A Phase 3/4 Study to Evaluate the Safety, Immunogenicity, and Effects on the Alpha1-Proteinase Inhibitor (A1PI) Levels in Epithelial Lining Fluid Following Glassia Therapy in A1PI-Deficient Subjects
Phase: PHASE3
Conditions: Alpha1-antitrypsin Deficiency
Sponsor: Baxalta now part of Shire

BAXALTA CONFIDENTIAL – RESTRICTED: DO NOT DISTRIBUTE WITHOUT PRIOR APPROVAL
CLINICAL STUDY PROTOCOL
PRODUCT: GLASSIA
STUDY TITLE: A Phase 3/4 Study to Evaluate the Safety, Immunogenicity, and 
Effects on the Alpha1-Proteinase Inhibitor (A1PI) Levels in Epithelial Lining Fluid 
Following GLASSIA Therapy in A1PI-Deficient Subjects
STUDY SHORT TITLE: Ph 3/4 GLASSIA Safety, Immunogenicity, and 
Bronchoalveolar Lavage Study
PROTOCOL IDENTIFIER: 471101
CLINICAL TRIAL PHASE 3/4
AMENDMENT 3: 2015 AUG 26
Replaces Amendment 2: 2015 MAY 07
ALL VERSIONS: 
Amendment 3: 2015 AUG 26
Amendment 2: 2015 MAY 07
Amendment 1: 2015 JAN 19
Original: 2011 JUL 05
OTHER ID(s)
IND NUMBER: 14774
Study Sponsor(s): 
Baxalta US Inc.
One Baxter Way
Westlake Village, CA  91362
USA
 
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1. STUDY PERSONNEL
1.1 Authorized Representative (Signatory) / Responsible Party
, MD
, Global Clinical Development
Baxalta US Inc.
1.2 Study Organization
The name and contact information of the responsible party and individuals involved with 
the study (eg, investigator(s), sponsor’s medical expert and study monitor, sponsor’s 
representative(s), laboratories, steering committees, and oversight committees [including 
ethics committees (ECs)], as applicable) will be maintained by the sponsor and provided 
to the investigator.
 
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2. SERIOUS ADVERSE EVENT REPORTING
The investigator will comply with applicable laws/requirements for reporting serious 
adverse events (SAEs) to the ECs.
ALL SAEs ARE TO BE REPORTED ON THE ADVERSE EVENT ELECTRONIC 
CASE REPORT FORM (ECRF) 
WITHIN 24 HOURS AFTER BECOMING AWARE OF THE EVENT. IF THE 
ECRF IS NOT AVAILABLE THEN THE SAE MUST BE REPORTED ON THE 
SERIOUS ADVERSE EVENT REPORT (SAER) FORM AND 
TRANSMITTED TO THE SPONSOR TO MEET THE 24 HOUR TIMELINE 
REQUIREMENT.
See SAE Protocol Sections for further information and SAER form for contact 
information.
Further details are also available in the study team roster.
For definitions and information on the assessment of these events, refer to the following:

AE, Section 12.1

SAE, Section 12.1.1.1

Assessment of AEs, Section 12.1.2
 
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STUDY DESIGN
Study Type/ 
Classification/ 
Discipline
Safety, Immunogenicity, Efficacy
Control Type
Concurrent (active)
Study Indication Type
Treatment
Intervention Model
Parallel
Blinding/Masking
Double-blind
Study Design
This Phase 3/4, prospective, 2-arm, double-blind, randomized, controlled, 
multicenter study will assess the safety, immunogenicity, and effects on the 
antigenic and functional A1PI levels in the ELF following GLASSIA 
administration via a 5-micron in-line filter at a dosage of 60 mg/kg BW/week 
(the dosing regimen that is currently approved by the Food and Drug 
Administration [FDA]) for 25 weeks in approximately 36 A1PI-deficient 
subjects. Subjects will be required to undergo bronchoscopy/bronchoalveolar 
lavage (BAL) procedures at baseline and during augmentation therapy for the 
evaluation of the effects of GLASSIA augmentation therapy on the levels of 
A1PI and 
 in the ELF  Once the target of 15 to 18 evaluable 
subjects has been reached, the remaining subjects to be enrolled will be waived 
from undergoing the baseline and on-treatment bronchoscopy/BAL procedures. 
A subject will be considered evaluable only if acceptable BAL samples 
(defined as a total recovery of ≥20% of the instilled volume of saline) are 
obtained at both baseline and on-treatment BAL visits.
A1PI-deficient subjects, who are A1PI treatment naïve or have been treated 
with A1PI augmentation therapy prior to study entry, will be enrolled. Subjects 
who are receiving or have recently been exposed to A1PI augmentation therapy 
at the time of study enrollment will be required to undergo an adequate washout 
period (minimum of 4 weeks from the time of prior A1PI treatment 
withdrawal) during screening. Screening A1PI measurement may be repeated 
due to suspected inadequate washout. During the washout period, subjects will 
be allowed to undergo other screening procedures for eligibility determination.
Subjects meeting eligibility criteria will be required to undergo 
bronchoscopy/BAL procedures at baseline to collect BAL samples for the 
evaluation of the effects of GLASSIA augmentation therapy at the labeled 
dosage of 60 mg/kg BW/week on the levels of A1PI and 
 in 
the ELF. Subjects who have completed the baseline bronchoscopy/BAL visit 
and have acceptable BAL samples will be randomized in a 1:1 ratio to one of 
the 2 treatment arms as shown in Table 3-1. Subjects who are waived from the 
bronchoscopy/BAL procedures will be randomized after completing screening 
procedures and confirmation of eligibility (note that BAL-related eligibility 
criteria are not applicable for these subjects).
 
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Table 3-1
Treatment Assignments
Treatment 
Arm
No. of Subjects 
Per Arm
Treatment
1
18
GLASSIA lot with particle loads 
representing the high end within the 
normal range observed in GLASSIA lots 
manufactured
2
18
GLASSIA lot with particle loads 
representing the low end within the 
normal range observed in GLASSIA lots 
manufactured
During the treatment period, all subjects will receive weekly IV infusions of 
GLASSIA at 60 mg/kg BW administered at a rate of 0.2 mL/kg/min for 25 
weeks (ie, 25 planned infusions) via an IV administration set that includes a 5-
micron in-line filter. The first infusion (Week 1), as well as infusions during 
Week 13 and Week 25, must be administered at the study site to facilitate 
monitoring and reporting of potential adverse events (AEs) associated with 
GLASSIA infusions. At the investigator’s discretion, subsequent infusions may 
be administered at the study site or at another suitable location (eg, the 
subject’s home) by a qualified healthcare professional, as acceptable per local 
regulations and standard practices of the study site. The infusion rate may be 
decreased or the infusion may be interrupted or discontinued in an individual 
subject in the event of intolerable moderate to severe infusion-related AEs
and/or at the discretion of the investigator.
Subjects will be asked to return to the study site every 6 weeks (ie, during 
Weeks 1, 7, 13, 19, and 25) for body weight measurements, as well as physical 
examination, vital sign measurements, and blood draw for plasma A1PI and 
safety laboratory sample collection, as applicable (see Table 20.2-1 and 
Table 20.3-1 for detailed list of study procedures/laboratory assessments). The 
on-treatment BAL visit will be conducted between Week 12 and Week 14 
following initiation of GLASSIA augmentation therapy for the determination of 
antigenic and functional A1PI levels in ELF. After completing the on-treatment 
BAL visit, subjects will continue to receive weekly GLASSIA infusions until 
Week 25 (the last infusion visit), followed by the study completion visit (Week 
26) at 7 (±3) days post-last infusion.
If a subject experiences a moderate or severe chronic obstructive pulmonary 
disease (COPD) exacerbation and/or lower respiratory tract infection (LRTI)
during the screening period, baseline BAL visit will be postponed once in order 
for the subject to recover from the exacerbation (ie, any signs and symptoms of 
the COPD exacerbation and/or LRTI are no longer clinically evident) and 
remain stable for at least 4 weeks after the end of exacerbation. If a moderate or 
severe episode of COPD exacerbation and/or LRTI occurs during the treatment 
phase, the subject should continue with the planned study visits and to receive 
weekly infusions of GLASSIA as planned, unless deemed medically 
inappropriate by the investigator. However, the on-treatment BAL visit will be 
postponed until clinical resolution of the exacerbation (ie, any signs and 
 
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SUBJECT SELECTION
Targeted Accrual
Enrollment will be closed when both conditions are met: 
(a) 15 to 18 evaluable subjects with acceptable BAL samples 
collected from both the baseline and on-treatment BAL visits
(b) A minimum of 36 randomized subjects.
Number of Groups/Arms/Cohorts
2
Inclusion Criteria
A subject must meet ALL of the following criteria to be eligible for inclusion in this study:
1.
Male or female subjects meeting the following age criteria:
(a) For subjects who will undergo bronchoscopy/BAL procedures: 18 to 65 years of age at the 
time of screening.
(b) For subjects who will be waived from undergoing bronchoscopy/BAL procedures (after 
adequate number of BAL evaluable subjects has been reached): 18 years of age or older at the 
time of screening.
2.
Documented A1PI genotype of Pi*Z/Z, Pi*Z/Null, Pi*Malton/Z, Pi*Null/Null, or other “at-risk”
allelic combinations (excluding MS, MZ, and SZ) confirmed using a commercial genotyping kit.
3.
Endogenous plasma (antigenic) A1PI level of <11 µM (A1PI measurement may be repeated for 
subjects with an initial screening A1PI level of 11 µM or above that is suspected to be due to 
inadequate washout of prior A1PI therapy).
4.
Subject must have at least one of the following: clinical diagnosis of emphysema, evidence of 
emphysema on computerized tomography (CT) scan of the chest, and/or evidence of airway 
obstruction which is not completely reversed with bronchodilator treatment at the time of 
screening.
5.
If the subject is being treated with any respiratory medications including inhaled bronchodilators, 
inhaled anticholinergics, inhaled corticosteroids, or low-dose systemic corticosteroids (prednisone 
≤10 mg/day or its equivalent), the doses of the subject’s medications have remained unchanged 
for at least 14 days prior to screening.
6.
The subject is a nonsmoker or has ceased smoking for a minimum of 13 weeks prior to screening
(serum cotinine level at screening within normal range of a nonsmoker) and agrees to refrain from 
smoking throughout the course of the study.
7.
If female of childbearing potential, the subject presents with a negative pregnancy test at 
screening and agrees to employ adequate birth control measures for the duration of the study.
8.
The subject is willing and able to comply with the requirements of the protocol.
9.
The subject must have pulmonary functions at the time of screening meeting both of the 
following:
(a) Post-bronchodilator forced expiratory volume in 1 second (FEV1) ≥50% of predicted
(b) If FEV1 is >80% predicted, then FEV1/forced vital capacity (FVC) must be <0.7.
Note: Inclusion criterion #9 is not applicable to subjects who are enrolled after the target of 15 to 18 
evaluable subjects has been reached and who are therefore not required to undergo the 
bronchoscopy/BAL procedures.
 
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Exclusion Criteria
A subject who meets ANY of the following criteria is NOT eligible for this study:
1.
The subject is experiencing or has a history of clinically significant pulmonary disease (other than 
COPD, emphysema, chronic bronchitis, mild bronchiectasis, and stable asthma).
2.
The subject is experiencing or has a history of cor pulmonale.
3.
The subject routinely produces more than one tablespoon of sputum per day.
4.
The subject has a history of frequent pulmonary exacerbations (greater than 2 moderate or severe 
exacerbations within 52 weeks prior to screening; see Section 10.4 for the definition of moderate 
and severe exacerbations).
5.
The subject is experiencing a pulmonary exacerbation at the time of screening (subject may be re-
screened 4 weeks after the clinical resolution of an exacerbation).
6.
The subject has clinically significant abnormalities (other than emphysema, chronic bronchitis, or 
mild bronchiectasis) detected on chest X-ray or CT scan at the time of screening. (Past records
obtained within 52 weeks prior to screening may be used, if available.)
7.
The subject has clinically significant abnormalities detected on a 12-lead electrocardiogram 
(ECG) performed at the time of screening. (Past records obtained within 26 weeks prior to 
screening may be used, if available.)
8.
The subject has clinically significant congestive heart failure with New York Heart Association 
(NYHA) Class III/IV symptoms.
9.
The subject is experiencing an active malignancy or has a history of malignancy within 5 years 
prior to screening, with the exception of the following: adequately treated basal cell or squamous 
cell carcinoma of the skin, carcinoma in situ of the cervix, or stable prostate cancer not requiring 
treatment.
10. The subject has a history of lung or any other organ transplant, is currently on a transplant list, or 
has undergone major lung surgery.
11. The subject is receiving long-term around-the-clock oxygen supplementation. (The following are 
allowed: short-term use of oxygen supplementation [eg, for the management of acute COPD 
exacerbation], oxygen supplementation required during night time only, and supplemental O2 with 
continuous positive airway pressure [CPAP] or bi-level positive airway pressure [BiPAP]).
12. Known history of hypersensitivity following infusions of human blood or blood components.
13. Immunoglobulin A (IgA) deficiency (<8 mg/dL at screening).
14. Abnormal clinical laboratory results obtained at the time of screening meeting any of the 
following criteria:
a.
Serum alanine aminotransferase (ALT) >3.0 times upper limit of normal (ULN)
b.
Serum total bilirubin >2.0 times ULN
c.
>2+ proteinuria on urine dipstick analysis
d.
Serum creatinine >2.0 times ULN
e.
Absolute neutrophil count (ANC) <1500 cells/mm3
f.
Hemoglobin (Hgb) <9.0 g/dL
g.
Platelet count <100,000/mm3
15. Ongoing active infection with hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus 
(HCV), or human immunodeficiency virus (HIV) Type 1/2 infection at the time of screening.
16. The subject has any clinically significant medical, psychiatric, or cognitive illness, or any other 
uncontrolled medical condition (eg, unstable angina, transient ischemic attack) that, in the opinion 
of the investigator, would impede the subject’s ability to comply with the study procedures, pose 
increased risk to the subject’s safety, or confound the interpretation of study results.
 
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17. The subject has participated in another clinical study involving an investigational product (other 
than A1PI) or investigational device within 30 days prior to enrollment or is scheduled to 
participate in another clinical study involving an investigational product or device during the 
course of this study.
18. The subject is a family member or employee of the investigator.
19. If female, the subject is nursing at the time of screening.
20. The subject has contraindication(s) to bronchoscopy such as recent myocardial infarction, 
unstable angina, other cardiopulmonary instability, tracheal obstruction or stenosis, moderate to 
severe hypoxemia or any degree of hypercapnia, unstable asthma, Stage 4 or 5 chronic kidney 
disease, pulmonary hypertension, severe hemorrhagic diathesis, and cervical C1/C2 arthritis.
21. The subject has had lung surgery which may interfere with bronchoscopy.
22. Known history of allergic/hypersensitivity reactions to medications used during and for 
perioperative care associated with the bronchoscopy/BAL procedures, such as local anesthetics, 
sedatives, pain control medications.
23. The subject is receiving and requires long-term (>4 weeks) immunosuppressive therapy, such as 
systemic corticosteroids at doses greater than 10 mg/day of prednisone (or its equivalent), 
mycophenolate mofetil, azathioprine, cyclophosphamide, and rituximab.
24. If a subject is receiving anticoagulant or anti-platelet therapy (such as warfarin and clopidogrel), 
the subject is unwilling to or unable to safely discontinue anticoagulant or anti-platelet therapy 
within 7 days prior to until at least 24 hours after the BAL procedures. An exception is low-dose 
aspirin alone which is allowed.
Note: Exclusion criteria #20, 21, 22, 23, and 24 are not applicable to subjects who are enrolled after 
the target of 15 to 18 evaluable subjects has been reached and who are therefore not required to
undergo the bronchoscopy/BAL procedures.
STATISTICAL ANALYSIS
Sample Size Calculation
The sample size calculation for the BAL component of the study was based on the natural log transformed 
primary endpoint data, ELF antigenic A1PI level (nM), generated during a previous clinical study (Clinical
Protocol 460502; Baxter Healthcare Corporation) for the evaluation of the effects of A1PI augmentation 
therapy with ARALAST NP on the levels of A1PI and other analytes in the ELF. In Clinical Study 460502, 
a mean difference from pre- to post-treatment in ELF antigenic A1PI of 1.32 with standard deviation of 
0.96 on natural log scale was observed. Using this variance estimate, a sample size of 15 evaluable subjects 
should be sufficient to detect a mean difference in the natural log transformed ELF antigenic A1PI of 
approximately 0.87 with 90% power, using a paired t-test and a one-sided significance level of 0.025. 
A sample size of 15 evaluable subjects will also be sufficient to detect a mean difference in the natural log 
transformed ELF functional A1PI (ANEC) of approximately 1.04, with 90% power, assuming a standard 
deviation in the differences between pre- and post-treatment ANEC values to be 20% higher than that for 
antigenic A1PI.
Based on the experience from Clinical Study 460502, it is estimated that approximately 26 to 32 subjects 
will be needed in order to achieve 15 to 18 BAL evaluable subjects, respectively. Thus, an overall study 
enrollment target of 36 subjects should be adequate to meet the target sample size for the BAL component 
of the study.
 
