A Randomized, Double Blind, Placebo-Controlled Study to Assess Efficacy, Safety and Tolerability of ISIS 304801 in Patients With Partial Lipodystrophy With an Open-Label Extension
Phase: PHASE2
Conditions: Lipodystrophy
Sponsor: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

 
 
 
 
1 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
A Randomized, Double Blind, Placebo-Controlled Study to Assess Efficacy, 
Safety and Tolerability of ISIS 304801 in Patients with Partial Lipodystrophy 
with an Open-Label Extension 
 
Principal Investigator:  
 
*Rebecca J. Brown, M.D., M.H.Sc. 
  
Associate Investigators:  
 
Monica Skarulis, M.D. 
*Phillip Gorden, M.D. 
 
Robert Shamburek, M.D. 
*Elaine Cochran, M.S.N., C.R.N.P. 
*Megan Startzell, R.N., M.P.H. 
Ahmed Gharib, M.D. 
Theo Heller, M.D. 
Christopher Koh, M.D., M.H.Sc. 
Marissa Lightbourne, M.D. (NICHD) 
 
Non-Investigator Research Staff: 
Michelle Ashmus, BSN, RN 
Non-NIH Collaborators: 
 
Elif, Oral, M.D. (Metabolism, Endocrinology, and Diabetes at 
 the University of Michigan) 
 
 
 
 
 
Abhimanyu Garg, M.D. (University of Texas Southwestern) 
Stephen O’Rahilly, M.D. (Univ. of Cambridge, Metabolic 
 Research Labs, UK) 
Robert Semple, M.D. (Univ. of Cambridge, 
UK) 
 
 
 
 
 
David Savage, M.D. (Univ. of Cambridge, UK) 
Morey W. Haymond, MD (Baylor College of Medicine) 
 
 
 
 
 
Shaji K. Chacko, Ph.D. (Baylor College of Medicine) 
 
 
 
 
 
Robert E. Eckel, M.D., Ph.D. (University of Colorado Anschutz  
Medical Campus) 
 
 
 
 
 
Kimberley D. Bruce, Ph.D. (University of Colorado Anschutz  
Medical Campus) 
 
 
 
 
 
Masami Murakami, M.D. (Gunma University Graduate School of 
 Medicine; Japan) 
Katsuyuki Nakajima, Ph.D. (Gunma University Graduate School of 
 Medicine; Japan) 
 
*Indicates those who are allowed to obtain informed consent 
 
 
 
Protocol Overview 
Protocol Title:  
A Randomized, Double Blind, Placebo-Controlled Study to 
Assess Efficacy, Safety and Tolerability of ISIS 304801 in 
Patients with Partial Lipodystrophy with an Open-Label 
Extension 
Abbreviated Title:  
ApoC-III ASO in lipodystrophy 
IRB:  
NIDDK/NIAMS  
Research Type:  
Phase II Clinical Trial 
Multi-site Collaboration:  
No 
Intramural Collaboration: 
No 
 
 

 
 
 
 
2 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Ionizing Radiation Use: 
(X-rays, e.g., CT; radioisotope, e.g. PET; 
etc.)  
Research Indicated  
Investigational New Drug/Device:  
Yes 
Patient Self-Referral Allowed:  
Yes  
List Protocol On Web:  
Yes  
Is tissue being collected for research 
purposes:  
Yes 
 
Conflict of Interest  
The protocol involves no drugs/devices/products that may lead to payments and/or royalties to be paid to the 
investigators or the NIH. 
   
The investigators have no equity, consultative, or other financial relationship with a non-NIH source related 
to this protocol which might be considered a conflict of interest.  
 
Time Frame 
Start Date:  
12/1/2015 
End Date:   4/30/2020 
 

 
 
 
 
3 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Table of Contents 
Contents 
Table of Contents _____________________________________________ 3 
Precis – Abstract _____________________________________________ 6 
STUDY GLOSSARY ____________________________________________ 7 
1. Study Objectives ___________________________________________ 9 
1.1 Primary Objective _______________________________________________ 9 
1.2 Secondary/Tertiary Objectives _____________________________________ 9 
2. Introduction ______________________________________________ 9 
2.1 Lipodystrophy __________________________________________________ 9 
2.2 Therapeutic Rationale __________________________________________ 11 
2.3 ISIS 304801 __________________________________________________ 13 
2.3.1 Mechanism of Action __________________________________________________________ 13 
2.3.2 Chemistry __________________________________________________________________ 13 
2.3.3 Preclinical Experience _________________________________________________________ 14 
2.3.4 Clinical Experience ___________________________________________________________ 15 
2.4 Rationale for Dose and Schedule of Administration ____________________ 16 
3. Subject Eligibility Assessment and Enrollment ____________________ 17 
3.1 Inclusion Criteria ______________________________________________ 17 
3.2 Exclusion Criteria ______________________________________________ 18 
4. Study Design _____________________________________________ 20 
4.1 Design/Randomization __________________________________________ 20 
4.2 Outcome Measures _____________________________________________ 21 
4.2.1 Primary outcome: ____________________________________________________________ 21 
4.2.2 Secondary outcomes: _________________________________________________________ 21 
4.2.3 Tertiary/Exploratory outcomes: _________________________________________________ 21 
5. Statistical Considerations ___________________________________ 22 
5.1 Sample Size Justification ________________________________________ 22 
5.2 Statistical Methods for Data Analysis _______________________________ 24 
6. Experimental Plan _________________________________________ 25 
6. 1 Diet ________________________________________________________ 25 
6.2 Medications __________________________________________________ 25 
6.2.1 Pre-study Medications _________________________________________________________ 25 
6.2.2 ISIS 304801 ________________________________________________________________ 25 

 
 
 
 
4 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
6.3 Study Procedures ______________________________________________ 26 
6.3.1 Study Schedule ______________________________________________________________ 26 
6.3.2 Prescreening ________________________________________________________________ 26 
6.3.3 Initial Visit – Includes Screening (Week -1) and the first week of dosing (Week 1) _________ 27 
6.3.4 In-person follow-up visits ______________________________________________________ 27 
6.3.5 Home nurse visits ____________________________________________________________ 27 
6.3.6 Telephone follow-up __________________________________________________________ 28 
6.3.7 Post-Treatment ______________________________________________________________ 28 
6.3.8 Follow-up Visits for Early Termination from Treatment Period _________________________ 28 
6.3.9 Follow-up Visits for Early Termination from Post-Treatment Follow-up Period _____________ 29 
6.3.10 End of Study _______________________________________________________________ 29 
6.3.11 Post-Study Obligations _______________________________________________________ 29 
6.4 Study Assessments _____________________________________________ 29 
6.4.1 Patient Reported Outcomes ____________________________________________________ 29 
6.4.2 Detailed Metabolic Phenotyping _________________________________________________ 29 
6.4.3 Pharmacokinetic Analysis ______________________________________________________ 32 
7. Human Subject Protection ___________________________________ 34 
7.1 Data and Safety Monitoring Plan __________________________________ 34 
7.1.1 Investigational New Drug application _____________________________________________ 35 
7.1.2 Data and Safety Monitoring Board _______________________________________________ 35 
7.1.3 Study monitoring ____________________________________________________________ 35 
7.1.4 Adjudication Committees ______________________________________________________ 35 
7.2 Adverse Events, Protocol Deviations, and Unanticipated Problems ________ 36 
7.2.1 Definitions __________________________________________________________________ 36 
7.2.2 Monitoring and Recording Adverse Events _________________________________________ 37 
7.2.3 Evaluation of Adverse Events (Serious and Non-Serious) _____________________________ 37 
7.3  Reporting ____________________________________________________ 39 
7.4 Procedures for Handling Special Situations __________________________ 40 
7.4.1 Contraception and Pregnancy ___________________________________________________ 40 
7.4.2 Abnormalities of Laboratory Tests _______________________________________________ 41 
7.4.3 Prescheduled or Elective Procedures or Routinely Scheduled Treatments ________________ 41 
7.4.4 Dosing Errors _______________________________________________________________ 41 
7.5 Safety Monitoring Rules _________________________________________ 42 
7.5.1 Safety Monitoring Rules for Liver Chemistry Tests ___________________________________ 42 
7.5.2 Safety Monitoring Rules for Renal Function ________________________________________ 43 
7.5.3 Safety Monitoring Rules for Platelet Count Results __________________________________ 43 
7.5.4 Safety Monitoring for Minor Bleeding Events _______________________________________ 43 
7.5.5 Safety Monitoring for Constitutional Symptoms _____________________________________ 43 
7.5.6 Safety Monitoring for LDL-C Elevations ___________________________________________ 44 
7.5.7 Safety Monitoring Rule for Documented Severe Hypoglycemia _________________________ 44 
7.5.8 Monitoring Rule for Hyperglycemia ______________________________________________ 45 
7.5.9 Acute Pancreatitis ____________________________________________________________ 46 
7.6 Stopping Rules ________________________________________________ 46 
7.6.1 Stopping Rules for Liver Chemistry Elevations ______________________________________ 47 
7.6.2 Stopping Rules for Renal Function Test Results _____________________________________ 47 
7.6.3 Stopping Rule for Platelet Count Results __________________________________________ 47 
7.6.4 Stopping Rule for Documented Severe Hypoglycemia ________________________________ 50 

 
 
 
 
5 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
7.7 Adjustment of Dose and/or Treatment Schedule ______________________ 50 
7.8 Withdrawal Criteria ____________________________________________ 50 
7.9 Rationale for Subject Selection ___________________________________ 51 
7.10 Risks/Benefits Analysis including Considerations of Alternatives to Participation
 _______________________________________________________________ 51 
7.10.1 Benefits ___________________________________________________________________ 51 
7.10.2 Risks/Discomforts ___________________________________________________________ 52 
7.10.3 Alternatives to participation ___________________________________________________ 55 
7.11 Financial Compensation ________________________________________ 56 
7.12 Consent Procedures ___________________________________________ 56 
7.13 Research Use, Storage and Disposition of Human Subjects’ Samples and Data56 
7.14 Collaborations _______________________________________________ 57 
Appendix A:  Schedule of Study Procedures ________________________ 59 
Appendix B:  List of Laboratory Analytes __________________________ 62 
Appendix C:  PK Sampling Schedules _____________________________ 64 
Appendix D:  Investigator Qualifications and Roles __________________ 65 
Appendix E:  Financial Compensation_____________________________ 67 
Appendix F:  EQ-5D-5L Health Questionnaire (English and Spanish versions)68 
Appendix G:  SF-36v2 Health Survey (English and Spanish versions)___75  
Appendix H:  Brief Pain Inventory (Short Form) (English and Spanish 
versions)_________________________________________________82  
Appendix I:  Ionis Pharmaceuticals, Inc. “Dosing and Potential Injection Site 
Responses” Patient Handout__________________________________86  
Appendix J: Single Patient Allowed to Stay on Study_______________88 
Appendix K: Labs which may be perofrmed in the Event a Platelet count is Less 
Than the Lower Limit of Normal (x 2) or < 100,000/mm3 (x 1)____89 
References_______________________________________________ 90  
 
 
 

 
 
 
 
6 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Precis – Abstract 
 
Background 
Lipodystrophy is a rare disease of deficient adipose mass, characterized by severe hypertriglyceridemia as 
well as insulin resistance, diabetes mellitus, fatty liver disease, acute pancreatitis, and early cardiovascular 
events.  Apolipoprotein C-III (apoC-III) regulates triglyceride metabolism, and apoC-III levels strongly 
correlate with serum triglycerides in a variety of patient populations. Patients with genetically low levels of 
apoC-III have lower triglycerides and reduced cardiovascular disease, while individuals with genetically 
elevated levels of apoC-III have higher triglycerides and increased non-alcoholic fatty liver disease and 
insulin resistance.  Pharmacologic reduction of apoC-III using anti-sense oligonucleotides (ASOs) reduce 
triglycerides by ~60-70% in a tested patient populations. 
 
Aim 
The purpose of this study is to determine if apoC-III reduction using an ASO to apoC-III (ISIS 304801) will 
reduce triglycerides and improve insulin resistance, diabetes, and hepatic steatosis in patients with 
lipodystrophy.  The primary hypothesis to be tested is: 
1. ISIS 304801will reduce log10 fasting serum triglycerides. 
Secondary and tertiary hypotheses to be tested are: 
2. ISIS 304801will improve glucose metabolism by improving insulin resistance. 
3. ISIS 304801 will reduce hepatic steatosis. 
4. ISIS 304801 will improve cardiovascular risk markers. 
We will also explore the mechanism of action of apoC-III ASO by studying lipoprotein lipase activity and 
lipoprotein particle distribution. 
 
Methods 
This study will enroll up to 20 patients with partial lipodystrophy with a goal of 10 study completers.   The 
study will be conducted in two phases.  The first is a 16-week, randomized, double-blind, placebo-controlled 
design.  Subjects will be treated with ISIS 304801 at a target dose of 300 mg per week or placebo.  Following 
this phase, all subjects will enter a 12 month open-label extension in which they will receive active drug.  
Patients who experience benefit (triglyceride lowering ≥50%) may receive an additional 12 months of open-
label drug (up to 24 months, total). Measurement of the primary outcome (serum triglycerides) and key 
secondary outcomes will be performed at baseline prior to the intervention, after 16 weeks (primary and 
secondary outcomes) of blinded drug or placebo, and after an additional 4 months of active drug in subjects 
initially randomized to placebo. 
 
 
 
 
 
 
 
 
 

 
 
 
 
7 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
STUDY GLOSSARY  
 
Abbreviation 
Definition 
2′-MOE 
2′-O-(2-methoxyethyl) 
AE 
adverse event 
ALT 
alanine aminotransferase (SGPT) 
ANA 
antinuclear antibody 
apoA1 
apolipoprotein A1 
apoB 
apolipoprotein B 
apoC-III 
apolipoprotein C-III 
apoE 
apolipoprotein E 
aPTT 
activated partial thromboplastin time 
ASO 
antisense oligonucleotide 
AST 
aspartate aminotransferase (SGOT) 
BMI 
body mass index 
BP 
blood pressure 
DEXA 
dual-energy X-ray absorptiometry 
DSMB 
Data and Safety Monitoring Board 
EKG 
electrocardiogram 
eCRF 
electronic Case Report Form 
FPG 
fasting plasma glucose 
FPL 
FSH 
familial  partial lipodystrophy 
follicle-stimulating hormone 
GCP 
Good Clinical Practice 
HBsAg 
hepatitis B surface antigen 
HBV 
Hepatitis B virus 
HbA1C 
Hemoglobin A1C 
HCV 
hepatitis C virus 
HDL-C 
high-density lipoprotein cholesterol 
hERG 
human ether-a-go-go 
HIV 
human immunodeficiency virus 
IDL 
intermediate-density lipoprotein 
IRB 
Institutional Review Board 
ISIS 304801 
antisense inhibitor of apolipoprotein C3 
LDL-C 
low-density lipoprotein cholesterol 
LPL 
lipoprotein lipase 
MRI 
magnetic resonance imaging 
NCS 
not clinically significant 
NIDDK 
National Institute of Diabetes and Digestive and Kidney Diseases 
NOAEL 
no observable adverse effect level 
NYHA 
New York Heart Association 

 
 
 
 
8 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
OLE 
open-label extension 
on study 
The patient is ‘on study’ from signing of the informed consent 
until their last study visit 
PCOS 
Polycystic ovary syndrome 
PFS 
pre-filled syringes 
PK 
pharmacokinetic(s) 
PL 
partial lipodystrophy 
PT 
prothrombin time 
REMS 
SAE 
Risk Evaluation and Mitigation Strategy 
serious adverse event 
SAT 
SC 
subcutaneous adipose tissue 
subcutaneous(ly) 
Study Day 1 
defined as the first day Study Drug product is administered to the 
patient 
Study Drug 
ISIS 304801 or placebo 
SUSAR 
suspected unexpected serious adverse reaction 
TChol 
total cholesterol 
TG 
triglyceride(s) 
TRL 
triglyceride-rich lipoprotein 
ULN 
upper limit of normal 
VAT 
VLDL-C 
visceral adipose tissue 
very low-density lipoprotein cholesterol 
WBC 
white blood cell 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
9 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
1. Study Objectives 
1.1 Primary Objective 
To evaluate the efficacy of 16 weeks of ISIS 304801 compared to placebo on the change in log10 fasting 
triglycerides (TG). 
 
1.2 Secondary/Tertiary Objectives 
To evaluate the efficacy of 16 weeks of ISIS 304801 as compared to placebo (between group comparison) on 
additional lipid, glycemic, hepatic, and cardiovascular parameters (see Outcome Measures), as well as safety 
and tolerability of ISIS 304801.  In addition, the effects of ISIS 304801 (defined as tertiary outcomes) as 
compared to immediately prior to treatment (pre-post within subject comparision) for 16 weeks on these 
outcomes will be evaluated. 
 
2. Introduction 
2.1 Lipodystrophy 
Lipodystrophy syndromes are a group of rare metabolic diseases characterized by selective loss of adipose 
tissue that leads to ectopic fat deposition in liver and muscle and the development of insulin resistance, 
diabetes, dyslipidemia and fatty liver disease 1-4.  These syndromes are categorized according to the 
distribution of fat loss into generalized or partial and according to the underlying etiology as inherited or 
acquired 2-4. This classification scheme yields 4 major lipodystrophy subtypes: congenital generalized 
lipodystrophy, acquired generalized lipodystrophy, familial partial lipodystrophy, and acquired partial 
lipodystrophy. These syndromes constitute a significant medical unmet need as these patients are refractory to 
current therapies mainly used to treat diabetes and elevated TG levels in an attempt to reduce the risk of 
serious associated complications (coronary artery disease, diabetic nephropathy, cirrhosis and pancreatitis). 
 
Deficiency of adipose tissue in patients with lipodystrophy leads to a deficiency of adipose-derived hormones, 
including leptin, which in turn contributes to the metabolic complications of lipodystrophy.  Between 2000 
and 2014, the NIDDK intramural research program conducted an open-label clinical trial the recombinant 
human leptin analog, metreleptin, in patients with generalized and partial forms of lipodystrophy.  This study 
showed that metreleptin ameliorates metabolic and endocrine abnormalities in lipodystrophy, including 
reducing food intake, improving insulin resistance and diabetes, reducing ectopic lipid, and normalizing 
reproduction5-14.  The best results were achieved in patients with generalized lipodystrophy who had low 
leptin levels [mean (SD): 1.3 (1.1) ng/mL], while patients with PL who had a wider range of baseline leptin 
values [mean (SD): 4.9 (3.1) ng/mL] had a more varied and attenuated response.  Based on these data, 
metreleptin was approved by the FDA in February 2014, for patients with generalized, but not partial, 
lipodystrophy.  Because of the risks associated with the development of neutralizing antibodies and 
lymphoma, Myalept is available only through a risk evaluation and mitigation strategy (REMS) program, 
which requires prescriber and pharmacy certification and special documentation15.  
 
The current study focuses on partial lipodystrophy for which there is no specific treatment and an unmet 
medical need. Partial Lipodystrophy (PL) has a higher prevalence (estimated ~2-3 in one million) than 
generalized lipodystrophy, but the true prevalence is unknown because these patients are greatly under-
diagnosed2,3.  Like generalized lipodystrophy, both genetic and acquired forms exist. Acquired 
lipodystrophies may be caused by medications, autoimmune mechanisms or other unknown mechanisms 

 
 
 
 
10 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
(idiopathic). An acquired form seen in patients with the human immunodeficiency virus (HIV) on protease 
inhibitors has become the most prevalent form of PL, with an estimate of 100,000 patients in the United 
States alone, with many more patients in other countries.  No specific pharmacologic treatment currently 
exists for the non-HIV-associated forms of PL.   
 
The diagnosis of PL is mainly clinical and needs to be considered in patients presenting with the triad of 
insulin resistance (with or without overt diabetes), significant dyslipidemia in the form of 
hypertriglyceridemia, and fatty liver 16. Patients often present with diabetes and severe insulin resistance 
requiring high doses of insulin. Other evidence of severe insulin resistance is provided by the presence of 
acanthosis nigricans and PCOS (with symptoms like hyperandrogenism and oligomenorrhea). Some patients 
develop severe hypertriglyceridemia resulting in episodes of pancreatitis. In many patients, the TG levels 
remain persistently elevated despite fully optimized therapy or diet modifications. Radiographic evidence of 
hepatic steatosis or steatohepatitis with hepatomegaly and/or elevated transaminases is common 17.  
 
Careful clinical assessment of fat distribution through visual and physical examination can confirm the 
diagnosis. Patients with FPL have reduced subcutaneous fat in the limbs and truncal regions and may have 
excess subcutaneous fat deposition in neck, face and intra-abdominal regions. Patients with the Dunnigan 
variety have normal body fat distribution in childhood and gradually lose subcutaneous fat from the 
extremities and trunk around the time of puberty. In women, the loss of fat may be most striking in the 
buttocks and hips. At the same time these patients accumulate fat on the face (“double chin”), neck and upper 
back (“Cushingoid appearance with buffalo hump”).  The extent of adipose tissue loss usually determines the 
severity of the metabolic abnormalities. Patients display prominent muscularity and phlebomegaly (enlarged 
veins) in the extremities and complain of disproportionate hyperphagia. The condition in females is more 
easily recognized than in men, and so is reported more often. Patients may also have a family history of 
similar physical appearance and/or fat loss.  Genetic testing, when available, is confirmatory.2,16,18 
  
Current treatment includes lifestyle modification such as reducing caloric intake and increasing energy 
expenditure via exercise. Conventional therapies used to treat severe insulin resistance (metformin, 
thiazolidinediones, GLP-1s, insulin), and/or high TGs (dietary fat restriction, fibrates, fish oils) are not very 
efficacious in these patients 3. 
 
Partial Lipodystrophy is an orphan indication for which there is a significant unmet medical need. 
Diabetes and/or hypertriglyceridemia associated with this condition can lead to serious complications 17 
such as: 
• 
Acute pancreatitis, especially when triglyceride levels are >1,000 mg/dL 
• 
Accelerated microvascular complications from uncontrolled diabetes 
• 
Accelerated cardiovascular disease from lipid abnormalities and insulin resistance 
• 
Steatohepatitis that can progress to cirrhosis 
• 
Proteinuric nephropathies which can progress to end stage renal disease 
  
In patients with generalized lipodystrophy the metabolic complications are partially related to leptin 
deficiency, and can be ameliorated in part by leptin replacement. However, leptin deficiency alone cannot 
explain the severity of metabolic disease in patients with PL who have variable leptin levels. Unpublished 

 
 
 
 
11 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
data from our group showed that elevated apoC-III plays a role in the hypertriglyceridemia seen in both 
generalized lipodystrophy and PL and might therefore represent a therapeutic target in these patients. 
 
