Pharmacoepidemiology Study to Define the Long-term Safety Profile of Tenofovir Disoproxil Fumarate (Tenofovir DF, Viread®) and Describe the Management of Tenofovir DF-associated Renal and Bone Toxicity in Chronic Hepatitis B (CHB)-Infected Adolescents Aged 12 to <18 Years in Europe
Phase: PHASE4
Conditions: Hepatitis B
Sponsor: Gilead Sciences

CLINICAL STUDY PROTOCOL
Study Title:
Pharmacoepidemiology study to define the long-term safety 
profile of tenofovir disoproxil fumarate (Tenofovir DF, 
Viread®) and describe the management of Tenofovir 
DF-associated renal and bone toxicity in Chronic Hepatitis B 
(CHB)-infected adolescents aged 12 to <18 years in Europe 
Sponsor:
Gilead Sciences International Ltd.,
Flowers Building, Granta Park
Cambridge, CB21 6GT, United Kingdom
IND Number:
This is a non-IND study
EudraCT Number:
2014-004939-39
Clinical Trials.gov 
Identifier:
Not Available
Indication:
Chronic Hepatitis B
Protocol ID:
GS-EU-174-1403
Gilead Study Director:
Name:
Telephone:
Fax:
Pager:
Gilead Medical Monitor:
Name:
Benedetta Massetto, MD
Telephone:
Fax:
European Union QPPV
Name:
Telephone:
Protocol Version/Date:
Original:
3 November 2014
CONFIDENTIALITY STATEMENT
The information contained in this document, particularly unpublished data, is the property or 
under control of Gilead Sciences, Inc., and is provided to you in confidence as an 
investigator, potential investigator, or consultant, for review by you, your staff, and an 
applicable Institutional Review Board or Independent Ethics Committee. The information is 
only to be used by you in connection with authorized clinical studies of the drug described in 
the protocol. You will not disclose any of the information to others without written 
authorization from Gilead Sciences, Inc., except to the extent necessary to obtain informed 
consent from those persons to whom the drug may be administered.
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD

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TABLE OF CONTENTS
TABLE OF CONTENTS ..............................................................................................................................................2
LIST OF IN-TEXT TABLES........................................................................................................................................4
PROTOCOL SYNOPSIS ..............................................................................................................................................5
GLOSSARY OF ABBREVIATIONS AND DEFINITION OF TERMS ...................................................................10
1.
INTRODUCTION ..............................................................................................................................................13
1.1.
Background............................................................................................................................................13
1.2.
Medicinal Product Name: ......................................................................................................................14
1.2.1.
General Information.............................................................................................................15
1.2.2.
Preclinical Pharmacology and Toxicology:..........................................................................15
1.2.3.
Studies in HIV-1 and HBV Infected Pediatric Subjects.......................................................16
1.2.4.
Tenofovir DF Studies in HBV and HIV-1-Infected Pediatric and 
Adolescent Subjects.............................................................................................................16
1.3.
Information about Comparator Product: ................................................................................................18
1.4.
Rationale for This Study ........................................................................................................................18
1.5.
Compliance ............................................................................................................................................21
2.
OBJECTIVES.....................................................................................................................................................22
3.
STUDY DESIGN ...............................................................................................................................................23
3.1.
Endpoints ...............................................................................................................................................23
3.2.
Study Design..........................................................................................................................................23
3.3.
Study Treatments ...................................................................................................................................26
3.4.
Duration of Treatment............................................................................................................................27
3.5.
Discontinuation Criteria.........................................................................................................................27
3.6.
Source Data............................................................................................................................................27
4.
SUBJECT POPULATION..................................................................................................................................29
4.1.
Number of Subjects and Subject Selection ............................................................................................29
4.2.
Inclusion Criteria ...................................................................................................................................29
4.3.
Exclusion Criteria ..................................................................................................................................29
5.
ADMINISTRATION OF TENOFOVIR DF TREATMENT .............................................................................31
5.1.
Randomization, Blinding and Treatment Codes ....................................................................................31
5.1.1.
Procedures for Breaking Treatment Codes: .........................................................................31
5.2.
Description and Handling of Tenofovir DF ...........................................................................................31
5.2.1.
Formulation..........................................................................................................................31
5.2.2.
Packaging and Labeling .......................................................................................................31
5.2.3.
Storage and Handling...........................................................................................................32
5.3.
Dosage and Administration of Tenofovir DF.........................................................................................32
5.4.
Prior and Concomitant Medications.......................................................................................................32
5.4.1.
Prior to Study Entry .............................................................................................................32
5.4.2.
During the Study ..................................................................................................................33
5.5.
Devices...................................................................................................................................................33
5.6.
Accountability for Tenofovir DF ...........................................................................................................33
5.6.1.
Tenofovir DF Return or Disposal.........................................................................................34

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6.
STUDY PROCEDURES ....................................................................................................................................35
6.1.
Subject Enrollment and Treatment Assignment.....................................................................................35
6.2.
Pre-treatment Assessments.....................................................................................................................35
6.2.1.
Screening Visit.....................................................................................................................35
6.3.
Baseline Visit.........................................................................................................................................36
6.3.1.
Assignment...........................................................................................................................36
6.3.2.
Baseline Assessments...........................................................................................................36
6.4.
Treatment Assessments..........................................................................................................................37
6.4.1.
Group 1: Week 4, 44 Assessments.......................................................................................37
6.4.2.
Group 1: Week 12 and 36 Assessments ...............................................................................38
6.4.3.
Groups 1 and 2: Week 24 and 72 Assessments....................................................................38
6.4.4.
Groups 1 and 2: Week 48 Assessments................................................................................39
6.4.5.
Groups 1 and 2: Week 60 and 84 Assessments....................................................................40
6.4.6.
Groups 1 and 2: Week 96 Assessments/End of Treatment Visit..........................................41
6.5.
Assessments for Premature Discontinuation from Study.......................................................................42
6.6.
Criteria for Discontinuation of Study Treatment ...................................................................................42
6.7.
End of Study ..........................................................................................................................................43
7.
ADVERSE EVENTS AND TOXICITY MANAGEMENT...............................................................................44
7.1.
Definitions of Adverse Events, Adverse Reactions, and Serious Adverse Events.................................44
7.1.1.
Adverse Events.....................................................................................................................44
7.1.2.
Serious Adverse Events........................................................................................................45
7.1.3.
Clinical Laboratory Abnormalities and Other Abnormal Assessments 
as Adverse Events or Serious Adverse Events.....................................................................45
7.2.
Assessment of Adverse Events and Serious Adverse Events.................................................................46
7.2.1.
Assessment of Causality for Tenofovir DF Treatment and Procedures ...............................46
7.2.2.
Assessment of Severity ........................................................................................................46
7.3.
Investigator Requirements and Instructions for Reporting Adverse Events and Serious 
Adverse Events to Gilead.......................................................................................................................46
7.4.
Gilead Reporting Requirements.............................................................................................................48
7.5.
Toxicity Management ............................................................................................................................49
7.5.1.
Grades 1 and 2 Laboratory Abnormality or Clinical Event..................................................49
7.5.2.
Grade 3 Laboratory Abnormality or Clinical Event.............................................................49
7.5.3.
Grade 4 Laboratory Abnormality or Clinical Event.............................................................50
7.5.4.
Management of Elevated Serum Creatinine and Decreased Creatinine 
Clearance..............................................................................................................................50
7.5.5.
Management of Reduced Serum Phosphate.........................................................................51
7.5.6.
Management of Bone Abnormalities ...................................................................................51
7.5.7.
Management of ALT Flares .................................................................................................51
7.6.
Special Situations Reports .....................................................................................................................54
7.6.1.
Definitions of Special Situations..........................................................................................54
7.6.2.
Instructions for Reporting Special Situations.......................................................................55
8.
STATISTICAL CONSIDERATIONS................................................................................................................57
8.1.
Analysis Objectives and Endpoints........................................................................................................57
8.1.1.
Analysis Objectives..............................................................................................................57
8.1.2.
Primary Endpoint .................................................................................................................57
8.1.3.
Secondary Endpoints............................................................................................................58
8.1.4.
Other Endpoints of Interest ..................................................................................................58
8.2.
Analysis Conventions ............................................................................................................................58
8.2.1.
Analysis Sets........................................................................................................................58
8.3.
Data Handling Conventions ...................................................................................................................59
8.4.
Demographic Data and Baseline Characteristics ...................................................................................59

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8.5.
Efficacy Analysis...................................................................................................................................60
8.5.1.
Primary Analysis..................................................................................................................60
8.5.2.
Secondary Analyses .............................................................................................................60
8.6.
Safety Analysis ......................................................................................................................................60
8.6.1.
Extent of Exposure...............................................................................................................61
8.6.2.
Adverse Events.....................................................................................................................61
8.6.3.
Laboratory Evaluations ........................................................................................................62
8.6.4.
Other Safety Evaluations:  Analyses of BMD......................................................................62
8.7.
Pharmacokinetic Analysis......................................................................................................................62
8.8.
Biomarker Analysis................................................................................................................................62
8.9.
Sample Size............................................................................................................................................63
8.10.
Data Monitoring Committee ..................................................................................................................63
8.11.
Endpoint Adjudication Committee.........................................................................................................63
8.12.
Investigator Responsibilities ..................................................................................................................63
8.12.1.
Good Clinical Practice .........................................................................................................63
8.12.2.
Independent Ethics Committee (IEC) Review and Approval...............................................64
8.12.3.
Informed Consent.................................................................................................................64
8.12.4.
Confidentiality .....................................................................................................................64
8.12.5.
Study Files and Retention of Records..................................................................................65
8.12.6.
Case Report Forms...............................................................................................................66
8.12.7.
Drug and Supplies Accountability and Return.....................................................................66
8.12.8.
Inspections ...........................................................................................................................67
8.12.9.
Protocol Compliance............................................................................................................67
8.13.
Sponsor Responsibilities........................................................................................................................67
8.13.1.
Protocol Modifications.........................................................................................................67
8.13.2.
Study Report and Publications .............................................................................................67
8.14.
Joint Investigator/Sponsor Responsibilities ...........................................................................................68
8.14.1.
Payment Reporting...............................................................................................................68
8.14.2.
Access to Information for Monitoring..................................................................................68
8.14.3.
Access to Information for Auditing or Inspections ..............................................................68
8.14.4.
Study Discontinuation..........................................................................................................69
9.
REFERENCES ...................................................................................................................................................70
10.
APPENDICES ....................................................................................................................................................73
Appendix 1.
Investigator Signature Page....................................................................................................74
Appendix 2.
Study Procedures Table..........................................................................................................76
Appendix 3.
Management of Clinical and Laboratory Adverse Events......................................................78
Appendix 4.
GSI Grading Scale for Severity of Adverse Events and Laboratory 
Abnormalities.........................................................................................................................79
Appendix 5.
Pregnancy Precautions, Definition for Female of Childbearing Potential............................104
Appendix 6.
Lactic Acidosis Guidelines...................................................................................................107
LIST OF IN-TEXT TABLES
Table 1-1.
Mean (± SD) Tenofovir Pharmacokinetic Parameters by Age Groups for
Pediatric Patients ............................................................................................................15

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PROTOCOL SYNOPSIS
Gilead Sciences International Ltd.
Flowers Building, Granta Park
Cambridge, CB21 6GT, United Kingdom
Study Title: 
Pharmacoepidemiology study to define the long-term safety profile 
of tenofovir disoproxil fumarate (Tenofovir DF, Viread®) and 
describe the management of Tenofovir DF-associated renal and 
bone toxicity in Chronic Hepatitis B (CHB)-infected adolescents 
aged 12 to <18 years in Europe
IND Number:
EudraCT Number:
Clinical Trials.gov 
Identifier:
This is a non-IND study
2014-004939-39
Not Available
Study Centers 
Planned:
Approximately 20 centers in Europe.
Objectives:
The primary objective of this study is as follows:

To characterize the long term (i.e., 96 weeks of follow up) bone 
safety profile of open-label Tenofovir DF treatment in 
CHB-infected adolescents.  This includes prospectively evaluating 
and comparing the bone mineral density (BMD) change between 
CHB- infected adolescents 12 to < 18 years of age treated with 
Tenofovir DF in European treatment centers who are assigned to 
one of two schedules for renal and bone laboratory monitoring 
and BMD measurement. Primary study outcome will be the 
percent changes in BMD from Baseline through study Week 96.
The secondary objectives of this study are as follows: 

To document all serious adverse drug reactions (SADR) and all 
renal- and bone-related adverse events (AEs), including renal and 
bone laboratory abnormalities

To determine the time to diagnosis of renal and bone AEs and 
document the resulting patient management and outcome(s)

To assess the clinical management and outcomes of renal- and 
bone-related ≥ Grade 3 laboratory markers and clinical SAEs

To assess the efficacy and tolerability of Tenofovir DF in 
adolescents with CHB infection

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
To assess the use of oral vitamin D, calcium and phosphate 
supplementation and explore the association between supplement 
use and rates of bone and renal AEs

To describe the demographics and disease characteristics of 
adolescents with CHB infection treated with Tenofovir DF.

To describe reasons for discontinuation of Tenofovir DF.
Study Design:
This is an interventional study involving two assigned monitoring 
groups of chronic HBV infected adolescents who will receive 
treatment with open-label, market-authorized Tenofovir DF and 
followed prospectively to a primary endpoint at 96 weeks.  
Subjects will be assigned to one of two monitoring groups 
(Group 1 or 2); subjects in both groups will follow pre-set 
schedules for bone and bone biomarker monitoring.  Group 1 will 
receive more frequent BMD, bone biomarker, and renal function 
monitoring compared to Group 2 over the 96 week period.  
Subjects will be assigned but not blinded to one of the two 
monitoring groups.
Number of Subjects 
Planned:
100 subjects to receive treatment with Tenofovir DF and assigned 
to one of two monitoring groups (50 in each group)
Target Population:
Adolescents aged 12 to <16 years at the time of enrollment who 
are diagnosed with CHB and are Tenofovir DF treatment naïve
Duration of 
Treatment:
Subjects will be treated for 96 weeks with Tenofovir DF treatment
Diagnosis and Main 
Eligibility Criteria:
At screening, CHB subjects aged 12 to <16 years of age (e.g., 
HBsAg-positive for at least 6 months), weighing ≥35kg will be 
eligible for the study.  Subjects must be naïve to Tenofovir DF, but 
could have received interferon or any oral anti-HBV 
nucleoside/nucleotide therapy.  Subjects experienced on interferon 
must have discontinued therapy for a minimum of six months; 
treatment-experienced subjects receiving oral anti-HBV 
nucleoside/nucleotide treatment at screening must continue their 
current treatment regimen until Tenofovir DF is initiated; subjects 
previously treated with an oral anti-HBV nucleoside/nucleotide 
should initiate Tenofovir DF without a treatment washout period to 
prevent ALT flare. Pregnant or breastfeeding females will not be 
eligible for the study.

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Study Procedures/
Frequency:
Screening measures for Groups 1 and 2 will include determining a 
subject’s eligibility into the study with the following criteria:  current 
age, documentation of chronic HBV infection (e.g., positive 
laboratory results for HBsAg for at least 6 months prior to screening,
a medical assessment affirming CHB status), ability to swallow solid 
tablets, likelihood of adherence to treatment regimen, obtaining 
written informed consent from subject’s parent or legal guardian or 
obtaining informed assent from the subject.  
Baseline measures for Groups 1 and 2 will include laboratory 
assessments for HBV DNA, HBV serology, HCV, HDV, and HIV 
polymerase chain reaction (PCR) testing, HBV genotyping, serum 
renal and bone chemistries, liver function, hematology, urinalysis.  
Dual Energy X-ray Absorptiometry (DEXA) imaging and a physical 
exam, including current concomitant medications (including dietary 
supplements) and any renal or bone AEs, will also be collected.
FREQUENCY OF STUDY PROCEDURES (Appendix 2):
Subjects enrolled to either Group 1 or 2 will have the following 
measures assessed: 

HBV DNA: every 12 weeks

HBV serology:  every 24 weeks

Liver chemistry (i.e., alanine aminotransferase (ALT), alkaline 
phosphatase (ALP), aspartate aminotransferase (AST), total 
and direct bilirubin, total protein, albumin, gamma glutamyl 
transpeptide (GGT)): every 24 weeks

Hematology (i.e., complete blood count with differential and 
platelets, PT/INR): every 24 weeks

Physical Examination and Drug Dispensing:  every 12 weeks
Subjects enrolled to Group 1 will have the following additional 
monitoring;

DEXA: every 24 weeks from Baseline to Week 96 (5 scans)

Serum bone chemistry (i.e., calcium, phosphorus, vitamin D 
levels (25-hydroxy and 1,25 dihydroxyvitamin), parathyroid 
hormone (PTH), osteocalcin, bone-specific alkaline phosphatase, 
N and C telopeptides): every 24 weeks

Serum renal chemistry (i.e., glucose, creatinine (fasting), 
calculated creatinine clearance): every 4 weeks from Baseline to 
Week 48 and every 12 weeks thereafter, according to SmPC

Urinalysis (i.e., protein, glucose, creatinine, phosphate, 
bicarbonate, blood): every 4 weeks from Baseline to Week 48 and 
every 12 weeks thereafter

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Subjects enrolled to Group 2 will have the following monitoring:

DEXA: every 48 weeks from Baseline to Week 96 (3 scans)

Serum bone chemistry (i.e., calcium, phosphorus, vitamin D 
levels (25-hydroxy and 1,25 dihydroxyvitamin), PTH, 
osteocalcin, bone-specific alkaline phosphatase, N and C 
telopeptides): every 48 weeks

Serum renal chemistry and urinalysis according local standards
of care 
Product, Dose, and 
Mode of 
Administration:
245mg oral Tenofovir disoproxil fumarate (Tenofovir DF)
following enhanced patient monitoring protocol for bone and renal 
biomarkers
Reference Therapy, 
Dose, and Mode of 
Administration:
245mg oral Tenofovir DF following local standards of care for 
patient monitoring for renal biomarkers
Criteria for 
Evaluation:
Safety:
The primary safety endpoint is the indication of a cumulative 
incidence of a ≥4% decrease from Baseline BMD of the spine or 
whole body through Week 96. Secondary endpoints include bone 
and renal AEs.  Bone AEs may include reports of bone pain or 
fractures. Renal AEs may include reductions in creatinine 
clearance, and clinical and laboratory evidence of Grade 3 or 
greater renal tubulopathy or toxicity (e.g. proximal renal 
tubulopathy, Fanconi syndrome).
Bone and renal AEs, concomitant medications (including dietary 
supplements) and specified clinical laboratory tests will be 
collected each time subjects from Group 1 or Group 2 return for 
scheduled monitoring by the study site over a 96 week period.
Efficacy:
An efficacy analysis will be conducted after the last assigned 
subject reaches Week 96.  The analysis will evaluate the difference 
in the proportion of subjects (Group 1 and 2 data will be pooled, as 
subjects have exposure to a single mode of therapy) achieving a 
composite endpoint of HBV DNA 400 copies/mL and ALT 
normal at Week 96.
Pharmacokinetics:
Not applicable

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Statistical Methods:
The primary safety analysis will be performed after the last subject 
reaches Week 96 on Tenofovir DF treatment among both 
monitoring groups.  The primary analysis will evaluate quantitative 
reductions in spine or whole body BMD compared to baseline 
assessments through DEXA scanning.  A key secondary study 
objective is to assess within-group and between-group differences 
in renal biomarker changes (e.g., creatinine clearance using the 
Schwartz formula, glucosuria, proteinuria) suggestive of renal 
toxicity.  To evaluate the time to detection of renal or bone AEs 
among the assigned monitoring groups, estimations of incidence 
rates (events over person time on Tenofovir DF) and time to event 
analysis will be determined.  The evaluation of other clinically 
relevant endpoints such as sustained virologic response, serologic 
status, and development of Tenofovir DF resistance will also be 
assessed as secondary study outcomes for each monitoring group 
and as a combined cohort.  
Approximately 100 subjects are projected to enroll by the end of 
the study (50 in each group).  
This study will be conducted in accordance with the guidelines of Good Clinical Practice 
(GCP) including archiving of essential documents.

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GLOSSARY OF ABBREVIATIONS AND DEFINITION OF TERMS
ADR
Adverse drug reaction
AE
adverse event
ALP
alkaline phosphatase
ALT
alanine transferase
AST
aspartate transaminase
BMC
bone mineral content
BMD
bone mineral density
CRF
case report form
CHB
chronic hepatitis b
CDC
U.S. Centers for Disease Control and Prevention
CHIPS
Collaborative HIV Pediatrics Study
CRO
Contract research organization
CSR
clinical study report
DEXA
Dual energy x-ray absorptiometry
DMC
Data Monitoring Committee
DSPH
Drug Safety & Public Health
DSUR
Development  Safety Update Report
EDD
Estimated date of Delivery
EMA
European Medicines Agency
EU
European Union
FAS
Full Analysis Set
FDA
(United States) Food and Drug Administration
GPP
Good Pharmacoepidemiology Practices (guidelines for)
GSI
Gilead Sciences, Inc.
GVP
Good Pharmacovigilance Practices (guidelines for)
HAART
highly active anti-retroviral therapy
HCC
hepatocellular carcinoma
HDPE
high density polyethylene
HIPPA
Health Insurance Portability and Accountability Act
ICH
International Conference on Harmonization
IEC
Independent Ethics Committee
IND
Investigational New Drug (Application)
INR
International Normalized Ratio
InVS
French Institute for Public Health Surveillance
IRB
institutional review board
OBR
Optimized background regimen
PAS
Post-Authorization Study
PASS
Post-Authorization Safety Study

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GLOSSARY OF ABBREVIATIONS AND DEFINITION OF TERMS (CONTINUED)
PhRMA
Pharmaceutical Research and Manufacturers of America
PI
protease inhibitor
PRT
proximal renal tubulopathy
REMS
Risk Evaluation and Mitigation Strategy
SADR
serious adverse drug reaction
SAE
serious adverse event
SAP
statistical analysis plan
SmPC
Summary of Product Characteristics
SOC
System Organ Class
SOP
standard operating procedure
SSR
Special situation report
STI
sexually transmitted infection
SUSAR
Serious Unexpected Suspected Adverse Reaction
US, USA
United States, United States of America

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EPIDEMIOLOGIC TERMS AND DEFINITIONS
Analytical dataset
The minimum set of data required to perform the statistical analyses leading to the 
results of the primary objective(s) of the study
Bias
Systemic error in the design, conduct or analysis of a study that results in a mistaken 
estimate
Cases
Group of individuals with the condition of interest
Cohort
Group of people characterized by a common experience (e.g.,  occurrence of a 
specified disease, exposure to a given medication)
Confounder
Extraneous factor that accounts for a difference in disease frequency between the 
exposure groups; associated factors serving as surrogates for these factors are also 
commonly called confounders
Confounding by 
indication 
A patient characteristic that is related to the outcome of interest and which 
influences treatment choice (exposure)
Controls
Group of individuals without the condition of interest but are otherwise similar to 
cases, or unexposed to or not treated with the agent of interest
Date at which a study 
commences
Date of the start of data collection
Effect modifier 
If an effect measure varies within categories or levels of a variable, that variable is 
described as an effect-measure modifier 
End of data collection
The date from which the analytical dataset is completely available
Exposure
A variable whose effect is of interest and is being studied
External validity 
Whether or not the results from the study can be generalized to other populations
Internal validity
Whether or not the study provides an unbiased estimate of what it claims to estimate
Odds
The ratio of the probability that an event will happen to the probability that it will 
not happen
Outcome
An event (such as disease occurrence or death) that is studied in relation to exposure
Prevalence
Proportion of persons with the exposure/outcome at a specific point in time
Rate
A measure of event occurrence, calculated by dividing the total number of events by 
the total amount of person-time within an exposure category
Relative Risk (RR)
A general term that can refer to the ratio of 2 risks or the ratio of 2 rates
Risk
The proportion of a fixed cohort in which an outcome occurs during a specified 
period of time
Start of data collection
Date from which information on the first study subject is first recorded in the study 
dataset

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1.
INTRODUCTION
1.1.
Background
Chronic hepatitis B (CHB) infection continues to be an important worldwide cause of 
morbidity and mortality. Worldwide, an estimated 2 billion people have been infected with 
HBV, and more than 350 million have chronic long-term liver infections {26857}.  Up to 
60% of the world’s population lives in a high HBV endemicity region, such as China or other 
regions in Asia.  Even after acute infection with HBV, approximately 3% to 5% of adults and 
up to 95% of children fail to clear the infection and develop CHB{1635}.
The incidence of HBV infection and patterns of transmission vary greatly throughout the 
world. HBV incidence rates have dramatically decreased {6666}, attributable in part to 
improved socio economic and sanitary conditions, but most importantly due to mass 
immunization programs, which have been recommended by the WHO since 1991. In Europe, 
Italy set an early example by offering a free HBV immunization program in 1984 and a 
mandatory program for infants and 12-year-olds beginning in 1991. Between 1987 and 2011, 
HBV incidence reported to Italy’s longitudinal surveillance program declined from 10.4 per 
100,000 inhabitants to 0.8 per 100,000{10698}, {26852}.  Seroepidemiology studies in Italy 
have demonstrated that 56.1% of children 10 years old and under, and 53.8% of those aged 
11 to 20 show vaccination-induced immunity to HBV, but only 11.3% of those above age 40 
have vaccination-induced immunity.  In France, the incidence of HBV infection appears to 
have been declining from 21 per 100,000 in 1991 to 6 per 100,000 in 1996 {10789}.  Today, 
the French Institute for Public Health Surveillance (InVS) reports acute HBV infection at an 
incidence of 1.1 per 100,000 inhabitants among those 0 to 19 years, and 3.6 per 100,000 
among 20 to 39 year olds {26853}.  Despite the marked reductions in population-based HBV 
susceptibility through vaccination, the burden of HBV morbidity and related mortality 
continue to present significant public health challenges.  
Western and northern Europe are areas of low endemicity (< 2% prevalence), while some 
countries of Eastern Europe are areas of high endemicity (> 8% prevalence) {19056}. In areas 
with high endemicity, such as Asia and sub-Saharan Africa, CHB infections are usually the 
result of perinatal (vertical) or child-to-child (horizontal) transmission. The mode of 
transmission has clinical implications because 90% of children infected in the first year of 
life and 30% to 50% of children infected between ages 1 and 4 years develop CHB.
Despite the availability of HBV vaccine programs in many countries, new HBV infections 
are still common, including areas of low endemicity such as the United States (US) and 
Europe {26406}.  In Europe, 13.34 million people are chronically infected with HBV, with an 
estimated 36,000 deaths from HBV related causes annually {24854}, {25143}.  Among 
28 reporting EU countries, over 17,000 cases of HBV were reported in 2011; with over 
two-thirds of cases being newly identified CHB {26854}, {26858}.  Challenges with reporting 
acute and chronic HBV cases mean that calculations of burden are very likely 
underestimated.  CHB infection is the primary source of HBV-related morbidity and 
mortality, with up to 25% of early deaths associated with HBV cirrhosis or liver cancer 
{26858}.  Those with CHB infection have a 12 to 300 times greater risk of hepatocellular 
carcinoma (HCC) than non-carriers {26858}.

