosing Instructions

Intravenous (IV) Injections

Intravenous injections will be administered via a cannula using an infusion pump.

Subcutaneous (SC) Injections for GSK2315698

The skin is cleaned using the appropriate aseptic swab and allowed to dry.

The skin is bunched between the thumb and forefinger.

A BD Microfine (or similar insulin) syringe will be used.

The needle is inserted at an approximately 90° angle.

The site of injection will usually be as per below in the subject’s abdominal area with the 1st injection at site 1, and the 2nd injection at site 2 and 3rd at site 3 over 24 hours. If SC injections are required for longer than 24 hours then the sites should be close to those used previously but in the same general area. Other sites (e.g. arm) may be used if abdominal area is considered not suitable by the Investigator or designee.

A pen mark (using surgical permanent pen) will be placed close to the injection site to prevent re-injection at the same site. Injection sites should be at least 2.5cm apart.


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Site of subcutaneous injection


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14.4. Appendix 4: MDRD Equation

4-variable MDRD

To convert Cr in μmol/l to mg/dl divide by 88.4

Equations

GFR= 186.3 x (SCr/88.4)-1.154 x age-0.203 x (0.742 if female) x (1.21 if black) where SCr = serum creatinine in μmol/l,

IF SCr in mg/dl (usually US):

GFR = 186.3 x (SCr)-1.154 x (age, y)-0.203 x 1.212 (if black) x 0.742 (if female).

Ethnic group- only has adjustment for African/African American

Classification- for groups


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14.5. Appendix 5: Protocol Amendment Changes

AMENDMENT 01

Where the Amendment Applies

Section 3.4 Dose Adjustment/ Stopping Criteria

Section 3.4.1.2 QTc withdrawal criteria

Section 3.5 Time and Events table

Section 4.2.2 Exclusion Criteria

Summary of Amendment Changes with Rationale

Clarification of the minimum interval between dosing and the timeframe for dose escalation decisions as requested by Regulatory Authority.

Addition of a change from baseline withdrawal criterion for QTc as requested by Regulatory Authority.

Minor typographical errors in Time and Events tables Section 3.5 have been corrected for clarity and consistency with the text.

Addition of an additional exclusion criterion relating to dementia and cerebral amyloid angiopathy as requested by Regulatory Authority for compatibility with Investigator’s Brochure.

List of Specific Changes

Section 3.4 Dose Adjustment/ Stopping Criteria

PREVIOUS TEXT

The decision to proceed to the next dose level of GSK2398852, will be made by the GSK Study Team and the investigator based on safety, tolerability with all available preliminary pharmacokinetic and pharmacodynamic data obtained at prior dose levels. The actual doses to be administered may be adjusted based on the available information and may involve either an increase or a decrease in the planned dose.

REVISED TEXT

The decision to proceed to the next dose level of GSK2398852, will be made by the GSK Study Team and the investigator based on safety, tolerability with all available preliminary pharmacokinetic and pharmacodynamic data obtained at prior dose levels. The actual doses to be administered may be adjusted based on the available informationand may involve either an increase or a decrease in the planned dose.


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The interval between subjects starting dosing will be a minimum of 14 days and the decision on dosing the next subject will be made after a minimum of 7 days of follow up after dosing with GSK2398852.

Section 3.4.1.2 QTc withdrawal criteria

Additional QTc withdrawal criteria as below:

Change (increase) from baseline: QTc >60 ms


Additional exclusion criteria added as number 16:

16. Subjects with dementia or a diagnosis of cerebral amyloid angiopathy.


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AMENDMENT 02


Section 4.2.1 Inclusion Criteria


Section 1.4.2 Potential risks associated with study procedures

Section 14.3 Appendix 3 Preparation of dosing solutions

Table 1 Outline dose escalation plan for GSK2398852 Part A [2 subjects per dose level]

Section 3.3 Investigational product and other study treatment dosage/administration

Section 3.5 Time and Events Table


Increase in the maximum age of participants from 65 to 70 years.

During recruitment the median age for potential subjects otherwise eligible for the study has been found to be 68 years. On this basis it is proposed the increase the eligible age limit to 70 years. Given the other stringent eligibility criteria this change is not expected to materially change the risk benefit balance for participants.

To amend the information relating to the dose of radiation associated with fluoroscopy for liver biopsy.

The benchmark figure for this procedure is 0.5-1 mSv, we have however been made aware that data from the site that will be performing this procedure (the Royal Free Hospital) show that the administered dose during this procedure can be higher- up to 2mSv. The dose in the protocol and patient information has therefore been amended to better reflect clinical experience at the site used for this study. This amended figure has been submitted to and approved by ARSAC. This change relates only to those undergoing liver biopsy.

The shelf life of GSK2315698 has been extended to 72hrsThis was a substantial amendment to the IMPD and has been approved by the MHRA. A non substantial change has been made to reflect this new shelf life.

Duration of infusion for GSK2398852 corrected to up to 1hrThis was a typographical error noticed and has been corrected to remain consistent with other study documentation.

Minor clarifications to the time and events tableA number of small changes have been made for the purposes to clarification and/or to correct minor inconsistencies and errors.


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Section 4.2.1 Inclusion Criteria

PREVIOUS TEXT

4. Male or female between 18 and 65 years of age inclusive, at the time of signing the informed consent.

REVISED TEXT

4. Male or female between 18 and 70 years of age inclusive, at the time of signing the informed consent.


PREVIOUS TEXT

8 Subjects with echocardiogram (within 6 months) consistent with significant cardiac amyloid whether symptomatic or not.

REVISED TEXT

8 In a subject in whom there is a clinical suspicion of cardiac amyloid, an echocardiogram is consistent with significant cardiac amyloid, whether symptomatic or not.

Section 1.4.2 Potential risks associated with study procedures

PREVIOUS TEXT

The radiation dose associated with fluoroscopic screening is between 0.5-1 mSv. The (maximum) total dose for 2 biopsies will therefore be 2 mSv.


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REVISED TEXT

The radiation dose associated with fluoroscopic screening is approximately 2mSv per biopsy. The (maximum) total dose for 2 biopsies will therefore be approximately 4 mSv.

Section 14.3 Appendix 3 Preparation of dosing solutions

PREVIOUS TEXT

Expiry of solutions following preparation is 48 hours when stored at up to 25C.

REVISED TEXT

Expiry of solutions following preparation is 72 hours including administration over a maximum of 24 hours at 25°C. The solutions should be stored prior to use at 2-8°C.

PREVIOUS TEXT

The GSK2398852 Solutions for Infusion must be administered over up to a 3 hour duration using a infusion giving set with a infusion line, 3 way extension set, and cannula.

REVISED TEXT

The GSK2398852 Solutions for Infusion must be administered over up to a 1 hourduration using a infusion giving set with a infusion line, 3 way extension set, and cannula.

PREVIOUS TEXT

Sub-cutaneous administration


Expiry of solutions following preparation is 48hours when stored at up to 25C.

REVISED TEXT



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AMENDMENT 03


Section 1.3 Study Design and Rationale


Section 1.3.2 Dose Rationale

Section 1.4.2 Potential risks associated with administration of GSK2398852

Section 2 Objectives and Endpoints

Table 2 Overview of study flow for a single subject

Section 3.3 Investigational Product and other study treatment dosage/administration.

Section 3.4 Dose adjustment/stopping criteria

Section 3.5 Time and Events Table

Section 4.1 Number of Subjects

Section 5.3.1 Interim Analysis

Section 6.5.3 Exploratory Biomarkers

Section 9.3.1 GSK2315698 and GSK2398852 Solution

Section 14.3 Appendix 3: Preparation of dosing solutions


Increase in study population for Part A from 10 to 16 subjects

Results to date indicate that the intervention is well tolerated with encouraging evidenceof a pharmacodynamic response in some subjects. Recruitment of additional subjects will allow for further exploration of safety and of dose-response and to provide more robust data to make necessary clinical decisions for Part B.

Additional clarity around continuation of GSK2315698 after administration of GSK2398852

Data to date indicate that the distribution of GSK2398852 is very rapid. In a some subjects there is a small proportion of the dose that appears to circulate. In practice the LLQ of the assay is proving to be 300 ng/mL. Therefore it is not possible to demonstrate values below the LLQ. The amount of antibody in the circulation at a ‘worst case’ concentration of 300 ng/ml would be 0.9 mg. We have now observed that the administration of GSK2398852 in subjects with up to 2 mg/L of circulating SAP is well


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tolerated without evidence of adverse effect. On this basis were 0.9 mg of mAb to bind to SAP it is unlikely to cause adverse effects. We have also added text to clarify that the potential risk (and therefore the cut off defined) is related to free antibody; antibody fragments or antibody already bound to SAP may be identified by the assay but do not represent a risk for formation of further immune complexes.

Inclusion of elastography as appropriate PD marker.

Preliminary data indicate that elastography may be a sensitive early marker of pharmacodynamic effect in this intervention. We have therefore added additional clarity around the use of this measure.

Additional clarity around dose of GSK2398852 to be administered.

Preliminary data would indicate that the PD response is more closely related to the absolute dose administered than to the dose on a mg/kg basis. Additional wording has been included to provide clarity on the dose to be administered.