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4. TABLE OF CONTENTS
1. STUDY PERSONNEL ................................................................................................. 2
1.1 Authorized Representative (Signatory) / Responsible Party .............................. 2
1.2 Study Organization................................................................................................. 2
2. SERIOUS ADVERSE EVENT REPORTING........................................................... 3
3. SYNOPSIS..................................................................................................................... 4
4. TABLE OF CONTENTS ........................................................................................... 12
5. LIST OF ABBREVIATIONS .................................................................................... 17
6. BACKGROUND INFORMATION .............................. ........................................... 20
6.1 Description of Investigational Product ............... ............................................... 23
6.1.1 Rationale for the Selection of Dosing Regimen........................................... 23
6.1.2 Rationale for the Selection of Route of Administration and Infusion 
Rate................................................. ............................................................... 23
6.2 Clinical Condition/Indication .............................................................................. 23
6.3 Population To Be Studied............ ........................................................................ 24
6.4 Findings From Nonclinical and Clinical Studies ............................................... 24
6.4.1 Summary of Nonclinical Data....................................................................... 24
6.4.2 Summary of Clinical Data............................................................................. 24
6.5 Evaluation of Anticipated Risks and Benefits of the Investigational Product(s) 
to Human Subjects................................................................................................ 25
6.6 Compliance Statement.......................................................................................... 25
7. STUDY PURPOSE AND OBJECTIVES ................................................................. 26
7.1 Study Purpose ....................................................................................................... 26
7.2 Primary Objectives............................................................................................... 26
7.3 Secondary Objective............................................................................................. 26
7.4 Exploratory Objective.......................................................................................... 26
8. STUDY DESIGN......................................................................................................... 26
8.1 Brief Summary...................................................................................................... 26
8.2 Study Design.......................................................................................................... 26
8.3 Duration of Study Period(s) and Subject Participation .................................... 28
8.4 Outcome Measures ............................................................................................... 29
8.4.1 Primary Outcome Measures......................................................................... 29
8.4.2 Secondary Outcome Measures ..................................................................... 29
 
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8.4.3 Exploratory Outcome Measures .................................................................. 29
8.5 Randomization and Blinding............................................................................... 29
8.5.1 Unblinding Procedures at Study Sites ......................................................... 30
8.6 Study Stopping Rules............................................................................................ 30
8.7 Investigational Product(s).................................................................................... 30
8.7.1 Packaging, Labeling, and Storage................................................................ 30
8.7.2 Preparation of Infusion Solution.................................................................. 31
8.7.3 Administration ............................................................................................... 31
8.7.4 Description of Treatment.............................................................................. 31
8.7.5 Investigational Product Accountability ....................................................... 31
8.8 Source Data ........................................................................................................... 32
9. SUBJECT SELECTION, WITHDRAWAL, AND DISCONTINUATION .......... 32
9.1 Inclusion Criteria.................................................................................................. 32
9.2 Exclusion Criteria................................................................................................. 33
9.3 Withdrawal and Discontinuation ........................................................................ 36
10. STUDY PROCEDURES .......................................................................................... 37
10.1 Informed Consent and Enrollment ................................................................... 37
10.2 Subject Identification Code................................................................................ 37
10.3 Screening and Study Visits............. ................................................................... 37
10.3.1 Screening Visit ........................ .................................................................... 37
10.3.1.1 Confirmation of Severe Congenital A1PI Deficiency........................ 38
10.3.1.2 Pulmonary Function Tests................................................................... 38
10.3.1.3 Rescreening ........................................................................................... 39
10.3.2 Infusion Visits............................................................................................... 39
10.3.2.1 IP Administration................................................................................. 40
10.3.2.2 Management of Treatment-Emergent (S)AEs................................... 41
10.3.2.3 Pre-Medications.................................................................................... 42
10.3.2.4 Post-Infusion Follow-Up ...................................................................... 42
10.3.3 Clinical Assessment Visits........................................................................... 42
10.3.4 BAL Visits..................................................................................................... 43
10.4 COPD Exacerbation and Lower Respiratory Tract Infection (LRTI).......... 44
10.5 Medications and Non-Drug Therapies.............................................................. 46
10.6 Subject Completion/Discontinuation ................................................................ 47
10.7 Procedures for Monitoring Subject Compliance............................................. 48
11. ASSESSMENT OF EFFICACY.............................................................................. 48
11.1 ELF Antigenic and Functional A1PI Levels..................................................... 48
11.2 
.................................................................................... 48
12. ASSESSMENT OF SAFETY................................................................................... 49
 
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12.1 Adverse Events.................................................................................................... 49
12.1.1 Definitions..................................................................................................... 49
12.1.1.1 Serious Adverse Event.......................................................................... 49
12.1.1.2 Non-Serious Adverse Event ................................................................. 50
12.1.1.3 Adverse Reactions Plus Suspected Adverse Reactions ..................... 50
12.1.1.4 Unexpected Adverse Events................................................................. 50
12.1.1.5 Adverse Events Potentially Associated with Protein Aggregates..... 51
12.1.1.6 Preexisting Diseases.............................................................................. 51
12.1.2 Assessment of Adverse Events.................................................................... 51
12.1.2.1 Severity .................................................................................................. 52
12.1.2.2 Causality................................................................................................ 53
12.1.2.3 Safety Reporting ................................................................................... 54
12.2 Urgent Safety Measures ..................................................................................... 55
12.3 Untoward Medical Occurrences........................................................................ 55
12.4 Non-Medical Complaints ................................................................................... 56
12.5 Medical, Medication, and Non-Drug Therapy History................................... 56
12.6 Physical Examinations........................................................................................ 57
12.7 Clinical Laboratory Parameters........................ ............................................... 57
12.7.1 Hematology and Clinical Chemistry.......................................................... 57
12.7.2 Complement Activation and Immune Complex Panel............................. 58
12.7.3 Viral Serology and Nucleic Acid Tests....................................................... 58
12.7.4 Urine Tests.................................................................................................... 59
12.7.5 Assessment of Clinical Laboratory Values................................................ 59
12.7.5.1 Assessment of Abnormal Laboratory Values..................................... 59
12.7.6 Biobanking.................................................................................................... 60
12.8 Plasma Antigenic and Functional A1PI Levels................................................ 60
12.9 Immunogenicity ......... ........................................................................................ 61
12.10 Vital Signs.......................................................................................................... 62
13. STATISTICS............................................................................................................. 63
13.1 Sample Size and Power Calculations ................................................................ 63
13.2 Datasets and Analysis Cohorts .......................................................................... 63
13.2.1 Full Analysis Set........................................................................................... 63
13.2.2 Per-Protocol Analysis Set............................................................................ 64
13.2.3 BAL Analysis Set ......................................................................................... 64
13.2.4 Safety Analysis Set....................................................................................... 64
13.3 Handling of Missing, Unused, and Spurious Data........................................... 64
13.4 Methods of Analysis............................................................................................ 64
13.4.1 Efficacy Outcome Measures ....................................................................... 64
13.4.2 Exposure....................................................................................................... 65
13.4.3 Safety Outcome Measures........................................................................... 66
13.5 Planned Interim Analysis of the Study ............................................................. 67
14. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS .................................... 68
 
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15. QUALITY CONTROL AND QUALITY ASSURANCE...................................... 68
15.1 Investigator’s Responsibility.............................................................................. 68
15.1.1 Final Clinical Study Report........................................................................ 68
15.2 Training ............................................................................................................... 68
15.3 Monitoring........................................................................................................... 68
15.4 Auditing ............................................................................................................... 69
15.5 Non-Compliance with the Protocol ................................................................... 69
15.6 Laboratory and Reader Standardization ......................................................... 69
16. ETHICS ..................................................................................................................... 69
16.1 Subject Privacy ................................................................................................... 69
16.2 Ethics Committee and Regulatory Authorities................................................ 69
16.3 Informed Consent ............................................................................................... 70
16.4 Data Monitoring Committee.............................................................................. 70
17. DATA HANDLING AND RECORD KEEPING................................................... 71
17.1 Confidentiality Policy ......................................................................................... 71
17.2 Study Documents and Case Report Forms....................................................... 71
17.3 Document and Data Retention........................................................................... 71
18. FINANCING AND INSURANCE..... ..................................................................... 72
19. PUBLICATION POLICY........................................................................................ 72
20. SUPPLEMENTS....................................................................................................... 73
20.1 Study Flow Chart................................................................................................ 73
20.2 Schedule of Study Procedures and Assessments.............................................. 74
20.3 Schedule of Clinical Laboratory Assessments.................................................. 78
20.4 Thresholds for Clinically Significant Laboratory Abnormalities .................. 82
21. REFERENCE LIST.................................................................................................. 84
22. SUMMARY OF CHANGES.................................................................................... 87
Tables
Table 3-1 Treatment Assignments..................................................................................... 6
Table 8-1 Treatment Assignments................................................................................... 27
Table 20.2-1 Schedule of Study Procedures and Assessments........................................ 74
Table 20.3-1 Clinical Laboratory Assessments ............................................................... 78
 
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Figures
Figure 10-1 Exacerbation of COPD................................................................................. 45
Figure 20-1 Study Flow Chart for Baxalta Clinical Study 471101 ................................. 73
 
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5. LIST OF ABBREVIATIONS
Abbreviation
Definition
˚C
Degree Celsius
˚F
Degree Fahrenheit
A1PI
Alpha1-Proteinase Inhibitor
AAT
Alpha1-antitrypsin
AE/AEs
Adverse event/adverse events
ALP
Alkaline phosphatase
ALT
Alanine aminotransferase
ANC
Absolute neutrophil count
ANEC
Anti-neutrophil elastase capacity
APE
Acute pulmonary exacerbation
AR/ARs
Adverse reaction/adverse reactions
AST
Aspartate aminotransferase
ATS
American Thoracic Society
BAL
Bronchoalveolar lavage
B19V
Parvovirus B19
BiPAP
Bi-level positive airway pressure
BUN
Blood urea nitrogen
BW
Body weight
C3
Complement component 3
C4
Complement component 4
CFR
Code of Federal Regulations
CH50
50% hemolytic complement activity of serum
CIs
Confidence intervals
cm
Centimeter(s)
COPD
Chronic obstructive pulmonary disease
CPAP
Continuous positive airway pressure
CPK
Creatine phosphokinase
CRF(s)
Case Report Form(s)
CT
Computerized tomography
dL
Deciliter(s)
DMC
Data Monitoring Committee
EC
Ethics Committee
ECG
Electrocardiogram
eCRF
Electronic case report form
 
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Abbreviation
Definition
EDC
Electronic data capture
EDTA
Ethylenediaminetetraacetic acid
ELF
Epithelial lining fluid
EP
European Pharmacopeia
ERS
European Respiratory Society
FAS
Full analysis set
FDA
United States Food and Drug Administration
FEV1
Forced expiratory volume in one second
FVC
Forced vital capacity
GCP
Good Clinical Practice
GGT
Gamma-glutamyl-transferase
HAV
Hepatitis A virus
HBV
Hepatitis B virus
Hct
Hematocrit
HCV
Hepatitis C virus
HEV
Hepatitis E virus
Hgb
Hemoglobin
HIV
Human immunodeficiency virus
hpf
High power field
ICF
Informed consent form
ICH
International Conference on Harmonization
IgA
Immunoglobulin A
in
Inch(es)
IP
Investigational product
IRT
Interactive response technology
IV
Intravenous
IWRS
Interactive Web Response System
kD
Kilodalton(s)
kg
Kilogram(s)
lb
Pound(s)
LDH
Lactic dehydrogenase
LRT
Lower respiratory tract
LRTI
Lower respiratory tract infection
μM
Micromolar
MDI
Metered dose inhaler
 
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Abbreviation
Definition
MedDRA
Medical Dictionary for Regulatory Activities
mg
Milligram(s)
min
Minute (s)
mL
Milliliter(s)
mm3
Cubic millimeter
mm Hg
Millimeter(s) of mercury
NAT
Nucleic acid test
NE
Neutrophil elastase
nM
Nanomolar(s)
NMC
Non-medical complaint
NYHA
New York Heart Association 
O2
Oxygen
PCR
Polymerase chain reaction
PP
Per protocol
ppm
Parts per million
RBC
Red blood cell
SAE
Serious adverse event
SAER
Serious adverse event report
S/D
Solvent/detergent
SIC
Subject identification code
ULN
Upper limit of normal
US
United States
USP
United States Pharmacopeia
WBC
White blood cell
 
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6. BACKGROUND INFORMATION
Alpha1-Proteinase Inhibitor (A1PI), also known as alpha1-antitrypsin (AAT), is a serum 
glycoprotein of molecular mass 52 kD. The protein is synthesized in the liver and is 
reported to be present in the serum at levels between 20 and 53 μM (104 to 275.6 
mg/dL).1
Severe A1PI deficiency (also known as AAT deficiency) is an autosomal recessive 
hereditary disorder affecting an estimated 34,395 to 48,904 individuals in the United 
States (US), with 91.6% being Caucasian Americans, 7.8% Hispanic Americans, and 
0.5% African Americans.2; 3 Individuals with a severe deficiency are defined as those 
with serum A1PI levels less than 35% of the average normal level,4; 5 or less than 
11 μM.6; 7; 8 Severely affected individuals may have no detectable A1PI protein in their 
serum. In addition, genetic variants associated with reduced A1PI levels also produce an 
altered form of A1PI, the capacity of which to inhibit neutrophil elastase (NE) is 
reduced.9 In clinical practice, majority (96%) of A1PI deficiency related diseases are 
linked to Pi*ZZ genotype, with the remaining 4% to Pi*SZ and other rare or null 
genotypes.
Individuals with Pi*ZZ show a significant intracellular polymerization of their A1PI in 
the liver, often resulting in liver damage with a variable clinical presentation. In addition, 
the profound suppression of A1PI secretion into the systemic circulation significantly 
increases the risk of developing panacinar emphysema.10 The threshold level of A1PI in 
the lower respiratory tract (LRT) needed to provide clinical benefit is not known;
however, emphysema in A1PI-deficient subjects has been thought to develop because the 
level of A1PI in the LRT is insufficient to inhibit serine proteases. Serine proteases, such 
as NE, are present in the LRT in higher than normal concentrations as a result of
inflammation or infection.11 If left unchecked, due to insufficient A1PI, the proteolytic 
activity of these proteases can destroy the connective tissue framework of the lung 
parenchyma.12; 13
Therapy for A1PI-deficient subjects is directed towards replacement or augmentation of 
serum A1PI levels.6; 8; 11; 13; 14; 15; 16; 17; 18 This therapy is based on the concept that an 
increase in the serum level of A1PI will lead to higher A1PI concentrations in the lung 
parenchyma, which in turn, may mitigate the A1PI protease imbalance, thereby 
preventing or slowing the destruction of lung tissue and thus the clinical course of the 
disease.6; 11 Wewers et al. showed that, at steady-state, augmentation therapy with once a 
week dosing of A1PI (60 mg/kg body weight [BW]/week) resulted in trough circulating 
A1PI levels to >11 µM in subjects with A1PI deficiency of Pi*Z/Z genotype.11
 
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Historically, it was believed that 11 µM is the protective threshold level, based on the 
assumption that subjects with Pi*Z/Z, Pi*Null/Null, or Pi*Z/Null genotypes had severe 
A1PI deficiency (circulating A1PI levels below 11 µM) and emphysema; whereas
subjects with Pi*S/Z genotype, who at that time were considered to have an average 
A1PI level of 11 µM, were protected from emphysema. 
GLASSIA is the only sterile, ready-to-use, liquid preparation of purified human A1PI 
indicated for chronic augmentation and maintenance therapy in adults with clinically 
evident emphysema due to severe congenital deficiency of A1PI. The product was 
approved by the US Food and Drug Administration (FDA) in 2010, on the basis of safety 
and biochemical demonstration in a Phase 1 dose-escalation and a Phase 2/3 pivotal 
clinical trial in a total of 65 individual subjects with severe A1PI deficiency.
The clinical lots used in the GLASSIA Phase 2/3 trial contained small amounts of visible 
protein particulates which were aggregates of the A1PI. Protein aggregation is a known 
phenomenon with protein therapeutics and has been shown to be present in active 
comparator used in the Phase 2/3 trial, as well as other commercially available A1PI 
products upon reconstitution of the lyophilized powder. During the Phase 2/3 clinical 
trial, no safety signals of concern were reported  The most common adverse reactions
(ARs) (>0.5% of infusions) reported were headache and upper respiratory tract infection. 
These adverse events (AEs) were consistent with those reported for the other licensed 
A1PI products. Potential immunogenicity following repeated administration of 
GLASSIA was evaluated in the Phase 2/3 trial, where 50 subjects received weekly 
infusions of either GLASSIA or PROLASTIN (active comparator) from Week 1 to Week 
12 and then weekly infusions of GLASSIA (all subjects) from Week 13 to Week 24. 
Immunogenicity was monitored at baseline, Week 12, and Week 24. All samples were 
negative for the presence of anti-A1PI antibodies, with the exception of a single sample 
(Week 12) with a low titer of 2 in one subject. The Week 24 sample from this subject was 
negative, suggesting a low level, transient immunogenic response. Nevertheless, as an 
added precautionary measure, it is recommended that GLASSIA be filtered twice before 
product administration: through a 5 micron filter needle during product pooling and then 
through a 5 micron in-line filter during product administration (see GLASSIA package 
insert and/or investigator's brochure [IB]).
The effectiveness of the in-line filtration procedure in removing visible and subvisible 
particles in GLASSIA was examined in a recent in vitro study. Four GLASSIA lots were 
chosen to represent the high and low ends of the range of particle counts normally 
observed for GLASSIA manufactured. (Note that all GLASSIA lots must meet the 
requirements for visible and subvisible particulates set forth by the United States 
 
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Pharmacopeia [USP] and the European Pharmacopeia [EP] prior to release for use in 
humans). The use of a 5-micron in-line filter has been shown to effectively remove 
visible particles (from several to >10 particles in unfiltered solution to no more than 
2 particles per 50-mL vial after filtration) and subvisible particles (by 12- to 76-fold for 
particles across all particle size categories ranging from 2 to >100 micron) (data on file). 
In fact, the 5-micron in-line filter is also effective in reducing the number of particles that 
are smaller (2 to 5-micron in diameter) than the nominal 5-micron pore-size of the filter 
from an average of 23227 to 489 particles per 50-mL vial, representing a 49-fold 
reduction. The filtration process did not alter the A1PI potency, as demonstrated by a lack 
of difference in the elastase inhibitory activity measurements in unfiltered and filtered 
GLASSIA solution.
Nevertheless, given a lack of clear understanding and the paucity of direct clinical 
evidence correlating parenteral administration of protein aggregates to clinical AEs and 
risk of immunogenicity, there have been theoretical concerns about protein aggregates in 
a therapeutic product on the safety risks to humans. To address these concerns, a key goal 
of this study is to evaluate the clinical safety profile of GLASSIA with focus on AEs of 
interest that have been suggested to be potentially associated with protein aggregates and 
visible/subvisible particles, such as pulmonary embolism particularly of non-thrombotic 
or microvascular origin, unexplained chest pain, dyspnea, or cardiopulmonary arrest of 
non-cardiac etiology, interstitial pneumonitis, injection site reactions, granuloma, 
hypersensitivity or anaphylactic reactions, and immunogenicity incidence. GLASSIA lots 
containing particles of ≥2 micron in diameter representative of the high and low ends of 
the range normally observed in GLASSIA manufacturing will be selected for evaluation 
in this study. All GLASSIA administrations will follow the 2-step filtration process 
(through a 5 micron filter needle during product pooling and then through a 5 micron in-
line filter during product administration) as outlined in the GLASSIA package insert
and/or IB.
The second goal of this study is to obtain additional safety data, and to evaluate the 
effects of GLASSIA augmentation therapy on the levels of A1PI and 
 in 
the ELF following weekly intravenous (IV) augmentation therapy with GLASSIA in 
subjects with emphysema due to congenital A1PI deficiency. In the pivotal Phase 2/3
study, there were fewer subjects (7 subjects in the GLASSIA group and 2 subjects in the 
active comparator group) than planned (15 subjects) having ELF analyte results available 
for evaluation. Additionally, effect of GLASSIA augmentation therapy on ELF functional 
A1PI (ie, anti-neutrophil elastase capacity [ANEC]) could not be examined due to 
missing data. Thus, this study is designed to include bronchoscopy/bronchoalveolar 
 
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lavage (BAL) visits to collect data for the assessments of change from baseline in the 
antigenic and functional A1PI levels in the ELF following 13 weeks of weekly IV 
administration of GLASSIA at the approved dose of 60 mg/kg BW.
6.1 Description of Investigational Product
GLASSIA is a sterile, ready-to-use, liquid preparation of purified human A1PI. The 
solution contains 2% active A1PI in a phosphate-buffered saline solution. The specific 
activity of GLASSIA is at least 0.7 mg functional A1PI per mg of total protein (the 
specific activity of a particular lot will be provided in the certificate of analysis). The 
product is clear and colorless to yellow-green and may contain a few particles (ie, protein 
filaments).
GLASSIA supplied in the US is prepared from human plasma obtained from US-licensed 
plasma collection centers by a modified version of the cold ethanol fractionation process 
and the A1PI is then purified using chromatographic methods. GLASSIA does not 
contain stabilizers or any other added substances (such as sucrose, albumin or mannitol). 
GLASSIA contains no preservatives and no latex.
Further information can be found in the GLASSIA package insert and/or IB.
6.1.1 Rationale for the Selection of Dosing Regimen
The dosing regimen of GLASSIA chosen for this study, 60 mg/kg given intravenously 
once per week, is the standard FDA-approved dosing regimen for GLASSIA, as well as 
all other plasma-derived A1PI products in the same class. At this dosage, GLASSIA has 
been demonstrated to be safe and well tolerated in a total of 65 subjects with congenital 
A1PI-deficiency, and was shown to increase and maintain circulating trough antigenic 
and functional A1PI levels to 14.7 µM (median; range: 11.6-18.5 µM) and 11.9 µM
(median; range: 8.2-16.9 µM), respectively (see GLASSIA package insert and/or IB).
6.1.2 Rationale for the Selection of Route of Administration and Infusion Rate
The route of administration (intravenous infusion), as well as the infusion rate (0.2 mL/kg 
BW/min), selected for this study are in accordance with the FDA-approved package 
insert.
6.2 Clinical Condition/Indication
GLASSIA is indicated for chronic augmentation and maintenance therapy in adults with 
clinically evident emphysema due to severe congenital deficiency of A1PI (AAT 
deficiency).
 