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There is a paucity of aggregated incidence data on HBV in children in Europe, partly due to 
the difficulty in identifying cases, as affected children are often virtually asymptomatic while 
Hepatitis B surface antigen (HBsAg) or Hepatitis B e (core) antigen (HBeAg) positive.   A 
seroprevalence study conducted in 2007 within the Netherlands demonstrated an overall 
prevalence of 0.5% (95% CI 0.2-1.1) among children 0 to 14 years, and among indigenous 
children, the prevalence is only 0.1% (95% CI 0-1.0).  The overall prevalence of HBV in the 
Netherlands is estimated at 3.5% {26855}.  In a recent cross-sectional study among a large 
sample of UK schoolchildren aged 7 to 11 years old, 0.26% (95% CI 0.14-0.44) had 
persistent acute, or resolved HBV infection {26851}.   Unlike infection during adulthood, 
children often exhibit immune tolerance during their initial infection with HBV, with only a 
very small proportion of children clearing HBsAg and either exhibiting HBeAg loss or 
seroconversion {27079}
Following acute hepatitis B infection, up to 90% of children become chronic carriers of the 
virus. Hepatitis B virus infection in children is usually asymptomatic, with a low rate of 
disease progression during the first 2 decades of life. There are four characteristic 
immunologic phases to this disease. In the first phase, the immune tolerant phase, patients 
have high HBV DNA levels and have detectable HBsAg and HBeAg. The hallmark of this 
phase is a normal ALT. The second phase that follows, known as the immune active stage, is 
characterized by persistently elevated ALT levels, an indicator of liver damage, even though 
children may show no signs or symptoms of disease. The third phase, the inactive HBsAg 
carrier stage, is characterized by undetectable or low levels of HBV DNA and the presence of 
anti-HBe antibodies. This third stage can evolve into a fourth stage, reactivation, in which 
ALT levels are abnormal and HBV DNA levels are increased.
The management of CHB in children and adolescents is still evolving {17786}. Current 
consensus is that no treatment is indicated in the immune tolerant (phase 1) or the inactive 
carrier state (phase 3). For children and adolescents in stages 2 or 4; however, treatment may 
be warranted in order to suppress viral replication and to prevent the emergence of 
complications, such as cirrhosis, decompensated liver disease, and HCC. Among infants and 
young children infected with HBV, 15-25% will die prematurely from these conditions 
{2826}.   Although histological abnormalities are usually less severe in children than in 
adults, HBV infected infants and children are at higher risk for the eventual development of 
cirrhosis and primary HCC. In HBeAg-positive patients, treatment can lead to HBeAg loss 
and, more rarely, anti-HBe seroconversion, with the goal of subsequent HBsAg loss and 
seroconversion to anti-HBs. Achieving durable viral suppression in CHB infection usually 
requires long-term therapy, preferably utilizing potent oral regimens that limit the 
development of resistance.
1.2.
Medicinal Product Name:
Tenofovir disoproxil fumarate, Tenofovir DF (Viread®)

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1.2.1.
General Information
Tenofovir disoproxil fumarate (Tenofovir DF; 9-[(R)-2-[[bis[[(isopropoxycarbonyl) 
oxy]methoxy]phosphi-nyl] methoxy]propyl] adenine fumarate (1:1); GS4331-05) is an oral 
prodrug (bisPOC-PMPA) of tenofovir (PMPA), an acyclic nucleoside phosphonate 
(nucleotide) analogue of adenosine 5’-monophosphate. Tenofovir DF has activity against 
HBV and HIV, and is indicated for use in HBV infection and in combination with other 
antiretroviral agents in the treatment of HIV-1 infection in adults. Tenofovir DF is primarily 
excreted by the kidney by both filtration and an active tubular transport system with 
approximately 70 to 80% of the dose excreted unchanged in urine following intravenous 
administration of Tenofovir DF. (VIREAD Company Core Data Sheet (CCDS), May 2013). 
Tenofovir DF was approved for the treatment of CHB in adults within the EU in April 2008.
On November 27, 2012, Tenofovir DF was approved by the European Commission for the 
treatment of HIV in children 2 to less than 18 years of age, and for the treatment of chronic 
HBV in children 12 to less than 18 years of age.  
Steady-state pharmacokinetics of Tenofovir DF were evaluated in 31 HIV-1 infected U.S. 
pediatric patients. Tenofovir DF exposure achieved in pediatric patients receiving oral daily
doses of VIREAD 300 mg (tablet) or 8 mg/kg of body weight (powder) up to a maximum
dose of 300 mg was similar to exposures achieved in adults receiving once-daily doses of
300 mg (GS-US-104-0352 Week 48 Clinical Study Report, GS-US-104-0321 Week 48 
Clinical Study Report).
Table 1-1.
Mean (± SD) Tenofovir Pharmacokinetic Parameters by Age
Groups for Pediatric Patients
Dose and Formulation
300 mg Tablet
8 mg/kg Oral Powder
12 to < 18 Years (N = 8)
2 to < 12 Years (N = 23)
Cmax (μg/mL)
0.38 ± 0.13
0.24 ± 0.13
AUCtau (μg•h/mL)
3.39 ± 1.22
2.59 ± 1.06
Tenofovir exposure in HBV infected pediatric patients (12 to < 18 years of age) receiving 
oral daily dose of VIREAD 300 mg tablet was similar to exposures achieved in adults 
receiving once-daily doses of 300 mg.  (GS-US-174-0115 Week 72 Study Report)
For further information on Viread®, refer to the investigator’s brochure for Viread®, 
8th edition, dated 31 March 2014.
1.2.2.
Preclinical Pharmacology and Toxicology:
Not applicable

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1.2.3.
Studies in HIV-1 and HBV Infected Pediatric Subjects
1.2.4.
Tenofovir DF Studies in HBV and HIV-1-Infected Pediatric and 
Adolescent Subjects
Study GS-US-174-0115 is an ongoing randomized, double-blind, double-dummy, 
multicenter study to evaluate the efficacy, safety, and tolerability of Tenofovir DF versus 
placebo in adolescents aged 12 to 17 years with CHB infection (hepatitis B early antigen 
[HBeAg]+ or HBeAg; HBV DNA 105 copies/ mL). Subjects had to be 
Tenofovir DF-naive, but could previously have received interferon or any other oral 
anti-HBV nucleoside/nucleotide therapy. Subjects were required to take a daily multivitamin 
that provided 100% of the recommended daily allowance of vitamin D. 
The study consisted of two parts, an initial 72-week, randomized, double-blind period in 
which subjects (n = 106) were randomized 1:1 to receive TDF (n = 52; 300 mg once daily) or 
placebo (n = 54), following which subjects were eligible to receive open-label TDF for a 
further 120 weeks. This second part of the study is ongoing. DEXA scans of the spine and 
whole body were performed at baseline and at Weeks 24, 48, and 72, and will subsequently 
be performed at Week 96 and then annually until Week 192. Randomization was not 
performed until the baseline DEXA scan had been performed.
The primary safety endpoint was the cumulative incidence of at least a 6% decrease from 
baseline in BMD of the spine through Week 72. The cumulative incidence of at least a 6% 
decrease from baseline in BMD of the whole body through Week 72 was a secondary 
endpoint. Both of these proportions through Week 48 were also secondary endpoints, as were 
corresponding changes in lumbar spine and whole body Z-scores. Other safety endpoints 
included percent change from baseline in lumbar spine and whole body BMD. 
Recent data from the GS-EU-174-0115 trial reported HBV DNA lower than 400 copies/mL 
in 88.5% of Tenofovir DF receiving patients after 72 weeks of treatment.  At this same study 
milestone, no subjects met the primary safety endpoint of a 6% decrease in lumbar spine 
BMD.   As expected for an adolescent population, both treatment arms experienced an 
overall increase in mean spine BMD.  The mean (SD) change in lumbar spine BMD Z-score 
from baseline to Week 72 in the Tenofovir DF arm was -0.05 (0.310). The mean (SD) change 
in lumbar spine BMD Z score in the placebo arm was 0.07 (0.377). The mean change in 
whole body BMD Z score in the Tenofovir DF arm was -0.15 (0.379). The mean change in 
whole body BMD Z-score in the placebo arm was 0.06 (0.361). Using age and gender 
matched cohorts, the magnitude of the effect of Tenofovir DF on lumbar spine and whole 
body BMD also does not appear to be clinically relevant.  
The mean (SD) change in creatinine from baseline to Week 72 was 0.1 (0.10) for the 
Tenofovir DF group and 0.1 (0.09) for the placebo group. No subject had a confirmed 
increase from the baseline serum creatinine concentration of at least 0.5 mg/dL, a confirmed 
creatinine clearance rate of < 50 mL/min, or a confirmed serum phosphorus concentration 
< 2 mg/dL.  This study will continue to follow subjects to Week 192.

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Two open-label, single-arm, single-center clinical studies have been performed to evaluate 
the safety and pharmacokinetics of Tenofovir DF in a small number of HIV-1-infected 
children. Studies 926 and 927 were 96 Week pharmacokinetic and safety studies, which 
enrolled treatment-experienced children with advanced HIV disease. All subjects received 
open-label Tenofovir DF as a component of a new antiretroviral regimen.
Study 926 was a Phase 1 study in which subjects received six days of Tenofovir DF
monotherapy followed by the addition of individualized antiretroviral regimens. Monitoring 
for bone toxicity included measurement of lumbar spine bone mineral density by DEXA.
Study 926 was conducted at the National Cancer Institute, National Institutes of Health. 
Eighteen subjects with a median (range) age of 11.9 years (6.216.2 years) were studied. 
Subjects received Tenofovir DF at a dose of ~ 175 mg/m2 (administered in multiples of 
75 mg tablets) once daily. Subjects had extensive treatment experience: median (range) 
duration of prior antiretroviral therapy was 9.7 years (4.813.5). At Week 48, median (range) 
decrease in log10 HIV RNA was 1.52 (4.0 to 0.52). HIV RNA was 50 copies/mL in 
4 children (400 copies/mL in 6 children). Results from Study 926 demonstrated that 
Tenofovir DF-containing HAART regimens were effective and well tolerated in heavily 
treatment-experienced, HIV-infected children. However, five of 15 subjects evaluated at 
48 weeks of treatment developed a 6% decrease from baseline in bone mineral density. Of 
these subjects, two required discontinuation of Tenofovir DF, but decreases in BMD had 
partially or completed resolved by week 96. One additional subject developed a 6% 
decrease from baseline in bone mineral density by Week 96. None of the six subjects 
experienced a bone fracture {8548},{9505}.
Study 927 was designed to assess safety and single-dose and steady-state pharmacokinetics 
(PK) of Tenofovir DF in HIV-1 infected, treatment-experienced children. Seven subjects 
were enrolled, including three children who were naive to Tenofovir DF and four patients 
who were Tenofovir DF experienced. Subjects received Tenofovir DF once daily at a dose of 
approximately 5 mg/kg (administered in multiples of 75 mg tablets). In the three children 
who were naive to Tenofovir DF, single dose PK studies were assessed over 48 hours after 
the first dose. In the four Tenofovir DF-experienced children, steady-state PK studies were 
assessed over 10 hours on Day 7, when Tenofovir DF was administered with an optimized 
background antiretroviral regimen.
The primary efficacy endpoint was virologic response, measured as a change from baseline 
in log10 HIV-1 RNA. Limited data available from these patients showed that, overall, 
treatment with Tenofovir DF resulted in a decline in mean plasma HIV-1 RNA of 0.95 log10
copies/mL from baseline to Week 72, and a decline in median plasma HIV-1 RNA of 0.39 
log10 copies/mL from baseline at Week 108. These overall declines were seen despite high 
prior exposure and virological failure/intolerance to multiple antiretrovirals in all patients. 
Steady state PK parameters of Tenofovir DF in children and adolescents treated with 
Tenofovir DF-containing regimens were similar to those seen in HIV-infected adults treated 
with 300 mg once daily. Tenofovir DF was safe and well tolerated when given for a mean 
duration of 100 weeks in combination with other antiretrovirals. A renal tubular disorder and 
increase in urinary beta-2 microglobulin were the only events to occur that were considered 

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possibly/probably related to Tenofovir DF. These events, in a subject who had a history of 
probable tubulopathy while receiving Tenofovir DF before the study, resolved after 
withdrawal of Tenofovir DF. The limited available bone mineral density data in this study do 
not suggest a decline in BMD with increased exposure to Tenofovir DF. No bone fractures 
occurred during the study.
In a third study, 28 HIV-infected pediatric subjects (ages 5–17.9 years) receiving HAART 
therapy consisting of lamivudine, stavudine and a protease inhibitor (PI) with stable 
undetectable viral loads were randomized to switch the PI to efavirenz and stavudine to 
tenofovir at baseline (Group 1) or at Week 24 (Group 2). At 96 weeks, virological 
suppression and unchanged CD4 counts were maintained in all subjects {11526}. Tenofovir
DF therapy was well tolerated. Through 96 weeks, no child experienced a Grade 1 or higher 
increase in serum creatinine or phosphorus, and mean serum creatinine, phosphorus and 
bicarbonate values were unchanged {11445}. The authors concluded that no evidence of 
impaired glomerular filtration or tubular renal function was observed in HIV-infected 
children treated with Tenofovir DF for 96 weeks. The authors also evaluated bone mineral 
content (lumbar spine and whole-body bone mineral content (BMC) and BMD via DEXA 
scan in 16 subjects in this study through 12 months of Tenofovir DF treatment {10417}. 
DEXA scans were obtained 12 months prior to therapy switch, at baseline, and 12 months 
after switch to Tenofovir DF. The authors calculated expected changes in bone 
measurements from data obtained from 166 healthy children. The BMC and BMD 
increments observed before and after switching to Tenofovir DF did not differ significantly 
from those calculated in healthy controls. Although the sample size is small, results from this 
study suggest that 12 months of Tenofovir DF treatment does not impair bone mineral 
accrual in HIV-infected children.
Most recently, a clinical trial of Tenofovir DF in pediatric and/or adolescent HIV-1-infected 
subjects is ongoing. Study GS-US-104-352 is evaluating 100 HIV-infected children and 
adolescents (2 to 16 years of age) who are virologically suppressed (HIV-1 RNA 
400 copies/mL) on their current antiretroviral regimen containing either stavudine or 
zidovudine. Subjects are randomized 1:1 to continue on the same stavudine- or zidovudine-
containing regimen, or to replace stavudine or zidovudine with Tenofovir DF while 
continuing their other background antiretroviral agents. The study will assess the efficacy, 
safety (including BMD) and tolerability of switching to Tenofovir DF, compared to 
continuing stavudine or zidovudine therapy. The study duration is 48 weeks. Enrollment is 
ongoing, with a total of 97 subjects enrolled to date.
1.3.
Information about Comparator Product:
Not applicable.
1.4.
Rationale for This Study
Tenofovir DF-associated bone toxicities have not been well understood in children.  One 
theory is that Tenofovir DF may stimulate bone reabsorption which can be detected with 
increases in bone markers and calcium excretion. Among children and adolescents, skeletal 

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growth increases and these same indicators may be expected to be present in children without 
Tenofovir DF exposure.  Bone events or abnormalities, such as fractures, related to both 
proximal renal tubulopathy (PRT) and loss of BMD have been documented in both control 
and Tenofovir DF-receiving arms in adult HIV trials.  Among HIV-1 positive adolescents 
(GS-US-104-0321), the Tenofovir DF-receiving arm reported osteopenia in 6.7% of subjects 
(3/45) and 4.8% (2/42) in the placebo group, and among HBV infected adolescents, there 
were no reported bone events meeting the safety criteria of ≥6% BMD loss 
(GS-US-174-0115).  In pediatric clinical trials of HIV-1 infected children (2-11 years), no 
bone events associated with BMD loss were reported up through 144 weeks of follow up 
time (GS-US-104-0352).
In a limited study of six pediatric subjects taking Tenofovir DF, two children developed 
BMD decreases of greater than 6% over the course of treatment.  Contrary to these findings 
was a cross over trial from Italy where no notable decreases in BMD were detected when 
pediatric patients taking d4T and protease inhibitor HIV treatment regimens switched to 
Tenofovir DF/3TC/EFV.  The Collaborative HIV Paediatric study (CHIPS) based in Ireland 
and the UK, reported no BMD decreases in their longitudinal cohort {15423}.  Among HIV 
infected adults taking Tenofovir DF, the observed pattern is that BMD loss is sustained early 
in the therapeutic course [TIME] and stabilizes with no further notable BMD loss; this 
pattern has not been established in the limited registered studies on either HIV or HBV 
infected children.     
Renal toxicity associated with Tenofovir DF has been previously identified in small subsets
of study participants across randomized controlled clinical trials.  In an NIH systematic 
review of Tenofovir DF’s renal safety profile, the mean difference in reduction of creatinine 
clearance among subjects on Tenofovir DF was 3.92 mL/min (2.13-5.70 mL/min 95% 
confidence interval) compared to controls, and no clear associations between treatment and 
proteinuria, hypophosphatemia, nor fractures.  A modest increase in risk of acute renal injury 
(0.7%, 0.2-1.2% 95% confidence interval) was noted.  The clinical impact of these findings 
is unknown {16177}.  Among registered studies the detection on renal toxicities has been 
very low, ranging between 1 to 2%.  Detailed information and sequelae as a result of serious 
renal toxicities, such as Fanconi syndrome, come from case series or single reports.  A recent 
NIH report documented 7 of 51 (14%) adult patients treated for CHB with Tenofovir DF 
(and/or adefovir) who developed renal tubular dysfunction after 22 to 94 months on therapy.  
Subjects with renal tubular dysfunction had an average age of 58, and 6 of the 7 were male.  
All affected subjects had hypophosphatemia, with others having one or more indications of 
hypouricemia, increased serum creatinine, proteinuria, or glycosuria {20768}.  
The available data to characterize the incidence of renal toxicities in children is lacking, and 
collected primarily within registration studies of CHB and Tenofovir DF.  As Tenofovir DF 
also has the indication for treatment of pediatric HIV, the drug’s safety profile has some 
overlay to both the HIV and the HBV-infected populations.   Among pediatric subjects 
completing 144 weeks of  treatment in clinical trial GS-US-104-0352, 4 of 89 (4.5%) patients 
discontinued Tenofovir DF treatment for HIV-1 as a result of new onset adverse reactions 
suggestive of PRT (e.g., glycosuria, hypophosphatemia).  

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Data from Collaborative HIV Pediatrics Study (CHIPS) in Ireland and the UK reported that 
among the 159 HIV-1 positive children taking Tenofovir DF (since 2001) of a cohort of 
1253 participants, 6 (3.8%) developed renal toxicities including PRT, Fanconi syndrome, and 
acute renal failure.  Five of the six were also taking concurrent NRTI and PI combinations, 
and were receiving a higher concentration of Tenofovir DF (two were greater than 120% of 
the recommended Tenofovir DF dosing regimen), likely due to advanced disease (Riordan et 
al, 2009). A study derived from the same CHIPS cohort evaluated renal toxicities and of 
those 456 participants on antiretroviral therapy, 20 developed hypophosphatemia (4.4%), 
10 of whom were on Tenofovir DF (2.2%). Incidence of hypophosphatemia associated with 
Tenofovir DF was 4.3/100 person-years and among controls (not exposed to Tenofovir DF) it 
was 0.9/100 person-years. Recommendations from these studies include longitudinal 
monitoring of renal function {15423}. 
Independent and sponsored studies in recent years have shown that Tenofovir DF use among 
adults with diagnoses of HBV or HIV carries a modest risk of BMD decreases or acute renal 
injury compared to placebo or other non-Tenofovir DF containing treatments.  Reported 
decreases in bone mineral density among patients on Tenofovir DF therapy compared to 
age-and height adjusted bone density scores are rare across all age strata seen in clinical trials 
and observational studies (GS-US-104-0321, GS-US-104-0352, GS-US-174-0115).  Among 
HIV- and HBV-infected adolescents and children, understanding the longitudinal risk of 
changes in bone mineral density is critical for managing Tenofovir DF-treatment plans 
weighed against any possible alterations to bone development in children. 
Adverse event data from Gilead-sponsored trials have shown increases in creatinine among 
0.2% of subjects, and renal failure in 0.06%.  In the Viread® Expanded Access Program, 
0.04% of subjects were diagnosed with new onset PRT (including Fanconi syndrome). In 
pediatric HIV study GS-US-104-0352, 0.05% of patients between 2 and 12 years of age 
developed PRT; there were no reports of PRT in the parallel trial among adolescents with 
HIV.  Some mediating factors identified in past studies have included advancing age, 
pre-existing renal insufficiencies, use of known nephrotoxic medications, and low weight.  
Renal injuries while on Tenofovir DF treatment have been reversible after discontinuation of 
Tenofovir DF with complete resolution within 4 months for the majority of subjects.  The 
follow up period and sample size of study subjects reporting renal injury have been limited 
and it is prudent to evaluate these potential risks over a longer timeframe and under real 
world conditions.  
Among adolescent patients with CHB, available interim 72 Week clinical trial data indicate 
that 5.8% (95% confidence band of 1.2-15.9%) of subjects experienced a ≥4% decrease in 
BMD; by comparison 3.7% (95% CI 0.4-12.5%) of placebo controls had a BMD loss of 
≥4%.  In this same trial, no renal adverse drug reactions were detected by Week 72.  
Detecting renal or bone AEs in CHB adolescents taking Tenofovir DF are infrequent events, 
and the pool of Tenofovir DF-naïve subjects within the EU suitable for enrollment is limited. 
With a fixed sample size of 100 (50 in each monitoring group) one would expect to detect 4-
5 renal or bone adverse drug reactions across both real-world groups (both receive equivalent 
treatment) over 96 weeks.  

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1.5.
Compliance
This study will be conducted in compliance with this protocol, Good Clinical Practice (GCP), 
and all applicable regulatory requirements.

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2.
OBJECTIVES
The primary objective of this study is as follows:

To characterize the long term (i.e., 96 weeks of follow up) bone safety profile of 
open-label Tenofovir DF treatment in CHB-infected adolescents.  This includes 
prospectively evaluating and comparing the bone mineral density (BMD) change between 
CHB- infected adolescents 12 to < 18 years of age treated with Tenofovir DF in 
European treatment centers who are assigned to one of two schedules for renal and bone 
laboratory monitoring and BMD measurement. Primary study endpoint will be the 
percent changes in BMD from Baseline through study Week 96.
The secondary objectives of this study are as follows: 

To document all serious adverse drug reactions (SADR) and all renal- and bone-related
adverse events (AEs), including renal and bone laboratory abnormalities

To determine the time to diagnosis of renal and bone AEs and document the resulting 
patient management and outcome(s)

To assess the clinical management and outcomes of renal- and bone-related ≥Grade 3 
laboratory markers and clinical SAEs.

To assess the efficacy and tolerability of Tenofovir DF in adolescents with CHB infection

To assess the use of oral vitamin D, calcium and phosphate supplementation and explore 
the association between supplement use and rates of bone and renal AEs

To describe the demographics and disease characteristics of adolescents with CHB 
infection treated with Tenofovir DF.

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3.
STUDY DESIGN
3.1.
Endpoints
The primary endpoint of this study is:

The identification of bone AEs occurring in subjects taking Tenofovir DF between 
Baseline and Week 96 of treatment including the identification of ≥4% reduction in BMD 
within subjects and between monitoring groups from Baseline.
The secondary endpoints of this study are:

Documentation of renal or bone AEs and outcomes among subjects receiving Tenofovir 
DF, including time to medication withdrawal or discontinuation

Subjects’ cumulative exposure time on Tenofovir DF at the time renal or bone AEs are 
detected up to and including Week 96 or to study discontinuation (subjects without renal 
or bone AEs will contribute cumulative exposure time on Tenofovir DF from Baseline to 
Week 96 or to study discontinuation). The cumulative time to renal or bone AEs will be 
expressed as incident rates.

