A Phase II Pilot Single-arm Safety and Tolerability Study of ILB® in Patients With Motor Neurone Disease (MND)/ Amyotrophic Lateral Sclerosis (ALS)
Phase: PHASE2
Conditions: Amyotrophic Lateral Sclerosis, Motor Neuron Disease
Sponsor: University of Birmingham

                            
 
 
A Phase II pilot safety and tolerability study of ILB in patients with 
Motor Neurone Disease (MND)/ Amyotrophic Lateral Sclerosis 
(ALS)  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                       
 
 
 
 
 
 
 
 
 
 
 
 
Trial Protocol Version 
8.0 
Date 
 25-Nov-2020 
Sponsor 
University of Birmingham 
EudraCT Number 
2018-000668-28 
ISRCTN 
TBC 
Clinicaltrials.gov identifier 
 NCT03705390 
Sponsor Protocol Number 
RG_17-250 
CRCTU Reference 
XX2007 

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IRAS number 242984 
 
 
ALS Study_Protocol v8.0_25Nov2020 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
Study Management Group 
 
Chief Investigator 
 
 
Dr Venkataramanan Srinivasan  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Co-Investigators 
 
 
Mr Simon Bach 
 
 
 
 
 
 
 
Dr Lennart Persson 
 
 
Kristian Brock  
  
 
Lead Clinical Pharmacist 
 
Amisha Desai 
 
 
 
 
Clinical Coordinator 
 
Dr Nicholas Davies 
 
 
  
 
Dr Tom Hayton 
  
 
TikoMed Medical Expert 
 
Anders Svensson 
 
 
 
 
Translational Collaborators 
 
 Dr Zsuzsanna Nagy 
 
 
 
  
 
 
 
 
 
Trial Coordinator 
 
 Siân Jenkins 
 
  
                  
Senior Trial Coordinator 
 
Abigail Clutterbuck-James 
 
 
 
 
 
 
 
Trial Biostatistician  
 
 
Victoria Homer 
 
 
 
 
 
  
 
 
 
Senior Trial Biostatistician 
 
Daniel Slade 
 
 
  
 

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Property of the University of Birmingham 
Trial Management Team Leader           Mr Darren Barton 
 
 
 
 
ALS Trial Office 
D3B – Diagnostics Drugs Devices & Biomarkers, CRCTU  
Heritage Building 
5th  Floor East, ITM,  
Mindelsohn Way,  
Edgbaston,  
Birmingham,  
B15 2TH  
 
Enquires 
 
  
 
 
 ALS@trials.bham.ac.uk 
 
 
 
Registration   
 
 
 
 
Emergency Registration  
                                          
 
 
Serious Adverse Event Reporting 
 
 
+  
 
 
 
 
 
 
SPONSOR 
The University of Birmingham, Edgbaston, Birmingham, B15 2TT 
 
 
 
 
 
 
 
 
 

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SIGNATURE PAGE 
 
 ALS Trial Protocol  v8.0_25 Nov 2020 
 
This protocol has been approved by: 
 
Name: 
Dr Venkataramanan Srinivasan 
Trial Role: 
Chief Investigator 
Signature: 
___________________________ 
Date: 
DD / MON / YYYY 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
This protocol describes the ALS trial and provides information about procedures for patients taking part 
in the ALS trial. The protocol should not be used as a guide for treatment of patients not taking part in 
the ALS trial. 
 
 
This Protocol was written using CRCTU-PRT-QCD-002 Version 1.0 
 
 

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Property of the University of Birmingham 
 
AMENDMENTS 
 
The following amendments and/or administrative changes have been made to this protocol since the 
implementation of the first approved version 
 
Amendment 
number 
Date of 
amendment 
Protocol 
version 
number 
Type 
of 
amendment                Summary of amendment 
1 
31-May-2018 
2.0 
Substantial 
Amendments to Data 
Protection (Section 15) to 
incorporate the General Data 
Protection Regulation 
(GDPR) 2018 
2 
11-June-2018 
3.0 
Not applicable 
Minor amendments following 
internal review by Research 
Governance 
3 
20-Jul-2018 
4.0 
Substantial 
Amendments to Section 1.2.3 
(rationale for dose), Schedule 
of assessments to include a 
week 26 visit, contraception 
advice clarified, amendments 
to RSI and AE reporting as 
per MHRA initial assessment 
of CTA request 
4 
04-Apr-2019 
5.0 
Substantial 
Amendment to 1.1.5. Update 
to background of ILB in line  
with Investigator Brochure 
V3.0  
 
Schedule of assessments, 
Section 2.0, Section 7.4 and 
Appendix 12 have been 
amended to add PBMC 
sample collection to assess 
phenotypic profiling.  
 
 
Section 4.0 eligibility criteria 
has been amended to update 
the lung function 
assessments inclusion 
criteria (inclusion criteria 4), 
changes to the homeostasis 
markers (inclusion criteria 6) 
and clarification to exclusion 
criteria 10. 
 
Amendment to schedule of 
assessments, section 7.3.1 
Myoglobin has been removed 
from the biochemistry sample 
analysis 

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5 
 
6.0 
Substantial 
Clinical Coordinator 
Clinical coordinator added 
2.1 Primary Objective 
Time frame for objective has 
been removed 
3.0 Trial Design 
4.2 Eligibility Criteria 
Eligibility criteria to continue 
onto the treatment extension 
has been added. 
Trial Duration 
Trial duration has been 
amended depending on if 
patients continue onto 
treatment extension 
Trial Schema 
Updated based on treatment 
extension 
Schedule of Assessments 
Pregnancy testing to be 
completed at screening and 
prior to Day 1 treatment 
Additional schedule added for 
patients who go onto the 
treatment extension after 10 
weeks. 
5.1 Consent 
Patient process to re-consent 
to treatment extension 
6.1.3 Treatment 
Continuation Registration 
7.2 Treatment Schedule 
7.6 Treatment Interruptions 
‘Maximum of 2 weeks without 
treatment’ has been 
removed. This is reviewed at 
clinicians discretion 
 
 
 
 
 

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6 
16-Jan-2020 
7.0 
Substantial 
Schedule of assessments 
Option to extend treatment to 
a maximum of up to 48 
weeks based on clinical 
assessments and a 
discussion between the 
patient and clinician.  
 
Week 11 lung function tests 
have been moved to week 9. 
 
Week 11 intensive visit 
moved to week 10. 
 
Trial Schema 
Updated to reflect the 
possible further treatment 
period of up to a maximum of 
48 weeks. 
 
Clinical assessments 
Thyroid and troponin tests 
have been removed from 
assessments post week 24 in 
order to reduce treatment 
costs 
 
Dynamometer test 
Has been introduced into the 
study in order to assess the 
muscle strength using a 
hand-held device.  
 
 

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7 
 
8.0 
Substantial 
Trial Synopsis 
Updated to include single 
point long-term remote follow 
up visit starting in Q1 2021; 
Amended secondary 
outcome measures and 
exploratory outcome 
measures; list of biomarkers 
to be analysed; Updated trial 
duration 
 
Schedule of assessments 
Updated to include single 
point long-term remote follow 
up visit and collection of 
ALSFRS-R. ALSAQ-40, 
concomitant and current 
medication 
 
Trial Schema 
Updated to include single 
point long-term remote follow 
up visit 
 
2.4 Secondary Outcome 
Measures 
Updated to include PK 
analysis 
 
2.5 Exploratory Outcome 
Measures 
List of all biomarkers to be 
analysed  
 
3. Trial Design 
Updated to include single 
point long-term remote follow 
up visit 
 
5.1 Informed Consent 
5.1.2 Added for electronic re-
consent for the single point 
long-term remote follow up 
visit  
 
7.3.5 Quality of life 
Updated to include the 
collection of QoL data in the 
form of ALSAQ-40 in single 
point long-term remote follow 
up visit  
7.4 Sample collection 
Amendments throughout to 

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reflect planned analysis, 
sample storage and 
laboratories involved 
 
7.14 Patient Follow Up 
Updated to include single 
point follow-up visit 
 
8.2.1.2 Serious Adverse 
Events 
Updated to reflect e-mail 
reporting procedure. 
 
11. End of Trial Definition 
Amended to coincide with 
updated timelines; final 
summary of clinical trial 
report and addendum 
including data from single 
point long-term remote follow 
up visits 
Non-substantial changes 
 
1. Changes to trial 
management personal / 
trial management group  
2. All references to saliva 
sample collection and 
analysis removed as per 
previous amendment 
3. Removal of fax 
information for SAE 
reporting in line with 
updated processes 
4. Reformatted reference 
library to link to correct 
references, amending a 
formatting error in 
previous versions  
 
 
 
 
 
 
 
 
 
 

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TRIAL SYNOPSIS  
Trial Title 
A Phase II pilot single-arm safety and tolerability study of ILB in patients with Motor Neurone Disease 
(MND)/ Amyotrophic Lateral Sclerosis (ALS) 
Trial Design 
This is a phase IIa, pilot, single arm (uncontrolled) study to assess the safety and tolerability of ILB 
Objectives 
Primary: 
• 
To determine the safety and tolerability of ILB administered subcutaneously weekly in ALS 
patients 
Secondary: 
To describe the effect of ILB administered subcutaneously weekly  
o 
upon the severity of symptoms associated with ALS present at entry into the study 
o 
upon development of new symptoms associated with ALS during the study 
o 
upon patients’ quality of life  during the study 
 
• 
To assess changes in biomarkers, including urinary p75ECD and plasma NfL.  
 
 
Outcome Measures 
Primary 
Our primary outcome measures will inform whether the therapy is feasible in this patient group. 
• 
Safety 
o 
Measured by the incidence of serious adverse events (SAEs) and adverse events 
(AEs) using CTCAE v4.0.  Events will be summarised by grade, relatedness, 
admitting event (for SAEs); expectedness and sequelae. 
• 
Tolerability 
o 
Measured by the incidence of intolerable adverse events. An intolerable adverse 
event will satisfy all of the following criteria: 
1. Associated with a serious adverse event or a drug discontinuation of 
greater than three weeks; 
2. Grade 3, 4 or 5 in severity according to CTCAE version 4;  
3. In the opinion of the Investigator is i) definitely related or ii) probably related 
or iii) possibly related to the study drug treatment. 
o 
Adverse events which are considered unrelated or probably not related will not be 
classed as intolerable events. 
• 
Quantity of study drug administered 
o 
Total drug administered, number of administrations, number and length of 
interruptions and number of discontinuations will be reported. 
Secondary 
Our secondary outcome measures will provide data on patient function and disease progression. 
• 
Revised ALS Functional Rating Scale (ALSFRS-R) 
o 
This is a functional rating scale, including assessments of communication, mobility, 
feeding, dressing and respiration. 
• 
ALS Assessment Questionnaire (ALSAQ-40) 

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o 
This patient-reported outcome measures the subjective well-being of patients. It is 
broader than ALSFRS-R and adds assessment of emotional reactions. 
• 
Urinary p75ECD 
o 
This is a biological fluid-based biomarker of ALS disease progression. 
• 
PK ILB in plasma following administration 
o 
This quantifies the amount of drug detectable in the blood after administration over 
time 
• 
NfL in plasma 
o 
This is a blood‐based biomarker for neurodegeneration. 
 
Exploratory: 
• 
HPLC analyses of purine-pyrimidine metabolites (serum) 
• 
HPLC analysis of fat-soluble vitamins and antioxidants (serum) 
• 
HPLC analyses of amino acids (AA) and amino-group containing compounds (ACCG) (serum) 
• 
Spectrophotometric analysis of lactate  
o 
Blood samples will be collected for analysis of change in PBMC phenotypic balance  
o 
HGF release after ILB administration (ELISA from PK samples) 
o 
Creatine kinase and Myoglobin from plasma as markers of muscle atrophy associated with ALS 
 
Patient Population 
Patients with a diagnosis of ALS  
Sample Size 
This study seeks to recruit 15 patients 
 
For the purposes of safety, it is proposed that the first 2 patients will be recruited as Sentinel patients. 
These will be recruited in series and each will be assessed for 2 weeks before the next patient will be 
recruited.  Data on Sentinel patients will be assessed by an independent safety monitoring committee.  
If the safety monitoring committee is satisfied that the product has an acceptable safety profile in the 
sentinel patients, the study will be opened to general recruitment. 
 
 
For a patient to be evaluable completion of at least one treatment is required. 
 
Main Eligibility Criteria 
Inclusion Criteria: 
1. Patients ≥18 years and who have provided written informed consent to participate in the study 
2. Prior to trial entry patients will have a definite diagnosis of ALS according to El Escorial Criteria 
(Appendix 10). All patients will demonstrate either: 
 presence of Upper Motor Neuron (UMN) (increased tone, brisk reflexes) as well as 
Lower Motor Neuron (LMN) (weakness, wasting and fasciculation) signs in the bulbar 
region and at least two of the other spinal regions (cervical, thoracic or lumbosacral) 
 
or 
 
 presence of UMN and LMN signs in all three spinal regions (cervical, thoracic or 
lumbosacral) 
 

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3. Electrophysiological tests (Electromyography (EMG) / Nerve Conduction Study (NCS)) that 
supports the diagnosis of Motor Neurone Disease (MND) including; i) reduced recruitment 
(reduced interference pattern with firing rates over 10 Hz), ii) Large motor unit action potentials 
(large amplitude, long duration), and Fibrillation potentials. 
4. Forced Vital Capacity (FVC) ≥50% of predicted value for gender, height and age at screening 
and/or a mean Sniff Nasal Inspiratory Pressure (SNIP) ≥50% of predicted value for age 
5. Adequate haematological function (Hb≥10g/dl, absolute neutrophil count ≥1.5x109/L and a 
platelet count ≥60 x109/L   
6. International Normalised Ratio (INR) ≤ 1.5, Activated Partial Thromboplastin Time (aPTT) ≤ 40 
seconds, Prothrombin Time (PT) ≤13.5 seconds 
7. Patient willing and able to comply with schedule visits, treatment plan and other study 
procedures. 
8. Patients taking Riluzole must have discontinued treatment ≥28 days prior to study entry  
9. Women Of Child Bearing Potential (WOCBP) who agree to use highly effective means of 
contraception (as defined in the Heads of Medicines Agencies_Clinical Trials Facilitation 
Group (HMA_CTFG) guideline (see Appendix 8) and in combination with a barrier 
contraception method (condom, diaphragm or cap) for the entirety of the study,  
 
Exclusion Criteria: 
1. Patients classified as either probable or possible ALS according to El Escorial Criteria (see 
Appendix 10).  
2. Subjects in whom other causes of neuromuscular weakness have not been excluded 
3. Assisted ventilation of any type within 3 months before the screening visit or at screening 
4. Patients requiring Radiologically Inserted Gastrostomy (RIG) or Percutaneous Endoscopic 
Gastroscopy (PEG) feeding 
5. Involvement in any other interventional study involving use of another IMP or biological product, 
within 3 months of screening 
6. Any use of antioxidants, edaravone, tirasemtiv or CK-2127107 within 1 month before the 
screening visit. 
7. Any botulinum toxin use within 3 months before the screening visit 
8. Any form of stem cell or gene therapy for the treatment of amyotrophic lateral sclerosis (ALS) 
9. Neuroimaging of brain and cervical spine with Magnetic Resonance imaging(MRI) indicating 
compressive myelopathy as an alternate diagnosis 
10. Laboratory examinations including Acetylcholine receptor (AChR) antibodies and Muscle 
Specific Kinase (MuSK) antibodies to exclude Bulbar onset Myasthenia gravis from Bulbar onset 
Motor neuron disease as an alternate diagnosis and Antinuclear Antibodies (ANA), Anti-
neutrophil cytoplasmic antibodies (ANCA), Extractable Nuclear Antigen (ENA) antibodies, 
Creatine Kinase (CK), electrophoresis and immunoglobulin indicating an alternate diagnosis for 
muscle disease like Myositis. It is at the Chief Investigators discretion to determine if positive 
results from any of the mentioned tests indicates an alternative diagnosis. 
11. Abnormal liver function defined as AST and/or ALT >3 times upper limit of normal 
12. Any head trauma, intracranial or spinal surgery within 3 months of trial entry 
13. Patients who have had recurrent falls will be excluded to reduce the risk of intracerebral 
haemorrhage with this Investigational Medicinal Product (IMP) 
14. Current use of an anticoagulant e.g Warfarin, Aspirin, Clopidogrel, any novel anticoagulants 
(NOAC)s or low molecular weight subcutaneous heparin  
15. Uncontrolled severe hypertension defined as systolic blood pressure (SBP) ≥220 mmHg or 
diastolic blood pressure (DBP)  ≥120 mmHg 
16. Current or previous history of heparin-induced thrombocytopenia 
17. Active peptic ulcer disease 
18. Known hypersensitivity to sulphur 
19. Severe liver insufficiency 
20. Patients with evidence of major psychiatric illness, significant cognitive impairment or clinically 
evident dementia that may interfere with the patient’s ability to comply with study procedures. 

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21. Pulmonary illness (e.g. asthma or Chronic Obstructive Pulmonary Disease (COPD) requiring 
regular treatment 
22. Patient judged to be actively suicidal by the investigator during 3 months before the screening 
visit 
23. Subjects with a diagnosis of another neurodegenerative disease (e.g. Parkinson`s disease, 
Alzheimer’s disease and Frontotemporal dementia) 
24. Pregnant and/or breastfeeding 
 
Treatment Extension Eligibility Criteria 
 
The following must be met for patients to be considered for treatment extension beyond 10 weeks: 
 
Inclusion: 
1. Completed 10 weeks of treatment 
2. Favourable toxicity profile, as reviewed by the PI 
3. Forced Vital Capacity (FVC) ≥50% of predicted value for gender, height and age at screening 
and/or a mean Sniff Nasal Inspiratory Pressure (SNIP) ≥50% of predicted value for age 
4. Patient willing to continue 
 
Exclusion: 
1. Meeting any of the patient stopping rules (see section 7.1.6) 
2. Pregnancy/breast feeding 
3. Patients who have had recurrent falls will be excluded to reduce the risk of intracerebral 
haemorrhage with this Investigational Medicinal Product (IMP) 
4. Patients requiring Radiologically Inserted Gastrostomy (RIG) or Percutaneous Endoscopic 
Gastroscopy (PEG) feeding 
5. use of an anticoagulant e.g Warfarin, Aspirin, Clopidogrel, any novel anticoagulants (NOAC)s 
or low molecular weight subcutaneous heparin  
6. Worsening function status and unable to attend weekly outpatient appointments. 
Trial Duration 
Recruitment: 12 months 
 
Treatment Duration: The initial trial period is 10 weeks, with the option to extend treatment following 
an assessment of the patient to confirm they do not meet any patient stopping criteria and are deemed 
eligible by the PI. Patients can potentially be treated up to a maximum of 48 weeks. 
 
Due to the early discontinuation of treatment and follow up visits as a result of the COVID-19 pandemic, 
a single remote follow up visit for each patient will be starting in Quarter 1 of 2021. Patients will be 
required to re-consent for this additional visit and data collection.  
 
Patient Stopping Rules: 
Patients will have treatment of ILB stopped if any of the following prospective criteria are met during 
the treatment period: 
• 
The patient experiences a Serious Adverse Event related to IMP 
• 
If there is a decrease in ALSFRS-R score (>50%) compared to baseline 
• 
If a patient becomes pregnant during the study treatment period 

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• 
Unacceptable toxicity – any adverse event which, in the investigators opinion, requires 
termination of the study drug 
• 
Unforeseen events – any event which in the judgement of the Investigator makes further 
treatment inadvisable 
• 
SAE requiring discontinuation of treatment 
• 
If a patient requires an anticoagulant e.g Warfarin, Aspirin, Clopidogrel, any novel 
anticoagulants (NOAC)s or low molecular weight subcutaneous heparin during the clinical trial 
• 
PTT or aPTT > 1.5 x ULN 
• 
INR > 1.8 x ULN 
 
Patients, who stop weekly dosing, will be invited to remain in the observational part of the study up to 
24 weeks, to enable assessment of safety related measures. Patients that discontinue ILB and 
subsequently start or re-commence Riluzole therapy will also be invited to remain in the observational 
part of the study up to 24 weeks. 
 
Rescue Medication 
In the event patients are discontinued from dosing with ILB, they will be offered (supportive) standard of 
care with the option of starting Riluzole therapy.  Riluzole is a drug that affects several neurotransmitter 
systems and signalling pathways1. From in vitro studies2-4 and the patient side-effect profile of the drug 
it is clear that Riluzole affects glutamatergic signalling in neurones and most importantly it inhibits Ca-
dependent downstream signalling in these cells. This suggests that Riluzole inhibits the mechanisms 
that are pivotal for neuronal regeneration induced by ILB.  Based on the mechanism of action of ILB 
Riluzole is predicted to inhibit activity of ILB.  Therefore, patients discontinuing trial treatment of ILB 
must have a ≥7 day washout period before commencing Riluzole therapy due to the potential interaction 
between the two drugs. 
 
Rescue medications will be administered outside the remit of the proposed study. 
 
Trial Stopping Rules: 
The clinical trial will be subject to periodic reviews by an independent safety monitoring committee.  The 
trial will be suspended if any of the following conditions are met: 
a) ≥1 patient in the first Sentinel patients experiences a Serious Adverse Event related to IMP 
b) ≥33% of patients (with n > 3) recruited to the study show a significant decrease in ALSFRS-R 
score (>50%) compared to baseline during the 10-week dosing period. 
c) ≥33% of patients (with n > 3) recruited to the study show a significant decrease in Quality of Life 
(ALSAQ-40) (>50%) compared to baseline during the 10 week dosing period. 
In the event that the trial is suspended, the MHRA and REC will be advised and recruitment will not 
recommence until after submission and approval of a Substantial Amendment. 
 
 
 Follow-up: 2 weeks following final IMP administration 
The trial was terminated early as a result of the COVID-19 pandemic. Therefore, a single remote follow 
up visit for each patient will be conducted, starting in Quarter 1 of2021 to collect Quality of Life and 
current medication data. 

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Trials Office Contact Details 
ALS Trial Office 
D3B – Diagnostics Drugs Devices & Biomarkers, CRCTU  
Heritage Building 
5th Floor East, ITM,  
Mindelsohn Way,  
Edgbaston,  
Birmingham,  
B15 2TH  
 
 
 
Enquires 
 +44(0) 121 371 8108  
 ALS@trials.bham.ac.uk 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Trial Schema 
 
 
 

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*Additional assessments conducted at week 5, week 9, week 14, week 19, week 24, end of treatment 
visit and subsequent additional weeks if treatment extended past 24 weeks (please see schedule of 
assessments table below)

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Schedule of Assessments (1) Main Trial 
 
 
Screening  
≤ 14 days of 
Registration  
(up to 28 days 
prior to Day 1 
for those 
patients taking 
Riluzole prior to 
trial entry) 
 
Treatment Period** 
Follow-up (Observational 
Period) following 
discontinuation of ILB*** 
All Follow-up visits (+/- 3 days) 
Week 1 
Week 2 
Week 3 
Week 4 
Week 5 
Week 6 
Week 7 
Week 8 
Week 9 
 
Week 10 
 
 
Week 
12**** 
 
 
Week 
16 
 
Week 20 
 
 
Week 
24**** 
 
 
Time schedule 
Days +/- 1 day 
Visit 1 
Day ≤ 14 
Visit 2 
Day 1 
Visit 3 
Day 8 
Visit 4 
Day 15 
Visit 5 
Day 22 
Visit 6 
Day 29 
Visit 7 
Day 36 
 
Visit 8 
Day 43 
Visit 9 
Day 50 
Visit 10 
Day 57 
Visit 11 
Day 64 
 
Visit 
13 
Day  
78  
 
Visit 
14 
Day 
106 
Visit 
15 
Day 
134 
Visit 
16 
Day 
162 
1. Medical history* 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. Eligibility 
Assessment 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.  ALSFRS-R1 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
4.  Informed Consent▲ 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
5.  Registration♠ 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
6.  Concomitant drug 
history 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
7. Vital signs2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
8. ECG 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
 
 
 
9. Lung Function Tests 
(FVC) 3 
X 
 
 
 
 
X 
 
 
 
X 
 
X 
 
 
X 
10. Sniff Nasal 
Inspiratory Pressure 
(SNIP) 4 
X 
 
 
 
 
X 
 
 
 
X 
 
X 
 
 
X 
11.Haematology Tests5 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 

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Screening  
≤ 14 days of 
Registration  
(up to 28 days 
prior to Day 1 
for those 
patients taking 
Riluzole prior to 
trial entry) 
 
Treatment Period** 
Follow-up (Observational 
Period) following 
discontinuation of ILB*** 
All Follow-up visits (+/- 3 days) 
Week 1 
Week 2 
Week 3 
Week 4 
Week 5 
Week 6 
Week 7 
Week 8 
Week 9 
 
Week 10 
 
 
Week 
12**** 
 
 
Week 
16 
 
Week 20 
 
 
Week 
24**** 
 
 
Time schedule 
Days +/- 1 day 
Visit 1 
Day ≤ 14 
Visit 2 
Day 1 
Visit 3 
Day 8 
Visit 4 
Day 15 
Visit 5 
Day 22 
Visit 6 
Day 29 
Visit 7 
Day 36 
 
Visit 8 
Day 43 
Visit 9 
Day 50 
Visit 10 
Day 57 
Visit 11 
Day 64 
 
Visit 
13 
Day  
78  
 
Visit 
14 
Day 
106 
Visit 
15 
Day 
134 
Visit 
16 
Day 
162 
12. Coagulation Tests6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
13 Biochemistry Tests7 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
14. Creatine Kinase 
(serum) 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
 
 
 
15.U&Es & LFTs8 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
16.Thyroid Function 
Tests9 
X 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
X 
17.Immunoglobulins 10 
X 
 
 
 
 
 
 
 
 
 
X 
X 
 
 
 
18.Quality of Life 
Questionnaire11 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
X 
X 
19. Urinary p75ECD12 
 
X 
 
 
 
X 
 
 
 
 
X 
X 
 
 
X 
20. NfL levels13 
 
X 
 
 
 
X 
 
 
 
 
X 
X 
 
 
 
21. Exploratory   
Biomarkers (serum and 
PBMC)14 
 
X 
 
 
 
X 
 
 
 
 
X 
X 
 
 
X 
22. Pregnancy test (for 
WOCBP only) 
X 
X 
 
 
X 
 
 
 
X 
 
X 
X 
 
 
 
23.PK Sampling15 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Screening  
≤ 14 days of 
Registration  
(up to 28 days 
prior to Day 1 
for those 
patients taking 
Riluzole prior to 
trial entry) 
 
Treatment Period** 
Follow-up (Observational 
Period) following 
discontinuation of ILB*** 
All Follow-up visits (+/- 3 days) 
Week 1 
Week 2 
Week 3 
Week 4 
Week 5 
Week 6 
Week 7 
Week 8 
Week 9 
 
Week 10 
 
 
Week 
12**** 
 
 
Week 
16 
 
Week 20 
 
 
Week 
24**** 
 
 
Time schedule 
Days +/- 1 day 
Visit 1 
Day ≤ 14 
Visit 2 
Day 1 
Visit 3 
Day 8 
Visit 4 
Day 15 
Visit 5 
Day 22 
Visit 6 
Day 29 
Visit 7 
Day 36 
 
Visit 8 
Day 43 
Visit 9 
Day 50 
Visit 10 
Day 57 
Visit 11 
Day 64 
 
Visit 
13 
Day  
78  
 
Visit 
14 
Day 
106 
Visit 
15 
Day 
134 
Visit 
16 
Day 
162 
24. Dynamometer test 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
25. Study drug 
administration  
2mg /kg s.c.16 
 
  X ♠ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
26. Adverse 
Event/Toxicity 
Reporting 
 
Throughout 
Throughout 
Throughout 
 
 
 
 
 

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ALS Study_Protocol v8.0_25Nov2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
Schedule of Assessments (2) Treatment Extension (Week 11 to Week 24) 
 