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6.3 Population To Be Studied
Subjects with severe congenital A1PI-deficiency and emphysema are planned for 
enrollment into this study. 
6.4 Findings From Nonclinical and Clinical Studies
6.4.1 Summary of Nonclinical Data
GLASSIA was evaluated in two single dose general toxicology studies in Sprague-
Dawley rats and New Zealand White rabbits, and one repeated dose study in New 
Zealand White rabbits. 
In single dose studies, a single dose of 0, 60 and 600 mg/kg (rabbits) or 640 mg/kg (rats) 
was administered intravenously and the animals were observed for 14 days. There were 
no changes in body weight, clinical chemistry, hematology and gross pathology that 
could be attributed to GLASSIA administration.
In the repeated dose study, New Zealand White rabbits received GLASSIA (300 mg/kg) 
once daily for five consecutive days. Animals were monitored for changes in clinical 
signs, body weight, clinical chemistry, hematology, necropsy and histopathology on 
Day 1 or 14 after the last administration. A minor increase in group mean neutrophils was 
measured on Day 1 after the last GLASSIA administration. Recovery was observed after 
14 days.
Long-term studies in animals to evaluate carcinogenesis, mutagenesis or impairment of 
fertility have not been conducted.
Animal reproduction studies have not been conducted with GLASSIA.
No toxicological effects due to the solvent/detergent reagents, tri-(n)-butyl phosphate, 
and polysorbate 80 (Tween 80), used in the virus inactivation procedure are expected 
since the residual levels are less than 5 and 20 ppm, respectively.
6.4.2 Summary of Clinical Data
Findings from clinical studies are provided in the GLASSIA package insert and/or IB.
 
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6.5 Evaluation of Anticipated Risks and Benefits of the Investigational Product(s) to 
Human Subjects
Transmission of blood-borne diseases is a theoretical risk since GLASSIA is derived 
from pooled human plasma. To decrease the potential contamination with blood-borne 
viruses, stringent procedures have been employed in the manufacture of this product from 
the screening of plasma donors through plasma collection and preparation. To further 
reduce the risk of viral transmission, the manufacturing process includes two steps of 
viral removal or inactivation: (1) treatment with a solvent/detergent (S/D) mixture of tri-
n-butyl phosphate and polysorbate 80 (Tween 80) which inactivates enveloped viral 
agents such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and 
hepatitis C virus (HCV); and, (2) a nanofiltration step through a 15 nm filter which can 
remove both enveloped and non-enveloped viral agents (such as hepatitis A virus 
[HAV]). In vitro virus clearance studies demonstrated a virus log reduction factor of 4 or 
greater. To date, no seroconversion for hepatitis B or C (HBV or HCV) or human 
immunodeficiency virus (HIV) or any other known infectious agent have been reported 
with the use of GLASSIA during the clinical studies.
GLASSIA is contraindicated in subjects with a history of anaphylactic or severe 
hypersensitivity reactions to human A1PI preparations.
GLASSIA may contain trace amounts of immunoglobulin A (IgA). GLASSIA is 
contraindicated in subjects with known antibodies to IgA, and in subjects with selective 
or severe IgA deficiency who may develop anti-IgA antibodies that can result in severe 
hypersensitivity and anaphylactic reactions. IF ANAPHYLACTIC OR SEVERE 
ANAPHYLACTOID REACTIONS OCCUR, THE INFUSION MUST BE 
DISCONTINUED IMMEDIATELY. Epinephrine, antihistamines, and other appropriate 
supportive therapy should be available for the treatment of any acute anaphylactic or 
anaphylactoid reactions.
6.6 Compliance Statement
This study will be conducted in accordance with this protocol, the International 
Conference on Harmonisation Guideline for Good Clinical Practice E6 (ICH GCP, 
April 1996), Title 21 of the US Code of Federal Regulations (US CFR), the European 
Clinical Trial Directive (2001/20/EC and 2005/28/EC), and applicable national and local 
regulatory requirements.
 
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7. STUDY PURPOSE AND OBJECTIVES
7.1 Study Purpose
The purpose of the study is two-fold: (1) to further evaluate the safety and potential 
immunogenicity of GLASSIA following IV administration via in-line filtration; and, (2) 
to assess the effects of GLASSIA augmentation therapy on the levels of A1PI and 
 
in the ELF following IV administration at a dosage of 60 mg/kg BW/week for 
25 weeks in subjects with emphysema due to congenital A1PI deficiency.
7.2 Primary Objectives
1.
To evaluate the effectiveness of the use of 5-micron in-line filter on the safety and 
potential immunogenicity of GLASSIA.
2.
To determine the effects of weekly IV augmentation therapy with GLASSIA at a 
dosage of 60 mg/kg BW on antigenic and functional A1PI levels in ELF in 
subjects with congenital A1PI deficiency.
7.3 Secondary Objective

To collect additional safety information for GLASSIA.
7.4 Exploratory Objective
 
 
8. STUDY DESIGN
8.1 Brief Summary
This Phase 3/4, prospective, 2-arm, double-blind, randomized, controlled, multicenter 
study will assess the safety, immunogenicity, and effects on the antigenic and functional 
A1PI levels in the ELF following GLASSIA administration via a 5-micron in-line filter at 
a dosage of 60 mg/kg BW/week (the dosing regimen that is currently approved by the 
Food and Drug Administration [FDA]) for 25 weeks in A1PI-deficient subjects who are 
A1PI-treatment naïve, who are currently receiving A1PI treatment at the time of 
enrollment, or who have previously received A1PI treatment.
8.2 Study Design
A1PI-deficient subjects, who are A1PI treatment naïve or have previously been treated 
with A1PI augmentation therapy, will be enrolled. Subjects who are receiving or have 
recently been exposed to A1PI augmentation therapy at the time of study enrollment will 
 
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be required to undergo an adequate washout period (minimum of 4 weeks from the time 
of prior A1PI treatment withdrawal) during screening. Screening A1PI measurement may 
be repeated due to suspected inadequate washout. During the washout period, subjects 
will be allowed to undergo other screening procedures for eligibility determination.
Subjects meeting eligibility criteria will be required to undergo bronchoscopy/BAL 
procedures at baseline and following IP treatment for the evaluation of the effects of 
GLASSIA augmentation therapy at the labeled dosage of 60 mg/kg BW/week on the 
levels of A1PI and 
 in the ELF. Once the target of 15 to 18 evaluable 
subjects has been reached, the remaining subjects to be enrolled will be waived from 
undergoing the baseline and on-treatment bronchoscopy/BAL procedures. A subject will 
be considered evaluable only if acceptable BAL samples (defined as a total recovery of 
≥20% of the instilled volume of saline) are obtained at both baseline and on-treatment 
BAL.
Enrollment will be closed when both conditions are met: 
(a) 15 to 18 evaluable subjects with acceptable BAL samples collected from both the 
baseline and on-treatment BAL visits
(b) A minimum of 36 randomized subjects.
If for any reasons the target of 15 to 18 evaluable subjects have not been attained with 
initial 36 randomized subjects, additional subjects will be enrolled to achieve the BAL 
enrollment target.
Subjects who have completed the baseline bronchoscopy/BAL visit and have acceptable 
BAL samples will be randomized in a 1:1 ratio to one of the 2 treatment arms as shown in 
Table 8-1. Subjects who are waived from the bronchoscopy/BAL procedures will be 
randomized after completing screening procedures and confirmation of eligibility (note 
that BAL-related eligibility criteria are not applicable for these subjects).
Table 8-1
Treatment Assignments
Treatment 
Arm
No. of Subjects Per 
Arm
Treatment
1
18
GLASSIA lot with particle loads representing the high end within 
the normal range observed in GLASSIA lots manufactured
2
18
GLASSIA lot with particle loads representing the low end within 
the normal range observed in GLASSIA lots manufactured
 
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During the treatment period, subjects in both treatment arms will receive weekly IV 
infusions of GLASSIA at 60 mg/kg BW administered at a rate of 0.2 mL/kg/min for 
25 weeks (ie, 25 planned infusions) via an IV administration set that includes a 5-micron 
in-line filter. The first infusion (Week 1), as well as infusions during Week 13 and 
Week 25, must be administered at the study site to facilitate monitoring and reporting of 
potential AEs associated with GLASSIA infusions. At the investigator’s discretion, 
subsequent infusions may be administered at the study site or at another suitable location 
(eg, the subject’s home) by a qualified healthcare professional, as acceptable per local 
regulations and standard practices of the study site.
Subjects will be asked to return to the study site every 6 weeks (ie, during Weeks 1, 7, 13, 
19, and 25) for body weight measurements, as well as physical examination, vital sign
measurements, and blood draw for plasma A1PI and safety laboratory sample collection, 
as applicable (see Table 20.2-1 and Table 20.3-1 for detailed list of study 
procedures/laboratory assessments). The on-treatment BAL visit will be conducted 
between Week 12 and Week 14 following initiation of GLASSIA augmentation therapy 
for the determination of antigenic and functional A1PI levels and 
in 
ELF. After completing the on-treatment BAL visit, subjects will continue to receive 
weekly GLASSIA infusions until Week 25 (the last infusion visit), followed by the study 
completion visit (Week 26) at 7 (±3) days post-last infusion.
The overall study design is illustrated in Figure 20-1 (Supplement 20.1).
8.3 Duration of Study Period(s) and Subject Participation
The overall duration of the study will be approximately 2 years from study initiation (ie, 
first subject enrolled) to study completion (ie, last subject last visit).
The recruitment period is expected to be approximately 16 months. The duration of each 
subject’s participation from enrollment to subject completion (ie, last study visit) is 
anticipated to be approximately 8 months (unless the subject withdraws or is prematurely 
discontinued from the study), including:
a screening period of up to 6 weeks,
a baseline period of up to 2 weeks (for subjects undergoing baseline BAL 
procedure),
a treatment period of 25 weeks, and 
a post-treatment safety follow-up period of 7 (±3) days after the last infusion.
 
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8.4 Outcome Measures
8.4.1 Primary Outcome Measures
Safety
1. Number (proportion) of AEs considered potentially related to the presence of protein 
aggregates in the GLASSIA solution
2. Incidence of treatment-emergent ARs plus suspected ARs
3. Number (proportion) of infusions that are discontinued, slowed, or interrupted due to 
an AE
4. Number (proportion) of subjects who develop binding and/or neutralizing anti-A1PI 
antibodies
Efficacy
1. Antigenic A1PI levels in ELF
2. Functional A1PI (also known as ANEC) levels in ELF
8.4.2 Secondary Outcome Measures
Safety
1. Incidence of treatment-emergent AEs
2. Number (proportion) of subjects who experienced a shift from normal or clinically 
insignificant abnormal laboratory values at baseline to clinically significant abnormal 
laboratory values following GLASSIA administration
3. Number (proportion) of subjects with treatment-emergent seroconversion or positive 
viral nucleic acid test (NAT) for parvovirus B19 (B19V)
8.4.3 Exploratory Outcome Measures
 
8.5 Randomization and Blinding
This is a 2-arm, double-blind, randomized, controlled clinical study. In order to 
minimize/avoid bias, subjects meeting all eligibility criteria (Section 9.1 and Section 9.2) 
will be randomly assigned to 1 of 2 treatment arms at a ratio of 1:1. Note that 
randomization is to take place only after the subject has successfully completed the 
 
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baseline BAL visit with verification of having evaluable BAL samples collected. For 
those subjects to be enrolled after the target of 15 to 18 evaluable BAL subjects have 
been achieved and thus exempted from BAL procedures, randomization will take place 
upon confirmation of the main study eligibility criteria (Section 9.1 and Section 9.2) 
being met.
Randomization codes will be generated and maintained by an Interactive Response 
Technology (IRT) via an Interactive Web Response System (IWRS). Treatment
assignment will not be revealed to the subject, investigators, study site personnel or the 
sponsor, except for unblinded study personnel such as the unblinded biostatistician.
8.5.1 Unblinding Procedures at Study Sites
The randomization assignment is not to be revealed before the study is terminated, except 
in emergency cases when unblinding is necessary for the clinical management of an SAE. 
In such events, every attempt must be made to inform the sponsor before breaking the 
blind or immediately when unblinding has been performed. The investigator may request 
for the treatment assignment of the specific individual subject involved in the emergency 
event via the centralized randomization service or the unblinded biostatistician.
8.6 Study Stopping Rules
The study may be terminated by the sponsor in the event of unexpected safety or medical 
concerns. Specific stopping rules will not be established for this study, as GLASSIA is an 
approved product (in the US) with a demonstrated record of safety at the approved
dosage of 60 mg/kg BW/week which is to be employed in this study.
8.7 Investigational Product(s)
8.7.1 Packaging, Labeling, and Storage
Packaging: GLASSIA will be supplied as a sterile, non-pyrogenic, ready-to-use solution 
in single use vials containing 1 gram of functional A1PI in 50 mL of solution.
Dosage Form: Injection, solution
Labeling: The product will be labeled according to the valid regulatory requirements for 
clinical studies.
Storage: GLASSIA must be stored at 2-8 ˚C (36 to 46 ˚F). Do not freeze the product. Do 
not use past the expiration date.
 
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8.7.2 Preparation of Infusion Solution
The dose (in mg) will be calculated based on the subject’s body weight at screening and 
at each subsequent study visit. Dose adjustments based on body weight changes from 
Screening or previous visit will be made if the subject’s body weight changes by >5%.
Only body weight measurements taken using standardized procedures during study visits 
(Weeks 1, 7, 13, 19, or 25) will be used for dose calculations.
The volume of infusion solution (in mL) will be calculated based on the content of 
functional A1PI (potency) in GLASSIA vials, as specified in the certificate of analysis to 
be provided with a particular GLASSIA lot and as printed on the product carton and vial.
For instructions for the preparation and administration of GLASSIA infusion solution, 
please refer to the GLASSIA package insert and/or IB.
8.7.3 Administration
GLASSIA is for intravenous use only.
Route of administration: IV infusion via a 5-micron in-line filter
Rate of administration: 0.2 mL/kg BW/min
(The rate of infusion will be regulated by an ambulatory infusion pump.)
8.7.4 Description of Treatment
Treatment: GLASSIA [Alpha1-Proteinase Inhibitor (Human)]
Dose: 60 mg/kg BW/week
Dosage frequency: Once every week (± 2 days)
Treatment period: 25 weeks (ie, 25 planned infusions), to be followed by a 7 (± 3 days)
post-treatment safety follow-up period
8.7.5 Investigational Product Accountability
The investigator will ensure that the IP(s) is stored as specified in the protocol and that 
the storage area is secured, with access limited to authorized study personnel. The 
investigator will maintain records that the IP(s) was received, including the date received,
drug identity code, date of manufacture or expiration date, amount received and 
disposition. IP(s) must be dispensed only at the study site or other suitable location 
(eg, infusion center; home, as applicable per study design). Records will be maintained 
that include the subject identification code (SIC), dispensation date, and amount 
 
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dispensed. All remaining partially used and/or unused IP(s) will be returned to the 
sponsor or sponsor’s representative after study completion/termination, or destroyed with 
the permission of the sponsor in accordance with applicable laws and study site 
procedures. If IP(s) is to be destroyed, the investigator will provide documentation in 
accordance with sponsor’s specifications.
8.8 Source Data
Per ICH GCP, source data are defined as all information in original records and certified 
copies of original records of clinical findings, observations, or other activities in a clinical 
trial that are necessary for the reconstruction and evaluation of the trial. Source data are 
contained in source documents (original records or certified copies), which may be in 
paper and/or electronic format. Source data for this study comprise the following: 
hospital records, medical records, clinical and office charts, laboratory notes, 
memoranda, evaluation checklists, outcomes reported by subjects, pharmacy dispensing 
records, recorded data from automated instruments, copies or transcriptions certified after 
verification as being accurate copies, microfiches, photographic negatives, microfilm or 
magnetic media, x-rays, subject files, records entered into web and/or phone IRT system
and/or any direct data capture system, and records kept at the pharmacy, at the 
laboratories and at medico-technical departments involved in the clinical study.
For additional information on study documentation and case report forms (CRFs), see 
Section 17.2.
9. SUBJECT SELECTION, WITHDRAWAL, AND DISCONTINUATION
9.1 Inclusion Criteria
A subject must meet ALL of the following criteria to be eligible for inclusion in this 
study:
1. Male or female subjects meeting the following age criteria:
(a) For subjects who will undergo bronchoscopy/BAL procedures: 18 to 65 years 
of age at the time of screening.
(b) For subjects who will be waived from undergoing bronchoscopy/BAL 
procedures (after adequate number of BAL evaluable subjects has been 
reached): 18 years of age or older at the time of screening.
2. Documented A1PI genotype of Pi*Z/Z, Pi*Z/Null, Pi*Malton/Z, Pi*Null/Null, or 
other “at-risk” allelic combinations (excluding MS, MZ, and SZ) confirmed using a 
commercial genotyping kit.
 
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3. Endogenous plasma (antigenic) A1PI level of <11 µM (A1PI measurement may be 
repeated for subjects with an initial screening A1PI level of 11 µM or above that is 
suspected to be due to inadequate washout of prior A1PI therapy).
4. Subject must have at least one of the following: clinical diagnosis of emphysema, 
evidence of emphysema on computerized tomography (CT) scan of the chest, and/or 
evidence of airway obstruction which is not completely reversed with bronchodilator 
treatment at the time of screening.
5. If the subject is being treated with any respiratory medications including inhaled 
bronchodilators, inhaled anticholinergics, inhaled corticosteroids, or low-dose 
systemic corticosteroids (prednisone ≤10 mg/day or its equivalent), the doses of the 
subject’s medications have remained unchanged for at least 14 days prior to 
screening.
6. The subject is a nonsmoker or has ceased smoking for a minimum of 13 weeks prior 
to screening (serum cotinine level at screening within normal range of a nonsmoker) 
and agrees to refrain from smoking throughout the course of the study.
7. If female of childbearing potential, the subject presents with a negative pregnancy test 
at screening and agrees to employ adequate birth control measures for the duration of 
the study.
8. The subject is willing and able to comply with the requirements of the protocol.
9. The subject must have pulmonary functions at the time of screening meeting both of 
the following:
(a) Post-bronchodilator forced expiratory volume in 1 second (FEV1) ≥50% of 
predicted
(b) If FEV1 is >80% predicted, then FEV1/forced vital capacity (FVC) must be <0.7.
Note: Inclusion criterion #9 is not applicable to subjects who are enrolled after the target 
of 15 to 18 evaluable subjects has been reached and who are therefore not required to 
undergo the bronchoscopy/BAL procedures.
9.2 Exclusion Criteria
A subject who meets ANY of the following criteria is NOT eligible for this study:
1. The subject is experiencing or has a history of clinically significant pulmonary 
disease (other than COPD, emphysema, chronic bronchitis, mild bronchiectasis, and 
stable asthma).
2. The subject is experiencing or has a history of cor pulmonale.
3. The subject routinely produces more than one tablespoon of sputum per day.
 