Increase in duration of infusion for GSK2398852

Preliminary data indicate that relatively large doses (>500 mg) of GSK2398852 are required for a PD effect. Subjects who have subsequently shown evidence of a PD response have also reported symptoms during or immediately following the infusion of mAb. The symptoms resolved in a few hours and none were medically serious . There were no features suggestive of acute hypersensitivity or of cytokine release. In common with other monoclonal antibodies given at high doses and by intravenous administration and as a precaution flexibility has been added to allow for a longer duration of administration.



PREVIOUS TEXT

Although safety is the primary objective of this part pharmacodynamic activity will be assessed using a novel technique EqMRI(including organ volume) [Flett, 2010]

With small numbers of subjects it is possible that a positive signal on MRI may not be apparent. If no signal of pharmacodynamic activity is observed on MRI then additional subjects with liver involvement will be enrolled (Part A extension) which will include a liver biopsy (as well as MRI)


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REVISED TEXT

Although safety is the primary objective of this part pharmacodynamic activity will beassessed by methods including using a novel technique EqMRI(including organ volume) [Flett, 2010] ,and elastography, SAP scan, and biochemistry

With small numbers of subjects it is possible that a positive pharmacodynamic signal on MRI may not be apparent. If no signal of pharmacodynamic activity is observed on MRIthen additional subjects with liver involvement will be enrolled (Part A extension) which will include a liver biopsy (as well as MRI).

Section 1.4.2 Potential risks associated with administration of SAP depleter GSK2315698

Additon of the paragraph below:

Reactions associated with the infusion of anti-SAP

Symptoms include but are not limited to: warm feelings, flushing, headache, increased heart rate, diarrhoea/loose stools, nausea, abdominal discomfort. Symptoms are self limiting and occurred during and up to 12 hours after the dose.

Figure 4 Study outline and Decision Tree

PREVIOUS TEXT


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REVISED TEXT

Section 1.3.1 Notes on pharmacodynamic assessments, paragraph 4 Elastography

PREVIOUS TEXT

This is a non invasive ultrasound based technique measuring the speed of propagation of elastic waves through the liver.

REVISED TEXT

This is a non invasive ultrasound based technique measuring the speed of propagation of elastic waves. through the liver.

Section 1.3.2 Dose Rationale, paragraph 5

PREVIOUS TEXT

Following administration of GSK2398852 administration of GSK2315698 will continue in order to maintain depletion of circulating SAP. Administration of GSK2315698 will continue until the concentration of GSK2398852 has fallen to 100 ng/mL


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REVISED TEXT

Following administration of GSK2398852 administration of GSK2315698 will continue in order to maintain depletion of circulating SAP. Administration of GSK2315698 will continue until the inferred concentration of free GSK2398852 has fallen to below 100 ng/mL or below the LLQ..

This update has been made consistently throughout the protocol wherever the threshold levels have been mentioned.

Section 1.3.2 Dose rationale. Dose escalation in Part A

PREVIOUS TEXT

In Part A two subjects will be studied at each dose but only one subject will be dosed at a time.

REVISED TEXT

In Part A it is planned that two or more subjects will be studied at each dose level but only one subject will be dosed at a time.

PREVIOUS TEXT

Decisions about the next dose level will be made following safety review of the prior subjects’ data; dose levels may be changed (increased and lowered) and dose levels may be repeated depending on the observed safety.

REVISED TEXT

Decisions about the next dose level will be made following safety review of the prior subjects’ data; dose levels may be changed (increased and lowered) and dose levels may be repeated depending on the observed safety and PD. For each subject the precise dose to be administered will be defined as an absolute dose level (mg) for the avoidance of doubt. Dose may also be adjusted to provide an absolute (mg) rather than mg/kg dose level.

Section 1.3.2 Dose Rationale, Subjects with large amyloid loads

The below sentence has been added to the end of this paragraph:

Additional patients may be studied at any dose level in order to add scientific clarity where necessary e.g. to optimise the rate of antibody infusion in terms of tolerability and PD effect, or to define variation attributable to varying anatomic distribution of amyloid load.


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PREVIOUS TEXT

Dose escalation is subject to a safety review of previous dose(s). Doses may be reduced as well as increased.

REVISED TEXT


Section 2 Objectives and Endpoints, Exploratory

Addition of Elastography assessment of liver as an endpoint.

Table 2 Overview of study flow for single subject

Table updated to reflect longer inpatient phase and provide further clarity around timings of assessments.


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Intravenous infusion not to exceed 1 hour infusion duration

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Section 3.5 Time and events Tables

All time and events tables updated to provide further clarity and to properly reflect longerinpatient phase based on emerging data. Additional Table 5 added to show assessments to be performed during extended inpatient stays.


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Approximately 10 subjects will be enrolled in to Part A. A further 6 may be enrolled if the Part A extension is conducted.

The number of subjects in Part B will be re-estimated based on data from Part A and available data from the ongoing EqMRI enabling study, but is proposed to be approximately 30.

Additional subjects may be enrolled to allow for evaluation of additional dose levels.


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For all parts of the study Aadditional subjects may be enrolled to allow for evaluation of additional dose levels or to add scientific clarity within one dose level.

Section 5.3.1 Interim analysis, During Part A

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Safety data will be reviewed by the study team on an ongoing basis during Part A. Dose escalation decisions will be based on safety (including AEs, clinical laboratory data, vital signs, ECGs), and PK and (GSK2315698 and GSK2398852 concentrations),

REVISED TEXT

Safety dData will be reviewed by the study team on an ongoing basis during Part A. Dose escalation decisions will be based on safety data (including AEs, clinical laboratory data, vital signs, ECGs), and PK and (GSK2315698 and GSK2398852 concentrations), and PD, (EqMRI (volume of distribution), elastography SAP scan data, and biochemistry).


Additional sub section added:

Section 6.5.3.4 Elastography

An elastography assessment will be performed and may be used as a PD marker measuring changes in the stiffness of the organs in response to drug treatment.


Inclusion of reference to technical agreement with document number.

Update to duration of infusion of GSK2398852 from 1 hour to a maximum 8 hours in line with previous changes.


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AMENDMENT 04


Changes to study design details relating to Part B of the study

Part A has shown that in subjects with a large amyloid load including the liver substantial reduction in liver amyloid load can be achieved with the a single dose of GSK2399852 but that more than one dose may be required to target amyloid in other organs. Part B will focus on evaluation of the PD response following a second dose. Part B will be an open label dose adaptive design in up to 30 patients. Patients may be invited for more than one dosing session and therefore repeated assessments. This includes additional exposure to ionising radiation which has been detailed in Section 1.4.3.

Removal of Part A extension

The part A extension was included in this study design as an option should a PD signal not be achieved from Part A. Since this has been achieved with the SAP scan and elastography there is no longer a need to conduct the Part A extension involving liver biopsies.

Inclusion of DPD bone scan

The DPD bone scan may be conducted on patients with cardiac TTR systemic amyloidosis. Recently it has been shown that 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) which has been in routine clinical use for many years as a bone scan agent can also be used to image cardiac amyloid in patients with ATTR. If any patients with ATTR are recruited they may undergo this investigation instead of SAP scintigraphy as a more relevant PD measure.

Increase in threshold level of GSK2398852 in the blood to inform cessation of GSK2315698.

The threshold level has been increased from 100ng.mL to 1000ng/mL. In those with large amyloid load there is approx 3 mg of SAP remaining in the circulation when the anti-SAP mAb is administered. This has been well tolerated without evidence of immune complex disease. The molecular weight of GSK2398852 and SAP are similar. If CPHPC is stopped when there is 1000 ng/mL (1mg/L) of mAb in the circulation this would have the potential to form approx 3mg of immune complex. Given the formation of this amount of complex has been well tolerated when the mAb is first administered raising this threshold is not expected to increase the risk to subjects. Subjects will continue to be closely monitored.


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Inclusion of details around symptoms associated with the infusion of GSK2398852 seen in Part A.

Part A showed some patients who subsequently showed a pharmacodynamic response experienced symptoms during or shortly after the infusion of GSK2398852. Details of these symptoms have been included in the protocol with a plan to slow the rate of infusion and if required pre-medicate with a non-specific anti-histamine as a way to mitigate the response. The available evidence is that at least some these symptoms are related to the pharmacodynamic response.

Changes to the objectives and endpoints

The objectives and endpoints have been updated to reflect the revised design of part B focusing more on the PD response in a dose adaptive manner rather than the original randomised approach.

Addition of Clinical Unit Cambridge as a second site

In order to help manage the greater number of subjects for part B a second site has been brought on board to allow greater flexibility and to be able to dose more patients per month between the two sites.

Changes to inclusion exclusion criteria

The inclusion exclusion/ criteria have been updated to allow for inclusion of patients with a mild degree of cardiac amyloid. Cardiac involvement is common in systemic amyloidosis and now that we have preliminary safety information it is appropriate to start to include patients with this organ involved. Only those with mild involvement will be included and the existing criteria to exclude those at high risk will remain.


Section 1.2.3 Current PKPD model for GSK2315698 and SAP

Deletion of Figure 3 - Summary of SAP depletion by GSK2315698 in study CPH114527 (preliminary data, time scale limited from 0 to 80h post dose, concentrations in log scale)


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With small numbers of subjects it is possible that a positive pharmacodynamic signal may not be apparent. If no signal of pharmacodynamic activity is observed then additional subjects with liver involvement will be enrolled (Part A extension) which will include a liver biopsy (as well as MRI). The liver, (commonly affected in most forms of systemic amyloidosis), is expected to be readily accessible to GSK2398852 (good blood supply and fenestrated capillary endothelium), and can be readily biopsied. The presence of macrophages and macrophage-derived giant cells (and evidence of amyloid clearance) as assessed on liver biopsy is considered the gold standard assessment of pharmacology


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in this intervention. If no evidence of pharmacology is observed at the highest well tolerated dose using any of the measures of pharmacodynamic activity then the second part of the study will not take place.