Schedule of 
Assessments 
Week 
11 
Week 
12 
Week 
13 
Week 
14 
Week 
15 
Week 
16 
Week 
17 
Week 
18 
Week 
19 
Week 
20 
 
Week 
21 
 
Week 
22 
Week 
23 
Week 
24 
 
 
Week 26**** 
Treatment 
continuation# 
Time schedule 
Days +/- 1 day≠ 
 
Day 71 
Day 
78 
Day 
85 
Day 
92 
Day 
99 
Day 
106 
 
Day 
113 
Day 
120 
Day 
127 
Day 
134 
 
Day 
141 
Day 
148 
 
Day 155 
Day 162 
End of 
treatment visit  
Only for those 
patients 
completing up to 
48 weeks of 
treatment  
Treatment beyond 24 
weeks will be a 
discussion between 
patient and clinician. If 
treatment is continued, 
treatment and visits will 
follow the same pattern 
as week 11-24 for a 
maximum of 48 weeks 
1. Re-consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.  ALSFRS-R1 
X 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
3.  Concomitant drug 
history 
Throughout 
4. Vital signs2 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
5. ECG 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
6. Lung Function Tests 
(FVC)3 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
7. Sniff Nasal 
Inspiratory Pressure 
(SNIP) 4 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
8.Haematology Tests5 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
9. Coagulation Tests6 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
10 Biochemistry Tests7 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
11. Creatinine Kinase 
(serum) 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
12.U&Es & LFTs8 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
13.Thyroid Function 
Tests9 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 

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IRAS number 242984 
 
 
 
 
 
 
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Property of the University of Birmingham 
Schedule of 
Assessments 
Week 
11 
Week 
12 
Week 
13 
Week 
14 
Week 
15 
Week 
16 
Week 
17 
Week 
18 
Week 
19 
Week 
20 
 
Week 
21 
 
Week 
22 
Week 
23 
Week 
24 
 
 
Week 26**** 
Treatment 
continuation# 
Time schedule 
Days +/- 1 day≠ 
 
Day 71 
Day 
78 
Day 
85 
Day 
92 
Day 
99 
Day 
106 
 
Day 
113 
Day 
120 
Day 
127 
Day 
134 
 
Day 
141 
Day 
148 
 
Day 155 
Day 162 
End of 
treatment visit  
Only for those 
patients 
completing up to 
48 weeks of 
treatment  
Treatment beyond 24 
weeks will be a 
discussion between 
patient and clinician. If 
treatment is continued, 
treatment and visits will 
follow the same pattern 
as week 11-24 for a 
maximum of 48 weeks 
14.Immunoglobulins10 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
15.Quality of Life 
Questionnaire11 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
 
16 Urinary p75ECD12 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
17. NfL levels13 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
18. Exploratory 
Biomarkers (serum and 
PBMC)14 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
19. Pregnancy test (for 
WOCBP only) 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
20. Dynamometer test 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
21. Study drug 
administration  
2mg /kg bw s.c.15 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
23. Adverse 
Event/Toxicity 
Reporting 
Throughout 
 
 
 
 

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ALS Study_Protocol v8.0_25Nov2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
Schedule of Assessments (2) Treatment Extension (Week 25 to Week 38) 
 
Schedule of 
Assessments 
Week 
25 
Week 
26 
Week 
27 
Week 
28 
Week 
29 
Week 
30 
Week 
31 
Week 
32 
Week 
33 
Week 
34 
 
Week 
35 
 
Week 
36 
Week 
37 
Week 
38 
 
 
Week 40**** 
Treatment 
continuation 
Time schedule 
Days +/- 1 day≠ 
 
Day 
169 
Day 
176 
Day 
183 
Day 
190 
Day 
197 
Day 
204 
 
Day 
211 
Day 
218 
Day 
225 
Day 
232 
 
Day 239 
Day 246 
 
Day 253 
Day 260 
End of treatment 
visit  Only for 
those patients 
completing up to 
38 weeks of 
treatment  
Extended treatment will 
be a discussion between 
patient and clinician. If 
treatment is continued, 
treatment and visits will 
follow the same pattern 
as week 11-24 for a 
maximum of 48 weeks 
1. Re-consent 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.  ALSFRS-R1 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
3.  Concomitant 
drug history 
Throughout 
4. Vital signs2 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
5. ECG 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
6. Lung Function 
Tests (FVC)3 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
7. Sniff Nasal 
Inspiratory 
Pressure (SNIP) 4 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
8.Haematology 
Tests5 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
9. Coagulation 
Tests6 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
10 Biochemistry 
Tests7 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
11. Creatinine 
Kinase (serum) 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
12.U&Es & 
LFTs8 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
13.Thyroid 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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ALS Study_Protocol v8.0_25Nov2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
Schedule of 
Assessments 
Week 
25 
Week 
26 
Week 
27 
Week 
28 
Week 
29 
Week 
30 
Week 
31 
Week 
32 
Week 
33 
Week 
34 
 
Week 
35 
 
Week 
36 
Week 
37 
Week 
38 
 
 
Week 40**** 
Treatment 
continuation 
Time schedule 
Days +/- 1 day≠ 
 
Day 
169 
Day 
176 
Day 
183 
Day 
190 
Day 
197 
Day 
204 
 
Day 
211 
Day 
218 
Day 
225 
Day 
232 
 
Day 239 
Day 246 
 
Day 253 
Day 260 
End of treatment 
visit  Only for 
those patients 
completing up to 
38 weeks of 
treatment  
Extended treatment will 
be a discussion between 
patient and clinician. If 
treatment is continued, 
treatment and visits will 
follow the same pattern 
as week 11-24 for a 
maximum of 48 weeks 
Function Tests9 
14.Immunoglobul
ins10 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
15.Quality of Life 
Questionnaire11 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
 
16 Urinary 
p75ECD12 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
17. NfL levels13 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
18. Exploratory 
Biomarkers 
(serum and 
PBMC)14 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
19. Pregnancy test 
(for WOCBP 
only) 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
20. Dynamometer 
test 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
X 
X 
21. Study drug 
administration  
2mg /kg bw s.c.15 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
23. Adverse 
Event/Toxicity 
Reporting 
Throughout 
 

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IRAS number 242984 
 
 
 
 
 
 
ALS Study_Protocol v8.0_25Nov2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
Schedule of Assessments (2) Treatment Extension (Week 39 to Week 48) 
 
Schedule of 
Assessments 
Week 
39 
Week 
40 
Week 
41 
Week 
42 
Week 
43 
Week 
44 
Week 
45 
Week 
46 
Week 
47 
Week 
48 
 
 
Week 50**** 
Time schedule 
Days +/- 1 day≠ 
 
Day 
267 
Day 
274 
Day 
281 
Day 
288 
Day 
295 
Day 
302 
 
Day 
309 
Day 
316 
Day 
323 
Day 
330 
 
End of treatment 
visit  Only for 
those patients 
completing up to 
48 weeks of 
treatment  
1. Re-consent 
 
 
 
 
 
 
 
 
 
 
 
2.  ALSFRS-R1 
 
 
 
 
X 
 
 
 
 
X 
X 
3.  Concomitant drug 
history 
Throughout 
4. Vital signs2 
 
 
 
 
X 
 
 
 
 
X 
X 
5. ECG 
 
 
 
 
X 
 
 
 
 
X 
X 
6. Lung Function Tests 
(FVC)3 
 
 
 
 
X 
 
 
 
 
X 
X 
7. Sniff Nasal 
Inspiratory Pressure 
(SNIP) 4 
 
 
 
 
X 
 
 
 
 
X 
X 
8.Haematology Tests5 
 
 
 
 
X 
 
 
 
 
X 
X 
9. Coagulation Tests6 
 
 
 
 
X 
 
 
 
 
X 
X 
10 Biochemistry Tests7 
 
 
 
 
X 
 
 
 
 
X 
X 
11. Creatinine Kinase 
(serum) 
 
 
 
 
X 
 
 
 
 
X 
X 
12.U&Es & LFTs8 
 
 
 
 
X 
 
 
 
 
X 
X 
13.Thyroid Function 
Tests9 
 
 
 
 
 
 
 
 
 
 
 
14.Immunoglobulins10 
 
 
 
 
X 
 
 
 
 
X 
X 
15.Quality of Life 
Questionnaire11 
 
 
 
 
X 
 
 
 
 
X 
X 

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IRAS number 242984 
 
 
 
 
 
 
ALS Study_Protocol v8.0_25Nov2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
Schedule of 
Assessments 
Week 
39 
Week 
40 
Week 
41 
Week 
42 
Week 
43 
Week 
44 
Week 
45 
Week 
46 
Week 
47 
Week 
48 
 
 
Week 50**** 
Time schedule 
Days +/- 1 day≠ 
 
Day 
267 
Day 
274 
Day 
281 
Day 
288 
Day 
295 
Day 
302 
 
Day 
309 
Day 
316 
Day 
323 
Day 
330 
 
End of treatment 
visit  Only for 
those patients 
completing up to 
48 weeks of 
treatment  
16 Urinary p75ECD12 
 
 
 
 
 
 
 
 
 
 
 
17. NfL levels13 
 
 
 
 
 
 
 
 
 
 
X 
18. Exploratory 
Biomarkers (serum and 
PBMC)14 
 
 
 
 
 
 
 
 
 
 
X 
19. Pregnancy test (for 
WOCBP only) 
 
 
 
 
X 
 
 
 
 
X 
X 
20. Dynamometer test 
 
 
 
 
X 
 
 
 
 
X 
X 
21. Study drug 
administration  
2mg /kg bw s.c.15 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
23. Adverse 
Event/Toxicity 
Reporting 
Throughout 
 
 

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IRAS number 242984 
 
 
 
 
 
 
ALS Study_Protocol v8.0_25Nov2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
Schedule of Assessments – Single Point Long-Term Remote Follow Up Visit 
Schedule of Assessments 
 
Time Schedule (8 week period) 
Quarter 1 2021 
1. 
Re-consent 
X 
2. 
ALSFRS-R1 
X 
3. 
Quality of Life Questionnaire11 
X 
4. 
Concomitant Medication 
X 
 
 
 

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Property of the University of Birmingham 
Schedule of Events 
 
*to include an assessment of any mental or physical contraindications to study entry 
 
** For patients that discontinue treatment prior to Week 10, follow-up should continue 4 weekly, after 
the end of treatment visit, up to week 24. These visits should all follow the week 16 assessments apart 
from the final visit which follows week 24. 
 
*** If patients do not continue treatment after week 10, follow the Follow-up (Observational Period) 
schedule in Schedule of Assessments (1) Main Trial. If the criteria is met for IMP treatment to continue 
beyond week 10, follow Schedule of Assessments (2): Treatment Extension after week 10.  
 
**** End of treatment visit should occur 2 weeks after last dose of IMP (as per the Week 12 assessments) 
regardless of how many treatment doses a patient has received.  
  
# Patients that reach week 24 of treatment and are still eligible, the patient will discuss their future 
treatment options with the clinician and decide together whether to continue treatment which can be 
extended up to a maximum of 48 weeks. A formal review will be held every 90 days to decide whether 
continuation of treatment is in the best interest of the patient.  
  
▲ Patients on Riluzole prior to study entry must discontinue treatment on the day of consent and must have a 28 
day wash-out period (i.e. discontinue Riluzole ≥28 days prior to commencing study drug). Screening tests in this 
patient group can commence up to 28 days prior to Day 1 but study drug must not be commenced until 28 days 
has elapsed since last dose of Riluzole 
 
♠ Registration and the start of study drug dosing (Week 1, Day 1) must not be < 28 days from the last    
dose of Riluzole  
 
≠ If patients have an interruption to treatment the time schedule in days pauses until they recommence 
treatment. 
 
1    
The Amyotrophic Lateral Sclerosis Functional Rating Scale (Revised) (ALSFRS-R) 
2   
Vital Signs (must be performed prior to administration of study drug) – Blood pressure, heart 
rate, body temperature, pulse oximetry and respiration rate. Results of oximetry must be the 
average of three recordings.  Body weight, height (at screening only) and Body Mass Index 
(BMI) 
3 
Forced Vital Capacity (FVC)  
4 
Sniff Nasal Inspiratory Pressure (SNIP) results must be recorded as the mean of three 
recordings. The same nostril used at baseline must be used for subsequent visits/assessments 
5    
To include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) (must be performed 
prior to administration of study drug) 
6   
To include International Normalized Ratio (INR), Activated Partial Thromboplastin Time (APTT) 
and Prothrombin Time (PT) (must be performed prior to administration of study drug) 
7    
Biochemistry tests to include:  Troponin I (up to 24 weeks), C-reactive protein (CRP), Glucose, 
Calcium (must be performed prior to administration of study drug) 
8    
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs), (must be performed prior to 
administration of study drug) 

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9    
To include Thyroid Stimulating Hormone (TSH), Free Thyroxine (Free T4)  
10   
Immunoglobulins (IgG, IgM) 
11  
ALS Assessment Questionnaire (ALSAQ-40) (must be performed prior to administration of 
study drug)  
12 
Urinary p75ECD    (must be performed prior to administration of study drug) 
13 
Neurofilament Light Chain (NfL) sample - Collect whole blood to allow for 4-5ml plasma for 
analysis (must be performed prior to administration of study drug) 
14 
Collection of Exploratory Biomarker blood samples (must be performed prior to administration 
of study drug). See Appendix 12 and the latest version of the Laboratory Manual for full details 
15 
Pharmacokinetic (PK) sample  
16 
The time of study drug administration will be recorded at each visit. All subsequent doses must 
be given within +/- 24 hours of the Day 1 Week 1 administration time  
 
 
 
 
 

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Property of the University of Birmingham 
 
ABBREVIATIONS 
 
AA 
 
Amino Acids 
 
ABPI 
 
Association of the British Pharmaceutical Industry 
 
ACCG  
Amino-group containing compounds 
 
ACHR  
Acetylcholine Receptor  
 
ADL 
 
Activities of Daily Living 
 
AE 
 
Adverse Event 
 
ALP  
 
Alkaline Phosphate 
 
ALS 
 
Amyotrophic Lateral Sclerosis 
 
ALSAQ-40 
Amyotrophic Lateral Sclerosis Assessment Questionnaire (40 item/questions) 
 
ALSFRS-R 
Amyotrophic Lateral Sclerosis Functional Rating Scale (revised) 
 
ALT 
 
Alanine Transaminase 
 
ANA 
 
Antinuclear Antibodies 
 
ANCA  
Anti-neutrophil cytoplasmic antibodies 
 
API 
 
Active Pharmaceutical Ingredient 
 
APTT  
Activated Partial Thromboplastin Time 
 
AST 
 
Aspartate Aminotransferase 
 
BDNF  
Brain Derived Neurotrophic Factor 
 
BBB 
 
Blood Brain Barrier 
 
BMI 
 
Body Mass Index 
 
CK 
 
Creatine Kinase 
 
CK-MB  
(serum) Creatine Kinase – Muscle, Brain 
 
CNTF  
Ciliary Neurotrophic Factor 
 

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ALS Study_Protocol_ v8.0_25Nov2020 
 
 
 
 
 
 
 
 
Property of the University of Birmingham 
COPD  
Chronic Obstructive Pulmonary Disease 
 
CRCTU 
Cancer Research UK Clinical Trials Unit 
 
CRF 
 
Case Report Form 
 
CRP 
 
C-reactive protein 
 
CSF 
 
Cerebrospinal Fluid 
 
CTCAE  
Common Terminology Criteria for Adverse Events 
 
CTFG  
Clinical Trials Facilitation Group 
 
CV 
 
Curriculum Vitae 
 
DMC 
 
Data Monitoring Committee 
 
DS 
 
Dextran Sulfate 
 
DSUR   
Developmental Safety Update Report 
 
D3B 
 
Diagnostics, Drugs, Devices and Biomarkers 
 
ECD 
 
Extracellular Domain 
 
ECG 
 
Electrocardiogram 
 
EGFR  
Estimated Glomerular Filtration Rate 
 
ELISA  
Enzyme-Linked Immunosorbent Assay 
 
EMG 
 
Electromyography 
 
ENA 
 
Extractable Nuclear Antigen 
 
eRDC  
Electronic Remote Data Capture 
 
ESR 
 
Erythrocyte Sedimentation Rate (ESR) 
 
FBC 
 
Full Blood Count 
 
FDA 
 
Food and Drug Administration 
 
FGF 
 
Fibroblast Growth Factor 
 
FVC 
 
Forced Vital Capacity 
 

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GCP 
 
Good Clinical Practice 
 
G-CSF  
Granulocyte Colony Stimulating Factor 
 
GGT 
 
Gamma-Glutamyl Transpeptidase 
 
GLP 
 
Good Laboratory Practice 
 
GMP 
 
Good Manufacturing Practice 
 
GP 
 
General Practitioner 
 
Hb 
 
Haemoglobin 
 
HGF 
 
Hepatocyte Growth Factor 
 
HLI 
 
Hind-limb Ischemia 
 
HMA 
 
Heads of Medicines Agencies 
 
HPLC  
High Performance Liquid Chromatography 
 
HrHGF  
Human Recombinant Hepatocyte Growth Factor 
 
HUVEC 
Human Umbilical Vein Endothelial Cells 
 
IB 
 
Investigator Brochure 
 
ICF 
 
Informed Consent Form 
 
IGF-1  
Insulin-like Growth Factor 1 
 
IgG 
 
Immunoglobulin G 
 
IgM 
 
Immunoglobulin M 
 
IMP 
 
Investigational Medicinal Product 
 
 
INR 
 
International Normalised Ratio 
 
ISF 
 
Investigator Site File 
 
ITM 
 
Institute of Translational Medicine 
 
i.v 
 
Intravenous 
 
kDa 
 
kilo Dalton 
 

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LFT 
 
Liver Function Tests 
 
LMN 
 
Lower Motor Neuron 
 
LMW-DS 
Low Molecular Weight Dextran Sulfate 
 
LPLV 
 
Last Patient Last Visit 
 
MBP 
 
Myelin Basic Protein 
 
MCV 
 
Mean Cell Volume 
 
Mg 
 
Milligram 
 
MHRA  
Medicines and Healthcare Products Regulatory Agency 
 
Ml 
 
Millilitre 
 
MND 
 
Motor Neurone Disease 
 
MS 
 
Multiple Sclerosis 
 
MUSK  
Muscle-Specific Kinase 
 
NAA 
 
N-acetyl-aspartate 
 
NaCL  
Sodium Chloride 
 
NCS 
 
Nerve Conduction Study 
 
NFL 
 
Neurofilament, light 
 
NHS 
 
National Health Service 
 
NOAC  
Novel Anticoagulants 
 
P75ECD  
Extracellular domain of p75 
 
PBMC  
Peripheral Blood Mononuclear Cells  
 
PEG 
 
Percutaneous Endoscopic Gastrostomy 
 
PCR 
 
Polymerase Chain Reaction 
 
pH 
 
Potential of Hydrogen 
 
PI 
 
Principal Investigator 
 

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PIS  
 
Patient Information Sheet 
 
PK 
 
Pharmacokinetics 
 
PT 
 
Prothrombin Time 
 
QOL 
 
Quality of Life 
 
REC 
 
Research Ethics Committee 
 
RIG 
 
Radiologically Inserted Gastrostomy 
 
RNA 
 
Ribonucleic Acid 
 
SAE 
 
Serious Adverse Event 
 
SAR 
 
Serious Adverse Reaction 
 
SC 
 
Subcutaneous 
 
sncRNA 
Small Non-coding RNA 
 
SNIP 
 
Sniff Nasal Inspiratory Pressure 
 
SUSAR  
Suspected Unexpected Serious Adverse Reaction 
 
T4 
 
Thyroxine 
 
TMG 
 
Trial Management Group 
 
TSC 
 
Trial Steering Committee 
 
TSH 
 
Thyroid Stimulating Hormone 
 
UE  
 
Urea and Electrolytes 
 
UK 
 
United Kingdom 
 
μl  
 
Microliter 
 
ULN 
 
Upper Limit of Normal 
 
UMN 
 
Upper Motor Neuron 
 
VEGF  
Vascular Endothelial Growth Factor 
 
WBC 
 
White Blood Cell Count 
 

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WMA 
 
World Medical Association 
 
WOCBP 
Women Of Child Bearing Potential 
 
 

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Table of Contents 
SPONSOR ..........................................................................................................................................ii 
Signature page .................................................................................................................................iii 
AMENDMENTS .................................................................................................................................iv 
Trial Synopsis ..................................................................................................................................ix 
Trial Schema ................................................................................................................................. xv 
Schedule of Assessments (1) Main Trial ...................................................................................... xvii 
Schedule of Assessments (2) Treatment Extension (Week 11 to Week 24) .................................... xx 
Schedule of Assessments (2) Treatment Extension (Week 25 to Week 38) .................................. xxii 
Schedule of Assessments (2) Treatment Extension (Week 39 to Week 48) ................................. xxiv 
Schedule of Assessments – Single Point Long-Term Remote Follow Up Visit ............................. xxvi 
Schedule of Events ..................................................................................................................... xxvii 
Abbreviations ............................................................................................................................... xxix 
1 Background and Rationale ........................................................................................................ 39 
1.1 
Background ....................................................................................................................... 39 
1.1.1 
Amyotrophic Lateral Sclerosis ........................................................................................ 39 
1.1.2 
Treatment for ALS patients ............................................................................................ 39 
1.1.3 
ILB ................................................................................................................................. 40 
1.1.4 
Mechanism of action ...................................................................................................... 40 
1.1.5 
Previous human experience with ILB.............................................................................. 41 
1.2 
Trial Rationale ................................................................................................................... 42 
1.2.1 
Justification for patient population .................................................................................. 42 
1.2.2 
Justification for design.................................................................................................... 43 
1.2.3 
Choice of treatment........................................................................................................ 43 
1.2.4 
Justification for single point long-term remote follow up visit ........................................... 46 
2. Objectives and Outcome Measures .......................................................................................... 47 
2.1 
Primary Objective .............................................................................................................. 47 
2.2 
Secondary Objectives ........................................................................................................ 47 
2.3 
Primary Outcome Measures .............................................................................................. 47 
2.4 
Secondary Outcome Measures .......................................................................................... 47 
2.5 
Exploratory Outcome Measures ......................................................................................... 48 
3. Trial Design ................................................................................................................................ 49 
4. Eligibility ..................................................................................................................................... 50 
4.1 
Main Eligibility criteria ........................................................................................................ 50 
4.2 
Treatment Extension Eligibility Criteria ............................................................................... 52 
5. Consent and Screening ............................................................................................................. 53 
5.1 
Informed Consent .............................................................................................................. 53 
5.1.1 
Treatment Extension ...................................................................................................... 53 
5.1.2 
Single Point Long-Term Remote Follow Up .................................................................... 54 
5.2 
Screening .......................................................................................................................... 54 
6. Trial Entry ................................................................................................................................... 55 
6.1 
Registration ....................................................................................................................... 55 
6.1.1 
Emergency Registration ................................................................................................. 55 
6.1.2 
Protocol waivers or exemptions ...................................................................................... 56 
6.1.3 
Treatment Extension registration .................................................................................... 56 
7. Treatment Details ....................................................................................................................... 57 
7.1 
Investigational Medicinal Product ....................................................................................... 57 

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7.1.1 
Dosage, Form and Composition ..................................................................................... 57 
7.1.2 
Packaging and Labelling ................................................................................................ 57 
7.1.3 
Storage and handling ..................................................................................................... 57 
7.1.4 
Trial Treatment .............................................................................................................. 58 
7.1.5 
Continuation of treatment beyond 10 weeks  
7.1.6 
Patient Stopping Rules................................................................................................... 58 
7.1.7 
Rescue Medication ........................................................................................................ 58 
7.1.8 
Special Warnings and Special Precautions for use ......................................................... 58 
7.2 
Treatment Schedule .......................................................................................................... 59 
7.3 
Assessments ..................................................................................................................... 65 
7.3.1 
Blood chemistry and Haematology ................................................................................. 65 
7.3.1.1 
Liver Chemistry Management ..................................................................................... 65 
7.3.2 
Physical examination/symptom assessment ................................................................... 66 
7.3.3 
Electrocardiogram (ECG) ............................................................................................... 66 
7.3.4 
Lung Function Tests ...................................................................................................... 66 
7.3.5 
Quality of Life ................................................................................................................. 66 
7.3.6 
Pregnancy testing .......................................................................................................... 67 
7.4 
Sample Collection .............................................................................................................. 67 
7.4.1 
Blood samples ............................................................................................................... 67 
7.4.2 
Urine Samples ............................................................................................................... 69 
7.5 
Dose Modifications ............................................................................................................ 69 
7.6 
Treatment Interruptions ...................................................................................................... 69 
7.7 
Treatment Compliance ....................................................................................................... 69 
7.8 
Treatment Discontinuation ................................................................................................. 70 
7.9 
Treatment after the end of the study................................................................................... 70 
7.10 
Supportive Treatment ........................................................................................................ 70 
7.11 
Concomitant Medication .................................................................................................... 70 
7.12 
Prohibited Medication ........................................................................................................ 70 
7.13 
Contraception and Pregnancy ............................................................................................ 70 
7.14 
Patient Follow Up............................................................................................................... 71 
7.15 
Patient Withdrawal ............................................................................................................. 75 
8. Adverse Event Reporting........................................................................................................... 76 
8.1 
Reporting Requirements .................................................................................................... 76 
8.1.1 
Adverse Events.............................................................................................................. 76 
8.1.1.1 
Pre-existing conditions ............................................................................................... 76 
8.1.2 
Serious Adverse Events ................................................................................................. 76 
8.1.2.2   Liver Related Toxicity: Biochemistry.............................................................................. 77 
8.1.3 
Reporting period ............................................................................................................ 77 
8.2 
Reporting Procedure .......................................................................................................... 78 
8.2.1 
Site ................................................................................................................................ 78 
8.2.2 
Trials Office ................................................................................................................... 79 
8.2.3 
Reporting to the Competent Authority and Research Ethics Committee .......................... 79 
8.2.4 
Investigators .................................................................................................................. 79 
8.2.5 
Data Monitoring Committee ............................................................................................ 79 
8.2.6 
Manufacturer of Investigational Medicinal Product .......................................................... 79 
9. Data Handling and Record Keeping .......................................................................................... 80 
9.1 
Data Collection .................................................................................................................. 80 
9.2 
Data Collection Procedure ................................................................................................. 82 

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9.2.1 
Electronic Remote Data Capture (eRDC) systems only .................................................. 82 
9.2.2 
Paper Case Report Forms only ...................................................................................... 82 
9.3 
Archiving ........................................................................................................................... 83 
10. Quality Management .................................................................................................................. 84 
10.1 
Site Set-up and Initiation .................................................................................................... 84 
10.2 
On-site Monitoring ............................................................................................................. 84 
10.3 
Central Monitoring ............................................................................................................. 84 
10.4 
Audit and Inspection .......................................................................................................... 84 
10.5 
Notification of Serious Breaches ........................................................................................ 85 
11. End of Trial Definition ................................................................................................................ 86 
12. Statistical Considerations ......................................................................................................... 86 
12.1 
Definition of Outcome Measures ........................................................................................ 86 
12.2 
Analysis of Outcome Measures .......................................................................................... 86 
12.2.1 
Analysis of Primary Outcome Measures ..................................................................... 86 
12.2.2 
Analysis of Secondary Outcome Measures ................................................................ 86 
12.3 
Planned Sub Group Analyses ............................................................................................ 87 
12.4 
Planned Interim Analysis.................................................................................................... 87 
12.5 
Planned Final Analyses ..................................................................................................... 87 
12.6 
Power Calculations ............................................................................................................ 87 
13. Trial Organisational Structure ................................................................................................... 88 
13.1 
Sponsor ............................................................................................................................. 88 
13.2 
Coordinating Centre ........................................................................................................... 88 
13.3 
Trial Management Group ................................................................................................... 88 
13.4 
Trial Steering Committee ................................................................................................... 88 
13.5 
Data Monitoring Committee ............................................................................................... 88 
13.6 
Finance ............................................................................................................................. 89 
13.6.1 
Payments to individual NHS Trusts (per-patient payment) .......................................... 89 
14. Ethical Considerations .............................................................................................................. 90 
15. Confidentiality and Data Protection .......................................................................................... 91 
16. Insurance and Indemnity ........................................................................................................... 92 
17. Publication Policy ...................................................................................................................... 92 
18. Reference List ............................................................................................................................ 93 
Appendix 1 – ALS Functional rating scale revised (ALSFRS-R) ................................................... 96 
Appendix 2 - WMA Declaration of Helsinki .................................................................................... 99 
Appendix 3 - Definition of Adverse Events .................................................................................. 102 
Appendix 4 - Common Toxicity Criteria Gradings ....................................................................... 104 
Appendix 5 – Liver safety required actions and follow-up assessments ................................... 105 
Appendix 6 – ALS Assessment Questionnaire (ALSAQ-40) ....................................................... 107 
Appendix 7 – EQuation for estimated Glomerular filtration Rate ............................................... 117 
Appendix 8 – HMA CTFG guidelines on contraception ............................................................... 118 
Appendix 9 – El escorial world federation of neurology criteria for the diagnosis of als.......... 120 
Appendix 10 – Sniff nasal inspiratory pressure (snip) & Forced vital capacity (FVC) ............... 137 
Appendix 11 – Targeted metabolic markers in serum (And urine p75) ...................................... 138 
  
 
 
 
 
 

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LIST OF FIGURES 
 
Figure 1 Chemical structure of ILB .................................................................................................... 40 
Figure 2 HGF levels at 30 min to 9 hours after administration of 3-24 mg/kg ILB in human (clinical 
study LMW-DS-102).......................................................................................................................... 45 
 
 
LIST OF TABLES 
 
Table 1 Mean pharmacokinetic exposure parameters in plasma from healthy volunteers ................... 44 
Table 2 Dose Modifications for Adverse Events ................................................................................. 69 
Table 3 ALS Trial Case Report Form ................................................................................................. 80 
 
 

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1 
BACKGROUND AND RATIONALE  
1.1 
Background 
1.1.1 
Amyotrophic Lateral Sclerosis 
 
 
Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig´s disease is a rare neurological disease 
and is the most common Motor Neurone Disease. It is a fatal disease with specific loss of motor neurons 
in the spinal cord, brain stem and motor cortex leading to progressive paralysis and usually death within 
five years of diagnosis.  The disease begins focally in the central nervous system and then spreads 
relentlessly. The clinical diagnosis, defined by progressive signs and symptoms of upper and lower 
motor neuron dysfunction, is confirmed by clinical findings, electromyography, blood and cerebrospinal 
fluid (CSF) analysis. Additional testing with for instance Magnetic Resonance Imaging (MRI) excludes 
other conditions. The disease is heterogeneous, but most patients die of respiratory muscle weakness 
less than 3-5 years from symptom-onset. Like other age-related neurodegenerative diseases, ALS has 
genetic, metabolic and environmental triggers. 
 