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4. The subject has a history of frequent pulmonary exacerbations (greater than 2 
moderate or severe exacerbations within 52 weeks prior to screening; see 
Section 10.4 for the definition of moderate and severe exacerbations).
5. The subject is experiencing a pulmonary exacerbation at the time of screening 
(subject may be re-screened 4 weeks after the clinical resolution of an exacerbation).
6. The subject has clinically significant abnormalities (other than emphysema, chronic 
bronchitis, or mild bronchiectasis) detected on chest X-ray or CT scan at the time of 
screening. (Past records obtained within 52 weeks prior to screening may be used, if 
available.)
7. The subject has clinically significant abnormalities detected on a 12-lead 
electrocardiogram (ECG) performed at the time of screening. (Past records obtained 
within 26 weeks prior to screening may be used, if available.)
8. The subject has clinically significant congestive heart failure with New York Heart 
Association (NYHA) Class III/IV symptoms.
9. The subject is experiencing an active malignancy or has a history of malignancy 
within 5 years prior to screening, with the exception of the following: adequately 
treated basal cell or squamous cell carcinoma of the skin, carcinoma in situ of the 
cervix, or stable prostate cancer not requiring treatment.
10. The subject has a history of lung or any other organ transplant, is currently on a 
transplant list, or has undergone major lung surgery.
11. The subject is receiving long-term around-the-clock oxygen supplementation. (The 
following are allowed: short-term use of oxygen supplementation [eg, for the 
management of acute COPD exacerbation], oxygen supplementation required during 
night time only, and supplemental O2 with continuous positive airway pressure 
[CPAP] or bi-level positive airway pressure [BiPAP]).
12. Known history of hypersensitivity following infusions of human blood or blood 
components.
13. Immunoglobulin A (IgA) deficiency (<8 mg/dL at screening).
14. Abnormal clinical laboratory results obtained at the time of screening meeting any of 
the following criteria:
a.
Serum alanine aminotransferase (ALT) >3.0 times upper limit of normal 
(ULN)
b.
Serum total bilirubin >2.0 times ULN
c.
>2+ proteinuria on urine dipstick analysis
d.
Serum creatinine >2.0 times ULN
e.
Absolute neutrophil count (ANC) <1500 cells/mm3
 
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f.
Hemoglobin (Hgb) <9.0 g/dL
g.
Platelet count <100,000/mm3
15. Ongoing active infection with hepatitis A virus (HAV), hepatitis B virus (HBV), 
hepatitis C virus (HCV), or human immunodeficiency virus (HIV) Type 1/2 infection
at the time of screening.
16. The subject has any clinically significant medical, psychiatric, or cognitive illness, or 
any other uncontrolled medical condition (eg, unstable angina, transient ischemic 
attack) that, in the opinion of the investigator, would impede the subject’s ability to 
comply with the study procedures, pose increased risk to the subject’s safety, or 
confound the interpretation of study results.
17. The subject has participated in another clinical study involving an investigational 
product (other than A1PI) or investigational device within 30 days prior to enrollment 
or is scheduled to participate in another clinical study involving an investigational 
product or device during the course of this study.
18. The subject is a family member or employee of the investigator.
19. If female, the subject is nursing at the time of screening.
20. The subject has contraindication(s) to bronchoscopy such as recent myocardial 
infarction, unstable angina, other cardiopulmonary instability, tracheal obstruction or 
stenosis, moderate to severe hypoxemia or any degree of hypercapnia, unstable 
asthma, Stage 4 or 5 chronic kidney disease, pulmonary hypertension, severe 
hemorrhagic diathesis, and cervical C1/C2 arthritis.
21. The subject has had lung surgery which may interfere with bronchoscopy.
22. Known history of allergic/hypersensitivity reactions to medications used during and 
for perioperative care associated with the bronchoscopy/BAL procedures, such as 
local anesthetics, sedatives, pain control medications.
23. The subject is receiving or requires long-term (>4 weeks) immunosuppressive 
therapy, such as systemic corticosteroids at doses greater than 10 mg/day of 
prednisone (or its equivalent), mycophenolate mofetil, azathioprine, 
cyclophosphamide, and rituximab.
24. If a subject is receiving anticoagulant or anti-platelet therapy (such as warfarin and 
clopidogrel), the subject is unwilling to or unable to safely discontinue anticoagulant 
or anti-platelet therapy within 7 days prior to until at least 24 hours after the BAL 
procedures. An exception is low-dose aspirin alone which is allowed.
Note: Exclusion criteria #20, 21, 22, 23, and 24 are not applicable to subjects who are 
enrolled after the target of 15 to 18 evaluable subjects has been reached and who are 
therefore not required to undergo the bronchoscopy/BAL procedures.
 
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9.3 Withdrawal and Discontinuation
Any subject may voluntarily withdraw (ie, reduce the degree of participation in the study) 
consent for continued participation and data collection. The reason for withdrawal will be 
recorded on the appropriate CRF. Assessments to be performed at the termination visit 
(including in cases of withdraw or discontinuation) are described in Section 10.6, 
Section 20.2, and Section 20.3.
Discontinuation (ie, complete withdrawal from study participation) may be due to 
dropout (ie, active discontinuation by subject) or loss to follow-up (ie, discontinuation by 
subject without notice or action). Additionally, the investigator and sponsor have the 
discretion to discontinue any subject from the study if, in their judgment, continued 
participation would pose an unacceptable risk for the subject.
Subjects also will be withdrawn from treatment or discontinued from further study 
participation for the following reasons:
1. The subject becomes pregnant. IP exposure will be discontinued. Attempts will be 
made to follow the subject through completion of the pregnancy and up to 1 year 
post-delivery, if feasible. The investigator will record a narrative description of 
the course of the pregnancy and its outcome.
2. The subject begins nursing. IP exposure will be discontinued. The investigator 
will record a narrative description of the course of the baby’s development.
3. The subject develops a serious AE, which, based on the medical judgment of the 
investigator, prevents completion of participation in the study.
4. The subject fails to comply with protocol requirements or procedures that may 
include, but are not limited to:
The subject frequently misses scheduled administration of the IP, defined as 
missing a total of >20% (ie, >5) of planned infusions, or 4 or more 
consecutive weekly infusions.
The subject is treated with any A1PI product (including commercially 
available GLASSIA) other than IP.
The subject participates in another clinical study and/or receives an 
investigational product/device other than IP.
5. The sponsor terminates the study.
For subjects undergoing BAL procedures, if no acceptable BAL samples can be obtained 
from any of the 3 lobes attempted during the baseline BAL visit, the subject will not be 
randomized and will be discontinued from the study. These subjects may be re-screened 
after the target enrollment of BAL evaluable subjects is completed. If acceptable 
 
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BAL samples can be obtained during the baseline BAL visit but not from the on-
treatment BAL visit (between Week 12 to Week 14), the subject will continue to 
complete the remaining infusion visits and the study completion visit. These subjects
would not be considered as a BAL evaluable subject.
10. STUDY PROCEDURES
The overall study flow chart is illustrated in Figure 20-1 (Supplement 20.1). Details on 
the procedures to be performed at each study visit, including screening, can be found in 
Supplement 20.2 Schedule of Study Procedures and Assessments and Supplement 20.3
Schedule of Clinical Laboratory Assessments.
10.1 Informed Consent and Enrollment
Any patient who provides informed consent (ie, signs and dates the informed consent 
form [ICF]) is considered enrolled in the study.
10.2 Subject Identification Code
The following series of numbers will comprise the subject identification code (SIC): 
protocol identifier (eg, 471101) to be provided by the sponsor, 2- or 3-digit number study 
site number (eg, 02) to be provided by the sponsor, and 3- or 4-digit subject number 
(eg, 0003) reflecting the order of enrollment (ie, signing the ICF). For example, the third 
subject who signed an ICF at study site 02 will be identified as Subject 471101-020003. 
All study documents (eg, CRFs, clinical documentation, sample containers, drug 
accountability logs, etc.) will be identified with the SIC. Additionally, a uniquely coded 
SIC(s) is permitted as long as it does not contain a combination of information that 
allows personal identification of a subject (eg, collection of a subject’s initials and birth 
date would not be permitted), in compliance with laws governing data privacy.
10.3 Screening and Study Visits
10.3.1 Screening Visit
After informed consent has been obtained from the subject and/or their legally authorized 
representative, subjects will be screened on-site for eligibility based on the Inclusion and 
Exclusion Criteria defined in Section 9.1 and Section 9.2, respectively. Randomization is 
to take place after the subject has met all eligibility criteria and, as applicable, the subject 
has successfully undergone the baseline BAL visit with evaluable BAL samples 
collected.
The study site is responsible for maintaining an enrollment/screening log that includes all 
subjects enrolled. The log also will serve to document the reason for screening failure. 
 
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All screening data will be collected and reported in CRFs, regardless of screening 
outcome.
10.3.1.1 Confirmation of Severe Congenital A1PI Deficiency
To establish eligibility for participation in the study, the subject’s diagnosis of severe 
congenital A1PI deficiency must be confirmed during screening that includes 2 tests:

A1PI genotype (prior documented A1PI genotype may be used, but must be 
confirmed using a commercial genotyping kit which will be supplied)

Measurement of endogenous plasma A1PI level
Subjects must have A1PI genotype of Pi*Z/Z, Pi*Z/Null, Pi*Malton/Z, or Pi*Null/Null,
or other “at-risk” allelic combinations (excluding MS, MZ, and SZ) AND plasma 
antigenic A1PI level of <11 µM in order to meet eligibility criteria. A subject’s past (pre-
study) records, if available, may be used as an initial assessment (eg, a subject will be 
considered ineligible based on past record of Pi*SZ genotype). Results of these screening 
tests will be used to establish the subject’s eligibility for participation in the study.
For those subjects who are receiving or have recently been exposed to A1PI 
augmentation therapy at the time of study enrollment, the presence of exogenously 
administered A1PI may interfere with the verification of endogenous plasma A1PI levels. 
Therefore, these subjects will be required to have their pre-study A1PI therapy withdrawn 
for a minimum of 4 weeks to allow A1PI to return to the subject’s unaugmented levels. 
The 4-week washout period should be adequate, based on an average A1PI half-life of 
4.6 days and that typically 4 to 5 half-lives would be required (ie, 18 to 23 days). 
However, in light of inter-subject variability in A1PI half-life, some subjects may require 
a longer washout period. Therefore, screening A1PI measurement may be repeated in the 
event of suspected inadequate washout resulting in initial screening A1PI level of >11
µM.
During the washout period, these subjects will be allowed to undergo other screening 
procedures (Supplement 20.2 and Supplement 20.3).
10.3.1.2 Pulmonary Function Tests
10.3.1.2.1 Spirometry
Spirometry tests are to be conducted according to standard guidelines published by the 
American Thoracic Society and European Respiratory Society.19; 20 Whenever possible, 
all measurements should be performed with the same equipment around the same time of 
the day (± 2 hours) during site visits to minimize equipment and diurnal variability. All 
 
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spirometric measurements (FEV1 and FVC) are to be measured 30 ± 5 minutes following 
administration of a short-acting β-2 agonist bronchodilator (eg, a total of 400 µg of 
salbutamol [2 x 200 µg or 4 x 100 µg] or its equivalent). Spirometric measurements 
(FEV1 and FVC) are to be performed in triplicate, and the highest value at each time 
point for each variable is to be used for analyses. The spirometry equipment is to be 
calibrated according to the manufacturer’s recommendation and documented in a 
maintenance log. The same method for the calculation of predicted normal values will be 
applied for all subjects and assessment time points to maintain standardization.
10.3.1.3 Rescreening
Subjects may be rescreened once for study eligibility. Subjects who have failed screening 
for any of the following reasons may be rescreened:
1. Circulating antigenic A1PI level of ≥11 µM that is suspected to be due to inadequate 
washout of the prior A1PI therapy
2. Erroneous screening results
3. Pulmonary exacerbation at the time of initial screening (Note: subjects may be re-
screened 4 weeks after the clinical resolution of an exacerbation.)
4. Ineligibility due to failure to meet protocol pre-specified time intervals (eg, inclusion 
criteria #7 and 8, and exclusion criteria #7 and 15)
Subjects who were discontinued early from the study due to failure to yield adequate 
baseline BAL samples will be allowed to rescreen after the target enrollment of BAL 
evaluable subjects is completed.
If a subject is to be re-screened, the study completion/termination CRF should be 
completed. The subject or his/her legally authorized representative must sign a new ICF
prior to rescreening procedures. A new SIC will be assigned, and new CRFs will be used 
for the subject upon re-enrollment. All screening procedures, with the exception of A1PI 
genotype (unless repeat is necessary, eg, the test was not performed or erroneous result 
was obtained during initial screening), will be performed during rescreening.
10.3.2 Infusion Visits
GLASSIA will be administered as IV infusions at 60 mg/kg BW every week (± 2 days)
for a total of 25 infusions. Scheduling of all infusion or study visits will be based on the 
date of the first IP infusion visit (Week 1, Day 1).
 
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10.3.2.1 IP Administration
Description of GLASSIA treatment including treatment period, dose and dosing 
frequency, mode of administration, as well as preparation of infusion solution are detailed 
provided in Section 8.7.
The first infusion (Week 1), as well as infusions during Week 13 and Week 25, must be 
administered at the study site to facilitate monitoring and reporting of potential AEs 
associated with GLASSIA infusions. At the investigator’s discretion, all other infusions 
may be administered at the study site or at another suitable location (eg, the subject’s 
home) by a qualified healthcare professional, as acceptable per local regulations and 
standard practices of the study site.
During Weeks 1, 7, 13, 19, and 25 infusion visits, vital signs (ie, body temperature, 
respiratory rate, pulse rate, and systolic and diastolic blood pressure; see Section 12.10
and Table 20.3-1 for additional details) are to be taken on the day of infusion at any time 
prior to the start of an infusion, at each rate reduction due to AE(s) and/or infusion 
interruption/discontinuation due to AE(s), and at 30 (± 15) minutes after the completion 
of an infusion. The investigator should be contacted to determine appropriate action to be 
taken, as necessary, if vital signs meet any of the following criteria:

Systolic blood pressure ≤80 mm Hg or ≥180 mm Hg and/or diastolic blood 
pressure: ≤50 mm Hg or ≥110 mm Hg

Pulse rate ≤48 beats/min or ≥110 beats/min

Respiratory rate ≤8 breaths/min or ≥24 breaths/min

Body temperature ≥38.2 ºC (101 ºF) 
For each infusion, the following IP administration information will be recorded in the 
appropriate CRF(s):

Date, start and end time of the infusion

Planned infusion volume

Actual volume infused

Infusion rate, including each infusion rate change (if any) and reason

Infusion interruptions or early discontinuation (if any), including the time of 
infusion interruption (or early stop) and restart 

AE(s)

Concomitant use of any medications and any non-drug therapies, including those 
used to treat AE(s)
 
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10.3.2.2 Management of Treatment-Emergent (S)AEs
Mild-to-moderate non-serious AEs or other constitutional symptoms that developed 
during an infusion may be treated by standard-of-care medical interventions appropriate 
for the AE at the investigator’s discretion. In the event that the AE continues or increase 
in severity despite interventions, the infusion rate may be decreased by 0.04 mL/kg 
BW/min or the infusion may be temporarily interrupted at the investigator’s discretion. If 
the AE is not resolving, the infusion rate may be further decreased in a stepwise manner 
by 0.04 mL/kg BW/min or discontinued. Once an AE resolves, the infusion may be 
resumed or continued at an infusion rate as tolerated by the subject (but not to exceed 
0.2 mL/kg BW/min) at the discretion of the investigator.
If a severe, non-serious AE or SAE occurs during an infusion, the infusion should be 
interrupted pending assessment by the investigator, and appropriate action is to be taken 
to treat the AE. The infusion may be restarted if the AE resolves in response to 
interventions and/or reduction in infusion rate and if it’s deemed safe by the investigator.
In the event of a life-threatening SAE, study personnel should take immediate steps to 
preserve the subject’s well-being and call for emergency assistance, as well as contact the 
investigator and report the SAE as described in Section 2. 
For moderate-to-severe hypersensitivity reactions (ie, urticaria, low blood pressure,
angioedema, or wheezing), the infusion should be stopped immediately and the subject
should be treated according to the standard of care at the discretion of the investigator. 
Prior to further IP administrations, the investigator should consult the sponsor’s Medical 
Monitor.
In the event a subject develops a rash at any time during the study, the nature, severity, 
extent of the eruption, its temporal relationship to the last IP administration, and the 
likely cause(s) should be examined prior to the next scheduled infusion. Management of 
rashes includes, but is not limited to, the following:

Minor rashes are those involving 10% of body surface or less without bleeding or
signs of secondary infection. Minor rashes may be treated as indicated with 
topical medications, including anti-pruritic and corticosteroid creams. Infusions 
can be continued if the rash is confirmed to be minor and/or deemed unrelated to 
IP.
 
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
Major rashes are those that involve more than 10% of the body surface, are 
progressive, are associated with hemorrhage and/or secondary infection, or 
require systemic corticosteroid treatment. These should be treated appropriately 
and infusions should be discontinued immediately until the condition has resolved 
completely or is judged to be not clinically significant. Procedures (eg, biopsy of
the lesion) may be performed to investigate the pathophysiology of the rash. At 
the discretion of the investigator, IP treatment may be resumed only after the rash 
has resolved and the subject’s condition is deemed medically safe and 
appropriate. Pre-medications such as oral or topical corticosteroid treatment may 
be administered for the subsequent 2 infusions, as applicable, at the discretion of 
the investigator in accordance with the standard of care at the investigative site. 
Subjects with recurrent major rashes, rashes that recur upon re-challenge of IP 
despite (pre-)medication(s), or rashes that do not resolve within 6 weeks will be 
discontinued from further IP administration and will be followed as outlined in 
Section 9.3.
Any rate reductions, interruptions or discontinuation of an infusion and, if applicable, any
medications and/or non-drug therapies used to treat AE(s), must be recorded in the
appropriate CRF(s).
10.3.2.3 Pre-Medications
If the same type of mild-to-moderate, non-serious AE expected to be related to IP 
infusion (eg, headache, chills, fever, flushing, and malaise) or other constitutional 
symptoms recurs for 2 or more infusions, the subject may be pre-medicated for 
subsequent infusion(s) at the discretion of the investigator in accordance with the 
standard of care at the investigative site. The use of any pre-medications must be 
recorded in the appropriate CRF(s).
10.3.2.4 Post-Infusion Follow-Up
Following each infusion visit, telephone follow-up will be conducted by the 
investigator/designee at 72 hours (+ 1 business day) to document AEs, and/or 
administration of concomitant medications or non-drug therapies, which may have 
occurred within 72 hours after the completion of an infusion.
10.3.3 Clinical Assessment Visits
Following Week 1 visit, subjects will be asked to return to the study site during Week 13 
and Week 25 for on-treatment clinical and safety laboratory assessments, as well as 
plasma A1PI measurements. Additional blood samples will be drawn for the monitoring 
 
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of plasma A1PI levels during Week 7 and Week 19, which may take place at study site or 
at another suitable location (eg, the subject’s home) by a qualified healthcare 
professional. Following the last infusion (Week 25), subjects will return to the study site 
7 ±3 days post-infusion for study completion assessments.
A detailed list of assessments to be performed at each clinical assessment visit is 
provided in Supplement 20.2 and Supplement 20.3.
10.3.4 BAL Visits
This section applies to subjects who are to undergo bronchoscopy/BAL procedures. 
Bronchoscopy/BAL procedure will be waived for subjects who are enrolled after 15 to 18 
BAL evaluable subjects have been obtained. An evaluable subject is defined as a subject 
who has successfully completed both the baseline and the on-treatment BAL visits, and 
has acceptable BAL sample (defined as a total recovery of ≥20% of the instilled volume 
of saline) collected from each visit.
Subjects will be asked to undergo the bronchoscopy/BAL procedures on 2 occasions: at 
baseline (prior to randomization) and following initiation of GLASSIA treatment for 12 
to 14 weeks.
The baseline BAL visit must be conducted after verification of deficient plasma 
(antigenic) A1PI levels (below 11 M) has been obtained. Subjects who have been 
receiving A1PI augmentation therapy prior to study entry must have plasma samples
collected within 10 days prior to the baseline BAL visit for the measurement of plasma 
(antigenic) A1PI levels to verify the adequacy of the washout from A1PI therapy prior to 
performing BAL. The baseline bronchoscopy/BAL visit must be completed prior to 
randomization and within 48 hours prior to the first IP administration. In order for a 
subject to be randomized and remain in the study, the subject must have acceptable BAL 
sample (total recovery of ≥20% of the total original instilled volume of saline). If no 
acceptable BAL samples can be obtained from any of the 3 lobes attempted during the 
baseline BAL visit, the subject will undergo early termination visit and be discontinued 
from the study.
During GLASSIA augmentation therapy, the subject will be asked to undergo the on-
treatment BAL visit between Week 12 and Week 14. The on-treatment 
bronchoscopy/BAL procedure will be conducted at 7 (± 1) days following the last IP 
infusion, but must be completed prior to the next IP infusion. Whenever possible, it is 
recommended that sufficient time (typically 24 to 48 hours) is allowed for the subject to 
recover from the bronchoscopy/BAL procedures prior to IP administration. 
 