Documentation of the medical management and classification of detected renal or bone 
laboratory abnormalities

Analysis of subjects’ virological and immunological status from Baseline to Week 96 
under real world treatment practices

Report provider recommendations and subject adherence to dietary supplements (e.g., 
Vitamin D, calcium)

Documentation of subject demographics, new medical issues, medications, biometrics, 
treatment adherence

Reasons for discontinuation of Tenofovir DF
3.2.
Study Design
The study will be a prospective cohort comprised of HBV infected adolescents who initiate 
Tenofovir DF therapy in clinics across Europe.  The subjects will be assigned to one of two
monitoring groups using a validated computer-generated tool for randomization.  Subjects 
will be assigned to Group 1 or 2 upon enrollment into the study but prior to Baseline 
laboratory and DEXA imaging assessments.
DEXA scans are non-invasive tests to measure bone mineral density as well as skeletal 
maturity and bone mass.  DEXA scans emit an average effective dose of 0.001 milli Sieverts 

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(mSv) in adults {22238}. These scans emit very minor radiation (i.e., in comparison, one 
mammogram has an effective dose of 0.4 mSv), and with such low doses of radiation do not 
pose concerning health hazards.  Data are based on adult studies and may have a higher 
relative effective dose, particularly in very young children.  Repeated DEXA scans should be 
conducted using the same model of equipment, if possible, and scans should be read in a 
standardized manner.
Group 1 will receive Tenofovir DF for the treatment of CHB infection, followed over 
96 weeks using an enhanced monitoring protocol which includes more frequent laboratory 
bone biomarker testing and lumbar spine and whole-body DEXA scans than specified for 
Group 2.  With the exception of an enhanced monitoring protocol for bone and renal 
outcomes, subjects will be managed according to local standards of care.
Group 2 will be the comparator group of subjects receiving Tenofovir DF for the treatment of 
CHB infection and with the exception of pre-specified bone monitoring, managed according 
to local standards of care.  Group 2 will receive bone biomarker testing, lumbar spine and
whole-body DEXA at Baseline, Weeks 48 and 96.
Both groups will be monitored for 96 weeks on Tenofovir DF during clinic visits for  
response to treatment, AEs, adherence to supplementary vitamins and mineral intake 
assessments.  
Both groups will be required to have DEXA (whole body and spine) scans for BMD at 
Baseline (week 0) and prior to receipt of Tenofovir DF, and at the end of the study period 
(Week 96). Group 2 will be a comparator cohort to Group 1 in evaluating the hypothesis of 
whether enhanced monitoring for renal and BMD changes and AEs provides a net benefit in 
preventing renal- or bone-related adverse outcomes to adolescents receiving Tenofovir DF
therapy for HBV.
For this study design and limited age groupings, matching at enrollment on other factors such 
as demographics, would likely have a marginal benefit on the strength of the results; 
matching may occur (e.g., age, gender, ethnicity, duration of Tenofovir DF exposure) during 
the analysis phase as specified in the statistical analysis plan (SAP).  
The strengths of the study include a focus on long term outcomes related to renal and bone 
adverse event reporting in a vulnerable population.  Use of two real world cohorts will permit 
the evaluation of whether a schedule of more frequent clinical assessments of adolescent 
patients on Tenofovir DF benefit from early detection of potential AEs.  Previous studies 
across multiple HIV and HBV infected patient populations have demonstrated a modest risk 
for both bone and renal AEs related to Tenofovir DF-containing medications.  Understanding 
whether changes in monitoring frequency for serum and urine biomarkers and use of more 
frequent DEXA may provide early detection to subtle changes in bone or renal dynamics and 
be beneficial in enhancing patient outcomes.  

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The feasibility of study design implementation has been assessed using clinical trials data 
from GS-US-174-0115.  Demographic, adverse event reporting, clinical and laboratory 
markers, and DEXA screen results at baseline and at regular intervals from clinical trials 
show a range of 90-100% reporting adherence for key variables, when applicable.  
The primary safety analysis will be conducted after the last assigned subject reaches Week 96
of Tenofovir DF treatment.
Subjects with the following characteristics will be eligible for enrollment: 12 to <16 years of 
age with chronic HBeAg-positive or HBeAg-negative HBV infection (e.g., HBsAg-positive 
for at least 6 months) 
Subjects must be naïve to Tenofovir DF, but could have received prior treatment with other 
anti-HBV nucleoside/nucleotide therapy or interferon (e.g., treatment failure). Previous 
treatment with interferon should have ended at least six months prior to the Screening Visit. 
Screening measures for Monitoring Groups 1 and 2 will include determining a subject’s 
eligibility into the study with the following criteria:  current age, documentation of chronic 
HBV infection, prior Tenofovir DF exposure, weight, laboratory assessments, ability to 
swallow solid tablets, subject’s ability to adhere to treatment regimen, obtaining written 
informed consent from subject’s parent or legal guardian or obtain informed assent from the 
subject  
Baseline measures for Monitoring Groups 1 and 2 will include laboratory assessments for 
HBV DNA, HBV serology, HCV, HDV, and HIV polymerase chain reaction (PCR) testing, 
HBV genotyping, serum renal and bone chemistries, liver function, hematology, urinalysis.  
DEXA imaging, a physical exam (including pregnancy testing for females), current 
concomitant medications and any reported prior bone and renal AEs, will also be collected.
FREQUENCY OF STUDY PROCEDURES (Appendix 2):
Subjects enrolled to either Group 1 or 2 will have the following measures assessed: 

HBV DNA: every 12 weeks

HBV serology: every 24 weeks

Liver chemistry (i.e., alanine aminotransferase (ALT), alkaline phosphatase (ALP), 
aspartate aminotransferase (AST), total and direct bilirubin, total protein, albumin, 
gamma glutamyl transpeptide (GGT),): every 24 weeks

Hematology (i.e., complete blood count with differential and platelets, PT/INR): every 
24 weeks

Urinalysis (i.e., protein, glucose, creatinine, phosphate, bicarbonate, blood): every 
24 weeks

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
Physical Examination and Drug Dispensing:  every 12 weeks

Documentation of bone or renal AEs since the subject’s last visit

Documentation of medical management in the event of bone or renal AEs
Subjects enrolled to Group 1 will have the following additional monitoring;

DEXA: every 24 weeks from Baseline to Week 96 (5 scans)

Serum bone chemistry (i.e., calcium, phosphorus, vitamin D levels (25-hydroxy and 1, 
25 dihydroxyvitamin), parathyroid hormone (PTH), osteocalcin, bone-specific alkaline 
phosphatase, N and C telopeptides): every 24 weeks

Serum renal chemistry (i.e., glucose, creatinine (fasting), calculated creatinine clearance): 
every 4 weeks from Baseline to Week 48 and every 12 weeks thereafter, according to 
SmPC

Urinalysis (i.e., protein, glucose, creatinine, phosphate, bicarbonate, blood): every 
4 weeks from Baseline to Week 48 and every 12 weeks thereafter
Subjects enrolled to Group 2 will have the following monitoring:

DEXA: every 48 weeks from Baseline to Week 96 (3 scans)

Serum bone chemistry (i.e., calcium, phosphorus, vitamin D levels (25-hydroxy and 1,25 
dihydroxyvitamin), PTH, osteocalcin, bone-specific alkaline phosphatase, N and C 
telopeptides): every 48 weeks

Serum renal chemistry and urinalysis according to local standards of care 
Subjects who permanently discontinue Tenofovir DF will be asked to return for an end of 
treatment visit within 72 hours of the last dose of Tenofovir DF. Subjects who permanently 
discontinue Tenofovir DF will be followed for 24 weeks off treatment or up to initiation of 
local standard of care treatment, whichever occurs first. 
3.3.
Study Treatments
The proposed study is an open-label trial of 245mg oral Tenofovir DF taken once daily. 
Tenofovir DF is packaged in white, high-density polyethylene (HDPE) bottles with a white 
child resistant cap. There are 30 tablets per bottle. Each bottle also contains silica gel as a 
desiccant to protect the product from humidity and fiber packing to protect the product 
during handling and shipping.
During Weeks 0 to 96, subjects will be provided with sufficient supplies for 12 weeks of 
dosing. At a minimum, each bottle will be labeled with a lot number, the protocol number, 
administration instructions, storage instructions, expiration date, Sponsor name and address. 

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Additional information will be included according to the requirements of the protocol and 
local law.
Tenofovir DF will be supplied by Gilead as per its current commercial tablet formulation for 
the EU (245mg) for patients greater than 35 kg.  There will be no difference in medication 
formulation or frequency as per Tenofovir DF SmPC among subjects assigned to either 
Group 1 or Group 2.
3.4.
Duration of Treatment
Subjects will be treated with Tenofovir DF therapy for 96 weeks (each subject will receive a 
total of 96 weeks of Tenofovir DF treatment). Tenofovir DF is currently approved for use in 
patients across all specified study countries with participating study clinics aged 12 years of 
age and up.
3.5.
Discontinuation Criteria
Treatment medication may be discontinued in the following instances:

Intercurrent illness that would, in the judgment of the investigator, affect assessments of 
clinical status to a significant degree

Unacceptable toxicity, as defined in the toxicity management section of the protocol, or 
toxicity that, in the judgment of the investigator, compromises the ability to continue 
study-specific procedures or is considered to not be in the subject’s best interest

Therapeutic failure

Subject or legal guardian requests to discontinue for any reason

Subject non-compliance with taking Tenofovir DF or sustained inability to adhere to 
Tenofovir DF treatment plan

Pregnancy during the study

Discontinuation of the study at the request of Gilead Sciences, regulatory agency or an 
IEC
3.6.
Source Data
Source data will include sequential notes containing at least the following information for 
each subject:

Subject identification (name, date of birth, gender)

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
Documentation that subject meets eligibility criteria, i.e., history, physical examination 
and confirmation of diagnosis to support inclusion and exclusion criteria

Participation in study (including study number)

Study discussed and date of informed consent

Dates of all visits

Documentation that protocol specific procedures were performed

Results of monitored parameters, as required by the protocol

Start and end date of Tenofovir DF (preferably with drug dispensing information)

Record of all AEs and other safety parameters (start and end date, and preferably 
including causality and intensity);

Concomitant medications (including start and end dates, dose if relevant; dose changes)

Date of study completion and reason for early discontinuation, if applicable
All clinical study documents must be retained by the investigator until at least 2 years after 
the investigation is discontinued and regulatory authorities have been notified. Investigators 
may be required to retain documents longer if required by applicable regulatory 
requirements, by local regulations, or by an agreement with Gilead Sciences. The
investigator must notify Gilead Sciences before destroying any clinical study records.
Should the investigator wish to assign the study records to another party or move them to
another location, Gilead Sciences must be notified in advance.  If the investigator cannot 
guarantee this archiving requirement at the study site for any or all of the documents, special 
arrangements must be made between the investigator and Gilead Sciences to store these in 
sealed containers outside of the site so that they can be returned sealed to the investigator in 
case of a regulatory audit. When source documents are required for the continued care of the 
subject, appropriate copies should be made for storage outside of the site.

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4.
SUBJECT POPULATION
4.1.
Number of Subjects and Subject Selection
4.2.
Inclusion Criteria
Subjects must meet all of the following inclusion criteria to be eligible for participation in 
this study.
1) 12 to <16 years of age
2) Documented chronic HBV infection (e.g. positive serum HBsAg6 months)
3) Weight 35 kg
4) Able to swallow oral tablets
5) Negative serum -HCG pregnancy test (for post-menarchal females only)
6) Estimated glomerular filtration rate (creatinine clearance) 80 mL/min/1.73m2
  
Estimated creatinine clearance using Schwartz Formula 
(mL/min/1.73m2) = k L/Scr
[(k is a proportionality constant: for adolescent females 12 years old, k = 0.55, and for 
adolescent males 12 years, k = 0.70); L is height in centimeters (cm); and Scr is serum 
creatinine (mg/dL)]
7) Parent or legal guardian of potential study subjects able to provide written informed 
consent prior to any screening evaluations and willing to comply with study requirements 
or subject able to provide written assent as determined by IEC/local requirements and at 
the Investigator’s discretion.
4.3.
Exclusion Criteria
Subjects who meet any of the following exclusion criteria are not to be enrolled in this study.
1) Prior Tenofovir DF therapy; subjects may have received prior interferon or oral anti-HBV 
nucleoside/nucleotide therapy (subjects experienced on interferon must have discontinued 
therapy for a minimum of six months; treatment-experienced subjects receiving oral anti-
HBV nucleoside/nucleotide treatment at screening should continue their current treatment 
regimen until Tenofovir DF is initiated (i.e., to prevent ALT flare))

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2) Sexually-active males or females of reproductive potential who are not willing to use an 
effective method of contraception during the study. For females, a barrier contraception 
method should be used in combination with one other form of contraception (see 
Appendix 5 for further details).  
3) Females who are pregnant or breastfeeding, or females who wish to become pregnant 
during the course of the study.
4) Known hypersensitivity to Tenofovir DF, the metabolites or formulation excipients
5) Any condition (including alcohol or substance abuse) or prior therapy that, in the opinion 
of the Investigator, would make the subject unsuitable for the study or unable to comply 
with treatment requirements

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5.
ADMINISTRATION OF TENOFOVIR DF TREATMENT
5.1.
Randomization, Blinding and Treatment Codes
After screening and once eligibility has been confirmed, subjects will be assigned a subject 
number and monitoring arm (i.e., Group 1 or Group 2). A centralized procedure will be used, 
to assign subjects to the respective monitoring arm. For the 96 weeks of the study, Tenofovir 
DF will be dispensed to the subject in numbered bottles from supplies stored at the study site. 
Tenofovir DF monitoring groups will be randomly allocated, but the allocation to one or the 
other group will not be blinded.  Subjects will be informed of the two monitoring groups at 
the time of study screening and informed of their assignment to one of the two selected CHB 
management monitoring groups after consent is obtained at the subject’s screening 
appointment.    
All Baseline tests and procedures must be completed prior to the administration of the 
first dose of Tenofovir DF. Initiation of treatment with Tenofovir DF should take place
within 24 hours of the Baseline Visit.
For duration of the study, Tenofovir DF 245mg will be supplied by Gilead. 
5.1.1.
Procedures for Breaking Treatment Codes:
Not applicable
5.2.
Description and Handling of Tenofovir DF
5.2.1.
Formulation
Tenofovir DF tablets are light blue, almond-shaped, film-coated tablets containing 245 mg of 
Tenofovir disoproxil. Each tablet contains the following inactive ingredients: 
microcrystalline cellulose, lactose monohydrate, pregelatinized starch, croscarmellose 
sodium, and magnesium stearate. The Tenofovir DF tablets are film-coated to mask taste. 
Each tablet is film-coated with a mixture of lactose monohydrate, hypromellose 
(hydroxypropyl methylcellulose), glycerol triacetate, titanium dioxide, and indigo carmine 
aluminum lake.
5.2.2.
Packaging and Labeling
Tenofovir DF is packaged in white, high-density polyethylene (HDPE) bottles with a white 
child resistant cap. There are 30 tablets per bottle. Each bottle also contains silica gel as a 
dessicant to protect the product from humidity and fiber packing to protect the product during 
handling and shipping.
During Weeks 0 to 96, subjects will be provided with sufficient supplies for 12 weeks of 
dosing. At a minimum, each bottle will be labeled with a lot number, the protocol number, 
administration instructions, storage instructions, expiration date, Sponsor name and address. 

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Additional information will be included according to the requirements of the protocol and 
local law.
5.2.3.
Storage and Handling
Tenofovir DF tablets should be stored at 25C (77F); excursions are permitted to 15-30C 
(59–86F).
To ensure product stability, Tenofovir DF should not be dispensed in a container other than 
the one supplied.
5.3.
Dosage and Administration of Tenofovir DF
Subjects will be assigned to receive one of the following treatments in an unblinded fashion:
Group 1: open-label Tenofovir DF 245mg PO once daily, enhanced monitoring
Group 2: open-label Tenofovir DF 245mg PO once daily, Tenofovir DF, local standards of 
care for monitoring
Subjects will be instructed to take one tablet by mouth daily. Tenofovir DF can be taken 
without regard to food.
After 96 weeks of protocol-guided monitoring, each subject will switch to medical 
management for CHB as per local standards of care.  
Active study subjects will be dispensed Tenofovir DF at baseline and through the end of the 
study (until each subject reaches Week 96). Subjects will be instructed to return empty 
containers as well as unused study medication in the original container at each study visit. 
The investigator will be responsible for maintaining accurate records for Tenofovir DF and 
Tenofovir DF bottles dispensed and returned. The inventory must be available for inspection 
by the study monitor. Study medication supplies, including partially used or empty bottles, 
must be accounted for and the dispensing logs must be verified by the study monitor prior to 
destruction or return.
5.4.
Prior and Concomitant Medications
5.4.1.
Prior to Study Entry
Refer to Exclusion Criteria in Section 4.3. 

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5.4.2.
During the Study
Use of the following medications is not advised while subjects are taking Tenofovir DF, and 
subjects should be followed closely by their providers:

Antiviral agents with anti-HBV activity, including lamivudine, emtricitabine, entecavir, 
adefovir, telbivudine, clevudine, or others

Antiviral agents associated with potential renal impairment (e.g., cidofovir, acyclovir, 
valacyclovir, ganciclovir, valgancicyclovir)

Interferon and pegylated interferon

Nephrotoxic agents (e.g., aminoglycoside antibiotics,  cisplatin, foscarnet, 
IV amphotericin B, IV pentamidine, cyclosporine, tacrolimus, chronic daily non-steroidal 
anti-inflammatory drugs)

Hepatotoxic agents (e.g., anabolic steroids, isoniazid, itraconazole, ketoconazole, 
lovastatin, rifabutin, rifampin, simvastatin)

Competitors of renal excretion, such as probenecid

Systemic chemotherapeutic agents

Interleukin-2 [IL-2] and other immunomodulating agents

Systemic corticosteroids

Investigational agents, except with written approval of the Sponsor
All concomitant medications, including vitamin supplements, herbal remedies and hormonal 
contraception, must be recorded in the appropriate section of the Case Report Forms.
5.5.
Devices
Not applicable
5.6.
Accountability for Tenofovir DF
The investigator is responsible for ensuring adequate accountability of all used and unused 
Tenofovir DF. This includes acknowledgement of receipt of each shipment of Tenofovir DF
(quantity and condition). All used and unused Tenofovir DF dispensed to subjects must be 
returned to the site.
Tenofovir DF accountability records will be provided to each study site to:

Record the date received and quantity of Tenofovir DF

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
Record the date, subject number, subject initials, the Tenofovir DF lot numbers dispensed

Record the date, quantity of used and unused Tenofovir DF returned, along with the 
initials of the person recording the information.
5.6.1.
Tenofovir DF Return or Disposal
At study initiation, the monitor will evaluate the site’s standard operating procedure for drug 
disposal/destruction in order to ensure that it complies with Gilead requirements. Drug may 
be returned or destroyed on an ongoing basis during the study if appropriate. At the end of 
the study, following final drug inventory reconciliation by the monitor, the study site will 
dispose of and/or destroy all unused drug supplies, including empty containers, according 
these procedures.
All drug supplies and associated documentation will be periodically reviewed and verified by 
the study monitor over the course of the study.

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6.
STUDY PROCEDURES
The study procedures to be conducted for each subject enrolled in the study are presented in 
tabular form in Appendix 2 and described in the text that follows. 
The investigator must document any deviation from protocol procedures and notify the study 
sponsor or contract research organization (CRO).
6.1.
Subject Enrollment and Treatment Assignment
The study population will consist of HBV-infected adolescents who are between 12 to 
<16 years of age at the commencement of the study and receiving Tenofovir DF for the 
treatment of CHB during study treatment.  The study population will also be enrolled through 
one of the approximately 20 participating European clinics across several countries (eg., 
Bulgaria, Poland, Romania, Italy, Germany, France, Spain, and the United Kingdom) 
projected to commence in June 2015.
Eligibility criteria will include a confirmed diagnosis of HBV infection in subjects who are 
Tenofovir DF treatment naïve. At screening, adolescent subjects (12 to<16 years of age) 
with documented chronic hepatitis B (e.g HBsAg-positive for ≥6 months), weighing 35 kg 
will be eligible for the study. 
Subjects must be naïve to Tenofovir DF, but could have received interferon or any oral 
anti-HBV nucleosides/nucleotide therapy. Subjects experienced on oral anti-HBV 
nucleoside/nucleotide therapy must have discontinued therapy prior to screening. Subjects 
must have discontinued interferon at least six months prior to screening. 
Data will be collected from subjects prospectively from initial enrollment into the study 
(baseline) and up to 96 weeks, study completion, loss to follow-up or death, whichever 
occurs first.  Subjects who discontinue Tenofovir DF will be followed until reversibility has 
occurred for up to 6 months from the date of the observed SAE. 
The data will contain medical records, demographics, diagnoses, procedures, medications, 
and laboratory tests (including DEXA).
6.2.
Pre-treatment Assessments
6.2.1.
Screening Visit
Subjects will be screened within 30 days before assignment to determine eligibility for 
participation in the study. The following will be performed and documented at screening:
1) Obtain written informed consent
2) Obtain medical history
3) Complete physical examination including, vital signs, body weight, and height

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4) Screen for pregnancy and contraceptive use 
5) Conduct preliminary serum renal chemistry and urinalysis (to be averaged with Baseline 
renal chemistry values)
Subjects meeting all of the inclusion criteria and none of the exclusion criteria will return to 
the clinic within 30 days after screening for commencement into the study.
From the time of obtaining informed consent through the first administration of 
Tenofovir DF, record all renal and bone AEs and any SAEs (not limited to bone or renal) on 
the adverse events case report form (CRF/eCRF).  All other untoward medical occurrences 
observed during the screening period, including exacerbation or changes in medical history
are to be captured on the medical history CRF/eCRF.  See Section 7 Adverse Events and 
Toxicity Management for additional details.
6.3.
Baseline Visit
The Baseline Visit should occur within 30 (3) days of the initial Screening Visit. All 
baseline tests and procedures should be completed prior to the receipt of the first dose of 
Tenofovir DF. Subjects will be dispensed Tenofovir DF medication at their Baseline Visit. 
Tenofovir DF should be initiated within 24 hours of the Baseline Visit.
6.3.1.
Assignment
Once eligibility has been confirmed, subjects will be assigned a subject number and 
monitoring group. 
6.3.2.
Baseline Assessments
The following assessments and procedures will be performed and recorded on CRFs for 
Groups 1 and 2 at the Baseline Visit:

Changes in medical status since screening

Physical exam including body weight and height

Blood samples for:
— HBV DNA and HBV genotyping (A-H)
— HBV serology (HBeAg and HBsAg; anti-HBe and anti-HBs (if Ag negative))
HCV, HDV, HIV screening
— Hematology (CBC with differential and platelets,PT/INR)
— Serum renal chemistry (glucose, creatinine, creatinine clearance (calculated))

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— Liver chemistry tests (ALT, ALP, AST, total and direct bilirubin, total protein, 
albumin, GGT) 
— Serum bone chemistry (calcium, phosphorus, 1,25 hydroxy vitamin D, PTH, 
osteocalcin, bone alkaline phosphatase, N and C telopeptides), fasting recommended 
but not required

Urinalysis (glucose, protein, creatinine, phosphate, bicarbonate, blood)

DEXA scan of spine and whole body (DEXA may be performed between Screening and 
Baseline Visits, but must be performed no later than the Baseline Visit), and prior to 
receipt of Tenofovir DF.