Of the 5-10% of cases that are inherited, mutations have been discovered for a high proportion. In 
addition to genetic factors, metabolic factors, inflammatory diseases, age, tobacco use, and athleticism 
may contribute to sporadic ALS, but important aetiologies are unidentified for most patients. ALS disease 
contains postulated pathophysiological mechanisms, including mitochondrial dysfunction, aggregation 
of misfolded protein, oxidative stress, excitotoxicity, inflammation and apoptosis, and involve both motor 
neurons and surrounding glial cells. There is clinical and pathological overlap with other 
neurodegenerative diseases, particularly frontotemporal dementia. The mechanisms leading to disease 
propagation in the brain are a current focus of research. 
 
Many neurotrophic growth factors are known to promote survival of neurons and various factors have 
been investigated both pre-clinically and clinically for the treatment of ALS. Yet no substantial positive 
effects upon growth factor-therapy have been observed in clinical studies using ciliary neurotrophic 
factor (CNTF), brain derived neurotrophic factor (BDNF), insulin-like growth factor (IGF-1), or 
granulocyte colony stimulating factor G-CSF. But, for various reasons, in these studies the dose and/or 
the administration route were not optimized for therapeutic efficacy, hence, results should be interpreted 
carefully5.  Studies in the rat ALS-model using human recombinant hepatocyte growth factor (hrHGF) 
have shown functional recovery in the animals6. HGF is a pleiotropic growth factor and also a potent 
survival-promoting factor for motor neurons. In the first clinical study performed ILB was found to 
increase (up to 100-fold) plasma levels of hepatocyte growth factor (HGF) in healthy volunteers7. This 
effect was verified in a number of clinical studies.8, 9  
 
1.1.2 
Treatment for ALS patients 
 
There is as yet no cure for ALS, and management is focused on a combination of neuroprotective 
medication, multidisciplinary clinics and respiratory support. Speciality clinics for ALS emerged in the 
1980s and most large centres in developed countries currently offer multidisciplinary care10. Patients 
treated by ALS care teams may have higher quality of life11 and longer survival12. Malnutrition and 
dehydration are common as ALS advances. Later therapy often includes percutaneous gastric feeding 
and non-invasive ventilatory support. 
 
To date, one medication (Riluzole, licensed in 1996) has been proven to prolong survival somewhat in 
ALS13. Riluzole was developed because it possesses anti-glutamatergic properties that might reduce 

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excitotoxicity in ALS. Riluzole slowed disease progression in two randomized controlled trials,14, 15 and 
prolongs survival in patients with ALS by about 2-3 months13. The most common side effects are 
exanthema, diarrhoea, dizziness, fatigue, nausea, and somnolence. Elevation of liver enzymes can 
occur, but rarely to levels that are clinically meaningful. Many patients in Europe and more than half of 
ALS patients in the U.S. take riluzole16. 
 
Numerous trials have so far been unable to identify another neuroprotective agent. Researchers now 
aim to slow disease progression by targeting known pathophysiological pathways or genetic defects. 
Until there is better understanding of the causes and mechanisms underlying progression that lead to 
more robust neuroprotective agents, symptomatic therapies can extend life and improve quality of life. 
Palliative care providers such as hospices give emotional and physical support to patients and families 
throughout much of the disease course17. 
 
 
1.1.3 
ILB 
 
During the development, this specific molecule and solutions of this molecule have been known under 
several names: DSSS5, ILB, TM-500, TM-700, LMW-DS and IBsolvMIR.  These are all different names 
of exactly the same molecule and solutions of this molecule that are collectively referred to as ILB.  
 
The investigational product, ILB, is a sulfated form of polymerised anhydroglucose which contains 
approximately 17% sulphur. The backbone of the chain may vary in length. ILB has an average 
molecular weight of 5,000 Dalton and is negatively charged. 
The ILB formulation for subcutaneous injection contains 100 mg/ml of the active substance and 9 mg/ml 
of NaCl and is a hypertonic solution. 
 
1.1.4 
Mechanism of action 
 
Motor neurone dysfunction and degeneration in ALS involves several pathogenic mechanisms, which 
include disturbed energy metabolism, cytoskeletal abnormalities, changes in transcription, glutamate 
excitotoxicity, glial hyper activation and reduced glutamate uptake18.  In our in vitro models we found 
that ILB is able to modulate molecular processes relevant to ALS2-4 generally enhancing the protective 
effect of growth factors. In glial cells the ILB reduces oxidative stress, mitochondrial dysfunction and 
glial activation. It also promotes cell survival, differentiation, myelin basic protein (MBP) expression and 
glutamate uptake.  In neuronal cultures ILB reduces neuronal cell death, oxidative stress and 
mitochondrial dysfunction.  In neurones the compound also promotes differentiation, neurite outgrowth 
and cellular homeostasis. Most importantly glutamate production and release in neuronal cells is NOT 
affected by ILB.  
Figure 1 Chemical structure of ILB 

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Glutamate production and release (followed by Ca-mediated signalling cascades) in neuronal cells is 
one of the most important factors required for synaptic remodelling necessary for regeneration and 
repair of neuronal networks affected in ALS (and indeed all neurodegenerative diseases). This process 
is controlled by the growth factors modulated by ILB and leads to the neurite outgrowth and 
differentiation of these cells. This is the process that will lead to a measurable functional benefit in the 
nervous system and clinical improvement in the patients.  
1.1.5 
Previous human experience with ILB 
 
Dextran sulfate was originally developed and explored more than 50 years ago for its anticoagulant 
properties19.Since then, it has been shown to have a number of additional clinical effects and low 
molecular weight dextran sulfate (LMW-DS), has clinically been investigated as an antiviral compound20, 
21,in patients with post-perfusion lung damages22,and in stroke patients23. 
 
ILB has been evaluated in a phase I, open single-centre study in healthy volunteers (n=34)7.  This study 
was designed to find the optimal dosing regimen for maintaining predetermined plasma concentrations 
of ILB during a 5-hour infusion period, with the intention to be used as guidance for single-dose short-
term administration in the subsequent phase II study in diabetic patients (n=10). The results of the phase 
I study indicate that ILB in doses that maintain APTT up to 150 seconds for 5 hours, corresponding to a 
total exposure of approximately 15 mg/kg, can be safely infused with no signs of increased bleeding or 
other severe side effects.  
An open dose-finding study in healthy male volunteers (n=24) was performed with the objective to 
evaluate pharmacokinetics, safety, tolerability and pharmacodynamics effects of mobilization of CD34+ 
cells, lymphocytes and HGF8.  The study was divided into two parts, Part A and Part B. In Part A, the 
doses 3,6,9,12 and 15 mg/kg of ILB was administered as single 10-minutes` infusions to 3 subjects per 
dose level (15 subjects in total). In Part B, 3 subjects received 18 mg/kg and 6 subjects received 24 
mg/kg.  ILB was well tolerated and showed no serious adverse events in the investigated doses (up to 
24 mg/kg).  ILB caused an increase in both HGF and lymphocyte levels, but did not fulfil the intended 4-
fold increase in CD34+ stem cell mobilisation.  The half-life in human was again confirmed to be 
approximately 3 hours. 
A randomised, open-label, placebo-controlled, single centre study in healthy male volunteers was 
performed9.  The aim was to evaluate the efficacy, safety and tolerability of ILB treatment in combination 
with the current standard hematopoietic mobilisation therapy, subcutaneous (s.c) injections of filgrastim 
once daily for 5 days.  ILB treatment, when administered as a single 10 minutes` infusion (18 mg/kg) 
following 5 days of once daily s.c. treatment with filgrastim, was compared to a single s.c. injection of 
plerixafor or a 10 minutes` infusion of NaCl (control) following 5 days of once daily s.c. treatment with 
filgrastim.  A stem cell mobilising effect of ILB superior to the current standard was not achieved, and 
the study was ended prematurely.  No safety issues were reported in the administered 18mg/kg dose. 
A phase I study was performed in healthy male volunteers (n=12)24. The aim was to investigate the 
pharmacokinetics and bioavailability of ILB after s.c. administration compared to the i.v. administration 
route, as well as assessing the local tolerability at the s.c. injection site.  The s.c. injection was well 
tolerated with only mild, transient local effects.  Despite no prior administration of antihistamines, no 
hypersensitivity reactions were observed.  Altogether, the bioavailability and tolerability found in the 
present study with s.c. administered ILB, justify the use of this formulation in clinical studies.  The 
pharmacokinetics corresponded well with data from previous clinical and nonclinical studies with a lower 
and delayed maximum plasma concentration, and a longer half-life for the s.c. as compared to the i.v. 
administration.  The s.c. injections was well tolerated with only mild, transient local effects. No 
hypersensitivity reactions were observed. 
A phase II open, randomised, multi-center study, was performed to investigate the effects of ILB in 
pancreatic islet transplantation in diabetes type 1 patients compared to heparin (i.e. conventional 

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treatment)25.  In this study, 19 transplantations (repetitive transplantations are included in this number) 
with ILB was performed in 10 patients.  ILB was administered as a bolus dose of 1.5 mg/kg immediately 
prior to transplantation, followed by intraportal infusion of 3.0 mg/kg together with the islet transplant.  A 
continuous ILB infusion was maintained during 5 hours after transplant with a total daily dose of up to 
18.3 mg/kg.   The primary endpoint was not fulfilled as ILB did not show superiority over heparin with 
regard to C-peptide response from the mixed-meal tolerance test.  Thirty-one serious adverse events 
were reported during the study (including the pre-randomization period), but none of the SAEs appeared 
due to the study interventions.  The results from this study show that administration of ILB is as safe 
and effective as the heparin standard therapy for allogenic islet transplantation. 
 
1.2 
Trial Rationale 
 
1.2.1 
Justification for patient population  
 
HGF is a potent survival-promoting factor for motor neurons and has been suggested for ALS 
treatment26, 27. Human recombinant HGF (hrHGF) has been shown to attenuate spinal motor neuron 
degeneration in transgenic ALS rat models, and improve functional recovery in a non-human primate 
model of contusive cervical spinal cord injury6, 28.  In a model of ALS in mice (SOD1 mutation), over-
expression of HGF in the nervous system showed reduced motor neuron death and axonal degeneration 
as well as a prolonged life span29. HGF appears to be a good candidate for the treatment of ALS since 
it passes the blood-brain barrier (BBB)30 and the HGF levels in ALS patients seem dysregulated31. ILB 
administration increases the plasma level of HGF in human healthy volunteers8, 9, 32 and in rats and 
mice33-35. The levels in humans are increased >50-fold after intravenous administration of 3 mg/kg8.  In 
TikoMed`s clinical and non-clinical studies, it has been shown that the mobilising effects of HGF is 
greater in man than in rodents32, 35.  
 
Other growth factors with potential therapeutic use in ALS are vascular endothelial growth factor (VEGF) 
and fibroblast growth factors (FGF). VEGF treatment increases survival, delays disease onset, improves 
motor functions, protects motor neurons and the neuromuscular junction in studies on rodent ALS 
models. VEGF is an attractive therapeutic factor since it passes the BBB and is down-regulated in the 
late stage of ALS5. FGF can protect motor neurons after axotomy-induced apoptosis and support 
neuronal regeneration5. Sulfated polysaccharides, like ILB, have been shown to bind and affect levels 
and potentiate VEGF and FGF signalling/effects. BDNF was one of the first neurotrophic factors 
discovered and demonstrated positive effects on motor neuron survival. BDNF has been administered 
in clinical trials in ALS patients. After administration of ILB a minor plasma concentration increase of 
BDNF has been documented in healthy volunteers8, 36. This demonstrates that ILB has an effect on a 
variety of growth factors and neurotrophic factors.   The effect of ILB on growth factors has also been 
demonstrated in a gene array study, which also showed a potential for ILB to reduce glutamate signalling 
and oxidative stress which are both known factors of neurodegenerative diseases3. 
 
ALS is a type of motor neurone disease that causes premature cell death of anterior horn cells and of 
motor neurons in the cerebral cortex. In an in vitro study on cultured human motor neurons and mouse 
cortical neurons ILB promoted the differentiation of neuronal cells within a very short period of time2. A 
gene expression study has been performed in 4 cell lines (HUVEC, Schwann cell, motor neuron and 
cortical cerebral neuronal cells). Using the gene expression data for `in silico` modelling, results indicate 
that ILB inhibits neuronal cell death, apoptosis, cell differentiation and homeostasis; and activates 
angiogenesis, migration of cells, cell viability, cell survival, proliferation of cells, cell cycle progression, 
cell transformation and expression of RNA. Under normal culture conditions the motor neurons and also 
cortical neurons appear to suffer from significant oxidative stress, leading to activation of some apoptotic 

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mechanisms as well as production of beta-amyloid in cells further exacerbating oxidative stress and 
mitochondrial fragmentation and oxidation of fatty acids. The addition of ILB to the cultures ameliorates 
these negative effects by preventing apoptosis, preventing beta-amyloid production and Lewy bodies, 
and subsequent damage by inhibiting fatty acid oxidation3. Furthermore, ALS is associated with 
aberrations in intracellular calcium levels, which could be mitigated by administration of ILB, as 
bradykinin is also a known regulator of intracellular calcium levels37. 
 
ILB administration in a model of multiple sclerosis has shown positive effects on disease progression38, 
39. In a rat stroke model, ILB administration indicated improved motor function, which could be a neuro-
protective effect and/or a result of increased angiogenesis40. Increased angiogenesis after ILB 
administration have been established in a number of hind-limb ischemia (HLI) studies on both mice and 
rats41-44. 
 
Several reports have demonstrated the reductions of blood flow and glucose metabolism in the cerebral 
cortex and the spinal cord in both ALS patients and the animal studies45-48. In an ALS model in mice, in 
vivo capillary imaging showed progressive decrease of capillary diameter, capillary density, and red 
blood cell speed during the disease course49. ILB is known to activate the Kinin-Kallikrein system which 
activates bradykinin through factor XII in the coagulation cascade.  Bradykinin is a highly angiogenic 
peptide with a potential to restore blood flow in ischaemic tissues, an effect that has been well 
documented in several animal models of ischaemic diseases using ILB.   In a series of studies it has 
been documented that ILB promotes increased angiogenesis selectively in ischemic/injured areas. This 
may contribute to a beneficial effect in ALS patients.  
 
In conclusion, it is possible that the positive effect of ILB in ALS would be mediated through an increase 
of tissue factors. It is also possible that ILB has a direct effect on neuronal cells, as displayed in vitro 
with e.g. increased cell differentiation and decreased apoptosis. This effect might contribute to a 
beneficial effect in the treatment of neurological diseases including ALS and could be one mechanism 
behind the positive effects observed in MS and ischemic stroke models. In addition, an angiogenic effect 
may contribute to beneficial effects in ALS.as shown in a number of previous animal models40-44. 
 
1.2.2 
Justification for design  
 
We have proposed a single-arm design because it will allow us to quickly and effectively achieve the 
objectives of this trial. Specifically, it will allow us to assess the safety and tolerability of repeated doses 
of ILB and assess any early signs of potential efficacy. 
 
1.2.3 
Choice of treatment  
 
Patients will receive 2mg/kg of ILB subcutaneously for ten weeks once per week in the first instance, 
during out-patient appointments at site.   
 
Data from toxicity studies performed in mice, rats and monkeys, data from studies in healthy subjects 
and diabetes patients, and additional information obtained from the literature with similar substances, 
indicate that the proposed doses have a favourable safety profile. 
 
In the two-part dose-finding study in healthy volunteers clinical study LMW-DS-1028 using LMW-DS, 
dose proportionality of ILB was indicated by an apparent linear increase in Cmax with increasing doses 
(3-24 mg/kg), and also AUCinf appeared to increase linearly with increasing dose (see Table 1). Further, 

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the pharmacokinetic parameters in study LMW-DS-102 correlated well with the results from other 
healthy volunteer studies, LMW-DS-101 (4.5 mg/kg)7 and TM-104 (6 mg/kg, i.v. and s.c)24. Based on 
these results, it was considered reasonable to expect that the pharmacokinetics of ILB is approximately 
linear also at 2 mg/kg, and thus it could be anticipated that a dose of 2 mg/kg would after s.c. 
administration give a Cmax around 5 mg/L and the AUC would be around 30 h*mg/L.  
Table 1 Mean pharmacokinetic exposure parameters in plasma from healthy volunteers 
 
Dose # 
(mg/kg) 
Cmax  
(mg/L) 
AUCinf (h*mg/L) 
Treatment 
Clinical Study No. 
4.5  
32.1 
65.5 
1.5 mg/kg, i.v. 
bolus and 3 mg/kg, 
20 minutes i.v. 
infusion 
LMW-DS-101 
6 
63.1 
106 
10 min i.v. infusion 
TM-104 
6 
14.6 
92 
s.c. 
3 
29.4 
NC 
10 minutes i.v. 
infusion 
LMW-DS-102 
6 
70.0 
154* 
9 
76.8 
156* 
12 
120 
264 
15 
171 
337 
18 
159 
330 
24 
209 
457 
Linear Extrapolation for 2 mg/ml 
 
2 
~5 
~30 
s.c. 
# PK results not fully comparable between i.v. studies, as different i.v. dosing schedules  
Mean of n=3 or n=6 (24 mg/kg only) and n=12 (cross-over) in TM-104 
NC: Not Calculated 
*one subject 
This is a first-in-patient study to carefully evaluate the safety and tolerability of ILB in ALS patients. 
Doses up to 24 mg/kg ILB has been administered to 79 healthy volunteers, but as ILB has never been 
administered to ALS patients and never more than two subsequent injections, a careful approach with 
low dose (2 mg/kg) with 1-week dosing interval has been chosen.  
 
The vast majority of all cases of ALS are not caused by genetic factors, and for this population there are 
currently no animal models available. As a consequence, no in vivo pharmacology studies in ALS have 
been performed as a basis for this study. The rationale for the use of ILB in ALS is based on results 
from previous clinical trials and in vitro testing, and the dose and dosing interval is balanced to achieve 
an appropriate safety margin, as the safety of the ALS patients is here of utmost importance. 
 
Production of several growth factors are dysregulated in ALS, and the study drug ILB has been shown 
to clearly increase the levels of growth factors such as HGF in both clinical and in vivo studies. In a 
dose-response study in healthy volunteers, where ILB was administered in a wide range of doses 
between 3-24 mg/kg, a similar increase (> 50-fold) in HGF levels was nonetheless reached, irrespective 
of the dose, within 30 minutes to 1 hour after administration (Figure 2). By extrapolating, it is anticipated 
that a significant increase in HGF levels will be reached with the dose of 2 mg/kg chosen for this study. 
Between 3-9 hours after ILB administration, the HGF levels drop in roughly a dose-dependent manner. 

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Through its receptor c-MET, HGF activates the RAS-RAF pathway downstream, which in turn activates 
MAPK to translocate to the nucleus and activate transcription factors responsible for regulating a large 
number of genes49. That ILB has this effect on gene expression has been demonstrated through a gene 
array study, where the presence of ILB reduced expression of genes associated with oxidative stress, 
glutamate synthesis and apoptosis. As a similar increase in levels of HGF is achieved early after ILB 
administration, a similar effect on gene expression could also be reached, irrespective of the ILB dose 
administered.  
 
 
Figure 2 HGF levels at 30 min to 9 hours after administration of 3-24 mg/kg ILB in human (clinical study LMW-
DS-102) 
 
A similar increase (> 50-fold) in HGF levels is reached, irrespective of the dose, within 30 minutes to 1 
hour after administration. By extrapolating, it is anticipated that a significant increase in HGF levels will 
be reached with the dose of 2 mg/kg chosen. Between 3-9 hours after ILB administration, the HGF levels 
drop in roughly a dose-dependent manner. 
 
An intermittent dosing with 1-week interval has been chosen as a balance between a safe dose and an 
effective dose; As up to 24 mg/kg has been administered in man and toxicology studies show safe 
dosing of 15 mg/kg in rat and 30 mg/kg in monkey daily for 28 days, the 2 mg/kg dose with dosing once 
weekly provides a good safety margin (see also Section 5.4.2.3 in the updated IB, version 3.0). From 
an efficacy perspective, considering that the effect of ILB is on a gene level, there is reason to believe 
that even though the ILB per se is eliminated within less than 24 hours, the downstream effects may be 
more long lasting. Therefore, we propose a 1-week dosing interval in this first-in-patient study. 
 
At this point, our view is that, for safety reasons, it is too soon to initiate a full dose-response study with 
ILB in ALS-patients. By starting at a low dose and infrequent dosing in a few ALS patients, this study 
will safely evaluate the tolerability of ILB, detect any early signs of potential efficacy on for instance 
biomarkers.  
 
0
20000
40000
60000
80000
100000
120000
0
5
10
15
20
25
HGF (pg/ml)
Dose (mg/kg)
baseline
30 min
1 h
3 h
6 h
9 h
Trend (30 min)
Trend (1 h)
Trend (3 h)
Trend (6 h)
Trend (9 h)

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1.2.4 
Justification for single point long-term remote follow up visit 
 
A single point long-term remote follow up visit is planned for a time period of 8 weeks starting in Quarter 
1 of 2021. Each patient will be asked to provide consent for this visit. Additional ALSFRS-R and Quality 
of Life data will be collected along with information on any medication each patient is taking for their 
ALS. The aim of this visit is to check on the wellbeing of participants and to increase scientific impact of 
the study which was terminated early as a result of the ongoing COVID-19 pandemic in 2020. The 
additional data will be analysed and provided in an addendum to the final report of the study results. 
 
Patients with MND of any type are at a higher risk of developing severe complications and dying 
following COVID-19 infection50. As the study requires frequent visits to hospital, specifically for 
treatment, a risk/benefit analysis was completed by the study management team (March 2020) which 
concluded that that whilst the COVID-19 pandemic was prevalent in the United Kingdom currently 
recruited patients would receive no further treatment and recruitment of additional patients would be 
suspended. In October 2020 it was decided that due to the ongoing situation with regards to COVID-19 
pandemic in the United Kingdom further treatment and recruitment of additional patients would be 
permanently ended. This study remains valid and in order to maximise the scientific value of the study 
and the clinical potential of the data collected, one additional follow–up visit to collect some secondary 
outcome data (as detailed above) was deemed to be substantially beneficial for developing the 
intervention for future patients whilst minimising the impact on the patients who have participated in this 
clinical study.  
 
 
 

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2. OBJECTIVES AND OUTCOME MEASURES  
2.1 
Primary Objective 
- 
To determine the safety and tolerability of ILB administered subcutaneously weekly in ALS 
patients. 
2.2 
Secondary Objectives 
 
To describe the effect of ILB administered subcutaneously weekly  
o 
upon severity of symptoms associated with ALS present at entry into the study 
o 
upon development of new symptoms associated with ALS during the study 
o 
upon patients quality of life (ALSAQ-40) during the study 
 
To assess changes in biomarkers, including urinary p75ECD and NfL in plasma 
2.3 
Primary Outcome Measures 
Our primary outcome measures will inform whether the therapy is feasible in this patient group. 
• 
Safety 
o 
Measured by the incidence of serious adverse events (SAEs) and adverse events (AEs) 
using CTCAE v4.0.  Events will be summarised by grade, relatedness, admitting event 
(for SAEs); expectedness and sequelae. 
o 
Tolerability 
o 
Measured by the incidence of intolerable adverse events. An intolerable adverse 
event will satisfy all of the following criteria: 
1. Associated with a serious adverse event or a drug discontinuation of   greater 
than three weeks; 
2. Grade 3, 4 or 5 in severity according to CTCAE version 4;  
3. In the opinion of the Investigator is i) definitely related or ii) probably related 
or iii) possibly related to the study drug treatment. 
o 
Adverse events which are considered unrelated or probably not related will not be 
classed as intolerable events. 
o 
Quantity of study drug administered 
o 
Total drug administered, number of administrations, number and length of 
interruptions, and number of discontinuations will be reported. 
2.4 
Secondary Outcome Measures 
Our secondary outcome measures will provide data on patient function and disease progression 
• 
Revised ALS Functional Rating Scale (ALSFRS-R) 
o 
This is a functional rating scale, including assessments of communication, mobility, 
feeding, dressing and respiration. 
• 
ALS Assessment Questionnaire (ALS AQ-40) 
o 
This patient-reported outcome measures the subjective well-being of patients. It is 
broader than ALSFRS-R and adds assessment of emotional reactions. 
• 
Urinary p75ECD 
o 
This is a biological fluid-based biomarker of ALS disease progression 
• 
PK ILB in plasma following administration 
o 
This quantifies the amount of drug detectable in the blood after administration 
over time 
• 
NfL in plasma 
o 
This is a blood‐based biomarker for neurodegeneration 

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2.5 
Exploratory Outcome Measures 
 
• 
HPLC analyses of purine-pyrimidine metabolites (serum) 
• 
HPLC analysis of fat-soluble vitamins and antioxidants (serum) 
• 
HPLC analyses of amino acids (AA) and amino-group containing compounds (ACCG) (serum) 
• 
Spectrophotometric analysis of lactate 
• 
PBMC samples will be collected for analysis of change in phenotypic balance 
• 
HGF release in plasma following ILB administration (ELISA from PK samples) 
• 
Creatine kinase and Myoglobin from plasma as markers of muscle atrophy associated with ALS 
 
 
 
 
 

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3. TRIAL DESIGN  
This is a Phase IIa, pilot, single arm (uncontrolled) study, which seeks to recruit 15 patients with a 
diagnosis of ALS.  The trial has no control arm because control outcomes will not address the primary 
objective of the trial. On recruitment to the study, patients will undergo a baseline screening assessment 
(within 14 days of initiation of treatment with ILB, or within 28 days for those patients discontinuing 
Riluzole at screening) to include a medical history, vital signs, haematology and blood biochemistry 
(laboratory assessments).  Patients will also complete a baseline assessment on the ALS Functional 
Rating Scale (ALSFRS-R) and a Quality of Life Assessment (ALSAQ-40).   
Patients will receive 2mg/kg of ILB subcutaneously, weekly for ten weeks (in the first instance), during 
out-patient visits at site. Dosing beyond 10 weeks (initially to 24 weeks and a maximum of up to 48 
weeks) is dependent upon a formal review of the patient’s eligibility, their wishes and the most suitable 
treatment options. If treatment extension is agreed (at the PIs discretion), patients will initially go on to 
complete an additional 14 weeks of treatment, with the option to extend treatment further. While patients 
are on the treatment extension phase of the trial a formal review will occur every 90 days.   
During the clinical trial, regular assessments of adverse events, vital signs, haematology and blood 
biochemistry (laboratory assessments), ALSFRS-R and Quality of Life (ALSAQ-40) will be performed.  
These will be scheduled to occur weekly (during the main trial phase) and monthly thereafter in follow-
up and/or treatment extension phase as per the schedule of events. 
 