These data show (left graph) that apoC-III is significantly higher in lipodystrophy patients compared to age, 
sex, and race matched obese controls (30.4 ± 22.7 mg/dL in lipodystrophy versus 16.1 ± 6.9 in controls, 
p<0.0001).  In addition, apoC-III levels are very strongly correlated with triglyceride levels in patients with 
lipodystrophy (right graph, R2 = 0.52, p<0.0001), such that an elevated triglyceride level is highly predictive 
of an elevated apoC-III level. 
 
 
 
 
 
 
 
 
 
 
By reducing apoC-III and TG levels, ISIS 304801 may improve the metabolic profile of patients with PL and 
reduce their risk of acute pancreatitis. In addition, apoC-III inhibition may also improve insulin sensitivity in 
these patients and potentially lead to a reduction in the complications associated with diabetes. It is unknown 
whether this mechanism could improve hepatic steatosis and reduce cirrhosis risk. 
 
2.2 Therapeutic Rationale 
ApoC-III is a 79 amino acid glycoprotein synthesized principally in the liver 19 (Figure 1). ApoC-III is a 
major regulator of lipoprotein metabolism and plays a pivotal role in regulating plasma TG levels 20. It is a 
component of TG-rich lipoproteins (TRLs) and a potent inhibitor of lipoprotein lipase (LPL) 21. At higher 
concentrations, apoC-III also inhibits the activity of hepatic lipase22, an enzyme which plays an important role 
in the conversion of dense VLDL to intermediate-density lipoprotein (IDL) and to LDL 23, as well as in the 
remodeling of HDL 24. In addition, increased apoC-III content adversely affects apoE-mediated hepatic 
uptake of TG-rich remnants 25. Thus, elevated plasma apoC-III levels are associated with impaired hydrolysis 
and retarded clearance of TG-rich particles, resulting in the accumulation of VLDL-TG and chylomicrons in 
plasma and the development of hypertriglyceridemia 26. 

 
 
 
 
12 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
Figure 1 
ApoC-III Regulates Lipoprotein Metabolism by Multiple Mechanisms 
Courtesy of P. Gordts and J. Esko.  
HL=hepatic lipase, IDL=intermediate-density lipoprotein, LDL=low-density lipoprotein, LDLR=LDL receptor, 
LRP1=Low density lipoprotein receptor-related protein 1 ; LPL=lipoprotein lipase, LSR=lipolysis-stimulated 
receptor, , SDC1=Syndecan-1TG=triglyceride, VLDL=very low-density lipoprotein. 
 
In humans, decreased apoC-III has been associated with low triglycerides and protection from cardiovascular 
disease, while gene variants with elevated apoC-III have been associated with high triglycerides and fatty 
liver disease. A heterozygous null mutation in the apoC-III gene (R19X) in Old Order Amish individuals 
causing life-long apoC-III deficiency (~50% of normal) resulted in lower plasma TG levels (fasting and post-
prandial), a cardioprotective lipid profile (i.e., higher HDL-C and lower LDL-C) and reduced atherosclerosis 
(as measured by coronary artery calcification) compared with noncarriers 27.  
 
Jorgensen et al. had similar findings and showed that lifelong low levels of nonfasting triglycerides due to 
three loss-of-function mutations (R19X, IVS2+1G→A, A43T) in apoC-III were associated with reduced risk 
of ischemic heart disease in the general population 28. Recent genetic studies involving mendelian 
randomization suggest that this association may be causal 29,30.  By contrast, gain of function polymorphisms 
in Apo-CIII that lead to lifelong increases in Apo-CIII have been associated with increased triglycerides and 
non-alcoholic fatty liver disease.  

 
 
 
 
13 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
The clinical effects of apo-CIII inhibition in hypertriglyceridemia have been recently published. In one study, 
apoC-III inhibition with ISIS 304801 led to reduced apoC-III and triglyceride levels in various animal models 
and in humans in recent phase 1 clinical trials 31,32. A recent phase 2 clinical trial in three patients with severe 
hypertriglyceridemia due to the familial chylomicronemia syndrome likewise showed robust reduction of 
apoC-III levels, with concomitant 56-86% reduction in fasting triglycerides 33. 
 
In patients with lipodystrophy, preliminary data from our group has demonstrated that apo-CIII levels are 
elevated compared to controls, and correlate strongly with triglycerides 34.  Moreover, triglyceride reductions 
with leptin replacement correlated with reductions in apo-CIII.  These data support the idea that apo-CIII 
excess plays a role in the hypertriglyceridemia of lipodystrophy, and that apo-CIII lowering could represent a 
promising therapeutic target in this condition. 
 
2.3 ISIS 304801 
2.3.1 Mechanism of Action 
ISIS 304801 is a second-generation antisense oligonucleotide (ASO) drug targeted to human apoC-III. It is 
complementary to a region within the 3ʹ untranslated region of the apoC-III mRNA and binds to the mRNA 
by Watson and Crick base pairing. The hybridization (binding) of ISIS 304801 to the cognate mRNA results 
in the RNase H-mediated degradation of the apoC-III mRNA, thus preventing production of the apoC-III 
protein. Maximal antisense-mediated reduction of target mRNA levels is typically greater than 90% of control 
levels in sensitive tissues 35,36. Furthermore, reduction in target mRNA levels using this approach correlates 
directly with a subsequent reduction in target protein levels. 
 
2.3.2 Chemistry 
Chemically, ISIS 304801 is a synthetic chimeric oligomer of 20 nucleotides (i.e., a 20-mer) that are connected 
sequentially by phosphorothioate linkages. The nucleotide sequence of ISIS 304801 (Figure 2) is 
complementary to a 20-nucleotide stretch within the 3ʹ untranslated region of the apoC-III mRNA transcript at 
base position 489-508. Structurally, the oligonucleotide has 3 regions. Two of them, the 5 nucleotides at the 5′ 
end and the 5 nucleotides at the 3′ end, are composed of 2ʹ-O-(2-methoxyethyl) (MOE)-modified 
ribonucleotides. These MOE-modified nucleotides confer (1) increased affinity to the target mRNA 37,38, (2) 
increased resistance to exonucleases and endonucleases (thereby increasing stability in tissue)39, and (3) 
amelioration of some of the high dose toxicities thereby resulting in an improved safety profile compared to 
first generation antisense drugs containing phosphorothioate modified oligodeoxynucleotides (DNA)40. The 
third region, the central portion of the oligonucleotide, is composed of 10 oligodeoxynucleotides. This 
chimeric design is called a MOE-Gapmer, and ISIS 304801 employs this chimeric structure to enable use of 
the RNase H-mechanism for antisense activity. This is because while the 2ʹ-MOE modifications confer 
increased stability and affinity, they do not support RNase H catalysis of RNA hybridized to 2ʹ-MOE-
modified nucleotides38. This is caused by conformational changes induced in the heteroduplex by 2ʹ-
alkoxy:RNA hybrids that are not recognized by RNase H enzymes41,42. By limiting the number of 2ʹ-MOE 
modifications to nucleotides flanking the phosphorothioate oligodeoxynucleotide core, the beneficial 
attributes of the 2ʹ-MOE chemistry are preserved while also retaining RNase H recognition. 
 

 
 
 
 
14 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
Figure 2 
Design of Chimeric 2ʹ-MOE Phosphorothioate Oligonucleotides  
(MOE-Gapmer).  The sequence of ISIS 304801 is shown. 
 
2.3.3 Preclinical Experience 
Inhibition of apoC-III using ISIS 304801 has been shown to potently reduce hepatic apoC-III mRNA as well 
as plasma apoC-III protein and TG in a dose- and time-dependent fashion in several species, including human 
apoC-III transgenic mice, and other rodent and monkey models. Treatment with ISIS 304801 also resulted in 
reduced VLDL and chylomicron TG and reduced postprandial TG in hypertriglyceridemic monkeys43. 
 
The pharmacokinetics (PK) and toxicity of ISIS 304801 have been assessed in mice, rats, and cynomolgus 
monkeys. General toxicity studies with ISIS 304801 for up to 39 weeks of treatment followed by a 20-week 
recovery period are complete. The preclinical toxicology program for ISIS 304801 consists of single-dose 
safety pharmacology studies in the monkey (cardiovascular) and mouse (neurobehavioral and pulmonary 
assessment studies), in vitro and in vivo genetic toxicity assessment, repeat-dose fertility and/or 
developmental reproductive toxicology studies in the mouse and rabbit and evaluation in the in vitro human 
Ether-á-go-go -related gene (hERG) assay. 
 
ISIS 304801 treatment-related findings in mice and monkeys were generally consistent with those expected 
for the 2′-MOE-class of ASOs. Treatment-related findings included effects consistent with drug accumulation 
in tissues in rodents and monkeys, species-dependent proinflammatory response in rodents and monkeys and 
complement activation and reductions in platelet counts in the monkey. In the mouse and monkey general 
toxicity studies, reduction of hepatic apoC-III mRNA (>75%) was not associated with any findings that could 
be considered related to the pharmacologic inhibition of apoC-III for up to 39 weeks of treatment. 
 
The long-term, chronic toxicology studies in rodents with ISIS 304801 produced a significant 
proinflammatory response that led to subsequent effects on the heart at high doses. The rodent species are 
most sensitive to the proinflammatory effects of antisense molecules. Importantly, these effects on the heart 
were not observed in the monkey chronic toxicity studies even at the highest doses tested where drug 
exposure was higher than that in rodents.  Because these changes were not observed in monkeys, the findings 
in the heart are considered to be rodent-specific and not relevant to humans. Nevertheless, such effects are 
monitorable by measurement of echocardiograms and cardiac troponin T that will be included in this clinical 
study.  
 
2′-MOE 
2′-Deoxy 
2′-MOE 
(RNase H 
Sensitive) 
A  G  C 
T T
C  T 
T G T
C C A G C 
T T T A
T
Phosphorothioate 
Backbone 

 
 
 
 
15 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
ISIS 304801 caused no untoward effects in safety pharmacology studies (in vitro and in vivo) and was non-
genotoxic (in vitro and in vivo). ISIS 304801 had no effects on fertility or embryo/fetal development in the 
mouse or rabbit reproductive toxicity studies. In these studies, ISIS 304801 was detected in placental tissue 
but not in fetal tissue indicating that little, if any, drug was able to cross the placenta to reach the fetus. 
Reduction of apoC-III mRNA (64% in males and 47% in females) also did not affect fertility or cause 
untoward effects on embryo/fetal development in mice. 
 
Detailed information concerning the preclinical studies conducted with ISIS 304801 can be found in the 
ISIS 304801 Investigator’s Brochure. 
 
2.3.4 Clinical Experience 
Detailed information concerning the clinical studies conducted with ISIS 304801 can be found in the ISIS 
304801 Investigator’s Brochure.  A summary is included below. 
 
ISIS 304801 has been evaluated in one Phase 1 study and two Phase 2 studies, all double blinded and placebo 
controlled.  The total exposures comprise 99 patients and healthy volunteers administered ISIS 304801 from 
50 to 400 mg subcutaneously up to 3 months (compared to 37 administered placebo). 
 
All clinical trials of ISIS 304801 have shown very large and clinically meaningful reductions in fasting apoC-
III and TG (~80% and 70%, respectively, mean reduction from baseline with 300 mg dose) with a very high 
degree of consistency of response between the different patient groups.  This includes healthy volunteers, 
patients with moderate to severe hypertriglyceridemia not on background TG-lowering therapy, patients with 
moderate to severe hypertriglyceridemia on a background of stable fibrate therapy, patients with Familial 
Chylomicronemia Syndrome (FCS), and patients with hypertriglyceridemia and T2DM.  Comparison of the 
effects of ISIS 304801 at the 300 mg/week dose across several patient populations is shown in Table 2. 
 
Table 2 
Mean Percent Change from Baseline of Lipid Parameters in Hypertriglyceridemia 
Patients Treated with ISIS 304801 (300 mg/wk for 12 weeks) in Phase 2 Studies 
Mean % (SD) 
Change from 
Baseline 
Monotherapy in 
Hypertriglyceridemia and 
T2DM (N = 7) 
Mean Baseline TG 
259 mg/dL 
Monotherapy in 
Hypertriglyceridemia  
(N = 11) 
Mean Baseline TG 
559 mg/dL 
Add-on to Fibrate in 
Hypertriglyceridemia  
(N = 10) 
Mean Baseline TG 
394 mg/dL 
ApoC-III 
-88% (6.0)* 
-80% (9.3)*** 
-71% (13.0)** 
Triglycerides 
-72% (8.3)* 
-71% (14.1)*** 
-64% (8.9)** 
HDL-C 
+40% (19.8)* 
+46% (24.0)*** 
+52% (23.7)** 
* 
p ≤0.05 vs. placebo 
** p ≤0.01 vs. placebo 
*** p ≤0.001 vs. placebo 
 
In addition to the lipid analysis, the effect of lowering apoC-III on glycemic control and insulin sensitivity 
was evaluated in the subgroup of patients with hypertriglyceridemia and type 2 diabetes, by measuring 

 
 
 
 
16 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
fructosamine, glycated albumin, and HbA1c and by performing a hyperinsulinemic euglycemic clamp at 
baseline and at the end of the treatment period.   
 
Statistically significant decreases were observed in the mean change from Baseline in % glycated albumin and 
in fructosamine 1 week after the last dose and in HbA1c and fructosamine at the end of the Follow-up Period 
(3 months after the last dose).  These significant effects later in the Follow-up Period were likely a result of 
the long duration of response of ISIS 304801.  Trends were also observed towards improvement in all 
measures of peripheral insulin sensitivity, but the small sample size of patients with valid clamps performed 
within the protocol-specified time window likely precluded statistical significance. 
 
In clinical studies conducted to date, ISIS 304801 has been well tolerated and has shown a favorable safety 
profile. There has been no clinical or laboratory evidence of drug-drug interactions. 
 
To date, there have been no ISIS 304801 associated laboratory abnormalities suggestive of an effect on the 
renal (serum creatinine, proteinuria) or hepatic systems (alanine aminotransferase [ALT], aspartate 
aminotransferase [AST], bilirubin) despite many patients in the Phase 2 clinical trials receiving concomitant 
medications that are known to be associated with elevations in hepatic enzymes, such as fibrates and statins. 
In Phase 2 studies, there was a mild decrease of platelet count associated with ISIS 304801 administration that 
recovered in the post-treatment period and was not associated with platelet-related adverse events (AEs). 
 
The most frequently observed AEs with ISIS 304801 were local reactions at the injection site. Local 
cutaneous reactions at the injection site, defined as those events presenting as either pain, tenderness, 
erythema, pruritus or swelling occurring on the day of injection and persisting for at least 2 days (~15% of 
injections), were almost always mild, resolved spontaneously, were non-progressive, and were not associated 
with systemic sequelae. 
 
2.4 Rationale for Dose and Schedule of Administration 
The dose and schedule selected for this study is 300 mg of ISIS 304801 or placebo per week for 16 weeks, 
followed by a 12 month open label extension of 300 mg of ISIS 304801 per week. Patients who experience 
benefit (triglyceride lowering ≥50 may receive an additional 12 months of open label drug (up to 24 months, 
total). The dose of 300 mg per week is supported by both the cumulative nonclinical data available to date and 
the Phase 2 clinical data. In nonclinical studies, ISIS 304801 treatment-related effects in rodents and monkeys 
were consistent with drug accumulation in tissues and also include species-specific proinflammatory 
responses. In the monkey, the no observable adverse effect level (NOAEL) was defined by the cumulative 
clinical pathology results and histopathology data provide an adequate clinical safety margin. Nonclinical 
findings were not considered to be related to the pharmacologic inhibition of apoC-III. 
 
The safety data to date suggest that ISIS 304801 has been well tolerated at dose levels up to 300 mg in 
patients with high TG (including type 2 diabetes patients and administration in combination with fibrates and 
statins) with the most common AEs being local to the injection site and predominantly mild. A pooled 
analysis of safety for the Phase 2 studies did not demonstrate any clear difference in safety or tolerability 
between the different doses tested (100 mg, 200 mg, and 300 mg per week for 13 weeks). Analysis of the 
cohorts in which ISIS 304801 was studied at different doses demonstrates dose-dependent pharmacology with 

 
 
 
 
17 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
respect to pharmacodynamic effect on the target, apoC-III, with a clear difference in the TG-lowering effect 
between the different doses in the 100 mg to 300 mg dose range as compared to placebo. 
 
In addition to the nonclinical and clinical experience of ISIS 304801, the dose and schedule of administration 
is supported by the preclinical and clinical safety experience of several other 2′-MOE-modified ASOs that 
have been administered intravenously and SC in multiple clinical studies at doses up to 1200 mg and for 
treatment durations that exceed 24 months 44. 
 
3. Subject Eligibility Assessment and Enrollment 
3.1 Inclusion Criteria 
1. Age ≥18 years at enrollment (the time of informed consent, week -1) 
2. Fasting TG levels ≥500 mg/dL (≥5.7 mmol/L) at enrollment. If the fasting TG value is <500 mg/dL (<5.7 
mmol/L) but ≥350 mg/dL (≥4.0 mmol/L) up to two additional tests may be performed in order to qualify, 
and a single level ≥500 mg/dL will permit enrollment. 
OR 
3. Fasting TG levels ≥   200 mg/dL (2.6mmol/L) with a hemoglobin A1C over 7% 
4. Willing to maintain their customary physical activity level and to follow a diet moderate in carbohydrates 
and fats with a focus on complex carbohydrates and replacing saturated for unsaturated fats 
5. Clinical diagnosis of lipodystrophy based on deficiency of subcutaneous body fat in a partial fashion 
assessed by physical examination, and low skinfold thickness in anterior thigh by caliper measurement: 
men (≤ 10mm) and women (≤ 22 mm), plus one of the following: 
 
a) Genetic diagnosis of familial PL (e.g., mutations in LMNA, PPAR-γ, AKT2, or PLIN1 genes) 
OR 
b) Family history of familial PL or abnormal and similar fat distribution PLUS 1 minor criterion 
(below), OR 
c) 2 minor criteria (below) in the absence of genetic diagnosis of family history 
 
MINOR Criteria 
a. Diabetes mellitus with requirement for high doses of insulin, eg, requiring ≥200 U/day, ≥2 
U/kg/day, or currently taking U-500 insulin 
b. Presence of acanthosis nigricans on physical examination 
c. History of polycystic ovary syndrome (PCOS) or PCOS-like symptoms (hirsutism, 
oligomenorrhea, and/or polycystic ovaries) 
d. History of pancreatitis associated with hypertriglyceridemia 
e. Evidence of non-alcoholic fatty liver disease 
- 
Hepatomegaly and/or elevated transaminases in the absence of a known cause of liver 
disease or  
- 
Radiographic evidence of hepatic steatosis (e.g., on ultrasound or CT) 
 
6. Satisfy one of the following: 

 
 
 
 
18 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
a) Females:  Non-pregnant and non-lactating; surgically sterile (e.g., tubal occlusion, hysterectomy, 
bilateral salpingectomy, bilateral oophorectomy), post-menopausal (defined as 12 months of 
spontaneous amenorrhea in females >55 years of age or, in females ≤55 years, 12 months of 
spontaneous amenorrhea without an alternative medical cause and follicle-stimulating hormone 
(FSH) levels in the postmenopausal range for the laboratory involved), abstinent*, or if engaged 
in sexual relations of child-bearing potential, patient is using an acceptable contraceptive method 
(refer to Section 7.4.1) from time of signing the informed consent form until at least 13 weeks 
after the last dose of Study Drug administration.  
b) Males:  Surgically sterile, abstinent*, or if engaged in sexual relations with a female of 
child-bearing potential, patient is utilizing an acceptable contraceptive method (refer to 
Section 7.4.1) from the time of signing the informed consent form until at least 13 weeks after the 
last dose of study drug administration. 
 
*   Abstinence is only an effective method of birth control when this is  the preferred and usual 
lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-
ovulation methods), declaration of abstinence for the duration of a trial and withdrawal are not 
acceptable methods of contraception. 
 