Review of bone and renal AEs and any associated medical management

Concomitant medications (including dietary supplements such as calcium, vitamin D, 
phosphorus)

Tenofovir DF dispensing and instructions on appropriate dosing and administration

Screening for pregnancy
6.4.
Treatment Assessments
6.4.1.
Group 1: Week 4, 44 Assessments
The following evaluations will be performed at Weeks 4, 8, 16, 20, 28, 32, 40, and 44, unless 
otherwise specified. Study visits are to be completed 7 days of the protocol-specified visit 
date, based on the Baseline Visit. Week 48 assessments are outlined in the following section 
(Section 6.4.4). Group 2 subjects will follow local standard of care for renal monitoring and 
AE collection.  
The following assessments and procedures will be performed and recorded on CRFs:

Changes in medical status or symptoms from prior visit

Body weight and height 

Blood samples for:
Serum renal chemistry (creatinine, glucose, creatinine clearance (calculated))

Urinalysis (protein, glucose, creatinine, phosphate, bicarbonate, blood)

Assessment of medication adherence

Review of bone and renal AEs and any associated medical management

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
Concomitant medications (including dietary supplements such as calcium, vitamin D, 
phosphorus)
6.4.2.
Group 1: Week 12 and 36 Assessments
Study Visit for Weeks 12 and 36 should be completed 7 days of the protocol-specified visit 
date, based on the Baseline Visit. Group 2 subjects will follow local standard of care for renal 
monitoring and AE collection. The following assessments and procedures will be performed 
and recorded on CRFs:

Complete physical examination including, vital signs, body weight and height

Urinalysis (protein, glucose, creatinine, phosphate, bicarbonate, blood)
Blood samples for:

Serum renal chemistry (creatinine, glucose, creatinine clearance (calculated))

Plasma HBV DNA (PCR method)

Review of bone and renal AEs and any associated medical management

Concomitant medications (including dietary supplements such as calcium, vitamin D, 
phosphorus)Assessment of medication adherence

Tenofovir DF dispensing and instructions on appropriate dosing and administration

Screening for pregnancy
Subjects who discontinue the study prior to the Week 12 or 36 Visit will complete all 
Week 12 or 36 assessments and procedures at an Early Drug Discontinuation Visit, to be 
completed within 72 hours of last dose of Tenofovir DF. Subjects who have received at least 
one dose of Tenofovir DF and permanently discontinue treatment will be followed for 
24 weeks off treatment or up to initiation of an alternative treatment regimen, whichever 
occurs first.
6.4.3.
Groups 1 and 2: Week 24 and 72 Assessments
Study Visit for Weeks 24 and 72 should be completed 7 days of the protocol-specified visit 
date, based on the Baseline Visit. Group 2 subjects will follow local standard of care for renal 
monitoring. The following assessments and procedures will be performed and recorded on 
CRFs:

Complete physical exam including vital signs, body weight and height

Blood samples for:

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— Plasma HBV DNA (for PCR)
— HBV serology (HBeAg and HBsAg; anti-HBe and anti-HBs (if HBsAg negative))
— Hematology (CBC with differential and platelets, PT/INR)
— Group 1: Serum renal chemistry (glucose, creatinine, creatinine clearance
(calculated))
— Liver chemistry (ALT, ALP, AST, total and direct bilirubin, total protein, albumin, 
GGT) 
— Group 1 Only: Serum bone chemistry* (calcium, phosphorus, 1,25 hydroxy vitamin 
D, PTH, osteocalcin, bone alkaline phosphatase, N and C telopeptides) *fasting 
recommended but not required

Group 1 Only: DEXA scan of spine and whole body 

Group 1: Urinalysis (glucose, protein, creatinine, phosphate, bicarbonate, blood)

Review of bone and renal AEs and any associated medical management

Concomitant medications (including dietary supplements such as calcium, vitamin D, 
phosphorus)

Tenofovir DF dispensing and instructions on appropriate dosing and administration

Screening for pregnancy
Subjects who discontinue the study prior to the Week 24 or 72 Visit will complete all 
Week 24 or 72 assessments and procedures at an Early Drug Discontinuation Visit, to be 
completed within 72 hours of last dose of Tenofovir DF. Subjects who have received at least 
one dose of Tenofovir DF and permanently discontinue treatment will be followed for 
24 weeks off treatment or up to initiation of an alternative treatment regimen, whichever 
occurs first.
6.4.4.
Groups 1 and 2: Week 48 Assessments 
Study Visit for Weeks 48 should be completed 7 days of the protocol-specified visit date, 
based on the Baseline Visit. Group 2 subjects will follow local standard of care for renal 
monitoring.  The following assessments and procedures will be performed and recorded on 
CRFs:

Complete physical exam including vital signs, body weight and height

Blood samples for:
— Plasma HBV DNA (for PCR)

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— HBV serology (HBeAg and HBsAg; anti-HBe and anti-HBs (if HBsAg negative))
— Hematology (CBC with differential and platelets, PT/INR)
— Group 1: Serum renal chemistry (glucose, creatinine, creatinine clearance)
— Liver chemistry (ALT, ALP, AST, total and direct bilirubin, total protein, albumin, 
GGT) 
— Groups 1 and 2: Serum bone chemistry* (calcium, phosphorus, 1,25 hydroxy vitamin 
D, PTH, osteocalcin, bone alkaline phosphatase, N and C telopeptides) *fasting 
recommended but not required

Group 1: Urinalysis (glucose, protein, creatinine, phosphate, bicarbonate, blood)

Groups 1 and 2: DEXA scan of spine and whole body 

Review of bone and renal AEs and any associated medical management

Concomitant medications (including dietary supplements such as calcium, vitamin D, 
phosphorus)Assessment of medication adherence

Tenofovir DF dispensing and instructions on appropriate dosing and administration

Screening for pregnancy
Subjects who discontinue the study prior to the Week 48 Visit will complete all Week 48 
assessments and procedures at an Early Drug Discontinuation Visit, to be completed within 
72 hours of last dose of Tenofovir DF. Subjects who have received at least one dose of 
Tenofovir DF and permanently discontinue treatment will be followed for 24 weeks off 
treatment or up to initiation of an alternative treatment regimen, whichever occurs first.
6.4.5.
Groups 1 and 2: Week 60 and 84 Assessments
Study Visit for Weeks 60 and 84 should be completed 7 days of the protocol-specified visit 
date, based on the Baseline Visit. Group 2 subjects will follow local standard of care for renal 
monitoring. The following assessments and procedures will be performed and recorded on 
CRFs:

Complete physical exam including vital signs, body weight and height

Blood samples for:
— Plasma HBV DNA (for PCR)
— Group 1: Serum renal chemistry (glucose, creatinine, creatinine clearance 
(calculated))

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
Group 1: Urinalysis (glucose, protein, creatinine, phosphate, bicarbonate, blood)

Review of bone and renal AEs and any associated medical management

Concomitant medications (including dietary supplements such as calcium, vitamin D, 
phosphorus)

Tenofovir DF dispensing and instructions on appropriate dosing and administration

Screening for pregnancy
Subjects who discontinue the study prior to the Week 60 or 84 Visit will complete all 
Week 60 or 84 assessments and procedures at an Early Drug Discontinuation Visit, to be 
completed within 72 hours of last dose of Tenofovir DF. Subjects who have received at least 
one dose of Tenofovir DF and permanently discontinue treatment will be followed for 
24 weeks off treatment or up to initiation of active treatment, whichever occurs first.
6.4.6.
Groups 1 and 2: Week 96 Assessments/End of Treatment Visit
The Study Visit for Week 96/End of Treatment should be completed 7 days of the 
protocol-specified visit date, based on the Baseline Visit. The following assessments and 
procedures will be performed and recorded on CRFs:

Complete physical exam including vital signs, body weight and height

Blood samples for:
— Plasma HBV DNA (for PCR)
— HBV serology (HBeAg and HBsAg; anti-HBe and anti-HBs (if Ag negative))
— Hematology (CBC with differential and platelets, total and direct bilirubin, total 
protein, albumin, GGT, PT/INR)
— Serum renal chemistry (glucose, creatinine, creatinine clearance)
— Liver chemistry (ALT, ALP, AST, total and direct bilirubin, total protein, albumin, 
GGT)
— Serum bone chemistry* (calcium, phosphorus, 1,25 hydroxy vitamin D, PTH, 
osteocalcin, bone alkaline phosphatase, N and C telopeptides) *fasting recommended 
but not required

Urinalysis (glucose, protein, creatinine, phosphate, bicarbonate, blood)

Groups 1 and 2: DEXA scan of spine and whole body 

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
Review of bone and renal AEs and any associated medical management

Concomitant medications (including dietary supplements such as calcium, vitamin D, 
phosphorus)Assessment of medication adherence

Tenofovir DF accountability

Screening for pregnancy
Subjects who discontinue the study prior to the Week 96 Visit will complete all Week 96
assessments and procedures at an Early Drug Discontinuation Visit, to be completed within 
72 hours of last dose of Tenofovir DF. Subsequent off-study therapy, if any, is at the 
discretion of the subject/physician and will not be provided by Gilead Sciences. Subjects who 
have received at least one dose of Tenofovir DF and permanently discontinue Tenofovir DF
treatment will be followed for 24 weeks off treatment or up to initiation of standard of care 
treatment, whichever occurs first.
The study treatment will end after the each subject reaches Week 96.  
6.5.
Assessments for Premature Discontinuation from Study
If a subject discontinues Tenofovir DF (for example, as a result of an AE), every attempt 
should be made to keep the subject in the study and continue to perform the required study-
related follow-up and procedures (see Section 6.6, Criteria for Discontinuation of Study 
Treatment). If this is not possible or acceptable to the subject or investigator, the subject may 
be withdrawn from the study.
6.6.
Criteria for Discontinuation of Study Treatment
Study medication (Tenofovir DF) may be discontinued in the following instances:

Intercurrent illness that would, in the judgment of the investigator, affect assessments of 
clinical status to a significant degree 

Unacceptable toxicity, as defined in the toxicity management section of this protocol, or
toxicity that, in the judgment of the investigator, compromises the ability to continue 
study-specific procedures or is considered to not be in the subject’s best interest

Therapeutic failure 

Subject request to discontinue for any reason

Subject non-compliance with taking Tenofovir DF or sustained inability to adhere to 
Tenofovir DF treatment plan

Pregnancy during the study; refer to Appendix 5

Discontinuation of the study at the request of Gilead, a regulatory agency or independent 
ethics committee (IEC)

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6.7.
End of Study
The end of study is defined as the completion of Tenofovir DF therapy and close-out 
monitoring by the last enrolled subject (e.g., last enrolled subject completes 96 Weeks of 
treatment and monitoring). 

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7.
ADVERSE EVENTS AND TOXICITY MANAGEMENT
7.1.
Definitions of Adverse Events, Adverse Reactions, and Serious Adverse 
Events
7.1.1.
Adverse Events
An adverse event (AE) is any untoward medical occurrence in a clinical study subject 
administered a medicinal product, which does not necessarily have a causal relationship with 
the treatment. An AE can therefore be any unfavorable and/or unintended sign, symptom, or 
disease temporally associated with the use of a medicinal product, whether or not considered 
related to the medicinal product. AEs may also include pre- or post-treatment complications 
that occur as a result of protocol specified procedures, lack of efficacy, overdose, drug 
abuse/misuse reports, or occupational exposure. Preexisting events that increase in severity 
or change in nature during or as a consequence of participation in the clinical study will also 
be considered AEs.
An AE does not include the following:

Medical or surgical procedures such as surgery, endoscopy, tooth extraction, and
transfusion. The condition that led to the procedure may be an adverse event and must be 
reported.

Pre-existing diseases, conditions, or laboratory abnormalities present or detected before
the screening visit that do not worsen

Situations where an untoward medical occurrence has not occurred (e.g., hospitalization 
for elective surgery, social and/or convenience admissions)

Overdose without clinical sequelae, unless the subject is hospitalized (see Section 7.6.1)

Any medical condition or clinically significant laboratory abnormality with an onset date 
before the consent form is signed and not related to a protocol-associated procedure is not 
an AE. It is considered to be pre-existing and should be documented on the medical 
history CRF.

Uncomplicated pregnancy

An induced elective abortion to terminate a pregnancy without medical reason

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7.1.2.
Serious Adverse Events
A serious adverse event (SAE) is defined as an event that, at any dose, results in the 
following:

Death

Life-threatening (Note: The term “life-threatening” in the definition of “serious” refers to 
an event in which the subject was at risk of death at the time of the event; it does not refer 
to an event that hypothetically might have caused death if it were more severe.)

In-patient hospitalization or prolongation of existing hospitalization

Persistent or significant disability/incapacity

A congenital anomaly/birth defect

A medically important event or reaction: such events may not be immediately 
life-threatening or result in death or hospitalization but may jeopardize the subject or may 
require intervention to prevent one of the other outcomes constituting SAEs. Medical and 
scientific judgment must be exercised to determine whether such an event is a reportable 
under expedited reporting rules. 
Examples of medically important events include intensive treatment in an emergency room 
or at home for allergic bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization; and development of drug dependency or drug abuse. For the avoidance of 
doubt, infections resulting from contaminated medicinal product will be considered a 
medically important event and subject to expedited reporting requirements.
The purposes of this study, in addition to the above criteria, the following must be reported 
as an SAE:
7.1.3.
Clinical Laboratory Abnormalities and Other Abnormal Assessments as 
Adverse Events or Serious Adverse Events
Renal or bone biomarker or imaging abnormalities without clinical significance are usually
not recorded as AEs or SAEs. However, renal or bone laboratory or imaging abnormalities 
(eg, clinical chemistry, hematology, DEXA, and urinalysis) that require medical or surgical 
intervention or lead to Tenofovir DF interruption, modification, or discontinuation must be 
recorded as an AE, as well as an SAE, if applicable. In addition, laboratory or other abnormal 
assessments (eg, electrocardiogram, x-rays, vital signs) that are associated with signs and/or 
symptoms must be recorded as an AE or SAE if they meet the definition of an AE or SAE as 
described in Sections 7.1.1 and 7.1.2. If the laboratory abnormality is part of a syndrome, 
record the syndrome or diagnosis (eg, anemia), not the laboratory result (ie, decreased 
hemoglobin).
For specific information on handling of clinical laboratory abnormalities in this study, please 
refer to Appendix 4.

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7.2.
Assessment of Adverse Events and Serious Adverse Events
The investigator or qualified sub investigator is responsible for assessing AEs and SAEs for 
causality and severity, and for final review and confirmation of accuracy of event
information and assessments.
7.2.1.
Assessment of Causality for Tenofovir DF Treatment and Procedures
The investigator or qualified sub investigator is responsible for assessing the relationship to 
Tenofovir DF therapy using clinical judgment and the following considerations:

No: Evidence exists that the adverse event has an etiology other than Tenofovir DF. For 
SAEs, an alternative causality must be provided (eg, pre-existing condition, underlying 
disease, intercurrent illness, or concomitant medication).

Yes: There is reasonable possibility that the event may have been caused by the 
medicinal product (i.e., Tenofovir DF).  
The site investigator or sub-investigator may further classify renal or bone AEs as an ADR or 
SADR, if an association of the clinical event to Tenofovir DF and the degree of AE 
seriousness can be ascertained.  All SAEs (i.e., not limited to renal or bone events) will be 
reported. 
It should be emphasized that ineffective treatment should not be considered as causally 
related in the context of adverse event reporting. 
The relationship to study procedures (eg, invasive procedures such as venipuncture or 
biopsy) should be assessed using the following considerations:

No: Evidence exists that the adverse event has an etiology other than the study procedure.

Yes: The adverse event occurred as a result of protocol procedures, (eg., venipuncture)
7.2.2.
Assessment of Severity
Severity should be recorded and graded according to the GSI Grading Scale for Severity of
Adverse Events and Laboratory Abnormalities (Appendix 4). For AEs associated with 
laboratory abnormalities, the event should be graded on the basis of the clinical severity in 
the context of the underlying conditions; this may or may not be in agreement with the
grading of the laboratory abnormality.
7.3.
Investigator Requirements and Instructions for Reporting Adverse 
Events and Serious Adverse Events to Gilead 
Requirements for collection prior to Tenofovir DF initiation:
After informed consent, but prior to initiation of Tenofovir DF, the following types of events 
should be reported on the case report form (CRF/eCRF): all SAEs and AEs related to 
protocol-mandated procedures.

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Adverse Events
Following initiation of Tenofovir DF, collect all bone and renal AEs, regardless of cause or 
relationship, until 30 days after last administration of Tenofovir DF must be reported to the 
CRF/eCRF database as instructed.
All bone and renal AEs should be followed up until resolution or until the adverse event is 
stable, if possible. Gilead Sciences may request that certain AEs be followed beyond the 
protocol defined follow up period.
Serious Adverse Events
All bone and renal SAEs, regardless of cause or relationship, that occurs after the subject first 
consents to participate in the study (i.e., signing the informed consent) and throughout the 
duration of the study, including the protocol-required post treatment follow-up period, must 
be reported to the CRF/eCRF database and Gilead Drug Safety and Public Health (DSPH) as 
instructed. This also includes any bone and renal SAEs resulting from protocol-associated 
procedures performed after informed consent is signed.
Any SAEs and deaths that occur after the post treatment follow-up visit but within 30-days of 
the last dose of Tenofovir DF, regardless of causality, should also be reported. 
Investigators are not obligated to actively seek bone and renal SAEs after the protocol 
defined follow up period, however, if the investigator learns of any SAEs that occur after 
study participation has concluded and the event is deemed relevant to the use of 
Tenofovir DF, he/she should promptly document and report the event to Gilead DSPH.

All bone and renal AEs and (S)ADRs and all SAEs (not limited to bone and renal
events) will be recorded in the CRF/eCRF database within the timelines outlined in the 
CRF/eCRF completion guideline.

At the time of study start, SAEs will be reported using a paper serious adverse event 
reporting form. During the study conduct, sites may transition to an electronic SAE
(eSAE) system. Gilead will notify sites in writing and provide training and account 
information prior to implementing an eSAE system.
Serious Adverse Event Paper Reporting Process

All pre-specified SAEs will be recorded on the serious adverse event report form and
submitted by faxing or emailing the report form within 24 hours of the investigator’s 
knowledge of the event to the attention of Gilead DSPH or to the designated CRO.
CRO (TBD)
Contacts (TBD)
Gilead Sciences DSPH 
Representative:
Fax:
+1 650 522 5477
E-mail:
safety_fc@gilead.com

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Electronic Serious Adverse Event (eSAE) Reporting Process

Site personnel record all SAE data in the eCRF database and from there transmit the SAE 
information to Gilead DSPH within 24 hours of the investigator’s knowledge of the 
event. Detailed instructions can be found in the eCRF completion guidelines.

If for any reason it is not possible to record the SAE information electronically, i.e, the 
eCRF database is not functioning, record the SAE on the paper serious adverse event 
reporting form and submit within 24 hours as described above.

As soon as it is possible to do so, any SAE reported via paper must be transcribed into the 
eCRF Database according to instructions in the eCRF completion guidelines.

If an SAE has been reported via a paper form because the eCRF database has been 
locked, no further action is necessary.

For fatal or life-threatening events, copies of hospital case reports, autopsy reports, and 
other documents are also to be submitted by e-mail or fax when requested and applicable. 
Transmission of such documents should occur without personal subject identification, 
maintaining the traceability of a document to the subject identifiers.

Additional information may be requested to ensure the timely completion of accurate 
safety reports.

Any medications necessary for treatment of the SAE must be recorded onto the 
concomitant medication section of the subject’s CRF/eCRF and the event description 
section of the SAE form.
7.4.
Gilead Reporting Requirements
Depending on relevant local legislation or regulations, including the EU Clinical Trials 
Directive (2001/20/EC) and relevant updates, and other country-specific legislation or 
regulations, Gilead may be required to expedite to worldwide regulatory agencies reports of 
SAEs, SADRs, or suspected unexpected serious adverse reactions (SUSARs). In accordance 
with the EU Clinical Trials Directive (2001/20/EC), Gilead or a specified designee will 
notify worldwide regulatory agencies and the relevant IEC in concerned Member States of 
applicable SUSARs as outlined in current regulations.
Assessment of expectedness for SAEs will be determined by Gilead using reference safety 
information specified in the investigator’s brochure or relevant local label as applicable. 
All investigators will receive a safety letter notifying them of relevant SUSAR reports
associated with any Tenofovir DF treatment. The investigator should notify the IEC of 
SUSAR reports as soon as is practical, where this is required by local regulatory agencies, 
and in accordance with the local institutional policy. 

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7.5.
Toxicity Management 
All clinical toxicities and/or abnormal laboratory findings should be investigated for etiology
and graded according to the uniform guidelines detailed in Appendix 5. The Gilead Sciences
Medical Monitor is available for consultation on all medical and toxicity-related issues and
may be contacted as shown below:
Gilead Sciences Medical 
Monitor
Name:
Benedetta Massetto, MD
Telephone:
Mobile:
Fax:
Email:

All clinical and clinically significant laboratory toxicities will be managed according to 
uniform guidelines detailed in Appendix 5.

Grade 3 and 4 clinically significant laboratory abnormalities should be confirmed by 
repeat testing within 3 calendar days of receipt of results and before drug discontinuation, 
unless such a delay is not consistent with good medical practice. 

Clinical events and clinically significant laboratory abnormalities will be graded 
according to the GSI Grading Scale for Severity of Adverse Events and Laboratory 
Abnormalities (Appendix 4).

When restarting Tenofovir DF following resolution of the adverse event, the drug should 
be restarted at full dose or modified dose that is dependent upon discussion with the 
Gilead Sciences Medical Monitor.

Any recurrence of the Tenofovir DF-related Grade 3 or 4 clinical or clinically significant 
laboratory adverse event following dose interruption mandates permanent discontinuation 
of drug.

Any questions regarding toxicity management should be directed to the Gilead Sciences 
Medical Monitor.
7.5.1.
Grades 1 and 2 Laboratory Abnormality or Clinical Event

Continue Tenofovir DF at the discretion of the investigator.
7.5.2.
Grade 3 Laboratory Abnormality or Clinical Event

For Grade 3 clinically significant laboratory abnormality or clinical event, Tenofovir DF 
may be continued if the event is considered to be unrelated to drug.

For a Grade 3 clinical event, or clinically significant laboratory abnormality confirmed by 
repeat testing, that is considered to be related to Tenofovir DF, drug should be withheld 
until the toxicity returns to Grade 2.
PPD
PPD
PPD
PPD

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
If a laboratory abnormality recurs to Grade 3 following restarting Tenofovir DF and is 
considered related to Tenofovir DF, then Tenofovir DF should be permanently 
discontinued and the subject managed according to local practice. Recurrence of 
laboratory abnormalities considered unrelated to Tenofovir DF may not require 
permanent discontinuation.
7.5.3.
Grade 4 Laboratory Abnormality or Clinical Event
For a Grade 4 clinical event or clinically significant Grade 4 laboratory abnormality 
confirmed by repeat testing that is considered related to Tenofovir DF, Tenofovir DF should 
be permanently discontinued and the subject managed according to local practice. The 
subject should be followed as clinically indicated until the laboratory abnormality returns to 
baseline or is otherwise explained, whichever occurs first. A clinically significant Grade 4 
laboratory abnormality that is not confirmed by repeat testing should be managed according 
to the algorithm for the new toxicity grade. 
Tenofovir DF may be continued without dose interruption for a clinically non-significant 
Grade 4 laboratory abnormality (e.g., Grade 4 CPK after strenuous exercise, or triglyceride 
elevation that is nonfasting or that can be medically managed) or a clinical event considered 
unrelated to Tenofovir DF.
7.5.4.
Management of Elevated Serum Creatinine and Decreased Creatinine 
Clearance

Glomerular filtration rate (estimated creatinine clearance) will be calculated at each visit 
using the Schwartz Formula for subjects ages 12–17 as follows:
Schwartz Formula (mL/min/1.73 m2) = k L/Scr
[(k is a proportionality constant, for adolescent females 12 years old is 0.55; and for 
adolescent males 12 years old is 0.70); L is height in centimeters (cm); and Scr is serum 
creatinine (mg/dL)]

If creatinine clearance decreases to 50 mL/min/1.73 m2 (confirmed) at any time during 
the study, Tenofovir DF should be permanently discontinued, followed by 24 weeks of 
monthly monitoring in treatment-free follow up if alternative HBV therapy is not 
initiated.

Subjects with estimated creatinine clearance 70 mL/min/1.73 m2 and serum creatinine 
increased 0.5 mg/dL above baseline should have the serum creatinine and creatinine 
clearance confirmed by repeating testing within three calendar days of receipt of results 
and before Tenofovir DF discontinuation, unless such a delay is not consistent with good 
medical practice.

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
Subjects with confirmed estimated creatinine clearance 70 mL/min/1.73 m2 and serum 
creatinine increased 0.5 mg/dL above baseline should have Tenofovir DF discontinued, 
and the subject should be followed weekly for two weeks. After two weeks, if the 
estimated creatinine clearance is 70 mL/min/1.73/m2, Tenofovir DF may be resumed, 
with monitoring as described below. If the estimated clearance remains 
70 mL/min/1.73 m2, Tenofovir DF should be permanently discontinued, followed by 
24 weeks of monthly monitoring in treatment-free follow up if alternative HBV therapy 
is not initiated.

The serum creatinine and estimated creatinine clearance should be rechecked within two 
weeks after restarting treatment to ensure that the subject has stabilized. Once this has 
been determined, the subject should be evaluated at regularly scheduled study visits.