Following the suspension of treatment in March 2020 and the early termination of the study in October 
2020 due to the COVID-19 pandemic, as well as the high risk status of participants, a single point 
long-term remote follow up visit will take place starting in Quarter 1 of 2021.  
Patients will be asked to re-consent for this additional visit and data capture which will be conducted 
by the site PI via video call over an 8 week period. 
During this remote visit, data collected will include ALSFRS-R, Quality of Life (ALSAQ-40) and 
concomitant medication – patients will be asked to provide information on any medication they have 
been taking for their condition, such as standard of care Riluzole. 
 

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4. ELIGIBILITY  
4.1 
Main Eligibility criteria 
 
Inclusion Criteria: 
 
1. 
Patients ≥18 years and who have provided written informed consent to participate in the study 
2. 
Prior to trial entry patients will have a definite diagnosis of ALS according to El Escorial Criteria 
(Appendix 10). All patients will demonstrate either: 
 presence of Upper Motor Neuron (UMN) (increased tone, brisk reflexes) as well as 
Lower Motor Neuron (LMN) (weakness, wasting and fasciculation) signs in the 
bulbar region and at least two of the other spinal regions (cervical, thoracic or 
lumbosacral) 
 
or 
 
 presence of UMN and LMN signs in all three spinal regions (cervical, thoracic or 
lumbosacral) 
 
3. 
Electrophysiological tests (Electromyography (EMG) / Nerve Conduction Study (NCS)) that 
supports the diagnosis of Motor Neurone Disease (MND) and to exclude mimic disorders 
4. 
Forced Vital Capacity (FVC) ≥50% of predicted value for gender, height and age at screening 
and/or a mean Sniff Nasal Inspiratory Pressure (SNIP) ≥50% of predicted value for age 
5. 
Adequate haematological function (Hb≥10g/dl absolute neutrophil count ≥1.5x109/L and a 
platelet count ≥60 x109/L   
6. 
International Normalised Ratio (INR) ≤ 1.5, Activated Partial Thromboplastin Time (aPTT) ≤ 40 
seconds, Prothrombin Time (PT) ≤ 13.5 seconds 
7. 
Patient willing and able to comply with schedule visits, treatment plan and other study 
procedures. 
8. 
Patients taking Riluzole must have discontinued treatment ≥28 days prior to study entry (and 
following consent to take part in the study) 
9. 
Women Of Child Bearing Potential (WOCBP) who agree to use highly effective means of 
contraception (as defined in the Heads of Medicines Agencies_Clinical Trials Facilitation Group 
(HMA_CTFG) guideline (see Appendix 8) and in combination with a barrier contraception 
method (condom, diaphragm or cap) for the entirety of the study 
  
Exclusion Criteria: 
 
1. 
Patients classified as either probable or possible ALS according to El Escorial Criteria (see 
Appendix 10).  
2. 
Subjects in whom other causes of neuromuscular weakness have not been excluded 
3.  
Assisted ventilation of any type within 3 months before the screening visit or at screening 
4 
Patients requiring Radiologically Inserted Gastrostomy (RIG) or Percutaneous Endoscopic 
Gastroscopy (PEG) feeding 
5. 
Involvement in any other interventional study involving use of another IMP or biological product, 
within 3 months of screening 

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6. 
Any use of antioxidants, edaravone, tirasemtiv or CK-2127107 within 1 month before the 
screening visit 
7. 
Any botulinum toxin use within 3 months before the screening visit. 
8. 
Any form of stem cell or gene therapy for the treatment of amyotrophic lateral sclerosis (ALS) 
9. 
Neuroimaging of brain and cervical spine with Magnetic Resonance imaging (MRI) indicating 
compressive myelopathy as an alternate diagnosis 
10. 
Laboratory examinations including Acetylcholine receptor (AChR) antibodies and Muscle 
Specific Kinase (MuSK) antibodies to exclude Bulbar onset Myasthenia gravis from Bulbar onset 
Motor neuron disease as an alternate diagnosis and Antinuclear Antibodies (ANA), Anti-
neutrophil cytoplasmic antibodies (ANCA), Extractable Nuclear Antigen (ENA) antibodies, 
Creatine Kinase (CK), electrophoresis and immunoglobulin indicating an alternate diagnosis for 
muscle disease like Myositis. It is at the Chief Investigators discretion to determine if positive 
results from any of the mentioned tests indicates an alternative diagnosis. 
11. 
Abnormal liver function defined as Aspartate Transaminase (AST) and/or Alanine 
Transaminase (ALT) >3 times upper limit of normal 
12. 
Any head trauma, intracranial or spinal surgery within 3 months of trial entry 
13. 
Patients who have had recurrent falls will be excluded to reduce the risk of intracerebral 
haemorrhage with this IMP 
14. 
Current use of an anticoagulant e.g Warfarin, Aspirin, Clopidogrel, any novel anticoagulants 
(NOAC)s or low molecular weight subcutaneous heparin  
15. 
Uncontrolled severe hypertension defined as systolic blood pressure (SBP) ≥ 220 mmHg  
 
or diastolic blood pressure (DBP) ≥120 mmHg 
16. 
Current or previous history of heparin-induced thrombocytopenia 
17. 
Active peptic ulcer disease 
18. 
Known hypersensitivity to sulphur 
19. 
Severe liver insufficiency 
20. 
Patients with evidence of major psychiatric illness, significant cognitive impairment or clinically 
evident dementia that may interfere with the patients’ ability to comply with study procedures 
21. 
Pulmonary illness (e.g. asthma or Chronic Obstructive Pulmonary Disease (COPD)) requiring 
regular treatment 
22. 
Patient judged to be actively suicidal by the investigator during 3 months before the screening 
visit 
23. 
Subjects with a diagnosis of another neurodegenerative disease (e.g. Parkinson`s disease, 
Alzheimer’s disease and Frontotemporal dementia 
24.  
Pregnant and/or breastfeeding 
 
 
 
 
 
 
 
 
 
 
 

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4.2 
Treatment Extension Eligibility Criteria 
 
The following must be met for patients to be considered for treatment extension beyond 10 weeks: 
 
Inclusion: 
1. Completed 10 weeks of treatment 
2. Favourable toxicity profile, as reviewed by the PI 
3. Forced Vital Capacity (FVC) ≥50% of predicted value for gender, height and age at screening 
and/or a mean Sniff Nasal Inspiratory Pressure (SNIP) ≥50% of predicted value for age 
4. Patient willing to continue 
 
Exclusion: 
1. Meeting any of the patient stopping rules (see section 7.1.6) 
2. Pregnancy/breast feeding 
3. Patients who have had recurrent falls will be excluded to reduce the risk of intracerebral 
haemorrhage with this Investigational Medicinal Product (IMP) 
4. Patients requiring Radiologically Inserted Gastrostomy (RIG) or Percutaneous Endoscopic 
Gastroscopy (PEG) feeding 
5. use of an anticoagulant e.g Warfarin, Aspirin, Clopidogrel, any novel anticoagulants (NOAC)s 
or low molecular weight subcutaneous heparin  
6. Worsening function status and unable to attend weekly out-patient appointments. 
 
 

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5. CONSENT AND SCREENING  
5.1 
Informed Consent 
 
It is the responsibility of the Investigator (detailed in the site delegation log) to obtain written informed 
consent for each patient prior to performing any trial related procedure. A Patient Information Sheet 
(PIS) is provided to facilitate this process. Investigators must ensure that they adequately explain the 
aim, trial treatment, anticipated benefits and potential hazards of taking part in the trial to the patient. 
The Investigator should also stress that the patient is completely free to refuse to take part or withdraw 
from the trial at any time. The patient should be given ample time (a minimum of 24 hours) to read the 
Patient Information Sheet and to discuss their participation with others outside of the site research team. 
The patient must be given an opportunity to ask questions which should be answered to their 
satisfaction. The right of the patient to refuse to participate in the trial without giving a reason must be 
respected. 
 
If the patient expresses an interest in participating in the trial they should be asked to sign and date the 
latest version of the Informed Consent Form (ICF). The Investigator (detailed in the site delegation log) 
must then sign and date the form. A copy of the ICF should be given to the patient, a copy should be 
filed in the hospital notes, and the original placed in the Investigator Site File (ISF). Once the patient is 
entered into the trial the patient’s trial number should be entered on the Informed Consent Form 
maintained in the ISF.  In addition, if the patient has given explicit consent a copy of the signed Informed 
Consent Form must be sent in the post to the Trials Office for review.  
 
Details of the informed consent discussions should be recorded in the patient’s medical notes, this 
should include date of, and information regarding, the initial discussion, the date consent was given, 
with the name of the trial and the version number of the Patient Information Sheet and Informed Consent 
Form. Throughout the trial the patient should have the opportunity to ask questions about the trial and 
any new information that may be relevant to the patient’s continued participation should be shared with 
them in a timely manner. On occasion it may be necessary to re-consent the patient in which case the 
process above should be followed and the patient’s right to withdraw from the trial respected. 
 
Electronic copies of the Patient Information Sheet and Informed Consent Form are available from the 
Trials Office and should be printed or photocopied onto the headed paper of the local institution. 
 
Details of all patients approached about the trial should be recorded on the Patient Screening/Enrolment 
Log and with the patient’s prior consent their General Practitioner (GP) should also be informed that 
they are taking part in the trial. A GP Letter is provided electronically for this purpose. 
 
5.1.1 
Treatment Extension 
If patients are eligible to continue treatment after week 10 they will receive an additional patient 
information sheet which will detail the treatment extension phase of the trial. Patients will be asked to 
sign and date an additional informed consent form to confirm they agree to continue treatment beyond 
week 10.  
 

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5.1.2 
Single Point Long-Term Remote Follow Up 
Electronic consent will be taken for the single point long-term remote follow up visit. Electronic PIS will 
be supplied to the participants prior to the visit. Consent will be taken at the beginning of the video visit 
by use of an electronic consent form that the patient will complete and return to the clinician. In this 
scenario, a simple typewritten e-signature will be sufficient. 
 
5.2 
Screening  
Prior to the formal screening process patients will be required to provide written informed consent 
BEFORE any non-standard of care assessment can be performed, as detailed in section 5.1. It is 
anticipated that the majority of the screening process will be completed at the same visit (i.e. all blood 
tests performed on the same day). 
Each patient who has consented, and enters the screening process, will be allocated a registration 
number. The site will be provided with a Patient Screening/Enrolment log, which is pre-populated with 
site specific screening numbers. Please use this number in any correspondence with the ALS Trial 
Office. If the patient is eligible for the trial, the screening number should be completed on the Registration 
Form. A Trial Number will be allocated once the patient is registered. 
 
Screening Visit (within 14 days of registration) or (within 28 days for those patients taking 
Riluzole prior to trial entry) 
Visit 1 
 
• 
Informed consent (patients on Riluzole must discontinue treatment at this visit) 
• 
Medical history* 
• 
Amyotrophic Lateral Sclerosis Functional Rating Scale (revised) (ALSFRS-R)  
• 
Eligibility Assessment 
• 
Concomitant drug history 
• 
Vital signs (blood pressure, heart rate, body temperature, pulse oximetry and respiration rate). 
Results of pulse oximetry should be the average of three recordings. Body weight, height and 
Body Mass Index (BMI) 
• 
Electrocardiogram (ECG) 
• 
Lung Function Tests (Forced Vital Capacity (FVC))≥50% of predicted value for gender, height 
and age at screening 
• 
Sniff Nasal Inspiratory Pressure (SNIP) Results must be recorded as the mean of three 
recordings Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation 
Rate (ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (to include, Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Serum Creatine Kinase – Muscle, Brain (CK-MB) 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Thyroid Stimulating Hormone (TSH), Free Thyroxine (Free T4) 
• 
Immunoglobulins (IgG, IgM) 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Pregnancy test for WOCBP 
 
 
 
*to include an assessment of any mental or physical contraindications to study entry 

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6. TRIAL ENTRY 
6.1 
Registration 
After the results of the screening visit are available the following must be verified by the local site PI 
and/or Co-investigators before registering the patient onto the trial: 
 
• 
Patient`s ICF 
• 
Confirmation of all the inclusion criteria 
• 
Review of all the exclusion criteria 
• 
Completion of Eligibility Checklist & Registration Form 
 
All of the above must be completed before proceeding onto patient registration. 
 
Sentinel patients that are eligible for inclusion in the trial and have signed an ICF will be registered via 
the ALS Trials Office. Informed consent must be obtained prior to registration. An Eligibility Checklist 
and Registration Form must be completed and faxed to the ALS Trial Office.  
 
Registration line: 
TEL: +44 (0) 121 371 8492 (09:00 – 17:00, Monday-Friday) 
 
The patient’s eligibility will be confirmed at registration by the ALS Trial Office. If eligible for the trial, the 
patient will be allocated a unique Trial Number. 
 
Following recruitment of the first two sentinel patients all other patients that are eligible for inclusion in 
the trial and have signed an ICF will be registered via the online electronic remote data capture system 
(eRDC). Informed consent must be obtained prior to registration. A paper Eligibility Checklist must also 
be completed and faxed to the ALS Trials Office at the time of registration. The registration line will be 
open during office hours (09:00 – 17:00, Monday-Friday). 
 
Registration of patients can be achieved by logging on to: 
https://www.cancertrials.bham.ac.uk 
Full details will be provided to sites separately. 
 
The schedule for investigations and follow up visits is summarised in the Schedule of Assessments 
table. 
 
A copy of the patients ICF must be sent in the post to the ALS Trial Office, if the patient has given explicit 
consent for this. 
 
At this time point, patients will be allocated a unique trial number to preserve patient confidentiality.  
Trial drug prescriptions must include the patient’s Trial Number.  
 
6.1.1 
Emergency Registration 
In case of any problems with on-line registration (eRDC) system a paper eligibility checklist and 
registration form should be completed.  Site staff should then telephone the ALS Trial Office using the 

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following telephone numbers listed below where the registration falls within office hours.  If a registration 
falls outside of office hours and there is a problem with the online system the registration will not be able 
to be completed until the trial office opens. 
 
                                            Contact details for emergency registration: 
 
Tel: +44 (0) 121 371 8492 (09.00 – 17.00, Mon-Fri) 
Email: ALS@trials.bham.ac.uk 
 (include in subject header “emergency randomisation) 
A unique trial number may not be allocated at the time of emergency registration; this will be allocated 
by the ALS Trial Office as soon as possible afterwards. 
6.1.2 
Protocol waivers or exemptions 
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 schedule of 
events table, and other sections of the study protocol is mandatory. 
 
6.1.3 
Treatment Extension registration 
 
If patients are eligible and agree to continue treatment beyond 10 weeks, the following will be 
completed: 
- 
Patient complete treatment continuation ICF 
- 
Confirmation of the inclusion criteria 
- 
Review of the exclusion criteria 
- 
Completion of Treatment Extension registration form 
 
 
A copy of the patients ICF must be sent to the ALS Trial Office, if the patient has given explicit consent 
for this. A treatment continuation form will be completed, stating how many/if any weeks the patient has 
not received treatment between the end of the initial 10 week treatment stage and the beginning of the 
treatment extension phase. 
 
 

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7. TREATMENT DETAILS 
 
7.1 
Investigational Medicinal Product 
The Investigational Medicinal Product (IMP) ILB is a type of low molecular weight dextran sulfate (LMW-
DS).  
 
7.1.1 
Dosage, Form and Composition 
The IMP contains 100mg/ml ILB in 0.9% NaCl and is a sterile, yellow-brownish solution for 
subcutaneous injection.  The active pharmaceutical ingredient is a type of low molecular weight dextran 
sulfate (LMW-DS). 
 
The IMP was manufactured according to current Good Manufacturing Practice by APL in Umeå, Sweden 
to meet all requirements for parenteral solutions: 
 
 
Apotek Produktion & Laboratorier AB (APL) 
Formvägen 5B 
SE-906 04 UMEÅ 
Sweden 
 
The analytical testing of the IMP is mainly performed by APL, but parts of the release testing (average 
molecular weight and free sulfate content) were conducted at: 
 
Eurofins Biopharma Product Testing Sweden 
Seminariegatan 29 
SE-752 28 Uppsala 
 
Patients will receive 2mg/kg of ILB subcutaneously for ten weeks (in the first instance) once per week.   
7.1.2 
Packaging and Labelling  
 
The IMP is filled in a 2.9ml glass vial sealed with a rubber stopper and a tear off aluminium cap. The 
vials are provided in paper boxes and there will be 36 x 2.9ml glass vials in each box. Each vial will be 
labelled in accordance with local law, all applicable regulatory requirements and Good Clinical Practice 
(GCP).  
  
7.1.3 
Storage and handling 
The ILB vials must be stored at +2 to +8°C, and be in room temperature no more than one hour prior to 
administration. The IMP ILB should be administered as specified in the protocol.  
 
Further handling details can be found in the current version of the ALS Pharmacy Manual 
 

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7.1.4 
Trial Treatment 
This clinical trial is a single-arm safety and tolerability study therefore all patients registered onto the 
trial will receive the same treatment as detailed below: 
 
Treatment Group: All patients will receive ILB.  Administration will be weekly subcutaneous injections 
at a dose of 2mg/kg once per week for 10 weeks (in the first instance).  
 
7.1.5 
Continuation of treatment beyond 10 weeks (initially to 24 weeks up to a maximum of 
48 weeks) 
See Schedule of Assessments (2): Treatment extension. All patients will be reviewed for eligibility to 
continue treatment beyond 10 weeks by the PI.  
7.1.6 
Patient Stopping Rules 
 
Patients will have treatment of ILB stopped if any of the following prospective criteria are met during 
the treatment period: 
• 
The patient experiences a Serious Adverse Event related to IMP 
• 
If there is a decrease in ALSFRS-R score (>50%) compared to baseline 
• 
If a patient becomes pregnant during the study treatment period 
• 
Unacceptable toxicity – any adverse event which, in the investigators opinion, requires 
termination of the study drug 
• 
Unforeseen events – any event which in the judgement of the Investigator makes further 
treatment inadvisable 
• 
SAE requiring discontinuation of treatment 
• 
If a patient requires an anticoagulant e.g Warfarin, Aspirin, Clopidogrel, any novel 
anticoagulants (NOAC)s or low molecular weight subcutaneous heparin during the clinical trial 
• 
PTT or aPTT > 1.5 x ULN 
• 
INR > 1.8 x ULN 
 
Patients, who stop weekly dosing, will be invited to remain in the observational part of the study up to 
24 weeks, to enable assessment of safety related measures. Patients that discontinue ILB and 
subsequently start or re-commence Riluzole therapy will also be invited to remain in the observational 
part of the study up to 24 weeks. 
 
7.1.7 
Rescue Medication 
 
See protocol page (ix) 
7.1.8 
Special Warnings and Special Precautions for use 
The early clinical studies show that short-term treatment with ILB is well tolerated.  However, prolonged 
treatment may lead to more serious adverse events.  ILB prolongs APTT in a dose-dependent manner, 
and after prolonged treatment in humans with a similar compound, but with higher molecular weight, 
thrombocytopenia has been observed.  Both these effects might lead to bleeding complications.   
 
A hypersensitivity reaction may occur as reported in a previous study. 
 

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7.2 
Treatment Schedule 
 
The following treatment schedule is based on an initial 10 week schedule of drug administration 
with the option to continue to 24 weeks in the first instance.  
 
Treatment Week 1 – Day 1 (not <28 days prior to last dose of Riluzole for those on treatment) 
Visit 2 
 
• 
Eligibility Assessment 
• 
ALSFRS-R 
• 
Registration (must not be <28 days prior to last dose of Riluzole for those on treatment) 
• 
Concomitant drug history 
• 
Vital signs 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation Tests (to include INR, APTT and PT) 
• 
Biochemistry tests (to include Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire (ALSAQ-40) 
• 
Urinary p75ECD 
• 
Neurofilament Light Chain (NfL) levels (collect 10mls of whole blood to allow for 4-5mls plasma 
for analysis) 
• 
Collection of exploratory biomarker blood samples 
• 
PK Testing 
• 
Study Drug administration (the time of study drug administration must be recorded) 
• 
Adverse event/Toxicity reporting 
• 
Dynamometer test 
 
Treatment Week 2-4  
(Visits 3, 4 and 5) 
 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation Tests (to include INR, APTT and PT) 
• 
Biochemistry tests (to include Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire (ALSAQ-40) 
• 
Pregnancy test for WOCBP (Week 4, day 22 only) 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given at  within +/- 24 hours of the Day 1 Week 1 administration time  
• 
Adverse event/Toxicity reporting 
• 
Dynamometer test 
 
Treatment Week 5  
(Visit 6) 
• 
ALSFRS-R 
• 
Concomitant drug history 

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• 
Vital signs 
• 
ECG 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation tests (INR, APTT and PT) 
• 
Biochemistry tests (to include Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Serum Creatine Kinase – Muscle, Brain (CK-MB) 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Urinary p75ECD levels 
• 
Neurofilament Light Chain (NfL) levels (collect 10mls of whole blood to allow for 4-5mls plasma 
for analysis) 
• 
Collection of Exploratory Biomarker Blood Samples 
• 
Lung Function Tests (Forced Vital Capacity (FVC))≥50% of predicted value for gender, height 
and age at screening 
• 
Sniff Nasal Inspiratory Pressure (SNIP) Results must be recorded as the mean of three 
recordings Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation 
Rate (ESR) 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time  
• 
Adverse event/Toxicity reporting 
• 
Dynamometer test 
 
Treatment Week 6, 7, 8  
(Visit 7, 8 and 9) 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (to include: Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Pregnancy test for WOCBP (Week 8, day 50 only) 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time 
Adverse event/Toxicity reporting 
• 
Dynamometer test 
 
 
 

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Treatment Week 9 
(Visit 10) 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs 
• 
Lung Function Tests (FVC) 
• 
SNIP test 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (to include: Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Dynamometer test 
 
Treatment Week 10 
(Visit 11) 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs 
• 
ECG 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (to include: Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Creatinine Kinase  
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Thyroid function tests 
• 
Immunoglobulins 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Urinary p75ECD levels 
• 
Neurofilament Light Chain (NfL) levels (collect 10mls of whole blood to allow for 4-5mls plasma 
for analysis) 
• 
Collection of exploratory biomarker blood samples 
• 
Pregnancy test for WOCBP 
• 
Dynamometer test 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time  
 
 
Prior to Week 11 
• 
A formal review will be conducted to discuss patient eligibility to determine whether to 
continue treatment beyond 10 weeks. If a patient consents to continued treatment they 
will follow the below continuation of treatment visits. If a patient is not eligible/ does not 
want to continue treatment they will follow the follow up (observation period) schedule.  
 
 

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Treatment Week 11 
 
• 
Re-consent 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time  
• 
Adverse event/Toxicity reporting 
 
Treatment Week 12-24 
• 
Concomitant drug history 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time  
• 
Adverse event/Toxicity reporting 
 
Treatment Week 14 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs 
• 
ECG 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation tests (INR, APTT and PT) 
• 
Biochemistry tests (to include Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Serum Creatine Kinase – Muscle, Brain (CK-MB) 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Lung Function Tests (Forced Vital Capacity (FVC))≥50% of predicted value for gender, height 
and age at screening 
• 
Sniff Nasal Inspiratory Pressure (SNIP) Results must be recorded as the mean of three 
recordings Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation 
Rate (ESR) 
• 
Pregnancy test for WOCBP 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time 
Adverse event/Toxicity reporting 
• 
Dynamometer test 
 
Treatment Week 15, 16,17 and 18 
• 
Concomitant drug history 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time 
Adverse event/Toxicity reporting 
 
 

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Treatment Week 19 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs 
• 
ECG 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation tests (INR, APTT and PT) 
• 
Biochemistry tests (to include Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Serum Creatine Kinase – Muscle, Brain (CK-MB) 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Lung Function Tests (Forced Vital Capacity (FVC))≥50% of predicted value for gender, height 
and age at screening 
• 
Sniff Nasal Inspiratory Pressure (SNIP) Results must be recorded as the mean of three 
recordings Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation 
Rate (ESR) 
• 
Pregnancy test for WOCBP 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time 
Adverse event/Toxicity reporting 
• 
Dynamometer test 
 
Treatment Week 20-23 
• 
Concomitant drug history 
• 
Study Drug administration (The time of study drug administration will be recorded at each 
visit. All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time 
Adverse event/Toxicity reporting 
 
Treatment Week 24 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs 
• 
ECG 
• 
Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation Rate (ESR) 
• 
Coagulation tests (INR, APTT and PT) 
• 
Biochemistry tests (to include Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Serum Creatine Kinase – Muscle, Brain (CK-MB) 
• 
Urea and Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life questionnaire(ALSAQ-40) 
• 
Urinary p75ECD levels 
• 
Neurofilament Light Chain (NfL) levels (collect 10mls of whole blood to allow for 4-5mls plasma 
for analysis) 
• 
Collection of Exploratory Biomarker Blood Samples 
• 
Lung Function Tests (Forced Vital Capacity (FVC))≥50% of predicted value for gender, height 
and age at screening 
• 
Sniff Nasal Inspiratory Pressure (SNIP) Results must be recorded as the mean of three 
recordings Haematology tests (to include Full Blood Count (FBC), Erythrocyte Sedimentation 
Rate (ESR) 

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• 
Pregnancy test for WOCBP 
• 
Study Drug administration (The time of study drug administration will be recorded at each visit. 
All  doses must be given within +/- 24 hours of the Day 1 Week 1 administration time Adverse 
event/Toxicity reporting 
• 
Dynamometer test 
 
If after review, patients are eligible to continue treatment beyond 24 weeks up to a maximum of 
48 weeks, they will repeat the treatment and assessment schedule week 11 – 24. 
 
 

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7.3 
Assessments 
7.3.1 
Blood chemistry and Haematology 
The following blood tests will be performed at each visit.  All safety assessments will be done in local 
laboratories at the investigative site. 
 