Part B will be a randomised partially blinded part with the principal objective of assessing the dose response of the GSK2398852 in more detail. Subjects and study staff responsible for administration of study procedures will be blinded and GSK staff will be unblinded to the treatment received. The choice of PD measure in this part will be determined by the findings in Part A (and Part A extension if applicable). If MRI is found to be sensitive to changes in amyloid load then this will be used in Part B in patients with moderate to large amyloid load involving the spleen. Some subjects with liver involvement will be included in Part B and asked to undergo a liver biopsy in order to provide validation of the EqMRI findings. If however it is found that pharmacological action can only be reliably assessed on liver biopsy then this will be used in all subjects in Part B. The decision tree for this part is outlined in Figure 3. The subject numbers in Part B will be re-estimated based on the exploratory information obtained in Part A (and Part A extension if applicable) as well as available data from the on-going EqMRI enabling work (CRT114645).


Subjects who receive a pharmacologically inactive dose (e.g. those at the start of the study in Part A) may be offered the opportunity to participate in Part B after a suitable washout period (at least 3 months after their first dose to allow for re-equilibration of SAP), providing the safety profile is acceptable.

REVISED TEXT

With small numbers of subjects it is possible that a positive pharmacodynamic signal may not be apparent. If no signal of pharmacodynamic activity is observed then additional subjects with liver involvement will be enrolled (Part A extension) which will include a liver biopsy (as well as MRI). The liver, (commonly affected in most forms of systemic amyloidosis), is expected to be readily accessible to GSK2398852 (good blood supply and fenestrated capillary endothelium), and can be readily biopsied. The presence of macrophages and macrophage-derived giant cells (and evidence of amyloid clearance) as assessed on liver biopsy is considered the gold standard assessment of pharmacology in this intervention. A liver biopsy may be performed on a small number of subjects in Part B if required to validate PD responses. If no evidence of pharmacology is observed at the highest well tolerated dose using any of the measures of pharmacodynamic activity then the second part of the study will not take place.

Part B will be a randomised partially blinded part with the principal objective of assessing the dose response of the GSK2398852 in more detail. Subjects and study staff responsible for administration of study procedures will be blinded and GSK staff will be unblinded to the treatment received. The choice of PD measure in this part will be determined by the findings in Part A (and Part A extension if applicable). If MRI is found to be sensitive to changes in amyloid load then this will be used in Part B in patients with


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moderate to large amyloid load involving the spleen. Some subjects with liver involvement will be included in Part B and asked to undergo a liver biopsy in order to provide validation of the EqMRI findings. If however it is found that pharmacological action can only be reliably assessed on liver biopsy then this will be used in all subjects in Part B. The decision tree for this part is outlined in Figure 3. The subject numbers in Part B will be re-estimated based on the exploratory information obtained in Part A (and Part A extension if applicable) as well as available data from the on-going EqMRI enabling work (CRT114645).

Part B will have an open label dose adaptive design. The objective will be to further evaluate the safety, tolerability, PK, and PD of GSK2398852. Part A has shown that in subjects with a large amyloid load including the liver substantial reduction in liver amyloid load can be achieved with the a single dose of GSK2399852 but that more than one dose may be required to target amyloid in other organs. Part B will focus on evaluation of the PD response to a second dose. Subjects from part A will be invited to participate and new subjects will be recruited. In the event that a second dose shows PD response only in the liver a third dose will be considered on a case by case basis. Doses will be administered at least 2 months apart to allow for completion of follow up and evaluation of the response before another dose is considered. A small number of subjects in Part B may be asked to undergo liver biopsy to validate PD findings observed on other measures.


Subjects who receive a pharmacologically inactive dose (e.g. those at the start of the study in Part A) may be offered the opportunity to participate in Part B after a suitable washout period (at least 3 months after their first dose to allow for re-equilibration of SAP), providing the safety profile is acceptable.


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Section 1.3.1 Notes on pharmacodynamic assessments

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EqMRI

This non-invasive MRI technique estimates the extracellular space (volume of distribution of gadolinium) in key organs (liver, spleen and heart) and data from an ongoing enabling study (CRT114645) shows that it is able to distinguish those with small, medium and large amyloid loads in organs of interest [Figure 4]. Its ability to measure changes in amyloid load has not been established as there are no current interventions that reliably reduce amyloid load. It will be used in Part A of this study in an exploratory manner, in subjects with moderate amyloid load involving the spleen. It will also be used in the Part A extension of this study if applicable in an exploratory manner, in subjects with moderate to large amyloid load involving the spleen and liver. Indeed, based on preliminary results shown in Figure 4, in which amyloid load was scored by SAP scintigraphy, the volume of distribution in the spleen seems to be the most informative in terms of EqMRI assessment. This investigation will include an assessment of organ volume as this may also be a measure of pharmacodynamic activity.

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EqMRI

This non-invasive MRI technique estimates the extracellular space (volume of distribution of gadolinium) in key organs (liver, spleen and heart) and data from an ongoing enabling study (CRT114645) shows that it is able to distinguish those with small, medium and large amyloid loads in organs of interest [Figure 4]. Its ability to measure changes in amyloid load has not been established as there are no current interventions that reliably reduce amyloid load. It will be used in Part A and B of this study in an exploratory manner, in subjects with moderate amyloid load involving the spleen. It will also be used in the Part A extension of this study if applicable in an exploratory manner, in subjects with moderate to large amyloid load involving the spleen and liver. Indeed, based on preliminary results shown in Figure 4, in which amyloid load was scored by SAP scintigraphy, the volume of distribution in the spleen seems to be the most informative in terms of EqMRI assessment. This investigation will include an assessment of organ volume as this may also be a measure of pharmacodynamic activity.

Addition of DPD bone scan into Section 1.3.1

DPD- Bone scan. For patients with cardiac TTR systemic Amyloidosis

Recently it has been shown that 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) which has been in routine clinical use for many years as a bone scan agent can also be used to image cardiac amyloid in patients with ATTR. If any patients with ATTR are recruited they may undergo this investigation instead of SAP scintigraphy.


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Section 1.3.2 Dose Rationale

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Paragraph 5

Administration of GSK2315698 will continue until the inferred concentration of free GSK2398852 has fallen to below 100 ng/mL or below the LLQ.

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Paragraph 5

Administration of GSK2315698 will continue until the inferred concentration of free GSK2398852 has fallen to below 100 1000 ng/mL or below the LLQ.

This update has been made consistently throughout the protocol wherever the threshold levels have been mentioned.

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Part A extension (if required)

If no evidence of pharmacology is seen in the EqMRI from subjects in Part A, this may be because;

1. The number of subjects studied so far is inadequate,

2. The EqMRI cannot detect changes in amyloid load

3. There is no pharmacodynamic effect.

Evaluation of sample size (Section 5.2.1.1) shows that 6 subjects should be sufficient to detect a change based on existing EqMRI data. Up to 6 subjects will be studied in this part using both MRI and liver biopsy as PD markers at the highest well tolerated dose level. If it becomes clear after several subjects that EqMRI is not detecting changes that are readily apparent on liver biopsy, lower dose levels may also be explored.

Part B

The purpose of Part B is to provide a robust assessment of dose/response. The precise selection of numbers of subjects and dose levels will be informed by the results from PartA and available data from the ongoing EqMRI enabling study and Part A extension, where applicable. It is anticipated that up to 5 doses of interest will be selected. These may not be identical to those administered in part A but the highest dose will not be higher than the highest well tolerated dose from Part A. It is anticipated that there will be 6 subjects studied at each dose level and subjects will be randomized to the available doses. Subjects and study staff who will be responsible for administration of study procedures will be blinded to the dose received. GSK staff will be unblinded.


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Part A extension (if required)

If no evidence of pharmacology is seen in the EqMRI from subjects in Part A, this may be because;

4. The number of subjects studied so far is inadequate,

5. The EqMRI cannot detect changes in amyloid load

6. There is no pharmacodynamic effect.

Evaluation of sample size (Section 5.2.1.1) shows that 6 subjects should be sufficient to detect a change based on existing EqMRI data. Up to 6 subjects will be studied in this part using both MRI and liver biopsy as PD markers at the highest well tolerated dose level. If it becomes clear after several subjects that EqMRI is not detecting changes that are readily apparent on liver biopsy, lower dose levels may also be explored.

Part B

The purpose of Part B is to provide a robust assessment of dose/response. The precise selection of numbers of subjects and dose levels will be informed by the results from Part A and available data from the ongoing EqMRI enabling study and Part A extension, where applicable. It is anticipated that up to 5 doses of interest will be selected. These may not be identical to those administered in part A but the highest dose will not be higher than the highest well tolerated dose from Part A. It is anticipated that there will be 6 subjects studied at each dose level and subjects will be randomized to the available doses. Subjects and study staff who will be responsible for administration of study procedures will be blinded to the dose received. GSK staff will be unblinded.