If creatinine clearance decreases to 70 mL/min/1.73 m2 (confirmed) following 
restarting Tenofovir DF treatment, Tenofovir DF should be permanently discontinued, 
followed by 24 weeks of monthly monitoring in treatment-free follow up if alternative 
HBV therapy is not initiated.
7.5.5.
Management of Reduced Serum Phosphate
If serum phosphate is confirmed to be < 3.0 mg/dl (0.96 mmol/l) in any paediatric patient 
receiving Tenofovir DF, renal function should be re-evaluated within one week, including 
measurements of blood glucose, blood potassium and urine glucose concentrations. If renal 
abnormalities are suspected or detected then consultation with a nephrologist should be 
obtained to consider interruption of Tenofovir DF treatment.
7.5.6.
Management of Bone Abnormalities
Among Group 1 subjects, if bone abnormalities are detected or suspected in paediatric patients, 
consultation with an endocrinologist and/or nephrologist should be obtained. Group 2 subjects with 
detected or suspected bone abnormalities should be managed as per the local standard of care.
7.5.7.
Management of ALT Flares
Flares on treatment: Spontaneous exacerbations in CHB are relatively common and are 
characterised by transient increases in serum ALT. After initiating antiviral therapy, serum 
ALT may increase in some patients.  In patients with compensated liver disease, these 
increases in serum ALT are generally not accompanied by an increase in serum bilirubin 
concentrations or hepatic decompensation. Patients with cirrhosis may be at a higher risk for 
hepatic decompensation following hepatitis exacerbation, and therefore should be monitored 
closely during therapy.
Flares after treatment discontinuation: Acute exacerbation of hepatitis has also been 
reported in patients who have discontinued HBV therapy. Post-treatment exacerbations are 
usually associated with rising HBV DNA, and the majority appears to be self-limited. 
However, severe exacerbations, including fatalities, have been reported. Hepatic function 

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should be monitored at repeated intervals with both clinical and laboratory follow-up for at 
least 6 months after discontinuation of HBV therapy. If appropriate, resumption of HBV 
therapy may be warranted. In patients with advanced liver disease or cirrhosis, treatment 
discontinuation is not recommended since post-treatment exacerbation of hepatitis may lead 
to hepatic decompensation.  Liver flares are especially serious, and sometimes fatal in 
patients with decompensated liver disease.
On-Treatment ALT Flare and Post-Treatment Exacerbation of Hepatitis are defined as: 

Serum ALT 2 baseline and 10 ULN, with or without associated symptoms OR

Confirmed ALT elevation (defined as 1-grade shift or 2 previous value) associated with 
confirmed changes outside of the normal range in other laboratory parameters suggestive 
of worsening hepatic function (total bilirubin 2 mg/dL above baseline, abnormal 
PT 2 seconds or INR 0.5 over baseline, abnormal serum albumin 1 g/dL below 
baseline or elevated serum lactate levels (if available), defined as 2 ULN per the Adult 
AIDS Clinical Trials Group (AACTG) guidelines).
7.5.7.1.
Management of ALT Flare in Subjects Receiving Tenofovir DF
If laboratory results indicate (1) elevation of ALT 2 baseline and 10 ULN OR 
(2) abnormal laboratory parameters suggestive of worsening hepatic function (abnormal 
bilirubin 2mg/dL above baseline, abnormal PT 2 sec above baseline, INR 0.5 above 
baseline, abnormal albumin 1 g/dL decrease from baseline or elevated serum lactate 
levels 2 ULN along with any ALT elevation (i.e., grade shift or 2 previous value), the 
following is recommended:

Schedule the subject to return to the clinic as soon as possible and ideally no later than 
one week after the initial labs were drawn. During the visit, perform a clinical assessment 
of the subject. The assessment should include a physical examination and evaluation of 
the subject’s mental status. 

Draw blood samples, request lactate testing and send for confirmation of elevated serum 
transaminases (ALT/AST), total bilirubin and PT/INR, and albumin. [Note: If, in the 
investigator’s judgment, the central laboratory cannot provide adequate turn around time, 
the confirmation test may also be performed at a local laboratory. However, the central 
laboratory results are considered definitive].
If the elevations are confirmed, request the central clinical laboratory to conduct reflex 
testing for serum HBV DNA, HBV serology (HBeAg, HBeAb, and HBsAg), HDV, HAV 
IgM, and HCV serology. 
Based on the results of the confirmatory tests, the following treatment modifications are 
recommended:

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Elevated Liver Enzymes, Normal Bilirubin, Normal PT/INT, Normal Albumin, Normal 
Lactate
If ALT and/or AST levels are elevated (i.e., 2 baseline and 10 ULN) but total 
bilirubin and PT/INR, albumin and lactate are normal, the subject may remain on Tenofovir 
DF and should be monitored every week until ALT/AST return to normal or baseline levels. 
During monitoring:

If ALT/AST levels decline within 4 weeks, the subject should remain on study and return 
to the clinic per protocol.

If after 4 weeks of monitoring, ALT/AST values remain elevated (e.g., 2 baseline 
and 10 ULN) or have worsened, with bilirubin 2.5 × ULN, PT 1.5 ULN, or 
abnormal albumin or lactate levels, the investigator should consult with the Gilead 
Medical Monitor.

If ALT remains 2 baseline and 10 ULN and the bilirubin or PT values are 
confirmed at 2.5 ULN or 1.5 ULN, respectively, the investigator should consider 
discontinuing Tenofovir DF and initiating alternative HBV therapy (see below). 
However, prior to initiating alternative therapy, medical management of the subject 
should be discussed with the Gilead Medical Monitor. (Note: Once a subject has started 
alternative therapy, s/he must be discontinued from the study.)
Elevated Liver Enzymes, Elevated Bilirubin and PT/INR (Grade 2) Symptomatic 
Elevated Lactate (2 ULN) or Asymptomatic Elevated Lactate (4 ULN)
If ALT/AST values are elevated (i.e., 2 baseline and 10 ULN) and bilirubin or PT 
values are confirmed at 2.5 ULN or 1.5 ULN , respectively, or lactate levels are 
increased (symptomatic and 2 ULN or asymptomatic and 4 ULN) the investigator 
should consider discontinuing Tenofovir DF and initiating alternative HBV treatment. The 
subject must be monitored weekly for as long as enzyme levels and bilirubin and PT/INR 
remain elevated or above baseline values. Refer to Appendix 6.
Lactic Acidosis 
Guidelines
6 for specific guidelines for the management of symptomatic and asymptomatic
hyperlactatemia.

If the ALT/AST levels return to the baseline level and/or Grade 2 or lower during the first 
8 weeks of monitoring, Tenofovir DF may be resumed. 

If the ALT/AST levels, bilirubin, PT/INR or lactate levels remain elevated up through 
Week 8 or deteriorate at any point, the investigator should consult with the Gilead 
Medical Monitor.

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7.5.7.2.
Management of Exacerbation of Hepatitis in Subjects Who Have 
Discontinued Study Medication (Tenofovir DF)
If laboratory results indicate (1) an ALT elevation 2 baseline and 10 ULN OR 
(2) abnormal laboratory parameters suggestive of worsening hepatic function 
(bilirubin 2 mg/dL above baseline, abnormal PT 2 secs above baseline, abnormal 
albumin 1 g/dL below baseline or elevated lactate levels 2 ULN) along with any ALT 
elevation (i.e., 1 grade shift or 2 previous value) and the subject is on no post-study therapy 
for HBV, the following is recommended:

Schedule the subject to return to the clinic as soon as possible and ideally no later 
than 1 week after the initial labs were drawn. During the visit, perform a clinical 
assessment of the subject. The assessment should include a physical examination and 
evaluation of the subject’s mental status.

Draw blood samples and request lactate testing and confirmation of elevated serum 
transaminases (ALT/AST), bilirubin, PT/INR, and albumin. [Note: If, in the 
investigator’s judgment, the central lab cannot provide adequate turn around time, the 
confirmation test may also be performed at a local lab. However, the central lab results 
are considered definitive].

If the elevations are confirmed (e.g., ALT 2 baseline and > 10 ULN) 
OR (2) abnormal laboratory parameters suggestive of worsening hepatic function 
(abnormal bilirubin 2 mg/dL above baseline, abnormal PT 2 secs above baseline, 
abnormal albumin 1 g/dL below baseline, or elevated lactate levels 2 ULN) along 
with any ALT elevation (i.e., 1 grade shift or 2 previous value), request the clinical 
laboratory to conduct reflex testing for serum HBV DNA, HBV serology 
(HBeAg, HBeAb, and HBsAg), HDV, HAV IgM and HCV. If serum HBV DNA is 
increasing, the investigator should consider immediate initiation of approved therapy. 
The subject should be followed until the abnormal ALT/AST values, bilirubin, PT/INR, 
albumin or lactate laboratory parameters return to normal or baseline up to a maximum of 
6 months after the initial occurrence of the event.  Refer to Appendix 6.
Lactic Acidosis 
Guidelines
for specific guidelines for the management of symptomatic and asymptomatic
hyperlactatemia.
7.6.
Special Situations Reports
7.6.1.
Definitions of Special Situations
Special situation reports include reports of pregnancy; medication error, abuse, misuse, or 
overdose; lack of effect; adverse reactions in infants following exposure from breastfeeding; 
and adverse reactions associated with product complaints and occupational exposure. 

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Medication error is any unintentional error in the prescribing, dispensing, or administration 
of a medicinal product while in the control of the health care provider, subject, or consumer.
Abuse is defined as persistent or sporadic intentional excessive use of a medicinal product by 
a subject.
Misuse is defined as any intentional and inappropriate use of a medicinal product that is not 
in accordance with the protocol instructions or the local prescribing information.
An overdose is defined as an accidental or intentional administration of a quantity of a 
medicinal product given per administration or cumulatively which is above the maximum 
recommended dose as per protocol or in the product labelling (as it applies to the daily dose 
of the subject in question). In cases of a discrepancy in drug accountability, overdose will be 
established only when it is clear that the subject has taken the excess dose(s). Overdose 
cannot be established when the subject cannot account for the discrepancy except in cases in 
which the investigator has reason to suspect that the subject has taken the additional dose(s).
Product complaint is defined as complaints arising from potential deviations in the 
manufacture, packaging, or distribution of the medicinal product.  
Lack of effect is defined as the failure of the expected or intended pharmacologic action or 
therapeutic effect as described in the pharmacology and/or indications section of the current 
product labeling. 
Occupational exposure is defined as exposure to a medicinal product as a result of one’s 
professional or non-professional occupation.
7.6.2.
Instructions for Reporting Special Situations
7.6.2.1.
Instructions for Reporting Pregnancies
The investigator should report pregnancies in female study subjects that are identified after 
initiation of study medication (i.e., Tenofovir DF) and throughout the study to the CRO or 
Gilead DSPH Gilead DSPH using the pregnancy report form within 24 hours of becoming 
aware of the pregnancy.
Refer to Section 7.3 and the CRF/eCRF completion guidelines for full instructions on the 
mechanism of pregnancy reporting.
The pregnancy itself is not considered an AE nor is an induced elective abortion to terminate 
a pregnancy without medical reasons.
Any premature termination of pregnancy (eg, a spontaneous abortion, an induced therapeutic 
abortion due to complications or other medical reasons) must be reported within 24 hours as 
an SAE. The underlying medical reason for this procedure should be recorded as the AE
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A spontaneous abortion is always considered to be an SAE and will be reported as described 
in Sections 7.1.1 and 7.1.2. Furthermore, any SAE occurring as an adverse pregnancy 
outcome post study must be reported to Gilead DSPH.
The subject should receive appropriate monitoring and care until the conclusion of the 
pregnancy. The outcome should be reported to CRO [TBD] or Gilead DSPH using the 
pregnancy outcome report form. If the end of the pregnancy occurs after the study has been 
completed, the outcome should be reported directly to Gilead DSPH. Gilead DSPH contact 
information is as follows: Email: Safety_FC@gilead.com and Fax: +1 (650) 522-5477. 
Refer to Appendix 5 for Pregnancy Precautions, Definition for Female of Childbearing 
Potential, and Contraceptive Requirements.
7.6.2.2.
Reporting Other Special Situations
All other special situation reports must be reported on the special situations report form and 
forwarded to Gilead DSPH within 24 hours of the investigator becoming aware of the 
situation. These reports must consist of situations that involve Tenofovir DF and/or Gilead 
concomitant medications, but do not apply to non-Gilead concomitant medications. 
Special situations involving non-Gilead concomitant medications donot need to be reported
on the special situations report form; however, for special situations that result in renal or 
bone AEs due to a non-Gilead concomitant medication, the AE should be reported on the AE 
form. 
Any inappropriate use of concomitant medications prohibited by this protocol should not be 
reported as “misuse,” but may be more appropriately documented as a protocol deviation.
Refer to Section 7.3 and the CRF/eCRF completion guidelines for full instructions on the 
mechanism of special situations reporting.
All clinical sequelae in relation to these special situation reports will be reported as AEs or 
SAEs at the same time using the AE CRF/eCRF and/or the SAE report form. Details of the 
symptoms and signs, clinical management, and outcome will be reported, when available.

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8.
STATISTICAL CONSIDERATIONS
8.1.
Analysis Objectives and Endpoints
8.1.1.
Analysis Objectives
The primary objective of this study is:

To characterize the long term (i.e., 96 weeks of follow up) bone safety profile of 
open-label Tenofovir DF treatment in CHB-infected adolescents.  This includes 
prospectively evaluating and comparing the BMD change between CHB infected 
adolescents 12 to < 18 years of age treated with Tenofovir DF in European treatment 
centers who are assigned to one of two schedules for renal and bone laboratory 
monitoring and BMD measurement. The primary study endpoint will be the percent 
changes in BMD from Baseline through study Week 96.
The secondary objectives of this study are as follows: 

To document all SADRs and all renal- and bone-related AEs including renal and bone 
laboratory abnormalities, as applicable

To determine the time to diagnosis of renal and bone AEs and document the resulting 
patient management and outcome(s)

To assess the clinical management and outcomes of any renal- or bone related ≥ Grade 3 
laboratory markers and clinical SAEs.

To assess the efficacy and tolerability of Tenofovir DF 245mg once daily in adolescents 
aged 12 to <18 years with CHB infection

To assess the use of oral vitamin D, calcium and phosphate supplementation and explore 
the association between supplement use and rates of bone and renal AEs

To describe the demographic characteristics, the disease characteristics, of adolescents 
with CHB infection treated with Tenofovir DF.

To describe reasons for discontinuation of Tenofovir DF.
8.1.2.
Primary Endpoint
The primary endpoint of this study is:

The identification of bone AEs occurring in subjects taking Tenofovir DF between 
Baseline and Week 96 of treatment, including the identification of ≥4% percent reduction 
in BMD within subjects and between monitoring groups from Baseline.

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8.1.3.
Secondary Endpoints

Documentation of renal or bone AEs and outcomes among subjects receiving 
Tenofovir DF, including rates of medication withdrawal or drug discontinuation

Subjects’ cumulative exposure time on Tenofovir DF at the time renal or bone AEs are 
detected up to and including Week 96 or to study discontinuation (subjects without renal 
or bone AEs will contribute cumulative exposure time on Tenofovir DF from Baseline to 
Week 96 or to study discontinuation).  The cumulative time to renal or bone AEs will be 
expressed as incident rates.

Documentation of the medical management and classification of detected renal or bone 
laboratory abnormalities

Analysis of subjects’ virological and immunological status from Baseline to Week 96 
under real world treatment practices

Report provider recommendations and subject adherence to dietary supplements (e.g., 
Vitamin D, calcium)

Documentation of subject demographics, new medical issues, medications, biometrics, 
treatment adherence

Reasons for discontinuation of Tenofovir DF
8.1.4.
Other Endpoints of Interest
Not applicable
8.2.
Analysis Conventions
All individual subject data will be listed as measured. All statistical summaries and analyses 
will be performed using SAS® software (SAS Institute, Cary, North Carolina, USA) or other 
standard software tools including the STATA software (STATACorp LP, College Station, 
TX, USA).
8.2.1.
Analysis Sets
The analysis set will be the Full Analysis Set (FAS), which includes all subjects enrolled in 
the study.
8.2.1.1.
Efficacy
An efficacy analysis will be conducted after the last assigned subject reaches Week 96.  The 
analysis will evaluate the difference in the proportion of subjects (Group 1 and 2 data will be 
pooled, as subjects have exposure to a single mode of therapy) achieving a composite 

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endpoint of HBV DNA 400 copies/mL and ALT normal at Week 72, using a two-sided 
Fisher exact test with a non-completer equals failure approach.
The primary analysis set for safety analyses will include all randomized subjects who 
received at least one dose of Tenofovir DF. All data collected during the course of the study 
(on treatment and during the treatment-free follow up window) will be included in the safety 
summaries. Normalized bone biomarker ranges (i.e., calcium, phosphorus, vitamin D levels, 
PTH, osteocalcin, bone alkaline phosphatase, N and C telopeptides) in pediatric populations 
have not been established.  Bone serum biomarkers will be collected in parallel to DEXA 
scan schedules for Groups 1 and 2 and summarized and compared to DEXA z-score findings.
8.2.1.2.
Interim Analysis
An analysis for collected renal and bone adverse event data will be conducted after the first 
50 patients are enrolled and complete Week 48 of the study.  Final analyses will be 
conducted after all subjects have completed the study.  All data collected during treatment
plus 30 days will be included in the safety summaries.
8.2.1.3.
Pharmacokinetics
Not applicable
8.2.1.4.
Biomarkers
Not applicable
8.3.
Data Handling Conventions
Missing data can have an impact upon the interpretation of the trial data. In general, values 
for missing data will not be imputed.
For the primary endpoint and categorical secondary efficacy endpoints, missing data will be 
detailed in a separate statistical analysis plan.
Sensitivity analyses will be performed if warranted.
8.4.
Demographic Data and Baseline Characteristics
Demographic and baseline measurements will be summarized using standard descriptive 
methods 
Demographic summaries will include sex, race/ethnicity, randomization stratification group, 
and age.
Baseline data will include a summary of body weight, height, body mass index, log10 (HBV 
DNA) level, HBV serology, liver tests, creatinine clearance calculations using the Schwartz 

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formula, hematology, previous nucleoside and interferon exposure, genotype, bone mineral 
density (via DEXA scan), and serum bone biochemical markers.
For categorical demographic and baseline characteristics, a two-sided Fisher exact test may 
be used to compare monitoring groups. Similarly, for continuous demographic and baseline 
characteristics, a Wilcoxon rank sum test may be used to compare monitoring groups.
8.5.
Efficacy Analysis
8.5.1.
Primary Analysis
An efficacy analysis will be conducted after the last assigned subject reaches Week 96.  The 
analysis will evaluate the difference in the proportion of subjects (Group 1 and 2 data will be 
pooled, as subjects have exposure to a single mode of therapy) achieving a composite 
endpoint of HBV DNA 400 copies/mL and ALT normal at Week 96, using a two-sided 
Fisher exact test with a non-completer equals failure approach.
8.5.2.
Secondary Analyses 
Not applicable
8.6.
Safety Analysis
All safety data collected on or after the date that Tenofovir DF was first dispensed up to the 
date of last dose of Tenofovir DF will be summarized by monitoring group. Data for any pre-
treatment and treatment-free follow up periods will be included in data listings. 
The primary safety analysis will be performed after the last assigned subject reaches 
Week 96. The analysis will evaluate the difference between renal or bone AEs recorded 
within each of the monitoring groups with respect to the primary safety endpoint, estimating 
the cumulative incidence proportions using time-to-event methodology and performing 
comparisons using 95% confidence intervals for differences in proportions. 
The proportion of subjects in each monitoring group with renal or bone AE leading to 
permanent discontinuation of Tenofovir DF through Week 96 will be summarized.
Descriptive statistics such as n, mean, standard deviation, median, Q1, Q3, minimum and 
maximum) by monitoring group will be used to report demographics and time to event 
summaries, and a Wilcoxon rank sum test may be used to compare AEs between monitoring 
groups.
For categorical safety data including incidence of AEs and categorizations of laboratory data, 
a Fisher’s exact test will be used to compare monitoring groups. For continuous safety data 
including laboratory data, a Wilcoxon Rank sum test will be used to compare monitoring
groups. Subgroup analyses of safety endpoints will include analyses by assigned monitoring 
group, age groups, and geographical location of study site.

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8.6.1.
Extent of Exposure
A subject’s extent of exposure to drug treatment will be generated from the Tenofovir DF
drug administration page of the CRF. Exposure data will be summarized by monitoring
group.
8.6.2.
Adverse Events
Clinical and laboratory AEs will be coded using the Medical Dictionary for Regulatory 
Activities (MedDRA). System Organ Class (SOC), High-Level Group Term (HLGT), 
High-Level Term (HLT), Preferred Term (PT), and Lower-Level Term (LLT) will be 
attached to the clinical database.
Events will be summarized on the basis of the date of onset for the event. A treatment-
emergent adverse event will be defined as any adverse event that begins on or after the date 
of first dose up to the date of last dose of Tenofovir DF plus 30 days.
Summaries (number and percentage of subjects) of treatment-emergent AEs related to bone 
or renal SOCs (hierarchically ordered by SOC, HLT, and PT) will be provided by treatment 
group:

all treatment-emergent bone or renal AEs, 

all related treatment-emergent bone or renal AEs, 

combined Grade 2, 3, and 4 treatment-emergent bone or renal AEs, 

combined Grade 3 and 4 treatment-emergent bone or renal AEs, 

combined Grade 2, 3, and 4 related treatment-emergent bone or renal AEs, 

combined Grade 3 and 4 related treatment-emergent bone or renal AEs, 

all AEs that caused permanent discontinuation from Tenofovir DF, 

all AEs that caused permanent discontinuation from study, 

all AEs that caused change in dose or temporary interruption of Tenofovir DF, 

all serious AEs (all SOCs, i.e., not limited to bone or renal SOCs), and

all serious bone or renal related AEs.
Events will be summarized based on the date of onset for the event. A treatment-emergent 
adverse event will be defined as any adverse event that begins on or after the date of first 
dose of Tenofovir DF. Events that occur prior to the first dose of Tenofovir DF or after the 
last dose of Tenofovir DF will be included in data listings.

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8.6.3.
Laboratory Evaluations
Selected laboratory data (using conventional units) will be summarized using only observed 
data. Data and change from baseline at all scheduled time points will be summarized.
Selected laboratory data (using conventional units) will be summarized by the observed data 
and by the change from baseline across time. 
Graded laboratory abnormalities will be defined using the grading scheme defined in 
Appendix 4. Grading of laboratory abnormalities for analysis purposes will be performed by 
the central laboratory.
Incidence of treatment-emergent laboratory abnormalities, defined as values that increase at 
least one toxicity grade from baseline at any time post baseline, will be summarized by 
monitoring group. If baseline data are missing, then any graded abnormality (i.e., at least a 
Grade 1) will be considered treatment-emergent.
Laboratory abnormalities that occur before the first dose of Tenofovir DF or after the last 
dose of Tenofovir DF plus 30 days will be included in a data listing.
8.6.4.
Other Safety Evaluations:  Analyses of BMD
Cumulative incidence of at least a 4% decrease from baseline in BMD (spine BMD and 
whole body BMD) using time-to-event methodology will be summarized and compared 
between treatment groups using 95% confidence intervals for difference in person time rates.
The percent change from baseline in BMD (spine BMD and whole body BMD) will be 
summarized over time and compared between treatment groups using the Generalized Linear 
Model. Lumbar spine and whole body z-scores (derived from DEXA-derived BMD 
assessments) and the changes in z-scores from Baseline will be summarized.
BMD (via DEXA scan) and serum bone biochemical markers will be summarized over time. 
Changes from study baseline in bone biochemical markers will also be summarized after 
adjusting for potential confounders such as age and gender..
8.7.
Pharmacokinetic Analysis
Not applicable
8.8.
Biomarker Analysis
Not applicable
PPD

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8.9.
Sample Size
Pediatric patients receiving Tenofovir DF may exhibit renal toxicities (e.g., proximal renal 
tubulopathy) among 4.5% of subjects (95% confidence band of 0.4-8.6%).   Among 
adolescent patients with CHB, available interim 72 Week clinical trial data indicate that 5.8% 
(95% confidence band of 1.2-15.9%) of subjects experienced a ≥4% decrease in BMD; by 
comparison 3.7% (95% CI 0.4-12.5%) of placebo controls had a BMD loss of ≥4% .  In this 
same trial, no renal adverse drug reactions were detected by Week 72.  Detecting renal or 
bone AEs in CHB adolescents taking Tenofovir DF are infrequent events, and the pool of 
Tenofovir DF-naïve subjects within the EU suitable for enrollment is limited. With a fixed 
sample size of 100 (50 in each monitoring group) we would expect to detect 4-5 renal or 
bone adverse drug reactions across both real-world groups (both receive equivalent 
treatment) over 96 weeks.  
The study employs two monitoring protocols which specify the same laboratory and imaging 
tests for bone and renal markers, but differ in the frequency of testing.  Group 1 will receive 
more frequent monitoring which is protocol-defined or SmPC specified, and Group 2 will be 
monitored according to a less frequent DEXA schedule for BMD and will follow the local 
standard of care for renal monitoring.  It is hypothesized (H0) that there will be no difference 
in the timing, management, or subject outcomes resulting from renal or bone AEs among the 
two monitoring regimens.  With a one-tailed test of α=0.05, and assuming a non-inferiority 
margin of 0.10, the study has at least 80% power to detect a difference between the 
monitoring regimens beyond the specified margin of non-inferiority.  
8.10.
Data Monitoring Committee
Not applicable
8.11.
Endpoint Adjudication Committee
Not applicable
8.12.
Investigator Responsibilities
8.12.1.
Good Clinical Practice
The investigator will ensure that this study is conducted in accordance with the principles of 
the Declaration of Helsinki (as amended in Edinburgh, Tokyo, Venice, Hong Kong, and 
South Africa), International Conference on Harmonisation (ICH) guidelines, or with the laws 
and regulations of the country in which the research is conducted, whichever affords the 
greater protection to the study subject. These standards are consistent with the European 
Union Clinical Trials Directive 2001/20/EC and Good Clinical Practice Directive 
2005/28/EC.
The investigator and all applicable sub investigators will comply with 21 CFR, Part 54, 1998, 
providing documentation of their financial interest or arrangements with Gilead, or 
proprietary interests in the drug under study. This documentation must be provided prior to 