3.2 Exclusion Criteria 
1. A diagnosis of generalized lipodystrophy 
2. Current or history of autoimmune diseases (even with a diagnosis of PL) unless approved by the 
Investigator and Sponsor Medical Monitor 
3. Acute pancreatitis within 4 weeks of enrollment 
4. History within 6 months of enrollment of acute or unstable cardiac ischemia (myocardial infarction, acute 
coronary syndrome, new onset angina), stroke, transient ischemic attack, or unstable congestive heart 
failure requiring a change in medication 
5. Major surgery within 3 months of enrollment 
6. History of heart failure with New York Heart Association functional classification (NYHA) greater than 
Class II  
7. Uncontrolled hypertension (blood pressure [BP] >160/100 mm Hg) 
8. Any of the following laboratory values at enrollment: 
a. Cardiac troponin T >ULN 
b. Measured or estimated (in case of triglycerides > 400 mg/dL) LDL-C >130 mg/dL on maximal 
tolerated statin therapy 
c. Hemoglobin HbA1c ≥9.5% 
d. Hepatic:  
i. Total bilirubin >ULN  
ii. ALT >3.0 x ULN.  Higher levels will be permitted after a safety review by a hepatologist, 
that includes no evidence of cirrhosis.   
iii. AST >3.0 x ULN.  Higher levels will be permitted after a safety review by a hepatologist, 
that includes no evidence of cirrhosis.   
 
e. Renal:  

 
 
 
 
19 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
i. Persistently positive (2 out of 3 tests ≥ trace positive) for blood on urine dipstick.  In the 
event of a positive test eligibility may be confirmed with urine microscopy showing ≤ 5 
red blood cells per high power field (urine will be screened at admission and repeated if 
abnormal).  If RBC are high every effort will be made to determine if the source is renal 
or benign, such as from menstrual bleeding.  If the presence of RBC is determined to be 
from a non-renal source, the PI will make the decision to proceed with protocol testing 
and/or randomization.    
ii. Two out of three consecutive tests ≥ 1+ for protein on urine dipstick. In the event of a 
positive test eligibility may be confirmed by either a spot urine albumin to creatinine ratio 
<1000mg/g or a quantitative total urine albumin measurement of < 1g/24 hrs (urine will 
be screened at admission and repeated if abnormal) 
iii. Estimated creatinine clearance calculated according to the formula of Cockcroft and 
Gault <60 mL/min 
f. Platelet count below 140,000 K/uL 
g. Clinically significant (as determined by the Investigator or Sponsor) abnormalities on laboratory 
examination that will increase risk to the patient or interfere with data integrity 
9. Uncontrolled hypothyroidism (abnormal thyroid function tests should be approved by the Investigator) 
10. History within 6 months of enrollment of screening of drug or alcohol abuse 
11. History of bleeding diathesis or coagulopathy or clinically significant abnormality in coagulation 
parameters at enrollment 
12. Active infection requiring systemic antiviral or antimicrobial therapy that will not be completed prior to 
enrollment 
13. Known history of or positive test for human immunodeficiency virus (HIV), hepatitis C or chronic 
hepatitis B 
14. Malignancy within 5 years, except for basal or squamous cell carcinoma of the skin or carcinoma in situ 
of the cervix that has been successfully treated 
15. Treatment with another investigational drug, biological agent, or device within one month of enrollment, 
or 5 half-lives of investigational agent, whichever is longer 
16. Unwilling to comply with contraceptive and lifestyle (diet/exercise) requirements  
17. Use of any of the following: 
a. Use of metreleptin within the last 3 months prior to enrollment 
b. Antidiabetic, lipid lowering, or atypical antipsychotic medication, unless on a stable dose for at 
least 3 months prior to enrollment 
c. Insulin unless on a stable daily insulin dose regimen (± 20 %) for at least 4 weeks prior to 
enrollment  
d. Use of nicotinic acid or derivatives within the last 4 weeks prior to enrollment 
e. Systemic corticosteroids or anabolic steroids within 6 weeks prior to enrollment unless approved 
by the Investigator 
f. Antihypertensive medication unless on a stable dose for at least 4 weeks prior to enrollment 
g. Tamoxifen, estrogens or progestins unless on a stable dose for at least 4 months prior to 
enrollment and dose and regimen expected to remain constant throughout the study 
h. Oral anticoagulants unless on a stable dose for at least 4 weeks prior to enrollment and regular 
clinical monitoring is performed 
i. 
Prior exposure to ISIS 304801 

 
 
 
 
20 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
j. 
Anti-obesity drugs [e.g., the combination of phentermine and extended-release topiramate 
(Osymia, orlistat (Xenical), liraglutide [rDNA origin] injection (Saxenda) and lorcaserin (Belvig), 
phentermine, amphetamines, herbal preparations] within 12 weeks prior to screening 
k. Any other medication unless stable at least 4 weeks prior to enrollment (occasional or intermittent 
use of over-the-counter medications will be allowed at Investigator’s discretion) 
18. Blood donation of 50 to 499 mL within 30 days or of >499 mL within 60 days  
19. Have any other conditions, which, in the opinion of the Investigator or the Sponsor would make the 
patient unsuitable for inclusion, or could interfere with the patient participating in or completing the study 
 
4. Study Design 
4.1 Design/Randomization 
This study has two components.  Initially, subjects will receive ISIS 304801 or placebo, in a 1:1 randomized, 
double-blinded fashion for 16 weeks.  Randomization will occur after verification that all eligibility criteria 
have been met. The randomization will be stratified by use of lipid-lowering medications.  After completion 
of 16 weeks, all subjects will receive ISIS 304801 for 12 months in an open-label extension (OLE) phase.  
After discontinuation of ISIS 304801 (due to study end or any other reason) subjects will be followed for an 
additional 12 week withdrawal phase when possible.  Patients who experience benefit (triglyceride lowering 
≥50%) may receive an additional 12 months of open label drug (up to 24 months, total).  This period may 
initiate immediately following the standard 12 month OLE, or following the withdrawal phase. 
 

 
 
 
 
21 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
4.2 Outcome Measures 
4.2.1 Primary outcome:  
Efficacy of 16 weeks of ISIS 304801 as compared to placebo (between group comparison) on the change in 
log10 fasting triglycerides (TG).   
 
4.2.2 Secondary outcomes: 
Efficacy of 16 weeks of ISIS 304801 as compared to placebo (between group comparison) on: 
 
Lipids 
• 
Percent change in fasting TG 
• 
Absolute change in fasting TG 
• 
Change in lipolysis rate measured using stable isotope tracers  
• 
Change from baseline in liver volume and hepatic steatosis (as assessed by magnetic resonance 
imaging [MRI] and magnetic resonance spectroscopy [MRS])  
• 
Lipoprotein lipase activity 
 
Glycemic 
• 
Change in total body insulin sensitivity using the hyperinsulinemic euglycemic clamp 
• 
Change in hepatic glucose production and hepatic insulin sensitivity using stable isotope tracers in 
combination with the hyperinsulinemic euglycemic clamp 
• 
Change in hemoglobin A1c (HbA1c) 
• 
Change in fasting plasma glucose 
 
Safety 
• 
Safety and tolerability of ISIS 304801 
• 
Prospectively adjudicated acute pancreatitis events (Atlanta classification) and Major Adverse 
Cardiovascular Events (MACE)  
 
Pharmacokinetic 
• 
Plasma ISIS 304801 level 
 
4.2.3 Tertiary/Exploratory outcomes: 
Efficacy of 16 weeks and 16 months of ISIS 304801 as compared to immediately prior to treatment (pre-post 
within subject comparison) on: 
 
Lipids 
• 
Change in other fasting lipid measurements: high-density lipoprotein cholesterol (HDL-C), low-
density lipoprotein cholesterol (LDL-C), total cholesterol (TChol), very low-density lipoprotein 
cholesterol VLDL-C, non-HDL-C, apolipoprotein B (apoB), apolipoprotein B-48 (apoB48), 
apolipoprotein A1 (apoA1), apolipoprotein CIII (apoC-III; total, chylomicron, VLDL, LDL and 
HDL), and free fatty acids 
• 
Change in lipoprotein particle size/number by nuclear magnetic resonance (NMR) 
• 
Triglyceride (and other lipid particle) clearance following mixed meal testing 

 
 
 
 
22 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
Glycemic 
• 
Change in 24-h glucose (using 7-point plasma blood glucose) 
• 
Change in fasting and area under the curve for insulin and C-peptide during mixed meal testing 
• 
Reduction in insulin use  
 
Adipose tissue 
• 
Change in skinfold thickness and dual-energy X-ray absorptiometry (DEXA) 
• 
Change in abdominal VAT and SAT volumes 
• 
Change in adiponectin and leptin 
• 
Change in body weight and waist circumference 
 
Cardiovascular 
• 
Carotid intima-media thickness (by ultrasound) 
• 
Coronary artery wall thickness and diameter change after hand-grip exercise (by MRI) 
 
Patient Reported Outcomes 
• 
Change in Quality of Life (EQ-5D, SF36)  
• 
Change in hunger visual analog scale 
• 
Change in pain 
 
Other 
• 
Change in testosterone 
• 
Metabolomics 
• 
Liver histopathology 
 
Efficacy of 16 weeks of ISIS 304801 as compared to placebo (between subject comparison) on the primary 
and secondary outcomes, above. 
 
5. Statistical Considerations 
5.1 Sample Size Justification 
The primary outcome variable is the change in log10 fasting triglycerides from before treatment to16weeks of 
active drug treatment compared to placebo groups.  
Preliminary data are available for 28 patients treated with ISIS 304801 and 24 treated with placebo.  For the 
ISIS 304801 group, these data show a difference from baseline to follow-up of -423 (SD 400, 95% CI -578 to 
-268) mg/dL and -0.485 (SD 0.221, 95% CI -0.57 to -0.40) log10 mg/dL.  Converting the difference in log10 
mg/dL to a percent change [100*(10^-0.485-1)] results in a percent change of -67 % (95% CI -73% to -60%). 
For the placebo group, the absolute change is -12 (SD 406, 95% CI -12 to 184) mg/dL and -0.011 (SD 0.224, 
95% CI -0.105 to 0.084) log10 mg/dL.  The percent change for the placebo group is -3% (95% CI -21% to 
21%.  
 

 
 
 
 
23 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
For comparison of placebo and ISIS 304801 we have chosen a SD of 0.25 log10 mg/dL and a difference of 
0.50 log10 mg/dL. A trial with 5 patients in each group has 79% power to detect a difference of 0.50 log10 
mg/dL triglycerides in the change from baseline to follow-up between the ISIS and placebo groups, assuming 
a SD of 0.25 log10 mg/dL and a two-sided significance level of 0.05. 
 
 
Where preliminary data were available, sample size calculations were performed for secondary and tertiary 
study outcomes in addition to the primary outcome.  The preliminary data and power estimates for a sample 
size of 10 subjects (using one-sample t-test for off versus on drug comparisons) are summarized in the table 
below.  Based on these calculations, the study should be adequately powered to detect differences in total 
body insulin sensitivity, hepatic insulin sensitivity, fasting glucose, apoC-III serum level, HDL-C, VLDL-C, 
and apolipoprotein B48.  
 
Based on these calculations, we plan to enroll a maximum of 20 patients, with a goal of 10 patients 
completing the study (defined as completing 16 weeks of active drug treatment). The accrual ceiling of 20 is 
planned because subjects will consent to the study prior to screening, thus we are accounting for up to 10 
screen failures in the accrual ceiling.  
 
  
Outcome 
Model 
Treatment 
Treat-
ment 
Duration 
Mean of 
∆ on-off 
drug 
(SD) 
Power 
Primary 
outcome 
Absolute change 
log[serum triglycerides] 
(mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-0.48 
(0.22) 
>0.95 
  
% change serum 
triglycerides (%) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-63 (20) 
>0.95 
 
Absolute change serum 
triglycerides (mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-423 
(400) 
0.85 
Secondary 
outcomes 
Hemoglobin A1C (%) 
Type 2 
diabetes 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-0.2 
(0.36) 
0.35 
  
Total body insulin 
sensitivity (glucose 
infusion rate during clamp, 
mg*kg-1*min-1) 
Type 2 
diabetes 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
1.6 (1.2) 
>0.95 
  
Hepatic insulin sensitivity 
(% suppression of 
endogenous glucose 
production during clamp) 
Type 2 
diabetes 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
11.0 
(5.6) 
>0.95 
  
Fasting plasma glucose 
(mg/dL) 
Type 2 
diabetes 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-35 (36) 
0.78 

 
 
 
 
24 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
  
ApoCIII serum level 
(mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-15.3 
(7.5) 
>0.95 
  
HDL-C (mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
13.3 
(10.1) 
>0.95 
Tertiary 
Outcomes 
LDL-C (mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
31.3 
(47.3) 
0.46 
  
Total Cholesterol (mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-32 (72) 
0.24 
  
VLDL-C (mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-77 (60) 
0.95 
  
non-HDL-C (mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-46 (74) 
0.42 
  
Apolipoprotein B (mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-5.8 (30) 
0.09 
  
Apolipoprotein B-48 
(mg/dL) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-0.44 
(0.43) 
0.82 
  
Free Fatty Acids (uEq/L) 
Familial 
chylomicron-
emia 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-0.40 
(0.44) 
0.73 
  
Body Weight (kg) 
High TG +/- 
diabetes 
and/or fibrate 
ApoCIII 
ASO 300 
mg/wk 
 16 wk 
-0.87 
(1.69) 
0.30 
 
5.2 Statistical Methods for Data Analysis 
 
Descriptive statistics such as mean and standard deviation (or median and interquartile range) will be used to 
summarize data in raw scale or change from baseline per visit. 
 
The primary outcome, change in log10 TG at Week 16 from baseline, and continuous secondary outcomes 
will be compared between ISIS 304801 and placebo groups  using either two-sample t-test or Wilcoxon rank 
sum  test as appropriate based on change from Baseline at Week 16 . Changes from baseline based on 
tertiary/exploratory outcomes as well as change on log10 TG at Week 16 will be examined using either one-
sample t-test or Wilcoxon signed rank test as appropriate.  
 
Repeated measures analysis of covariance using linear mixed models will be conducted in order to investigate 
trends on selected response variables and to compare active and placebo group while possible covariates are 
taken into account. There are three possible covariates: (1) Baseline level of the outcome of interest, (2) 
Baseline level of ApoCIII, and (3) Change in ApoCIII before and after the 16 week active drug intervention. 

 
 
 
 
25 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Inclusion of covariates will be checked using linear mixed models by checking Akaike Information Criteria 
(AIC) with inclusion of one covariate at a time   
 
Analyses will include all available data even if patients do not adhere to their assigned treatments.  Additional 
analyses will examine the effect of adherence to study results.  We will also investigate the effect of missing 
data on the results using standard methods for missing data. 
  
A p-value of 0.05 or less is considered significant. 
 
6. Experimental Plan 
6. 1 Diet 
2-8 weeks prior to the first study visit, all patients will be counseled by an NIH dietician (in person or via 
long-distance contact) to follow a moderate diet composed of ~50% kcal from carbohydrates (focusing on 
complex carbohydrates and avoidance of concentrated sugars like juice and candy) and 30% or less kcal from 
fat (focusing on decreasing intake of trans and saturated fats and increasing intake of mono-unsaturated fats), 
with an emphasis on mixed meals (combination of protein, carbohydrate and fat). Patients should maintain 
their customary physical activity level throughout the study.  Patients will be advised to limit alcohol 
consumption to moderate use (not more than 3 drinks/week and not more than 1 drink/day for females and not 
more than 5 drinks/week and not more than 2 drinks/day for males). One drink = 5 ounces (150 mL) of wine 
or 12 ounces (360 mL) of beer or 1.5 ounces (45 mL) of hard liquor. 
 
6.2 Medications 
6.2.1 Pre-study Medications 
With the exception of insulin and sulfonylureas subjects will continue their pre-admission medications at 
stable doses throughout the study.  This includes oral hypoglycemic agents, and other medications either 
related or unrelated to lipodystrophy or its complications. Insulin and sulfonylurea doses may be reduced per 
investigator judgment in case of hypoglycemia.   
 
6.2.2 ISIS 304801 
 
6.2.2.1 Formulation, storage conditions/stability: 
Study Drug (ISIS 304801 or placebo) characteristics are listed below.   
 
The Study Drug is contained in glass prefilled syringes (PFS). The Study Drug must be stored securely at 2° 
to 8° Celsius and be protected from light.  The investigative team will provide patients with instructions in 
Study Drug storage and administration. 
 
Study Drug Characteristics 
Study Drug 
ISIS 304801 
Placebo 
Strength 
200 mg/ mL  
Not Applicable 
Volume/Formulation 
1.5 mL solution per PFS 
1.5 mL solution per PFS 

 
 
 
 
26 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Dose 
300 mg once weekly 
Not applicable 
Route of 
Administration 
SC 
SC 
 
6.2.2.2 Availability 
ISIS 304801 and placebo are supplied by Ionis Pharmaceuticals. 
 
6.2.2.3 Initial Drug Shipment and Re-Supply 
A completed Drug Request Form must be emailed, at least 5 days prior to the expected delivery date, to Ionis 
Clinical Supplies.   
 
6.2.2.4 Study Drug Accountability 
The study staff is required to document the receipt, dispensing, and return/destruction of Study Drug supplies 
provided by the Sponsor. At the end of the study, and after full accountability is performed on study drug or 
site closure, study drug destruction will occur at NIH. 
 
 
 
6.2.2.5 Study Drug Administration 
For each individual patient, Study Drug will be administered SC as a single 1.5 mL injection once weekly for 
Weeks 1-68. Self-administration will be allowed after appropriate training of the patient and/or caregiver.  
Patients should receive 1 dose per week, with weeks always defined relative to Study Day 1. For example, if a 
patient receives the first dose on a Monday, subsequent doses should be given on Mondays, if possible. If a 
patient misses an injection, or if dosing on the usual day is not possible, the patient can reschedule the 
injection provided that 2 doses are administered at least 2 days apart. 
 
Every effort should be made to ensure the previous week’s dose is given 7 days prior to a scheduled clinic 
visit. Subjects will not be removed from the study because of missed dosing; however, subjects missing more 
than 2 doses before Week 13 may not be evaluable for the primary endpoint. 
 
6.3 Study Procedures 
6.3.1 Study Schedule 
A detailed schedule of study visits and testing to be performed at each visit is given in Appendix A. 
 
6.3.2 Prescreening 
Prior to the first study visit, patients will undergo prescreening via an in-person NIH visit under another 
protocol, or via long-distance review of medical history and records, to maximize the likelihood that subjects 
will meet all inclusion/exclusion criteria at the time of the initial study visit.  Dietary counseling will be 
provided in-person or via long-distance communication 2-8 weeks prior the initial study visit as per section 
6.1, and prior to the written informed consent process.  If an outside LDL-C lab result is available and is 
within 3 months of a subject’s initial NIH visit, the outside value will be considered as part of their enrollment 
criteria.  The test will be remeasured once at NIH but will ensure there are no delays in study procedures as a 
result of this test not being available until ~7 days after it is drawn.  

 
 
 
 
27 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
6.3.3 Initial Visit – Includes Screening (Week -1) and the first week of dosing (Week 1) 
Subjects will be admitted to the Metabolic Research Unit in the NIH Clinical Center.  Upon admission, they 
will undergo a history and physical examination, and baseline labs will be obtained.  Height, weight, blood 
pressure, resting pulse, and temperature will be obtained. Subjects will undergo the informed consent process 
prior to any study-related testing. 
 
Testing used to assess subject eligibility includes: 
• 
Physical examination (including skin-fold measurements, blood pressure) 
• 
Urinalysis and/or 24 hour urine for protein and blood 
• 
Lipid panel 
• 
Fasting insulin 
• 
Pregnancy test (females) 
• 
Cardiac troponin T  
• 
Hemoglobin A1c 
• 
Hepatic panel 
• 
Serum creatinine 
• 
Thyroid function tests 
• 
Coagulation panel (PT, aPTT) 
• 
Viral hepatitis studies 
• 
12-Lead EKG 
• 
Echocardiogram 
 
If a subject meets all eligibility criteria, he/she will undergo randomization and will proceed with the Week 1 
schedule per Appendix A. 
 
6.3.4 In-person follow-up visits 
Patients will come to NIH for follow-up visits every 4 months.  Testing will be performed as per the Study 
Schedule (Appendix A) 
 
6.3.5 Home nurse visits 
Home nurse visits for safety and/or efficacy labs and vital signs will be conducted every week (unless the 
patient is coming for an in-person visit) for the duration of the study, as detailed in Appendix A.  Home (or 
visits at a location convenient for the subject) visits will be completed by trained service providers, sourced 
through a home health care agency, GlobalCare Clinical Trials.  Service providers will receive detailed 
training on all necessary study procedures and are also required to comply with patient privacy and data 
protection laws as well as regulatory guidelines for Good Clinical Practices and ICH guidelines.  Home health 
care is provided to ease patient burden while still allowing for adequate safety monitoring. If feasible, patients 
can also complete these visits as outpatient visits at the NIH clinical center.  Visits will be approximately 1 
hour in length.  In the unlikely event a service provider is unavailable to collect blood from a subject, the NIH 
study team will send a prescription to the subject so that they can have their labs drawn by a local lab facility.  
Prior approval to cover the cost of the lab tests is required by NIH.  Patients will be made aware there is a 

 
 
 
 
28 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
possibility they may need to cover the costs through either their health insurance provider or pay out of 
pocket.   
 
All visits (home and in-person) will have a visit window of at least +/- 7 days.  All reasonable attempts should 
be made to ensure compliance with the visit schedule as outlined in Appendix A.  However, in the event that a 
visit does not occur or is delayed, all subsequent visits should be calculated based on the time elapsed since 
Day 1 rather than from the date of the previous visit.   
 
6.3.6 Telephone follow-up 
Telephone contact between the study team and each subject for review of adverse events, concomitant 
medications, and general study requirements will be conducted every month for the placebo controlled period 
and the first 6 months of the open label extension, and every 2 months thereafter (unless the patient is coming 
for an in-person visit), as detailed in Appendix A. 
 
6.3.7 Post-Treatment 
After completion of the open label extension (week 68), patients will enter the 12-week post-treatment 
evaluation period.  This period consists of home platelet monitoring every week for six weeks and then again 
at a single NIH visit on week 80 as outlined in Appendix A.   
 
Immediately after week 68, or after the post-treatment evaluation period, patients may choose to receive an 
additional 12 months of open label drug (up to 24 months, total).  They will be offered this option if their 
triglycerides improved by ≥ 50%.  Justification for this additional extension are: 
 
a.  The patients received ≥50% improvement in triglycerides and they have no other effective 
treatment options. 
b. To collect additional safety data over a longer term 
c. To collect additional efficacy data over a longer term 
 
Home health care visits will not be available during the extended open-label period.  Patients must obtain 
platelet and other safety monitoring locally through their health insurance provider or pay out of pocket.  This 
monitoring will include weekly CBC for platelet count, and monthly CBC with differential, lipid panel, 
coagulation studies, urine protein:creatinine ratio, liver function tests, and chemistry panel.  Hemoglobin A1c 
will be measured every 3 months.  Study staff will remain in weekly contact with patients to review safety 
labs and any adverse events.  Patients will return to NIH at the end of the 12 month extended open-label use 
period, or earlier if there are any safety concerns that, in the judgment of the PI, require in-person evaluation.  
During the NIH visit at the end of the 12 month period, patients may undergo optional evaluation including 
any test listed in section 6.4 except liver biopsy.  All concomitant medications, including those for diabetes or 
hyperlipidemia, may be adjusted as clinically appropriate per the judgment of the investigator during the 
extended open-label period. 
 
6.3.8 Follow-up Visits for Early Termination from Treatment Period 
Any patient who discontinues early from the placebo-controlled or OLE periods will be encouraged to attend 
a final in-person follow-up visit (Week 80 visit assessments per Appendix A) approximately 12 weeks after 
their last dose of Study Drug.  If the patient declines or is unable to participate in the above, a home nurse 

 
 
 
 
29 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
visit for safety/efficacy labs (equivalent to week 74 visit in Appendix A) and telephone follow-up will be 
attempted, ideally ~12 weeks from the last dose of Study Drug. 
 
6.3.9 Follow-up Visits for Early Termination from Post-Treatment Follow-up Period 
The patient who requests to withdraw from the study during the Post-Treatment Follow-up Period should be 
encouraged to have a home nurse visit for safety/efficacy labs (equivalent to week 74 visit in Appendix A) 
and telephone follow-up, ideally ~12 weeks from the last dose of Study Drug.  
 
If a patient withdraws due to an AE at any time during the study, the Investigator will arrange for the patient 
to have appropriate follow-up until the AE has resolved or stabilized.  Appropriate follow up may include 
home nursing visits or visits to NIH if necessary. 
 
6.3.10 End of Study 
After completion of this study, subjects may continue to receive care through NIH via protocol 76-DK-0006 
(Studies of Molecular Genetics of Insulin Secretion, Insulin Action and Diabetes Mellitus), but cannot 
continue to take the study drug through this study. 
 
6.3.11 Post-Study Obligations 
There are no anticipated post-study obligations. 
 
6.4 Study Assessments 
 
6.4.1 Patient Reported Outcomes 
1. Hunger and Widespread Pain Diaries: All patients will complete hunger and pain questionnaires at 
each in-person visit. (Appendix H).  
 