The purpose of Part B is to provide a preliminary assessment of dose/response in relation to amyloid load. The precise selection of numbers of subjects and dose levels will be informed by the results from Part A and available data from the ongoing review of Part B data, including PD assessments. Information from part A has shown that doses of GSK2398852 should be individualised based on amount and location of amyloid. More than one dose may be required to target amyloid in organs other than the liver. Decisions about dose levels will be based on an individual subject's disease profile and prior subjects’ data; dose levels may be changed (increased and lowered) and dose levels may be repeated depending on the observed safety, PK and PD. For each subject the precise dose to be administered will be defined as an absolute dose level (mg) for the avoidance of doubt.

The dose of GSK2398852 given on a single occasion will not exceed 3000 mg (equivalent to 30 mg/kg in a 100 kg individual).


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Section 1.4.2 Potential risks associated with administration of GSK2398852

Additional paragraph added


Symptoms include but are not limited to: warm feelings, flushing, headache, increases and decreases in heart rate and blood pressure, diarrhoea/loose stools, nausea, abdominal discomfort. Symptoms are self limiting and mainly occurred during infusion and the first 12 hours after the commencement of dosing with GSK2398852. The available evidence is that these symptoms are related to engagement of the target mechanism and may be mitigated by slowing the rate of infusion of GSK2399852 (including splitting the dose during the day).

Section 1.4.3 potential risks associated with study procedures

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SAP scan (with SPECT/CT)

Subjects will be exposed to two additional doses of ionising radiation due to their participation in this study. The ionising radiation exposure from SAP scanning comes from the administered radioligand and CT examination. The total radiation burden per subject is calculated as 8 mSv per scan; total 16 mSv for two scans.

The International Commission on Radiological Protection (ICRP) Publication 60 has recommended a maximum occupational adult effective dose limit of 20 mSv per year, averaged over a defined period of 5 years (not exceeding 50 mSv in a single year) [ICRP 60, 1990]. The additional radiation associated with participation in this study is not expected to represent a significant safety risk to subjects.


REVISED TEXT

SAP scan (with SPECT/CT) and 99mTc-DPD Bone scan (TTR subjects only)

Subjects will be exposed to two additional doses of ionising radiation due to their participation in this study.

The ionising radiation exposure from SAP scanning comes from the administered radioligand and CT examination. The total radiation burden per subject is calculated as 8 mSv per SAP scan; total 16 mSv for two scans. Subjects with TTR amyloid will undergo a DPD bone scan and will be exposed to 6.7mSv per scan, total 13.4 mSv. Subjects will receive either an SAP scan or a DPD scan, not both.

A baseline SAP/DPD scan at session 2/3 will only be performed if it has been greater than 3 months since the previous scan. If subjects do receive a second (or third) dose


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of GSK2398852 and a baseline scan is performed this will involve additional exposure to radiation.

The International Commission on Radiological Protection (ICRP) Publication 60 has recommended a maximum occupational adult effective dose limit of 20 mSv per year, averaged over a defined period of 5 years (not exceeding 50 mSv in a single year) [ICRP 60, 1990]. The additional radiation associated with participation in this study is not expected to represent a significant safety risk to subjects.


It is recognised that if subjects receive more than one dose of GSK2398852 the 20mSv limit may be exceeded but this is considered justified because (i) data from part A show that GSK2398852 can lead to substantial amyloid clearance which may be of benefit to the subject (ii) subjects will only be given a second dose if there is evidence from the first dose that they may benefit (iii) systemic amyloidosis has a poor prognosis and no currently available treatments directly target amyloid clearance (iv) the SAP scan provides vital evidence of the PD effect of GSK2398852.

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Liver biopsy (Part A extension and Part B only)

Liver biopsies will be conducted in the minimum number of subjects in order to provide robust pharmacodynamic information as outlined in Section 1.3.

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Liver biopsy (Part A extension and Part B only)

Liver biopsies will may be conducted in the minimum number of subjects in order to provide robust pharmacodynamic information as outlined in Section 1.3.

Section 2 Objectives and Endpoints

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Primary (Part A)



Evaluate pharmacokinetics of single doses of GSK2398852 and GSK2315698 when co-



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administered

Primary (Part B)



Evaluate pharmacokinetics of single doses of GSK2398852and GSK2315698 when co-administered


Evaluate dose response of single doses of GSK2398852 when co-administered with GSK2315698

The main measure of dose response will be determined by information from part A (and part A extension if required). The options are:

-Volume of distribution of gadolinium in the spleen as a measure of amyloid load (EqMRI)

-Liver histology examination for presence of giant cells, activation of macrophages, and amyloid clearance


Evaluate SAP concentrations in blood during administration of single doses of GSK2398852 when co-administered with GSK2315698






Assess effect of single doses of GSK2398852 when co-administered with GSK2315698 on amyloid load, both overall and in affected organs

-Volume of distribution of gadolinium in organs of interest as a measure of amyloid load (EqMRI of, liver, heart)


-Elastography assessment of liver



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-If part A extension conducted: Liver histology examination for presence of giant cells, activation of macrophages, and amyloid clearance

Assess effect of single doses of GSK2398852 when co-administered with GSK2315698 on organ function in organs affected by amyloid deposition

Biomarkers of organ function in amyloid affected organs .e.g.: protein excretion, creatinine; creatinine clearance; Pro NT-BNP, KIM-1, NGAL

Assess individual patient quality of life, as measured by the MOS Short Form 36 (MOS SF-36) of patients prior to and following a single dose of GSK2398852

Explore the impact of a single dose of GSK2398852 on individual patient quality of life compared to individual quality of life at baseline (prior to receiving a single dose of GSK2398852), as measured by the MOS SF-36.


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REVISED TEXT


Primary (Part A)



Evaluate pharmacokinetics of single doses of GSK2398852 and GSK2315698 when co-administered


Primary (Part B)

Evaluate safety and tolerability of after single doses of GSK2398852 when co-administered with GSK2315698


Evaluate pharmacokinetics of after single doses of GSK2398852 and GSK2315698 when co-administered


Preliminary evaluateevaluation of dose response of single after doses of GSK2398852 when co-administered with GSK2315698

The main measuresof dose PD response will be determined by information from part A (and part A extension if required). The options are:may include:

- -Volume of distribution of gadolinium in the spleen as a


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measure of amyloid load (EqMRI)

- SAP scan assessment of amyloid load before and after treatment.


-Liver histology examination for presence of giant cells, activation of macrophages, and amyloid clearance


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Evaluate SAP concentrations in blood during administration of single doses of GSK2398852 when co-administered with GSK2315698






Assess effect of after singledoses of GSK2398852 when co-administered with GSK2315698 on amyloid load, both overall and in affected organs

-Volume of distribution of gadolinium in organs of interest as a measure of amyloid load (EqMRI of, liver, heart)


-Elastography assessment of liver (Part A)

-SAP scan assessment of amyloid load before and after treatment (Part A)

- DPD scan (TTR subjects in Part B only)

-If part A extension liver biopsyconducted: Liver histology examination for presence of giant cells, activation of macrophages, and amyloid clearance

Assess effect of single after doses of GSK2398852 when co-administered with GSK2315698 on organ function in organs affected by amyloid deposition

Biomarkers of organ function in amyloid affected organs .e.g.: protein excretion, creatinine; creatinine clearance; Pro NT-BNP, KIM-1, NGAL, liver function tests.

Assess individual patient quality of life, as measured by the MOS Short Form 36 (MOS SF-36) of patients prior to and following a single dose of GSK2398852

Explore the impact of a single dose of GSK2398852 on individual patient quality of life compared to individual quality of life at baseline (prior to receiving a single dose of GSK2398852), as measured by the


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MOS SF-36.






Inclusion of Table 3 - Overview of study flow for a single subject in Part B

Section 3.1.1 Outline of study assessments

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Details of the study assessments are given in Section 6. A brief outline is provided here and in Table 2 . The schedule of assessments is the same for all parts of the study however the precise timing of assessments will be refined based on the experience in Part A. The timings given here are for guidance and may be altered.

Potential subjects will be identified by the National Amyloidosis Centre (Royal Free Hospital) and if they express an interest, invited to attend for consent and screening which will be conducted by Quintiles Research, London.

Following successful screening subjects will undergo a baseline assessment of their disease in the month prior to the study drug administration, followed by an inpatient phase based at Quintiles where they will receive the study treatment (approx 7 days), and an outpatient phase where they will have various safety assessments and study follow up. [Table 2].






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Inpatient dosing

The dosing will be open label in part A (and part A extension). However the dose level will be blinded in Part B to subjects and study staff responsible for the administration of study procedures but unblinded to GSK staff.

Unlike many other mAbs, clearance of GSK2398852 from the blood is expected to be rapid owing to the large excess of target antigen in the tissues.

REVISED TEXT

Details of the study assessments are given in Section 6. A brief outline is provided here and in Table 2 Table 2 and Table 3. The schedule of assessments is the same for all parts of the study however the precise timing of assessments will be refined based on the experience in Part A. The timings given here are for guidance and may be altered.

Potential subjects will be identified by the National Amyloidosis Centre (Royal Free Hospital) and if they express an interest, invited to attend for consent and screening which will be conducted by one of the Clinical Research Units; Quintiles Research, London, or Clinical Unit Cambridge.

Following successful screening subjects will undergo a baseline assessment of their disease in the month prior to the study drug administration, followed by an inpatient phase based at Quintiles one of the Clinical Research Units where they will receive the study treatment (approx 7 days), and an outpatient phase where they will have various safety assessments and study follow up. [Table 2 Table 2 and Table 3].