 
 
 
 
 
 
 
 
 
 
 
7.3.1.1 Liver Chemistry Management 
 
There are no liver-specific stopping criteria as such (although there are opportunities for an independent 
committee to review general safety data and, if necessary, advise the trial be stopped. In the event of 
Biochemistry 
Blood test 
U&Es 
Sodium 
Potassium 
Urea 
Creatinine 
*Estimated Glomerular      Filtration Rate (eGFR) (calculated by 
Cockcroft-Gault equation or alternative as per institutional practice 
– Appendix 6) 
LFTs 
Albumin 
Aspartate transaminase (AST) 
Alanine Transaminase (ALT) 
Alkaline Phosphatase (ALP) 
Bilirubin (direct and indirect if total is ≥30) 
Gamma Glutamyl Transpeptidase (GGT) 
 
Other 
 
Serum Creatine Kinase-MB (CK-MB) 
Troponin I (not tested after treatment week 24) 
C-reactive protein (CRP) 
Glucose 
Calcium 
Thyroid Stimulating Hormone (TSH) (not tested after treatment 
week 24) 
Free Thyroxine (Free T4) (not tested after treatment week 24) 
Immunoglobulin G (IgG) 
Immunoglobulin M (IgM) 
Haematology 
Blood test 
FBC 
Haemoglobin 
Platelets 
Red Blood Cells 
White Blood Cells 
Haematocrit 
Mean Cell Volume (MCV) 
Mean Cell Haemoglobin 
Neutrophils 
Lymphocytes 
Monocytes 
Eosinophils 
Basophils 
Other 
ESR 
Coagulation Tests 
INR 
APTT 
PT 

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liver parameters deviating from the thresholds described in Appendix 5, follow instructions in that 
section. 
 
Liver chemistry increased monitoring criteria have been designed to assure subject safety and evaluate 
liver event aetiology (in alignment with the FDA premarketing clinical liver safety guidance). 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM174
090.pdf 
 
7.3.2 
Physical examination/symptom assessment  
All physical assessments will be performed by a suitability qualified medical practitioner/research nurse 
PRIOR TO ADMINISTRATION OF STUDY DRUG and shall include: 
• 
Blood pressure 
• 
Heart rate 
• 
Pulse oximetry. Results of oximetry should be the average of three recordings 
• 
Weight (kg) to allow for accurate dosing of IMP 
• 
Height (at screening only) 
• 
Body Mass Index (BMI) 
• 
Body temperature 
• 
Respiratory rate 
• 
Adverse Event assessment/reporting 
• 
Dynamometer test 
7.3.3 
Electrocardiogram (ECG) 
• 
12 lead electrocardiogram (performed prior to administration of study drug) 
 
7.3.4 
Lung Function Tests (performed prior to administration of study drug) 
• 
Lung Function Tests (Forced Vital Capacity (FVC))  
Ventilatory support is indicated when the FVC is less than 50 per cent of predicted in many 
patients with respiratory muscle weakness51 therefore an FVC ≥50% of predicted value for 
gender, height and age is required for trial entry. FVC will also be measured at Week 12, Week 
24 and 2 weeks after the end of treatment. Should patients continue treatment beyond 24 
weeks, FVC will be measured as per the Schedule of Assesments 
• 
Sniff Nasal Inspiratory Pressure (SNIP). Results must  be recorded as the mean of three 
recordings and the same nostril used at baseline must  be used for subsequent 
visits/assessments  
 
7.3.5 
Quality of Life (performed prior to administration of study drug) 
• 
Amyotrophic Lateral Sclerosis Functional Rating Scale (Revised) (ALSFRS-R) 
• 
QOL ALSAQ-40  
Quality of Life assessments will be performed at treatment weeks (Weeks 1 – 10) and during follow up 
visits (Week 12, 16, 20 and 24).  Should patients continue treatment beyond 10 weeks Quality of Life 
assessments will be performed as per the Schedule of Assessments.  
All patients will be invited to provide data on Quality of Life in a single point long-term remote follow up 
visit conducted over an 8 week period starting in Quarter 1 of 2021.  

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7.3.6 
Pregnancy testing 
Urine pregnancy test for WOCBP ≤7 days prior the first dose of IMP and every 4 weeks during the study. 
Should patients continue treatment beyond 10 weeks urine pregnancy test for WOCBP will also be 
performed regularly as per the Schedule of Assessments. 
 
7.4 
Sample Collection 
7.4.1 
Blood samples 
7.4.1.1 Pharmacokinetic samples 
For all patients, blood samples for the determination of ILB levels will be collected as detailed in the 
Schedule of Assessments in the study protocol.   
Samples (plasma) for PKs should be collected from whole blood, collected in anti-coagulant-treated 
Vacutainer tubes (3.2% sodium citrate (blue-topped)). Serum should not be prepared. 
Samples for ILB measurements should be sent (single/few batches) to: 
 
Eurofins BioPharma Product Testing Munich GmbH 
Chun-Wei Lee 
Behringstr. 6-8 
821 52 Planegg 
Germany 
+49 89 899 65 00 (phone) 
Chun-WeiLee@eurofins.com 
 
Time Point 
Blood Sample Type 
Volume of blood (ml) 
Pre-dose (30 minutes prior to ILB injection) 
Blood Plasma 
14 
30 minutes post-injection 
Blood Plasma 
3.5 
60 minutes post-injection 
Blood Plasma 
3.5 
120 minutes post –injection 
Blood Plasma 
3.5 
150 minutes post-injection 
Blood Plasma 
3.5 
180 minutes post-injection 
Blood Plasma 
3.5 
240 minutes post-injection 
Blood Plasma 
3.5 
360 minutes post-injection 
Blood Plasma 
3.5 
 
Please use the current version of the laboratory manual for further information. 
 
The remaining PK samples should be stored in a -80⁰C freezer and will be shipped in batches for HGF 
measurement (exploratory biomarker) to the Neuregenix laboratory.  

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7.4.1.2 NfL levels (performed prior to administration of study drug) 
• 
10mls Whole Blood collected in EDTA-treated Vacutainer tubes (lavender/purple top) (to allow 
for 4-5mls plasma for analysis). 
Samples should be stored in a -80⁰C freezer and will be shipped in batches to Sahlgrenska University  
Hospital, (Neurokemi lab), Gothenburg, Sweden  
 
Please see the latest version of the laboratory manual for further information 
7.4.1.3 Exploratory Biomarker Blood Samples (performed prior to administration of study drug) 
 
Exploratory biomarker samples for: 
 
a) HPLC analysis of purines, pyrimidines, oxidative/nitrosative stress compounds (n = 60) 
b) HPLC analysis of fat-soluble vitamins and antioxidants (n = 60) 
c) HPLC analysis of amino acids and amino group-containing compounds (n = 60) 
d) Spectrophotometric analysis of lactate (n = 60) 
e) PBMC samples will be collected for analysis of change in phenotypic balance 
f) HGF release in plasma following ILB administration (ELISA from PK samples) 
g) Creatine kinase and Myoglobin from plasma as markers of muscle atrophy associated with ALS 
 
Please see the latest version of the laboratory manual for further information. 
 
 
Samples 
Visit 
Blood sample  type 
Volume (ml) 
NfL 
Wk 1, Wk 5, Wk 11/12*, 
week 24, week 26** 
Plasma 
6 
Exploratory Biomarker 
Wk1, Wk5, Wk11/12*, 
Wk24, Wk26** 
Serum 
5 
Exploratory Biomarker 
Wk1, Wk5, Wk11/12*, 
Wk24, Wk 26** 
PBMC 
10 
 
*Week 11 if patients continue onto the treatment extension phase of the trial. Week 12 if patients are 
on end of treatment visit. 
** Patients who complete 24 weeks of treatment and do not continue on to further treatment will have 
an end of treatment visit week 26. 
Please see Appendix 12 and the latest version of the laboratory manual for further information. 
 
7.4.1.4 Research Samples 
 
Any remaining blood samples at the end of the study will be shipped and stored at the Sponsor’s biobank 
for use in future ethically and scientifically approved research in the UK or overseas; including genetic 
studies, research which may use animals or in vitro models, and research involving private or 
commercial companies.  

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Please see the latest version of the laboratory manual for further information. 
 
7.4.2 
Urine Samples (performed prior to administration of study drug) 
 
Where possible the first urine of the morning should be obtained for each patient for: 
• 
Urinary p75ECD levels 
Please see Appendix 12 and the latest version of the laboratory manual for further information 
 
7.5 
Dose Modifications  
 
During the dosing period, if patients experience any adverse events the following criteria must be 
followed: 
 
Table 2 Dose Modifications for Adverse Events 
CTCAE Grade 
ACTION 
Grade 1-2  
At the discretion of the treating 
clinician continue treatment 
Grade 3  
The treating clinician should 
consider stopping study 
treatment at this point. Or omit 
dose until resolved to grade 1-2 
Grade 4 
Discontinue study treatment 
 
Definition of Grade – see NCI Common Terminology Criteria for Adverse Events version 4 (NCI CTCAE 
v4) 
 
7.6 
Treatment Interruptions 
At the discretion of the treating clinician, patients can recommence study drug following omitted dose(s) 
up until Week 10 and after consent to continue treatment after week 10.The treatment interruption 
guidelines will also apply should treatment fall over a public holiday (e.g. Easter break) and due to 
logistics a patient is unable to attend a hospital visit and receive study drug. 
 
7.7 
Treatment Compliance  
ILB will be administered subcutaneously to patients at the site; they will receive study treatment directly 
from the investigator or designee (as documented on the study delegation log), under medical 
supervision.  The date and time of each dose administered in the clinic will be recorded in the source 
documents.   
 
The full and accurate record of drug preparation, (batch numbers, and time of preparation, dispensing 
and time of actual administration) will be maintained by the individual site pharmacy.  This information 
will be provided to the sponsor upon request and some information will be recorded in the case report 

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forms.  Full drug accountability records will be maintained by the participating site and some of this 
information will also be recorded within the case report forms. 
Please refer to the current ALS pharmacy manual. 
 
7.8 
Treatment Discontinuation 
See Patient Stopping Rules and Trial Stopping Rules (see protocol page (xiv)) 
 
7.9 
Treatment after the end of the study 
 
See protocol page (xiv) Rescue Medication  
 
7.10 Supportive Treatment 
 
See RESCUE MEDICATION page (xiv) of the protocol 
 
7.11 Concomitant Medication  
Patients may continue with previous concomitant treatments (i.e. prescription, non-prescription or 
alternative therapies) at the same doses and schedule as prior to the start of trial treatment, at the 
discretion of the local investigator provided the medication is not prohibited within the exclusion criteria 
for trial participation. 
 
All medication that each participant is taking at the time, and within 3 months prior, to enrolment will be 
recorded. New medications or changes to current medications during the trial will also be recorded. 
The pharmaceutical/trade name, dose, route of administration, indication, start/stop date of each new 
medication within the trial will be recorded. Any drug that is licensed within the United Kingdom and 
Europe, that is deemed necessary for the participant’s health-care, will be permitted at the discretion of 
the Chief Investigator.  
 
7.12 Prohibited Medication 
The following medications or therapies are prohibited: 
• 
Any other investigational medicinal or biological product, within 3 months of screening 
• 
Use of Riluzole within 28 days of 1st dose of ILB  
• 
Use of Riluzole during study treatment. Patients considered suitable to commence Riluzole 
following discontinuation of study treatment must have a ≥ 7 day wash-out period between the 
last dose of ILB and the first dose of Riluzole 
• 
Any use of antioxidants, edaravone, tirasemtiv or CK-2127107 within 1 month before the 
screening visit 
• 
Any botulinum toxin use within 3 months before the screening visit 
• 
Current use of an anticoagulant e.g Warfarin, Aspirin, Clopidogrel, any novel anticoagulants 
(NOAC)s or low molecular weight subcutaneous heparin  
7.13 Contraception and Pregnancy 
All WOCBP must agree to use a highly effective method of contraception as defined in the HMA_CRFG 
guidelines (see Appendix 8) from the Screening visit and throughout the trial period and following the 

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last dose of study drug.  Lactating women must agree to discontinue breast feeding before trial 
investigational medicinal product administration. 
 
For the purposes of this trial, a female patient of childbearing potential is a woman who has not had a 
hysterectomy, bilateral oophorectomy, or medically-documented ovarian failure.  Women ≤ 50 years of 
age with amenorrhea of any duration will be considered to be of childbearing potential. 
 
Men, if not vasectomised, must agree to use barrier contraception (condom plus spermicide) during 
heterosexual intercourse from screening through to trial completion and from the last dose of trial 
investigational medicinal product. 
 
Refer to section 8.1.2.1 if a pregnancy is reported, either that of a female participant, or the 
partner of a male participant. 
 
7.14 Patient Follow Up 
 
This follow up schedule is based on patients who discontinue treatment after 10 weeks of drug 
administration..  
 
End of treatment visit (Week 12) (Day 78 +/-3 days) 
Visit 12 
(2 weeks after last dose of IMP) 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs (blood pressure, heart rate, body temperature, pulse oximetry and respiration rate).  
Results of oximetry should be the average of three recordings. Body weight and Body Mass 
Index (BMI) 
• 
ECG 
• 
Lung Function Tests (FVC)  
• 
SNIP  
• 
Haematology tests (FBC, ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Creatinine Kinase 
• 
Urea & Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Thyroid Function Tests (TSH, Free T4) 
• 
Immunoglobulins (IgG, IgM) 
• 
Quality of Life questionnaire (ALSAQ-40) 
• 
Urinary p75ECD 
• 
NfL levels 
• 
Collection of exploratory biomarker blood samples  
• 
Pregnancy test for WOCBP 
• 
Adverse Event assessment/reporting 
 
An end of treatment visit must be performed 2 weeks from the last dose of ILB regardless of how 
many treatment doses a patient has received.  
 

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In the event a patient discontinues treatment prior to the end of week 10 the follow up schedule 
as detailed in the Schedule of Assessments 1 should be followed using the Week 16 schedule 
as a guide for visits. If drug administration ends at week 10, follow up visits should continue 
every 4 weeks from week 12 at which point patients should continue with the follow up schedule 
as per the Schedule of Assessments 1 table. i.e. week 12, week 16, week 20 and week 24 follow 
up visits. 
 
If drug administration is approved to continue after week 10 but the patient discontinues early, 
prior to the end of week 24, follow up visits should continue every 4 weeks until week 24 where 
an end of treatment visit will occur. 
 
Follow up schedule for patients who finish treatment at week 10 
 
Week 16  
Visit 13 
• 
ALSFRS-R  
• 
Concomitant drug history 
• 
Vital signs (blood pressure, heart rate, body temperature, pulse oximetry and respiration rate).  
Results of oximetry should be the average of three recordings. Body weight 
• 
Haematology tests (FBC, ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (Troponin I, C-reactive protein (CRP), Glucose, Calcium) 
• 
Urea & Electrolytes (U&Es), Liver Function Tests (LFTs)  
• 
Quality of Life Questionnaire (ALSAQ-40) 
• 
Adverse Event assessment/reporting 
 
 

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Week 20  
Visit 14 
• 
ALSFRS-R  
• 
Concomitant drug history 
• 
Vital signs (blood pressure, heart rate, body temperature, pulse oximetry and respiration rate).  
Results of oximetry should be the average of three recordings. Body weight 
• 
Haematology tests (FBC, ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (Troponin I, C-reactive protein (CRP), Glucose, Calcium)  
• 
Urea & Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Quality of Life Questionnaire (ALSAQ-40) 
• 
Adverse Event assessment/reporting 
 
 
Week 24  
Visit 15 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs (blood pressure, heart rate, body temperature, pulse oximetry and respiration rate).  
Results of oximetry should be the average of three recordings. Body weight and Body Mass 
Index (BMI) 
• 
ECG 
• 
Lung Function Tests (FVC)  
• 
SNIP  
• 
Haematology tests (FBC, ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Creatinine Kinase 
• 
Urea & Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Thyroid Function Tests (TSH, Free T4) 
• 
Immunoglobulins (IgG, IgM) 
• 
Quality of Life questionnaire (ALSAQ-40) 
• 
Urinary p75ECD 
• 
NfL levels 
• 
Collection of exploratory biomarker blood  samples  
• 
Pregnancy test for WOCBP 
• 
Adverse Event assessment/reporting 
 
 
 

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Follow-up schedule 2 weeks after final IMP Administration 
• 
ALSFRS-R 
• 
Concomitant drug history 
• 
Vital signs (blood pressure, heart rate, body temperature, pulse oximetry and respiration rate).  
Results of oximetry should be the average of three recordings. Body weight and Body Mass 
Index (BMI) 
• 
ECG 
• 
Lung Function Tests (FVC)  
• 
SNIP  
• 
Haematology tests (FBC, ESR) 
• 
Coagulation tests (to include INR, APTT and PT) 
• 
Biochemistry tests (Troponin I, C-reactive protein (CRP), Glucose, Calcium 
• 
Creatinine Kinase 
• 
Urea & Electrolytes (U&Es), Liver Function Tests (LFTs) 
• 
Thyroid Function Tests (TSH, Free T4) 
• 
Immunoglobulins (IgG, IgM) 
• 
Quality of Life questionnaire (ALSAQ-40) 
• 
Urinary p75ECD 
• 
NfL levels 
• 
Collection of exploratory biomarker blood samples  
• 
Pregnancy test for WOCBP 
• 
Adverse Event assessment/reporting 
 
For patients who continue treatment, an end of treatment visit will occur 2 weeks after the last ILB 
injection, following the sample assessment as detailed for week 24 above. 
 
Single Point Long-Term Remote Follow up Visit 
All patients will be invited to provide quality of life data during an 8 week single point remote follow-up 
visit period starting in Quarter 1 of 2021.  
Patients will be asked to re-consent electronically. After electronic consent has been given, the visit will 
be completed by the ALS study clinician via video conference and the following assessed:  
• 
ALSFRS-R 
• 
ALSAQ-40 
• 
Concomitant medication including any current ALS treatment 
 
 

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7.15 Patient Withdrawal  
The Investigator will make every reasonable effort to keep each patient on treatment. However, if the 
Investigator removes a patient from the trial treatment or if (s)he declines further participation final 
assessments will be performed, if possible. All the results of the evaluations and observations, together 
with a description of the reasons for trial withdrawal, must be recorded in the CRF. 
In the event of a patient’s decision to withdraw from the trial, the Investigator must ascertain from which 
aspects of the trial the patient wishes to withdraw, and record the details on the appropriate CRF. All 
patients will continue to be followed-up (if they agree), and all information and tissue samples collected 
up until the point of retraction, will be retained and analysed. 
Patients who are removed from treatment due to adverse events (clinical or laboratory) will be treated 
and followed up according to accepted medical practice. All pertinent information concerning the 
outcome of such treatment must be recorded in the CRF. 
The following are justifiable reasons for the Investigator to withdraw a patient from trial: 
• 
Withdrawal of consent 
• 
Serious violation of the trial protocol (including persistent patient attendance failure and persistent 
non-compliance) 
• 
Withdrawal by the Investigator for clinical reasons not related to the trial drug treatment  
 
This section should also be applied in the event of continuation of treatment beyond 10 weeks.  
 
A patient that has not received any IMP treatment will be non-evaluable and therefore will be replaced.  

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8. 
ADVERSE EVENT REPORTING 
The collection and reporting of Adverse Events (AEs) will be in accordance with the Medicines for 
Human Use Clinical Trials Regulations 2004 and its subsequent amendments. Definitions of different 
types of AE are listed in Appendix 3. The Investigator should assess the seriousness and causality 
(relatedness) of all AEs experienced by the patient (this should be documented in the source data) with 
reference to the current IB Investigator Brochure. 
 
8.1 
Reporting Requirements 
8.1.1 
Adverse Events 
All medical occurrences which meet the definition of an AE (see Appendix 4 for definition) should be 
reported.  Please note this includes abnormal laboratory findings including those that are not clinically 
significant.  
  
8.1.1.1 Pre-existing conditions  
Any pre-existing conditions should be reported as medical history, and should not be reported as an AE 
unless the condition worsens by at least one CTCAE grade during the trial. The condition, however, 
must be reported in the CRF. 
 
8.1.2 
Serious Adverse Events  
Investigators should report AEs that meet the definition of an SAE (see Appendix 3 for definition) 
 
8.1.2.1 Monitoring pregnancies for potential Serious Adverse Events 
It is important to monitor the outcome of pregnancies of patients in order to provide SAE data on 
congenital anomalies or birth defects.  
 
In the event that a patient or their partner becomes pregnant during the SAE reporting period please 
complete a Pregnancy Notification Form (providing the patient’s details) and return to the ALS Trials 
Office as soon as possible. If it is the patient who is pregnant provide outcome data on a follow-up 
Pregnancy Notification Form. Where the patient’s partner is pregnant consent must first be obtained and 
the patient should be given a Pregnancy Release of Information Form to give to their partner. If the 
partner is happy to provide information on the outcome of their pregnancy they should sign the 
Pregnancy Release of Information Form. Once consent has been obtained provide details of the 
outcome of the pregnancy on a follow-up Pregnancy Notification Form. If appropriate also complete an 
SAE Form as detailed below. 
 
 

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8.1.2.2   Liver Related Toxicity: Biochemistry 
All liver related toxicity: (Biochemistry blood tests) will be reported in accordance with Appendix 5 of the 
study protocol. Specific information will be provided on a Serious Adverse Event Case Report Form and 
liver toxicity Case Report Form as applicable. Reporting of these events will need to be via expedited 
Serious Adverse Event procedures detailed in Section 8.2.1.2 of the protocol. The information relating 
to these procedures which will be reported under medically significant events (SAE categorisation) is 
also summarised below. 
 
Other Medically significant events that need to be reported as an SAE include: 
 
• 
Is associated with liver injury and impaired liver function defined as:  
 
o 
ALT > 3xULN and total bilirubin# > 2xULN (>35% direct), or   ALT > 3xULN and INR >1.5.  
 
# 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.  If INR measurement is obtained, the value is to be recorded 
on the SAE form.   
 
 
8.1.3 
Reporting period 
 
Details of all AEs will be documented and reported from the signing of the informed consent and will 
include the collection of all baseline AEs. AE collection will continue until 30 days after the end of 
treatment visit. 
 
Details of SAEs will be documented and reported for each patient from the date of consent until 30 days 
after their last administration of trial treatment. 
 
 

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8.2 
Reporting Procedure 
8.2.1 
Site 
8.2.1.1 Adverse Events 
AEs should be reported on an AE Form (and where applicable on an SAE Form). AEs should be 
completed at each visit and the information recorded on the case report form (eRDC) / or paper form as 
appropriate.  
AEs will be reviewed using the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0 
(see Appendix 4). Any AEs experienced by the patient but not included in the CTCAE should be graded 
by an Investigator and recorded on the AE Form in accordance with the following guidelines: Grade (1) 
Mild, Grade (2) Moderate, Grade (3) Severe, Grade (4) Life-threatening or Grade (5) Death. For each 
sign/symptom, the highest grade observed since the last visit should be recorded. 
8.2.1.2 Serious Adverse Events 
 
For more detailed instructions on SAE reporting refer to the SAE Form Completion Guidelines contained 
in the Investigator Site File (ISF).  
 
AEs defined as serious and which require reporting as an SAE should be reported on an SAE Form.  
When completing the form, the Investigator will be asked to define the causality and the severity of the 
AE which should be documented using the CTCAE version 4.0.  
On becoming aware that a patient has experienced an SAE, the Investigator (or delegate) must 
complete, date and sign an SAE Form.  The form should be scanned to the Trials Office  email address 
listed below as soon as possible and no later than 24 hours after first becoming aware of the event: 
To report an SAE by email, email a scanned copy of the SAE form to: 
 reg@trials.bham.ac.uk (cc in trial mailbox: als@trials.bham.ac.uk) 
 
On receipt the ALS Trials Office will allocate each SAE a unique reference number. This number will be 
included in a response e-mail as acknowledgement of receipt. If confirmation of receipt is not received 
within 1 working day please contact the Trials Office.  The SAE reference number should be quoted on 
all correspondence and follow-up reports regarding the SAE. The response e-mail from the ALS Trials 
Office should be filed with the SAE Form in the ISF. 
 
For SAE Forms completed by someone other than the Investigator the Investigator will be required to 
countersign the original SAE Form to confirm agreement with the causality and severity assessments.  
The form should then be returned to the ALS Trials Office in the post and a copy kept in the ISF. 
Investigators should also report SAEs to their own Trust in accordance with local practice. 
8.2.1.3 Provision of follow-up information 
Patients should be followed up until resolution or stabilisation of the event. Follow-up information should 
be provided on a new SAE Form (refer to the SAE Form Completion Guidelines for further information). 
 

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8.2.2 
Trials Office 
 
On receipt of an SAE Form seriousness and causality will be determined independently by a Clinical 
Coordinator. An SAE judged by the Investigator or Clinical Coordinator to have a reasonable causal 
relationship with the trial medication will be regarded as a Serious Adverse Reaction (SAR). The Clinical 
Coordinator will also assess all SARs for expectedness.  If the event meets the definition of a SAR that 
is unexpected (i.e. is not defined in the Investigator Brochure) it will be classified as a Suspected 
Unexpected Serious Adverse Reaction (SUSAR). 
 
8.2.3 
Reporting to the Competent Authority and Research Ethics Committee 
8.2.3.1 Suspected Unexpected Serious Adverse Reactions 
The ALS Trials Office will report a minimal data set of all individual events categorised as a fatal or life 
threatening SUSAR to the Medicines and Healthcare products Regulatory Agency (MHRA), Research 
Ethics Committee (REC) and to the Sponsor (University of Birmingham) within 7 days. Detailed follow-
up information will be provided within an additional 8 days. 
All other events categorised as SUSARs will be reported within 15 days. 
 
8.2.3.2 Serious Adverse Reactions 
The ALS Trials Office will report details of all SARs (including SUSARs) to the MHRA and REC annually 
from the date of the Clinical Trial Authorisation, in the form of a Developmental Safety Update Report 
(DSUR). 
8.2.3.3 Adverse Events 
Details of all AEs will be reported to the MHRA on request. 
8.2.3.4 Other safety issues identified during the course of the trial 
The MHRA and REC will be notified immediately if a significant safety issue is identified during the 
course of the trial.  
8.2.4 
Investigators 
Details of all SUSARs and any other safety issue which arises during the course of the trial will be 
reported to Principal Investigators. A copy of any such correspondence should be filed in the ISF.  
8.2.5 
Data Monitoring Committee 
The independent Data Monitoring Committee (DMC) will review all SAEs.  
8.2.6 
Manufacturer of Investigational Medicinal Product 
All Serious Adverse Reactions (SARs) and Suspected Unexpected Serious Adverse Reaction 
(SUSARs) will be reported to the TikoMed Medical Expert by email or fax within 72 hours of the sponsor 
categorising the event as a SAR/SUSAR. Subsequent acknowledgement from TikoMed is expected 
within 48 hours of receipt.  
 