2. Quality of Life Assessments:  All patients will complete Quality of Life Questionnaires (EQ-5D and 
SF-36) at each in-person visit.  (Appendix F & G). 
 
6.4.2 Detailed Metabolic Phenotyping 
1. Anthropometric measurements: Physical exams and vital signs will be performed as indicated in the 
Schedule of Procedures (Appendix A).  Height will be measured in the early morning on the first full 
day of the first inpatient visit. Vital signs will include weight, blood pressure, pulse rate, respiratory 
rate and body temperature.  Blood pressure and pulse rate will be recorded after the patient has been 
in a sitting position for at least 5 minutes.  Systolic and diastolic blood pressure should always be 
measured on the same arm (preferentially on the left arm).  Waist circumference will be measured at 
the iliac crest in triplicate to the nearest tenth of a cm using a stretch-less, tension-sensitive tape 
measure at the times indicated in the Schedule of Procedures (Appendix A).  Skinfold measurements 
will be obtained in triplicate to the nearest mm using regularly calibrated Lange skinfold calipers at 
the times indicated in the Schedule of Procedures (Appendix A).   
 

 
 
 
 
30 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
2. Fasting labs: Blood samples will be obtained following a minimum 8 hour fast for analytes described 
in Appendix A. Ideally the morning blood draw will be coordinated so that it will be collected 10 
hours after the evening meal.  Additional serum and plasma samples will be stored for future analysis. 
 
3. DEXA scan for total body composition:  DEXA scans will be conducted prior to administration of the 
first dose of study drug and repeated after the 16 week placebo controlled period, and again after 16 
weeks of open-label drug in those previously assigned to placebo.  A DEXA scan (iDXA, GE 
Healthcare, Madison WI) will be performed to determine total and regional body fat and lean soft 
tissue masses, bone mineral content and density. DEXA produces photons at two different energy 
levels, 40 and 70 KeV. The photons pass through tissues and attenuate at rates related to elemental 
composition. Bone mineral, with highly attenuating calcium and phosphorous, is readily distinguished 
from soft tissues. The different elemental profiles of fat and bone-mineral free lean components 
allows for the analysis of soft tissue fat content, so that bone mineral, fat, and bone mineral fat-free 
lean components may be resolved.  
 
4. Glucose and Lipid Turnover: Stable isotope tracers will be used to measure glucose and lipid 
turnover.  Endogenous glucose production will be measured using steady-state infusion of [6,6-
2H2]glucose tracer.  The fractional rate of gluconeogenesis will be measured using steady-state oral 
dosing of deuterated water (2H2O) 45. The rate of lipolysis will be measured using steady-state 
infusion of deuterium-labeled 2H5-glycerol, and the fatty acid turnover rate will be measured using 
steady-state infusion of [U-13C16] palmitate.  Subjects will fast after 8 pm.  A total of 3 grams per kg 
lean body mass of 2H2O will be given in four divided doses every two hours at 9 pm, 11 pm, 1 am, 
and 3 am in order to enrich the subject’s body water pool to approximately 0.5% 2H2O.  Beginning at 
~5 am,  a primed [6,6-2H2]glucose infusion will be given for 3 hours, after which blood samples to 
measure isotope enrichment will be measured over a period of 30 minutes at steady state.  Two hours 
after the [6,6-2H2]glucose infusion begins, a primed 2H5-glycerol infusion, and unprimed [U-13C16] 
palmitate infusion will be given for one hour, and isotope enrichment will be measured over a period 
of 30 minutes at steady state.  To assess the effects of hyperinsulinemia on glucose turnover, the 
glucose tracer infusion will be continued during the euglycemic, hyperinsulinemic clamp study, 
below, with blood samples for tracer enrichment obtained during the steady-state period of the clamp. 
 
5. Euglycemic Hyperinsulinemic Clamp:  This is the gold-standard test to measure insulin sensitivity.  
For insulin treated subjects, an overnight insulin drip may be given beginning at 6 pm the night prior 
to the clamp to maintain euglycemia.  After an 8-hour fast, insulin will be infused at a dose of 120 
mcU/m2*minute.  This dose is designed to suppress endogenous glucose production and near-
maximally stimulate glucose uptake in this group of very insulin resistant subjects.  20% dextrose 
enriched with 2.5% [6,6-2H2]glucose tracer will be infused at a variable rate to maintain blood 
glucose at approximately 100 mg/dL.  If subjects remain hyperglycemic without dextrose infusion 
after 1 hour of insulin infusion (by which time maximum insulin effect is expected), a higher steady 
state blood glucose concentration for the clamp may be used. During the insulin infusion, blood 
samples (0.5 mL) will be obtained every 5 minutes to measure blood glucose at the bedside.  At 
steady state, the rate of dextrose infusion provides an estimate of insulin-stimulated glucose disposal.  
Additional samples will be drawn to measure the glucose and lipid tracers (described above), insulin, 

 
 
 
 
31 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
and other hormone levels.  If technical problems occur with a clamp study (e.g. IV failure or failure to 
attain steady-state glucose and insulin levels), the clamp may be repeated if blood volume limits 
permit. 
 
6. Mixed meal test: The effect of a standardized liquid meal (Boost-plus) with fixed, balanced 
macronutrient content will be assessed.   Blood samples will be obtained for glucose, insulin, C-
peptide, lipid analysis, and research storage at -10, 0, 30, 60, 120, 180, 240, 300 and 360 minutes after 
consuming the liquid meal.  Visual analog scales for hunger and satiety will be obtained at the 0 and 
60 minute time points. 
 
7. Lipoprotein lipase activity: Measurement of lipoprotein lipase and hepatic lipase activities in plasma 
will be performed using blood samples obtained 10 minutes after intravenous infusion of 60 units/kg 
of unfractionated heparin using the methods of Iverius and Nilsson-Ehle46,47.  Lipoprotein lipase and 
hepatic lipase are bound to vessel walls and only released into the blood with an infusion of heparin.  
 
8. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Spectroscopy (MRS):  Hepatic, 
muscle and central body fat will be measured by magnetic resonance imaging (MRI) and magnetic 
resonance spectroscopy (MRS). Studies are performed on a 3T MRI scanner using phased-array coils. 
Hepatic and muscle fat fraction will be determined48.  Visceral and subcutaneous fat measurements 
will be obtained using standard T1 Spin Echo technique which presents fat as a bright signal that can 
be segmented for area and volume measurements. In addition, MRI scanning will be performed for 
angiography (without gadolinium), vessel wall, and endothelial function49. Each subject will be asked 
to perform a hand-grip exercise to obtain arterial dimensions. Before entering the magnet, we shall 
measure the maximal force production while hand squeezing a nonmagnetic hand-grip device. Later 
in the magnet at roughly one quarter of his/her maximal force, we will obtain MR data before, during, 
and after this exercise. The use of the device will be continuously monitored and the subject will be 
able to switch hands if one hand becomes fatigued.  
 
9. Carotid intima-media thickness (cIMT):  cIMT is an established marker of coronary artery disease 
and cardiovascular risk.  This is a non-invasive test using ultrasonography of the carotid arteries in the 
neck.   
 
10. 7-point plasma glucose: Plasma glucose will be measured prior to each meal, 90 minutes after each 
meal, and at bedtime.  Area under the curve for glucose will be calculated using the trapezoidal 
method. 
 
11. Liver biopsy: An optional liver biopsy will be performed in patients at the initial visit and at the end 
of the open label extension period (after 12-16 months of exposure to ISIS 304801). Biopsies will be 
performed transcutaneously unless there is a clinical reason for another approach (e.g. transjugular).  
These biopsies are performed primarily for research purposes, although clinical data about the 
severity of non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) will 
be obtained as well.  Patients will sign a research consent for each liver biopsy prior to the procedure.  
Patients will be allowed to refuse the biopsies and continue to participate in the rest of the study.  
Platelet count will be obtained prior to percutaneous liver biopsy, and the biopsy will not be 

 
 
 
 
32 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
performed if patients have evidence of coagulopathy unresponsive to vitamin K (INR >1.5) or low 
platelets (Platelets < 75,000 k/uL) which may place them at a potentially higher risk for bleeding.  
About half of the liver biopsy sample will be fresh frozen in liquid nitrogen and will be stored for 
molecular analyses and Metabolomics studies in collaboration with Dr. Elif Oral at the University of 
Michigan. 
 
Histologic analysis: Specimens will be graded for the severity of NAFLD/NASH pathology. 
Histological features of NAFLD/NASH will be studied using the validated NASH-CRN (NASH 
Clinical Research Network) scoring system (3). This scoring system comprises histological features, 
4 of which [steatosis (0-3), lobular inflammation (0-3), hepatocellular ballooning (0-2) and fibrosis 
(0-3 with grade 1 divided in three categories as well)] are evaluated semi-quantitatively.  NAFLD 
activity score (NAS) is the unweighted sum of steatosis, lobular inflammation and hepatocellular 
ballooning scores. Total of this together with the fibrosis score constitutes the total NASH score.   
 
12. Metabolomics:  Studies will be done in the Molecular Phenotyping Core of the Michigan 
Metabolomics and Obesity Center at the University of Michigan in collaboration with Dr. Elif Oral. 
Plasma samples collected in the fasting state and liver biopsy samples will be extracted according to 
the method of Bligh and Dyer 50 for analysis.  Lipomic studies will include measurement of 
subclasses of lipids and fatty acid composition.  Unbiased metabolomics studies of plasma will be 
conducted using LC/MS and GC/MS.   
 
6.4.3 Pharmacokinetic Analysis 
 
Each subject will have a single (not serial) plasma PK completed at the end of their week 1 visit.  The plasma 
PK of ISIS 304801 following extensive sampling will be assessed at Week 16 (Week 1 OLE) for all subjects, 
and Weeks 32 (Month 4 OLE).  Additionally, plasma trough levels throughout the 16-week and 12-month 
OLE treatment period and post-treatment levels during the 12-week follow up period will be measured.   
Details are given in Appendices A and C. 
 
For all patients who receive ISIS 304801 treatment, non-compartmental PK analysis of ISIS 304801 will be 
carried out on each individual subject data set.  The maximum observed drug concentration (Cmax) and the 
time taken to reach Cmax (Tmax) will be obtained directly from the concentration-time data.  Partial areas under 
the plasma concentration-time curve from zero time (predose) to selected times (t) after the SC administration 
(AUCt) will be calculated using the linear trapezoidal rule.  The plasma disposition half-life associated (t1/2λz) 
with the apparent terminal elimination phase will be calculated using a non-compartment method, if 
appropriate, using available data (Week 68 and later), from the equation t1/2λz=0.693λz, where λz is the rate 
constant associated with the apparent terminal elimination phase.  A minimum of three data points will be 
used to define z and the correlation of determination values (r2) had to be at or greater than 0.8 for the 
estimate to be accepted.  The samples at Week 68 (assumed pre-dose value for Week 69), Week 74, and 
Week 80 will be used to calculate the half-life. Other pharmacokinetic parameters, as appropriate, may be 
determined or calculated at the discretion of the pharmacokinetic scientist. 
 

 
 
 
 
33 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Plasma concentrations and PK parameters will be summarized with and without stratification by 
immunogenicity status using descriptive statistics.  Additional details regarding the PK analysis will be 
described in the Statistical Analysis Plan. 
 
Potential relationships between selected PD and PK measures may also be explored, where deemed 
appropriate.  
 
6.4. 4 Immunogenicity Analysis 
 
Immunogenicity (IM) results (screen positive/negative, confirmed positive/negative or unevaluable, and when 
applicable, titer of anti-ISIS 304801 antibodies) before, during, and after treatment with study drug 
(ISIS 304801) (i.e., sample ADA status) will be listed by treatment and study day.  Subject ADA status 
(positive/negative or unevaluable) for all evaluable patients, along with the study day associated with the first 
positive IM status emerged (Tfirst, i.e., onset of ADA development), the last positive IM status observed (Tlast), 
the duration of ADA response (number of days between Tfirst and Tlast) if appropriate, the last ADA sample 
collection day, and subject maximum titer if applicable, will be listed by treatment and study day.   
 
Additionally, the sample and subject IM incidence (number) and incidence rate (percent) will be summarized 
as the total number and percent of evaluated subjects with antibody negative, positive, and unknown status by 
treatment.  Furthermore, onset, duration, and titer of the ADA response, if applicable, will be summarized as 
median and range.  
 
Additional details regarding the immunogenicity data analysis will be described in the SAP. 
 
6.4.5 Safety Assessments 
1. Liver function, Kidney function, Platelets, LDL, and coagulation tests (detailed in Appendix B): 
Monitoring of the above (except for platelets) will be performed every 4 weeks for the first 6 months 
of treatment, and every 8 weeks thereafter, per the Study Schedule (Appendix A).  Platelets will be 
monitored every week for the duration of the study.   
 
2. Self-monitoring of blood glucose: In subjects with diabetes, a home glucometer will be distributed to 
patients who do not have one already at the first inpatient visit for home-based glucose monitoring (“Self-
Monitored Plasma Glucose” or SMPG). Training on the use of the glucometer will be provided as 
needed.  Fasting SMPG will be self-measured in the fasting state: daily if the patient is on insulin 
therapy, and weekly if on oral antidiabetic therapy.  
 
3. Urinalysis: Urinalysis and urine protein to creatinine ratio will be conducted as per the Study 
Schedule (Appendix A). 
 
4. Echocardiogram: Echocardiography for assessment of left and right ventricular function and mitral 
and aortic valve function will be conducted per the Study Schedule (Appendix A).  Cardiologists 
reviewing echocardiograms at NIH will not be aware of treatment assignment during the randomized 
period.  Results will be provided to the DSMB for their review. 

 
 
 
 
34 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
5. EKG: Standard 12-lead EKGs will be performed after the patient has been resting in a supine position 
for at least 5 minutes per the Study Schedule (Appendix A). 
 
6. Troponin T:  Cardiac troponin T will be measured per the Study Schedule (Appendix A). 
 
7. Pregnancy test: Pregnancy tests will be performed on female patients with reproductive potential at 
each inpatient visit. 
 
8. Pancreatitis: All patients will be given an instruction card that must be presented to the treating 
physician if a suspected case of pancreatitis occurs.  The card will explain that the patient is in a 
clinical trial and that serum lipase and/or amylase measures should be done in order to adjudicate the 
event, based on Atlanta Classification51.  If serum or amylase activity is less than 3 x ULN, imaging, 
preferably contrast-enhanced computed tomography (CT), should be considered to confirm the 
diagnosis of acute pancreatitis per the Atlanta Criteria. 
 
7. Human Subject Protection 
 
7.1 Data and Safety Monitoring Plan 
Safety data will be monitored on an ongoing basis by the Principal Investigator and captured by the Sponsor 
on the CRF.  Appropriately trained personnel will be granted access to Express 5.4, the Electronic data 
capture system for this trial.  
 
At least monthly, the Principal Investigator or designee will review vital signs (including at a minimum heart 
rate, systolic and diastolic blood pressure), adverse events (including all pre and post dosing adverse events), 
serum chemistry (including at a minimum alanine aminotransferase, aspartate aminotransferase, alkaline 
phosphatase, total bilirubin, blood urea nitrogen, and creatinine), coagulation (including at a minimum aPTT, 
PT, and INR ), and urinalysis (including at a minimum urine protein (by dipstick), urine blood, and urine 
white blood cells).  At least weekly, the Principal Investigator or designee will review hematology (at a 
minimum hemoglobin, absolute lymphocytes, absolute neutrophils, platelet count, WBCs) to advise on 
possible medication dose changes for safety reasons. 
 
The Ionis Medical Advisor will answer queries and provide safety management recommendations to the 
Principal Investigator as needed. Anticipated AE’s are fully described in the Investigator Brochure. Any 
safety issues identified in other apoC-III clinical trials will be promptly communicated by the Ionis to the 
Principal Investigator. 
 
A monthly cumulative summary safety report for all apo-CIII studies, including the current study, will be 
issued by Ionis Pharmaceuticals, including an assessment of fatal cases, SAEs, treatment discontinuations, 
treatment-related AEs with severity and relatedness, laboratory analysis, ECG and vital signs. Particular 
attention will be paid to protocol defined monitoring/stopping rules. This report will be sent monthly to the 
Principal Investigator and will be used by the Data and Safety Monitoring Board (DSMB) for their ongoing 
data safety review. 
 

 
 
 
 
35 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
7.1.1 Investigational New Drug application 
The investigators will be conducting this study with the oversight of the Food and Drug Administration 
(FDA) under an Investigational New Drug (IND) application. NIDDK will serve as IND sponsor.  Ionis 
Pharmaceuticals will provide NIDDK with a letter of cross reference authorization to their existing IND for 
ISIS 304801.   
 
7.1.2 Data and Safety Monitoring Board 
A Data and Safety Monitoring Board (DSMB) will be assembled by Ionis Pharmaceuticals and include an 
NIDDK statistician to review safety, tolerability and efficacy (as needed) data collected on ISIS 304801 
during this study.  The membership of the DSMB will be determined by the PI in collaboration with the 
Company.  Based on its ongoing assessment of the safety and tolerability of ISIS 304801, the DSMB will 
provide recommendations to the Principle Investigator for modifying, stopping or continuing the study as 
planned. The DSMB will meet approximately 3 times per year (exact schedule to be determined by DSMB 
Chair), and additional ad hoc meetings may be called by the Chair if an imminent significant safety concern 
arises (e.g. unexpected death of study participant, new serious safety issue identified in the drug development 
program).  Study data (blinded during the initial 4 month placebo controlled period) will be provided to the 
DSMB via from the study database maintained by Ionis Pharmaceuticals.  The NIDDK statistician will have 
access to the unblinding scheme, and can provide this to the DSMB on request.  The Investigator will review 
and respond to the DSMB recommendations in writing. Any recommendations of the DSMB will not be 
binding but require due consideration by the Investigator in consultation with the NIDDK/NIAMS IRB. If the 
DSMB recommends continuation of the study without modification, no formal response will be required. 
However, if the recommendations request action, such as a recommendation for termination of the study or 
modification of the protocol, the Investigator will provide a formal written response to the DSMB stating 
whether the recommendations will be followed and the plan for addressing the issues. 
 
7.1.3 Study monitoring 
Study procedures will be subject to audits and/or monitoring visits to ensure compliance with the protocol and 
applicable regulatory requirements consistent with the NIDDK quality assurance program plan.  Audit and/or 
monitoring visit results will be reported to the Principal Investigator for further reporting as appropriate.   
Study documents and pertinent hospital or clinical records will be reviewed to verify that the conduct of the 
study is consistent with the protocol plan.   
 
As required by FDA 21 CFR 312.50 (and NIH OHSRP’s SOP 23), trial procedures will be subject to review 
and/or monitoring visits to ensure compliance with the protocol and applicable regulatory requirements with 
the NIDDK quality assurance program plan.  Audit and/or monitoring visits results will be reported to the 
Principal Investigator/Sponsor for further reporting to the FDA consistent with applicable regulations.  The 
specific monitoring plan will be developed with the Principal Investigator and frequency of monitoring visits 
determined by such factors as study enrollment, data collection status and regulatory obligations.  Study 
documents and pertinent hospital or clinical records will be reviewed to verify that the conduct of the study is 
consistent with the protocol plan. 
 
7.1.4 Adjudication Committees 
All SAEs that occur during the study that are consistent with a major acute cardiovascular event (MACE) will 
be adjudicated by a blinded, independent committee as outlined in the MACE Adjudication Charter. 

 
 
 
 
36 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
All AEs and SAEs that occur during the study that are consistent with an event of acute pancreatitis will be 
adjudicated by a blinded, independent committee according to the Atlanta classification of acute pancreatitis51 
and as outlined in the Pancreatitis Adjudication Charter.  In addition, data for prior episodes of acute 
pancreatitis or suspected pancreatitis will be collected by review of each patient’s medical chart and these 
events will also be adjudicated. 
7.2 Adverse Events, Protocol Deviations, and Unanticipated Problems 
The collection, monitoring and analysis of adverse events will be the responsibility of the Principal 
Investigator and the investigative team.   
 
7.2.1 Definitions 
Adverse events, protocol deviations, unanticipated problems (UP), serious adverse events, sponsor and serious, 
are defined as described in NIH HRPP SOP 16 (“Reporting Requirements for Unanticipated Problems, 
Adverse Events and Protocol Deviations.”) with further details and modifications given below. All adverse 
events occurring during the study, including those observed by or reported to the research team, will be 
recorded, and will be summarized for the NIDDK/NIAMS IRB by the investigative team and to the FDA by 
NIDDK at the time of annual review.  
 
Adverse Event (AE) 
An adverse event is any unfavorable and unintended sign (including a clinically significant abnormal 
laboratory finding, for example), symptom, or disease temporally associated with the Study or use of 
investigational drug product, whether or not the AE is considered related to the investigational drug product. 
 
Adverse Reaction and Suspected Adverse Reaction 
An adverse reaction is any AE caused by the Study Drug. A suspected adverse reaction is any AE for which 
there is a reasonable possibility that the drug caused the AE. A suspected adverse reaction implies a lesser 
degree of certainty about causality than an adverse reaction. 
 
Serious Adverse Event (SAE) 
A SAE is any AE that in the view of either the Investigator or Sponsor, meets any of the following criteria: 
• 
Results in death 
• 
Is life threatening: that is, poses an immediate risk of death at the time of the event 
An AE or suspected adverse reaction is considered “life-threatening” if, in the view of either the 
Investigator or Sponsor, its occurrence places the patient at immediate risk of death. It does not 
include an AE or suspected adverse reaction that, had it occurred in a more severe form, might have 
caused death. 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization 
Hospitalization is defined as an admission of greater than 24 hours to a medical facility and does not 
always qualify as an AE. 
• 
Results in a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 

 
 
 
 
37 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
• 
Results in a congenital anomaly or birth defect in the offspring of the patient (whether the patient is 
male or female) 
• 
Important medical events that may not result in death, are not life-threatening, or do not require 
hospitalization may also be considered serious when, based upon appropriate medical judgment, they 
may jeopardize the patient and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition. Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, blood dyscrasias or convulsions that 
do not result in inpatient hospitalization, or the development of drug dependency or drug abuse 
 
Protocol Deviation:  
Any change, divergence, or departure from the NIDDK/NIAMS IRB-approved research protocol. The impact 
of a PD is characterized by designation as serious or not serious.  A protocol deviation is serious if it meets 
the definition of a Serious Adverse Event (see above) or if it compromises the safety, welfare or rights of 
subjects or others. 
 
7.2.2 Monitoring and Recording Adverse Events 
Any pre-existing conditions or signs and/or symptoms present in a patient prior to the start of the Study (i.e., 
before informed consent) should be recorded as Medical History and not recorded as AEs unless the pre-
existing condition worsened. The Investigator should always group signs and symptoms into a single term 
that constitutes a single unifying diagnosis if possible. 
 