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Subjects who have successfully completed the on-treatment BAL visit and have
acceptable BAL samples will be considered as an evaluable subject. If acceptable BAL 
samples cannot be obtained from any of the 3 lobes attempted during the on-treatment 
BAL visit, the subject will continue to complete the remaining infusion visits through 
Week 25 and the study completion visit (Week 26). These subjects, however, would not 
be considered as a BAL evaluable subject. New subjects may be enrolled to achieve the 
target of 15 to 18 evaluable subjects, as necessary.
During the BAL visits, plasma samples will be collected within 2 hours prior to the BAL 
procedure for the measurement of plasma urea, as well as plasma antigenic and functional 
A1PI levels. Vital signs will be measured within 2 hours prior to each BAL procedure 
and within 1 hour after the completion of the BAL procedure. Pre-BAL vital signs are to 
be assessed prior to bronchodilator and local anesthesia administration. The subject 
should be monitored for ECG, blood pressure, respiratory rate, and pulse oximetry during 
the procedure in accordance with standard practice at the local institution. The subject 
will remain in the hospital/clinic until, in the investigator s medical judgment, it is safe to 
discharge the subject. Subjects will be followed for post-BAL safety monitoring (ie, AEs 
and concomitant medications/non-drug therapies) at the study site or by telephone within 
2 weeks after each BAL procedure.
In order to assess the effects of GLASSIA maintenance treatment on the ELF A1PI 
levels, it is important for the on-treatment BAL procedure be performed after stable 
dosing of GLASSIA has been maintained for at least 4 half-lives of A1PI (ie, average 
half-life ~4.6 days, see GLASSIA package insert and/or IB). Thus, should a subject miss 
1 or more consecutive GLASSIA infusion(s) within 4 week(s) immediately prior to the 
scheduled on-treatment BAL visit, the BAL procedure will be rescheduled to occur after 
the subject has received at least 4 consecutive weekly GLASSIA administrations. The 
timing of the rescheduled BAL visit will follow the same requirements as described 
above for the on-treatment BAL visit.
10.4 COPD Exacerbation and Lower Respiratory Tract Infection (LRTI)
An exacerbation of COPD is defined as an acute event characterized by a worsening of 
the patient’s respiratory symptoms that is beyond normal day-to-day variations and lead 
to a change in medication. The onset of an exacerbation is defined as the first day of an 
increase in or new onset of more than one of the respiratory symptoms (cough, sputum, 
sputum purulence, wheezing, or dyspnea), compared to the subject’s usual clinical state, 
for at least 2 consecutive days and requiring treatment with antibiotics and/or systemic 
(oral, intramuscular or intravenous) corticosteroids. The end of an exacerbation is defined 
 
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as the first day that any signs and symptoms of COPD exacerbation and/or LRTI 
symptoms are no longer clinically evident (ie, the first day that a subject returns to his/her 
usual clinical state) for at least 2 consecutive days. As depicted in Figure 10-1, the total 
length of the episode includes any delay in treatment (time taken for treatment to be 
initiated after the onset of exacerbation) and time to resolution of signs and 
symptoms.21; 22
Figure 10-1
Exacerbation of COPD
If a subject experiences a moderate or severe COPD exacerbation and/or LRTI during the 
screening period, the baseline BAL visit will be postponed once in order for the subject to 
recover from the exacerbation (ie, any signs and symptoms of the COPD exacerbation 
and/or LRTI are no longer clinically evident) and remain stable for at least 4 weeks after 
the end of exacerbation. If a moderate or severe episode of COPD exacerbation and/or 
LRTI occurs during the treatment phase, the subject should continue with the planned 
study visits and to receive weekly infusions of GLASSIA as planned, unless deemed 
medically inappropriate by the investigator. However, the on-treatment BAL visit will be 
postponed until clinical resolution of the exacerbation (ie, any signs and symptoms of the 
COPD exacerbation and/or LRTI are no longer clinically evident) plus an additional 
minimum period of 4 weeks after the end of exacerbation.
The severity of a COPD exacerbation and/or LRTI will be categorized as mild, moderate,
or severe according to the following definitions:

Mild – treated at home without seeing a health care provider

Moderate – visit with health care provider (eg, home visit, visit to an outpatient 
facility or an emergency department, but not requiring admission to hospital)

Severe – hospitalization (an emergency department stay >24 hours is considered a 
hospitalization)
 
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Any occurrences of COPD exacerbation and/or LRTI are to be recorded on the AE CRF.
10.5 Medications and Non-Drug Therapies
The following medications are not permitted at any time during the course of the study:

Any A1PI augmentation therapy other than IP in this study; commercially 
available GLASSIA is also not permitted

Any investigational drug, biologic, or device other than IP in this study
A subject who has taken any of the above medications will be discontinued from further 
treatment and/or from the study. 
The following medications are not permitted within a pre-specified time interval prior to 
each BAL procedure:

Immunosuppressive therapies (such as systemic corticosteroids at doses greater 
than 10 mg/day of prednisone or its equivalent, mycophenolate mofetil, 
azathioprine, and cyclophosphamide) within 4 weeks prior to and during the BAL 
procedures
Rituximab at any time during the study

Anticoagulant or anti-platelet therapy (such as warfarin and clopidogrel) within 7 
days prior to and during the BAL procedures, with the exception of low-dose 
aspirin which is allowed.
The following medications are permitted during the course of the study provided that the 
dosage remains stable throughout the course of the study:
1. Any respiratory medications including inhaled bronchodilators, inhaled 
anticholinergics, inhaled corticosteroids, or low-dose systemic corticosteroids 
(prednisone ≤10 mg/day or its equivalent)
2. Theophylline
3. Other medications that a subject is taking for a pre-existing medical condition except 
for those listed under prohibited medications above
Dosages of permitted concomitant medications are to remain stable throughout the course 
of the study, unless otherwise medically indicated.
 
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10.6 Subject Completion/Discontinuation
A subject is considered to have completed the study when he/she ceases active 
participation in the study because the subject has, or is presumed to have, completed all 
study procedures according with the protocol (with or without protocol deviations).
Reasons for completion/discontinuation will be reported on the 
Completion/Discontinuation CRF, including: completed, screen failure, AE (eg, death), 
discontinuation by subject (eg, lost to follow-up [defined as 3 documented unsuccessful 
attempts to contact the subject], dropout), physician decision (eg, pregnancy, progressive 
disease, non-compliance with IP/protocol violation(s), recovery), study terminated by 
sponsor, or other (reason to be specified by the investigator, eg, technical problems). 
Regardless of the reason, all data available for the subject up to the time of 
completion/discontinuation should be recorded on the appropriate CRF. 
Every effort will be made to have discontinued subjects complete the study 
completion/termination visit. Subjects who are discontinued early from the study prior to 
receiving any IP administration will not need to undergo early termination procedures, 
except for those subjects who have undergone the baseline BAL procedure in which case 
subjects will be followed for potential post-BAL complications for a period of time in 
accordance with local institutional standard practice but not to exceed 30 days.
If the completion/termination visit is done as an additional, unscheduled visit, the 
assessment results shall be recorded with the completion/termination visit. If a subject 
terminates participation in the study and does not return for the completion/termination 
visit, their last recorded assessments shall remain recorded with their last visit. The 
reason for discontinuation will be recorded, and the data collected up to the time of 
discontinuation will be used in the analysis and included in the clinical study report. If 
additional assessments are required, the assessments shall be recorded separately. 
Assessments to be performed at the termination visit (including in cases of withdraw or 
discontinuation) can be found in Supplement 20.2 Schedule of Study Procedures and 
Assessments and Supplement 20.3 Schedule of Clinical Laboratory Assessments.
In the event of subject discontinuation due to an (S)AE, clinical and/or laboratory 
investigations that are beyond the scope of the required study observations/assessments 
may be performed as part of the evaluation of the event. These investigations will take 
place under the direction of the investigator in consultation with the sponsor, and the 
details of the outcome may be reported to the appropriate regulatory authorities by the 
sponsor.
 
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10.7 Procedures for Monitoring Subject Compliance
All study procedures are to be performed under the direct supervision of the 
investigator/a qualified healthcare professional at the study site or at another suitable 
location (eg, the subject’s home or infusion center), and thus, no separate procedures will 
be used to monitor subject compliance.
Trough antigenic and functional A1PI levels in plasma would be determined as a check 
on subject’s compliance/adherence to treatment.
11. ASSESSMENT OF EFFICACY
11.1 ELF Antigenic and Functional A1PI Levels
This study will evaluate the effects of GLASSIA weekly augmentation therapy on the 
A1PI levels in the ELF.
BAL samples will be analyzed for the determination of the following in the BAL fluid
using validated bioanalytical assays at a qualified laboratory:
1.
Antigenic A1PI level
2.
Functional A1PI (ANEC) level
3.
Urea level
ELF antigenic and functional A1PI levels will be estimated based on the respective 
values measured in the BAL fluid using the plasma-to-BAL urea correction method. This 
approach is based on the fact that urea is freely diffusible through most body 
compartments, including the alveolar wall. A dilution factor, k, will be determined with 
the following formula: dilution factor k = UP (concentration of urea in plasma)/UBAL
(concentration of urea in BAL fluid). Using this dilution factor, quantitative 
measurements of ELF A1PI and 
will be corrected accordingly.
11.2
 
 
 
 
 
 
 
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12. ASSESSMENT OF SAFETY
12.1 Adverse Events
12.1.1 Definitions
An AE is defined as any untoward medical occurrence in a subject administered an IP 
that does not necessarily have a causal relationship with the treatment. An AE can 
therefore be any unfavorable and unintended sign (eg, an abnormal laboratory finding), 
symptom (eg, rash, pain, discomfort, fever, dizziness, etc.), disease (eg, peritonitis, 
bacteremia, etc.), or outcome of death temporally associated with the use of the IP, 
whether or not considered causally related to the IP.
12.1.1.1 Serious Adverse Event 
A serious adverse event (SAE) is defined as an untoward medical occurrence that at any 
dose meets one or more of the following criteria:

Outcome is fatal/results in death (including fetal death)

Is life-threatening – defined as an event in which the subject was, in the judgment 
of the investigator, at risk of death at the time of the event; it does not refer to an 
event that hypothetically might have caused death had it been more severe.

Requires inpatient hospitalization or results in prolongation of an existing 
hospitalization – inpatient hospitalization refers to any inpatient admission, 
regardless of length of stay.

Results in persistent or significant disability/incapacity (ie, a substantial 
disruption of a person’s ability to conduct normal life functions)

Is a congenital anomaly/birth defect

Is a medically important event – a medical event that may not be immediately 
life-threatening or result in death or require hospitalization but may jeopardize the 
subject or may require medical or surgical intervention to prevent one of the other 
outcomes listed in the definitions above. Examples of such events are: 
Intensive treatment in an emergency room or at home for allergic 
bronchospasm, blood dyscrasias, or convulsions that do not result in 
hospitalization, or development of drug dependence or drug abuse 
 
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Reviewed and confirmed seroconversion for human immunodeficiency virus 
(HIV), hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus 
(HCV), hepatitis E virus (HEV), or parvovirus B19 (B19V)
12.1.1.1.1 Uncomplicated Pregnancies 
Uncomplicated pregnancies following maternal or paternal exposure to the IP are not 
considered an (S)AE; however, any pregnancy complication or pregnancy termination by 
therapeutic, elective, or spontaneous abortion shall be considered an SAE.
12.1.1.2 Non-Serious Adverse Event
A non-serious AE is an AE that does not meet the criteria of an SAE.
12.1.1.3 Adverse Reactions Plus Suspected Adverse Reactions
An AR plus suspected AR is any adverse event which met any of the following criteria: 
(a) an adverse event that began during infusion or within 72 hours following the end 
of IP infusion, or
(b) an adverse event considered by either the investigator and/or the sponsor to be 
possibly or probably related to IP administration, or 
(c) an adverse event for which causality assessment was missing or indeterminate.
In addition, safety data will also be analyzed for any ARs plus suspected ARs which met 
any of the following criteria:
(a) an adverse event that began during infusion or within 24 hours following the end 
of IP infusion, or
(b) an adverse event considered by either the investigator and/or the sponsor to be 
possibly or probably related to IP administration, or 
(c) an adverse event for which causality assessment was missing or indeterminate.
12.1.1.4 Unexpected Adverse Events
An unexpected adverse event is an AE whose nature, severity, specificity, or outcome is 
not consistent with the term, representation, or description used in the Reference Safety 
Information (eg, IB, package insert). “Unexpected” also refers to the AEs that are 
mentioned in the Reference Safety Information as occurring with a class of drugs or as 
anticipated from the pharmacological properties of the drug, but are not specifically 
mentioned as occurring with the particular drug under investigation.
 
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12.1.1.5 Adverse Events Potentially Associated with Protein Aggregates
The safety database will be reviewed and assessed for AEs that may potentially be 
associated with protein aggregates in GLASSIA solution.
12.1.1.6 Preexisting Diseases
Preexisting diseases that are present before entry into the study are described in the 
medical history, and those that manifest with the same severity, frequency, or duration 
after IP exposure, will not be recorded as AEs. However, when there is an increase in the 
severity, duration, or frequency of a preexisting disease, the event must be described on 
the AE CRF.
Any occurrences of COPD exacerbation and/or LRTI are to be recorded on the AE CRF 
(see Section 10.4).
12.1.2 Assessment of Adverse Events
Each AE from the first IP exposure until study completion/early discontinuation from the 
study will be described on the AE CRF using the medical diagnosis (preferred), or, if no 
diagnosis could be established at the time of reporting the AE, a symptom, or sign, in 
standard medical terminology in order to avoid the use of vague, ambiguous, or 
colloquial expressions (see definition in Section 12.1). Each AE will be evaluated by the 
investigator for:

Seriousness as defined in Section 12.1.1.1

Severity as defined in Section 12.1.2.1

Causal relationship to IP exposure or study procedure as defined in 
Section 12.1.2.2
For each AE, the outcome (ie, recovering/resolving, recovered/resolved, 
recovered/resolved with sequelae, not recovered/not resolved, fatal, unknown) and if 
applicable action taken (ie, dose increased, dose not changed, dose reduced, drug 
interrupted, drug withdrawn, not applicable, or unknown) will also be recorded on the AE 
CRF. Recovering/resolving AEs will be followed until resolution, medically stabilized, or 
30 days after the study completion/termination visit, whichever comes first. AE and other 
CRF(s), as applicable, will be updated if additional follow-up information is 
collected/reported prior to study completion (no additional reporting on CRF(s) is 
necessary after study completion).
 
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If the severity rating for an ongoing AE changes before the event resolves, the original 
AE report will be revised (ie, the event will not be reported as separate AE). During the 
course of any AE, the highest severity rating will be reported.
Deviations from the protocol-specified dosage (including overdosing [by >50%], 
underdosing [by >50%], abuse, and withdrawal), treatment errors (including incorrect 
route of administration, use of an incorrect product, and deviations from the protocol-
defined dosing schedule), failures of expected pharmacological actions, and unexpected 
therapeutic or clinical benefits will be followed with regard to occurrence of AEs, lack of 
efficacy, and/or other observations because these events may be reportable to regulatory 
authorities.
Any pregnancy that occurs after administration of IP will be reported on a Pregnancy
Report Form within 24 hours of awareness and followed-up at estimated date of delivery 
and 1 year post-delivery, if feasible. (S)AEs associated with these events must be 
reported on the appropriate (S)AE forms, and follow the guidance on timing of the report 
provided in Section 12.1.2.3.
If an investigator becomes aware of an SAE occurring in a subject after study 
completion, the SAE must be reported on the provided SAE Report Form within 24 hours 
after awareness; no additional reporting on CRFs is necessary.
For the purposes of this study, each AE (expected and unexpected) experienced by a 
subject undergoing bronchoscopy/BAL procedure will be recorded on the AE CRF.
12.1.2.1 Severity
The investigator will assess the severity of each AE using his/her clinical expertise and 
judgment based on the most appropriate description below:

Mild
The AE is a transient discomfort and does not interfere in a significant 
manner with the subject’s normal functioning level.
The AE resolves spontaneously or may require minimal therapeutic 
intervention.

Moderate
The AE produces limited impairment of function and may require therapeutic 
intervention.
The AE produces no sequela/sequelae.
 
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
Severe
The AE results in a marked impairment of function and may lead to 
temporary inability to resume usual life pattern.
The AE produces sequela/sequelae, which require (prolonged) therapeutic 
intervention.
These severity definitions will also be used to assess the severity of an AE with a study-
related procedure(s), if necessary.
12.1.2.2 Causality
Causality is a determination of whether there is a reasonable possibility that the IP is 
etiologically related to/associated with the AE. Causality assessment includes, eg, 
assessment of temporal relationships, dechallenge/rechallenge information, association 
(or lack of association) with underlying disease, presence (or absence) of a more likely 
cause, and physiological plausibility. For each AE, the investigator will assess the causal 
relationship between the IP and the AE using his/her clinical expertise and judgment 
according to the following most appropriate algorithm for the circumstances of the AE:

Not related (both circumstances must be met)
Is due to underlying or concurrent illness, complications, concurrent 
treatments, or effects of concurrent drugs
Is not associated with the IP (ie, does not follow a reasonable temporal 
relationship to the administration of IP or has a much more likely alternative 
etiology). 

Unlikely related (either 1 or both circumstances are met)
Has little or no temporal relationship to the IP 
A more likely alternative etiology exists

Possibly related (both circumstances must be met)
Follows a reasonable temporal relationship to the administration of IP
An alternative etiology is equally or less likely compared to the potential 
relationship to the IP

Probably related (both circumstances must be met)
Follows a strong temporal relationship to the administration of IP, which may 
include but is not limited to the following: 
o
Reappearance of a similar reaction upon re-administration (positive 
rechallenge)
o
Positive results in a drug sensitivity test (skin test, etc.)
 