 

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9. DATA HANDLING AND RECORD KEEPING  
9.1 
Data Collection  
Data will be collected during this clinical trial by utilising both electronic remote data capture (eRDC) 
systems and paper case report forms (CRF).     
The Case Report Form (CRF) will comprise the following forms:   
 
Table 3 ALS Trial Case Report Form 
 
Form 
Summary of data recorded 
Schedule for 
submission 
Paper/eRDC 
Eligibility Form 
(checklist) 
Confirmation of eligibility and 
satisfactory screening 
investigations where 
necessary 
Faxed/emailed 
at point of 
registration  
Paper 
Registration Form 
Patient details and 
registration number 
Faxed/emailed 
at point of 
registration  
Paper 
Treatment 
Extension 
Registration Form 
Patient details and 
registration number 
Faxed/emailed 
at point of re-
consent  
Paper 
Screening Visit   
 
Visit details including 
confirmation of blood tests 
and vital signs, records of 
medical history (including 
abnormal blood tests/values) 
and concomitant medications 
 
eRDC 
Treatment Form 
 
Actual IMP dose, dates 
given, details and reasons for 
dose reductions and delays; 
details of supportive 
treatment, confirmation of 
blood tests, vital signs, 
records of AEs and 
concomitant medications 
Within 1 week 
of treatment 
visit 
eRDC 
Treatment Form 
(Week 11 onwards 
– as applicable) 
Actual IMP dose, dates 
given, details and reasons for 
dose reductions and delays; 
details of supportive 
treatment, confirmation of 
blood tests, vital signs, 
records of AEs and 
concomitant medications 
Within 1 week 
of treatment 
visit 
eRDC 

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Adverse Event 
Form 
AE start and stop dates, 
grade, outcome and causality 
assessed by clinician 
Alongside 
each visit form 
eRDC 
Concomitant 
Medication Form 
Concomitant medications 
start and stop dates, dose, 
route, frequency and 
indication 
Alongside 
each visit form 
eRDC 
ALSFRS-R 
Patient response to ALSFRS 
Within 2 
weeks of visit 
date 
Paper initially and then 
transferred to eRDC by 
study team. 
ALSAQ-40 
Questionnaire 
Patient response to ALSAQ-
40 
Within 2 
weeks of visit 
date 
Paper initially and then 
transferred to eRDC by 
study team. 
Biochemistry  
Date, visit, results, clinical 
significance  
Within 2 
weeks of visit 
date 
eRDC 
Haematology 
Date, visit, results, clinical 
significance  
Within 2 
weeks of visit 
date 
eRDC 
Pharmacokinetics 
Date, visit, sample collection, 
time taken 
Within 2 
weeks 
eRDC 
Biomarker Sample 
Date, visit, sample collection, 
time taken 
Within 2 
weeks 
eRDC 
Liver Specific 
Toxicity – 
additional 
information form 
For the collection of 
additional information see 
Section 8.1.2.2 and Appendix 
5 of the protocol 
Within 72 
hours of liver 
toxicity event 
i.e elevated 
ALT, Bilirubin 
(see Appendix 
5) 
eRDC 
Follow-up Form 
 
Date, visit details including 
clinical 
assessment 
and 
results of trial procedures 
Within 2 
weeks of final 
visit  
eRDC 
Single point Long-
term Remote 
Follow Up Form 
Date, Re-consent, ALSFRS-
R, ALSAQ-40, Concomitant 
Medication 
Quarter 1 
2021 
eRDC 
Unscheduled visit 
form 
As required 
 
eRDC 
End of treatment 
form 
Date and visit details 
including a Summary of 
protocol defined treatment 
and reasons for treatment 
discontinuation, clinical 
assessment and results of 
trial procedures 
Within 2 
weeks of visit 
date 
eRDC 

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Death Form 
Date and cause of death 
Immediately 
upon 
notification of 
patient’s death 
eRDC 
Deviation Form 
Completed in the event of a 
deviation from the protocol 
Immediately 
upon 
discovering 
deviation 
eRDC 
Withdrawal Form 
Used to notify the Trials 
Office of patient withdrawal 
from the trial 
Immediately 
upon patient 
withdrawal 
eRDC 
Ad hoc forms 
Serious Adverse Event Form  
Relapse/Death Report Form  
Pregnancy Notification Form 
 
9.2 
Data Collection Procedure 
9.2.1 
Electronic Remote Data Capture (eRDC) systems only 
The majority of patient clinical data will be collected via bespoke electronic data capture systems 
(ERDC) developed by the CRCTU programming team. Access to the ERDC system will be via standard 
web portals software (Microsoft Internet Explorer Version 8+, Firefox and/or Chrome) and individual site 
staff will be granted access to the system via unique username and password. Additional detailed 
information/training will be provided by the sponsor via 1:1 training throughout the study and an ERDC 
guidance/completion document will be provided to study site personnel. 
 
9.2.2 
Paper Case Report Forms only 
The CRF must be completed, signed/dated and returned to the ALS Trials Office by the Investigator or 
an authorised member of the site research team (as delegated on the Site Signature and Delegation 
Log) within the timeframe listed above. The exceptions to this are the SAE Form and Withdrawal Form 
which must be co-signed by the Investigator. 
 
Entries on the CRF should be made in ballpoint pen, in blue or black ink, and must be legible. Any errors 
should be crossed out with a single stroke, the correction inserted and the change initialled and dated. 
If it is not obvious why a change has been made, an explanation should be written next to the change.  
Data reported on each form should be consistent with the source data or the discrepancies should be 
explained. If information is not known, this must be clearly indicated on the form. All missing and 
ambiguous data will be queried. All sections are to be completed before returning. 
Data not captured in the source data for e.g. Quality of Life, this data will be recorded directly onto the 
CRF.  
 
In all cases it remains the responsibility of the Investigator to ensure that the CRF has been completed 
correctly and that the data are accurate. The completed originals should be sent to the ALS Trials Office 
and a copy filed in the Investigator Site File. 
 

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Trial forms may be amended by the Trials Office, as appropriate, throughout the duration of the trial. 
Whilst this will not constitute a protocol amendment, new versions of the form must be implemented by 
participating sites immediately on receipt. 
 
9.3 
Archiving 
It is the responsibility of the Principal Investigator to ensure all essential trial documentation and source 
records (e.g. signed Informed Consent Forms, Investigator Site Files, Pharmacy Files, patients’ hospital 
notes, copies of CRFs etc) at their site are securely retained for at least 25 years after the end of the 
trial or following the processing of all biological material collected for research, whichever is the later.  
Do not destroy any documents without prior approval from the CRCTU Document Storage Manager.    
 
 

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10. QUALITY MANAGEMENT 
 
10.1 Site Set-up and Initiation 
All sites will be required to sign a Clinical Study Site Agreement prior to participation. In addition all 
participating Investigators will be asked to sign the necessary agreements and Investigator registration 
forms and supply a current CV to the ALS Trials Office.  All members of the site research team will also 
be required to sign the Site Signature and Delegation Log, which should be returned to the ALS Trials 
Office. Prior to commencing recruitment all sites will undergo a process of initiation.  Key members of 
the site research team will be required to attend either a meeting or a teleconference covering aspects 
of the trial design, protocol procedures, Adverse Event reporting, collection and reporting of data and 
record keeping.  Sites will be provided with an Investigator Site File and a Pharmacy File containing 
essential documentation, instructions, and other documentation required for the conduct of the trial.  The 
ALS Trials Office must be informed immediately of any change in the site research team. 
10.2 On-site Monitoring  
Monitoring will be carried out as required following a risk assessment and as documented in the ALS 
Quality Management Plan.  Additional on-site monitoring visits may be triggered for example by poor 
CRF return, poor data quality, low SAE reporting rates, excessive number of patient withdrawals or 
deviations.  If a monitoring visit is required the Trials Office will contact the site to arrange a date for the 
proposed visit and will provide the site with written confirmation. Investigators will allow the ALS trial 
staff access to source documents as requested.   
10.3 Central Monitoring  
Where a patient has given explicit consent sites are requested to send in copies of signed Informed 
Consent Forms for in-house review. 
 
Trials staff will be in regular contact with the site research team to check on progress and address any 
queries that they may have.  Trials staff will check incoming Case Report Forms for compliance with the 
protocol, data consistency, missing data and timing. Sites will be sent Data Clarification Forms 
requesting missing data or clarification of inconsistencies or discrepancies.  
Sites may be suspended from further recruitment in the event of serious and persistent non-compliance 
with the protocol and/or GCP, and/or poor recruitment.  Any major problems identified during monitoring 
may be reported to the Trial Management Group, and the relevant regulatory bodies.  This includes 
reporting serious breaches of GCP and/or the trial protocol to the Research Ethics Committee (REC) 
and the Medicines for Healthcare products Regulatory Agency (MHRA). 
10.4 Audit and Inspection 
The Investigator will permit trial-related monitoring, audits, ethical review, and regulatory inspection(s) 
at their site, providing direct access to source data/documents.  
Sites are also requested to notify the ALS Trials Office of any MHRA inspections.   
 
 

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10.5 Notification of Serious Breaches 
In accordance with Regulation 29A of the Medicines for Human Use (Clinical Trials) Regulations 2004 
and its amendments the Sponsor of the trial is responsible for notifying the licensing authority in writing 
of any serious breach of: 
• 
The conditions and principles of GCP in connection with that trial or; 
• 
The protocol relating to that trial, within 7 days of becoming aware of that breach  
For the purposes of this regulation, a “serious breach” is a breach which is likely to effect to a significant 
degree: 
• 
The safety or physical or mental integrity of the subjects of the trial; or 
• 
The scientific value of the trial 
Sites are therefore requested to notify the Trials Office of a suspected trial-related serious breach of 
GCP and/or the trial protocol. Where the Trials Office is investigating whether or not a serious breach 
has occurred sites are also requested to cooperate with the Trials Office in providing sufficient 
information to report the breach to the MHRA where required and in undertaking any corrective and/or 
preventive action. 
 
 

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11. END OF TRIAL DEFINITION 
The end of trial will be the date of Last Patient Last Visit (LPLV). The Trials Office will notify the MHRA 
and the REC that the trial has ended and a summary of the clinical trial report will be provided within 12 
months of the end of trial. 
 
After closure of the trial with the MHRA the Sponsor is no longer required to notify the MHRA and main 
REC of changes of Principal Investigator. However, sites should continue to notify the Trials Office of 
changes in Principal Investigator by completing and returning (where required) an Investigator 
Registration Form together with a current signed and dated CV. 
 
As a result of the ongoing COVID-19 pandemic, and the high at risk status of study participants, 
further recruitment and study treatment was paused temporarily. A decision was made by the funders 
and sponsor to terminate the study prematurely in October 2020. Last patient treatment visits were 
conducted in March 2020, however further follow up visits are planned to start in Quarter 1 of2021. 
The last remote follow-up visit will be regarded as the last data capture for this trial. 
 
 
12. STATISTICAL CONSIDERATIONS  
12.1 Definition of Outcome Measures 
Outcome measures are listed in Section 2. 
12.2 Analysis of Outcome Measures  
Numerical outcomes will be summarised and presented as means and standard deviations where the 
outcome is approximately normal; or median and inter-quartile ranges where non-normal. 
12.2.1 Analysis of Primary Outcome Measures  
12.2.1.1 Safety 
The number of SAEs and AEs will be calculated and summarised. Furthermore, the number of 
patients experiencing each will be calculated. Each of these analyses will be broken down by 
grade, relatedness, event type (admitting event for SAEs); expectedness (SAEs only) and 
sequelae (SAEs only).  
12.2.1.2 Tolerability 
Line listings for all intolerable adverse events will be given. The number of intolerable events will 
be calculated for each patient and summarised. 
12.2.1.3 Quantity of study drug administered 
Total drug administered, number of administrations, number and length of interruptions, and 
number of discontinuations will be calculated for each patient and summarised. 
12.2.2 Analysis of Secondary Outcome Measures  
 
Repeated measures numerical outcomes will be analysed by hierarchical models, with patient-level 
effects to account from baseline value and progression with respect to time. Transformations of the time 
variable and smoothed terms (e.g. splines) will be considered if the outcomes are found to be non-linear 
in time  
 

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ALSFRS-R and ALSAQ-40 are very granular ordinal variables. They have 49 and 101 levels respectively 
so a categorical analysis is not feasible. There are many instances in the literature of these outcomes 
being analysed as numbers52-56. As such, we will analyse these outcomes as numbers. 
12.3 Planned Sub Group Analyses  
There are no sub-group analyses planned. 
12.4 Planned Interim Analysis 
Interim analyses of safety outcomes and available efficacy outcomes will be presented to the relevant 
independent oversight committee after the sentinel patients and periodically thereafter.  
 
Proposed analysis for publications will occur at the following end points: 
- 
 
- 
We propose to conduct and submit for publication an analysis of available primary and 
secondary outcomes for all fifteen patients after the fifteenth patient has been evaluated 
to the fullest extent over the initial 10 week dosing period. 
- 
Further analysis of outcomes will be submitted for publication after all patients who 
continue treatment complete 24 weeks of treatment.  
12.5 Planned Final Analyses  
We will seek to conduct and distribute for publication the final analysis within 6 months of the final 
protocol assessment of the final patient.  
12.6 Power Calculations  
No sample size calculations have been undertaken. The sample size has been selected based on what 
is feasible to be recruited at a single centre in a reasonable timeframe for this phase of clinical trial.  
 
 

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13. TRIAL ORGANISATIONAL STRUCTURE 
13.1 Sponsor 
The trial is sponsored by the University of Birmingham 
13.2 Coordinating Centre 
The trial is being conducted under the auspices of the Cancer Research UK Clinical Trials Unit 
(CRCTU), University of Birmingham according to their local procedures. 
13.3 Trial Management Group 
The Trial Management Group (TMG) will be responsible for the day-to-day running and management of 
the trial and will meet by teleconference or in person as required.   Members of the TMG include the 
Chief Investigator (CI), CRCTU Trial Management Team Leader, Senior Trial Coordinator, Trial 
Coordinator, Lead Trial Statistician and a Pharmacy representative.  The TMG will meet or hold a 
teleconference every 2nd month during recruitment, or as required. 
13.4 Trial Steering Committee  
This clinical trial will not require a separate stand-alone Trial Steering Committee. Both the Data 
Monitoring Committee (DMC) and the TMG will undertake traditional roles of the TSC. 
13.5 Data Monitoring Committee  
Data analyses will be supplied in confidence to an independent Data Monitoring Committee (DMC), 
which will be asked to give advice on whether the accumulated data from the trial, together with the 
results from other relevant research, justifies the continuing recruitment of further patients. The DMC 
will operate in accordance with a trial specific charter based upon the template created by the Damocles 
Group. The DMC will meet as soon as possible following the recruitment of the first sentinel patient to 
discuss the data and safety following the recruitment of the first patient. The DMC will meet again as 
soon as possible following the recruitment of the second sentinel patient. During the general recruitment 
phase of the trial the DMC is scheduled to meet three monthly via teleconference and annually 
thereafter. 
 
Additional meetings may be called if recruitment is much faster than anticipated and the DMC may, at 
their discretion, request to meet more frequently or continue to meet following completion of recruitment. 
An emergency meeting may also be convened if a safety issue is identified. The DMC will report directly 
to the Trial Management Group TMG who will convey the findings of the DMC to the funders, MHRA 
and sponsor as applicable. The DMC may consider recommending the discontinuation of the trial if the 
recruitment rate or data quality are unacceptable or if any issues are identified which may compromise 
patient safety. The trial would also stop early if any of the Trial Stopping Rules as detailed on page (ix) 
of the protocol are met.  
  
In the event that the trial is suspended the MHRA and the REC will be advised and recruitment will not 
recommence until after submission and approval of a Substantial Amendment. 
 
 
 
 

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13.6 Finance 
 
This is a clinician-initiated and clinician-led trial funded by an educational grant from industry (TikoMed).  
TikoMed will be supplying the investigational medicinal product (IMP), ILB free of charge to all individual 
NHS Trusts that will be directly treating patients as part of this clinical trial.   
 
13.6.1 Payments to individual NHS Trusts (per-patient payment) 
 
Refer to the Clinical Study Site Agreement for details.  
 
 

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14. ETHICAL CONSIDERATIONS  
 
The trial will be performed in accordance with the recommendations guiding physicians in biomedical 
research involving human subjects, adopted by the 18th World Medical Association General Assembly, 
Helsinki, Finland, June 1964, amended at the 48th World Medical Association General Assembly, 
Somerset West, Republic of South Africa, October 1996. 
 
The trial will be conducted in accordance with the Research Governance Framework for Health and 
Social Care, the applicable UK Statutory Instruments, (which include the Medicines for Human Use 
Clinical Trials 2004 and subsequent amendments and the Data Protection Act 1998 and Good Clinical 
Practice (GCP). This trial will be carried out under a Clinical Trial Authorisation in accordance with the 
Medicines for Human Use Clinical Trials regulations. The protocol will be submitted to and approved by 
the main Research Ethics Committee (REC) prior to circulation.  
Before any patients are enrolled into the trial, the Principal Investigator at each site is required to obtain 
local R&D approval. Sites will not be permitted to enrol patients until written confirmation of R&D 
approval is received by the Trials Office.  
It is the responsibility of the Principal Investigator to ensure that all subsequent amendments gain the 
necessary local approval. This does not affect the individual clinicians’ responsibility to take immediate 
action if thought necessary to protect the health and interest of individual patients. 
 
 

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15. CONFIDENTIALITY AND DATA PROTECTION 
Personal data recorded on all documents will be regarded as strictly confidential and will be handled 
and stored in accordance with the General Data Protection Regulation and Data Protection Act 2018 for 
health and care research. The University of Birmingham, as the Sponsor for the ALS study, will be using 
information from patient medical records in order to undertake this trial and will act as the data controller 
for the study. This means that the University of Birmingham are responsible for looking after the 
information and using it properly. University of Birmingham and the NHS will keep identifiable information 
about the patients for at least 25 years after the study has finished, to allow the results of the study to 
be verified if needed.  
 
All information collected by the Sponsor will be securely stored at the Trials Office at the University of 
Birmingham on paper and electronically and will only be accessible by authorised personnel. The only 
people in the University of Birmingham who will have access to information that identifies a patient will 
be people who manage the study or audit the data collection process. 
 
The NHS will use the patient`s name and contact details to contact patients about the research study, 
and make sure that relevant information about the study is recorded for their care, and to oversee the 
quality of the trial. With the patient`s permission, the research team (at site) will notify the patient`s GP 
that they intend to participate in the study.  
 
With the patient’s consent, their full name (on consent form only), initials and date of birth will be 
collected at trial entry. The research team (at site) will send a copy of the signed consent form in the 
post to the Trials Office. This will be used to perform in-house monitoring of the consent process. 
 
In routine communication between the hospital and the Trials Office, the patient will only be identified 
by study number, initials and date of birth. Data may be provided to the Trials Office on paper or 
electronically. 
 
By taking part in the study, the patient will be agreeing to allow research staff from the Trials Office at 
the University of Birmingham to look at the study records, including their medical records. It may be 
necessary to allow authorised personnel from government regulatory agencies (e.g. Medicines and 
Healthcare products Regulatory Agency (MHRA), the Sponsor and/or NHS bodies to have access to 
patient medical and research records. This is to ensure that the study is being conducted to the highest 
possible standards.  Anonymised data from the study may also be provided to other third parties (e.g. 
the manufacturer of the trial treatment) for research, safety monitoring or licensing purposes. 
 
The Investigator must maintain documents not for submission to the Trials Office (e.g. Patient 
Identification Logs) in strict confidence. In the case of specific issues and/or queries from the regulatory 
authorities, it will be necessary to have access to the complete trial records, provided that patient 
confidentiality is protected.  
 
 

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16. INSURANCE AND INDEMNITY  
University of Birmingham employees are indemnified by the University insurers for negligent harm 
caused by the design or co-ordination of the clinical trials they undertake whilst in the University’s 
employment. 
In terms of liability at a site, NHS Trust and non-Trust hospitals have a duty to care for patients treated, 
whether or not the patient is taking part in a clinical trial. Compensation is therefore available via NHS 
indemnity in the event of clinical negligence having been proven. 
The University of Birmingham cannot offer indemnity for non-negligent harm. The University of 
Birmingham is independent of any pharmaceutical company, and as such it is not covered by the 
Association of the British Pharmaceutical Industry (ABPI) guidelines for patient compensation. 
  
17. PUBLICATION POLICY  
Results of this trial will be submitted for publication in a peer reviewed journal. The manuscript will be 
prepared by the Trial Management Group (TMG) and authorship will be determined by mutual 
agreement.  
Any secondary publications and presentations prepared by Investigators must be reviewed by the TMG. 
Manuscripts must be submitted to the TMG in a timely fashion and in advance of being submitted for 
publication, to allow time for review and resolution of any outstanding issues.  Authors must 
acknowledge that the trial was performed with the support of the University of Birmingham.  Intellectual 
property rights will be addressed in the Clinical Study Site Agreement between Sponsor and site. 
 
 

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TikoMed_AB. A randomised, open-label, placebo-controlled, single centre study in healthy 
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Miller RG, Mitchell JD, Lyon M, Moore DH. Riluzole for amyotrophic lateral sclerosis 
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Lacomblez L, Bensimon G, Leigh PN, Guillet P, Meininger V. Dose-ranging study of riluzole in 
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16. 
Walley T. Neuropsychotherapeutics in the UK: what has been the impact of NICE on 
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Gordon PH. Amyotrophic Lateral Sclerosis: An update for 2013 Clinical Features, 
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18. 
Taylor JP, Brown RH, Jr., Cleveland DW. Decoding ALS: from genes to mechanism. Nature. 
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Uppsala Läkarförening Förhandling. 1945;50:397-404. 
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Hiebert LM, Wice SM, Jaques LB, Williams KE, Conly JM. Orally administered dextran sulfate 
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Komai H, Naito Y, Okamura Y. Dextran sulfate as a leukocyte-endothelium adhesion molecule 
inhibitor of lung injury in pediatric open-heart surgery. Perfusion. 2005;20(2):77-82. 
23. 
Fujishima M, Omae T, Tanaka K, Iino K, Matsuo O, Mihara H. Controlled trial of combined 
urokinase and dextran sulfate therapy in patients with acute cerebral infarction. Angiology. 
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24. 
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the pharmacokinetics, safety and local tolerability of low molecular weight dextran sulfate (LMW-DS) 
solution given subcutaneously and intravenously to healthy volunteers. TM-104. 
25. 
NIAID/NIDDK. Open Randomized Multi-Center Study to Evaluate Safety and Efficacy of Low 
Molecular Weight Sulfated Dextran in Islet Transplantation. CIT-01. 
26. 
Maina F, Klein R. Hepatocyte growth factor, a versatile signal for developing neurons. Nat 
Neurosci. 1999;2(3):213-7. 
27. 
Tonges L, Ostendorf T, Lamballe F, Genestine M, Dono R, Koch JC, et al. Hepatocyte growth 
factor protects retinal ganglion cells by increasing neuronal survival and axonal regeneration in vitro 
and in vivo. J Neurochem. 2011;117(5):892-903. 
28. 
Ishigaki A, Aoki M, Nagai M, Warita H, Kato S, Kato M, et al. Intrathecal delivery of hepatocyte 
growth factor from amyotrophic lateral sclerosis onset suppresses disease progression in rat 
amyotrophic lateral sclerosis model. J Neuropathol Exp Neurol. 2007;66(11):1037-44. 
29. 
Sun W, Funakoshi H, Nakamura T. Overexpression of HGF retards disease progression and 
prolongs life span in a transgenic mouse model of ALS. J Neurosci. 2002;22(15):6537-48. 
30. 
Pan W, Yu Y, Yemane R, Cain C, Yu C, Kastin AJ. Permeation of hepatocyte growth factor 
across the blood-brain barrier. Exp Neurol. 2006;201(1):99-104. 
31. 
Tsuboi Y, Kakimoto K, Akatsu H, Daikuhara Y, Yamada T. Hepatocyte growth factor in 
cerebrospinal fluid in neurologic disease. Acta Neurol Scand. 2002;106(2):99-103. 
32. 
Schmidt P, Magnusson C, Lundgren T, Korsgren O, Nilsson B. Low molecular weight dextran 
sulfate is well tolerated in humans and increases endogenous expression of islet protective 
hepatocyte growth factor. Transplantation. 2008;86(11):1523-30. 
33. 
Redoxis_AB. Tolerability study of Tikomed lead compound after s.c. administration in rat; 
2013b. Report No. RX0113B. 
34. 
TikoMed_AB. Evaluation of different doses of LMW-DS on mobilisation of white blood cells 
and hepatocyte growth factor. 2012c. Report No. TM-MOB-REP-013. 
35. 
TikoMed_AB. Evaluation of low dose LMW-DS on hepatocyte growth factor and on 
mobilisation of white blood cells at different time points. 2012d. Report No. TM-MOBREP-014. 
36. 
TikoMed_AB. Effect of LMW-DS administration to healthy volunteers on plasma concentration 
of brain-derived neurotrophic factor (BDNF). TM-REP-HEX-002, 2014. 15 October 2014. 
37. 
Tadic V, Malci A, Goldhammer N, Stubendorff B, Sengupta S, Prell T, et al. Sigma 1 receptor 
activation modifies intracellular calcium exchange in the G93A(hSOD1) ALS model. Neuroscience. 
2017;359:105-18. 
38. 
Finland CRD. The Effect of Compound TM1 or TM2 on MOG1-125 Induced Chronic EAE in 
Rats. C144113, 2013. 23 October 2013. 
39. 
Redoxis_AB. Efficacy validation in an animal model of multiple sclerosis i.e. MOG35-55 
induced Experimental Autoimmune Encephalomyelitis (EAE) in mice. RX0083C, 2013. 18 January 
2013(12 April 2013). 
40. 
Pharmaseed_Ltd. Angiogenic efficacy of TM-700 in the rat stroke model – Transient Middle 
Cerebral Artery Occlusion.  TKM-003-EF, 2014.  29 October 2014. 
41. 
Pharmaseed_Ltd. Evaluation of angiogenesis in critical hind-limb ischemia mouse model 
TKM-001-EF, 2014.  8 March 2014. 
42. 
Pharmaseed_Ltd. The effect of TM-700 on angiogenesis in a mouse model of critical limb 
ischemia. TKM-002-EF, 2014. 27 November 2014. 
43. 
Pharmaseed_Ltd. Evaluation of TM-700 angiogenesis efficacy in a critical hind-limb ischemia 
mouse model TKM-005-EF, 2014. 29 January 2015. 
44. 
Pharmaseed_Ltd. Angiogenesis efficacy of TM-700 in the rat hind-limb ischemia model TKM- 
004-EF, 2014. 4 May 2015. 49. 
45. 
Dupuis L, Pradat PF, Ludolph AC, Loeffler JP. Energy metabolism in amyotrophic lateral 
sclerosis. Lancet Neurol. 2011;10(1):75-82. 

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46. 
Guo Z, Kindy MS, Kruman I, Mattson MP. ALS-linked Cu/Zn-SOD mutation impairs cerebral 
synaptic glucose and glutamate transport and exacerbates ischemic brain injury. J Cereb Blood Flow 
Metab. 2000;20(3):463-8. 
47. 
Waldemar G, Vorstrup S, Jensen TS, Johnsen A, Boysen G. Focal reductions of cerebral 
blood flow in amyotrophic lateral sclerosis: a [99mTc]-d,l-HMPAO SPECT study. J Neurol Sci. 
1992;107(1):19-28. 
48. 
Zhong Z, Deane R, Ali Z, Parisi M, Shapovalov Y, O'Banion MK, et al. ALS-causing SOD1 
mutants generate vascular changes prior to motor neuron degeneration. Nat Neurosci. 
2008;11(4):420-2. 
49. 
Organ SL, Tsao MS. An overview of the c-MET signaling pathway. Ther Adv Med Oncol. 
2011;3(1 Suppl):S7-S19. 
50. 
Bhaskar S, Bradley S, Israeli-Korn S, Menon B, Chattu VK, Thomas P, et al. Chronic 
Neurology in COVID-19 Era: Clinical Considerations and Recommendations From the REPROGRAM 
Consortium. Front Neurol. 2020;11:664. 
51. 
Miyazaki K, Masamoto K, Morimoto N, Kurata T, Mimoto T, Obata T, et al. Early and 
progressive impairment of spinal blood flow-glucose metabolism coupling in motor neuron 
degeneration of ALS model mice. J Cereb Blood Flow Metab. 2012;32(3):456-67. 
52. 
Atassi N, Berry J, Shui A, Zach N, Sherman A, Sinani E, et al. The PRO-ACT database: 
design, initial analyses, and predictive features. Neurology. 2014;83(19):1719-25. 
53. 
Cudkowicz ME, van den Berg LH, Shefner JM, Mitsumoto H, Mora JS, Ludolph A, et al. 
Dexpramipexole versus placebo for patients with amyotrophic lateral sclerosis (EMPOWER): a 
randomised, double-blind, phase 3 trial. Lancet Neurol. 2013;12(11):1059-67. 
54. 
Epton J, Harris R, Jenkinson C. Quality of life in amyotrophic lateral sclerosis/motor neuron 
disease: a structured review. Amyotroph Lateral Scler. 2009;10(1):15-26. 
55. 
Jenkinson C, Levvy G, Fitzpatrick R, Garratt A. The amyotrophic lateral sclerosis assessment 
questionnaire (ALSAQ-40): tests of data quality, score reliability and response rate in a survey of 
patients. J Neurol Sci. 2000;180(1-2):94-100. 
56. 
Jenkinson C, Peto V, Jones G, Fitzpatrick R. Interpreting change scores on the Amyotrophic 
Lateral Sclerosis Assessment Questionnaire (ALSAQ-40). Clin Rehabil. 2003;17(4):380-5. 
57. 
Miller RG, Rosenberg JA, Gelinas DF, Mitsumoto H, Newman D, Sufit R, et al. Practice 
parameter: the care of the patient with amyotrophic lateral sclerosis (an evidence-based review): 
report of the Quality Standards Subcommittee of the American Academy of Neurology: ALS Practice 
Parameters Task Force. Neurology. 1999;52(7):1311-23. 
 