Serious Adverse Events 
The collection of SAEs will begin after the patient signs the informed consent form and stop at the end of the 
patient’s follow-up period. When the Investigator is reporting by telephone, it is important to speak to 
someone in person versus leaving a message. An Initial Serious Adverse Event Form should be completed 
and a copy should be faxed to the Sponsor and to Ionis or designee. 
 
Detailed information should be actively sought and included on Follow-Up Serious Adverse Event Forms as 
soon as additional information becomes available. All SAEs will be followed until resolution. SAEs that 
remain ongoing past the patient’s last protocol-specified follow-up visit will be evaluated by the Investigator 
and Ionis. If the Investigator and Ionis agree the patient’s condition is unlikely to resolve, the Investigator will 
determine the follow-up requirement. 
 
Non-Serious Adverse Events 
The recording of non-serious AEs will begin after the patient signs the informed consent form and will stop at 
the end of the patient’s follow-up period. The Investigator will monitor each patient closely and record all 
observed or volunteered AEs on the Adverse Event Case Report Form. 
 
7.2.3 Evaluation of Adverse Events (Serious and Non-Serious) 
The Investigator’s opinion of the following should be documented on the Adverse Event Case Report Form: 
 
Relatedness 

 
 
 
 
38 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
The event’s relationship to the Study Drug (ISIS 304801 or placebo) is characterized by one (1) of the 
following: 
• 
Related: There is clear evidence that the event is related to the use of Study Drug, e.g., confirmation 
by positive re-challenge test 
• 
Possible: The event cannot be explained by the patient’s medical condition, concomitant therapy, or 
other causes, and there is a plausible temporal relationship between the event and Study Drug (ISIS 
304801 or placebo) administration 
• 
Unlikely/Remote: An event for which an alternative explanation is more likely (e.g., concomitant 
medications or ongoing medical conditions) or the temporal relationship to Study Drug (ISIS 304801 
or placebo) administration and/or exposure suggests that a causal relationship is unlikely (For 
reporting purposes, Unlikely/Remote will be grouped together with Not Related) 
• 
Not Related: The event can be readily explained by the patient’s underlying medical condition, 
concomitant therapy, or other causes, and therefore, the Investigator believes no relationship exists 
between the event and Study Drug 
 
Severity 
The event’s severity is characterized by one of the following: 
• 
Mild: The event is easily tolerated by the patient and does not affect the patient’s usual daily activities 
• 
Moderate: The event causes the patient more discomfort and interrupts the patient’s usual daily 
activities 
• 
Severe: The event is incapacitating and causes considerable interference with the patient’s usual daily 
activities 
 
If the event is an SAE, then all applicable seriousness criteria must be indicated.  
 
Action Taken with Study Drug 
Action taken with Study Drug (ISIS 304801 or placebo) due to the event is characterized by one of the 
following. 
• 
None: No changes were made to Study Drug (ISIS 304801 or placebo) administration and dose 
• 
Permanently Discontinued: Study drug was discontinued and not restarted 
• 
Temporarily Interrupted, Restarted – Same Dose: Dosing was temporarily interrupted or delayed due 
to the AE and restarted at the same dose 
• 
Reduced Dose: Dosing frequency was reduced 
 
Treatment Given for Adverse Event 
Any treatment (e.g., medications or procedures) given for the AE should be recorded on the Adverse Event 
Case Report Form. Treatment should also be recorded on the concomitant treatment or ancillary procedures 
CRF, as appropriate. 
 
Outcome of the Adverse Event 
If the event is a non-serious AE, then the event’s outcome is characterized by one of the following: 
• 
AE Persists: Patient terminates from the trial and the AE continues 
• 
Recovered: Patient recovered completely from the AE 

 
 
 
 
39 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
• 
Became Serious: The event became serious (the date that the event became serious should be 
recorded as the Resolution Date of that AE and the Onset Date of the corresponding SAE) 
• 
Change in Severity (if applicable): AE severity changed 
 
If the event is an SAE, then the event’s outcome is characterized by one of the following: 
• 
Ongoing: SAE continuing 
• 
Persists (as non-serious AE): Patient has not fully recovered but the event no longer meets serious 
criteria and should be captured as an AE on the non-serious AE eCRF (the SAE resolution date 
should be entered as the date of onset of that AE) 
• 
Recovered: Patient recovered completely from the SAE (the date of recovery should be entered as the 
SAE resolution date) 
• 
Fatal: Patient died (the date of death should be entered as the SAE resolution date) 
7.3  Reporting 
Serious unanticipated problems and serious protocol deviations will be reported to the NIDDK/NIAMS IRB 
and Clinical Director as soon as possible but not more than 7 days after the PI first learns of the event. Not 
serious unanticipated problems will be reported to the NIDDK/NIAMS IRB and Clinical Director as soon as 
possible but not more than 14 days after the PI first learns of the event. Non-serious protocol deviations will 
be reported to the NIDDK/NIAMS IRB (as soon as possible but not more than 14 days after the PI first learns 
of the event) only if they represent a departure from NIH policies for the conduct of human subjects research, 
adversely affect the health care of the subject(s) or compromise the interpretation or integrity of the research.  
Non-serious protocol deviations that result from normal subject scheduling variations or technical issues 
associated with sampling that does not impact the health of the subject or the interpretation of the study data 
will not be reported. 
 
For studies conducted under an IND, any event that is a serious, unexpected, and suspected adverse reaction 
(SUSAR) (related to study drug) will be reported by the Investigator to the NIDDK Clinical Director, 
NIDDK/NIAMS IRB, Food and Drug Administration (FDA), and Ionis Pharmaceuticals as soon as possible 
and no later than 7 days (for a death or life-threatening event) or 15 days (for all other SAEs) after the 
investigator’s or institution’s initial receipt of the information. All serious, unexpected, and suspected 
adverse reactions (SUSARS) will be reported in aggregate at the time of continuing review. 
 
IND Safety Reports will be submitted to the FDA by NIDDK. 
 
If only limited information is initially available, follow-up reports are required. If an ongoing SAE changes in 
its intensity or relationship to study drug or if new information becomes available, a follow-up SAE report 
should be sent to the FDA.  All SAEs should be followed to resolution or stabilization. 
 
Deaths will be reported by the investigative team to the NIDDK Clinical Director and NIDDK/NIAMS IRB 
within 7 days after the PI first learns of the event.  All deaths that have occurred among study participants 
since the previous review will be summarized at the time of continuing review. 
 

 
 
 
 
40 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
7.4 Procedures for Handling Special Situations 
7.4.1 Contraception and Pregnancy 
All patients of childbearing potential must refrain from sperm/egg donation and practice effective 
contraception from the time of signing the informed consent form until at least 3 months after their last dose 
of study treatment. 
 
For the purposes of this study, women of childbearing potential are defined as any female who has 
experienced menarche, and who does not meet one of the following conditions: 
 
• 
Postmenopausal:  12 months of spontaneous amenorrhea in females >55 years of age or, in females 
≤55 years, 12 months of spontaneous amenorrhea without an alternative medical cause and FSH 
levels in the postmenopausal range for the laboratory involved 
 
• 
6 weeks after surgical bilateral oophorectomy with or without hysterectomy 
• 
Post hysterectomy 
 
For the purposes of the study, effective contraception is defined as follows: 
For male patients: 
• 
Effective male contraception includes a vasectomy with negative semen analysis at follow-up, or the 
use of condoms together with spermicidal foam/gel/film/ cream/suppository.  Male patients must also 
encourage their female partner to use effective contraception from the time of signing the informed 
consent until 3 months after the patient’s last dose of study treatment.  Effective contraceptive for the 
female partner includes: surgical sterilization (e.g., bilateral tubal ligation), hormonal contraception, 
intrauterine contraception/device, or barrier methods (female condom*, diaphragm, sponge, cervical 
cap) together with spermicidal foam/gel/film/cream/suppository.  Male patients with partners that are 
pregnant must use condoms to ensure that the fetus is not exposed to the study drug. 
For female patients: 
• 
Using 1 or more of the following acceptable methods of contraception:  surgical sterilization (e.g., 
bilateral tubal ligation), hormonal contraception, intrauterine contraception/device, or any 2 barrier 
methods (a combination of male or female condom* with diaphragm, sponge, or cervical cap) 
together with spermicidal foam/gel/film/cream/suppository. 
*Note:  A female condom and a male condom should not be used together as friction between the two can 
result in either product failing. 
 
If a patient becomes pregnant or a pregnancy is suspected, or if a male patient makes or believes that he has 
made someone pregnant during the study, then the Investigator must be informed immediately.  An Initial 
Pregnancy Form should be submitted to Ionis or designee within 24 hours of first learning of the occurrence 
of pregnancy.  Follow-up information including delivery or termination is reported on Follow-up Pregnancy 
Forms and reported within 24 hours. 
 
Payment for all aspects of obstetrical care, child or related care will be the patient’s responsibility. 
 

 
 
 
 
41 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Female patients:  If a suspected pregnancy occurs while on the study (including follow-up), a pregnancy test 
will be performed.  The patient with a confirmed pregnancy will be immediately withdrawn from treatment 
with Study Drug.  However, the patient will be encouraged to complete the post-treatment follow-up portion 
of the study to the extent that study procedures do not interfere with the pregnancy.  Regardless of continued 
study participation, the study physician will assist the patient in getting obstetrical care and the progress of the 
pregnancy will be followed until the outcome of the pregnancy is known  (i.e., delivery, elective termination, 
or spontaneous abortion).  If the pregnancy results in the birth of a child, the Investigator and Ionis or 
designee may require access to the mother and infant’s medical records for an additional 8 weeks after birth. 
 
Male patients:  The progress of the pregnancy in a male patient’s partner should be followed until the 
outcome of the pregnancy is known (i.e., delivery, elective termination, or spontaneous abortion).  Male 
patients are not required to stop the study drug if their partner becomes pregnant.  If the pregnancy results in 
the birth of a child, additional follow-up information may be requested for the mother and infant.  Follow-up 
will be performed to the extent permitted by applicable regulations and privacy considerations. 
7.4.2 Abnormalities of Laboratory Tests 
Clinically significant abnormal laboratory test results may, in the opinion of the Investigator, constitute or be 
associated with an AE.  Examples of these include abnormal laboratory results that are associated with 
symptoms, or require treatment, e.g., bleeding due to thrombocytopenia, tetany due to hypocalcemia, or 
cardiac arrhythmias due to hyperkalemia.  Whenever possible, the underlying diagnosis should be listed in 
preference to abnormal laboratory values as AEs.  Clinically significant abnormalities will be monitored by 
the Investigator until the parameter returns to its baseline value.  The Investigator will consult with the Ionis 
Medical Advisor as needed, and for any exceptions to the above policy.  Laboratory abnormalities deemed not 
clinically significant (NCS) by the Investigator should not be reported as AEs.  Similarly, laboratory 
abnormalities reported as AEs by the Investigator should not be deemed NCS on the laboratory sheet. 
 
The Investigator is responsible for reviewing and signing all laboratory reports.  The signed clinical 
laboratory reports will serve as source documents. 
 
7.4.3 Prescheduled or Elective Procedures or Routinely Scheduled Treatments 
A prescheduled or elective procedure or a routinely scheduled treatment will not be considered an SAE, even 
if the patient is hospitalized; the Study Center must document all of the following: 
 
• 
The prescheduled or elective procedure or routinely scheduled treatment was scheduled (or was on a 
waiting list to be scheduled) prior to obtaining the patient’s consent to participate in the Study 
 
• 
The condition that required the prescheduled or elective procedure or routinely scheduled treatment 
was present before and did not worsen or progress in the opinion of the Investigator between the 
patient’s consent to participate in the Study and the timing of the procedure or treatment 
 
• 
The prescheduled or elective procedure or routinely scheduled treatment is the sole reason for the 
intervention or hospital admission 
 
7.4.4 Dosing Errors 

 
 
 
 
42 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Study Drug (ISIS 304801 or placebo) errors should be documented as Protocol Deviations.  A brief 
description should be provided in the deviation, including whether the patient was symptomatic (list 
symptoms) or asymptomatic, and the event accidental or intentional. Dosing details should be captured on the 
Dosing Case Report Form.  If the patient takes a dose of Study Drug (ISIS 304801 or placebo) that exceeds 
protocol specifications and the patient is symptomatic, then the symptom(s) should be documented as an AE 
and be reported per Section 7.2. 
 
Should an overdose occur, the Investigator or designee should refer to the Guidance to Investigator’s section 
of the Investigator’s Brochure and contact Ionis within 24 hours. 
 
7.5 Safety Monitoring Rules 
In addition to the standard monitoring of clinical safety parameters, the following guidelines are provided for 
the monitoring of selected parameters chosen based on preclinical and clinical observations. For the purposes 
of safety monitoring baseline is defined as the average of Day 1 pre-dose assessment and the last 
measurement prior to Day 1. 
 
Confirmation Guidance: At any time during the Study (Treatment or Post-Treatment Periods), the initial 
clinical laboratory results meeting the safety monitoring criteria presented below must be confirmed by 
performing measurements (ideally in the same laboratory that performed the initial measurement) on new 
specimens.  All new specimen collections should take place as soon as possible (ideally within 3 days of the 
initial collection).  For stopping rules, if the initial laboratory result is observed during the Treatment Period, 
the results from the retest must be available prior to administering the next dose of Study Drug (ISIS 304801 
or placebo). 
 
Re-dosing Guidance:  Patients with initial laboratory test values that reach a stopping rule must not be re-
dosed until the re-test results are available.  In general, patients who do not meet the stopping rules based 
upon retest may continue dosing.  However, the Investigator will decide whether additional close monitoring 
of the patient is appropriate.  If any of the stopping criteria described below are met below and are confirmed, 
the patient will be permanently discontinued from further treatment with Study Drug (ISIS 304801 or 
placebo), evaluated fully as outlined below and will be entered into the post-treatment evaluation portion of 
the study.  Consultation will be conducted between the Investigator and the Ionis Medical Advisor as needed. 
 
7.5.1 Safety Monitoring Rules for Liver Chemistry Tests 
The following rules are adapted from the draft guidance for industry, “Drug-Induced Liver Injury: 
Premarketing Clinical Evaluation,” issued by the U.S. Department of Health and Human Services, Food and 
Drug Administration, July 2009. For a definition of baseline please refer to guidance above. 
 
For patients with Baseline ALT or AST below 2 x ULN 
In the event of an ALT or AST measurement that is >3 x ULN (or the greater of 2 x baseline value or 3 x 
ULN if the baseline value was >ULN) at any time during the Study (Treatment or Post-Treatment Period), the 
initial measurement(s) should be confirmed as described above.  Additional, confirmatory measurements 
should also be performed if ALT or AST levels increase to 5 x ULN. 
 

 
 
 
 
43 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
For patients with baseline ALT or AST between ≥2 and <3 x ULN 
In the event of an ALT or AST measurement that is 2 x the baseline level any time during the study 
(Treatment or Post-Treatment Period), the initial measurement(s) should be confirmed as described above. 
Similarly, confirmatory measurements should also be performed if ALT or AST levels increase to 5 x ULN. 
 
Frequency of Repeat Measurements:  Patients with confirmed ALT or AST levels that are continuing to rise 
should have their liver chemistry tests (ALT, AST, ALP, INR and total bilirubin) retested at least bi-monthly 
until levels stabilize and begin to recover (ALT and AST levels become ≤1.2 x ULN or 1.2 x baseline value). 
 
Further Investigation into Liver Chemistry Elevations: For patients with confirmed ALT or AST levels >3 x 
ULN [or the greater of 2 x baseline value or 3 x ULN if the baseline value was >ULN], the following 
evaluations should be performed: 
1. Obtain a more detailed history of symptoms and prior and concurrent diseases 
2. Obtain further history for concomitant drug use (including nonprescription medications, herbal and 
dietary supplement preparations), alcohol use, recreational drug use, and special diets 
3. Obtain a history for exposure to environmental chemical agents and travel 
4. Serology for viral hepatitis (HAV IgM, HBsAg, HCV antibody, CMV IgM, and EBV antibody panel) 
5. Serology for autoimmune hepatitis (e.g., antinuclear antibody (ANA)) 
 
Additional liver evaluations, including gastroenterology/hepatology consultations, hepatic computed 
tomography (CT) or MRI scans, may be performed at the discretion of the Investigator, with consultation with 
the Sponsor Medical Monitor as needed.  Repetition of the above evaluations should be considered if a 
patient’s ALT and/or AST levels reach 5 x ULN. 
 
7.5.2 Safety Monitoring Rules for Renal Function 
Patients with confirmed persistent changes that are observed over 2 consecutive visits, at least 7 days apart, 
for the criterion below should be retested every two weeks with serum creatinine and urine chemistries until 
creatinine and P/C ratio stabilize: 
 
• 
P/C ratio change from baseline > 50% and ≥ 1.5 ULN 
 
7.5.3 Safety Monitoring Rules for Platelet Count Results 
Actions to be taken in the event of reduced platelet count are shown in Table 3 in Section 7.6.3. 
 
7.5.4 Safety Monitoring for Minor Bleeding Events 
Minor bleeding events are those that do not fulfill the criteria for major bleeding or clinically relevant, non-
major bleeding events (which are defined in Section 7.6.3), for example excess bruising, petechiae, gingival 
bleeding on brushing teeth.  If a minor bleeding event occurs, additional testing of coagulation parameters 
(aPTT, PT, INR) and platelet count should be performed, and the Investigator will consult with the Sponsor 
Medical Monitor as needed. 
 
7.5.5 Safety Monitoring for Constitutional Symptoms 
Patients will be instructed to promptly report any signs of symptoms of fever or constitutional symptoms that 
may arise during the study and the Investigator should closely evaluate all potential causes, including 

 
 
 
 
44 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
concomitant illness.  If patients experience persistent constitutional symptoms, the Investigator will determine 
whether additional monitoring or laboratory tests are required, with consultation with the Sponsor Medical 
Monitor as needed. 
 
7.5.6 Safety Monitoring for LDL-C Elevations 
Beginning at Week 16 (after which treatment is unblinded), laboratory alerts will be in place to notify the 
Investigator if a patient has an LDL-C > 160 mg/dL on two consecutive visits.  If this occurs, the Investigator 
will consider initiation or adjustment of treatment to lower LDL-C according to published guidelines (e.g., 
initiate statin therapy, increase the statin dose for patients who are already on treatment, add ezetimibe if on 
maximal statin therapy)52. 
 
7.5.7 Safety Monitoring Rule for Documented Severe Hypoglycemia  
Classification of Hypoglycemia  
1. Alert value for hypoglycemia  
≤70 mg/dL (≤3.9 mmol/L) plasma concentration  
 
2. Severe hypoglycemia  
Requires assistance of another person to actively administer carbohydrates, glucagon, or take other 
corrective actions. Plasma glucose concentrations may not be available during an event. Neurological 
recovery following plasma glucose levels returning to normal is considered sufficient evidence that an 
event was induced by low plasma glucose concentration. 
 
3. Documented symptomatic hypoglycemia  
Typical hypoglycemia symptoms accompanied by measured plasma glucose ≤70 mg/dL (≤3.9 
mmol/L). 
 
4. Asymptomatic hypoglycemia  
Not accompanied by typical hypoglycemia symptoms but with measured plasma glucose ≤70 mg/dL 
(≤3.9 mmol/L). 
 
5. Probable symptomatic hypoglycemia  
Typical hypoglycemia symptoms not accompanied by plasma glucose determination but likely caused 
by plasma glucose ≤70 mg/dL (≤3.9 mmol/L). 
 
A documented severe hypoglycemic event is defined as one in which the patient requires assistance of 
another person to obtain treatment for the event and has a plasma glucose level ≤70 mg/dL (≤3.9 mmol/L). 
The rescue treatment of hypoglycemia may include IV glucose or buccal or intramuscular glucagon. The 
definition of severe symptomatic hypoglycemia includes all episodes in which neurological impairment was 
severe enough to prevent self-treatment and which were thus thought to place patients at risk for injury to 
themselves or others. Note that “requires assistance” means that the patient could not help himself or herself. 
Someone being kind that assists spontaneously the patient when not necessary does not qualify as “requires 
assistance.” Severe hypoglycemia will be qualified as a SAE only if it fulfills SAE criteria.  
 

 
 
 
 
45 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
If a patient presents with symptoms of hypoglycemia, the Investigator will need to take immediate action to 
confirm the patient’s glucose level and treat the patient accordingly. Patients must be instructed on the 
monitoring and management of hypoglycemic episodes at the Baseline Visit.  Instructions should be provided 
to all patients on the appropriate use of a glucose meter. The experience of hypoglycemia may vary greatly 
from patient to patient.  However, there are certain classical signs and symptoms, of which patients should be 
aware as a clue that their blood glucose may be low. Common symptoms include headache, heart pounding, 
confusion, disorientation, numbness or tingling, pale skin, shakiness or tremulousness, increased appetite, 
anxiousness or nervousness, lightheadedness or dizziness, sweating, and weakness.  Many of these symptoms 
are listed in the diary provided to patients.  These diaries will be used only to assist the investigator in 
assessing the event.  Appropriate source documentation should capture the necessary information on the event 
with the aid of the diaries.  Patients must be given adequate instructions on the use of the diaries.   
 
If patients suspect they might be having a hypoglycemia reaction, they should check their blood glucose using 
their meters as soon as possible, before treatment if possible, provided they feel it is safe to do so.  If there is 
doubt about safety they should treat the event first, using some sugar, milk, or juice for example, then obtain 
and record a blood glucose value as soon as possible thereafter.  The time and nature of treatment should be 
noted, and especially if any blood glucose result was before or after treatment.  It would be helpful for the 
patient to note if a contributory factor (eg, missed or reduced meals, unaccustomed physical activity) occurred 
earlier in the day of the event.   
 
Doses of insulin and sulfonylureas may be reduced at the Investigator’s discretion for hypoglycemia.  Doses 
of other diabetes medications (e.g. metformin) should not be changed. 
 
7.5.8 Monitoring Rule for Hyperglycemia  
Assessment for rescue will be performed at each “visit” (including both telephone contacts and in-person 
visits).  Routine fasting SMPG and central lab alerts on FPG (and HbA1c after week 12) are set up to ensure 
that glycemic parameters remain under predefined thresholds values. If one fasting SMPG value exceeds the 
specific glycemic limit on one day, the patient checks it again during the two following days. If all the values 
in three consecutive days exceed the specific limit, the patient should contact the investigator and a central 
laboratory FPG measurement (and HbA1c after week 12) is performed. 
 