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o
Toxic level of the IP as evidenced by measurement of the IP 
concentrations in the blood or other bodily fluid
Another etiology is unlikely or significantly less likely
For events assessed as not related or unlikely related and occurring within 72 hours 
following completion of each IP administration, the investigator shall provide the 
alternative etiology. These causality definitions will also be used to assess the 
relationship of an AE with a study-related procedure(s), if necessary.
12.1.2.3 Safety Reporting
Adverse events/SAEs will be assessed at all study visits as outlined in the Schedule of 
Study Procedures and Assessments (see Table 20.2-1) and Section 12.1 above.
Adverse Events/SAEs are to be recorded on the AE page of the eCRF. Each event should 
be recorded separately.
Any SAE, including death due to any cause, which occurs during this study, whether or 
not related to the investigational product, must be reported immediately (within 24 hours 
of the study center’s first knowledge of the event). All SAEs must be reported via the 
Electronic Data Capture (EDC) system by completing the relevant electronic Case Report 
Form (eCRF) page(s) in English. Once the SAE has been recorded in the EDC system, 
the Sponsor and other designated recipients will be informed of the event automatically.
For instances in which the EDC may become unavailable, SAEs must be reported using 
the back-up paper SAE Report Form to meet the 24 hour timeline requirement (contacts 
and instructions to be provided in separate documentation). Once the EDC becomes 
available, the site must enter all SAE data as reported on the back-up paper SAE report 
form on the applicable eCRF pages.
The initial SAE information reported on the applicable eCRF pages (or back-up SAE 
Report Form, if applicable) must at least include the following:

Protocol Number

Subject identification number and demographics (gender, age at onset of event 
and/or date of birth)

Investigational product exposure

Medical Term for Event (Diagnosis preferably) 

Description of the (S)AE, including:
o
Date of onset
o
(S)AE treatment (drug, dose, route of administration)
 
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o
Causal relationship by the Investigator
o
Measures taken (i.e., action taken regarding investigational product in 
direct relationship to the AE)

Seriousness criteria (i.e., death, life-threatening, or other criterion)

Cause of death

Autopsy findings (if available)

Name, address, fax number, email, and telephone number of the reporting 
Investigator (for paper SAE Report Forms) 
12.2 Urgent Safety Measures
An urgent safety measure is an immediate action taken, which is not defined by the 
protocol, in order to protect subjects participating in a clinical trial from immediate harm. 
Urgent safety measures may be taken by the sponsor or clinical investigator, and may 
include any of the following: 

Immediate change in study design or study procedures

Temporary or permanent halt of a given clinical trial or trials

Any other immediate action taken in order to protect clinical trial participants 
from immediate hazard to their health and safety
The investigator may take appropriate urgent safety measures in order to protect subjects 
against any immediate hazard to their health or safety. The measures should be taken 
immediately and may be taken without prior authorization from the sponsor. In the 
event(s) of an apparent immediate hazard to the subject, the investigator will notify the 
sponsor immediately by phone and confirm notification to the sponsor in writing as soon 
as possible, but within 1 calendar day after the change is implemented. The sponsor will 
also ensure the responsible ethics committee is notified of the urgent measures taken in 
such cases according to local regulations.
12.3 Untoward Medical Occurrences
Untoward medical occurrences occurring before the first exposure to IP are not 
considered AEs (according to the definition of AE, see Section 12.1). However, each 
serious untoward medical occurrence experienced before the first IP exposure (ie, from 
the time of signed informed consent up to but not including the first IP exposure) will be 
described on the AE CRF (and SAE Report Form if eCRF is not available). These events 
will not be considered as SAEs and will not be included in the analysis of SAEs.
 
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For the purposes of this study, each non-serious untoward medical occurrence 
experienced by a subject undergoing study-related procedure(s) (eg, washout of a 
subject’s pre-study A1PI augmentation therapy, bronchoscopy/BAL procedures) will be 
recorded on the AE CRF. These events, if occurred before the first IP exposure, will not
be considered as AEs and will not be included in the analysis of AEs. On the other hand, 
these events, if occurred after initiation of IP treatment, will be considered as AEs and 
will be included in the analysis of AEs.
12.4 Non-Medical Complaints
A non-medical complaint (NMC) is any alleged product deficiency that relates to 
identity, quality, durability, reliability, safety and performance of the product but did not 
result in an AE. NMCs include but are not limited to the following:

A failure of a product to exhibit its expected pharmacological activity and/or 
design function, eg reconstitution difficulty

Missing components

Damage to the product or unit carton

A mislabeled product (eg, potential counterfeiting/tampering)

A bacteriological, chemical, or physical change or deterioration of the product 
causing it to malfunction or to present a hazard or fail to meet label claims
Any NMCs of the product will be documented on an NMC form and reported to the 
sponsor within 1 business day. If requested, defective product(s) will be returned to the 
sponsor for inspection and analysis according to procedures.
12.5 Medical, Medication, and Non-Drug Therapy History
At screening, the subject’s medical history will be described for the following body 
systems including severity (as defined in Section 12.1.2.1) or surgery and start and end 
dates, if known: eyes, ears, nose, and throat; respiratory; cardiovascular; gastrointestinal; 
musculoskeletal; neurological; endocrine; hematopoietic/lymphatic; dermatological; and 
genitourinary.
All medications taken and non-drug therapies received from enrollment until 
completion/termination will be recorded on the concomitant medications and non-drug 
therapies CRFs.
 
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12.6 Physical Examinations
At screening and subsequent study visits (as described in Table 20.2-1), a physical 
examination will be performed on the following body systems: general appearance, head 
and neck, eyes and ears, nose and throat, chest, lungs, heart, abdomen, extremities and 
joints, lymph nodes, skin, and neurological. At screening, if an abnormal condition is 
detected, the condition will be described on the medical history CRF. At study visits, if a 
new abnormal or worsened abnormal pre-existing condition is detected, the condition will 
be described on the AE CRF. If the abnormal value was not deemed an AE because it 
was due to an error, due to a preexisting disease (described in Section 12.1.1.6), not 
clinically significant, a symptom of a new/worsened condition already recorded as an AE, 
or due to another issue that will be specified, the investigator will record the justification 
on the source record.
12.7 Clinical Laboratory Parameters
The schedule of sample collection for clinical laboratory assessments is provided in 
Table 20.3-1 Clinical Laboratory Assessments. Detailed requirements for sample 
collection and handling can be found in the Laboratory Manual.
12.7.1 Hematology and Clinical Chemistry
The hematology panel will consist of complete blood count (hemoglobin [Hgb], 
hematocrit [Hct], erythrocytes [ie, red blood cell (RBC)] count, leukocytes [ie, white 
blood cell (WBC)] count with differential (ie, basophils, eosinophils, lymphocytes, 
monocytes, and neutrophils), absolute neutrophil count (ANC), absolute lymphocyte 
count, reticulocyte count, and platelet count.
The clinical chemistry panel will consist of sodium, potassium, calcium, chloride, 
bicarbonate, total protein, albumin, alanine aminotransferase (ALT), aspartate 
aminotransferase (AST), alkaline phosphatase (ALP), lactic dehydrogenase (LDH), 
gamma-glutamyl-transferase (GGT), bilirubin (direct and total), blood urea nitrogen 
(BUN), uric acid, creatinine, creatine phosphokinase (CPK), and glucose. 
Blood will be collected for the assessment of hematology and clinical chemistry 
parameters during each of the following visits: screening, Week 1 (prior to the first IP 
infusion; this will serve as baseline value), Week 13, Week 25, and at study completion 
(Week 26) visit. Samples to be collected on the day of IP administration (ie, Week 1, 
Week 13, and Week 25) must be collected prior to the start of IP infusion. Subjects who 
are discontinued early from the study will be asked to undergo hematology and clinical 
 
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chemistry assessments at the Early Termination visit, only if these subjects have been 
exposed to IP.
Hematology and clinical chemistry assessments will be performed on 
ethylenediaminetetraacetic acid (EDTA)-anticoagulated whole blood and serum samples, 
respectively, at a central laboratory.
12.7.2 Complement Activation and Immune Complex Panel
Complement activation and immune complex panel will consist of serum complement 
component 3 (C3), complement component 4 (C4), total complement (50% hemolytic 
complement activity of serum; CH50), C1q binding assay for circulating immune 
complexes.
Blood will be collected to obtain serum samples for the assessment of complement 
activation and circulating immune complexes during each of the following visits: Week 1 
(prior to the first IP infusion; this will serve as baseline value), Week 13, Week 25, and at 
study completion (Week 26) visit. Samples to be collected on the day of IP 
administration (ie, Week 1, Week 13, and Week 25) must be collected prior to the start of 
IP infusion. Subjects who are discontinued early from the study will be asked to undergo 
complement activation and immune complex evaluation at the Early Termination visit, 
only if these subjects have been exposed to IP.
Complement activation and immune complex assessments will be performed at a central 
laboratory.
12.7.3 Viral Serology and Nucleic Acid Tests
Viral serology tests for HAV antibody, hepatitis B virus surface antigen (HBsAg), HCV 
antibody, and HIV-1/HIV-2 antibody will be performed at screening for subject 
eligibility determination.
Viral testing for B19V will consist of B19V antibody serology test and NAT, based on 
real-time polymerase chain reaction (PCR) detection of B19V DNA. Serum samples will 
be collected prior to the first IP infusion during Week 1 (which serves as the baseline 
value) and at the last infusion visit (Week 25). If a subject’s Week 1 pre-dose sample is 
tested positive, then no further testing (eg, Week 25) is required. Any evidence of
seroconversion (eg, change from a negative test result at baseline [Week 1 prior to the 
first IP infusion] to a positive result at a post-baseline assessment) for B19V should be re-
tested. Subjects who are discontinued early from the study will be asked to undergo viral 
 
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serology and NAT testing at the Early Termination visit, only if these subjects have been 
exposed to IP.
Serology testing and NAT will be performed at a central laboratory.
12.7.4 Urine Tests
Urinalysis will consist of color, specific gravity, pH, protein, glucose, ketones, bilirubin, 
urobilinogen, blood, nitrite, leukocyte esterase, and microscopic examination (RBC, 
WBC, bacteria, casts). Urinalysis will be performed during each of the following visits:
screening, Week 1 (prior to the first IP infusion; this will serve as baseline value), Week 
13, Week 25, and at study completion (Week 26) visit. Samples to be collected on the 
day of IP administration (ie, Week 1, Week 13, and Week 25) must be collected prior to
the start of IP infusion. Urinalysis will be performed at a central laboratory.
Pregnancy test will be performed for females of childbearing potential at screening and at 
study completion (Week 26) visit. Subjects who are discontinued early from the study 
will be asked to undergo urinalysis and urine/serum pregnancy test (for females of 
childbearing potential only) at the Early Termination visit, only if these subjects have 
been exposed to IP. Urine pregnancy test will be performed, unless serum pregnancy test 
is mandatory as specified by local regulatory/institutional requirements.
12.7.5 Assessment of Clinical Laboratory Values
12.7.5.1 Assessment of Abnormal Laboratory Values
The investigator’s assessment of each safety-related laboratory value will be recorded on 
the laboratory form. For each abnormal laboratory value, the investigator will determine 
whether the value is considered clinically significant or not. For clinically significant 
values, the investigator will indicate if the value constitutes an new AE (see definition in 
Section 12.1, and record the sign, symptom, or medical diagnosis on the AE CRF), is a 
symptom or related to a previously recorded AE, is due to a pre-existing disease 
(described in Section 12.1.1.6), or is due to another issue that will be specified. If the 
abnormal value was not clinically significant, the investigator will indicate the reason, ie 
because it is due to a preexisting disease, due to a lab error, or due to another issue that 
will be specified. Additional tests and other evaluations required to establish the 
significance or etiology of an abnormal value, or to monitor the course of an AE should 
be obtained when clinically indicated. Any seroconversion result for B19V should be re-
tested. Any abnormal value that persists should be followed at the discretion of the 
investigator.
 
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In addition to investigator’s assessment of the clinical significance of laboratory 
abnormalities, clinical laboratory abnormalities with values that meet the criteria listed in 
Section 20.4 will be separately analyzed and reported.
12.7.6 Biobanking
Backup samples should be taken and stored appropriately for additional analysis, if 
necessary. These samples may be used for re-testing, further evaluation of an AE, or 
follow-up of other test results. The following samples are planned:

Plasma samples collected for the determination of the following analytes will 
each be split into duplicate aliquots of approximately equal volume (one of the 
2 aliquots will serve as the backup sample):
Plasma antigenic A1PI
Plasma functional A1PI (ie, ANEC)
Plasma urea

Serum samples collected for the determination of the following analytes will 
each be split into duplicate aliquots of approximately equal volume (one of the 2 
aliquots will serve as backup sample):
Anti-A1PI antibodies for binding antibody (screening and confirmatory)
assays
Anti-A1PI antibodies for neutralizing antibody assay

BAL samples collected for the determination of the following analytes will each 
be split into 2 or more aliquots of approximately equal volume (at least one of 
the aliquots will serve as backup sample; see laboratory manual for further 
details):
BAL antigenic A1PI
BAL functional A1PI (ie, ANEC)
BAL urea
Backup samples that remain after study testing is done may be stored and used for 
additional testing (eg, further evaluation of an abnormal test or an AE. Samples will be 
stored in a coded form for up to 2 years after the final study report has been completed, 
unless otherwise notified by the sponsor, and then the samples will subsequently be 
destroyed.
12.8 Plasma Antigenic and Functional A1PI Levels
Throughout the treatment period, plasma trough A1PI levels will be assessed to monitor 
the increase in and maintenance of plasma A1PI levels at target of 11 µM or greater. 
 
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Plasma samples for the determination of trough antigenic A1PI and functional A1PI (also 
known as ANEC) levels will be collected prior to the first IP infusion during Week 1, on 
the day of IP administration (must be collected prior to the start of IP infusion) during
Week 7, Week 13, Week 19, and Week 25, and at the study completion (Week 26) visit.
For subjects who are to undergo BAL assessments, plasma samples for baseline antigenic 
A1PI level will be collected within 10 days prior to the baseline BAL visit to verify the 
adequacy of the washout from A1PI therapy prior to performing the baseline BAL visit. 
Then, on the day of the baseline BAL visit, plasma samples for the measurement of 
antigenic and functional A1PI levels will be collected simultaneously with plasma 
samples for urea measurements within 2 hours prior to the BAL procedure. These values 
will be used for the calculation of the corresponding A1PI levels in ELF using plasma-to-
BAL urea correction method. Sample collection for plasma antigenic and functional A1PI 
and urea will be repeated on the day of the on-treatment BAL visit within 2 hours prior to 
the BAL procedure (see Section 10.3.4).
Subjects who are discontinued early from the study after having been exposed to IP 
administration will be asked to have a plasma sample collected for A1PI determination. 
The early termination plasma sample will be analyzed to support analysis/interpretation 
of the early termination anti-A1PI antibody assessment.
Sample analysis for the determination of plasma antigenic and functional A1PI levels will 
be performed using validated bioanalytical assays at a qualified laboratory.
12.9 Immunogenicity
Blood will be collected to obtain serum samples for monitoring the appearance/presence 
of anti-A1PI antibodies prior to the first IP infusion during Week 1, on the day of IP 
administration (must be collected prior to the start of IP infusion) during Week 13 and 
Week 25, and at study completion (Week 26) visit. Subjects who are discontinued early 
from the study after having been exposed to IP administration will be asked to have a 
serum sample collected for immunogenicity assessment at the Early Termination visit.
Unscheduled samples for the detection of circulating anti-A1PI antibodies may be 
collected as necessary and upon consultation with or notification by the sponsor, to 
support investigation of suspected immune-related adverse events. At any scheduled or 
unscheduled time points, plasma samples for the determination of circulating A1PI levels 
will be collected concurrently to assess potential interference with the assay. 
 
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Each sample is to be stored as duplicate aliquots each with sufficient volume needed for 
sample analysis. Detailed sample handling and storage instructions will be provided in 
the laboratory manual.
Anti-A1PI antibodies will be detected using validated binding and neutralizing anti-A1PI 
antibody assays at a qualified immunoassay laboratory. The presence of anti-A1PI 
antibodies in a sample will be detected using a screening assay and confirmed using a 
confirmatory assay. Only those samples with confirmed positive results will be further 
analyzed for the examination for the presence of neutralizing antibodies.
12.10 Vital Signs
Body height (in or cm) will be collected at screening only. Body weight (lb or kg) will be 
measured at screening and at study visits during Weeks 1, 7, 13, 19, and 25.
Vital signs will include body temperature (°C or °F), respiratory rate (breaths/min), pulse 
rate (beats/min), and systolic and diastolic blood pressure (mmHg). Blood pressure 
measurements will be taken when subjects are in either the sitting or supine position; the 
same position should preferably be maintained each time a blood pressure is measured. 
These vital signs will be measured at screening, during treatment period (Weeks 1, 7, 13, 
19, and 25), and at study completion (Week 26)/early termination visit (see also 
Section 10.3.2.1 and Table 20.3-1).
For each of the IP infusion visits where vital signs are to be taken, vital signs will be 
recorded at any time prior to the start of an infusion, at each rate reduction due to AE(s) 
and/or infusion interruption/discontinuation due to AE(s), and at 30 (± 15) minutes after 
the completion of an infusion. The investigator should be contacted to determine 
appropriate action to be taken, as necessary, if vital signs meet any of the following 
criteria:

Systolic blood pressure ≤80 mm Hg or ≥180 mm Hg and/or diastolic blood 
pressure: ≤50 mm Hg or ≥110 mm Hg

Pulse rate ≤48 beats/min or ≥110 beats/min

Respiratory rate ≤8 breaths/min or ≥24 breaths/min

Body temperature ≥38.2 ºC (101 ºF)
For subjects undergoing BAL procedures, vital signs will be measured within 2 hours 
prior to each BAL procedure and within 1 hour after the completion of the BAL 
procedure. Pre-BAL vital signs are to be performed prior to the administration of 
bronchodilator and local anesthesia.
 
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Vital sign values are to be recorded on the CRF. For each abnormal vital sign value, the 
investigator will determine whether or not to report an AE (see definition in Section 12.1
and record the medical diagnosis (preferably), symptom, or sign on the AE CRF). 
Additional tests and other evaluations required to establish the significance or etiology of 
an abnormal vital sign value or to monitor the course of an AE should be obtained when 
clinically indicated. Any abnormal value that persists should be followed at the discretion 
of the investigator.
13. STATISTICS
13.1 Sample Size and Power Calculations
The sample size calculation for the BAL component of the study was based on the natural 
log transformed primary endpoint data, ELF antigenic A1PI level (nM), generated during 
a previous clinical study (Clinical Protocol 460502; Baxter Healthcare Corporation) for 
the evaluation of the effects of A1PI augmentation therapy with ARALAST NP on the 
levels of A1PI and other analytes in the ELF. In Clinical Study 460502, a mean 
difference from pre- to post-treatment in ELF antigenic A1PI of 1.32 with standard 
deviation of 0.96 on natural log scale was observed  Using this variance estimate, a 
sample size of 15 evaluable subjects should be sufficient to detect a mean difference in 
the natural log transformed ELF antigenic A1PI of approximately 0.87 with 90% power, 
using a paired t-test and a one-sided significance level of 0.025.
A sample size of 15 evaluable subjects will also be sufficient to detect a mean difference 
in the natural log transformed ELF functional A1PI (ANEC) of approximately 1.04, with 
90% power, assuming a standard deviation in the differences between pre- and post-
treatment ANEC values to be 20% higher than that for antigenic A1PI.
Based on the experience from Clinical Study 460502, it is estimated that approximately 
26 to 32 subjects will be needed in order to achieve 15 to 18 BAL evaluable subjects, 
respectively. Thus, an overall study enrollment target of 36 subjects should be adequate 
to meet the target sample size for the BAL component of the study.
13.2 Datasets and Analysis Cohorts
13.2.1 Full Analysis Set
The full analysis set (FAS) will include all subjects who received at least one IP infusion 
and have at least one available A1PI measurement during the treatment period.
 