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the investigator’s (and any sub investigator’s) participation in the study. The investigator and 
sub investigator agree to notify Gilead of any change in reportable interests during the study 
and for 1 year following completion of the study. Study completion is defined as the date 
when the last subject completes the protocol-defined activities.
8.12.2.
Independent Ethics Committee (IEC) Review and Approval
The investigator (or sponsor as appropriate according to local regulations) will submit this 
protocol, informed consent form, and any accompanying material to be provided to the 
subject (such as advertisements, subject information sheets, or descriptions of the study used 
to obtain informed consent) to an IEC. The investigator will not begin any study subject 
activities until approval from the IEC has been documented and provided as a letter to the 
investigator.
Before implementation, the investigator will submit to and receive documented approval 
from the IEC any modifications made to the protocol or any accompanying material to be 
provided to the subject after initial IECapproval, with the exception of those necessary to 
reduce immediate risk to study subjects.
8.12.3.
Informed Consent
The investigator is responsible for obtaining written informed consent from each individual 
participating in this study after adequate explanation of the aims, methods, objectives, and 
potential hazards of the study and before undertaking any study-related procedures. 
Informed consent will be obtained by the parent or legal guardian of the subject, or informed 
assent will be obtained by the individual aged <18 years with the provision that the subject 
fully understands the terms of the study and understands their right to withdraw assent from 
the study at any time.  The investigator must use the most current IEC approved consent form 
for documenting written informed consent. Each informed consent (or assent as applicable) 
will be appropriately signed and dated by the subject or the subject’s legally authorized 
representative and the person conducting the consent discussion, and also by an impartial 
witness if required by IEC local requirements.
8.12.4.
Confidentiality
The investigator must assure that subjects’ anonymity will be strictly maintained and that 
their identities are protected from unauthorized parties. Only subject initials, date of birth, 
another unique identifier (as allowed by local law) and an identification code will be 
recorded on any form or biological sample submitted to the Sponsor, IEC, or laboratory. 
Laboratory specimens must be labeled in such a way as to protect subject identity while 
allowing the results to be recorded to the proper subject. Refer to specific laboratory 
instructions NOTE: The investigator must keep a screening log showing codes, names, and 
addresses for all subjects screened and for all subjects enrolled in the trial. Subject data will 
be processed in accordance with all applicable regulations. 
The investigator agrees that all information received from Gilead, including but not limited to
the investigator brochure, this protocol, CRF/eCRF, Tenofovir DF, and any other study 

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information, remain the sole and exclusive property of Gilead during the conduct of the study 
and thereafter. This information is not to be disclosed to any third party (except employees or 
agents directly involved in the conduct of the study or as required by law) without prior 
written consent from Gilead. The investigator further agrees to take all reasonable 
precautions to prevent the disclosure by any employee or agent of the study site to any third 
party or otherwise into the public domain.
8.12.5.
Study Files and Retention of Records
The investigator must maintain adequate and accurate records to enable the conduct of the 
study to be fully documented and the study data to be subsequently verified. These 
documents should be classified into at least the following two categories: (1) investigator’s 
study file, and (2) subject clinical source documents.
The investigator’s study file will contain the protocol/amendments, CRF and query forms, 
IEC and governmental approval with correspondence, informed consent, drug records, staff 
curriculum vitae and authorization forms, and other appropriate documents and 
correspondence.
The required source data should include sequential notes containing at least the following 
information for each subject:

Subject identification (name, date of birth, gender);

Documentation that subject meets eligibility criteria, i.e., history, physical examination, 
and confirmation of diagnosis (to support inclusion and exclusion criteria);

Documentation of the reason(s) a consented subject is not enrolled

Participation in study (including study number);

Study discussed and date of informed consent;

Dates of all visits;

Documentation that protocol specific procedures were performed;

Results of efficacy parameters;

Start and end date (including dose regimen) of Tenofovir DF, including dates of
dispensing and return;

Record of all AEs and other safety parameters (start and end date, and including causality 
and severity);

Concomitant medication (including start and end date, dose if relevant; dose changes);

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
Date of study completion and reason for early discontinuation, if it occurs.
All clinical study documents must be retained by the investigator until at least 2 years or 
according to local laws, whichever is longer, after the last approval of a marketing 
application in an ICH region (ie, United States, Europe, or Japan) and until there are no 
pending or planned marketing applications in an ICH region; or, if no application is filed or if 
the application is not approved for such indication, until 2 years after the investigation is 
discontinued and regulatory authorities have been notified. Investigators may be required to 
retain documents longer if specified by regulatory requirements, by local regulations, or by 
an agreement with Gilead. The investigator must notify Gilead before destroying any clinical 
study records.
Should the investigator wish to assign the study records to another party or move them to 
another location, Gilead must be notified in advance.
If the investigator cannot provide for this archiving requirement at the study site for any or all 
of the documents, special arrangements must be made between the investigator and Gilead to 
store these records securely away from the site so that they can be returned sealed to the 
investigator in case of an inspection. When source documents are required for the continued 
care of the subject, appropriate copies should be made for storage away from the site.
8.12.6.
Case Report Forms
For each subject consented, an eCRF will be completed by an authorized study staff member 
whose training for this function is documented according to study procedures. eCRF should 
be completed on the day of the subject visit to enable the sponsor to perform central 
monitoring of safety data.  Subsequent to data entry, a study monitor will perform source 
data verification within the EDC system. Original entries as well as any changes to data 
fields will be stored in the audit trail of the system.  Prior to database lock (or any interim 
time points as described in the clinical data management plan), the investigator will use 
his/her log in credentials to confirm that the forms have been reviewed, and that the entries 
accurately reflect the information in the source documents. The eCRF capture the data 
required per the protocol schedule of events and procedures. System-generated or manual 
queries will be issued to the investigative site staff as data discrepancies are identified by the 
monitor or internal Gilead staff, who routinely review the data for completeness, correctness, 
and consistency. The site coordinator is responsible for responding to the queries in a timely 
manner, within the system, either by confirming the data as correct or updating the original 
entry, and providing the reason for the update (e.g. data entry error). At the conclusion of the 
trial, Gilead will provide the site with a read-only archive copy of the data entered by that 
site. This archive must be stored in accordance with the records retention requirements 
outlined in Section 8.12.5.
8.12.7.
Drug and Supplies Accountability and Return
Gilead recommends that used and unused Tenofovir DF and supplies be returned to the 
shipping facility from which it came for eventual destruction. The study monitor will provide 

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instructions for return. If return is not possible, the study monitor will evaluate each study 
center’s drug disposal procedures and provide appropriate instruction for destruction of 
unused Tenofovir DF and supplies. If the site has an appropriate standard operating 
procedure (SOP) for drug destruction as determined by Gilead QA, the site may destroy used 
(empty or partially empty) and unused drug and supplies in accordance with that site’s 
approved SOP. A copy of the site’s approved SOP will be obtained for central files. 
If Tenofovir DF is destroyed on site, the investigator must maintain accurate records for all 
drug destroyed. Records must show the identification and quantity of each unit destroyed, the 
method of destruction, and the person who disposed of Tenofovir DF. Upon study 
completion, copies of drug accountability records must be filed at the site. Another copy will 
be returned to Gilead.
The study monitor will review Tenofovir DF and supplies and associated records at periodic 
intervals.
8.12.8.
Inspections
The investigator will make available all source documents and other records for this trial to 
Gilead’s appointed study monitors, to IECs, or to regulatory authority or health authority 
inspectors.
8.12.9.
Protocol Compliance
The investigator is responsible for ensuring the study is conducted in accordance with the 
procedures and evaluations described in this protocol.
8.13.
Sponsor Responsibilities
8.13.1.
Protocol Modifications
Protocol modifications, except those intended to reduce immediate risk to study subjects, 
may be made only by Gilead. All protocol modifications must be submitted to the EC in
accordance with local requirements. Approval must be obtained before modifications can be 
implemented.
8.13.2.
Study Report and Publications
A clinical study report (CSR) will be prepared and provided to the regulatory agency(ies).
Gilead will ensure that the report meets the standards set out in the ICH Guideline for 
Structure and Content of Clinical Study Reports (ICH E3). Note that an abbreviated report 
may be prepared in certain cases.
Investigators in this study may communicate, orally present, or publish in scientific journals 
or other scholarly media only after the following conditions have been met:

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The results of the study in their entirety have been publicly disclosed by or with the consent 
of Gilead in an abstract, manuscript, or presentation form or the study has been completed at 
all study sites for at least 2 years
The investigator will submit to Gilead any proposed publication or presentation along with 
the respective scientific journal or presentation forum at least 30 days before submission of 
the publication or presentation. 
No such communication, presentation, or publication will include Gilead’s confidential 
information (see Section 8.12.4).
The investigator will comply with Gilead’s request to delete references to its confidential 
information (other than the study results) in any paper or presentation and agrees to withhold 
publication or presentation for an additional 60 days in order to obtain patent protection if 
deemed necessary.
8.14.
Joint Investigator/Sponsor Responsibilities
8.14.1.
Payment Reporting
Investigators and their study staff may be asked to provide services performed under this 
protocol, e.g. attendance at Investigator's Meetings.  If required under the applicable statutory 
and regulatory requirements, Gilead will capture and disclose to Federal and State agencies 
any expenses paid or reimbursed for such services, including any clinical trial payments, 
meal, travel expenses or reimbursements, consulting fees, and any other transfer of value.
8.14.2.
Access to Information for Monitoring
In accordance with regulations and guidelines, the study monitor must have direct access to 
the investigator’s source documentation in order to verify the accuracy of the data recorded 
in the CRF/eCRF.
The monitor is responsible for routine review of the CRF/eCRF at regular intervals 
throughout the study to verify adherence to the protocol and the completeness, consistency, 
and accuracy of the data being entered on them. The monitor should have access to any 
subject records needed to verify the entries on the CRF/eCRF. The investigator agrees to 
cooperate with the monitor to ensure that any problems detected through any type of 
monitoring (central, on site) are resolved.
8.14.3.
Access to Information for Auditing or Inspections
Representatives of regulatory authorities or of Gilead may conduct inspections or audits of 
the clinical study. If the investigator is notified of an inspection by a regulatory authority the 
investigator agrees to notify the Gilead medical monitor immediately. The investigator agrees 
to provide to representatives of a regulatory agency or Gilead access to records, facilities, and 
personnel for the effective conduct of any inspection or audit.

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8.14.4.
Study Discontinuation
Both the sponsor and the investigator reserve the right to terminate the study at any time. 
Should this be necessary, both parties will arrange discontinuation procedures and notify the 
appropriate regulatory authority(ies) and IECs. In terminating the study, Gilead and the 
investigator will assure that adequate consideration is given to the protection of the subjects’ 
interests.

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9.
REFERENCES
1635
Lee WM. Hepatitis B virus infection. N Engl J Med 1997;337 (24):1733-45.
2826
McMahon BJ, Alberts SR, Wainwright RB, Bulkow L, Lanier AP. Hepatitis 
B-related sequelae. Prospective study in 1400 hepatitis B surface antigen-
positive Alaska native carriers. Arch Intern Med 1990;150 (5):1051-4.
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Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and 
current and emerging prevention and control measures. J Viral Hepat 2004;11 
(2):97-107.
8548
Hazra R, Gafni RI, Maldarelli F, Balis FM, Tullio AN, DeCarlo E, et al. 
Tenofovir disoproxil fumarate and an optimized background regimen of 
antiretroviral agents as salvage therapy for pediatric HIV infection. Pediatrics 
2005;116 (6):e846-54.
9505
Gafni RI, Hazra R, Reynolds JC, Maldarelli F, Tullio AN, DeCarlo E, et al. 
Tenofovir disoproxil fumarate and an optimized background regimen of 
antiretroviral agents as salvage therapy: impact on bone mineral density in 
HIV-infected children. Pediatrics 2006;118 (3):e711-8.
10417
Giacomet V, Mora S, Martelli L, Merlo M, Sciannamblo M, Vigano A. A 12-
month treatment with tenofovir does not impair bone mineral accrual in HIV-
infected children. J Acquir Immune Defic Syndr 2005;40 (4):448-50.
10698
Stroffolini T, Mele A, Tosti ME, Gallo G, Balocchini E, Ragni P, et al. The 
impact of the hepatitis B mass immunisation campaign on the incidence and 
risk factors of acute hepatitis B in Italy. J Hepatol 2000;33 (6):980-5.
10789
Flahault A, Maison P, Farran N, Massari V. Six years surveillance of hepatitis 
A and B in general practice in France. Euro Surveill 1997;2 (7):56-7.
11445
Vigano A, Zuccotti GV, Martelli L, Giacomet V, Cafarelli L, Borgonovo S, et 
al. Renal safety of tenofovir in HIV-infected children: a prospective, 96-week 
longitudinal study. Clin Drug Invest 2007;27 (8):573-81.
11526
Vigano A, Brambilla P, Cafarelli L, Giacomet V, Borgonovo S, Zamproni I, et 
al. Normalization of fat accrual in lipoatrophic, HIV-infected children 
switched from stavudine to tenofovir and from protease inhibitor to efavirenz. 
Antivir Ther 2007;12 (3):297-302.

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15423
Judd A, Boyd KL, Stohr W, Dunn D, Butler K, Lyall H, et al. Effect of 
tenofovir disoproxil fumarate on risk of renal abnormality in HIV-1-infected 
children on antiretroviral therapy: a nested case-control study. AIDS 2010;24 
(4):525-34.
16177
Cooper RD, Wiebe N, Smith N, Keiser P, Naicker S, Tonelli M. Systematic 
review and meta-analysis: renal safety of tenofovir disoproxil fumarate in 
HIV-infected patients. Clin Infect Dis 2010;51 (5):496-505.
17786
Jonas MM, Block JM, Haber BA, Karpen SJ, London WT, Murray KF, et al. 
Treatment of children with chronic hepatitis B virus infection in the United 
States: patient selection and therapeutic options Hepatology 2010;52 (6):2192-
205.
19056
World Health Organisation Global Alert and Response (GAR): Hepatitis B. 
October 2011. Available at 
http://www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/index1.html. 
Accessed 04 October 2011.  
20768
Gara N, Zhao X, Collins MT, Chong WH, Kleiner DE, Jake Liang T, et al. 
Renal tubular dysfunction during long-term adefovir or tenofovir therapy in 
chronic hepatitis B. Aliment Pharmacol Ther 2012;35 (11):1317-25.
22238
Mettler FA, Jr., Huda W, Yoshizumi TT, Mahesh M. Effective doses in 
radiology and diagnostic nuclear medicine: a catalog. Radiology 2008;248 
(1):254-63.
24854
Hope VD, Eramova I, Capurro D, Donoghoe MC. Prevalence and estimation 
of hepatitis B and C infections in the WHO European Region: a review of data 
focusing on the countries outside the European Union and the European Free 
Trade Association. Epidemiol Infect 2013:1-17.
25143
World Health Organigation (WHO). Hepatitis B Fact Sheet No. 204.  2012:
26406
Department Of Health & Human Services Centers for Disease Control and 
Prevention Division of Viral Hepatitis. Hepatitis B General Information. 
Publication No. 21-1073.  2010.
26851
Balogun MA, Parry JV, Mutton K, Okolo C, Benons L, Baxendale H, et al. 
Hepatitis B virus transmission in pre-adolescent schoolchildren in four multi-
ethnic areas of England. Epidemiol Infect 2013;141 (5):916-25.
26852
Boccalini S, Pellegrino E, Tiscione E, Pesavento G, Bechini A, Levi M, et al. 
Sero-epidemiology of hepatitis B markers in the population of Tuscany, 
Central Italy, 20 years after the implementation of universal vaccination. 
Human vaccines & immunotherapeutics 2013;9 (3).

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26853
Brouard C, Heraud-Bousquet V, Leon L, Pioche C, Antonal D, Lot F, et al. 
Incidence And Routes Of Transmission Of Hepatitis Bvirus In France, 2003–
2011 [Abstract 968]. Journal of Hepatology (EASL Abstracts) 2013;58:S399.
26854
European Centre for Disease Prevention and Control (ECDC). Hepatitis B and 
C surveillance in Europe, 2006–2011. Stockholm: ECDC.  2013.
26855
Hahne SJ, De Melker HE, Kretzschmar M, Mollema L, Van Der Klis FR, Van 
Der Sande MA, et al. Prevalence of hepatitis B virus infection in The 
Netherlands in 1996 and 2007. Epidemiol Infect 2012;140 (8):1469-80.
26857
World Health Organigation (WHO). Hepatitis B. Fact sheet N°204. Updated 
July 2013. 2013.
26858
Centers for Disease Control and Prevention (CDC). Hepatitis B.  
Epidemiology and Prevention of Vaccine-Preventable Diseases. 12 ed. 
Washington DC: Public Health Foundation; 2012: 115-38. 
27079
Alward WL, McMahon BJ, Hall DB, Heyward WL, Francis DP, Bender TR. 
The long-term serological course of asymptomatic hepatitis B virus carriers 
and the development of primary hepatocellular carcinoma. J Infect Dis 
1985;151 (4):604-9.

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10.
APPENDICES
Appendix 1.
Investigator Signature Page
Appendix 2.
Study Procedures Table
Appendix 3.
Management of Clinical and Laboratory Adverse Events
Appendix 4.
GSI Grading Scale for Severity of Adverse Events and Laboratory 
Abnormalities
Appendix 5.
Pregnancy Precautions, Definition for Female of Childbearing Potential

PPD
PPD
Viread® 245mg 
Protocol GS-EU-17 4-l403 
Gilead Sciences International Ltd. 
Appendix 1. 
Investigator Signature Page 
GILEAD SCIENCESINTERNATIONAL LTD. 
FLOWERS BUILDING, GRANTAPARK 
CAMBRIDGE, CB21 6GT, UNITED KINGDOM 
STUDY ACKNOWLEDGEMENT 
Final 
Original 
Pharmacoepidemiology study to defme the long-term safety profile oftenofovir disoproxil 
fumarate (Tenofovir DF, Viread®) and describe the management ofTenofovir DF-associated 
renal and bone toxicity in CHB-infected adolescents aged 12 to <18 years in Europe 
GS-EU-174-1403 Original Final, 3 November 2014 
This protocol has been approved by Gilead Sciences International Ltd. The following 
signature documents this approvaL 
Name Study Director (Printed) 
Author 
Gilead EU QPPV (Printed) 
Author 
Date 
CONFIDENTIAL 
Signature 
Page74 
3 NOV 20t4 

PPD
PPD
Vuead® 245mg 
P10tocol GS-EU-174-1403 
G1lead Sc1ences Intematwnal Ltd. 
Appendix 1. 
Investigatm· Signature Page 
GILEAD SCIENCESINTERNATIONAL LTD. 
FLOWERS BUILDING, GRANT A PARK 
CAMBRIDGE, CB21 6GT, UNITED KINGDOM 
STUDY ACKNOWLEDGEMENT 
Final 
011ginal 
Pharmacoepidem10logy study to define the long-term safety profile oftenofovir disoprox1l 
fumarate (Tenofov1r DF, V1read®) and desctibe the management ofTenofovir OF-associated 
renal and bone toxicity in CHB-infected adolescents aged 12 to <18 years in Europe 
GS-EU-174-1403 Original Fmal, 3 November 2014 
Thts protocol has been approved by Gilead Sciences International Ltd. The following 
s1gnatme documents this approval. 
Name Study Dtrector (Printed) 
Authot 
Date 
Author 
Date 
CONFIDENTIAL 
Signature 
Page 74 
3 NOV 2014 

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INVESTIGATOR STATEMENT
I have read the protocol, including all appendices, and I agree that it contains all necessary 
details for me and my staff to conduct this study as described. I will conduct this study as 
outlined herein and will make a reasonable effort to complete the study within the time 
designated.
I will provide all study personnel under my supervision copies of the protocol and access to 
all information provided by Gilead Sciences International Ltd. I will discuss this material 
with them to ensure that they are fully informed about the drugs and the study.
Principal Investigator Name (Printed)
Signature
Date
Site Number

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Appendix 2.
Study Procedures Table
Study Procedures
Screening
Baseline
4
12
24
36
48
60
72
84
96
30d Follow-Up
Written Informed Consent
x
Medical History
x
HBV DNA
x
x
x
x
x
x
x
x
x
HBV serology
x
x
x
x
x
x
HCV, HDV, HIV screening
x
HBV genotype
x
DEXA, Group 1
x
x
x
x
x
DEXA, Group 2
x
x
x
Serum bone chemistry, Group 1
x
x
x
x
x
Serum bone chemistry, Group 2
x
x
x
Serum renal chemistry, Group 1 x
x
x
x
x
x
x
x
x
x
x
Serum renal chemistry, Group 2* x
x
x
Liver chemistry
x
x
x
x
x
x
Hematology
x
x
x
x
x
Urinalysis, Group 1 (see * for 
Group 2)
x
x
x
x
x
x
x
x
x
x
x
Complete physical examination, x
x
x
x
x
x
x
x
x
x
Changes in medical status or 
symptoms, Group 1 (see ⱡ for 
Group 2)
x
x
Drug dispensed and 
accountability/Concomitant 
medications
x
x
x
x
x
x
x
x
x
x
Assess for AE, including renal 
and bone events (see ⱡ for 
Group 2)
x
x
x
x
x
x
x
x
x
x
x
Pregnancy test 
x
x
x
x
x
x
x
x
x
x
Study Week

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* Group 2 will follow local standard of care for renal monitoring, which may include Tenofovir DF SmPC recommended screening intervals
Definitions:
HBV serology
HBeAg, HBsAg, HbeAb, HBsAb
Serum bone chemistry
calcium, phosphorus, 1, 25 hydroxy Vitamin D, PTH, osteocalcin, bone alkaline phosphatase, N and C telopeptides
Serum renal chemistry
glucose, creatinine, creatinine clearance
Liver chemistry
Hematology
PT/INR,  complete blood count (CBC) with differential, platelets
Urinalysis
glucose, protein, urine creatinine, urine phosphate, bicarbonate, blood
Complete physical exam
includes vital signs, body weight and height
ⱡ Group 2 subjects may have changes in medical status or symptoms and new AE assessed upon return for renal monitoring, as per standard of care and within the 12 week intervals of scheduled 
physical examinations
alanine aminotransferase (ALT), alkaline aminophosphatase (ALP), aspartate aminotransferase (AST), total and direct bilirubin, total protein, albumin, gamma 
glutamyl transpeptide (GGT)

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Appendix 3.
Management of Clinical and Laboratory Adverse Events
Grade 1
(Mild)
Grade 4
(Possibly Life-Threatening)
Grade 3
(Severe)
Grade 2
(Moderate)
May continue 
dosing at the 
discretion of the 
investigator
Repeat lab to 
confirm toxicity 
grade
Repeat lab to 
confirm toxicity 
grade
If confirmed and possibly and/or probably related to 
study drugs:
1.
Withhold study drugs until Grade 2
2.
Restart all study drugs at full dose
If confirmed and unrelated to study 
drugs, dosing may continue at the 
discretion of the investigator
If confirmed and possibly 
or probably related to 
study drugs, discontinue 
study drugs dosing 
permanently and follow at 
periodic intervals at least 
weekly until a return to 
baseline or is otherwise 
explained
If Grade 3 or 4 recurrence that is confirmed and possibly or 
probably related to study drugs, discontinue all study drugs dosing 
permanently
If Grade 3 or 4 recurrence that is considered unrelated to 
study drugs, continue all study drugs at the same dose at the 
discretion of the investigator

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Appendix 4.
GSI Grading Scale for Severity of Adverse Events and Laboratory Abnormalities
Version: 18Junel2012
HEMATOLOGY
Grade 1
Grade 2
Grade 3
Grade 4
Hemoglobin
HIV POSITIVE
Adult and Pediatric 57 Days
8.5 to 10.0 g/dL 
85 to 100 g/L
7.5 to 8.5 g/dL 
75 to 85 g/L
6.5 to 7.5 g/dL 
65 to 75 g/L
6.5 g/dL
65 g/L
HIV NEGATIVE
Adult and Pediatric 57 Days 
10.0 to 10.9 g/dL
100 to 109 g/L
OR
Any decrease from Baseline
2.5 to 3.5 g/dL
25 to 35 g/L
9.0 to 10.0 g/dL
90 to 100 g/L
OR
Any decrease from Baseline
3.5 to 4.5 g/dL
35 to 45 g/L
7.0 to 9.0 g/dL
70 to 90 g/L
OR
Any decrease from Baseline
4.5 g/dL
45 g/L
7.0 g/dL
70 g/L
Infant, 36–56 Days
(HIV POSITIVE OR
NEGATIVE)
8.5 to 9.4 g/dL
85 to 94 g/L
7.0 to 8.5 g/dL
70 to 85 g/L
6.0 to 7.0 g/dL
60 to < 70 g/L
6.0 g/dL
< 60 g/L
Infant, 22–35 Days
(HIV POSITIVE OR
NEGATIVE)
9.5 to 10.5 g/dL
95 to 105 g/L
8.0 to 9.5 g/dL
80 to 95 g/L
7.0 to 8.0 g/dL
70 to 80 g/L
7.0 g/dL
70 g/L
Infant, 1–21 Days
(HIV POSITIVE OR
NEGATIVE)
12.0 to 13.0 g/dL
120 to 130 g/L
10.0 to 12.0 g/dL
100 to 120 g/L
9.0 to 10.0 g/dL
90 to 100 g/L
9.0 g/dL
90 g/L