The threshold values are defined as follows, depending on study period: 
• 
From baseline visit to week 12  (including value at week 12 ): FPG >270 mg/dL (15.0 mmol/L) 
• 
From week 12   to week 24  (including value at week 24 ): FPG >240 mg/dL (13.3 mmol/L) or 
HbA1c>9% (for patients with baseline HbA1c <8%) and HbA1c increase of more than 1% from 
baseline (for patients with baseline HbA1c ≥8%). 
• 
From week 24   up to week 68 : HbA1c >9% (for patients with baseline HbA1c <8%) and HbA1c 
increase of more than 1% from baseline (for patients with baseline HbA1c ≥8%).   
 
In case of FPG/HbA1c above the threshold values, the investigator should ensure that no reasonable 
explanation exists for insufficient glucose control and in particular that: 
• 
Plasma glucose was actually measured in the fasting condition (i.e. after at least 10 hours fast) 

 
 
 
 
46 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
• 
Absence of intercurrent disease which may jeopardize glycemic control.  In case of an emergency 
(e.g., surgery, infection), the investigator can take appropriate measures for glycemic control.  If the 
measure does not exceed 7 days, then it will not be considered a rescue.  If the measure lasts beyond 7 
days then it will be treated as a rescue.   
• 
Compliance to treatment is appropriate 
• 
Compliance to diet and lifestyle is appropriate 
 
If any of the above can reasonably explain the insufficient glycemic control, the investigator should undertake 
appropriate action, i.e. 
• 
Investigation and treatment of intercurrent disease (to be reported in AE/concomitant medication 
parts of the e-CRF), 
• 
Stress on the absolute need to be compliant to treatment, 
• 
Organize a specific interview with a Registered Dietician or other qualified nutrition professional and 
stress on the absolute need to be compliant to diet and lifestyle recommendations, 
• 
Schedule a FPG/HbA1c assessment at the next visit. 
 
If none from the above-mentioned reason can be found, or if appropriate action fails to decrease FPG/HbA1c 
under the threshold values, rescue medication may be introduced at the investigator discretion and according 
to local guidelines.  
 
Any patient who discontinues early from the placebo-controlled or OLE periods will be encouraged to attend 
a final in-person follow-up visit (Week 80 visit assessments per Appendix A) approximately 12 weeks after 
their last dose of Study Drug.  If the patient declines or is unable to participate in the above, a home nurse 
visit for safety/efficacy labs.  
 
If possible, an in-person visit for all assessments for primary and secondary efficacy and safety parameters 
planned in final primary endpoint assessment visit will be performed before adding the rescue medication. If 
an in-person visit cannot be conducted in a timely fashion, a home nurse visit for safety/efficacy labs will be 
attempted.  If rescue medication is required, patients will continue the study treatment and remain in the 
study, although planned tests that will be affected by the use of rescue medication may be cancelled.  
 
 
7.5.9 Acute Pancreatitis 
If a patient has an episode of acute pancreatitis, dosing with study drug should be suspended temporarily until 
the patient is clinically stable.  The suitability of the patient for continued dosing and the need for any 
modification to the treatment schedule will be determined by the Investigator, with consultation with the 
Sponsor Medical Monitor as needed. 
 
7.6 Stopping Rules 
For the purposes of stopping rules, baseline is defined as the average of Day 1 pre-dose assessment and the 
last measurement prior to Day 1.   Prior to discontinuing study drug in any patient, the Investigator will 
consult with the Sponsor Medical Monitor when possible. 
 

 
 
 
 
47 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
7.6.1 Stopping Rules for Liver Chemistry Elevations 
In the event of confirmed laboratory results meeting the following criteria, and the event is without an 
alternative explanation as determined by the Investigator, dosing of a patient with Study Drug 
(ISIS 304801) will be stopped permanently: 
1. ALT or AST > 8 x ULN, which is confirmed 
2. ALT or AST > 5 x ULN, which is confirmed and persists for ≥ 2 weeks   
3. ALT or AST > 3 x ULN (or the greater of 2 x baseline value or 3 x ULN if the baseline value was > 
ULN), which is confirmed and total bilirubin > 2 x ULN or INR > 1.5 
4. ALT or AST > 3 x ULN (or the greater of 2 x baseline value or 3 x ULN if the baseline value was > 
ULN), which is confirmed, and the new appearance (i.e., onset coincides with the changes in hepatic 
enzymes) of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, or 
eosinophilia (> ULN) felt by the Investigator to be potentially related to hepatic inflammation 
 
7.6.2 Stopping Rules for Renal Function Test Results 
In the event of persistent changes that are observed over 2 consecutive weeks, for any of the criteria below, 
dosing of a patient with Study Drug (ISIS 304801 or placebo) may be stopped temporarily: 
1. Quantitative total urine protein measurement of > 3.5 g/24 hours 
2. Estimated creatinine clearance calculated according to the formula of Cockcroft and Gault ≤ 40 
mL/min that is confirmed by a 24 hour urine collection 
The possible dosing re-initiation or follow-up schedule for any events meeting either of these criteria will be 
determined by the Investigator, in consultation with the Sponsor Medical Monitor as needed. 
 
7.6.3 Stopping Rule for Platelet Count Results 
In the event of a confirmed platelet count less than 75,000/mm3 that is associated with major bleeding or 
clinically relevant non-major bleeding (defined below53), dosing of a patient with study drug (ISIS 304801 or 
placebo) will be stopped permanently.  The follow-up schedule for any events meeting this stopping criterion 
will be determined by the Investigator in consultation with the Sponsor Medical Monitor as needed. 
 
In the event of any platelet count less than 25,000/mm3, or a platelet count less than 50,000/mm3 that occurs 
while the patient is on dosing at 300 mg every two weeks or 150 mg every week then dosing of a patient with 
Study Drug (ISIS 304801 or placebo) will be stopped permanently. Platelet count will be monitored daily 
until 2 successive values show improvement then monitored every 2-3 days until 2 successive values are > 
75kmm3, then monitored every 1 week.   
 
Administration of steroids is recommended for patients whose platelet count is less than ≤ 50K/mm3.  
Recovery in platelet count may be accelerated by administration of high dose steroids.  Treatment guidelines 
for immune thrombocytopenia (Provan et al.; 2010) recommend Dexamethasone 40 mg daily for 4 days every 
2-4 wk for 1-4 cycles; Prednis(ol)one 0.5-2 mg/kg/d for 2-4 weeks then taper; or Methylprednisolone 30 
mg/kg/day for 7 days (note: may require continuation with oral steroids after methyl prednisolone). 
 
In the event of a confirmed platelet count less than 75,000/mm3, and in the absence of major bleeding or 
clinically relevant non-major bleeding (defined below53), dosing of a patient with study drug (ISIS 304801 or 
placebo) will be suspended temporarily until the platelet count has recovered to ≥100,000/mm3.  If dosing is 
continued it should be at a reduced dose frequency of 300 mg every two weeks or a reduced dose of 150 mg 
per week. The suitability of the patient for continued dosing and the need for any modification to treatment 

 
 
 
 
48 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
schedule (refer to Section 7.7) will be determined by the Investigator (in consultation with the Ionis Medical 
Advisor as needed) and will be based on factors such as the original rate of decline in the patient’s platelet 
count, whether any bleeding events were experienced by the patient, and the speed of recovery of platelet 
count upon holding of dosing. 
 
If after the first dosing re-challenge the platelet count again falls below 50,000/mm3, then dosing of the 
patient must be held until the platelet count again returns to at least 100,000/mm3.  The suitability of the 
patient for continued dosing and the need for any further modification to treatment schedule or dose (refer to 
Section 7.7) will be re-examined by the Investigator (in consultation with the Sponsor Medical Monitor as 
needed) based on (at least) the factors mentioned above. 
 
If after the second re-challenge the platelet count falls below 50,000/mm3 and is subsequently confirmed (see 
Section 7.5), dosing with Study Drug will be stopped permanently.  The follow-up schedule for any events 
meeting this stopping criterion will be determined by the Investigator (in consultation with the Sponsor 
Medical Monitor as needed). 
 
Following rechallenge platelet count should be tested every week until count is stable. 
 
Any unreportable platelet count result must be rechecked and determined not to have met a stopping rule 
before dosing can continue.  
 
If there is no reportable platelet count within 14 days of the last platelet count, the investigator will contact the 
patient to hold dosing until a new platelet count is obtained and reviewed. 
 
Definition of Major Bleeding Events53: 
1. Fatal bleeding, and/or 
2. Symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, 
retroperitoneal, intraarterial or pericardial, or intramuscular with compartment syndrome, and/or 
3. Bleeding causing a fall in hemoglobin level of 20.0 g/L (1.24 mmol/L) or more within 24 hours, or 
leading to transfusion of two or more units of whole or red cells 
 
Definition of Clinically Relevant, Non-Major Bleeding Events53: 
1. Multiple-source bleeding 
2. Spontaneous hematoma >25 cm2 
3. Excessive wound hematoma (not injection site related) 
4. Macroscopic hematuria (spontaneous or lasting >24 hours if associated with an intervention) 
5. Spontaneous rectal bleeding; epistaxis, gingival bleeding, hemoptysis, hematemesis 
6. Bleeding after venipuncture for >5 minutes 
Actions in Patients With Low Platelet Count  
Platelet count 
Dosing Rules 
Monitoring Rules 
Normal range, 
>140K/mm³  
No action  
Monitor every week unless otherwise 
specified 
 
 

 
 
 
 
49 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
100K/mm³ - 140K/mm³   
Weekly 300 mg study drug 
administration 
Monitor every 1 week unless otherwise 
specified   
 
Obtain additional lab tests if 2 
occurrences of platelet count 100 K/mm³ 
-- 140K/mm³ or 1 occurrence of platelet 
count ≤ 100K/mm³** 
75K/mm³  - 100K/ mm³   
Permanently reduce dose 
frequency to 300 mg every 2 
weeks   
Monitor every 1week unless otherwise 
specified   
 
Obtain additional lab tests if 1 occurrence 
of platelet count ≤ 100K/mm³** 
50K/mm³ - 75K/mm³   
If occurs while on dose of 300 
mg every 2 weeks or 150 mg 
every week then permanently 
discontinue Study Drug, 
otherwise dose pause. 
 
When platelet count returns to 
>100K/mm3 restart dosing at 
dose frequency of 300 mg every 
2 weeks or 150 mg weekly1 (in 
consultation with the Ionis 
Medical Advisor as needed). 
 
Monitor every 2-3 days until two 
successive values are > 75K/mm³ then 
monitor every 1 week 
 
Consider discontinuation of 
antiplatelet/agents/NSAIDS/anticoagulant 
medication  
 
Obtain additional lab tests if 1 occurrence 
of platelet count ≤ 100K/mm³** 
≤ 50 K/mm³ 
Permanently discontinue Study 
Drug  
Monitor daily until 2 successive values 
show improvement, then monitor every 
2-3 days until 2 successive values are > 
75K/ mm³.  
 
Patient should be evaluated by a 
hematologist to provide diagnostic and 
therapeutic management 
 
Steroids recommended*.  It is strongly 
recommended that, unless the patient 
has a medical contraindication to 
receiving glucocorticoids, the patient 
receives glucocorticoid therapy to 
reverse the platelet decline. 
 
Monitor triglyceride levels weekly and 
continue AE monitoring during steroid 
therapy. 
 
Discontinue antiplatelet 
agents/NSAIDS/anticoagulant medication 
while platelet count <50K/mm³ if 

 
 
 
 
50 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
possible  
 
Obtain additional lab tests if 1 occurrence 
of platelet count ≤ 100K/mm³** 
*Recovery in platelet count may be accelerated by administration of high dose steroids. Treatment guidelines for 
immune thrombocytopenia (Provan et al. 2010) recommend Dexamethasone 40 mg daily for 4 days every 2-4 weeks for 
1-4 cycles; Prednis(ol)one 0.5-2 mg/kg/d for 2-4 weeks then taper; or Methylprednisolone 30 mg/kg/day for 7 days 
(note: may require continuation with oral steroids after methyl prednisolone) 
 
**See Appendix J 
 
7.6.4 Stopping Rule for Documented Severe Hypoglycemia 
In the event of a first instance of documented severe hypoglycemia, dosing of a patient with study drug 
(ISIS 304801) will be suspended temporarily. The need to adjust the background medication and the 
suitability of the patient for continued dosing will be determined by the Investigator in (in consultation with 
the Sponsor Medical Monitor as needed).  In the event of a second instance of documented severe 
hypoglycemia, after a re-challenge, dosing of a patient with study drug (ISIS 304801) will be stopped 
permanently. 
 
7.7 Adjustment of Dose and/or Treatment Schedule 
Dose adjustments for platelet count reduction must be made in accordance with Section 7.6.3 and Table  
(above). 
 
Other dose adjustments, including dose interruptions, and/or decreasing the dose frequency will be allowed 
for safety or tolerability, after consultation with the Ionis Medical Advisor if possible.  Dose adjustments 
should not occur unless absolutely necessary prior to the primary analysis time point (Week 12). 
 
7.8 Withdrawal Criteria 
1. Withdrawal of consent.  A subject wishes to withdraw from the study as stated in the informed 
consent (all subjects reserve the right to withdraw from the study without prejudice). 
2. Adverse event (or SAE).  The patient develops laboratory test abnormalities that meet any of the 
stopping rules listed above, or any other adverse event that in the investigator’s opinion 
necessitates withdrawal from the study. 
3. Investigator judgment.  An investigator feels it is in the subject's best interest to terminate 
participation. The detailed reasoning behind this decision will be documented. 
4. Pregnancy. 
5. Ineligibility.  Includes study entry criteria violation. 
6. Significant Protocol Deviation. Includes subject noncompliance or start of an unacceptable 
concomitant medication. 
 
The reason for discontinuation of study treatment must be recorded in the electronic case report form (eCRF) 
and source documentation. All efforts will be made to complete and report the observations as thoroughly as 
possible up to the date of withdrawal.  All information, including the reason for withdrawal from study, must 
be recorded in the eCRF. 
 

 
 
 
 
51 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Any patient who withdraws consent to participate in the study will be removed from further treatment and 
study observation immediately upon the date of request.  These patients should be encouraged to complete the 
early termination study procedures and observations at the time of withdrawal. For patients withdrawn for 
reasons other than withdrawal of consent, every effort should be made to complete the early termination study 
procedures and observations at the time of withdrawal. 
 
7.9 Rationale for Subject Selection 
The primary anticipated benefit of ISIS 304801 is TG reduction.  The severity of hypertriglyceridemia in 
patients with lipodystrophy is quite variable.  In this study, we are targeting the patient population to those 
with severe hypertriglyceridemia (>500 mg/dL) who are not only at increased risk for cardiovascular disease, 
but also at risk for acute pancreatitis.  Patients with generalized lipodystrophy already have available a highly 
effective, approved therapy: leptin replacement.  However, there are currently no approved therapies for 
patients with partial lipodystrophy.  Hence, the population of partial lipodystrophy patients with severe 
hypertriglyceridemia has substantial unmet medical need, and has the greatest benefit to risk ratio from 
participation in this study.  Based on our experience, we expect that the majority of subjects who enroll in this 
study will be female as females typically present with greater metabolic derangement.  In addition, we 
anticipate that the majority of subjects will be Caucasian based on the demographics of partial lipodystrophy.  
Patients under 18 years of age are excluded as severe metabolic complications of partial lipodystrophy 
typically develop in adulthood, and there currently is no safety data for ISIS 304801 in children.  Because 
there is a prospect for direct benefit, non-institutionalized adults who are unable to give informed consent but 
are considered able to comply with the study demands, will be eligible.  If we enroll patients who are unable 
to provide their own consent, we will follow the procedures specified in NIH SOP 14E (“Research Involving 
Adults Who Are or May Be Unable to Consent”).  If the study team has a concern that an adult patient may be 
unable to consent, the NIH Ability to Consent Assessment Team will be contacted to independently assess the 
subject’s ability to provide informed consent.  If the NIH Ability to Consent Assessment Team (ACAT) 
determines that the subject is not able to consent, an appropriate surrogate (assessed by the NIH ACAT) will 
be assigned. Consent for research participation will then be obtained from either the surrogate or a legally 
authorized representative. Individuals designated as durable power of attorney (DPA) for health care or other 
valid advanced directive, or court-appointed guardians are accepted as legally authorized representatives.  If 
after study enrollment, the patient is unable to comply with the protocol demands, they will be withdrawn 
from the protocol.   
 
7.10 Risks/Benefits Analysis including Considerations of Alternatives to Participation 
7.10.1 Benefits 
This study is characterized as greater than minimal risk with a prospect of direct benefit.  The primary 
anticipated benefit to patients is reduction in TG level, which may reduce the risk of cardiovascular disease 
and pancreatitis.  All clinical trials of ISIS 304801 have shown very large and clinically meaningful 
reductions in fasting apoC-III and TG (~80% and 70%, respectively, mean reduction from baseline with 
300 mg dose) with a very high degree of consistency of response between the different patient groups.  This 
includes healthy volunteers, patients with moderate to severe hypertriglyceridemia not on background TG-
lowering therapy, patients with moderate to severe hypertriglyceridemia on a background of stable fibrate 
therapy, patients with Familial Chylomicronemia Syndrome (FCS), and patients with hypertriglyceridemia 
and T2DM.  In 2 subjects, triglycerides decreased from ~1000 mg/dL at the end of the placebo controlled 
phase, to <150 mg/dL after 4 months of open-label drug, and were maintained in that range thereafter. In 1 
subject, triglycerides decreased from >500 at study entry to <150 at the end of the placebo controlled phase, 
and were maintained in that range thereafter.  In the 3 subjects who have completed the placebo-controlled 
period, insulin sensitivity increased on open label drug, and hemoglobin A1c decreased in parallel (by ~1%).   
Two subjects have not yet completed the placebo controlled phase.  Thus, based on current data, the drug 
appears highly effective in controlling triglycerides, improving insulin sensitivity, and lowering A1c.   

 
 
 
 
52 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Patients may also experience benefits in diabetes control.  Small studies of ISIS 304801 have shown 
significant decreases in glycated albumin, fructosamine, and/or HbA1c, and trends towards improvement in 
insulin sensitivity. 
 
The additional 12 months of open label extension is justified in subjects who have manifested ≥ 50% 
improvement in triglycerides on study drug because of the prospect of direct clinical benefit for individual 
subjects as well as the prospect of acquiring additional generalizable knowledge about the potential risks and 
benefits of this treatment in the patient population. 
 
7.10.2 Risks/Discomforts 
1. General:  Some patients may find the time needed to complete the research studies an inconvenience 
in their routine lives. 
 
2. ISIS 304801: A detailed discussion of side effects of ISIS 304801 is given in the Background section 
(2.3.3 and 2.3.4) of the protocol.  Briefly, pre-clinical studies of ISIS 304801 showed a 
proinflammatory response in rodents and monkeys and complement activation and reductions in 
platelet counts in the monkey. In clinical studies conducted to date, ISIS 304801 has been well 
tolerated and has shown a favorable safety profile, with no effects on renal or hepatic function or 
markers. There has been no clinical or laboratory evidence of drug-drug interactions. Phase 2 studies 
of ISIS 304801 have shown mild decreases of platelet count that recovered in the post-treatment 
period and was not associated with platelet-related adverse events. The most frequently observed AEs 
with ISIS 304801 were local reactions (pain, tenderness, erythema, pruritus or swelling) at the 
injection site. Injection site reactions persisting for at least 2 days were infrequent (~15% of 
injections), were almost always mild, resolved spontaneously, were non-progressive, and were not 
associated with systemic sequelae. 
 
Thrombocytopenia: Phase 2 studies of ISIS 304801 have shown mild decreases of platelet count that 
recovered in the post-treatment period and was not associated with platelet-related adverse events. In 
Phase 3 studies of ISIS 304801 in patients with familial chylomicronemia, two of 56 subjects 
experienced SUSARs of severe low platelet count, with nadirs of 17,000 and 9,000/mm3. Neither 
patient experienced bleeding during these events. No patient has developed severe thrombocytopenia 
in this study or in the multicenter industry sponsored study in partial lipodystrophy.  The one patient 
in the NIH study who developed platelets <100K did so in the context of pancytopenia due to viral 
bone marrow suppression, which promptly rebounded to the normal range without intervention.  
Adverse events possibly associated with the study drug have included systemic inflammatory 
reactions, the current case of heart failure, and the case of pancreatitis reported separately to the IRB 
in this study.  Due to N of 1 cases and lack of biological plausibility, it remains uncertain whether 
these events are causally related to study drug.   
 
Anaphylaxis: One patient with partial lipodystrophy enrolled in a drug-company sponsored study of 
ISIS 304801 experienced a SUSAR of anaphylactic reaction during the open label extension phase of 
the study, and recovered after standard therapy (fluids, antihistamines, steroids).  The study drug was 
permanently discontinued in this patient after this event. 
 

 
 
 
 
53 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Heart failure: One patient with partial lipodystrophy enrolled in the NIH study of ISIS 304801 
experienced a SUSAR of heart failure complicated by ascites during the 2nd open label extension 
phase of the study.  The subject also experienced pulmonary hypertension.  She was discharged home 
after an approximately two-week hospitalization and prescribed oral Lasix 40 mg twice a day (for 
continued diuresis) and close follow-up with her local cardiologist.   Heart failure has not been 
observed in other patients (or animals) who have taken this drug, but a causal relationship with the 
study drug could not be ruled out so the study drug was permanently discontinued in this patient after 
this event.  
 
3. Physical examination/Anthropometric measurements:  These tests are similar to a typical examination 
in a doctor’s office and do not present any special risk. 
 
4. Self-monitoring of blood glucose: Home blood glucose monitoring will be performed at a frequency 
approximating standard of care for patients with type 2 diabetes, and thus should present no added 
inconvenience or risk to patients participating in this study. 
 
5. Blood Sampling:  Peripheral blood draws (venipuncture) performed during this study for research will 
not exceed 10.5 mL/kg, or 550 mL (whichever is smaller) per 8-week period for adults.   Patients may 
experience some discomfort at the site of the needle entry, and there is a risk of bruising at the site.  
There is a remote risk of fainting or local infection.   
 
6. DEXA: The effective radiation dose with total body DEXA scanning is 0.00003 rem.  This is much 
less than the average daily background radiation from natural sources, and is not thought to increase 
lifetime cancer risk.  Subjects in this study will have up to four DEXA scans (total radiation dose 
0.00012 rem) per year. 
 