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13.2.2 Per-Protocol Analysis Set
The per-protocol (PP) analysis set will include a subset of the full analysis set, 
comprising subjects with no major protocol deviations. For the purpose of statistical 
analysis, major deviations include, but are not limited to, the following: failure to comply 
with the washout period for pre-study A1PI augmentation therapy, missing two or more 
consecutive weekly infusions and/or >15% of planned infusions, and use of an A1PI 
product (including commercially available GLASSIA) other than IP during the study 
treatment period.
13.2.3 BAL Analysis Set
The BAL analysis set will include a subset of the FAS analysis set, comprising subjects 
who meet all of the following criteria:

Subjects who have met all study inclusion and exclusion criteria, including 
additional BAL-related eligibility criteria

Subjects have successfully completed both the baseline and the on-treatment BAL 
visits and have a minimum of one evaluable sample per BAL visit with no 
missing infusion(s) within 4 weeks immediately preceding the on-treatment BAL 
procedure

Subjects must have available ELF data for both the baseline and the on-treatment
BAL visits in order to be included in the efficacy analyses for the assessment of 
ELF analyte levels following GLASSIA augmentation therapy.
13.2.4 Safety Analysis Set
The safety analysis set will include all subjects enrolled in the study who received at least 
one IP infusion.
13.3 Handling of Missing, Unused, and Spurious Data
No missing data imputation will be performed.
13.4 Methods of Analysis
13.4.1 Efficacy Outcome Measures
Antigenic and functional A1PI levels in the ELF will be estimated based on the 
corresponding BAL measurements at each time point using plasma-to-BAL urea 
correction method. ELF antigenic and functional A1PI levels, as well as changes from 
baseline, will be summarized descriptively and displayed graphically (data permitting)
based on data pooled across both treatment arms. For a given subject, if 
 
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BAL measurements are obtained from more than 1 lung lobe, then the urea-corrected 
values will be averaged at the corresponding time point prior to being summarized.
Since an increase from baseline in the mean ELF levels of antigenic A1PI is expected, a 
one-sided paired t-test will be conducted at an α-level of 0.025 with the following null 
and alternative hypotheses where the mean change in antigenic A1PI from baseline to the 
on-treatment BAL measurement is μd: 
Ho: Mean change in antigenic A1PI in the ELF from baseline to the on-treatment 
measurement will be less than or equal to zero.
Ho: μd ≤ 0
H1: Mean change in antigenic A1PI in the ELF from baseline to the on-treatment
measurement will be greater than zero.
H1: μd > 0
The mean change in functional A1PI (ANEC) from baseline to on-treatment 
measurement will be analyzed in a similar fashion, if data permit. The natural logarithm 
transformation may be applied to the ELF antigenic or functional A1PI values prior to 
analysis if the distributions are highly skewed. This analysis will be conducted with the 
BAL analysis set.
 
 
Changes from baseline in ELF and plasma antigenic and functional A1PI levels, as well 
as 
, will be summarized in the following subgroups: by 
sex, age (≤65, >65), race, and ethnicity. 
 
13.4.2 Exposure
Plasma trough antigenic and functional A1PI levels, as well as changes from baseline, 
will be summarized descriptively and displayed graphically (data permitting) based on 
data pooled across both treatment arms. Plasma antigenic and functional A1PI levels 
obtained at the baseline and on-treatment BAL visits will be summarized separately and, 
data permitting, to be correlated with the corresponding values in the ELF. Plasma A1PI 
levels obtained at the study completion (Week 26) or early termination visit will not be 
 
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part of this analysis. These analyses will be conducted with both the FAS and the PP 
analysis sets.
In the event of anti-A1PI antibody formation is detected, the individual antigenic and 
functional A1PI levels may be evaluated in conjunction with binding and neutralizing 
anti-A1PI antibody titers, as applicable.
13.4.3 Safety Outcome Measures
The safety analysis set will be used for the following analyses, unless otherwise stated:
AEs that are considered potentially related to the presence of protein aggregates or 
immune-mediated will be summarized descriptively with 95% confidence intervals (CIs) 
as appropriate for each AE of interest by each treatment arm and, if appropriate, pooled 
across both treatment arms. In the event of any clinically significant trends in treatment-
emergent AE(s) of interest, further analysis including potential correlation with the 
presence of particulates in the GLASSIA solution will be performed.
ARs plus suspected ARs, using a time frame for AE onset of (a) during and within 24
hours and (b) during and within 72 hours of completion of an infusion, will be tabulated 
separately and presented according to seriousness, severity, and causality, as well as by 
MedDRA preferred term. Similar tabulation of data will be conducted for AEs and SAEs.
The number (proportion) of subjects experiencing SAEs, AEs, related AEs, and/or ARs 
plus suspected ARs will be summarized by each treatment arm and, if appropriate, pooled 
across both treatment arms with their point estimates and exact 95% CIs.
The number (proportion) of infusions (defined as percentage of the total number of 
infusions administered) temporally associated with AEs or SAEs (defined as during or 
within (a) 24 hours and (b) 72 hours of completion of infusion) will be computed for each 
subject. The median (95% CI), minimum, and maximum of these numbers (or 
percentages, respectively) will be tabulated.
The number (proportion) of infusions (defined as percentage of the total number of 
infusions administered) causally associated with AEs or SAEs will be computed for each 
subject. The median (95% CI), minimum, and maximum of these numbers (or 
percentages, respectively) will be tabulated.
The number (proportion) of infusions (defined as percentage of the total number of 
infusions administered) associated with ARs will be computed for each subject. The 
 
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median (95% CI), minimum, and maximum of these numbers (or percentages, 
respectively) will be tabulated.
The number (proportion) of infusions that are discontinued, slowed, or interrupted due to 
an AE will be summarized. The rates of AEs and ARs expressed as the number of events 
that occurred in total number of infusions administered will be provided by MedDRA 
term.
The proportion of subjects who develop binding and/or neutralizing anti-A1PI antibodies 
will be summarized with their point estimates and exact 95% CIs. Treatment-emergent 
anti-A1PI antibody data will be listed along with the corresponding plasma antigenic and 
functional A1PI levels in the individual subject. Additionally, temporal relationship of 
anti-A1PI antibody formation with potentially immune-related AEs, if any, will be 
examined.
The number (proportion) of subjects who experienced a shift from normal or clinically 
non-significant abnormal laboratory values at baseline to clinically significant abnormal 
laboratory values will be summarized with their point estimates and exact 95% CIs. Any 
clinically significant laboratory values that are considered as clinically significant by the 
investigator (ie, reported as AEs), as well as in accordance with the thresholds provided 
in Section 20.4, will be analyzed and reported, including shift tables.
Changes in vital signs obtained pre- and post-infusions, as well as pre- and post-BAL
procedures as applicable, will be provided in a listing.
The proportion of subjects with confirmed treatment-emergent seroconversion by viral 
serology or nucleic acid test for B19V during or following treatment with GLASSIA will 
be summarized with exact 95% CIs.
Safety parameters will be summarized descriptively by sex, age (≤65, >65), race, and 
ethnicity. No hypothesis tests are planned; however, 
 
AEs that occur before treatment will be listed separately.
13.5 Planned Interim Analysis of the Study
Not applicable; no interim analyses are planned for this study.
 
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14. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS
The investigator/study site will cooperate and provide direct access to study documents 
and data, including source documentation for monitoring by the study monitor, audits by 
the sponsor or sponsor’s representatives, review by the EC, and inspections by applicable 
regulatory authorities, as described in the Clinical Study Agreement. If contacted by an 
applicable regulatory authority, the investigator will notify the sponsor of contact, 
cooperate with the authority, provide the sponsor with copies of all documents received 
from the authority, and allow the sponsor to comment on any responses, as described in 
the Clinical Study Agreement.
15. QUALITY CONTROL AND QUALITY ASSURANCE
15.1 Investigator’s Responsibility
The investigator will comply with the protocol (which has been approved/given favorable 
opinion by the EC), ICH GCP, and applicable regulatory requirements as described in the 
Clinical Study Agreement. The investigator is ultimately responsible for the conduct of 
all aspects of the study at the study site and verifies by signature the integrity of all data 
transmitted to the sponsor. The term “investigator” as used in this protocol as well as in 
other study documents, refers to the investigator or authorized study personnel that the 
investigator has designated to perform certain duties. Sub-investigators or other 
authorized study personnel are eligible to sign for the investigator, except where the 
investigator’s signature is specifically required.
15.1.1 Final Clinical Study Report 
The investigator, or coordinating investigator(s) for multicenter studies, will sign the 
clinical study report. The coordinating investigator will be selected before study start.
15.2 Training
The study monitor will ensure that the investigator and study site personnel understand 
all requirements of the protocol, the investigational status of the IP, and his/her regulatory 
responsibilities as an investigator. Training may be provided at an investigator’s meeting, 
at the study site, and/or by instruction manuals. In addition, the study monitor will be 
available for consultation with the investigator and will serve as the liaison between the 
study site and the sponsor.
15.3 Monitoring
The study monitor is responsible for ensuring and verifying that each study site conducts 
the study according to the protocol, standard operating procedures, other written 
instructions/agreements, ICH GCP, and applicable regulatory guidelines/requirements. 
 
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The investigator will permit the study monitor to visit the study site at appropriate 
intervals, as described in the Clinical Study Agreement. Monitoring processes specific to 
the study will be described in the clinical monitoring plan. 
15.4 Auditing
The sponsor and/or sponsor’s representatives may conduct audits to evaluate study 
conduct and compliance with the protocol, standard operating procedures, other written 
instructions/agreements, ICH GCP, and applicable regulatory guidelines/requirements. 
The investigator will permit auditors to visit the study site, as described in the Clinical 
Study Agreement. Auditing processes specific to the study will be described in the 
auditing plan.
15.5 Non-Compliance with the Protocol
The investigator may deviate from the protocol only to eliminate an apparent immediate 
hazard to the subject. In the event(s) of an apparent immediate hazard to the subject, the 
investigator will notify the sponsor immediately by phone and confirm notification to the 
sponsor in writing as soon as possible, but within 1 calendar day after the change is 
implemented. The sponsor (Baxalta) will also ensure the responsible ethics committee is 
notified of the urgent measures taken in such cases according to local regulations.
If monitoring and/or auditing identify serious and/or persistent non-compliance with the 
protocol, the sponsor may terminate the investigator’s participation. The sponsor will 
notify the EC and applicable regulatory authorities of any investigator termination.
15.6 Laboratory and Reader Standardization
Not applicable; each type of assay is planned to be conducted at a single laboratory
facility for consistency and standardization.
16. ETHICS
16.1 Subject Privacy
The investigator will comply with applicable subject privacy regulations/guidance as 
described in the Clinical Study Agreement.
16.2 Ethics Committee and Regulatory Authorities
Before enrollment of patients into this study, the protocol, ICF, any promotional 
material/advertisements, and any other written information to be provided will be 
reviewed and approved/given favorable opinion by the EC and applicable regulatory 
authorities. The EC’s composition or a statement that the EC’s composition meets 
 
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applicable regulatory criteria will be documented. The study will commence only upon 
the sponsor’s receipt of approval/favorable opinion from the EC and, if required, upon 
the sponsor’s notification of applicable regulatory authority(ies) approval, as described in 
the Clinical Study Agreement.
If the protocol or any other information given to the subject is amended, the revised 
documents will be reviewed and approved/given favorable opinion by the EC and 
applicable regulatory authorities, where applicable. The protocol amendment will only be 
implemented upon the sponsor’s receipt of approval and, if required, upon the sponsor’s 
notification of applicable regulatory authority(ies) approval.
16.3 Informed Consent
Investigators will choose patients for enrollment considering the study eligibility criteria. 
The investigator will exercise no selectivity so that no bias is introduced from this source. 
All patients and/or their legally authorized representative must sign an ICF before 
entering into the study according to applicable regulatory requirements and ICH GCP. 
Before use, the ICF will be reviewed by the sponsor and approved by the EC and 
regulatory authority(ies), where applicable, (see Section 16.2). The ICF will include a 
comprehensive explanation of the proposed treatment without any exculpatory 
statements, in accordance with the elements required by ICH GCP and applicable 
regulatory requirements. Patients or their legally authorized representative(s) will be 
allowed sufficient time to consider participation in the study. By signing the ICF, patients 
or their legally authorized representative(s) agree that they will complete all evaluations 
required by the study, unless they withdraw voluntarily or are terminated from the study 
for any reason.
The sponsor will provide to the investigator in written form any new information that 
significantly bears on the subjects’ risks associated with IP exposure. The informed 
consent will be updated, if necessary. This new information and/or revised ICF that have 
been approved by the applicable EC and regulatory authorities, where applicable, will be 
provided by the investigator to the subjects who consented to participate in the study (see 
Section 16.3).
16.4 Data Monitoring Committee
A Data Monitoring Committee (DMC) will not be used for this study, since the IP is 
already a licensed product and the dosing regimen being evaluated is already approved 
for chronic treatment in the patient population to be enrolled in this study.
 
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17. DATA HANDLING AND RECORD KEEPING
17.1 Confidentiality Policy
The investigator will comply with the confidentiality policy as described in the Clinical 
Study Agreement. 
17.2 Study Documents and Case Report Forms
The investigator will maintain complete and accurate paper format study documentation 
in a separate file. Study documentation may include information defined as “source data” 
(see Section 8.8), records detailing the progress of the study for each subject, signed 
ICFs, correspondence with the EC and the study monitor/sponsor, enrollment and 
screening information, CRFs, SAE reports (SAERs), laboratory reports (if applicable), 
and data clarifications requested by the sponsor. 
The investigator will comply with the procedures for data recording and reporting. Any 
corrections to paper study documentation must be performed as follows: 1) the first entry 
will be crossed out entirely, remaining legible; and 2) each correction must be dated and 
initialed by the person correcting the entry; the use of correction fluid and erasing are 
prohibited.
The investigator is responsible for the procurement of data and for the quality of data 
recorded on the CRFs. CRFs will be provided in electronic form. 
If electronic format CRFs are provided by the sponsor, only authorized study site 
personnel will record or change data on the CRFs. If data is not entered on the CRFs 
during the study visit, the data will be recorded on paper, and this documentation will be 
considered source documentation. Changes to a CRF will require documentation of the 
reason for each change. An identical (electronic/paper) version of the complete set of 
CRFs for each subject will remain in the investigator file at the study site in accordance 
with the data retention policy (see Section 17.3).
The handling of data by the sponsor, including data quality assurance, will comply with 
regulatory guidelines (eg, ICH GCP) and the standard operating procedures of the 
sponsor. Data management and control processes specific to the study will be described 
in the data management plan.
17.3 Document and Data Retention 
The investigator will retain study documentation and data (paper and electronic forms) in 
accordance with applicable regulatory requirements and the document and data retention 
policy, as described in the Clinical Study Agreement.
 
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18. FINANCING AND INSURANCE
The investigator will comply with investigator financing, investigator/sponsor insurance, 
and subject compensation policies, if applicable, as described in the Clinical Study 
Agreement.
19. PUBLICATION POLICY
The investigator will comply with the publication policy as described in the Clinical 
Study Agreement. 
 
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20. SUPPLEMENTS
20.1 Study Flow Chart
Figure 20-1
Study Flow Chart for Baxalta Clinical Study 471101
 
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20.2 Schedule of Study Procedures and Assessments
Table 20.2-1
Schedule of Study Procedures and Assessments
Procedures/
Assessments
Screening
(Max 6 
Weeks)
Baseline BALa
(Max 2 Weeks)
Week 
1
Week 7
(± 2
Days)
On-Treatment BAL 
(Week 12-14)b
Week 13
(± 2 Days)
Week 19
(± 2 Days)
Week 25
(± 2 Days)
Study Completion
(Week 26 ± 3 Days) / 
Early Terminationc
Informed Consentd
X
Eligibility Criteria
X
Randomization
Xe
Demographics
X
Medical and 
Medication History
X
Height
X
Body Weightf
X
X
X
X
X
X
Physical Exam
X
Xg
Xg
X
Vital Signs
X
Xh
Xh
Xh
Xh
Xh
ECGi
X
Chest X-ray/CTj
X
Pulmonary Function 
Testsk
X
Screening/Safety 
Laboratory Testsl
X
Xg
Xg
Xg
X
Screening/On-
Treatment Trough 
A1PIm
X
Xg
Xg
Xg
Xg
Xg
X
 
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Table 20.2-1
Schedule of Study Procedures and Assessments
Procedures/
Assessments
Screening
(Max 6 
Weeks)
Baseline BALa
(Max 2 Weeks)
Week 
1
Week 7
(± 2
Days)
On-Treatment BAL 
(Week 12-14)b
Week 13
(± 2 Days)
Week 19
(± 2 Days)
Week 25
(± 2 Days)
Study Completion
(Week 26 ± 3 Days) / 
Early Terminationc
Xg
Xg
Xg
Xg
Xg
Anti-A1PI 
Antibodiesm,n
Xg
Xg
Xg
X
Weekly GLASSIA 
Infusionso
X
Adverse Event
X
X
X
X
Concomitant 
Medications and 
Non-drug Therapies
X
X
X
X
Telephone Follow-
upp
X
Additional Procedures for Subjects Undergoing BAL Procedures
BAL Procedure
X
X
Vital Signs
Xq
Xq
BAL and Plasma 
Urea and A1PIm
X
X
Abbreviations: BAL = Bronchoalveolar lavage; ECG = Electrocardiogram; A1PI = Alpha1-Proteinase Inhibitor.
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Continued
a
For subjects who undergo bronchoscopy/BAL procedures (see Section 10.3.4 for more details). The baseline bronchoscopy/BAL visit will be 
postponed once if a subject experiences a moderate or severe COPD exacerbation and/or LRTI during the screening period (see Section 10.4 for 
more details).
b
The on-treatment BAL procedure will be performed between Week 12 and Week 14 (see Section 10.3.4 for more details). The on-treatment 
bronchoscopy/BAL visit will be postponed once if a subject experiences a moderate or severe COPD exacerbation and/or LRTI (see Section 10.4
for more details).
c
Subjects who are being discontinued from the study early and having been exposed to IP will be asked to return to the study site 7 ±3 days after the 
last infusion for early termination assessments. Subjects who are discontinued early from the study prior to receiving any IP administration will not 
need to undergo early termination procedures, except for those subjects who have undergone the baseline BAL procedure in which case subjects 
will be followed for potential post-BAL complications for a period of time in accordance with local institutional standard practice but not to exceed 
30 days.
d
Written informed consent must be obtained prior to performance of any study procedures including screening/re-screening procedures.
e
Randomization is to take place after verification of subject’s meeting all the main eligibility criteria, as well as additional bronchoscopy/BAL-
related eligibility criteria (as applicable). For those undergoing bronchoscopy/BAL procedures, randomization is to take place only after the subject
has successfully completed the baseline BAL visit with evaluable BAL samples collected.
f
Body weight will be taken at screening (for the calculation of the initial IP infusion dose [in mg] / volume [in mL]). Body weight will be monitored 
at 6-week intervals (ie, during Weeks 1, 7, 13, 19, and 25) throughout the study. All body weight measurements must be taken using standardized 
procedures. Dose adjustment based on body weight changes during the course of the study may be made if the changes are clinically significant (eg, 
>5%).
g
To be performed prior to dosing on the day of the IP administration. Measurements taken prior to the first IP infusion (Week 1) will serve as the 
baseline values.
h
During treatment period, vital signs (body temperature, respiratory rate, pulse rate, and systolic and diastolic blood pressure) are to be taken on the 
day of IP infusion during Weeks 1, 7, 13, 19, and 25 infusion visits at any time prior to the infusion, at each rate reduction due to AE(s) and/or 
infusion interruption/discontinuation due to AE(s), and at 30 (± 15) minutes after the completion of an infusion.
i
ECG obtained within 26 weeks prior to screening may be used, if available.
j
Chest X-ray or CT scan obtained within 52 weeks prior to screening may be used, if available.
k
Pulmonary function tests include spirometry (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]), which is to be taken 
30 ± 15 minutes after administration of a short-acting inhaled β2 agonist bronchodilator (eg, 400 μg of salbutamol, or its equivalent).
l
For laboratory assessments, see Table 20.3-1.
m
Samples will each be split into duplicate aliquots of approximate equal volume. One of the 2 aliquots will serve as the backup sample and stored 
appropriately until notified by the sponsor.
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Continued
n
In the event of suspected immune-related adverse events, unscheduled anti-A1PI antibody samples may be collected as necessary and upon 
consultation with or notification by the sponsor to support AE investigation. The unscheduled anti-A1PI antibody samples must be accompanied by 
plasma sample collection for the determination of antigenic and functional A1PI levels.
o
The first infusion (Week 1), as well as infusions at Week 13 and Week 25, must be administered at the study site. Other weekly infusions may be 
administered at the study site or at another suitable location (eg, the subject’s home) by a qualified healthcare professional, as acceptable per local 
regulations and standard practices of the study site.
p
Following each infusion visit, telephone follow-up will be conducted by the investigator/designee at 72 hours (+ 1 business day) to document AEs,
and/or administration of concomitant medications or non-drug therapies, which may have occurred within 72 hours after the completion of an 
infusion. Any adverse events that occur and/or concomitant medications/non-drug therapies that the subject takes after the post-infusion telephone 
follow-up will be collected during the subsequent weekly infusion visit.
q
Vital signs will be measured within 2 hours prior to each BAL procedure and within 1 hour after the completion of the BAL procedure. Pre-BAL 
vital signs are to be performed prior to the administration of bronchodilator and local anesthesia.
 