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HEMATOLOGY
Grade 1
Grade 2
Grade 3
Grade 4
Absolute Neutrophil Count 
(ANC)
Adult and Pediatric, 7 Days
1000 to 1300/mm3
750 to 1000/mm3
500 to 750/mm3
500/mm3
1.00 to 1.30 GI/L
0.75 to 1.00 GI/L
0.50 to 0.75 GI/L
0.50 GI/L
Infant, 2 – 7 Days
1250 to 1500/mm3
1.25 to 1.50 GI/L
1000 to 1250/mm3
1.00 to < 1.25 GI/L
750 to 1000/mm3
0.75 to < 1.00 GI/L
750/mm3
< 0.75 GI/L
Infant, 1 Day
4000 to 5000/mm3
4.00 to 5.00 GI/L
3000 to 4000/mm3
3.00 to < 4.00 GI/L
1500 to 3000/mm3
1.50 to < 3.00 GI/L
1500/mm3
< 1.50 GI/L
Absolute CD4+ Count
HIV NEGATIVE ONLY
Adult and Pediatric 
> 13 Years
300 to 400/mm3
300 to 400/μL
200 to 300/mm3
200 to 300/μL
100 to 200/mm3
100 to 200/μL
100/mm3
100/μL
Absolute Lymphocyte Count
HIV NEGATIVE ONLY
Adult and Pediatric 
13 Years
600 to 650/mm3
0.60 to 0.65 GI/L
500 to 600/mm3
0.50 to 0.60 GI/L
350 to 500/mm3
0.35 to 0.50 GI/L
350/mm3
0.35 GI/L
Platelets 
100,000 to < 125,000/mm3
100 to 125 GI/L
50,000 to 100,000/mm3
50 to 100 GI/L
25,000 to 50,000/mm3
25 to 50 GI/L
25,000/mm3
25 GI/L
WBCs 
2000/mm3 to 2500/mm3
1,500 to 2,000/mm3
1000 to 1,500/mm3
1000/mm3
2.00 GI/L to 2.50 GI/L
1.50 to 2.00 GI/L
1.00 to 1.50 GI/L
1.00 GI/L

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HEMATOLOGY
Grade 1
Grade 2
Grade 3
Grade 4
Hypofibrinogenemia
100 to 200 mg/dL
75 to 100 mg/dL
50 to 75 mg/dL
50 mg/dL
1.00 to 2.00 g/L
0.75 to 1.00 g/L
0.50 to 0.75 g/L
0.50 g/L
Hyperfibrinogenemia
ULN to 600 mg/dL
600 mg/dL
—
—
ULN  to 6.0 g/L
6.0 g/L
—
—
Fibrin Split Product 
20 to 40 μg/mL
40 to 50 μg/mL
50 to 60 μg/mL
60 μg/mL
20 to 40 mg/L
40 to 50 mg/L
50 to 60 mg/L
60 mg/L
Prothrombin Time (PT)
1.00 to 1.25 ULN
1.25 to 1.50 ULN 
1.50 to 3.00 ULN 
3.00 ULN 
International Normalized Ratio 
of prothrombin time (INR)
1.1 to 1.5 x ULN
>1.5 to 2.0 x ULN
>2.0 to 3.0 x ULN
>3.0 x ULN
Activated Partial
Thromboplastin Time (APTT)
1.00 to 1.66 ULN
1.66 to 2.33 ULN
2.33 to 3.00 ULN
3.00 ULN
Methemoglobin 
5.0 to 10.0%
10.0 to 15.0%
15.0 to 20.0%
20.0%

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CHEMISTRY
Grade 1
Grade 2
Grade 3
Grade 4
Hyponatremia 
130 to <LLN mEq/L
125 to 130 mEq/L
121 to 125 mEq/L
121 mEq/L
130 to <LLN mmol/L
125 to 130 mmol/L
121 to 125 mmol/L
121 mmol/L
Hypernatremia 
146  to 150 mEq/L
150 to 154 mEq/L
154 to 159 mEq/L
159 mEq/L
146  to 150 mmol/L
150 to 154 mmol/L
154 to 159 mmol/L
159 mmol/L
Hypokalemia 
3.0 to 3.4 mEq/L
2.5 to 3.0 mEq/L
2.0 to 2.5 mEq/L
2.0 mEq/L
3.0 to 3.4 mmol/L
2.5 to 3.0 mmol/L
2.0 to 2.5 mmol/L
2.0 mmol/L
Hyperkalemia 
5.6 to 6.0 mEq/L
6.0 to 6.5 mEq/L
6.5 to 7.0 mEq/L
7.0 mEq/L
5.6 to 6.0 mmol/L
6.0 to 6.5 mmol/L
6.5 to 7.0 mmol/L
7.0 mmol/L
Hypoglycemia
Adult and Pediatric
1 Month
55 to 64 mg/dL
40 to 55 mg/dL
30 to 40 mg/dL
30 mg/dL
3.03 to 3.58 mmol/L
2.20 to 3.03 mmol/L
1.64 to 2.20 mmol/L
1.64 mmol/L
Infant, 1 Month
50 to 54 mg/dL
2.8 to 3.0 mmol/L
40 to 50 mg/dL
2.2 to 2.8 mmol/L
30 to 40 mg/dL
1.7 to 2.2 mmol/L
30 mg/dL
1.7 mmol/L
Hyperglycemia, Nonfasting 
116 to 160 mg/dL
160 to 250 mg/dL
250 to 500 mg/dL
500 mg/dL
6.42 to 8.91 mmol/L
8.91 to 13.90 mmol/L
13.90 to 27.79 mmol/L
27.79 mmol/L
Hyperglycemia, Fasting
110 to 125 mg/dL
6.08 to 6.96 mmol/L
>125 to 250 mg/dL
>6.96 to 13.90 mmol/L
>250 to 500 mg/dL
>13.90 to 27.79 mmol/L
>500 mg/dL
>27.79 mmol/L
Hypocalcemia 
(corrected for albumin if 
7.8 to 8.4  mg/dL
7.0 to 7.8 mg/dL
6.1 to 7.0 mg/dL
6.1 mg/dL

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CHEMISTRY
Grade 1
Grade 2
Grade 3
Grade 4
appropriate*)
Adult and Pediatric
7 Days
1.94 to 2.10 mmol/L
1.74 to 1.94 mmol/L
1.51 to 1.74 mmol/L
1.51 mmol/L
Infant, 7 Days
6.5 to 7.5 mg/dL
1.61 to 1.88  mmol/L
6.0 to 6.5 mg/dL
1.49 to < 1.61 mmol/L
5.5 to 6.0 mg/dL
1.36 to < 1.49 mmol/L 
5.5 mg/dL
< 1.36 mmol/L
Hypercalcemia (corrected 
for albumin if appropriate*)
Adult and Pediatric 
7 Days
>ULN to 11.5 mg/dL
11.5 to 12.5 mg/dL
12.5 to 13.5 mg/dL
13.5 mg/dL
>ULN to 2.88 mmol/L
2.88 to 3.13 mmol/L
3.13 to 3.38 mmol/L
3.38 mmol/L
Infant, 7 Days
11.5 to 12.4 mg/dL
2.86 to 3.10  mmol/L
12.4 to 12.9 mg/dL
> 3.10 to 3.23  mmol/L
12.9 to 13.5 mg/dL
> 3.23 to 3.38  mmol/L
13.5 mg/dL
> 3.38 mmol/L
Hypocalcemia (ionized)
3.0 mg/dL to LLN
2.5 to < 3.0 mg/dL
2.0 to 2.5 mg/dL
2.0 mg/dL
0.74 mmol/L to LLN
0.62 to 0.74 mmol/L
0.49 to 0.62 mmol/L
0.49 mmol/L
Hypercalcemia (ionized)
ULN to 6.0 mg/dL
6.0 to 6.5 mg/dL
6.5 to 7.0 mg/dL
7.0 mg/dL
ULN to 1.50 mmol/L
1.50 to 1.63 mmol/L
1.63 to 1.75 mmol/L
1.75 mmol/L
Hypomagnesemia
1.40 to <LLN mg/dL
1.2 to <LLN mEq/L
1.04 to 1.40 mg/dL
0.9 to   1.2 mEq/L
0.67 to 1.04 mg/dL
0.6 to 0.9 mEq/L
0.67 mg/dL
0.6 mEq/L
0.58 to <LLN mmol/L
0.43 to 0.58 mmol/L
0.28 to 0.43 mmol/L
0.28 mmol/L
Hypophosphatemia
Adult and Pediatric
14 Years
2.0 to < LLN mg/dL
1.5 to 2.0 mg/dL
1.0 to 1.5 mg/dL
1.0 mg/dL
0.63  to LLN mmol/L
0.47 to 0.63 mmol/L
0.31 to 0.47 mmol/L
0.31 mmol/L

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CHEMISTRY
Grade 1
Grade 2
Grade 3
Grade 4
Pediatric 1 Year–14 Years 
3.0 to 3.5 mg/dL
0.96 to 1.12 mmol/L
2.5 to 3.0 mg/dL
0.80 to < 0.96 mmol/L
1.5 to 2.5 mg/dL
0.47 to < 0.80 mmol/L
1.5 mg/dL
< 0.47 mmol/L
Pediatric 1 Year
3.5 to 4.5 mg/dL
1.12 to 1.46 mmol/L
2.5 to 3.5 mg/dL
0.80 to < 1.12 mmol/L
1.5 to 2.5 mg/dL
0.47 to < 0.80 mmol/L
1.5 mg/dL
< 0.47 mmol/L
Hyperbilirubinemia 
Adult and Pediatric 
> 14 Days
1.0 to 1.5 ULN 
1.5 to 2.5 ULN
2.5 to 5.0 ULN 
5.0 ULN 
Infant, 14 Days
(non-hemolytic)
NA
20.0 to 25.0 mg/dL
342 to 428 μmol/L
25.0 to 30.0 mg/dL
> 428 to 513 μmol/L
30.0 mg/dL
> 513 μmol/L
Infant, 14 Days
(hemolytic)
NA
NA
20.0 to 25.0 mg/dL
342 to 428 μmol/L
25.0 mg/dL
> 428 μmol/L
Blood Urea Nitrogen
1.25 to 2.50 ULN 
2.50 to 5.00 ULN 
5.00 to 10.00 ULN 
10.00 ULN
Hyperuricemia
>ULN to 10.0 mg/dL 
10.0 to 12.0 mg/dL 
12.0 to 15.0 mg/dL 
15.0 mg/dL
>ULN to 597 μmol/L
597 to 716 μmol/L
716 to 895 μmol/L
895 μmol/L
Hypouricemia
1.5 mg/dL to LLN
1.0 to 1.5 mg/dL
0.5 to 1.0 mg/dL
0.5 mg/dL
87 μmol/L to LLN
57 to 87 μmol/L
27 to 57 μmol/L
27 μmol/L
Creatinine 
1.50 to 2.00 mg/dL
2.00 to 3.00 mg/dL
3.00 to 6.00 mg/dL 
6.00 mg/dL
133 to 177 μmol/L
177 to 265 μmol/L
265 to 530 μmol/L
530 μmol/L
Bicarbonate
16.0 mEq/L to LLN 
11.0 to 16.0 mEq/L
8.0 to 11.0 mEq/L
8.0 mEq/L
16.0 mmol/L to LLN
11.0 to 16.0 mmol/L
8.0 to 11.0 mmol/L
8.0 mmol/L

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CHEMISTRY
Grade 1
Grade 2
Grade 3
Grade 4
Triglycerides
(Fasting)
NA
500 to 750 mg/dL
750 to 1200 mg/dL
1200 mg/dL
5.64–8.47 mmol/L
8.47–13.55 mmol/L
13.55 mmol/L
LDL
(Fasting)
130 to 160 mg/dL
>160 to 190 mg/dL
> 190 mg/dL
NA
3.35 to 4.15 mmol/L
>4.15 to 4.92 mmol/L
>4.92 mmol/L
Pediatric >2 to <18 years
110 to 130 mg/dL
>130 to 190 mg/dL
> 190 mg/dL
NA
2.84 to 3.37 mmol/L
>3.37 to  4.92 mmol/L
>4.92 mmol/L
Hypercholesterolemia
(Fasting)
200 to 239 mg/dL
239 to 300 mg/dL
300 mg/dL
NA
5.16 to 6.19 mmol/L
6.19 to 7.77 mmol/L
7.77 mmol/L
Pediatric 18 Years
170 to 199 mg/dL
4.39 to 5.15 mmol/L
199 to 300 mg/dL
5.15 to 7.77 mmol/L
300 mg/dL
7.77 mmol/L
NA
Creatine Kinase
3.0 to 6.0 ULN
6.0 to 10.0 ULN
10.0 to 20.0 ULN
20.0 ULN
*Calcium should be corrected for albumin if albumin is < 4.0 g/dL

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ENZYMES
Grade 1
Grade 2
Grade 3
Grade 4
AST (SGOT) 
1.25 to 2.50 ULN
2.50 to 5.00 ULN
5.00 to 10.00 ULN
10.00 ULN
ALT (SGPT) 
1.25 to 2.50 ULN
2.50 to 5.00 ULN
5.00 to 10.00 ULN
10.00 ULN
GGT
1.25 to 2.50 ULN
2.50 to 5.00 ULN
5.00 to 10.00 ULN
10.00 ULN
Alkaline Phosphatase 
1.25 to 2.50 ULN
2.50 to 5.00 ULN
5.00 to 10.00 ULN
10.00 ULN
Total Amylase
1.0 to 1.5 ULN
1.5 to 2.0 ULN
2.0 to 5.0 ULN
5.0 ULN
Pancreatic Amylase
1.0 to 1.5 ULN
1.5 to 2.0 ULN
2.0 to 5.0 ULN
5.0 ULN
Lipase 
1.0 to 1.5 ULN
1.5 to 3.0 ULN
3.0 to 5.0 ULN
5.0 ULN
Albumin
3.0 g/dL to LLN
30 g/L to LLN
2.0 to 3.0 g/dL
20 to 30 g/L
2.0 g/dL
20 g/L
NA

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URINALYSIS
Grade 1
Grade 2
Grade 3
Grade 4
Hematuria (Dipstick) 
1
2
3-4+
NA
Hematuria (Quantitative) 
See Note below
                              Females
>ULN - 10 RBC/HPF
10-75 RBC/HPF
> 75 RBC/HPF
NA
                              Males
6-10 RBC/HPF
10-75 RBC/HPF
> 75 RBC/HPF
NA
Proteinuria (Dipstick)
1
2–3
4
NA
Proteinuria, 24 Hour Collection
Adult and Pediatric 
10 Years
200 to 999 mg/24 h
>999 to 1999 mg/24 h
>1999 to 3500 mg/24 h
3500 mg/24 h
Pediatric 3 Mo to 
< 10 Years
201 to 499 mg/m2/24 h
>499 to 799 mg/m2/24 h
>799 to 1000 mg/m2/24 h
1000 mg/ m2/24 h
Glycosuria (Dipstick)
1+
2-3
4
NA
Notes: 
Toxicity grades for Quantitative and Dipstick Hematuria will be assigned by Covance Laboratory, however for other laboratories, toxicity grades will only be assigned to Dipstick 
Hematuria.
With the exception of lipid tests, any graded laboratory test with a result that is between the LLN and ULN should be assigned Grade 0.
If the severity of a clinical AE could fall under either one of two grades (e.g., the severity of an AE could be either Grade 2 or Grade 3), select the higher of the two grades for the 
AE.

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CARDIOVASCULAR
Grade 1
Grade 2
Grade 3
Grade 4
Cardiac Arrhythmia (general)
(By ECG or physical exam)
Asymptomatic AND No 
intervention indicated
Asymptomatic AND Non-
urgent medical intervention 
indicated
Symptomatic, non-life-
threatening AND Non-
urgent medical intervention 
indicated 
Life-threatening arrhythmia 
OR Urgent intervention 
indicated
Cardiac-ischemia/Infarction
NA
NA
Symptomatic ischemia 
(stable angina) OR Testing 
consistent with ischemia 
Unstable angina OR Acute 
myocardial infarction
Hemorrhage (significant acute 
blood loss)
NA
Symptomatic AND No 
transfusion indicated
Symptomatic AND 
Transfusion of 2 units 
packed RBCs (for children 
10 cc/kg) indicated 
Life-threatening hypotension 
OR Transfusion of 2 units 
packed RBCs indicated (for 
children 10 cc/kg) indicated
Hypertension (with repeat 
testing at same visit)
140–159 mmHg systolic 
OR 
90–99 mmHg diastolic
159–179 mmHg systolic 
OR 
99–109 mmHg diastolic
179 mmHg systolic 
OR 
109 mmHg diastolic
Life-threatening consequences 
(eg, malignant hypertension) 
OR Hospitalization (other than 
ER visit) indicated
Pediatric 17 Years (with 
repeat testing at same visit)
NA
91st–94th percentile adjusted
for age, height, and gender 
(systolic and/or diastolic)
≥95th percentile adjusted 
for age, height, and gender 
(systolic and/or diastolic)
Life-threatening consequences 
(eg, malignant hypertension) 
OR Hospitalization indicated 
(other than emergency room 
visit)
Hypotension
NA
Symptomatic, corrected with 
oral fluid replacement
Symptomatic, IV fluids 
indicated
Shock requiring use of 
vasopressors or mechanical 
assistance to maintain blood 
pressure

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CARDIOVASCULAR
Grade 1
Grade 2
Grade 3
Grade 4
Pericardial Effusion
Asymptomatic, small 
effusion requiring no 
intervention
Asymptomatic, moderate or 
larger effusion requiring no 
intervention
Effusion with non-life-
threatening physiologic 
consequences OR Effusion 
with nonurgent intervention 
indicated
Life-threatening consequences 
(eg, tamponade) OR Urgent 
intervention indicated
Prolonged PR Interval
PR interval 
0.21 to 0.25 sec
PR interval
0.25 sec
Type II 2nd degree AV 
block OR Ventricular pause 
3.0 sec
Complete AV block 
Pediatric 16 Years
1st degree AV block
(PR > normal for age and 
rate)
Type I 2nd degree AV block 
Type II 2nd degree AV 
block 
Complete AV block
Prolonged QTc
Asymptomatic, QTc interval 
0.45 to 0.47 sec OR Increase 
interval 0.03 sec above 
baseline
Asymptomatic, QTc interval 
0.48 to 0.49 sec OR Increase 
in interval 0.03 to 0.05 sec 
above baseline
Asymptomatic, QTc interval 
0.50 sec OR Increase in 
interval 0.06 sec above 
baseline
Life-threatening 
consequences, eg, Torsade de 
pointes or other associated 
serious ventricular 
dysrhythmia
Pediatric 16 Years
Asymptomatic, QTc interval 
0.450 to 0.464 sec 
Asymptomatic, QTc interval 
0.465 to 0.479 sec 
Asymptomatic, QTc interval 
0.480 sec 
Life-threatening 
consequences, eg, Torsade de 
pointes or other associated 
serious ventricular 
dysrhythmia
Thrombosis/Embolism
NA
Deep vein thrombosis AND 
No intervention indicated (eg, 
anticoagulation, lysis filter, 
invasive procedure) 
Deep vein thrombosis AND 
Intervention indicated (eg, 
anticoagulation, lysis filter, 
invasive procedure) 
Embolic event (eg, pulmonary 
embolism, life-threatening 
thrombus) 

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CARDIOVASCULAR
Grade 1
Grade 2
Grade 3
Grade 4
Vasovagal Episode (associated 
with a procedure of any kind)
Present without loss of 
consciousness 
Present with transient loss of 
consciousness
NA 
NA
Ventricular Dysfunction 
(congestive heart failure, 
CHF)
NA
Asymptomatic diagnostic 
finding AND intervention 
indicated
New onset with symptoms 
OR Worsening symptomatic 
CHF
Life-threatening CHF
RESPIRATORY
Grade 1
Grade 2
Grade 3
Grade 4
Bronchospasm (acute)
FEV1 or peak flow reduced to 
70% to 80%
FEV1 or peak flow 50% to 69%
FEV1 or peak flow 25% to 
49% 
Cyanosis OR FEV1 or peak flow 
25% OR Intubation
Dyspnea or Respiratory 
Distress
Dyspnea on exertion with no 
or minimal interference with 
usual social & functional 
activities 
Dyspnea on exertion causing 
greater than minimal interference 
with usual social & functional 
activities 
Dyspnea at rest causing 
inability to perform usual 
social & functional activities 
Respiratory failure with 
ventilatory support indicated
Pediatric 14 Years
Wheezing OR minimal 
increase in respiratory rate for 
age
Nasal flaring OR Intercostal 
retractions OR Pulse oximetry 
90% to 95%
Dyspnea at rest causing 
inability to perform usual 
social & functional activities 
OR Pulse oximetry 90%
Respiratory failure with 
ventilatory support indicated

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OCULAR/VISUAL
Grade 1
Grade 2
Grade 3
Grade 4
Uveitis
Asymptomatic but detectable 
on exam
Symptomatic anterior uveitis OR 
Medical intervention indicated
Posterior or pan-uveitis OR 
Operative intervention 
indicated
Disabling visual loss in affected 
eye(s) 
Visual Changes (from 
baseline)
Visual changes causing no or 
minimal interference with 
usual social & functional 
activities
Visual changes causing greater 
than minimal interference with 
usual social & functional 
activities
Visual changes causing 
inability to perform usual 
social & functional activities
Disabling visual loss in affected 
eye(s)
SKIN
Grade 1
Grade 2
Grade 3
Grade 4
Alopecia
Thinning detectable by 
study participant or  
caregiver (for disabled 
adults)
Thinning or patchy hair loss 
detectable by health care 
provider
Complete hair loss
NA
Cutaneous Reaction – Rash
Localized macular rash 
Diffuse macular, 
maculopapular, or 
morbilliform rash OR Target 
lesions 
Diffuse macular, 
maculopapular, or morbilliform 
rash with vesicles or limited 
number of bullae OR 
Superficial ulcerations of 
mucous membrane limited to 
one site
Extensive or generalized 
bullous lesions OR 
Stevens-Johnson syndrome 
OR Ulceration of mucous 
membrane involving two 
or more distinct mucosal 
sites OR Toxic epidermal 
necrolysis (TEN)
Hyperpigmentation
Slight or localized
Marked or generalized
NA
NA
Hypopigmentation
Slight or localized 
Marked or generalized
NA
NA

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Pruritis (itching – no skin 
lesions) 
(See also Injection Site 
Reactions: Pruritis associated 
with injection)
Itching causing no or 
minimal interference with 
usual social & functional 
activities
Itching causing greater than 
minimal interference with 
usual social & functional 
activities
Itching causing inability to 
perform usual social & 
functional activities 
NA
GASTROINTESTINAL
Grade 1
Grade 2
Grade 3
Grade 4
Anorexia
Loss of appetite without 
decreased oral intake
Loss of appetite associated with 
decreased oral intake without 
significant weight loss 
Loss of appetite associated 
with significant weight loss 
Life-threatening consequences 
OR Aggressive intervention 
indicated [eg, tube feeding or 
total parenteral nutrition]
Ascites
Asymptomatic
Symptomatic AND Intervention 
indicated (eg, diuretics or 
therapeutic paracentesis)
Symptomatic despite 
intervention
Life-threatening consequences
Cholecystitis
NA
Symptomatic AND Medical 
intervention indicated
Radiologic, endoscopic, or 
operative intervention 
indicated
Life-threatening consequences 
(eg, sepsis or perforation) 
Constipation 
NA
Persistent constipation requiring 
regular use of dietary 
modifications, laxatives, or 
enemas 
Obstipation with manual 
evacuation indicated
Life-threatening consequences 
(eg, obstruction)

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GASTROINTESTINAL
Grade 1
Grade 2
Grade 3
Grade 4
Diarrhea 
Adult and Pediatric 
1 Year
Transient or intermittent 
episodes of unformed stools 
OR Increase of 3 stools 
over baseline/24 hr
Persistent episodes of unformed 
to watery stools OR Increase of 
4–6 stools over baseline per 
24 hrs. 
Bloody diarrhea OR Increase 
of 7 stools per 24-hour 
period OR IV fluid 
replacement indicated
Life-threatening consequences 
(eg, hypotensive shock)
Pediatric 1 Year
Liquid stools (more 
unformed than usual) but 
usual number of stools
Liquid stools with increased 
number of stools OR Mild 
dehydration
Liquid stools with moderate 
dehydration
Liquid stools resulting in 
severe dehydration with 
aggressive rehydration 
indicated OR Hypotensive 
shock
Dysphagia-Odynophagia 
Symptomatic but able to eat 
usual diet
Symptoms causing altered 
dietary intake without medical 
intervention indicated
Symptoms causing severely 
altered dietary intake with 
medical intervention indicated
Life-threatening reduction in 
oral intake
Mucositis/Stomatitis 
(clinical exam)
See also Proctitis, 
Dysphagia-Odynophagia
Erythema of the mucosa
Patchy pseudomembranes or 
ulcerations 
Confluent pseudomembranes 
or ulcerations OR Mucosal 
bleeding with minor trauma
Tissue necrosis OR Diffuse 
spontaneous mucosal bleeding 
OR Life-threatening 
consequences (eg, aspiration, 
choking)
Nausea 
Transient (24 hours) or 
intermittent nausea with no 
or minimal interference with 
oral intake
Persistent nausea resulting in 
decreased oral intake for 24–48 
hours
Persistent nausea resulting in 
minimal oral intake for 48 
hours OR Aggressive 
rehydration indicated (eg, 
IV fluids)
Life-threatening consequences 
(eg, hypotensive shock)
Pancreatitis
NA
Symptomatic AND 
Hospitalization not indicated 
(other than ER visit)
Symptomatic AND 
Hospitalization indicated 
(other than ER visit)
Life-threatening consequences 
(eg, sepsis, circulatory failure, 
hemorrhage)