7. Glucose and Lipid Turnover: The stable isotopes 13C is not associated with any toxicity at the doses 
used in these studies 54.  Deuterium at the doses given may cause temporary dizziness.  This risk will 
be minimized by dividing the 2H2O dose into four aliquots, and by giving the doses at night while 
subjects lie in bed.  If subjects need to get out of bed (e.g. to use the bathroom) the patient will first sit 
upright in bed for a few minutes prior to standing, and a nurse will be available to supervise and 
assist.  Palmitate must be complexed to albumin prior to delivery, and thus carries the risks associated 
with use of human blood products.  To minimize exposure to human albumin, uniformly labeled 13C16 
palmitate will be used, permitting use of the minimum possible dose of this tracer. 
 
8. Euglycemic Hyperinsulinemic Clamp Study: In order to assess insulin sensitivity, patients will 
receive an intravenous infusion of insulin and – via a second intravenous access – increasing amounts 
of glucose to maintain euglycemia.  Insertion of the necessary intravenous lines may cause the above-
mentioned discomfort and a possible skin infection.  Insulin infusion can induce hypoglycemia and 
hypokalemia.  Either event is very unlikely, since patients undergo frequent blood glucose 
measurements and are constantly observed for the presence of hypoglycemic symptoms by an 
experienced nurse and/or physician.  However, in order to prevent complications, two patent, well-
functioning intravenous lines are required during this procedure.  A stat potassium will be measured 
at the end of the insulin infusion, and oral KCL 40 mEq will be given if potassium is less than 3.5. 

 
 
 
 
54 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
9. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Spectroscopy (MRS): While MR 
scanning is thought to be safe, the procedure may cause anxiety in some patients since current 
equipment used at the Clinical Center uses a closed tube. Adult patients will be offered sedatives such 
as Valium if they express worry about being in a closed space. No intravenous contrast will be used in 
these studies. The hand-grip exercise may produce mild fatigue. 
 
10. Lipoprotein lipase activity: The primary risk of lipase assays involving heparin infusion of 60 
units/kg is bleeding (in <0.1% of subjects).  Testing will not be performed in subjects at increased 
bleeding risk, including those with platelet counts, prothrombin time, and partial thromboplastin time 
outside the normal range within 48 hours of testing, those with history of recent peptic ulcer disease 
or gastrointestinal bleeding, or other bleeding diathesis.  This test also involves minor risks associated 
with intravenous line placement. 
 
11. Mixed meal: This test requires one IV, but no adverse effects are anticipated. 
 
12. Carotid intima-media thickness:  This is a non-invasive ultrasonographic test.  No adverse effects are 
anticipated. 
 
13. Hunger and pain questionnaires: Patients may find it a minor inconvenience to fill out the 
questionnaires, but no adverse effects are anticipated. 
 
14. Liver biopsy: Risks and discomforts of liver biopsy are as follows: 
a. Pain.  About 20% of persons who undergo a liver biopsy experience pain in the side of body 
over the liver after the biopsy.  This pain usually lasts from a few minutes to several hours 
and may require pain medication.  In rare cases, the pain lasts a day or two. 
b. Fainting.  About 2% of persons pass out due to vasovagal reaction after a liver biopsy.  This 
is unlikely to cause harm, as patients will be lying in bed during the biopsy.  Atropine will be 
given to reverse the vasovagal reaction if it occurs, and may be given prior to the biopsy in 
individuals prone to these reactions. 
c. Infection.  A rare complication of liver biopsy is infection that spreads to the rest of the body 
because the needle goes through skin that is not completely clean or sterile or goes through 
infected bile (as occurs in patients with gallstones sometimes).  Antibiotics can treat such 
infections. 
d. Biopsy of another organ.  In rare instances, the biopsy needle misses the liver and hits another 
internal organ, such as the lung, gallbladder, kidney, or intestine.  This complication can be 
avoided by carefully selecting the site for the liver biopsy and using ultrasound to identify 
exactly where the liver is and the best position for the biopsy.  Usually, the other organ is not 
damaged by the needle puncture; however, it is possible that surgery might be needed to 
repair the hole. The most important complication of liver biopsy is bleeding.  A small amount 
of bleeding probably occurs in many patients after liver biopsy, but the amount of bleeding is 
usually too small to be detected or felt.  Severe bleeding occurs in about one of every 1000 
liver biopsies.  Severe bleeding is most likely to occur in someone with cancer of the liver or 
with abnormal clotting studies, but bleeding can also occur in patients with mild forms of 

 
 
 
 
55 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
liver disease.  Most cases of severe bleeding stop on their own with bed rest and observation 
for several days in the hospital.  In rare instances, a blood transfusion or even surgery is 
needed to sew up the tiny hole in the liver made by the biopsy.  Very rarely, in less than one 
in 10,000 cases, death has occurred from bleeding after a liver biopsy. At the NIH Clinical 
Center, the Liver Diseases Branch has performed approximately 150 liver biopsies each year 
for the last 40 years.  During this time, three patients developed serious, life-threatening 
complications of biopsy (two in the early1990s and one in 2014).  The first patient, who had 
cirrhosis due to hepatitis C and advanced hepatocellular carcinoma, bled intraperitoneally 
from the liver biopsy and died after surgical attempts to stop the bleeding were unsuccessful.  
The second patient had Gaucher’s disease and advanced cirrhosis with severe coagulopathy 
and was treated with platelet transfusions and fresh frozen plasma to correct the bleeding 
tendency; he tolerated liver biopsy well and was discharged a day later, but then returned in 
shock with a severe intra-abdominal bleed, and died despite surgical attempts at stopping the 
bleeding. The third patient had a history of Pre-B cell ALL status-post bone marrow 
transplantation and chronic coagulopathy.  The patient was seen on consultation for concern 
of liver graft-versus-host disease and developed a severe intraperitoenal bleed after liver 
biopsy.  Despite multiple interventions, including transfusions, arterial embolization and 
exploratory laparotomy, bleeding could not be stopped and the patient died.  Subjects will be 
kept overnight in the Clinical Center after the liver biopsy with careful monitoring for any 
evidence of bleeding.  The percutaneous liver biopsy will not be performed if the platelet 
level is below 75 K/ul. 
  
e. Risks and discomforts of medications used during liver biopsy are as follows:  Three 
medications are often used during a liver biopsy:  Xylocaine to numb the skin, a sedative such 
as Versed (midazolam) to make subjects drowsy during the biopsy, and atropine if subjects 
have a tendency to faint.  All three medications are safe when given in the usual doses.  In 
rare instances, they can induce allergic reactions which can be a skin rash, itching, wheezing, 
an asthma attack, or even anaphylaxis - or allergic shock.  All of the allergic complications 
can and will be treated if they arise.  Xylocaine, when given in high doses can also cause 
heart blockage, seizures, coma, or even death; but, in the doses given in this study it has no 
obvious effect on the heartbeat.  Atropine can cause dryness of the eyes and mouth, difficulty 
focusing the eyesight, constipation and difficulty passing urine.  All these side effects will 
disappear within a few hours.  Versed or Midazolam for sedation causes sleepiness and 
forgetfulness.  In high doses, it can cause over-sedation with coma and depression of 
breathing and even death.  This medication is given in small amounts with careful monitoring 
of sedation.  Standard medications and equipment used for conscious sedation will be 
available during the procedure.   
 
7.10.3 Alternatives to participation 
Participation in clinical trials is completely voluntary.  Refusal to participate will not affect a subject's ability 
to participate in other studies at NIH or elsewhere. 
 

 
 
 
 
56 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
7.11 Financial Compensation 
 All subjects will receive financial compensation for their time per Clinical Center guidelines for on-site 
visits, and additional compensation will be provided for specific procedures based on inconvenience units.  
See Appendix E.  There will be no compensation for the additional 12 month extended open-label period.   
 
7.12 Consent Procedures 
Written consent will be obtained at the first inpatient visit from each subject after detailed explanations of the 
planned procedures by the principal or an associated investigator (as listed on face sheet). The consent process 
will take place prior to any study procedures, however, the research team will talk with the subjects prior to 
coming to NIH to determine eligibility and to provide dietary recommendations.  The current 
NIDDK/NIAMS IRB-approved informed consent document will be signed by the subject and the Investigator.  
A witness will additionally sign the document to attest only to the validity of the signature of the subject, not 
the validity or quality of the consent.  A copy of the consent will be given to the subject for future reference. 
The signed documents will be sent to the Medical Records Department for placement in the subject's 
permanent CC medical record.  The consent process will additionally be documented in the electronic medical 
record (CRIS).   
 
We do not plan or anticipate the enrollment of non-English speaking subjects. However, they are not excluded 
from participation either. If there is unexpected enrollment of a research participant for which there is no 
translated extant IRB-approved consent document, the Principal Investigator and/or those authorized to obtain 
informed consent will use the short form consent process as described in MAS Policy M77-2, NIH SOP 12, 
45 CFR 46.117 (b), and 21 CFR 50.27 (b).  The summary that will be used is the English version of the extant 
IRB-approved consent document. We request prospective IRB approval of the use of the short form consent 
process for up to a maximum of 5 requests (either for individual participants or families of participants) in a 
given language, and will notify the IRB at the time of continuing review of the frequency of the use of the 
short form. Should we reach the threshold of 5 subjects and/or families speaking a single language, we will 
request an additional use of the short form from the IRB and will notify the Board that we plan to have any 
consent documents frequently used with that population translated into the language(s) they speak. 
 
Subjects have the right to withdraw participation from this protocol at any time.   
 
7.13 Research Use, Storage and Disposition of Human Subjects’ Samples and Data 
For future reference and potential use, we will store all samples (blood or fluids) in our locked freezers for an 
unlimited period of time. Samples will be labeled with coded identifiers linked to patient identity only via a 
secured database. Research records and data with personal identifiers will be stored in our locked offices, the 
medical record department, and the electronic study database. The electronic study database will be 
maintained by Ionis Pharmaceuticals.  Representatives of Ionis Pharmaceuticals will have access to research 
records and data with personal identifiers only when the representative is physically present in the NIH 
Medical Records department.  The electronic study database will not contain any personal identifiers, 
although it will contain dates on which labs or tests are performed.  This material will additionally be 
protected by medical record and computer access procedures.  Access to records and data associated with 
personal information will be restricted to the Principal Investigator, Co-Investigators, study support staff, and 
NIH database support staff. 
 

 
 
 
 
57 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Stored samples and/or data may be sent to outside collaborating laboratories, or shared with other NIH 
collaborating investigators, to study questions related to lipodystrophy or its complications (including, for 
example: glucose metabolism, diabetes, obesity, weight, appetite, steatohepatitis, and lipid metabolism). 
Samples may be sent to outside commercial laboratories for analysis.  Samples and data sent to outside 
laboratories and collaborators for analysis and/or testing will contain only coded numbers, without personal 
identifiers. Tech Transfer agreements will be completed before the exchange of samples and/or data with 
outside collaborators. 
 
Subjects may request that unused samples be removed from our freezers and returned to the subject, or be 
destroyed.  If no such request is made, we will keep samples until they are completely used or no longer of 
scientific value, at which time they will be destroyed. We do not plan to destroy personal medical information 
or stored data. The Principal Investigator will report loss or destruction of data or samples to the 
NIDDK/NIAMS IRB.  
 
7.14 Collaborations 
Metabolomic studies of plasma and liver biopsy specimens will be conducted in collaboration with Dr. Elif 
Oral at University of Michigan.  Deidentified samples will be shipped to the University of Michigan under a 
Material Transfer Agreement.  Raw data from Dr. Oral will not be sent to us, but overall results will be 
shared.  
 
Collaboration has been established with Professor Stephen O’Rahilly in Cambridge, England.  Our direct 
physician contacts are Dr. Robert Semple and Dr. David Savage.  The purpose of this collaboration is to share 
coded de-identified clinical data and results collected from subjects enrolled under this protocol at NIH.  The 
Laboratory at Cambridge University will use the coded data and results, including laboratory, anthropometric, 
imaging and demographic data, to characterize the phenotype of patients affected by lipodystrophy and to 
study the association between phenotypes and causative genetic mutations, in order to better understand the 
pathogenesis and natural history of lipodystrophy, improve the diagnosis, and predict and assess response to 
treatment.  
 
Collaboration has been established with Abhimanyu Garg, MD at the University of Texas Southwestern.  This 
collaborator is a former associate principal investigator of our original leptin protocol, and is a world’s expert 
on syndromes of lipodystrophy.  The purpose of this agreement is to transfer coded de-identified metabolic 
and clinical data, including laboratory, anthropometric, imaging and demographic data, to characterize the 
phenotype of patients affected by lipodystrophy and to study the association between phenotypes and 
causative genetic mutations, in order to better understand the pathogenesis and natural history of this disease, 
improve the diagnosis, and predict and assess response to treatment.  
 
Collaboration has been established with Dr. Morey W. Haymond, a board-certified pediatric endocrinologist 
and Professor of Pediatrics and Medicine at Baylor College of Medicine.  Our direct site contact will be Shaji 
Chacko, Ph.D.   The purpose of the collaboration is to assist in the conduct of the clinical studies determining 
the rates of glucose production and gluconeogenesis in subjects with a variety of forms and severity of 
lipodystrophy. This will include the analysis of coded human subject samples and interpretation of the results. 
 

 
 
 
 
58 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Collaboration has been established with Robert E. Eckel, M.D. and Kimberley D. Bruce, Ph.D. are professors 
at the University of Colorado Anschutz Medical Campus.  The secondary study objective of this protocol was 
to explore the mechanism of action of apoC-III ASO by measuring the lipoprotein lipase (LPL) activity and 
lipoprotein particle distribution to evaluate if we can strengthen the connection between LPL activity and the 
metabolic disturbances which is an area that has not been researched.  Therefore, the pre- and 10 minutes 
post-heparin infusion samples collected on the 5 enrolled partial lipodystrophy patients who were treated with 
ApoC3 antisense oligonucleotide will be shared with the collaborators who will run LPL assays.  Samples 
will be coded and the collaborators will share the results of their analysis. 
 
Collaboration has been established with Katsuyuki Nakajima, Ph.D. and Dr. Masami Murakami, professor of 
Gunma University Graduate School of Medicine (Department of Clinical Laboratory Medicine) located in 
Maebashi, Gunma, Japan.  The collaborators are interested in determining 4 types of markers found in the 
plasma of patients with lipodystrophy.  These markers (or “assay systems”) were developed in Dr. 
Murakami’s laboratory and include: (1) LPL activity (post-heparin plasma) and mass, (2) HTGL 
activity (post-heparin plasma) and mass, (3) GPIHBP1 mass, and (4) GPIHBP1 autoantibody.   They will run 
the above stated assays using specimens collected before and after leptin treatment.  Research has shown that 
Leptin lowers triglycerides in these patients, and hence we would hypothesize that LPL and HTGL activity 
might be increased after leptin treatment.  Therefore, we will send to the collaborators deidentified plasma 
collected from the lipodystrophy patients to test this hypothesis. 
 
 
 

 
 
 
 
59 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix A:  Schedule of Study Procedures 
 
Study Period 
Pre-
Screen 
Screen 
Double-Blind   
Open Label Extension 
Post 
Treatment 
Study Week (from enrollment) 
-8 to -
2 
  
1 
4 
8 
  
Primary  
Endpoints 
  
  
   
Primary  
Endpoints 
36 
40 
48 
56 
64 
68 
74 
80 
  
  
  
  
  
12 
13 
16 
20 
24 
28 
32 
-1 
Study week (from start of open label 
extension) 
  
  
  
  
  
  
  
4 
8 
12 
16 
20 
24 
32 
40 
48 
52 
  
  
Inpatient Visits 
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Home Nurse visit** 
  
  
  
x 
x 
x 
x 
  
x 
x 
x 
  
x 
x 
x 
x 
x 
  
x 
  
Telephone contact 
  
  
  
x 
x 
x 
x 
  
x 
x 
x 
  
x 
x 
x 
x 
x 
  
x 
  
Inclusion/Exclusion Criteria 
x 
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Medical History Review 
x 
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Vital Signs/Weight/Height 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Physical Exam 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Waist Circumference 
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Skinfold measurements 
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
DEXA Scan 
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
  
Glucose and Lipid Turnover 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Euglycemic Hyperinsulinemic Clamp 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Mixed Meal Test 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Urinalysis & protein:creatinine ratio 
  
x 
  
x 
x 
 
x  
x 
x 
x 
x 
x 
  
x 
  
x 
  
x 
  
x 
Liver Biopsy 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
 
 
MRI/MRS liver/heart 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
  
Carotid intima-media thickness 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
  
12-Lead EKG 
x 
  
  
  
  
  
x 
  
  
  
x1 
  
  
  
  
  
x 
  
  

 
 
 
 
60 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Echocardiogram 
x 
  
  
  
  
  
x 
  
  
  
x1 
  
  
  
  
  
x 
  
  
Fasting Blood Draws 
Chemistry Panel 
  
x 
  
x 
x 
x  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
CBC w/diff* 
  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Serum lipid panel 
  
xx2 
  
x 
x 
x 
x  
xx2 
x 
x 
x 
xx2 
x 
x 
x 
x 
x 
xx2 
x 
xx2 
Apolipoprotein panel 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Coag (PTT, PT, INR) 
x 
  
x 
x 
x  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Hepatitis B, C, HIV 
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Troponin T 
  
x 
  
  
  
  
  
x  
  
  
  
x 
  
  
  
  
  
x 
  
  
Thyroid function (TSH, free T4) 
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
HbA1c 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
x 
x 
x 
  
x 
Plasma glucose 
  
x 
  
x 
x 
  
  
x 
x 
x 
  
x 
x 
x 
x 
x 
x 
x 
x 
x 
Insulin, c-peptide 
 
x 
 
 
 
 
 
x 
 
 
 
x 
 
 
 
 
 
x 
 
x 
hsCRP 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Lipoprotein particle size/# (NMR) 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Sedimentation rate 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Complement (C5a, Bb) 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Plasma PK ISIS 304801 serial 
sampling (peak and trough) 
  
  
x  
 x 
  
 x 
X3 
  
  
  
X3 
  
  
  
  
  
 x 
x  
x  
Single plasma PK  
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anti ISIS 304801 Antibodies 
  
  
x 
x 
x 
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
FSH (women only, if applicable) 
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Testosterone (women only) 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Serum pregnancy 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Free Fatty Acids 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Leptin 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Lipoprotein lipase activity 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Adiponectin 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Research serum/plasma 
  
x 
  
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 

 
 
 
 
61 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
7-point plasma glucose 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Weekly Study Drug SQ Injection 
  
  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
  
  
Glucometer Dispensation/Training 
  
x 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
Hunger Diary 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Widespread Pain Diary 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Quality of Life Assessments 
  
  
x 
  
  
  
  
x 
  
  
  
x 
  
  
  
  
  
x 
  
x 
Review SMPG and Insulin Dose 
  
  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Diet/Alcohol Counseling 
---x--- 
  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Adverse Events 
  
  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Concomitant Medication Review 
x 
  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
1 Patients previously treated with placebo, only 
2 One sample obtained on each of two consecutive days 
     
  3           Sampling schedule can be found in Appendix C. 
          Unless specified, otherwise, PK and Antibodies will be collected predose. 
          PK and immunogenicity testing does not need to be collected fasting.   
 
*       Platelets will be assessed every week 
**    Home Health Nurse Visits (or lab draw by local lab facility when needed) will take place every week unless patient will be at NIH for in-
person visit.  
 
 
 
 
 
 
 
 

 
 
 
 
62 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix B:  List of Laboratory Analytes 
Based on emerging data from this or future studies, additional tests not listed below may be performed on stored samples to better characterize the 
profile of ISIS 304801. 
 
Clinical Chemistry 
Panel 
• Sodium 
• Potassium 
• Chloride 
• Bicarbonate 
• Total protein 
• Albumin 
• Calcium 
• Magnesium 
• Phosphorus 
• BUN 
• Creatinine 
• Uric Acid 
• Total bilirubin 
• Direct (conjugated) 
bilirubin 
• Indirect 
(unconjugated) 
bilirubin 
• ALT 
• AST 
• Alkaline phosphatase 
 
 
Screening Tests 
• Hepatitis B surface 
antigen 
• Hepatitis C antibody 
• HIV antibody 
• FSH (women only) 
• Serum βhCG 
(women only) 
• TSH, T3, T4 
 
Coagulation 
• aPTT (sec) 
• PT (sec) 
• INR 
 
Lipid Panel 
• Total Cholesterol 
• LDL-C 
• HDL-C 
• Triglycerides 
• VLDL-C 
• Non-HDL-C 
• apoC-III (total, 
chylomicron, VLDL,  
LDL, HDL) 
Hematology 
• 
Red blood cells 
• 
Hemoglobin 
• 
Hematocrit 
• 
MCV, MCH, 
MCHC 
• 
Platelets 
• 
White blood cells 
• 
WBC Differential 
(% and absolute) 
• 
Neutrophils 
• 
Eosinophils 
• 
Basophils 
• 
Lymphocytes 
• 
Monocytes 
 
Pharmacokinetics1  
& Immunogenicity 
• 
ISIS 304801 levels 
in plasma 
• 
Anti-ISIS 304801 
antibodies in 
plasma 
 
 
Urinalysis 
• Color 
• Appearance 
• Specific gravity 
• pH 
• Protein 
• Blood 
• Ketones 
• Urobilinogen 
• Glucose 
• Bilirubin 
• Leukocyte esterase 
• Nitrate 
• Microscopic 
examination2 
 
Other assessments 
• hsCRP 
• Sedimentation Rate 
• C5a, Bb 
• HbA1c 
• Glucose 
• Insulin 
• C-peptide 

 
 
 
 
63 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
• apoA-1 
• apoB 
• apoB-48 
• Lipoprotein particle 
size/number 
• Free fatty acids 
• Troponin T 
• Adiponectin 
• Leptin 
• Testosterone (women 
only) 
 
1 
Plasma PK samples may also be used for profiling of drug binding proteins, bioanalytical method validation purposes, stability assessments, 
metabolite assessments, immunogenicity testing (or possibly for purposes of immunogenicity assay development and/or validation), or to 
assess other actions of ISIS 304801 with plasma constituents 
2 
Will be performed on abnormal findings unless otherwise specified 
 

 
 
 
 
64 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix C:  PK Sampling Schedules 
 
 
Blood PK Sampling Schedule: Week 16 (Week 1 OLE) 
Week 16 
D1 
D2 
D3 
D4 
 
Predose1, 2, 3, 4, 6, 8,12 hours post SC injection 
 
24 hours 
 
48 hours 
 
72 hours 
 
Blood PK Sampling Schedule: Week 32 (Month 4 OLE) 
Week 32 
D1 
D2 
D3 
D4 
 
Predose, 1, 2, 3, 4, 6, 8,12 hours post SC injection 
 
24 hours 
 
48 hours 
 
72 hours 
 

 
 
 
 
65 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
Appendix D:  Investigator Qualifications and Roles 
 
Rebecca J. Brown, M.D., M.H.Sc. is a board certified pediatric endocrinologist, and an Assistant 
Clinical Investigator of the Diabetes Endocrinology, and Obesity Branch. Dr. Brown has six years of 
experience conducting clinical studies in children adults with diabetes, and has a Master’s degree in 
Clinical Research. She is the Principal Investigator of this study, and is responsible for the study design, 
implementation, and interpretation. 
 