Inpatient dosing

The dosing will be open label in part A and Part B. (and part A extension). However the dose level will be blinded in Part B to subjects and study staff responsible for the administration of study procedures but unblinded to GSK staff.


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Unlike many other mAbs, clearance of GSK2398852 from the blood is expected to be rapid owing to the large excess of target antigen in the tissues.

Section 3.2 treatment Assignment

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In Part A (plus Part A extension if required), doses will be administered sequentially as detailed in Section 1.3.2.

In Part B, subjects will be assigned to one of approximately 5 dose groups, in accordance with the randomisation schedule generated by Clinical Statistics prior to the start of Part B, using validated internal software. The number of dose groups and the allocation ratio will be confirmed at the end of Part A (or part A extension).

REVISED TEXT

In Part A (plus Part A extension if required), doses will be administered sequentially as detailed in Section 1.3.2.

In Part B, doses will be administered based on the subjects’ disease profile and safety review of prior subjects data. subjects will be assigned to one of approximately 5 dose groups, in accordance with the randomisation schedule generated by Clinical Statistics prior to the start of Part B, using validated internal software. The number of dose groups and the allocation ratio will be confirmed at the end of Part A (or part A extension).

Section 3.4 Dose Adjustment/Stopping Criteria

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The interval between subjects starting dosing will be a minimum of 14 days and the decision on dosing the next subject will be made after a minimum of 7 days of follow up after dosing with GSK2398852.


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REVISED TEXT

In Part A the interval between subjects starting dosing will be a minimum of 14 days and the decision on dosing the next subject will be made after a minimum of 7 days of follow up after dosing with GSK2398852.

Section 3.5 Time and Events Tables (Part A and Part B)

All time and events tables updated to provide further clarity and to properly reflect longer inpatient phase based on emerging data. Additional Tables added to provide break down of assessments to be performed for Part B and additional clarity around assessments to be performed during extended inpatient stays.


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For all parts of the study additional subjects may be enrolled to allow for evaluation of additional dose levels or to add scientific clarity within one dose level.


REVISED TEXT


The number of subjects in Part B will be re-estimated based on data from Part A and available data from the ongoing EqMRI enabling study, but is proposed to be up toapproximately 30.

Subjects from Part A may enrol in Part B. For all both parts of the study additional subjects may be enrolled to allow for evaluation of additional dose levels or to add scientific clarity within one dose level.


Section 4.2 Eligibility Criteria

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Inclusion Criterion 1





Part A extension (if required) Moderate to large amyloid load involving the spleen and liver (spleen involved to a moderate/large extent)


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Part B Moderate to large amyloid load involving the spleen (and liver in subset of subjects only)

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Part A extension (if required) Moderate to large amyloid load involving the spleen and liver (spleen involved to a moderate/large extent)

Part B Subjects from Part A

Subjects who did not participate in Part A

Moderate to large amyloid load involving the spleen (and liver in subset of subjects only)

And/or Mild cardiac involvement in a subset of subjects

Exclusion Criterion 7:

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Decompensated cardiac failure or a recent history of syncope associated with cardiac disease.

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Decompensated cardiac failure or a recent history of syncope or pre--syncope associated with cardiac disease.

Exclusion Criterion 8

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In a subject in whom there is a clinical suspicion of cardiac amyloid, an echocardiogram is consistent with significant cardiac amyloid, whether symptomatic or not.


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REVISED TEXT

In a subject in whom there is a clinical suspicion of cardiac amyloid: an echocardiogram shows significantly impaired systolic function, whether symptomatic or not, presence of symptoms consistent with NYHA functional class III or IV, NT-pro BNP >212 pMol/L (AL patients only)

Section 5.1 Hypotheses and Treatment Comparisons

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In Part A, no formal hypothesis will be tested.

If EqMRI is to be included in Part B, a model-based approach will be used to assess evidence of a response and the dose-response relationship based on the change from baseline in volume of distribution (Vd) in the spleen, should data permit.

If EqMRI is not to be included in Part B, then liver biopsy data from the Part A extension (presence of gaint cells, macrophage activity and amyloid clearance) will be used to confirm the key liver histology endpoint on which to base the primary PD analysis. If data permit, a model-based approach will be used to assess evidence of a response and the dose-response relationship as appropriate.

REVISED TEXT

In Part A and B, no formal hypothesesis will be tested.

If EqMRI is to be included in Part B, a model-based approach will be used to assess evidence of a response and the dose-response relationship based on the change from baseline in volume of distribution (Vd) in the spleen, should data permit.

If EqMRI is not to be included in Part B, then liver biopsy data from the Part A extension (presence of gaint cells, macrophage activity and amyloid clearance) will be used to confirm the key liver histology endpoint on which to base the primary PD analysis. If data permit, a model-based approach will be used to assess evidence of a response and the dose-response relationship as appropriate.

Section 5.2 Sample size considerations

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The planned sample size for part A is based primarily on feasibility. Sample size assumptions for part A are based on preliminary data from the on-going EqMRI enabling study CRT114645 (see Section 1.3, Figure 4).

Provisional sample size calculations for part B are also based on preliminary data from the ongoing EqMRI enabling study CRT114645 (see Section 1.3, Figure 4), as well as feasibility. A simple Emax model has been provisionally assumed to describe the relationship between dose and log-transformed volume of distribution at a single time point.


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REVISED TEXT

The planned sample size for part A and B is based primarily on feasibility. Sample sizeAssumptions for the evaluation of sample size part A are based on preliminary data from the on-going EqMRI enabling study CRT114645 (see Section 1.3, Figure 4).

Provisional sample size calculations for part B are also based on preliminary data from the ongoing EqMRI enabling study CRT114645 (see Section 1.3, Figure 4), as well as feasibility. A simple Emax model has been provisionally assumed to describe the relationship between dose and log-transformed volume of distribution at a single time point.

Section 5.2.1 Sample size Assumptions

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Section 5.2.1.1 Part A

Assuming a true response (i.e. change from baseline in log10 Vd) of -0.15 at the highest well-tolerated dose and a standard deviation of 0.04, a total of 100,000 trial simulations were performed, based on a log-normal distribution for Vd and various sample sizes from n=2 (i.e. the planned sample size for the top dose in Part A) to n=8 (i.e. the total planned sample size for the highest well-tolerated dose in both Part A and Part A extension combined).

For Part A of the study, if only the top dose is effective, with a true effect of -0.15, the probability of observing no subjects at the top dose (i.e. out of n=2) with a change in log10 Vd of -0.15 or better is very high (25%) and hence progression in to the Part A extension is quite likely under this scenario. However, the probability of observing nosubjects with a change in log10 Vd of -0.15 or better in the highest well-tolerated dose group (i.e. n=8) at the end of the part A extension is very low (<1%), assuming the highest well-tolerated dose has a true effect of -0.15, and hence there is only a low risk that a true signal based on EqMRI will be missed entirely. Further details regarding the probability of 1 or more subjects having a change in log10 Vd of -0.15 or better under these assumptions are given below.

Note, if we were to observe zero subjects with a response in the top dose group in part A (i.e. n=2), then the 95% credible interval for response rate would be (0.01, 0.71), and there would be a 0.13 probability, i.e. low probability, of the response rate being greater than 0.5. Furthermore, if at the end of the part A extension we have observed zerosubjects with a response in the highest well-tolerated dose group (i.e. n=8), then the 95% credible interval for the response rate would be (0.00, 0.34), and there would be < 0.01 probability of the response rate being greater than 0.5.

A further 100,000 trial simulations were also performed to assess the probability of observing a false positive, assuming no treatment effect at the highest well-tolerated dose (i.e. a change from baseline in log10 Vd of zero), and a standard deviation of 0.04, based on various sample sizes from n=2 (i.e. the planned sample size for the top dose in part A) to n=8 (i.e. the total planned sample size for the highest well-tolerated dose in both Part A and Part A extension combined). A change of -0.15 or better in log10 Vd (i.e. a false positive) was observed in < 1% of the simulated trials and for no more than one subject within any given simulated trial, i.e. there is a negligible risk of observing a strong signal


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(a false positive) based on EqMRI in any one subject (i.e. a change from baseline of -0.15 or better in log10 Vd) if there is truly no treatment effect.

REVISED TEXT

Section 5.2.1.1 Part A and B

Assuming a true response (i.e. change from baseline in log10 Vd) of -0.15 at the highest well-tolerated dose and a standard deviation of 0.04, a total of 100,000 trial simulations were performed, based on a log-normal distribution for Vd and various sample sizes from n=2 to 8 (i.e. the planned sample size for the top dose in Part A) to n=8 (i.e. the total planned sample size for the highest well-tolerated dose in both Part A and Part A extension combined).

For Part A of the study, if only the top dose is effective, with a true effect of -0.15, the probability of observing no subjects at the top dose (i.e. out of n=2) with a change in log10 Vd of -0.15 or better is very high (25%) and hence progression in to the Part A extension is quite likely under this scenario. However, The probability of observing nosubjects with a change in log10 Vd of -0.15 or better in the highest well-tolerated dose group (i.e. n=8) at the end of the part A extension at a given dose or higher is very low for an n ≥ 4 (≤ 6%), (<1%), assuming the highest well-tolerated dose has a true effect of -0.15, and hence there is only a low risk that a true signal based on EqMRI will be missed entirely. Further details regarding the probability of 1 or more subjects having a change in log10 Vd of -0.15 or better under these assumptions are given below.