 

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APPENDIX 1 – ALS FUNCTIONAL RATING SCALE REVISED (ALSFRS-R) 
 
Date:………………………………Name patient:…………………………………Date of Birth…………….. 
Patient`s number……………………………………………………………………Right-/left-handed 
 
 
 
  
 
 
  
 
 
   
 
 
  
 
 
  
 
 
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
  
 
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
 
 
  
 
  
 
  
 
  
 
  
 
 
 
 
 
 
   
 
 
  
 
 
  
 

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Interviewer`s name…………………………………………………………………………………………….. 
 
 
 
 
 
ALS Functional Rating Scale Revised (ALS-FRS-R) Version: May 2015 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX 2 - WMA DECLARATION OF HELSINKI  
WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI 
Recommendations guiding physicians in biomedical research involving human subjects 
Adopted by the 18th World Medical Assembly Helsinki, Finland, June 1964and amended by the29th 
World Medical Assembly, Tokyo, Japan, October 1975, 35th World Medical Assembly, Venice, Italy, 
October 1983, 41st World Medical Assembly, Hong Kong, September 1989 and the 48th General 
Assembly, Somerset West, Republic of South Africa, October 1996 
 
INTRODUCTION 
It is the mission of the physician to safeguard the health of the people. His or her knowledge and 
conscience are dedicated to the fulfilment of this mission. 
The Declaration of Geneva of the World Medical Association binds the physician with the words, "The 
Health of my patient will be my first consideration," and the International Code of Medical Ethics declares 
that, "A physician shall act only in the patient's interest when providing medical care which might have 
the effect of weakening the physical and mental condition of the patient." 
The purpose of biomedical research involving human subjects must be to improve diagnostic, 
therapeutic and prophylactic procedures and the understanding of the aetiology and pathogenesis of 
disease. 
In current medical practice most diagnostic, therapeutic or prophylactic procedures involve hazards. 
This applies especially to biomedical research. 
Medical progress is based on research which ultimately must rest in part on experimentation involving 
human subjects. 
In the field of biomedical research a fundamental distinction must be recognized between medical 
research in which the aim is essentially diagnostic or therapeutic for a patient, and medical research, 
the essential object of which is purely scientific and without implying direct diagnostic or therapeutic 
value to the person subjected to the research. 
Special caution must be exercised in the conduct of research which may affect the environment, and 
the welfare of animals used for research must be respected. 
Because it is essential that the results of laboratory experiments be applied to human beings to further 
scientific knowledge and to help suffering humanity, the World Medical Association has prepared the 
following recommendations as a guide to every physician in biomedical research involving human 
subjects. They should be kept under review in the future. It must be stressed that the standards as 
drafted are only a guide to physicians all over the world. Physicians are not relieved from criminal, civil 
and ethical responsibilities under the laws of their own countries. 
 
I. BASIC PRINCIPLES 
1. Biomedical research involving human subjects must conform to generally accepted scientific 
principles and should be based on adequately performed laboratory and animal experimentation 
and on a thorough knowledge of the scientific literature. 
2. The design and performance of each experimental procedure involving human subjects should be 
clearly formulated in an experimental protocol which should be transmitted for consideration, 
comment and guidance to a specially appointed committee independent of the investigator and the 
sponsor provided that this independent committee is in conformity with the laws and regulations of 
the country in which the research experiment is performed. 
3. Biomedical research involving human subjects should be conducted only by scientifically qualified 
persons and under the supervision of a clinically competent medical person. The responsibility for 

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the human subject must always rest with a medically qualified person and never rest on the subject 
of the research, even though the subject has given his or her consent. 
4. 4. Biomedical research involving human subjects cannot legitimately be carried out unless the 
importance of the objective is in proportion to the inherent risk to the subject. 
5. Every biomedical research project involving human subjects should be preceded by careful 
assessment of predictable risks in comparison with foreseeable benefits to the subject or to others. 
Concern for the interests of the subject must always prevail over the interests of science and society. 
6. The right of the research subject to safeguard his or her integrity must always be respected. Every 
precaution should be taken to respect the privacy of the subject and to minimize the impact of the 
study on the subject's physical and mental integrity and on the personality of the subject. 
7. Physicians should abstain from engaging in research projects involving human subjects unless they 
are satisfied that the hazards involved are believed to be predictable. Physicians should cease any 
investigation if the hazards are found to outweigh the potential benefits. 
8. In publication of the results of his or her research, the physician is obliged to preserve the accuracy 
of the results. Reports of experimentation not in accordance with the principles laid down in this 
Declaration should not be accepted for publication. 
9. In any research on human beings, each potential subject must be adequately informed of the aims, 
methods, anticipated benefits and potential hazards of the study and the discomfort it may entail. 
He or she should be informed that he or she is at liberty to abstain from participation in the study 
and that he or she is free to withdraw his or her consent to participation at any time. The physician 
should then obtain the subject's freely-given informed consent, preferably in writing. 
10. When obtaining informed consent for the research project the physician should be particularly 
cautious if the subject is in a dependent relationship to him or her or may consent under duress. In 
that case the informed consent should be obtained by a physician who is not engaged in the 
investigation and who is completely independent of this official relationship. 
11. In case of legal incompetence, informed consent should be obtained from the legal guardian in 
accordance with national legislation. Where physical or mental incapacity makes it impossible to 
obtain informed consent, or when the subject is a minor, permission from the responsible relative 
replaces that of the subject in accordance with national legislation. Whenever the minor child is in 
fact able to give a consent, the minor's consent must be obtained in addition to the consent of the 
minor's legal guardian. 
12. The research protocol should always contain a statement of the ethical considerations involved and 
should indicate that the principles enunciated in the present Declaration are complied with. 
II. MEDICAL RESEARCH COMBINED WITH PROFESSIONAL CARE 
 (Clinical Research) 
1. In the treatment of the sick person, the physician must be free to use a new diagnostic and 
therapeutic measure, if in his or her judgement it offers hope of saving life, re-establishing health or 
alleviating suffering. 
2. The potential benefits, hazards and discomfort of a new method should be weighed against the 
advantages of the best current diagnostic and therapeutic methods. 
3. In any medical study, every patient - including those of a control group, if any - should be assured 
of the best proven diagnostic and therapeutic method. This does not exclude the use of inert placebo 
in studies where no proven diagnostic or therapeutic method exists. 

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4. The refusal of the patient to participate in a study must never interfere with the physician-patient 
relationship. 
5. If the physician considers it essential not to obtain informed consent, the specific reasons for this 
proposal should be stated in the experimental protocol for transmission to the independent 
committee (I, 2). 
6. The physician can combine medical research with professional care, the objective being the 
acquisition of new medical knowledge, only to the extent that medical research is justified by its 
potential diagnostic or therapeutic value for the patient. 
III. NON-THERAPEUTIC BIOMEDICAL RESEARCH INVOLVING HUMAN 
SUBJECTS (Non-Clinical Biomedical Research) 
7. In the purely scientific application of medical research carried out on a human being, it is the duty of 
the physician to remain the protector of the life and health of that person on whom biomedical 
research is being carried out. 
8. The subject should be volunteers - either healthy persons or patients for whom the experimental 
design is not related to the patient's illness. 
9. The investigator or the investigating team should discontinue the research if in his/her or their 
judgement it may, if continued, be harmful to the individual. 
10. In research on man, the interest of science and society should never take precedence over 
considerations related to the wellbeing of the subject. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX 3 - DEFINITION OF ADVERSE EVENTS  
Adverse Event 
Any untoward medical occurrence in a patient or clinical trial subject administered a medicinal product 
and which does not necessarily have a causal relationship with this treatment. 
Comment:  
An AE can therefore be any unfavourable and unintended sign (including abnormal laboratory findings), 
symptom or disease temporally associated with the use of an investigational medicinal product, whether 
or not related to the investigational medicinal product. 
 
Adverse Reaction 
All untoward and unintended responses to an IMP related to any dose administered.  
Comment:  
An AE judged by either the reporting Investigator or Sponsor as having causal relationship to the IMP 
qualifies as an AR. The expression reasonable causal relationship means to convey in general that 
there is evidence or argument to suggest a causal relationship. 
 
Serious Adverse Event  
Any untoward medical occurrence or effect that at any dose:  
• 
Results in death  
• 
Is life-threatening* 
• 
Requires hospitalisation** or prolongation of existing inpatients’ hospitalisation 
• 
Results in persistent or significant disability or incapacity  
• 
Is a congenital anomaly/birth defect 
• 
Or is otherwise considered medically significant by the Investigator*** 
Comments:  
The term severe is often used to describe the intensity (severity) of a specific event. This is not the same 
as serious, which is based on patients/event outcome or action criteria. 
* Life threatening in the definition of an SAE refers to an event in which the patient was at risk of death 
at the time of the event; it does not refer to an event that hypothetically might have caused death if it 
were more severe. 
**Hospitalisation is defined as an unplanned, formal inpatient admission, even if the hospitalisation is a 
precautionary measure for continued observation. Thus, hospitalisation for protocol treatment (e.g. line 
insertion), elective procedures (unless brought forward because of worsening symptoms) or for social 
reasons (e.g. respite care) are not regarded as an SAE. 
*** Medical judgment should be exercised in deciding whether an AE is serious in other situations. 
Important AEs that are not immediately life threatening or do not result in death or hospitalisation but 
may jeopardise the subject or may require intervention to prevent one of the other outcomes listed in 
the definition above, should be considered serious. 
 
Serious Adverse Reaction  
An Adverse Reaction which also meets the definition of a Serious Adverse Event. 
 
Suspected Unexpected Serious Adverse Reaction 
A SAR that is unexpected i.e. the nature, or severity of the event is not consistent with the applicable 
product information. 

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A SUSAR should meet the definition of an AR, UAR and SAR. 
 
Unexpected Adverse Reaction 
An AR, the nature or severity of which is not consistent with the applicable product information (e.g. 
Investigator Brochure for an unapproved IMP or (compendium of) Summary of Product Characteristics 
(SPC) for a licensed product).  
When the outcome of an AR is not consistent with the applicable product information the AR should be 
considered unexpected. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX 4 - COMMON TOXICITY CRITERIA GRADINGS 
Toxicities will be recorded according to the Common Terminology Criteria for Adverse Events (CTCAE), 
version 4.0 (4.03 corrected).  The full CTCAE document is available on the National Cancer Institute 
(NCI) website. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX 5 – LIVER SAFETY REQUIRED ACTIONS AND FOLLOW-UP 
ASSESSMENTS 
 
Phase II liver chemistry increased monitoring criteria have been designed to assure subject safety 
and evaluate liver event aetiology (in alignment with the FDA premarketing clinical liver safety guidance). 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM174
090.pdf. 
  
Phase II liver chemistry increased monitoring criteria and required follow up 
assessments Liver Chemistry Increased Monitoring Criteria  
ALT-absolute  
ALT > 5xULN  
ALT Increase  
ALT >  3xULN persists for 4 weeks  
Bilirubin1, 2  
ALT > 3xULN and bilirubin  2xULN (>35% 
direct bilirubin)  
INR2  
ALT > 3xULN and INR>1.5, if INR measured  
Cannot Monitor  
ALT > 3xULN and cannot be monitored 
weekly for 4 weeks  
Symptomatic3  
ALT > 3xULN associated with symptoms (new 
or worsening) believed to be related to liver 
injury or hypersensitivity  
Required Actions and Follow up Assessments following ANY Liver Event  
Actions  
Follow Up Assessments  
 
• 
Report the event to Trials Office 
within 72 hours  
• 
Complete the liver event CRF and 
complete an SAE - if the event also 
meets the criteria for an SAE  
• 
Perform liver event follow up 
assessments  
• 
Monitor the subject until liver 
chemistries resolve, stabilize, or 
return to within baseline (see 
MONITORING below). “Baseline” 
refers to the laboratory assessments 
performed closest and prior to dosing 
of study treatment.  
MONITORING:  
For bilirubin or INR criteria:  
• 
Repeat liver chemistries (include ALT, 
AST, alkaline phosphatase, bilirubin) 
and perform liver event follow up 
assessments within 24 hrs  
 
• 
Viral hepatitis serology4  
• 
Blood sample for pharmacokinetic 
(PK) analysis, obtained within 7after 
an identified liver event if within 6 
months post dose.5  
• 
Serum creatine phosphokinase (CPK) 
and lactate dehydrogenase (LDH).  
• 
Fractionate bilirubin, if total bilirubin 
2xULN  
• 
Obtain complete blood count with 
differential to assess eosinophilia  
 
 
 
 
• 
Record the appearance or worsening 
of clinical symptoms of liver injury, or 
hypersensitivity, on the AE report 
form  

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• 
Monitor subjects twice weekly until 
liver chemistries resolve, stabilize or 
return to within baseline  
• 
A specialist or hepatology 
consultation is recommended  
 
For All other criteria:  
• 
Repeat liver chemistries (include ALT, 
AST, alkaline phosphatase, bilirubin) 
and perform liver event follow up 
assessments within 24-72 hrs  
• 
Monitor subjects weekly until liver 
chemistries resolve, stabilize or return 
to within baseline  
 
 
• 
Record use of concomitant 
medications on the concomitant 
medications report form including 
acetaminophen, herbal remedies, 
other over the counter medications.  
• 
Record alcohol use on the liver event 
alcohol intake case report form  
For bilirubin or INR criteria:  
• 
Anti-nuclear antibody, anti-smooth 
muscle antibody, Type 1 anti-liver 
kidney microsomal antibodies, and 
quantitative total immunoglobulin G 
(IgG or gamma globulins).  
• 
Serum acetaminophens adduct HPLC 
assay (quantifies potential 
acetaminophen contribution to liver 
injury in subjects with definite or likely 
acetaminophen use in the preceding 
week [James, 2009]).  
• 
Liver imaging (ultrasound, magnetic 
resonance, or computerised 
tomography) and /or liver biopsy to 
evaluate liver disease; complete Liver 
Imaging and/or Liver Biopsy CRF 
forms.  
 
1.    Serum bilirubin fractionation should be performed if testing is available. If serum bilirubin 
fractionation is not immediately available, discontinue study treatment for that subject if ALT 3xULN and 
bilirubin 2xULN. Additionally, if serum bilirubin fractionation testing is unavailable, record presence of 
detectable urinary bilirubin on dipstick, indicating direct bilirubin elevations and suggesting liver 
injury. 
2.    All events of ALT > 3xULN and bilirubin > 2xULN (>35% direct bilirubin) or ALT > 3xULN and 
INR>1.5, if INR measured which may indicate severe liver injury (possible ‘Hy’s Law’), must be reported 
as an SAE (excluding studies of hepatic impairment or cirrhosis); INR measurement is not required 
and the threshold value stated will not apply to subjects receiving anticoagulants 
3.    New or worsening symptoms believed to be related to liver injury (such as fatigue, nausea, vomiting, 
right upper quadrant pain or tenderness, or jaundice) or believed to be related to hypersensitivity (such 
as fever, rash or eosinophilia) 
4.    Includes: 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 
5.    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 cannot be approximated OR a PK 
sample cannot be collected in the time period indicated above, do not obtain a PK sample.  
 
 
 

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APPENDIX 6 – ALS ASSESSMENT QUESTIONNAIRE (ALSAQ-40)  
 
                                  
 
The research commercialisation office of the 
University of Oxford, previously called Isis Innovation, 
has been renamed Oxford University Innovation 
 
 
 
All documents and other materials will be updated 
accordingly. In the meantime the remaining content of this 
Isis Innovation document is still valid. 
 
 
URLs beginning www.isis-innovation.com/... are automatically 
redirected to our new domain, www.innovation.ox.ac.uk/... 
 
 
Phone numbers and email addresses for 
individual members of staff are unchanged 
 
 
Email: enquiries@innovation.ox.ac.uk 
 
 
 
 
 

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APPENDIX 7 – EQUATION FOR ESTIMATED GLOMERULAR FILTRATION RATE 
 
 
COCKCROFT-GAULT 
 
Creatinine clearance (estimated GFR) = ([(140 - age in years) x (wt in kg)] x 1.23)  
 
 
 
 
 
 
                   (serum creatinine in micromol/l) 
 
 
 
 
 
 
 
 

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APPENDIX 8 – HMA CTFG GUIDELINES ON CONTRACEPTION 
 
Birth control methods which may be considered as highly effective 
 
For the purpose of this guidance, methods that can achieve a failure rate of less than 1% per 
year when used consistently and correctly are considered as highly effective birth control 
methods. Such methods include: 
• 
combined (oestrogen and progestogen containing) hormonal contraception associated with 
inhibition of ovulation1 
o oral 
o intravaginal 
o transdermal 
• 
progestogen-only hormonal contraception associated with inhibition of ovulation1: 
o oral 
o injectable 
o implantable2 
• 
intrauterine device (IUD)2 
• 
intrauterine hormone-releasing system ( IUS)2 
• 
bilateral tubal occlusion2 
• 
vasectomised partner2,3 
• 
sexual abstinence4 
 
Acceptable birth control methods which may not be considered as highly effective  
 
Acceptable birth control methods that result in a failure rate of more than 1% per year include:  
 
• 
progestogen-only oral hormonal contraception, where inhibition of ovulation is not the primary 
mode of action  
• 
male or female condom with or without spermicide 
• 
cap, diaphragm or sponge with spermicide5 
 
Assessment of pharmacokinetic interaction between the IMP and hormonal Contraceptives and 
recommendations on the use of hormonal contraceptives 
 
For hormonal contraception methods, caution should be taken to possible interaction with a 
(Non-biologic) IMP. Interaction with the IMP leading to reduced efficacy of the hormonal 
contraception method can occur due to e.g. increased metabolism (enzyme induction). 
 
Birth control methods which are considered unacceptable in clinical trials 
 
Periodic abstinence (calendar, symptothermal, post-ovulation methods), withdrawal (coitus 
interruptus), spermicides only, and lactational amenorrhoea method (LAM) are not acceptable 
methods of contraception. Female condom and male condom should not be used together. 
 
 
 
 
 

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1 Hormonal contraception may be susceptible to interaction with the IMP, which may reduce the efficacy of the contraception 
method (see Section xx) 
2 Contraception methods that in the context of this guidance are considered to have low user dependency.  
3 Vasectomised partner is a highly effective birth control method provided that partner is the sole sexual partner of the WOCBP 
trial participant and that the vasectomised partner has received medical assessment of the surgical success.  
4 In the context of this guidance sexual abstinence is considered a highly effective method only if defined as refraining from 
heterosexual intercourse during the entire period of risk associated with the study treatments. The reliability of sexual abstinence 
needs to be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle of the subject.  
5 A combination of male condom with either cap, diaphragm or sponge with spermicide (double barrier methods) are also 
considered acceptable, but not highly effective, birth control methods  
 
 
 
 
 

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APPENDIX 9 – EL ESCORIAL WORLD FEDERATION OF NEUROLOGY 
CRITERIA FOR THE DIAGNOSIS OF ALS 
 
Criteria for the diagnosis of Amyotrophic Lateral Sclerosis 
 
The diagnoses of ALS requires the presence of 
 
1) Signs of lower motor neuron (LMN) degeneration by clinical, electrophysiological or 
neuropathologic examination, 
2) Signs of upper motor neuron (UMN) degeneration by clinical examination, and 
3) Progressive spread of signs within a region or to other regions, together with the absence of 
4) Electrophysiological evidence of other disease processes that might explain the signs of 
LMN and/or UMN degenerations; and 
5) Neuroimaging evidence of other disease processes that might explain the observed clinical 
and electrophysiological signs. 
 
Steps in the diagnosis of Amyotrophic Lateral Sclerosis 
 
The diagnoses of ALS is made possible by 
 
1) History, physical and appropriate neurological examinations to ascertain clinical finding 
which may suggest suspected, possible, probable or definite ALS, 
2) Electrophysiological examinations to ascertain findings which confirm LMN degeneration in 
clinically involved regions, identify LMN degeneration in clinically uninvolved regions and 
exclude other disorders, 
3) Neuroimaging examinations to ascertain findings which may exclude other disease 
processes, 
4) Clinical laboratory examinations, determined by clinical judgment, to ascertain possible 
ALS-related syndromes, 
5) Neuropathologic examinations, where appropriate, to ascertain findings which may confirm 
or exclude sporadic ALS, coexistent sporadic ALS, ALS-related syndromes or ALS variants, 
6) Repetition of clinical and electrophysiological examinations at least six months apart to 
ascertain evidence of progression. 
 
Clinical features in the diagnosis of ALS 
 
Patients with signs of LMN degeneration (weakness, atrophy and clinical fasciculation’s) and UMN 
degeneration (spasticity, pathologic reflexes, etc.) may be suspected as having ALS. Careful history,  
 
 

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physical and neurological examination must search for further clinical evidence of LMN and UMN 
signs in four regions of the central nervous system. 
 
 
Clinical features required for the diagnosis of ALS 
 
1) Signs of LMN degeneration (weakness, wasting and fasciculation) in one or more of the four 
regions (bulbar, cervical, thoracic, lumbosacral). LMN findings in a region are without 
regard to right or left, but 
are indicative of the level of neuraxis involved. Therefore, spread of weakness, wasting and 
fasciculation’s to another region is more important than spread from right to left or vice-
versa. 
2) Signs of UMN degeneration (increased or donic tendon reflexes, spasticity, pseudo bulbar 
features, Hoffmann reflex and extensor plantar response) in one or more of the four regions. 
These UMN signs are clinically appreciated best in the bulbar, cervical and lumbosacral 
regions.  UMN findings in a region are also without regard to right or left. Once the 
physical and neurological examinations provide information on the presence or absence of 
LMN and UMN signs in the four regions (bulbar, cervical, thoracic, lumbosacral) they must 
be ordered topographically in the manner to determine the certainty of the diagnosis of 
ALS. 
3) The topographical location of certain UMN and LMN signs in four regions of the CNS 
together with progression of these signs determines the certainty of the diagnoses of 
ALS. Progression is a cardinal feature of the clinical diagnosis of ALS. Progression of 
signs within a region and progression of signs to involve other regions are crucial to the 
diagnosis. 
 
Clinical examinations should be repeated at least every six (6) months to assess progression. 
 
Cases which meet the topographical criteria for probable or definite ALS but which lack progression 
during the twelve (12) month period diagnosis should be designated as possible ALS. 
 
Definite ALS 
is defined on clinical grounds alone by the presence of UMN as well as LMN signs in the bulbar region 
and at least two of the other spinal regions or the presence of UMN and LMN signs in three spinal 
regions. The important determinants of diagnosis of definite ALS in the absence of 
electrophysiological, neuroimaging and laboratory examinations are the presence of UMN and LMN 
signs together in multiple regions. 
 
 

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Probable ALS 
is defined on clinical grounds alone by UMN and LMN signs in at least two regions. While the regions 
may be different, some UMN signs must be rostral (above) the LMN signs. Multiple different 
combinations of UMN and LMN signs may be present in patients with probable ALS. 
 
Possible ALS 
is defined on clinical grounds alone when the UMN and LMN signs are in only one region or UMN 
signs alone are present in 2 or more regions or LMN signs are rostral to UMN signs (the latter 
distribution of signs needs to be differentiated from multiple non-ALS processes). Monomelic ALS, 
progressive bulbar palsy without spinal UMN and/or LMN signs and progressive primary lateral 
sclerosis without spinal LMN signs and progressive primary lateral sclerosis without spinal LMN signs 
constitute special cases which may develop LMN or UMN signs to meet the criteria for probable ALS 
with time or be subsequently confirmed at autopsy by specific LMN and UMN neuropathologic 
findings. 
 
Suspected ALS 
will manifest only LMN signs in 2 or more regions, although UMN pathology might be demonstrated 
at autopsy. However, only clinical signs are considered pertinent to this classification at the time of 
diagnostic evaluation. 
 
Supportive clinical features 
Clinical features that support the diagnosis of ALS include one or more of the following: 
 
1) abnormal pulmonary function test not explained by other causes, 
2) abnormal speech studies not explained by other causes, 
3) abnormal swallowing studies not explained by other causes, 
4) abnormal larynx function studies not explained by other causes, 
5) abnormal isokinetic or isometric strength test in clinically uninvolved muscles, 
6) abnormal muscle biopsy with evidence of denervation. 
 
Inconsistent clinical features 
Clinical findings inconsistent with the diagnoses of ALS include one or more of the following not 
explained by physiological changes associated with aging or other disease processes: 
 
 

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1) sensory dysfunction, 
2) sphincter abnormalities, 
3) autonomic nervous system dysfunction, 
4) anterior visual pathway abnormalities, 
5) movement abnormalities associated with probable Parkinson’s disease defined by 
DATATOP criteria, 
6) cognitive abnormalities associated with clinical Alzheimer’s disease as defined by NINCDS-
ADRDA criteria. 
 
If these clinical findings occur, then close attention should be paid to the possible diagnosis of other 
disease processes. 
 
Lower motor neuron and upper motor neuron signs may occur together with other clinical signs in 
disease where the pathologic process is not primary motor neuron degeneration. 
 
Types of ALS 
 
The clinical signs of progressive LMN and UMN degeneration seen in ALS may 
a) occur alone (sporadic ALS), 
b) be present incidentally with other pre-existing disease processes that have not developed 
in parallel with the ALS (coexistent sporadic ALS), 
c) Occur in association with laboratory-defined or epidemiologically defined abnormalities 
that are time- linked to the ALS (ALS-related syndromes), or 
d) Occur in association with clinical, genetic or epidemiological features which develop in 
parallel with the ALS (ALS variants). 
 
The physical and neurological examinations will allow for the clinical diagnosis of ALS to a particular 
degree of certainty as defined above; however, the history of the disease onset, toxic exposures, past 
medical history, injuries, family history, geographic location, etc., must be incorporated with the 
clinical examinations in determining whether the patient may have an ALS related syndrome or an 
ALS variant. 
 
ALS-related syndromes must meet the clinical, electrophysiological and neuroimaging criteria for 
possible, probable or definite ALS.  ALS-related syndromes have unique laboratory-defined or 
epidemiologically defined features which are time-linked to the development of the ALS phenotype.  
If correction of the associated laboratory feature does not result in correction of the ALS phenotype, 
then the patient with an ALS-related syndrome should be considered in the same way as a patient with 
sporadic ALS. 
 
 

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ALS-related syndromes include 
1) Monoclonal gammopathy (monoclonal gammopathy of unknown significance, 
Waldenstroms’s macroglobulinemia, osteosclerotic myeloma, etc.), 
2) Dysimmune motor system degeneration (autoimmune; high-titer GMI ganglioside antibody; 
etc.), 
3) Nonmalignant endocrine abnormalities (hyperthyroidism, hyperparathyroidism, 
hypogonadism, etc.), 
4) Lymphoma (Hodgkin’s and non-Hodgkin’s lymphoma). Cases of sporadic ALS associated 
with insulinoma, lung, colon or thyroid cancer are thought not to be casually related, 
5) Infection (HIV-1, HTLV-I, encephalitis lethargica, varicella-zoster, brucellosis, cat-scratch 
disease, Creutzfeldt-Jakob disease, syphilis, delayed post-poliomyelitis, etc.), 
6) Acquired enzyme defects (detoxification enzymes, etc.), 
7) Exogenous toxins (lead, mercury, arsenic, thallium, cadmium, manganese, aluminum, 
organic pesticides, lupin seeds, etc.), 
8) Physical injury (electric shock, radiation therapy, etc.), 
9) Vascular (vasculitis; ischemic (Dejerine anterior bulbar artery syndrome, etc.), 
10) Spondylotic myelopathy (painless myelopathy with no sensory signs, stabilization or 
progression post- surgery). 
 