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GASTROINTESTINAL
Grade 1
Grade 2
Grade 3
Grade 4
Proctitis (functional-
symptomatic)
Also see Mucositis/ 
Stomatitis for Clinical 
Exam
Rectal discomfort AND No 
intervention indicated
Symptoms causing greater than 
minimal interference with usual 
social & functional activities OR 
Medical intervention indicated 
Symptoms causing inability to 
perform usual social/
functional activities OR 
Operative intervention 
indicated 
Life-threatening consequences 
(eg, perforation)
Vomiting
Transient or intermittent 
vomiting with no or 
minimal interference with 
oral intake
Frequent episodes of vomiting 
with no or mild dehydration
Persistent vomiting resulting 
in orthostatic hypotension OR 
Aggressive rehydration 
indicated
Life-threatening consequences 
(eg, hypotensive shock)

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NEUROLOGICAL
Grade 1
Grade 2
Grade 3
Grade 4
Alteration in Personality-
Behavior or in Mood (eg, 
agitation, anxiety, 
depression, mania, 
psychosis)
Alteration causing no or 
minimal interference with 
usual social & functional 
activities 
Alteration causing greater than 
minimal interference with 
usual social & functional 
activities 
Alteration causing inability to 
perform usual social & 
functional activities 
Behavior potentially harmful 
to self or others (eg, 
suicidal/homicidal ideation or 
attempt, acute psychosis) OR 
Causing inability to perform 
basic self-care functions
Altered Mental Status 
For Dementia, see Cognitive 
and Behavioral/Attentional 
Disturbance (including 
dementia and ADD)
Changes causing no or 
minimal interference with 
usual social & functional 
activities
Mild lethargy or somnolence 
causing greater than minimal 
interference with usual social 
& functional activities
Confusion, memory 
impairment, lethargy, or 
somnolence causing inability 
to perform usual social & 
functional activities
Delirium OR obtundation, OR 
coma
Ataxia 
Asymptomatic ataxia 
detectable on exam OR 
Minimal ataxia causing no 
or minimal interference with 
usual social & functional 
activities
Symptomatic ataxia causing 
greater than minimal 
interference with usual social 
& functional activities
Symptomatic ataxia causing 
inability to perform usual 
social & functional activities 
Disabling ataxia causing 
inability to perform basic self-
care functions
Cognitive and 
Behavioral/Attentional 
Disturbance (including 
dementia and Attention 
Deficit Disorder) 
Disability causing no or 
minimal interference with 
usual social & functional 
activities OR Specialized 
resources not indicated
Disability causing greater than 
minimal interference with 
usual social & functional 
activities OR Specialized 
resources on part-time basis 
indicated
Disability causing inability to 
perform usual social & 
functional activities OR 
Specialized resources on a
full-time basis indicated
Disability causing inability to 
perform basic self-care 
functions OR 
Institutionalization indicated
CNS Ischemia
(acute)
NA
NA
Transient ischemic attack
Cerebral vascular accident 
(CVA, stroke) with 
neurological deficit 

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NEUROLOGICAL
Grade 1
Grade 2
Grade 3
Grade 4
Developmental delay –
Pediatric 16 Years
Mild developmental delay, 
either motor or cognitive, as 
determined by comparison 
with a developmental 
screening tool appropriate 
for the setting 
Moderate developmental 
delay, either motor or 
cognitive, as determined by 
comparison with a 
developmental screening tool 
appropriate for the setting 
Severe developmental delay, 
either motor or cognitive, as 
determined by comparison 
with a developmental 
screening tool appropriate for 
the setting 
Developmental regression, 
either motor or cognitive, as 
determined by comparison 
with a developmental 
screening tool appropriate for 
the setting
Headache 
Symptoms causing no or 
minimal interference with 
usual social & functional 
activities
Symptoms causing greater 
than minimal interference with 
usual social & functional 
activities
Symptoms causing inability to 
perform usual social & 
functional activities
Symptoms causing inability to 
perform basic self-care 
functions OR Hospitalization 
indicated (other than ER visit) 
OR Headache with significant 
impairment of alertness or 
other neurologic function 
Insomnia
NA
Difficulty sleeping causing 
greater than minimal 
interference with usual 
social/functional activities
Difficulty sleeping causing 
inability to perform usual 
social & functional activities
Disabling insomnia causing 
inability to perform basic self-
care functions
Neuromuscular Weakness 
(including myopathy & 
neuropathy) 
Asymptomatic with 
decreased strength on exam 
OR Minimal muscle weak-
ness causing no or minimal 
interference with usual 
social & functional activities
Muscle weakness causing 
greater than minimal 
interference with usual social 
& functional activities
Muscle weakness causing 
inability to perform usual 
social & functional activities 
Disabling muscle weakness 
causing inability to perform 
basic self-care functions OR 
Respiratory muscle weakness 
impairing ventilation

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NEUROLOGICAL
Grade 1
Grade 2
Grade 3
Grade 4
Neurosensory Alteration 
(including paresthesia and 
painful neuropathy)
Asymptomatic with sensory 
alteration on exam or 
minimal paresthesia causing 
no or minimal interference 
with usual social & 
functional activities 
Sensory alteration or 
paresthesia causing greater 
than minimal interference with 
usual social & functional 
activities 
Sensory alteration or 
paresthesia causing inability to 
perform usual social & 
functional activities
Disabling sensory alteration or 
paresthesia causing inability to 
perform basic self-care 
functions
Seizure: (new onset) 
NA
1 seizure 
2–4 seizures 
Seizures of any kind that are 
prolonged, repetitive (eg, 
status epilepticus), or difficult 
to control (eg, refractory 
epilepsy)
Seizure: (pre-existing) 
For Worsening of Existing 
Epilepsy the Grades Should 
Be Based on an Increase 
from Previous Level of 
Control to Any of These 
Levels
NA
Increased frequency of pre-
existing seizures (non-
repetitive) without change in 
seizure character OR 
infrequent breakthrough 
seizures while on stable meds 
in a previously controlled 
seizure disorder
Change in seizure character 
from baseline either in 
duration or quality (eg, 
severity or focality) 
Seizures of any kind that are 
prolonged, repetitive (eg, 
status epilepticus), or difficult 
to control (eg, refractory 
epilepsy)
Seizure 
– Pediatric 18 Years
Seizure, generalized onset 
with or without secondary 
generalization, lasting 
< 5 minutes with < 24 hours 
post ictal state
Seizure, generalized onset 
with or without secondary 
generalization, lasting 5–20 
minutes with 
< 24 hours post ictal state
Seizure, generalized onset 
with or without secondary 
generalization, lasting 
> 20 minutes 
Seizure, generalized onset 
with or without secondary 
generalization, requiring 
intubation and sedation
Syncope (not associated 
with a procedure)
NA
Present
NA
NA

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NEUROLOGICAL
Grade 1
Grade 2
Grade 3
Grade 4
Vertigo
Vertigo causing no or 
minimal interference with 
usual social & functional 
activities
Vertigo causing greater than 
minimal interference with 
usual social & functional 
activities 
Vertigo causing inability to 
perform usual social & 
functional activities
Disabling vertigo causing 
inability to perform basic self-
care functions

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MUSCULOSKELETAL
Grade 1
Grade 2
Grade 3
Grade 4
Arthralgia
See also Arthritis
Joint pain causing no or 
minimal interference with 
usual social & functional 
activities
Joint pain causing greater than 
minimal interference with usual 
social & functional activities
Joint pain causing inability 
to perform usual social & 
functional activities
Disabling joint pain causing 
inability to perform basic self-
care functions
Arthritis
See also Arthralgia
Stiffness or joint swelling 
causing no or minimal 
interference with usual 
social & functional activities
Stiffness or joint swelling causing 
greater than minimal interference 
with usual social & functional 
activities
Stiffness or joint swelling
causing inability to perform 
usual social & functional 
activities
Disabling joint stiffness or 
swelling causing inability to 
perform basic self-care 
functions
Bone Mineral Loss
BMD t-score or z-score
–2.5 to –1.0 
BMD t-score or z-score –2.5
Pathological fracture 
(including loss of vertebral 
height)
Pathologic fracture causing 
life-threatening consequences 
Pediatric 21 Years
BMD z-score 
–2.5 to –1.0
BMD z-score < –2.5
Pathological fracture 
(including loss of vertebral 
height)
Pathologic fracture causing 
life-threatening consequences 
Myalgia
(non-injection site)
Muscle pain causing no or 
minimal interference with 
usual social & functional 
activities
Muscle pain causing greater than 
minimal interference with usual 
social & functional activities
Muscle pain causing 
inability to perform usual 
social & functional activities
Disabling muscle pain causing 
inability to perform basic self-
care functions
Osteonecrosis
NA
Asymptomatic with radiographic 
findings AND No operative 
intervention indicated
Symptomatic bone pain with 
radiographic findings OR 
Operative intervention 
indicated
Disabling bone pain with 
radiographic findings causing 
inability to perform basic self-
care functions

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SYSTEMIC
Grade 1
Grade 2
Grade 3
Grade 4
Acute Systemic Allergic 
Reaction 
Localized urticaria 
(wheals) with no medical 
intervention indicated
Localized urticaria with medical 
intervention indicated OR Mild 
angioedema with no medical 
intervention indicated
Generalized urticaria OR 
Angioedema with medical 
intervention indicated OR 
Symptomatic mild 
bronchospasm
Acute anaphylaxis OR Life-
threatening bronchospasm OR 
laryngeal edema
Chills
Symptoms causing no or 
minimal interference with 
usual social & functional 
activities
Symptoms causing greater than 
minimal interference with usual 
social & functional activities 
Symptoms causing inability to 
perform usual social & 
functional activities
NA
Fatigue
Malaise
Symptoms causing no or 
minimal interference with 
usual social & functional 
activities
Symptoms causing greater than 
minimal interference with usual 
social & functional activities
Symptoms causing inability to 
perform usual social & 
functional activities
Incapacitating fatigue/malaise 
symptoms causing inability to 
perform basic self-care 
functions
Fever (nonaxillary)
37.7C to 38.6C
99.8F to 101.5F
38.7C to 39.3C
101.6F to 102.8F
39.4C to 40.5C
102.9F to 104.9F
40.5C 
104.9F
Pain- Indicate Body Site
See also Injection Site 
Pain, Headache, 
Arthralgia, and Myalgia
Pain causing no or 
minimal interference with 
usual social & functional 
activities
Pain causing greater than minimal 
interference with usual social & 
functional activities
Pain causing inability to 
perform usual social & 
functional activities
Disabling pain causing 
inability to perform basic self-
care functions OR 
Hospitalization (other than ER 
visit) indicated
Unintentional Weight 
Loss
NA
5% to 9% loss in body weight from 
baseline
10% to 19% loss in body 
weight from baseline
20% loss in body weight 
from baseline OR  Aggressive 
intervention indicated [eg, 
tube feeding or total parenteral 
nutrition]

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INJECTION SITE REACTION
Grade 1
Grade 2
Grade 3
Grade 4
Injection Site Pain (pain 
without touching)
Or Tenderness (pain when 
area is touched) 
Pain/tenderness causing no 
or minimal limitation of use 
of limb
Pain/tenderness limiting use of 
limb OR Pain/tenderness 
causing greater than minimal 
interference with usual social 
& functional activities
Pain/tenderness causing 
inability to perform usual 
social & functional activities
Pain/tenderness causing inability 
to perform basic self-care 
function OR Hospitalization 
(other than ER visit) indicated 
for management of 
pain/tenderness
Injection Site Reaction 
(Localized), 15 Years
Erythema OR Induration
of 5 5 cm to 9 9 cm (or 
2581 cm2)
Erythema OR Induration OR 
Edema 9 cm any diameter 
(or 81 cm2)
Ulceration OR Secondary 
infection OR Phlebitis OR 
Sterile abscess OR Drainage
Necrosis (involving dermis and 
deeper tissue)
Pediatric 15 Years
Erythema OR Induration 
OR Edema present but 
2.5 cm diameter
Erythema OR Induration 
OR Edema > 2.5 cm 
diameter but < 50% surface 
area of the extremity 
segment (eg, upper 
arm/thigh)
Erythema OR Induration 
OR Edema involving 
50% surface area of the 
extremity segment (eg, 
upper arm/thigh) OR 
Ulceration OR Secondary 
infection OR Phlebitis OR 
Sterile abscess OR 
Drainage
Necrosis (involving dermis and 
deeper tissue)
Pruritis Associated with 
Injection 
See also Skin: Pruritis 
(itching—no skin lesions)
Itching localized to injection 
site AND Relieved 
spontaneously or with 
48 h treatment 
Itching beyond the injection 
site but not generalized OR 
Itching localized to injection 
site requiring 48 h treatment 
Generalized itching causing 
inability to perform usual 
social & functional activities
NA

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ENDOCRINE/METABOLIC
Grade 1
Grade 2
Grade 3
Grade 4
Lipodystrophy (eg, back 
of neck, breasts, 
abdomen)
Detectable by study 
participant or caregiver 
(for young children and 
disabled adults)
Detectable on physical exam by 
health care provider
Disfiguring OR Obvious 
changes on casual visual 
inspection
NA
Diabetes Mellitus
NA
New onset without need to initiate 
medication OR Modification of 
current meds to regain glucose 
control
New onset with initiation of 
indicated med OR Diabetes 
uncontrolled despite treatment 
modification
Life-threatening consequences 
(eg, ketoacidosis, 
hyperosmolar non-ketotic 
coma) 
Gynecomastia
Detectable by study 
participant or caregiver 
(for young children and 
disabled adults)
Detectable on physical exam by 
health care provider
Disfiguring OR Obvious on 
casual visual inspection
NA
Hyperthyroidism 
Asymptomatic
Symptomatic causing greater than 
minimal interference with usual 
social & functional activities OR 
Thyroid suppression therapy 
indicated
Symptoms causing inability to 
perform usual social & 
functional activities OR 
Uncontrolled despite treatment 
modification 
Life-threatening consequences 
(eg, thyroid storm)
Hypothyroidism
Asymptomatic
Symptomatic causing greater than 
minimal interference with usual 
social & functional activities OR 
Thyroid replacement therapy 
indicated
Symptoms causing inability to 
perform usual social & 
functional activities OR 
Uncontrolled despite treatment 
modification 
Life-threatening consequences 
(eg, myxedema coma)
Lipoatrophy (eg, fat loss 
from the face, extremities, 
buttocks)
Detectable by study 
participant or caregiver 
(for young children and 
disabled adults)
Detectable on physical exam by 
health care provider
Disfiguring OR Obvious on 
casual visual inspection
NA

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GENITOURINARY
Grade 1
Grade 2
Grade 3
Grade 4
Intermenstrual Bleeding 
(IMB)
Spotting observed by participant 
OR Minimal blood observed 
during clinical or colposcopic 
exam
Intermenstrual bleeding not 
greater in duration or amount 
than usual menstrual cycle
Intermenstrual bleeding greater 
in duration or amount than usual 
menstrual cycle
Hemorrhage with life-
threatening hypotension OR 
Operative intervention 
indicated
Urinary Tract 
obstruction (eg, stone)
NA
Signs or symptoms of urinary 
tract obstruction without 
hydronephrosis or renal 
dysfunction
Signs or symptoms of urinary 
tract obstruction with 
hydronephrosis or renal 
dysfunction
Obstruction causing life-
threatening consequences
INFECTION
Grade 1
Grade 2
Grade 3
Grade 4
Infection (any other 
than HIV infection)
Localized, no systemic antiμbial 
treatment indicated AND 
Symptoms causing no or 
minimal interference with usual 
social & functional activities
Systemic antiμbial treatment 
indicated OR Symptoms 
causing greater than minimal 
interference with usual social 
& functional activities
Systemic antiμbial treatment 
indicated AND Symptoms 
causing inability to perform 
usual social & functional 
activities OR Operative 
intervention (other than simple 
incision and drainage) indicated
Life-threatening 
consequences (eg, septic 
shock)
Basic Self-care Functions: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding.
Usual Social & Functional Activities: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of transportation, pursuing a hobby, etc.

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Appendix 5.
Pregnancy Precautions, Definition for Female of Childbearing 
Potential 
1. Pregnancy and Contraception Requirements for Males and Females of 
Childbearing Potential 
The risks of treatment with Tenofovir DF during pregnancy have not been evaluated. 
Pregnancy must be excluded before the start of treatment with Tenofovir DF and prevented 
thereafter by reliable contraceptive methods. Pregnancy tests will be performed regularly 
throughout this study. Data available at this time suggest that this drug does not have a drug-
drug interaction (DDI) with hormones used for contraception. Please refer to the latest 
version of the investigator’s brochure for additional information. 
2. Definition of Female of Childbearing Potential
For the purposes of this study, a female subject of childbearing potential is a woman who has 
not had a hysterectomy, bilateral oophorectomy, or medically documented ovarian failure. 
This definition includes pubertal females regardless of whether or not she has had a menses 
(premenarchal, Tanner Stage 3) and perimenopausal women who have had a spontaneous 
menses in the last 12 months. A woman who has had a tubal sterilization is considered to be 
of childbearing potential.
Women ≤ 54 years of age with amenorrhea of any duration will be considered to be of 
childbearing potential unless they have had a hysterectomy, bilateral oophorectomy, or 
medically documented ovarian failure.
Women > 54 years of age with cessation (for ≥12 months) of previously occurring menses 
due to ovarian failure will not be considered to be of childbearing potential.
3. Contraceptive Requirements for Females
Female subjects of childbearing potential must agree to use protocol specified method(s) of 
contraception from the screening/enrollment visit throughout the study period and for
30 days following the last dose of Tenofovir DF or choose continuous heterosexual 
abstinence as a lifestyle choice. The investigator should counsel subjects on the protocol
specified method(s) for avoiding pregnancy during the study. These methods are 
recommended due to the low failure rate (ie, less than 1% per year). See Appendix Table 1
for the protocol specified contraceptive methods. Protocol specified contraceptive methods 
are as follows: (1) a combination of one hormonal method and one barrier method; (2) two 
barrier methods where one method is the male condom; or (3) use of an intrauterine device 
(IUD) or tubal sterilization; see below. Acceptable hormonal methods include injectable 
progesterone, progesterone implants, combination oral contraceptives, transdermal 
contraceptive patch, and vaginal ring. Acceptable barrier methods include diaphragm with 
spermicide, cervical cap with spermicide, and the male condom. Female subjects must use 
either a hormonal method or a barrier method if the partner has a vasectomy. If a subject has 
undergone tubal sterilization or has had a Copper T 380A IUD or LNg 20 IUD inserted, no 
other contraception is needed.  

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Female study subjects who are not heterosexually active must have periodic confirmation of 
continued abstinence from heterosexual intercourse and regular pregnancy testing while 
taking Tenofovir DF. The investigator should counsel subjects on the protocol specified
method(s) for avoiding pregnancy in case the subject chooses to engage in heterosexual 
intercourse.
Female subjects of childbearing potential must have a negative serum pregnancy test at 
screening and a negative urine pregnancy test at baseline (Day 1) prior to receiving the first 
dose of Tenofovir DF. Lactating females must discontinue nursing before Tenofovir DF
administration.
Appendix Table 1.
Protocol Specified Contraceptive Methods
Methods to Use by 
Themselves
Combination Methods
Hormone Methods
(choose one and use with a barrier 
method)
Barrier Methods
(use both OR choose one and use 
with a hormone method)
Intrauterine Devices (IUDs)
Copper T 380A IUD
LNg 20 IUD
Tubal Sterilization
Estrogen and Progesterone
Oral contraceptives
Transdermal patch
Vaginal ring
Progesterone
Injection
Implant
Diaphragm with spermicide
OR
Cervical cap with spermicide
Male condom (with or without 
spermicide)
Partner’s vasectomy must be used with a hormone or barrier method.
If tubal sterilization is via the Essure procedure, verification of tubal blockage by 
hysterosalpingogram (HSP) must be performed approximately 3 months after microinsertion. 
Prior to verification, Essure is not considered a reliable form of contraception and another 
contraception method described above should be used.
4. Contraceptive Requirements for Males
Male subjects must agree to use condoms and avoid sperm donation from the 
screening/enrollment visit throughout the study period and for 30 days after administration of 
the last dose of Tenofovir DF.
Use of condoms (except for lambskin) has been proven to decrease the risk of transmission 
of HIV and other sexually transmitted diseases. The use of spermicide is not recommended if 
the subject or subject’s partner is infected with HIV.

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5. Procedures to be Followed in the Event of Pregnancy
Subjects should be instructed to notify the investigator if they become pregnant at any time 
during the study, or if they become pregnant within 30 days of last Tenofovir DF dose.
Subjects who become pregnant or who suspect that they are pregnant during the study must 
report the information to the investigator. The investigator should report all pregnancies to 
the Gilead DSPH using the pregnancy report form within 24 hours of becoming aware of the 
pregnancy.
Instructions for reporting pregnancy and pregnancy outcome are outlined in Section 7.6.2.1.

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Appendix 6.
Lactic Acidosis Guidelines
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been 
reported with the use of nucleoside analogues alone or in combination with other 
antiretrovirals. A majority of these cases have been in women. Obesity and prolonged 
nucleoside exposure may be risk factors; however, cases have also been reported in subjects 
with no known risk factors. 
Guidelines for management of symptomatic hyperlactatemia and asymptomatic 
hyperlactatemia are outlined in Section A and B below and are derived from the AIDS 
Clinical Trials Group (ACTG) Lactic Acidosis Guidelines. Section C outlines venous lactate 
collection techniques.
Section A. Symptomatic Hyperlactatemia
Symptomatic hyperlactatemia is defined as a clinical suspicion of hyperlactatemia 
characterized by new, otherwise unexplained and persistent (2 weeks) occurrence of 1 or 
more of the following symptoms:

Nausea and vomiting

Abdominal pain or gastric discomfort

Abdominal distention

Increased LFTs

Unexplained fatigue

Dyspnea
AND

Venous lactate level greater than twice the upper normal limit (ULN) confirmed by 
repeat venous lactate analysis within 1 week and, if persistently elevated, arterial lactate 
with blood gas analysis. 
If the repeat venous lactate is elevated confirmation with an arterial lactate specimen and 
arterial blood gas (pH, PO2, PCO2, bicarbonate, oxygen saturation) should be performed 
within 48 hours. If the arterial specimen contains lactate at a level more than two times the 
upper limit of normal, the patient should be discontinued from the study and alternative 
therapy instituted. Subjects should be monitored weekly until signs and symptoms resolve. 
Hyperlactatemia should be followed until levels return to below two times the ULN and the 
patient.

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An elevated anion gap in a patient with metabolic acidosis suggests the diagnosis of lactic 
acidosis. It can be suspected when the sum of cations minus the sum of 
anions [(Na+ + K+) (Cl- + HCO3
-)] exceeds 18 mEq/L (18 mmol/L) in the absence of other 
causes of increased anion gap such as renal failure, salicylate ingestion or other poisoning, or 
significant ketonemia (e.g., diabetic ketoacidosis, alcohol). 
Management of symptomatic subjects with lactate levels of 1 to 2 times the ULN is left to the 
discretion of the Investigator. As some of the symptoms are sufficiently vague (e.g., fatigue) 
to be present in everyone, serial repeat testing is encouraged with plans to modify the 
regimen if the lactate level rises to greater than two times the ULN as outlined above.
Section B. Asymptomatic Hyperlactatemia
In ASYMPTOMATIC subjects, lactic acidosis will be defined as hyperlactatemia greater 
than four times the ULN. Any patient with a lactate level more than two times the ULN but 
less than or equal to four times the ULN, should be questioned closely for symptoms 
(described above) and have a repeat venous sample obtained in 1 week, and, if confirmed, 
subsequently at monthly intervals. 
If the patient fulfills the definition for ASYMPTOMATIC hyperlactatemia, repeat venous 
lactate should be obtained within a week with confirmation of a more than 4-fold venous 
elevation in lactate by arterial lactate measurement and arterial blood gas (pH, PO2, PCO2, 
bicarbonate, oxygen saturation) within 48 hours. If confirmed, the patient should be 
discontinued from the study and alternative therapy instituted. Hyperlactatemia should be 
followed until levels return to below two times the ULN.
Section C. Specimen Collection
Venous lactate levels are highly dependent on collection techniques. It is therefore 
recommended that the instructions below be followed closely. High lactate levels should be 
repeated for verification. If carefully collected, venous lactate level is equivalent to an 
arterial collection in most clinical situations. If it is not possible to collect the specimen 
without hand clenching or prolonged tourniquet time, an arterial lactate should be considered, 
as this will help exclude falsely elevated lactate levels. 
1. 
Have subject sit, relaxed for 5 minutes prior to venipuncture.
2.
Instruct subject to not clench the fist before or during the procedure and to relax the
hand as much as possible.
3.
If possible, do not use a tourniquet. If a tourniquet is necessary, then apply tourniquet
lightly and draw lactate first before the other samples with the tourniquet still in 
place.
4.
Collect the blood in a chilled gray-top (sodium fluoride-potassium oxalate) tube.
5.
Place the specimen immediately on ice and send to the laboratory for immediate 
processing, preferably within 30 minutes of collection.
6.
If random lactate is elevated, then repeat as above with the following additional 
patient instructions: no alcohol within 24 hours, no exercise within 8 hours, and no 
food or drink except water within 4 hours of the draw.