Note, if we were to observe zero subjects with a response in the top dose group in part A (i.e. n=2), then the 95% credible interval for response rate would be (0.01, 0.71), and there would be a 0.13 probability, i.e. low at a given dose or higher, the probability, of the response rate being greater than 0.5 would be low for any sample size (eg 13% for n=2, <10% for n ≥ 3, <=1% for n ≥ 6). Furthermore, if at the end of the part A extension we have observed zero subjects with a response in the highest well-tolerated dose group (i.e. n=8), then the 95% credible interval for the response rate would be (0.00, 0.34), and there would be < 0.01 probability of the response rate being greater than 0.5.

A further 100,000 trial simulations were also performed to assess the probability of observing a false positive, assuming no treatment effect at a given dose the highest well-tolerated dose (i.e. a change from baseline in log10 Vd of zero), and a standard deviation of 0.04, based on various sample sizes from n=2 (i.e. the planned sample size for the top dose in part A) to n=8 (i.e. the total planned sample size for the highest well-tolerated dose in both Part A and Part A extension combined). A change of -0.15 or better in log10 Vd (i.e. a false positive) was observed in < 1% of the simulated trials and for no more than one subject within any given simulated trial, i.e. there is a negligible risk of observing a strong signal (a false positive) based on EqMRI in any one subject at a given dose (i.e. a change from baseline of -0.15 or better in log10 Vd) if there is truly no treatment effect.


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Section 5.2.1.2 Part B deleted entirely.

Section 5.2.2 Sample size sensitivity

PREVIOUS TEXT

Section 5.2.2.1 Part A

To further assess the probability of observing a false positive, an additional 100,000 trial simulations were performed assuming no treatment effect at the highest well-tolerated dose (i.e. a change from baseline in log10 Vd of zero), and a larger standard deviation of 0.06, based on various sample sizes from n=2 (i.e. the planned sample size for the top dose in Part A) to n=8 (i.e. the total planned sample size for the highest well-tolerated dose in both Part A and Part A extension combined). The probability of observing a strong signal (a false positive) in one or more subject, i.e. a change of -0.15 or better in log10 Vd if there is truly no treatment effect, increases with increasing n but is no more than 5%. Probabilities were 1%, 2%, 2%, 4% and 5% for n=2, 3, 4, 6 and 8 respectively.

Section 5.2.2.2 Part B

Sample size sensitivity calculations were based on:

n=5 per arm (with all other assumptions the same)

sd=0.06 (with all other assumptions the same)

response (change from baseline in log10Vd) at 30mg/kg = -0.10 (with all other assumptions the same).

Note, additional sample size sensitivity calculations may be performed at the end of Part A as part of the sample size re-estimation.

A summary of the model-predicted responses at 30mg/kg and the model estimates of ED50 and Emax are given in tables below.

REVISED TEXT

Section 5.2.2.1 Part A and B

To further assess the probability of observing a false positive, an additional 100,000 trial simulations were performed assuming no treatment effect at the highest well-tolerated dose (i.e. a change from baseline in log10 Vd of zero), a given dose and a larger standard deviation of 0.06, based on various sample sizes from n=2 (i.e. the planned sample size for the top dose in Part A) to n=8 (i.e. the total planned sample size for the highest well-tolerated dose in both Part A and Part A extension combined). The probability of observing a strong signal (a false positive) in one or more subject, i.e. a change of -0.15 or better in log10 Vd if there is truly no treatment effect, increases with increasing n but is no more than 5% for up to n=8 at a given dose. Probabilities were 1%, 2%, 2%, 4% and 5% for n=2, 3, 4, 6 and 8 respectively.


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Section 5.2.2.2 Part B deleted entirely

Section 5.2.3 Sample size re-estimation

PREVIOUS TEXT

A re-estimation of the required sample size for Part B, including a re-assessment of the sample size sensitivity to revised assumptions, is planned at the end of Part A or the Part A extension as applicable.

If EqMRI is to be included in Part B, then the sample size re-estimation will be based on a review of the EqMRI data from Part A (and Part A extension if applicable) and available data from the currently ongoing EqMRI enabling study CRT114645.

If EqMRI is not to be included in Part B, then liver biopsy data from the Part A extension (presence of giant cells, macrophage activity and amyloid clearance) will be used to confirm the key liver histology endpoint on which to base the primary pharmacodynamic (PD) analysis for Part B and to inform the assumptions on which to base the sample size re-estimation.

REVISED TEXT

A re-estimation of the required sample size for Part B, including a re-assessment of the sample size sensitivity to revised assumptions, is planned at the end of Part A or the Part A extension as applicable.

If EqMRI is to be included in Part B, then the sample size re-estimation will be based ona review of the EqMRI data from Part A (and Part A extension if applicable) and available data from the currently ongoing EqMRI enabling study CRT114645. Sample size is based primarily on feasibility. However, the precise selection of numbers of subjects and dose levels in Part B will be informed by the results from Part A and available data from the ongoing review of Part B data including PD assessments As such, there will be no formal sample size re-estimation.

If EqMRI is not to be included in Part B, then liver biopsy data from the Part A extension (presence of giant cells, macrophage activity and amyloid clearance) will be used to confirm the key liver histology endpoint on which to base the primary pharmacodynamic (PD) analysis for Part B and to inform the assumptions on which to base the sample size re-estimation.

Section 5.3.1.1 Interim Analysis

PREVIOUS TEXT

Section 5.3.1.1 During Part A

Data will be reviewed by the study team on an ongoing basis during Part A. Dose escalation decisions will be based on safety data (including AEs, clinical laboratory data, vital signs, ECGs), PK (GSK2315698 and GSK2398852 concentrations), and PD (EqMRI (volume of distribution), elastography, SAP scan data and biochemistry).


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REVISED TEXT

Section 5.3.1.1 During Part A Section 5.3.1 Interim Analysis

Data will be reviewed by the study team on an ongoing basis during Part A and B. Dose escalation decisions will be based on safety data (including AEs, clinical laboratory data, vital signs, ECGs), PK (GSK2315698 and GSK2398852 concentrations), and PD (EqMRI (volume of distribution), liver elastography, SAP scan data, and biochemistry) and biomarker data.

Section 5.3.1.2 End of part A (and part A extension as applicable) deleted entirely.

Section 5.3.2.2 Safety Analyses

PREVIOUS TEXT

Safety data from Part A (and Part A extension if applicable) will be listed.

Safety data from Part B will be presented in tabular and/or graphical format and summarized descriptively according to GSK’s Integrated Data Standards Library (IDSL) standards.

REVISED TEXT

Safety data from Part A and B (and Part A extension if applicable) will be listed.

Safety data from Part B will be presented in tabular and/or graphical format and summarized as appropriate. descriptively according to GSK’s Integrated Data Standards Library (IDSL) standards.

Section 5.3.2.4 Pharmacodynamic Analyses

PREVIOUS TEXT

EqMRI

An Emax model will be used to evaluate the relationship between the change from baseline in log10-transformed Vd and dose, based on Part B data in the spleen, if data permit. Baseline log10-transformed Vd may be included in the model as a covariate as appropriate and a slope parameter may also be incorporated.


Maximum reduction from baseline in log10-transformed Vd attributable to drug (Emax)


attributable to drug (ED50)


If data permit, at each of the dose levels studied, the model-predicted reduction from baseline in log10-transformed Vd will be presented together with associated 95% confidence intervals.


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The timepoint on which to base the primary dose-response analyses will be determined from Part A data (and Part A extension data if applicable). An alternative data transformation of Vd may be used as appropriate. Alternative dose-response models may also be explored as appropriate, and if data permit.

Further details regarding the analysis of EqMRI data may be provided in the RAP.

Liver Histology

Assuming EqMRI is included in Part B as the key PD measure as planned, and only a small cohort of subjects within Part B undergo liver biopsies, then available liver histology data will be listed together with EqMRI data for comparison.

Should EqMRI not be included in Part B as the key PD measure, then a dose-response modeling approach based on the key liver histology endpoint confirmed based on Part A extension data will be explored as appropriate, if data permit. Further details will be provided in the RAP as applicable.

Pharmacokinetic/Pharmacodynamic Modelling

A PK/PD model including the effects of both compounds on SAP in plasma and in tissues (including amyloid tissues) will be investigated, using the plasma concentration data of GSK2315698, GSK2398852 and SAP. The existing PK/PD model of GSK2315698 developed in previous studies in healthy volunteers (CPH113776) and amyloidosis patients (CPH114527) will be used as the initial model. The PK parameters of both GSK2315698 and GSK239852, will be estimated from the model together with the SAP turn-over parameters.

EqMRI data and/or liver biopsy data may be integrated in to the model to enrich the information at the tissue level, mainly in terms of in-situ degradation of GSK2398852 -SAP complexes.

The PK/PD modeling will be the responsibility of the Clinical Pharmacokinetics Modeling & Simulation department within GlaxoSmithKline and will be performed using the non-linear mixed effects approach implemented in NONMEM version VII. Further details will be provided in the RAP.

Novel Biomarker(s) Analyses

The results of these biomarker investigations may be reported separately from the main clinical study report. All endpoints of interest from all comparisons will be descriptively and/or graphically summarized as appropriate to the data.