Elaine K. Cochran, M.S.N., CRNP, is a nurse practitioner in the Diabetes, Endocrinology and Obesity 
Branch, and is lead associate investigator of the ongoing study of leptin treatment in lipodystrophy 
patients.  She is an expert in the administration of leptin to patients with lipodystrophy.  Her role in this 
project will be to assist in clinical management and education of patients. 
 
Ahmed Gharib, M.D. is board certified in radiology and nuclear medicine. He has more than 10 years of 
experience in cardiac imaging including MR and CT in addition to MR spectroscopy. He is a tenure track 
investigator in the Biomedical and Metabolic a Imaging Branch (BMIB) in NIDDK with focus on 
imaging metabolic disorders and their effects on various organs.  His role in this project is to plan, 
perform, and interpret MR and CT imaging studies. 
 
Phillip Gorden, M.D. is a board certified endocrinologist, Senior Investigator in the Diabetes, 
Endocrinology and Obesity Branch, and Director Emeritus of the NIDDK.  He has over four decades of 
experience conducting clinical studies in patients with rare disorders of extreme insulin resistance, and is 
Principal Investigator of the ongoing study of leptin treatment in lipodystrophy patients.  His role in this 
project will be to work with Dr. Brown on study strategy, design, and interpretation. 
 
Theo Heller, M.D. is a board certified hepatologist and gastroenterologist and Chief of the Translational 
Hepatology Unit in the NIDDK Liver Diseases Branch.  He has 16 years of experience studying the 
connections between the innate immune system and liver-related damage and repair.  His role in this 
study will be to perform liver biopsies and provide interpretation of the results.   
 
Christopher Koh, M.D., M.H.Sc. is a board certified hepatologist and gastroenterologist and staff 
clinician in the Liver Diseases Virology Section of the NIDDK Liver Diseases Branch.  His role in this 
project will be to perform liver biopsies and interpret their results.   
 
Megan Startzell, RN, MPH is a research nurse in the Diabetes, Endocrinology and Obesity Branch.  Ms. 
Mattingly’s role in this project will be to assist Dr. Brown with the coordination of patient visits, patient 
education and communication. 
 
Elif Oral, MD, is an associate professor of internal medicine in Metabolism, Endocrinology, and 
Diabetes at the University of Michigan.  She played a critical role in the identification of three disease 
genes for lipodystrophy and pioneered the development of leptin therapy in lipodystrophy.  Her role in 
this project is to aid in study design and interpretation, and to perform metabolomic studies. 
 
Robert Shamburek, M.D. is a lipidologist and board certified internist and gastroenterologist. He is a 
Staff Clinician in the Lipid Metabolism Section, Cardiovascular and Pulmonary Branch of the National 
Heart, Lung, and Blood institute.  His role in this project is on the study design an interpretation. 
 

 
 
 
 
66 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Monica Skarulis, M.D. is a board-certified endocrinologist, and Special Volunteer with the Diabetes, 
Endocrinology and Obesity Branch.  Her role in this project is to work with Dr. Brown on study design 
and interpretation. 
 
Marissa Lightbourne, M.D. is a board-certified pediatrician, and clinical fellow in the National 
Institutes of Child Health and Development.  Her role in this project is to work with Dr. Brown on study 
design, interpretation, and publications.

 
 
 
 
67 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
Appendix E:  Financial Compensation 
 
  
Baseline 
admission 
Week 16 
Week 32 
Week 68 
Post-
treatment 
Procedure 
Inconvenience 
Units 
Compensation 
Count 
Total 
Count 
Total 
Count 
Total 
Count 
Total 
Count 
Total 
Inpatient 
stay 
n/a 
40 
9 
360 
9 
360 
9 
360 
8 
320 
4 
160 
Home labs 
1 
10 
0 
0 
15 
  150 
15 
150 
34 
 340 
4 
40 
7 point 
plasma 
glucose 
3 
30 
1 
30 
1 
30 
1 
30 
1 
30 
1 
30 
DEXA 
1 
10 
1 
10 
1 
10 
1 
10 
1 
10 
0 
0 
MRI 
5 
50 
1 
50 
1 
50 
1 
50 
1 
50 
  
0 
Mixed 
meal test 
2 
20 
1 
20 
1 
20 
1 
20 
1 
20 
1 
20 
Euglycemic 
Clamp 
5 
50 
1 
50 
1 
50 
1 
50 
1 
50 
1 
50 
Liver 
Biopsy 
5 
50 
1 
50 
1 
50 
0 
0 
0 
0 
0 
0 
Study 
diaries 
1 
10 
1 
10 
1 
10 
1 
10 
1 
10 
1 
10 
Visit 
completion 
bonus 
  
  
  
  
  
250 
  
250 
  
250 
  
250 
Total 
  
  
  
580 
  
 980 
  
 930 
  
1080 
  
560 
Grand 
total 4130 

 
 
 
 
68 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
Appendix F:  EQ-5D-5L Health Questionnaire (English and Spanish versions) 
 
 
 

 
 
 
 
69 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 

 
 
 
 
70 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 

 
 
 
 
71 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 

 
 
 
 
72 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 

 
 
 
 
73 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 

 
 
 
 
74 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix G:  SF-36v2 Health Survey (English and Spanish versions) 
 
 
 
 
 
 
 

 
 
 
 
75 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 

 
 
 
 
76 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 

 
 
 
 
77 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 

 
 
 
 
78 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 

 
 
 
 
79 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 

 
 
 
 
80 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
  
 
 
 
 
 

 
 
 
 
81 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix H:  Brief Pain Inventory (Short Form) (English and Spanish 
versions) 
 
 
 
 
 
 
 
 

 
 
 
 
82 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 

 
 
 
 
83 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
84 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 
 

 
 
 
 
85 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix I:  Ionis Pharmaceuticals, Inc. “Dosing and Potential Injection Site 
Responses” Patient Handout 
 
 
 
 
 
 
 
 
 

 
 
 
 
86 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
87 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix J:  Labs which may be performed in the Event a Platelet Count is 
Less Than the Lower Limit of Normal (x 2) or < 100,000/mm3 (x 1) 
 
ln patients who have any 2 occurrences of platelet count less than the lower limit of normal or who 
have any 1 occurrence of platelets <100,000/mm3 
 
Note: The actual labs that may be performed are subject to the PI’s decision and may change as we learn 
what the cause of the low platelets are. 
 
To Be Performed at Local Lab 
      Peripheral smear (should be performed locally, fixed and sent to central lab for review) 
      Fibrinogen split products or D-dimer on fresh blood 
To Be Performed at Central Lab 
Citrated sample for platelets Coagulation 
panel (PTI/INR, aPTT)  
CBC with reticulocytes 
     Folate (folic acid) 
     Vitamin B12 
     Fibrinogen 
     von Willebrand factor 
     Total globulins, total lgA, lgG and lgM 
     Complement:  total C3, total C4, 8b, C5a 
     hsCRP 
     Helicobacter pylori (breath test) 
     Serology for: 
           H8V, HCV, HIV (if not done recently for screening) 
           Rubella 
            CMV 
            EBV 
            Parvo 819 
 
Auto-antibody screen: 
     Anti phospholipid 
Rheumatoid factor 
Anti-dsDNA 
Anti-thyroid 
Auto-antibody screen: 
Anti phospholipid 
To Be Performed at Specialty Lab(s) 
      Antiplatelet antibodies and Anti-PF4 assay 
      Anti-ASO antibody 
 
 
 

 
 
 
 
88 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
Appendix K:  Single Patient Allowed to Stay on Study 
 
This amendment (for Appendix K) is in response to the Problem Report dated 6-2-17. Briefly, a patient 
with partial lipodystrophy and known steatohepatitis was enrolled in the protocol with an ALT of 140.  
This represents a protocol deviation as the exclusion criteria state that ALT needs to be <3xULN (NIH 
ULN is 33U/L). The study team inadvertently missed this when enrolling the patient and were alerted to 
problem when reviewing her week 4 laboratory results and noted an ALT of 167. 
 
After identifying this protocol deviation, the subject’s study medication was held pending discussions 
with the IRB and the drug manufacturer, Ionis Pharmaceuticals.  The PI spoke with the Ionis medical 
advisor, Andres Digenio, on 5-31-17.  He affirmed that, as NIDDK is the sponsor of the study, we have 
the authority to allow this patient to continue participating in the study.  He also affirmed that, as a 
representative of Ionis, he was fine with allowing the patient to continue study drug as a protocol 
violation.  The company would not wish us to change the exclusion criteria for the study, however, as the 
drug is currently in development and the company wishes to avoid any ambiguity about potential liver 
safety signals.  He affirmed that, although the drug is metabolized by the liver, there is no known safety 
signal for hepatoxicity with this drug.  However, the drug has never been tested in patients with liver 
enzymes as high as this patient’s.   
 
The PI obtained expert consultation from two NIDDK hepatologists, Chris Koh (an AI on the study) and 
Yaron Rotman (not associated with this study).  Both documented (attached to problem report) that they 
did not feel that this patient’s liver disease, and specifically, having an ALT >3x ULN, would increase 
risk to this subject.  The risk of idiosyncratic drug-induced liver injury (DILI) is not increased in patients 
with underlying liver disease, such as this patient.  Patients with advanced liver disease (e.g. cirrhosis) 
may be at increased risk for hepatic decompensation due to DILI if it occurs.  However, this patient does 
not have evidence of advanced liver disease (she has stable or improving ALT/AST over several years, no 
cirrhosis on biopsy, and normal liver synthetic function). 
 
Therefore, given this patient’s unchanged prospect of direct benefit from study participation, without any 
increase in risk, we plan to continue her participation in the study and resume dosing of the study drug.  
Because we respect the company’s request to not change the overall study exclusion criteria, we will not 
change the ALT/AST exclusion criteria, and will not enroll additional subjects who violate these 
exclusion criteria. 
 

 
 
 
 
89 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
 
References 
 
1. 
Shulman GI. Ectopic fat in insulin resistance, dyslipidemia, and cardiometabolic disease. N Engl J 
Med. Dec 4 2014;371(23):2237-2238. 
2. 
Garg A. Clinical review#: Lipodystrophies: genetic and acquired body fat disorders. J Clin 
Endocrinol Metab. Nov 2011;96(11):3313-3325. 
3. 
Chan JL, Oral EA. Clinical classification and treatment of congenital and acquired lipodystrophy. 
Endocr Pract. Mar-Apr 2010;16(2):310-323. 
4. 
Garg A. Acquired and inherited lipodystrophies. N Engl J Med. Mar 18 2004;350(12):1220-1234. 
5. 
Chan JL, Lutz K, Cochran E, et al. Clinical effects of long-term metreleptin treatment in patients 
with lipodystrophy. Endocr Pract. Nov-Dec 2011;17(6):922-932. 
6. 
Chong AY, Lupsa BC, Cochran EK, Gorden P. Efficacy of leptin therapy in the different forms of 
human lipodystrophy. Diabetologia. Jan 2010;53(1):27-35. 
7. 
Javor ED, Ghany MG, Cochran EK, et al. Leptin reverses nonalcoholic steatohepatitis in patients 
with severe lipodystrophy. Hepatology. Apr 2005;41(4):753-760. 
8. 
Moran SA, Patten N, Young JR, et al. Changes in body composition in patients with severe 
lipodystrophy after leptin replacement therapy. Metabolism. Apr 2004;53(4):513-519. 
9. 
Musso C, Cochran E, Javor E, Young J, Depaoli AM, Gorden P. The long-term effect of 
recombinant methionyl human leptin therapy on hyperandrogenism and menstrual function in 
female and pituitary function in male and female hypoleptinemic lipodystrophic patients. 
Metabolism. Feb 2005;54(2):255-263. 
10. 
Oral EA, Javor ED, Ding L, et al. Leptin replacement therapy modulates circulating lymphocyte 
subsets and cytokine responsiveness in severe lipodystrophy. J Clin Endocrinol Metab. Feb 
2006;91(2):621-628. 
11. 
Oral EA, Ruiz E, Andewelt A, et al. Effect of leptin replacement on pituitary hormone regulation 
in patients with severe lipodystrophy. J Clin Endocrinol Metab. Jul 2002;87(7):3110-3117. 
12. 
Oral EA, Simha V, Ruiz E, et al. Leptin-replacement therapy for lipodystrophy. N Engl J Med. Feb 
21 2002;346(8):570-578. 
13. 
Park JY, Javor ED, Cochran EK, DePaoli AM, Gorden P. Long-term efficacy of leptin replacement 
in patients with Dunnigan-type familial partial lipodystrophy. Metabolism. Apr 2007;56(4):508-
516. 
14. 
Safar Zadeh E, Lungu AO, Cochran EK, et al. The liver diseases of lipodystrophy: the long-term 
effect of leptin treatment. J Hepatol. Jul 2013;59(1):131-137. 
15. 
Endocrinologic and Metabolic Drugs Advisory Committee Briefing Document for metreleptin 
(BLA STN125390). 2013:29. 
16. 
Huang-Doran I, Sleigh A, Rochford JJ, O'Rahilly S, Savage DB. Lipodystrophy: metabolic insights 
from a rare disorder. J Endocrinol. Dec 2010;207(3):245-255. 
17. 
Handelsman Y, Oral EA, Bloomgarden ZT, et al. The clinical approach to the detection of 
lipodystrophy - an aace consensus statement. Endocr Pract. Jan 1 2013;19(1):107-116. 
18. 
Hegele RA, Joy TR, Al-Attar SA, Rutt BK. Thematic review series: Adipocyte Biology. 
Lipodystrophies: windows on adipose biology and metabolism. J Lipid Res. Jul 2007;48(7):1433-
1444. 
19. 
Ooi EM, Barrett PH, Chan DC, Watts GF. Apolipoprotein C-III: understanding an emerging 
cardiovascular risk factor. Clin Sci (Lond). May 2008;114(10):611-624. 
20. 
Chan DC, Chen MM, Ooi EM, Watts GF. An ABC of apolipoprotein C-III: a clinically useful new 
cardiovascular risk factor? Int J Clin Pract. May 2008;62(5):799-809. 

 
 
 
 
90 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
21. 
Lemieux I, Salomon H, Despres JP. Contribution of apo CIII reduction to the greater effect of 12-
week micronized fenofibrate than atorvastatin therapy on triglyceride levels and LDL size in 
dyslipidemic patients. Ann Med. 2003;35(6):442-448. 
22. 
Kinnunen PK, Ehnolm C. Effect of serum and C-apoproteins from very low density lipoproteins 
on human postheparin plasma hepatic lipase. FEBS Lett. Jun 15 1976;65(3):354-357. 
23. 
Mendivil CO, Zheng C, Furtado J, Lel J, Sacks FM. Metabolism of very-low-density lipoprotein and 
low-density lipoprotein containing apolipoprotein C-III and not other small apolipoproteins. 
Arterioscler Thromb Vasc Biol. Feb 2010;30(2):239-245. 
24. 
Brown RJ, Lagor WR, Sankaranaravanan S, et al. Impact of combined deficiency of hepatic lipase 
and endothelial lipase on the metabolism of both high-density lipoproteins and apolipoprotein 
B-containing lipoproteins. Circ Res. Aug 6 2010;107(3):357-364. 
25. 
Mann CJ, Troussard AA, Yen FT, et al. Inhibitory effects of specific apolipoprotein C-III isoforms 
on the binding of triglyceride-rich lipoproteins to the lipolysis-stimulated receptor. J Biol Chem. 
Dec 12 1997;272(50):31348-31354. 
26. 
Ito Y, Azrolan N, O'Connell A, Walsh A, Breslow JL. Hypertriglyceridemia as a result of human apo 
CIII gene expression in transgenic mice. Science. Aug 17 1990;249(4970):790-793. 
27. 
Petersen KF, Dufour S, Hariri A, et al. Apolipoprotein C3 gene variants in nonalcoholic fatty liver 
disease. The New England journal of medicine. Mar 25;362(12):1082-1089. 
28. 
Jorgensen AB, Frikke-Schmidt R, Nordestgaard BG, Tybjaerg-Hansen A. Loss-of-function 
mutations in APOC3 and risk of ischemic vascular disease. The New England journal of medicine. 
Jul 3;371(1):32-41. 
29. 
Jorgensen AB, Frikke-Schmidt R, West AS, Grande P, Nordestgaard BG, Tybjaerg-Hansen A. 
Genetically elevated non-fasting triglycerides and calculated remnant cholesterol as causal risk 
factors for myocardial infarction. Eur Heart J. Jun;34(24):1826-1833. 
30. 
Varbo A, Benn M, Tybjaerg-Hansen A, Jorgensen AB, Frikke-Schmidt R, Nordestgaard BG. 
Remnant cholesterol as a causal risk factor for ischemic heart disease. J Am Coll Cardiol. Jan 
29;61(4):427-436. 
31. 
Graham MJ, Lee RG, Bell TA, 3rd, et al. Antisense oligonucleotide inhibition of apolipoprotein C-
III reduces plasma triglycerides in rodents, nonhuman primates, and humans. Circ Res. May 
24;112(11):1479-1490. 
32. 
Gaudet D, Alexander VJ, Baker BF, et al. Antisense Inhibition of Apolipoprotein C-III in Patients 
with Hypertriglyceridemia. The New England journal of medicine. Jul 30;373(5):438-447. 
33. 
Gaudet D, Brisson D, Tremblay K, et al. Targeting APOC3 in the familial chylomicronemia 
syndrome. N Engl J Med. Dec 4 2014;371(23):2200-2206. 
34. 
A K, M W, BS A, et al. Apolipoprotein CIII Levels Are Elevated in Lipodystrophy Patients. 
Endocrine Society Annual Meeting; 2015; San Diego, CA. 
35. 
Crooke ST, Bennett CF. Progress in antisense oligonucleotide therapeutics. Annual review of 
pharmacology and toxicology. 1996;36:107-129. 
36. 
Zhang H, Lowenberg EC, Crosby JR, et al. Inhibition of the intrinsic coagulation pathway factor XI 
by antisense oligonucleotides: a novel antithrombotic strategy with lowered bleeding risk. 
Blood. Nov 25 2010;116(22):4684-4692. 
37. 
Altmann KH, Fabbro D, Dean NM, et al. Second-generation antisense oligonucleotides: 
structure-activity relationships and the design of improved signal-transduction inhibitors. 
Biochem Soc Trans. Aug 1996;24(3):630-637. 
38. 
McKay RA, Miraglia LJ, Cummins LL, Owens SR, Sasmor H, Dean NM. Characterization of a potent 
and specific class of antisense oligonucleotide inhibitor of human protein kinase C-alpha 
expression. J Biol Chem. Jan 15 1999;274(3):1715-1722. 

 
 
 
 
91 
CR 2019 version (IRB approved 9/24/2019) 
16-DK-0038 
Submitted to IRB:   
39. 
Geary RS, Yu RZ, Watanabe T, et al. Pharmacokinetics of a tumor necrosis factor-alpha 
phosphorothioate 2'-O-(2-methoxyethyl) modified antisense oligonucleotide: comparison across 
species. Drug Metab Dispos. Nov 2003;31(11):1419-1428. 
40. 
Henry S, Stecker K, Brooks D, Monteith D, Conklin B, Bennett CF. Chemically modified 
oligonucleotides exhibit decreased immune stimulation in mice. J Pharmacol Exp Ther. Feb 
2000;292(2):468-479. 
41. 
Inoue H, Hayase Y, Iwai S, Ohtsuka E. Sequence-dependent hydrolysis of RNA using modified 
oligonucleotide splints and RNase H. FEBS Lett. May 11 1987;215(2):327-330. 
42. 
Monia BP, Lesnik EA, Gonzalez C, et al. Evaluation of 2'-modified oligonucleotides containing 2'-
deoxy gaps as antisense inhibitors of gene expression. J Biol Chem. Jul 5 1993;268(19):14514-
14522. 
43. 
Graham MJ, Lee RG, Bell TA, 3rd, et al. Antisense oligonucleotide inhibition of apolipoprotein C-
III reduces plasma triglycerides in rodents, nonhuman primates, and humans. Circ Res. May 24 
2013;112(11):1479-1490. 
44. 
Santos RD, Duell PB, East C, et al. Long-term efficacy and safety of mipomersen in patients with 
familial hypercholesterolaemia: 2-year interim results of an open-label extension. Eur Heart J. 
Mar 1 2015;36(9):566-575. 
45. 
Chacko SK, Sunehag AL, Sharma S, Sauer PJ, Haymond MW. Measurement of gluconeogenesis 
using glucose fragments and mass spectrometry after ingestion of deuterium oxide. Journal of 
applied physiology. Apr 2008;104(4):944-951. 
46. 
Iverius PH, Ostlund-Lindqvist AM. Preparation, characterization, and measurement of 
lipoprotein lipase. Methods in enzymology. 1986;129:691-704. 
47. 
Nilsson-Ehle P. Measurements of lipoprotein lipase activity. In: Borensztajn J, ed. Lipoprotein 
Lipase. Vol 59. Chicago: Evener; 1987. 
48. 
Ouwerkerk R, Pettigrew RI, Gharib AM. Liver metabolite concentrations measured with 1H MR 
spectroscopy. Radiology. Nov 2012;265(2):565-575. 
49. 
Abd-Elmoniem KZ, Gharib AM, Pettigrew RI. Coronary vessel wall 3-T MR imaging with time-
resolved acquisition of phase-sensitive dual inversion-recovery (TRAPD) technique: initial results 
in patients with risk factors for coronary artery disease. Radiology. Dec 2012;265(3):715-723. 
50. 
Bligh EG, Dyer WJ. A rapid method of total lipid extraction and purification. Can J Biochem 
Physiol. Aug 1959;37(8):911-917. 
51. 
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the 
Atlanta classification and definitions by international consensus. Gut. Jan 2013;62(1):102-111. 
52. 
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of 
blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the 
American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 
Journal of the American College of Cardiology. Jul 1 2014;63(25 Pt B):2889-2934. 
53. 
Schulman S, Kearon C, Subcommittee on Control of Anticoagulation of the S, Standardization 
Committee of the International Society on T, Haemostasis. Definition of major bleeding in 
clinical investigations of antihemostatic medicinal products in non-surgical patients. Journal of 
thrombosis and haemostasis : JTH. Apr 2005;3(4):692-694. 
54. 
Jones PJ, Leatherdale ST. Stable isotopes in clinical research: safety reaffirmed. Clin Sci (Lond). 
Apr 1991;80(4):277-280.