ALS Variants must meet the clinical, electrophysiological and neuroimaging criteria for possible, 
probable or definite ALS.  The predominant presentation is that seen in sporadic ALS, but includes 
one or more features such as: 
 
1) 
Familial pattern of inheritance (multiple phenol-types characterized by age of onset; site of 
onset; length of survival; and presumed type of inheritance.) 
 
Familial ALS variants in genetic linkage studies should be characterized by an established genetic 
mode of inheritance over at least two generations and at least one clinically definite or autopsy 
confirmed case and compelling evidence excluding other possible causes. Affected sub pairs occurring 
in one generation alone may not result from a single gene effect. 
 
Examples: 
a) ALS with defined inheritance and known gene product (hexosaminidase A/B deficiency, 
superoxide dismutase deficiency) 
b) ALS with defined inheritance and chromosome linkage but no gene product 
(chromosome 21 associated familial ALS or chromosome 2 associated juvenile familial 
ALS) 
 
 
 

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c) ALS with defined inheritance and no known linkage or gene product (most cases or 
familial ALS). 
2) 
Geographic clustering (including disorders seen in the Western Pacific, Guam, Kii Peninsula, 
North Africa, Madras, etc.) 
3) 
Extrapyramidal signs (bradykinesia; cogwheel rigidity; tremor; clinically significant onset of 
supranuclear eye signs (pursuit abnormalities); familial or sporadic) 
4) 
Cerebellar degeneration (spinocerebellar abnormalities; familial or sporadic) 
5) 
Dementia (progressive cognitive abnormalities; familial or sporadic) 
6) 
Autonomic nervous system involvement (clinically significant abnormal cardiovascular 
reflexes; bowel or bladder control problems; familial or sporadic) 
7) 
Objective sensory abnormalities (decreased vibration; sharp-dull discrimination; blunting of 
cold sensation; familial or sporadic) 
 
Electrophysiological features in the diagnoses of ALS 
 
Patients with suspected, possible, probable or definite ALS on clinical grounds should have 
electrophysiological studies performed to confirm LMN degeneration in clinically affected regions, 
find electrophysiological evidence of LMN degeneration in clinically uninvolved regions and to 
exclude other pathophysiological processes. 
 
ALS may be most reliably identified when the clinical and electrophysiological findings are 
widespread, involving a sufficient number of regions so that other possible cause of similar EMG 
abnormalities are highly unlikely. The confirmation of the diagnosis of ALS depends on finding 
electrophysiological evidence of LMN degeneration in at least two muscles of different root or spinal 
nerves and different cranial or peripheral nerve innervation in two or more of the four (bulbar, 
cervical, thoracic, lumbosacral) regions. The features of LMN degeneration in a particular muscle are 
defined by electromyographic needle examination and nerve conduction studies using standard 
methods for each measure. 
 
Electrophysiological features required to identify definite primary LMN degeneration include all of 
the following: 
 
1) Reduced recruitment (reduced interference pattern with firing rates over 10 Hz), 
2) Large motor unit action potentials (large amplitude, long duration), and 
3) Fibrillation potentials. 
 
Electrophysiological features that support the identification of possible primary LMN degeneration 
include one or more of the following: 
 
 
 

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1) either reduced recruitment, large motor unit potentials, fibrillation potentials or unstable 
motor unit potentials alone, 
2) polyphasic motor unit potentials or increased single fiber density alone, 
3) low amplitude compound muscle actions potentials if the disease duration is over 5 years or 
if there is associated atrophy, 
4) low amplitude compound muscle action potentials, 
5) compound muscle action potential change between proximal and distal sites of stimulation 
that is uniform along the length of the nerve, 
6) up to 30% decrement in motor conduction velocity below established normal values if a low 
amplitude compound muscle action potential greater than 10 percent of normal is present, 
7) up to 50% decrement in motor conduction velocity below established normal values if the 
compound muscle action potential is below 10% or normal,, 
8) up to 20% decrement of the compound muscle action potential on 2 Hz repetitive 
stimulation, 
9) up to 10% decrement in sensory nerve conduction velocity and action potential amplitude 
from established normal values, 
10) complex repetitive discharges, and 
11) absence of fasciculations. 
 
Electrophysiological features compatible with UMN degeneration and not excluding ALS include one 
or more of the following: 
 
1) up to 30% increment in central motor conduction velocity, 
2) up to 10% decrement in somatosensory, evoked potential amplitude and up to 10% 
increment in somatosensory evoked potential latency, 
3) mild abnormalities of autonomic function, 
4) mild abnormalities of polysomnography, 
5) mild abnormalities of electronystagmography. 
 
Electrophysiological features that are inconsistent with the diagnoses of ALS or suggest the presence 
of additional other disease processes include one or more of the following: 
 
1) focal reduction in compound muscle action potential or more than 10% in a 4-cm segment, 
2) motor conduction velocities, F wave latencies or H wave amplitudes which are more than 
30% above established normal values, 
3) more than 20% decrement of repetitive stimulation at 2 Hz, 
4) sensory action potential latencies more than 20% above or sensory action potential 
amplitudes more than 20% below established normal values, 
 
 

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5) unstable motor unit potentials with no other electromyographic changes, 
6) more than 30% increment of central motor conduction velocity, 
7) more than 10% increment in sensory evoked potential latency or more than 10% decrement 
in sensory evoked potential amplitude, 
8) moderate or greater abnormalities in autonomic function or electronystagnography.  
 
Employing electrophysiological evidence of LMN degeneration to confirm the diagnosis of ALS 
 
The certainty of LMN degeneration is determined by the presence of the above finding for each 
muscle tested in the region. 
 
At least two muscles of different root or spinal nerve and different cranial or peripheral nerve 
inneveration in each region should show electrophysiological evidence of either definite, probable or 
possible LMN degeneration for that region to be ranked as showing definite, probable or possible 
LMN degeneration. 
 
Definite LMN degeneration by EMG has the same significance as clinical LMN degeneration and can 
upgrade the certainty of the clinical diagnoses of ALS in the same fashion as if the clinical signs of 
LMN degeneration were present in that region. 
 
Probable or possible LMN degeneration by EMG does not carry the same weight as either clinical 
signs of definite electrophysiological evidence of LMN degeneration in a particular region. 
 
However, the involvement of the regions with probable electrophysiological evidence of LMN 
degeneration or one region with probable and one region with possible electrophysiological evidence 
of LMN degeneration carries the same weight as one region with definite evidence of LMN 
degeneration in upgrading the certainty of diagnosis of ALS. 
 
A single region with electrophysiological evidence of probable LMN degeneration or two regions with 
electrophysiological evidence of possible LMN degeneration can be used to upgrade the certainty of 
the diagnosis of ALS from possible ALS to probable ALS but not from probable ALS to definite ALS. 
 
Neuroimaging features in the diagnosis of ALS 
 
Neuroimaging studies should be selected in order to exclude other conditions which may cause UMN 
and/or LMN signs that may stimulate sporadic ALS. 
 
 
 
 

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Neuroimaging features required for the diagnosis of ALS: 
• 
There are no neuroimaging tests which confirm the diagnosis of ALS. 
 
Neuroimaging features that support the diagnosis of ALS include one or more of the following: 
 
1) minimal bony abnormalities on plain x-ray of skull or spinal canal, 
2) Minimal abnormalities on head or spinal cord MRI scans without spinal cord and/or root 
compression, 
3) Minimal abnormalities on spinal cord myelography with post-myelography CT tomography 
showing no spinal cord and/or root compression. 
 
Neuroimaging features that are inconsistent with the diagnosis of ALS include one or more of the 
following: 
 
1) significant bony abnormalities on plain x-ray of skull or spinal canal, 
2) minimal abnormalities on head or spinal cord MRI scans without spinal cord and/or root 
compression, 
3) minimal abnormalities on spinal cord myelography with post-myelography CT tomography 
showing no spinal cord and/or room compression. 
 
Neuroimaging features that are inconsistent with the diagnosis of ALS include one or more of the 
following: 
 
1) significant bony abnormalities on plain x-rays of skull or spinal canal that might explain 
clinical findings, 
2) significant abnormalities of head or spinal cord MRI suggesting intraparenchymal processes, 
arteriovenous malformations or compression of brainstem/spinal cord and/or cranial nerve or 
spinal nerve roots by bony abnormalities, tumor, etc. MRI of craniocervical function if 
bulbar onset and/or MRI or pertinent spinal region if spinal onset, 
3) significant abnormalities of spinal cord myelography with/without CT tomography or CT 
tomography alone suggesting lesions as noted above, 
4) significant abnormalities on spinal cord angiography suggesting arteriovenous 
malformations.  
 
Employing neuroimaging evidence to confirm the diagnosis of ALS 
 
The absence of abnormalities in appropriately performed neuroimaging studies will raise patients with 
clinical and/or electrophysiological evidence of probable ALS to definite ALS. 
 
 

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The absence of neuroimaging abnormalities cannot raise possible ALS to probable ALS.  
 
Clinical laboratory features in the diagnosis of ALS 
 
The diagnostic process employed to confirm the diagnosis of sporadic ALS includes repeated clinical 
examinations, repeated electrophysiological examinations, neuroimaging to exclude other disorders  
and clinical laboratory examinations or exclude other disorders or support the diagnosis of ALS 
related syndromes. 
 
Clinical laboratory features required for the diagnoses of ALS 
• 
There are no clinical laboratory tests which confirm the diagnosis of ALS. 
 
Clinical laboratory features that support the diagnosis of ALS include one or more of the 
following: 
 
• 
normal complete blood count, platelet count, sedimentation rate, prothrombin time, 
• 
normal electrolyte (Na+, K+, C1, C02+, Mg2+, P04) renal (BUN, creatinine) and liver 
function (bilirubin, SGOT, SGPT, LDH) test, 
• 
creatine kinase (CK) elevation not more than 5 times upper limit of normal, 
• 
normal hexosaminidase A and B activity (if possible of deficiency indicated by suggestive 
family history or onset under 30 years of age), 
• 
normal cerebrospinal fluid cell count, protein (not more than 65 mg/dl), absence of 
intrathecal immunoglobulin synthesis, oligoclonal immunoglobulins and evidence of 
elevated intrathecal antibodies or infectious agents (syphilis, HIV-1, HTLV-I, etc.), if 
indicated, 
• 
normal parathyroid hormone level if calcium is borderline elevated, 
• 
normal free thyroid hormone concentrations if any thyroid function abnormalities 
• 
(borderline elevations in T4, T3, TSH); normal glycosylated hemoglobin, if indicated, 
• 
Normal serum protein electrophoresis and serum immunoeletrophresis with immunofixation; 
normal urine immunoelectrophoresis with immunofixation, if indicated, 
• 
Minimal abnormalities in screening test for collagen vascular diseases (anti-nuclear 
antibody; anti-DNA antibodies; rheumatoid factor, complement, anti-tissue specific 
antibodies), if indicated, 
• 
Minimal elevation in screening test for anti-neural antigen (GM1, GM2, GD1b gangliosides, 
myelin- associated glycoprotein, acetylcholine esterase, etc.) or anti-neuromuscular antigen 
(acetylcholine receptor, striated muscle, etc.) antibodies, if indicated. 
 
 
 

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Clinical laboratory features that support the diagnosis of ALS related syndromes 
 
• 
Abnormalities consistent with monoclonal gammopathy with/without significant elevation in 
monoclonal anti-neural antigen antibody, 
• 
Significant elevations in polyclonal anti-neural antigen (Gm1, Gm2, GD1b gagnliosides, 
myelin-associated glycoprotein, acetylcholine esterase, etc.) antibody, 
• 
Significant elevation in parathyroid hormone, thyroid hormone or other significant endocrine 
abnormalities, 
• 
Abnormalities consistent with lymphoma (Hodgkin’s or non-Hodgkin’s lymphoma), 
• 
Evidence of infection (HIV-1, HTLV-I, borrelia, syphilis, brucellosis, cat-scratch disease, 
varicella-zoster, influenza, Creutzfeldt-Jakob disease), 
• 
Evidence of intoxication (epidemiological evidence or elevated blood, urine, tissue or 
cerebrospinal fluid level of lead, mercury, arsenic, cadmium, manganese, aluminum, 
organic pesticides, lupin seeds, etc.), 
• 
Evidence of physical injury (epidemiological evidence of antecedent electrical or radiation 
injury or severe trauma), 
• 
Evidence of vasculitis (elevated erythrocyte sedimentation rate and cerebrospinal fluid 
abnormalities consistent with spinal cord vasculitis, i.e., markedly elevated cerebrospinal 
fluid protein) or ischemic injury to spinal cord without sensory signs, 
• 
Evidence of pre-existing mild or moderate spinal cord spondylotic compression, not 
amenable to surgical correction or not responding to surgical correction, which progressed 
with clinical signs consistent with at least probable ALS. 
 
Clinical laboratory features inconsistent with the diagnosis of ALS: 
 
There is no clinical laboratory finding which, if present with the proper clinical and 
electrophysiological signs of ALS and appropriate neuroimaging studies, rules out the diagnosis of 
ALS. 
 
ALS-related syndromes which present with the ALS phenotype as defined have been described with 
laboratory abnormalities (acquired or genetic), time-linked exposure to chemical, physical or infectious 
agents and pre-existing structural abnormalities. The correction of laboratory abnormalities, removal 
of chemical or physical agents, treatment of the associated disease (infection, tumor, structural 
abnormality) may or may not result in correction or stabilization of the ALS phenotype in ALS-related 
syndromes. 
 
If correction of the abnormality does not result in improvement, the patient will be considered 
to have an ALS related syndrome. 
 
 

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If correction of the abnormality does not result in improvement, then the patient will be considered to 
have an ALS related syndrome. 
 
If correction of the abnormality does not result in improvement then the patient will be considered to 
have sporadic ALS for the purpose of clinical studies and the therapeutic trials. 
 
Neuropathological features of the diagnosis of ALS: 
 
The clinical diagnosis may be supported or excluded by biopsy studies in the living patient and the 
pathological diagnosis may be proven or excluded by autopsy examination. 
 
Pathological studies in the living patient with sporadic ALS: 
 
Indications of biopsies: 
 
Biopsies of the skeletal muscle, peripheral nerve and other tissues are not required for the diagnosis of 
amyotrophic lateral sclerosis, unless the clinical, electrophysiological or laboratory studies have 
revealed changes that are atypical for ALS. In addition, the muscle biopsy may be used to demonstrate 
LMN involvement in a body region that had not been shown to be involved by other techniques. 
Muscle biopsy: 
 
Features required for the diagnosis: 
Disseminated single angulated atrophic muscle fibers, or small or large groups of such fibers. 
 
Features that strongly support the diagnosis: 
Angulated atrophic muscle fibers that are strongly positive when stained with oxidative enzyme stains 
and with non-specific esterase or that show immunoreactive surface staining with anti-NCAM 
antibodies. 
 
Features that are compatible with, and do not exclude the diagnosis: 
 
1) Scattered hypertrophied muscle fibers,, 
2) No more than a moderate number of target or targeted fibers,, 
 
 
 

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3) Fiber type grouping of not more than mild-to-moderate extent,, 
4) The presence of a small number of necrotic muscle fibers. 
 
Features that rule out the diagnoses or suggest the presence of additional disease: 
 
1) Significant infiltration with lymphocytes and other mononuclear inflammatory cells, 
2) Significant arteritis, 
3) Significant numbers of muscle fibers involved with the following structural changes: 
necrosis; rimmed vacuoles; nemaline bodies; central cores; accumulation of mitochondria 
(ragged red fibers), 
4) Large fiber type grouping, 
5) Giant axonal swellings from accumulation of masses of neurofilaments, but not of PAS 
positive bodies, in intramuscular nerves. 
 
Pathological studies at autopsy, other than in cases surviving for prolonged periods on life support 
systems 
 
Gross pathological changes 
 
Features required for the diagnosis: 
There are positive diagnostic features on gross pathological examination. 
 
Features that support the diagnosis: 
There are no positive diagnostic features on gross pathological examination. Features that support the 
diagnosis: 
 
1) selective atrophy of the motor cortex, 
2) grayness and atrophy of the anterior spinal nerve roots compared with normal, 
3) grayness of the lateral columns of the spinal cord, 
4) atrophy of skeletal muscles. 
 
Features that rule out the diagnosis of ALS or suggest the presence of additional disease: 
1) Plaques of multiple sclerosis. 
2) A focal cause of myelopathy. Light microscopic studies 
 
Features required for the diagnosis: 
 
 
 
 

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1) Some degree of loss of both of the following neuronal systems. Large motor neurons of the 
anterior horns of the spinal cord and motor nuclei of the brainstem (V motor, VII motor, I 
and X somatic motor, and XII); and large pyramidal neurons of the motor cortex and/or large 
myelinated axons of the corticospinal tracts. 
2) The following cellular pathological changes in the involved neuronal regions described 
above; neuronal atrophy with relative increase in lipofuscin and loss of Nissl substance. 
There should be evidence of different stages of the process of neuronal degeneration, 
including the presence of normal-appearing neurons, even in the same region. 
3) Evidence of degeneration of the corticospinal tracts and the same level.  
 
Features that strongly support the diagnosis: 
 
1) Lack of pathological change in the motor neurons of cranial nerves III, IV and VI, the 
intermediolateral column of the spinal cord, and Onuf’s nucleus. 
2) The occurrence of one or more of the following cellular pathological changes in the involved 
neuronal systems described above: 
• 
Axonal spheroids with accumulation of masses of neurofilaments, 
• 
Bunina bodies, 
• 
Basophilic cytoplasmic inclusions, 
• 
Non-basophilic hyaline bodies (“Lewy body-like structures”) seen in H&E stained 
sections, 
• 
Increased immunocytochemical staining for phosphorylated neurofiliments in 
perikarya of the motor neurons; 
• 
Atrophy or loss of the arborizations of the dendrites of the motor neurons of the 
anterior horns of the spinal cord and brainstem motor nuclei. 
• 
Wallerian degeneration in the anterior roots. 
 
Features that are compatible with, and do not exclude, the diagnoses: 
Variable involvement of Clark’s nucleus and the spinocerebellar tracts; posterior root ganglia, the 
posterior columns of the spinal cord and peripheral sensory nerves; the brainstem reticular neurons and 
the anterolateral columns of the spinal cord; the thalamus; subthalamic nucleus; and the subastantia 
nigra. 
 
Features that rule out the diagnosis or suggest the presence of additional disease: 
Major pathological involvement of other parts of the nervous system, including: cerebral cortex other 
than the motor cortex; basal ganglia; substantia nigra; cerebellum; cranial nerves II and VIII; dorsal 
root ganglia. 
 
The following cellular pathological changes in the involved neuronal systems described above: 
 
 
 

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• 
Extensive central chromatolysis; 
• 
Extensive active neuronophagia; 
• 
Neurofibrillary tangles; 
• 
The presence of abnormal storage material; 
• 
The presence of significant spongiform change; 
• 
The presence of extensive inflammatory cell infiltration.  
 
Electron-microscopic studies 
 
Features required for the diagnosis: 
Ultrastructural studies are not required for the diagnosis of ALS  
 
Features that strongly support the diagnosis: 
 
1) Accumulation of interwoven bundles of 10 nm neurofilaments in axonal spheroids or motor 
neuron perikarya, and thicker linear structures associated with dense granules (Hirano et al. 
1984 J. Neuropath. Ex. Neurol. 43:461), 
2) Bunina bodies (Hart et al. 1944 Acta Neuropath. 38:225). 
 
Features that are compatible with, and do not exclude the diagnosis: The presence of intra-axonal 
polyglucosan bodies. 
 
Features that rule out the diagnosis or suggest the presence of additional disease; 
 
1) The presence of significant numbers of definite viral particles, 
2) The presence of significant amounts of abnormal storage materials. 
3) Extensive vacuolation of neuronal perikarya. 
 
 
 
 
 
 
 
 
 
 
 
 

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Glossary 
 
Definite 
specific clinical exclusionary criteria met; no other diagnosis possible on basis 
of clinical distribution or laboratory findings 
 
Dementia 
progressive deterioration of specific cognitive functions 
 
Extraphyramidal 
clinical features localizable to basal ganglia and/or midline cerebellum 
 
Hyperreflexia 
spread of deep tendon reflex outside stimulated territory 
 
Minor 
subjective and objective complaints confirmed by examination (utilization of 
instrumental sensory testing may increase the detection of sensory 
abnormalities) 
 
Onset 
time of first subjective symptom noticed by patient which later is confirmed 
by examination 
 
Possible 
specific clinical and exclusionary criteria met 
 
Probable 
specific clinical and exclusionary criteria 
 
Radicular 
distribution conforming to particular nerve root  
 
Region 
brainstem, cervical, thoracic or lumbosacral spinal cord level (regional 
involvement is defined by either right or left sided signs 
 
Required 
necessary or sufficient 
 
Segment 
single brainstem or spinal cord level 
 
Spread 
involvement of new anatomic segments or regions in the central nervous 
system 
 
Support 
neither necessary nor sufficient, but may suggest 
 
 
 
 

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Systemic 
non-central nervous system 
 
Weakness 
decreased isometric strength 
 
Worsening 
increased weakness of muscles in previously affected segment 
 
--Reprinted from the Journal of the Neurological Sciences 124 (suppl.) 1994, Rev 5/96 
 
 
 
 
 
 
 

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APPENDIX 10 – SNIFF NASAL INSPIRATORY PRESSURE (SNIP) & FORCED 
VITAL CAPACITY (FVC) 
 
Normal Sniff Nasal Inspiratory Pressure (SNIP)  
 
Age groups 
(years) 
N (number of 
subjects) 
SNIP cm H₂O 
(standard deviation) 
Men 
20 to 35 
20 
117 (29.5) 
36 to 50 
20 
105 (24.5) 
51 to 65 
20 
111.5 (15.5) 
66 to 80 
20 
91 (21.5) 
Women 
20 to 35 
20 
84 (14.5) 
36 to 50 
20 
94 (21) 
51 to 65 
20 
83.5 (18) 
66 to 80 
20 
75.5 (11) 
Table representing maximum values of SNIP in healthy adults.  
 
Data from: Uldrey C, Fitting JW.  Maximal values of sniff nasal inspiratory pressure in healthy subjects. 
Thorax 1995; 50:371. 
 
Graphic 102592 Version 1.0 
 
Forced Vital Capacity (FVC) – Ventilatory support is indicated when the FVC is less than 50 per cent 
of predicted in many patients with respiratory muscle weakness57 therefore an FVC ≥50% of predicted 
value for gender, height and age is required for trial entry. FVC will also be measured at Week 12 and 
Week 24 as detailed in the Schedule of Assessments. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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APPENDIX 11 – TARGETED METABOLIC MARKERS IN SERUM (AND URINE 
P75) 
 
Study Rationale 
 
ALS, like all neurodegenerative conditions, leads to progressive neuronal loss. This loss, or damage, to 
nervous tissues is accompanied by the leaching into the blood and urine of various proteins and 
metabolites related to the breakdown of the tissue. Many of these breakdown products picked up in the 
blood will be common across the different neurodegenerative aetiologies. Some biomarkers are well 
established as indicators of brain damage in conditions including traumatic brain injury, stroke and ALS 
(such as lactic acid, p75ECD and NAA), whilst others are more novel and their utility is only now being 
uncovered. Such biomarker profiles will be of great future importance both in monitoring patient progress 
and also their response to treatments such as ILB. Here a panel of biomarkers have been chosen that 
are relevant to the known activities of ILB and to ALS, so they will provide insight into the mechanism 
and effects of ILB in the patient population under study. 
Study Design 
 
Biomarker score as a cumulative index linked to disease severity 
We recommend that the study design includes a group of control, age and sex matched, healthy 
controls, to perform the comparison of the different compounds determined in ALS patients. It should 
be underlined that a control group is mandatory to calculate the Biomarker Score. In fact, this cumulative 
index of pathological state needs: i) to determine what compounds are statistically different in controls 
and patients at zero time, in order to evidence what are the potential biomarkers of the disease; ii) to 
calculate the 10 – 90 percentiles of each biomarker in each control and patient at any time point; iii) to 
assign a value of 0 to those biomarkers falling within the 10 – 90 percentiles of controls and a value of 
1 to those biomarkers falling outside the 10 – 90 percentiles of controls; iv) to calculate the Biomarker 
Score by adding all the positive values in each control and patient at any time point; v) to perform all the 
further statistical comparisons, including the distribution frequency and the posterior probability curves 
(for a better comprehension of the Biomarker Score see Lazzarino G, Amorini AM, Petzold A, Gasperini 
C, Ruggieri S, Quartuccio ME, Lazzarino G, Di Stasio E, Tavazzi B. Serum compounds of energy 
metabolism impairment are related to disability, disease course and neuroimaging in multiple sclerosis. 
Mol Neurobiol 2017; 54: 7520-7533). 
 
Please note that we can use archived non-matched controls as our reference values. 
 
 
 
 
 

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Size of the study and number of samples to be assayed 
15 ALS patients, 4 serum withdrawals per individual = 60 samples to be assayed for the serum samples. 
4 PBMC samples per individual to be collected and stored for later analysis. 
 
Sample withdrawals, handling, storage and shipping 
 
Serum samples: In the case of serum samples, peripheral venous blood samples should be collected 
after at least 15 minutes of complete rest, using the standard tourniquet procedure, from the antecubital 
vein into a single VACUETTE® polypropylene tube containing serum separator and clot activator 
(Greiner-Bio One GmbH, Kremsmunster, Austria). After 30 minutes at room temperature, blood 
withdrawals should be centrifuged at 1,890 x g for 10 min and the resulting serum samples should be 
divided into two aliquots and clearly labeled to identify the sample. 
 
Prior to collection of blood samples please contact either: 
 
Professor Ann Logan on 
 
Or  
Dr Valentina Di Pietro on 
 
 
To inform of them of an imminent sample to collect from the Clinical Research Facility laboratory. 
 
Please do not freeze the serum samples. 
 
Analyses of metabolites in serum  
a) HPLC analysis of purines, pyrimidines, oxidative/nitrosative stress compounds (n = 60) 
b) HPLC analysis of fat-soluble vitamins and antioxidants (n = 60) 
c) HPLC analysis of amino acids and amino group-containing compounds (n = 60)d) Spectrophotometric 
analysis of lactate (n = 60) 
 
 
The 3 sets of HPLC analyses a), b) and c) require separate methods to determine the different classes 
of metabolites. Hence, 180 separate HPLC analyses + 60 spectrophometric lactate analyses are required 
for serum.  
 
 
 
PBMC samples: In the case of PBMC sample collection, peripheral venous blood samples should be 
collected after at least 15 minutes of complete rest, using the standard tourniquet procedure, from the 
antecubital vein into a single standard EDTA vacutainer (Greiner-Bio One GmbH, Kremsmunster, 

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Austria). 10ml of peripheral venous blood should be collected and securely transported to the Neuregenix 
laboratory.  
 
Prior to collection of blood samples please contact either: 
 
Professor Ann Logan on 
 
Or  
Dr Valentina Di Pietro on 
 
 
To inform them of an imminent sample to collect from the Clinical Research Facility laboratory. 
 
Please do not centrifuge or freeze the PBMC samples 
 
Analyses of PBMC 
a) PBMC samples will be collected for analysis of change in phenotypic balance.  
 
Urine samples: In the case of urine, if possible the first urine of the morning should be obtained from 
each patient.  Samples (at least 500μl, five hundred microliters) should be collected and clearly labelled 
to identify the sample 
 
Please contact either: 
 
Professor Ann Logan on 
 
Or  
Dr Valentina Di Pietro on 
 
 
To inform them of an imminent sample to collect from the Clinical Research Facility laboratory. 
 
Please do not freeze the urine samples. 
 
Analyses of p75ECD in urine 
a) ELISA of p75ECD (n=60) 
 
 
 
 
 
ALS Trial Office 
D3B – Diagnostics Drugs Devices & Biomarkers, CRCTU  

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5th  Floor East, ITM,  
Mindelsohn Way,  
Edgbaston,  
Birmingham,  
B15 2TH  
 
Enquires 
 
    
 
 
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