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REVISED TEXT

EqMRI

PD measures of interest may be presented graphically by subject, by dose and by baseline amyloid load/organ involvement for a preliminary assessment of dose response.

If data permit an Emax model will may be used to further evaluate the relationship between the change from baseline in log10-transformed Vd (and/or other PD measure) and dose, based on Part B data in the spleen, if data permit. Baseline PD measures log10-transformed Vd may be included in the model as a covariate as appropriate and a slope parameter may also be incorporated.


Maximum reduction from baseline in log10-transformed Vd (and/or other PDmeasure), attributable to drug (Emax)


(and/or other PD measure), attributable to drug (ED50)


If data permit, at each of the dose levels studied, the model-predicted reduction from baseline in log10-transformed Vd (and/or other PD measure) will be presented together with associated 95% confidence intervals.

The timepoint on which to base the primary dose-response analyses will be determined from Part A data (and Part A extension data if applicable). An alternative data transformation of Vd may be used as appropriate. Alternative dose-response models may also be explored as appropriate, and if data permit.

Further details regarding the analysis of EqMRI data and other PD measures may be provided in the RAP.

Liver Histology

Assuming EqMRI is included in Part B as the key PD measure as planned, and only a small cohort of subjects within Part B undergo liver biopsies, then Available liver histology data will be listed together with EqMRI and/or other PD measures of interestdata for comparison.

Should EqMRI not be included in Part B as the key PD measure, then a dose-response modeling approach based on the key liver histology endpoint confirmed based on Part A extension data will be explored as appropriate, if data permit. Further details will be provided in the RAP as applicable.


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Pharmacokinetic/Pharmacodynamic Modelling

A PK/PD model including the effects of both compounds on SAP in plasma and in tissues (including amyloid tissues) will be investigated, using the plasma concentration data of GSK2315698, GSK2398852 and SAP. The existing PK/PD model of GSK2315698 developed in previous studies in healthy volunteers (CPH113776) and amyloidosis patients (CPH114527) will be used as the initial model. The PK parameters of both GSK2315698 and GSK239852, will be estimated from the model together with the SAP turn-over parameters.

EqMRI data and/or liver biopsy other PD data of interest may be integrated in to the model to enrich the information at the tissue level, mainly in terms of in-situ degradation of GSK2398852 -SAP complexes.

The PK/PD modeling will be the responsibility of the Clinical Pharmacokinetics Modeling & Simulation department within GlaxoSmithKline and will be performed using the non-linear mixed effects approach implemented in NONMEM version VII. Further details will be provided in the RAP.

Novel Biomarker(s) Analyses

Novel biomarkers of interest may be presented graphically by subject, by dose and by baseline amyloid load/organ involvement for a preliminary assessment of dose response.

The results of these biomarker investigations may be reported separately from the main clinical study report. All endpoints of interest from all comparisons will be descriptively and/or graphically summarized as appropriate to the data.


Inclusion of Section 6.5.3, Section 6.5.4 and Section 6.5.5.4

6.5.3 SAP scan

SAP scintigraphy will be conducted and used as a PD marker. SAP scintigraphy will be used to evaluate amyloid load in liver, spleen, kidney, bone marrow and other involved organs. A qualitative and if possible quantitative assessment of amyloid load pre and post treatment will be made.

6.5.4 Liver Elastography

A liver elastography assessment will be performed and may be used as a PD marker measuring changes in the stiffness of the organs in response to drug treatment


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6.5.5.4 Bone scan

DPD scanning may be used in patients with ATTR cardiac Amyloidosis to evaluate PD response. A qualitative and if possible quantitative assessment of cardiac amyloid load pre and post treatment will be made.

Section 6.8.1 Questionnaire Administration

PREVIOUS TEXT

Subjects will complete the MOS SF-36 at Baseline, and Clinical follow-up (Day 14 and Day 42), as specified in Table 4 and Table 2 .

REVISED TEXT

Subjects will complete the MOS SF-36 at the time-points specified in the Time and Events Tables Baseline, and Clinical follow-up (Day 14 and Day 42), as specified in Table 4 and Table 2 .

Section 9.1 Blinding

PREVIOUS TEXT

Part A (and Part A extension) will be open-label. Part B will be partially blinded such that neither the subjects nor the staff responsible for conduct of study assessments are aware of the GSK2398852 dose level administered, this may include the duration of infusion. GSK staff will be un-blinded.

REVISED TEXT

Part A (and Part A extension) and Part B will be open-label. Part B will be partially blinded such that neither the subjects nor the staff responsible for conduct of study assessments are aware of the GSK2398852 dose level administered, this may include the duration of infusion. GSK staff will be un-blinded.

REVISED TEXT



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Section 2 Objectives and Endpoints, Exploratory

Addition of Elastography assessment of liver as an endpoint.

Table 2 Overview of study flow for single subject

Table updated to reflect longer inpatient phase and provide further clarity around timings of assessments.


PREVIOUS TEXT

Intravenous infusion not to exceed 1 hour infusion duration

REVISED TEXT


Section 3.5 Time and events Tables

All time and events tables updated to provide further clarity and to properly reflect longer inpatient phase based on emerging data. Additional Table 5 added to show assessments to be performed during extended inpatient stays.


PREVIOUS TEXT



Additional subjects may be enrolled to allow for evaluation of additional dose levels.

REVISED TEXT



For all parts of the study Aadditional subjects may be enrolled to allow for evaluation of additional dose levels or to add scientific clarity within one dose level.


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Section 5.3.1 Interim analysis, During Part A

PREVIOUS TEXT

Safety data will be reviewed by the study team on an ongoing basis during Part A. Dose escalation decisions will be based on safety (including AEs, clinical laboratory data, vital signs, ECGs), and PK and (GSK2315698 and GSK2398852 concentrations),

REVISED TEXT

Safety dData will be reviewed by the study team on an ongoing basis during Part A. Dose escalation decisions will be based on safety data (including AEs, clinical laboratory data, vital signs, ECGs), and PK and (GSK2315698 and GSK2398852 concentrations), and PD, (EqMRI (volume of distribution), elastography SAP scan data, and biochemistry).


Additional sub section added:

Section 6.5.3.4 Elastography

An elastography assessment will be performed and may be used as a PD marker measuring changes in the stiffness of the organs in response to drug treatment.

Section 8.1 Permitted Medication

Additional paragraph included regarding use of anti-histamine:

If a subject experiences symptoms during or shortly after infusion of GSK2398852 [Section 1.4.2] or is considered to be at risk of developing such symptoms consider administration of a (non-selective) antihistamine (e.g. Chlorphenamine 10-20 mg mg iv 30 mins before infusion of GSK2398852).


Detail around dose preparation removed and replaced with reference to technical agreement for details on dose preparation.


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AMENDMENT 05


Increase in the maximum age of participants (TTR only) from 70 to 75 years and allow use of anticoagulants in the TTR patients (only).

During recruitment the median age for potential subjects with TTR amyloidosis otherwise eligible for the study has been found to be >70 years. On this basis it is proposed to increase the eligible age limit of these TTR participants to 75 years. Given the other stringent eligibility criteria this change is not expected to materially change the risk benefit balance for participants.

Anticoagulants were prohibited medication as a general precaution in this FIH study. Many ATTR patients have atrial fibrillation (AF) and are therefore anti-coagulated. Given the increased clinical experience the team consider it appropriate to allow those patients with TTR amyloidosis who are anticoagulated to be enrolled.

Addition of patients with AL amyloidosis receiving chemotherapy for plasma cell dyscrasia

In future clinical studies the Anti-SAP treatment may be administered to patients prior to or during chemotherapy treatment (for plasma cell dyscrasia in AL amyloidosis) . The most common regimens include substantial doses of corticosteroids. While no traditional drug- drug interaction is anticipated, the corticosteroids have the potential to impair the pharmacodynamic response to anti-SAP therapy.. In this study a small number of subjects (AL amyloid only) may be recruited into Part B to investigate the impact of on-going chemotherapy treatment on a subject's response to GSK2315698 and GSK2398852. Subjects who have achieved a complete response (CR) or very good partial response (VGPR) after at least cycle 3 of chemotherapy will be eligible to receive the treatment during their next cycle of chemotherapy. By selecting those that have already achieved a good response to chemotherapy the addition of antiSAP treatment is not expected to materially alter the risk benefit for these patients,

Increase in threshold level of GSK2398852 in the blood to inform cessation of GSK2315698.

As our understanding of the PK of GSK2398852 increases we have observed that a proportion of patients demonstrate a prolonged ‘tail’ elimination phase. This is at a low concentration (< 5 mg/L). In some subjects this tail has not fallen further when CPHPC is stopped which means that the mAb cannot be free antibody as circulating SAP rises following cessation of CPHPC and would bind to free antibody. We previously raised the threshold concentration for cessation of CPHPC from 300 ng/mL to 1000 ng/mL with no adverse consequences. We therefore propose to raise the threshold for stopping CPHPC to 5000 ng/mL. If CPHPC is stopped when there is 5000 ng/mL (5mg/L) of mAb in the circulation this would have the potential to form approx up to 15 mg of immune complex. From the literature clinically important adverse effects are associated with >100 mg immune complex. On this basis the risk is considered low. The risk is further mitigated


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by the observation that the mAb may not be free antibody. Subjects will continue to receive CPHPC for a minimum of 7 days post mAb and will continue to be observed closely.

Changes to the objectives and endpoints

The objectives and endpoints have been updated to reflect the addition of the assessment of the interaction with chemotherapy in a small number (2-3) of subjects (AL amyloidosis only).

Changes to the example Time and Events tables for Part B

The time and events tables for Part B have been updated to reflect the on-going changes to maximise safety, PD and PK assessments that have been implemented to date in Part B.

Changes to interim analysis section

In addition to the planned ongoing review of data by the study team during Part A and B, a subset of data displays will be produced based on an interim data cut to inform internal decision making.


Section 1.3. Study Design and Rationale

ADDITIONAL TEXT

In future clinical studies the AntiSAP treatment may be administered to patients prior to or during chemotherapy treatment (for plasma cell dyscrasia in AL amyloidosis) and, due to the nature of that chemotherapy, there may be an effect on the PD response to AntiSAP therapy. In this study a small number of subjects (AL amyloid only) may be recruited into Part B to investigate the impact of on-going chemotherapy treatment on a subject's response to GSK2315698 and GSK2398852. Subjects who have achieved a complete response (CR) or very good partial response (VGPR) during chemotherapy will be eligible to receive the treatment at their next cycle of chemotherapy.

Section 1.3.2. Dose Rationale

Dose rationale for GSK2315698 (SAP deplete)

PREVIOUS TEXT

Following administration of GSK2398852 administration of GSK2315698 will continue in order to maintain depletion of circulating SAP. Administration of GSK2315698 will continue until the inferred concentration of free GSK2398852 has fallen to below 1000 ng/mL or below the LLQ. The SC route of administration might be considered instead of an infusion if a prolonged administration of GSK2398852 becomes necessary. At these concentrations the amount of circulating mAb is predicted to be ~0.3 mg (based on a


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plasma volume of 3L). This small amount of antibody is considered unlikely to cause substantial adverse effects if it were to form complexes with circulating SAP.

REVISED TEXT

Following administration of GSK2398852 administration of GSK2315698 will continue in order to maintain depletion of circulating SAP. Administration of GSK2315698 will continue until at least Day 7 and will continue until the inferred concentration of free GSK2398852 has fallen to below 5000 ng/mL or below the LLQ. The SC route of administration might be considered instead of an infusion if a prolonged administration of GSK2398852 becomes necessary. At these concentrations the amount of circulating mAb is predicted to be ~1.5 mg (based on a plasma volume of 3L). This small amount of antibody is considered unlikely to cause substantial adverse effects if it were to form complexes with circulating SAP.

Section 1.4.2. Potential risks associated with administration of GSK2398852

Formation of complexes of SAP and anti-SAP mAb

PREVIOUS TEXT

Following administration of GSK2398852, GSK2315698 will continue to be administered until the concentration of unbound GSK2398852 has fallen to 1000 ng/mL or below LLQ. Refer to Section.1.3.2.

REVISED TEXT

Following administration of GSK2398852, GSK2315698 will continue to be administered for at least 7 days and until the concentration of unbound GSK2398852 has fallen to 5000 ng/mL or below LLQ. Refer to Section.1.3.2.


ADDITIONAL TEXT

Additionally the administration of a non-selective antihistamine and corticosteroid prior to administration of GSK2398852 may also mitigate the symptoms associated with the infusion.


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ADDITIONAL SECTION

1.4.4. Part B chemotherapy regimen

Chemotherapy treatment for the plasma cell dyscrasia in patients with AL amyloidosis is varied but commonly consists of intermittent, repeated cycles of a combination of proteasome inhibitor, high dose corticosteroid and immunosuppressant.

Table 2 Example of chemotherapy cycle

Day 1 Day 8 Day 15 Day 22 Day 29

Bortezomib 1.3mg/m2 SC

Cyclophosphamide 350mg/m2 PO (max 500mg

Dexamethosone 20mg PO/IV

The cycle is repeated every 35 days

Patients who have demonstrated a complete response (CR) or a very good partial response (VGPR) in terms of free light chain levels as part of their clinical care, defined by their haematologist consultant, will be eligible to take part in the study. The administration of the AntiSAP treatment is not expected to interfere with the action of the chemotherapy medication. However, to minimise the impact of any interaction, dosing with GSK2398852 will occur immediately prior to or immediately after the final dose (e.g. Day 22 in the above example) of the cycle following confirmation of CR or VGPR.

The mechanism of action of the high dose corticosteroid and /or the immunosuppressant may interfere with the PD response to GSK2398852.

2. OBJECTIVE(S) AND ENDPOINTS

ADDITIONAL OBJECTIVE


Assess effect of chemotherapy standard of care on pharmacodynamic response in a subset of subjects (AL only)


-Volume of distribution of gadolinium inorgans of interestas a measure of amyloid load (EqMRI of spleen, liver, heart)




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Section 3.1 Study Design/Schematic

Table 4 Overview of study flow for a single subject in Part B

The table is updated to include that in some circumstances subjects may be allowed to self administer subcutaneous CPHPC in an outpatient setting at the investigators discretion and in agreement with the medical monitor.

Section 3.4. Dose Adjustment/Stopping Criteria

GSK2315698

PREVIOUS TEXT

GSK2315698 will be continued after the administration of GSK2398852 until the concentration of unbound GSK2398852 has fallen below 1000 ng/mL or below LLQ. Refer to Section 1.3.2.

REVISED TEXT

GSK2315698 will be continued after the administration of GSK2398852 for a minimum of 7 days and until the concentration of unbound GSK2398852 has fallen below 5000 ng/mL or below LLQ. Refer to Section 1.3.2.

3.5. Time and Events Tables (Part A, and Part B)

Table 7 Part B - Overview (for details of inpatient stay see Table 8

Baseline assessments at sessions 2 and 3 are added to the table to confirm that the following assessments are not required:

Physical examination

The following additional assessments are required (in addition to those at Session 1 baseline):

12-lead ECG, vital signs, haem/clin chem/urinalysis tests

Table 8 Part B - Details of inpatient stay (example scenario)

The table is updated based on refinement of timing changes from previous dosing sessions.


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4.2.1. Inclusion Criteria

PREVIOUS TEXT

3. Male or female between 18 and 70 years of age inclusive, at the time of signing the informed consent. Subject is ambulant and capable of attending for the study visit schedule.

REVISED TEXT

3. Male or female between 18 and 70 years of age inclusive(upper limit of 75 years for TTR patients), at the time of signing the informed consent. Subject is ambulant and capable of attending for the study visit schedule.

4.2.1. Exclusion Criteria

ADDITIONAL TEXT

17. Exclusions from EqMRI scanning

NB Subjects who have contraindication to MRI scanning may still enter the study but will not undergo the EqMRI scan

8.1. Permitted Medications

PREVIOUS TEXT

If a subject experiences symptoms during or shortly after infusion of GSK2398852 [Section 1.4.2] or is considered to be at risk of developing such symptoms consider administration of a (non-selective) antihistamine (e.g. Chlorphenamine 10-20 mg iv 30 mins before infusion of GSK2398852).

REVISED TEXT

If a subject experiences symptoms during or shortly after infusion of GSK2398852 [Section 1.4.2] or is considered to be at risk of developing such symptoms consider administration of a (non-selective) antihistamine (e.g. Chlorphenamine 10-20 mg iv 30 mins before infusion of GSK2398852).

Non selective antihistamine (e.g. Chlorphenamine 10-20 mg) and hydrocortisone (e.g. 50-100mg) are permitted prior to GSK2398852 dosing to prevent/alleviate GSK2398852 infusion reactions (see Section 1.4.2). Additional administrations of either or both medications are permitted at discretion of Investigator or designee if symptoms require this.


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8.2. Prohibited Medications

PREVIOUS TEXT

Induction or parenteral cytotoxic chemotherapy. Stable maintenance chemotherapy (e.g. oral cyclophosphamide) will be allowed providing this has been stable for at least 2 months

Use of anti-coagulant drugs.

REVISED TEXT

Induction or parenteral cytotoxic chemotherapy with the exception of the subjects enrolled to assess interaction with chemotherapy regimen.Stable maintenance chemotherapy (e.g. oral cyclophosphamide) will be allowed providing this has been stable for at least 2 months

Use of anti-coagulant drugs (except patients with TTR amyloidosis Use of anti-coagulant drugs will be permitted in TTR amyloidosis patients only)

5.3.1 Interim Analysis

PREVIOUS TEXT

Data will be reviewed by the study team on an ongoing basis during Part A and B. Dose escalation decisions will be based on safety data (including AEs, clinical laboratory data, vital signs, ECGs), PK (GSK2315698 and GSK2398852 concentrations), PD (EqMRI (volume of distribution), liver elastography, SAP scan data,biochemistry and biomarker data.

REVISED TEXT

Data will be reviewed by the study team on an ongoing basis during Part A and B. Dose escalation decisions will be based on safety data (including AEs, clinical laboratory data, vital signs, ECGs), PK (GSK2315698 and GSK2398852 concentrations), PD (EqMRI (volume of distribution), liver elastography, SAP scan data,biochemistry and biomarker data. A subset of data displays will also be produced based on an interim data cut off to inform internal decision making.

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TITLE PAGE...2012N132812_08 CONFIDENTIAL The GlaxoSmithKline group of companies SAP115570 2 Revision Chronology GlaxoSmithKline Document Number Date Version 2012N132812_00 2012-SEP-04