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20.3 Schedule of Clinical Laboratory Assessments
Table 20.3-1
Clinical Laboratory Assessments
Assessments
Screening
(Max 6 
Weeks)
Baseline BALa
(Max 2 Weeks)
Week 
1
Week 7
(± 2 Days)
On-Treatment 
BAL
(Week 12-14)b
Week 13
(± 2 Days)
Week 19
(± 2 Days)
Week 25
(± 2 Days)
Study Completion 
(Week 26 ± 3 Days) / 
Early Terminationc
Hematologyd
W
We
We
We
W
Clinical Chemistryf
S
Se
Se
Se
S
Complement 
Activation and 
Immune Complex 
Panelg
Se
Se
Se
S
HAV Antibody, 
HBsAg, HCV 
Antibody, and HIV-
1/HIV-2 Antibody
S
B19V Serology and 
NATh
Se
Se
S
Urinalysisi
U
Ue
Ue
Ue
U
Pregnancy Testj
S/U
S/U
Serum IgA
S
Serum Cotinine
S
Se
S
S
A1PI Genotype
S
Screening 
(Antigenic) A1PIk,l
P
On-Treatment 
Trough Plasma 
Antigenic A1PIl
Pe
Pe
Pe
Pe
Pe
P
 
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Table 20.3-1
Clinical Laboratory Assessments
Assessments
Screening
(Max 6 
Weeks)
Baseline BALa
(Max 2 Weeks)
Week 
1
Week 7
(± 2 Days)
On-Treatment 
BAL
(Week 12-14)b
Week 13
(± 2 Days)
Week 19
(± 2 Days)
Week 25
(± 2 Days)
Study Completion 
(Week 26 ± 3 Days) / 
Early Terminationc
On-Treatment 
Trough Plasma 
Functional A1PIl
Pe
Pe
Pe
Pe
Pe
P
Pe
Pe
Pe
Pe
Pe
Serum Anti-A1PI 
Antibodiesl
Se
Se
Se
S
Additional Procedures for Subjects Undergoing BAL Procedures
Plasma Ureal
Pm
Pm
Plasma Antigenic 
A1PIl
Pm,n
Pm
Plasma Functional 
A1PIl
Pm
Pm
Pm
Pm
BAL Ureal
L
L
BAL Antigenic 
A1PIl
L
L
BAL Functional 
A1PI (ANEC)l
L
L
L
L
L
L
 
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Table 20.3-1
Clinical Laboratory Assessments
Assessments
Screening
(Max 6 
Weeks)
Baseline BALa
(Max 2 Weeks)
Week 
1
Week 7
(± 2 Days)
On-Treatment 
BAL
(Week 12-14)b
Week 13
(± 2 Days)
Week 19
(± 2 Days)
Week 25
(± 2 Days)
Study Completion 
(Week 26 ± 3 Days) / 
Early Terminationc
L
L
Abbreviations: BAL = Bronchoalveolar lavage; W = Whole blood; S = Serum; HAV = Hepatitis A Virus; HBsAg = Hepatitis B virus surface antigen; 
HCV = Hepatitis C virus; HIV = Human immunodeficiency virus; NAT = Nucleic acid test; B19V = Parvovirus B19; U = Urine; 
IgA = Immunoglobulin A; A1PI = Alpha1-Proteinase Inhibitor; P = Plasma; L = Bronchoalveolar lavage fluid; ANEC = Anti-neutrophil elastase 
capacity; 
.
a
For subjects undergoing bronchoscopy/BAL procedures (see Section 10.3.4 for more details). The baseline bronchoscopy/BAL visit will be 
postponed once if a subject experiences a moderate or severe COPD exacerbation and/or LRTI during the screening period (see Section 10.4 for 
more details).
b
The on-treatment BAL procedure will be performed between Week 12 and Week 14 (see Section 10.3.4 for more details). The on-treatment 
bronchoscopy/BAL visit will be postponed once if a subject experiences a moderate or severe COPD exacerbation and/or LRTI (see Section 10.4
for more details).
c
Subjects who are being discontinued from the study early and having been exposed to IP will be asked to return to the study site 7 ±3 days after the 
last infusion for early termination assessments. Subjects who are discontinued early from the study prior to receiving any IP administration will not 
need to undergo early termination procedures, except for those subjects who have undergone the baseline BAL procedure in which case subjects 
will be followed for potential post-BAL complications for a period of time in accordance with local institutional standard practice but not to exceed 
30 days.
d
Hematology panel will consist of complete blood count (hemoglobin [Hgb], hematocrit [Hct], erythrocytes [ie, red blood cell (RBC)] count, 
leukocytes [ie, white blood cell (WBC)] count with differential (ie, basophils, eosinophils, lymphocytes, monocytes, and neutrophils), absolute 
neutrophil count (ANC), absolute lymphocyte count, reticulocyte count, and platelet count.
e
Samples must be collected prior to GLASSIA administration.
f
Clinical chemistry panel will consist of sodium, potassium, calcium, chloride, bicarbonate, total protein, albumin, alanine aminotransferase (ALT), 
aspartate aminotransferase (AST), alkaline phosphatase (ALP), lactic dehydrogenase (LDH), gamma-glutamyl-transferase (GGT), bilirubin (direct 
and total), blood urea nitrogen (BUN), uric acid, creatine, creatine phosphokinase (CPK), and glucose.
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Continued
g
Complement activation and immune complex panel will consist of serum C3, C4, total complement (CH50), C1q binding assay (circulating 
immune complexes).
h
Viral testing will consist of viral serology for parvovirus B19 (PVB19) antibody and NAT (PVB19 PCR). If a subject’s Week 1 pre-dose sample is 
tested positive, then no further testing (eg, Week 25) is required.
i
Urinalysis will consist of color, specific gravity, pH, protein, glucose, ketones, bilirubin, urobilinogen, blood, nitrite, leukocyte esterase, and 
microscopic examination (RBC, WBC, bacteria, casts).
j
For females of childbearing potential only. Urine pregnancy test will be performed, unless serum pregnancy test is mandatory as specified by local 
regulatory/institutional requirements.
k
For those subjects who are receiving or have recently been exposed to A1PI therapy at the time of study enrollment, pre-study A1PI therapy must 
be discontinued and sample for the determination of endogenous circulating A1PI level is to be taken after completion of an adequate washout 
period (approximately 4 half-lives; average half-life ~4.6 days). The screening A1PI measurement may be repeated if an exclusionary level (≥11
µM) is obtained that is suspected to be due to inadequate washout of the prior A1PI therapy.
l
Samples will each be split into duplicate aliquots of approximate equal volume. One of the 2 aliquots will serve as the backup sample and stored 
appropriately until notified by the sponsor.
m
Samples must be collected within 2 hours prior to BAL procedure.
n
For subjects who have received A1PI augmentation therapy prior to study entry, plasma sample for baseline antigenic A1PI level will be collected 
within 10 days prior to the baseline BAL visit to verify the adequacy of the washout from A1PI therapy prior to performing BAL.
 
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20.4 Thresholds for Clinically Significant Laboratory Abnormalities
Each abnormal laboratory test result will be assessed for clinical significance by the 
investigator based on the medical judgment of the investigator. Independently, abnormal 
clinical laboratory values that meet the following criteria will be analyzed and reported.
Laboratory Test
Lowest Alert 
Limit
Highest Alert 
Limit
Comment
Hematology
Hemoglobin (Hgb)
(M) 10.0 g/dL
(F) 9.0 g/dL
----
----
Serial Hgb values allow assessment 
of the rate of decline over time
Leukocytes
2800/mm3
16,000/mm3
To be interpreted in the context of 
clinical symptoms
Absolute neutrophil count
<1000 /mm3
---
Reticulocyte count
<0.5%
>10%
To be interpreted in relation to 
changes in Hgb and other evidence 
of bone marrow suppression or 
hemolysis 
Platelet count
<50,000/mm3
>750,000/mm3
Clinical Chemistry
Sodium 
<125 mmol/L
>160 mmol/L
Serial values allow assessment of 
rate of change
Potassium
<3 mmol/L
>6 mmol/L
To be interpreted in conjunction with 
possible changes in ECG 
ALT
--
>3x ULN
AST
---
>3x ULN
ALP
---
>3x ULN
LDH
---
>3x ULN
GGT
---
>3x ULN
Bilirubin (total and 
indirect)
---
>3x ULN
Serum creatinine
---
(M) >2.0 mg/dL
(F) >1.6 mg/dL
CPK
---
>5x ULN
Glucose
<30 mg/dL
>200 mg/dL
Hyperglycemia should be interpreted 
in the context of known diabetes as a 
comorbidity
Serum albumin
<3.0 g/dL
----
May indicate protein loss, 
inflammation or malnutrition
 
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Laboratory Test
Lowest Alert 
Limit
Highest Alert 
Limit
Comment
Complement Activation and Immune Complex
Serum C3
<70 mg/dL
---
Serum C4
<14 mg/dL
---
Total complement 
(CH50)
<30 U/ml
---
C1q binding/CICs
<12 mg/dL
Urinalysis
Protein
---
>3+
Must be interpreted in relation to 
urinary concentration. Only valid 
when urine specific gravity is ≥1.010
RBC
---
>15/hpf or gross 
hematuria
Abbreviations:  M = Male; F = Female; Hgb = Hemoglobin; ALT = Alanine aminotransferase; ULN = 
Upper limit of normal; AST = Aspartate aminotransferase; ALP = Alkaline phosphatase; LDH = Lactic 
dehydrogenase; GGT = Gamma-glutamyl-transferase; CPK = creatine phosphokinase; C3 = 
Complement component 3; C4 = Complement component 4; CH50 = 50% hemolytic complement 
activity of serum; RBC = Red blood cell; hpf = High power field.
 
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21. REFERENCE LIST
1. Alpha 1-antitrypsin deficiency: memorandum from a WHO meeting. Bull.World 
Health Organ. 1997;75: 397-415.
2. de Serres FJ, Blanco I. Prevalence of a1-antitrypsin deficiency alleles PI*S and 
PI*Z worldwide and effective screening for each of the five phenotypic classes 
PI*MS, PI*MZ, PI*SS, PI*SZ, and PI*ZZ: A comprehensive review. 
Ther.Adv.Respir.Dis. 2012;6: 277-295.
3. de Serres FJ, Blanco I, Fernández-Bustillo E. Ethnic differences in alpha-1 
antitrypsin deficiency in the United States of America. Ther.Adv.Respir.Dis. 
2010;4: 63-70.
4. Brantly M, Nukiwa T, Crystal RG. Molecular basis of alpha-1-antitrypsin 
deficiency. Am.J.Med. 1988;84: 13-31.
5. Hutchison DC. Natural history of alpha-1-protease inhibitor deficiency. Am.J.Med. 
1988;84: 3-12.
6. Hubbard RC, Crystal RG. Alpha-1-antitrypsin augmentation therapy for alpha-1-
antitrypsin deficiency. Am.J.Med. 1988;84: 52-62.
7. Ogushi F, Fells GA, Hubbard RC et al. Z-type alpha 1-antitrypsin is less competent 
than M1-type alpha 1- antitrypsin as an inhibitor of neutrophil elastase. 
J.Clin.Invest. 1987;80: 1366-1374.
8. Buist AS, Burrows B, Cohen A et al. Guidelines for the approach to the patient with 
severe hereditary alpha- 1-antitrypsin deficiency. American Thoracic Society. 
Am.Rev.Respir.Dis. 1989;140: 1494-1497.
9. Stoller JK. Clinical features and natural history of severe alpha 1- antitrypsin 
deficiency. Roger S. Mitchell Lecture. Chest. 1997;111: 123S-128S.
10. Crystal RG, Brantly ML, Hubbard RC et al. The alpha 1-antitrypsin gene and its 
mutations. Clinical consequences and strategies for therapy. Chest. 1989;95: 196-
208.
 
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11. Wewers MD, Casolaro MA, Sellers SE et al. Replacement therapy for alpha 1-
antitrypsin deficiency associated with emphysema. N.Engl.J.Med. 1987;316: 1055-
1062.
12. Casolaro MA, Fells G, Wewers M et al. Augmentation of lung antineutrophil 
elastase capacity with recombinant human alpha-1-antitrypsin. J.Appl.Physiol. 
1987;63: 2015-2023.
13. Crystal RG. Alpha 1-antitrypsin deficiency: pathogenesis and treatment. 
Hosp.Pract.(Off.Ed.) 1991;26: 81-89, 93.
14. Crystal RG. Alpha 1-antitrypsin deficiency, emphysema, and liver disease. Genetic 
basis and strategies for therapy. J.Clin.Invest. 1990;85: 1343-1352.
15. Hubbard RC, Sellers S, Czerski D et al. Biochemical efficacy and safety of monthly 
augmentation therapy for alpha-1-antitrypsin deficiency. JAMA. 1988;260: 1259-
1264.
16. Hubbard RC, Crystal RG. Augmentation therapy of alpha 1-antitrypsin deficiency. 
Eur.Respir.J.Suppl. 1990;9: 44s-52s.
17. Stoller JK. Alpha 1-antitrypsin deficiency and augmentation therapy in emphysema. 
Cleve.Clin.J.Med. 1989;56: 683-689.
18. Wewers MD, Casolaro MA, Crystal RG. Comparison of alpha-1-antitrypsin levels 
and antineutrophil elastase capacity of blood and lung in a patient with the alpha-1-
antitrypsin phenotype null-null before and during alpha-1-antitrypsin augmentation 
therapy. Am.Rev.Respir.Dis. 1987;135: 539-543.
19. Miller MR, Hankinson J, Brusasco V et al. Standardisation of spirometry. 
Eur.Respir.J. 2005;26: 319-338.
20. Miller MR, Crapo R, Hankinson J et al. General considerations for lung function 
testing. Eur.Respir.J. 2005;26: 153-161.
21. Tashkin DP, Celli B, Senn S et al. A 4-year trial of tiotropium in chronic 
obstructive pulmonary disease. N.Engl.J.Med. 2008;359: 1543-1554.
 
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22. Vijayasaratha K, Stockley RA. Relationship between frequency, length, and 
treatment outcome of exacerbations to baseline lung function and lung density in 
alpha-1 antitrypsin-deficient COPD. Int.J.Chron.Obstruct.Pulmon.Dis. 2012;7: 789-
796. Link to Publisher's Site: 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514009/pdf/copd-7-789.pdf.
 
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22. SUMMARY OF CHANGES
Protocol Amendment 3: 2015 AUG 26
Replaces: Protocol Amendment 2: 2015 MAY 07
In this section, changes from the previous version of the Protocol Amendment 2, dated 
2015 MAY 07, are described and their rationale is given.
1.
Throughout the document
Description of Change: Editorial/grammatical and/or administrative changes that do 
not substantively affect the study conduct or patient safety have been made.
Rearrangement/modifications of sections and text have been made to align with the 
current version of the sponsor’s protocol template. Changes in the numbering of 
sections without substantial/major changes in the content will not be listed 
individually in the list of changes below.
Purpose for Change: To comply with current protocol standards and regulatory 
requirements, to improve the readability and/or clarity of the protocol, to minimize
redundancy, to correct typos and inconsistencies, and to reflect minor 
administrative/operational changes.
2.
 
 
 
3.
Throughout the document
Description of Change: Inclusion of subjects based on their A1PI status at screening 
was revised to allow confirmation of historical documented A1PI status using a 
commercially-available kit.
Purpose for Change: This change was made so that documenting eligibility based on 
A1PI genotype may be done more easily at sites.
 
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4.
Section 12.1.2
Description of Change: Wording was added to clarify timing of reports for 
pregnancy and pregnancy outcomes during the study.
Purpose for Change: Made in accordance with updated pregnancy reporting SOPs 
within Pharmacovigilance and Safety Organization.
5.
Title Page, Investigator Acknowledgement
Description of Change: EudraCT number added.
Purpose for Change: EudraCT number assigned.
 
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INVESTIGATOR ACKNOWLEDGEMENT
PRODUCT: GLASSIA
STUDY TITLE: A Phase 3/4 Study to Evaluate the Safety, Immunogenicity, and 
Effects on the Alpha1-Proteinase Inhibitor (A1PI) Levels in Epithelial Lining Fluid 
Following GLASSIA Therapy in A1PI-Deficient Subjects
PROTOCOL IDENTIFIER: 471101
CLINICAL TRIAL PHASE 3/4
AMENDMENT 3: 2015 AUG 26
Replaces Amendment 2: 2015 MAY 07
ALL VERSIONS: 
Amendment 3: 2015 AUG 26
Amendment 2: 2015 MAY 07
Amendment 1: 2015 JAN 19
Original: 2011 JUL 05
OTHER ID(s)
IND NUMBER: 14774
By signing below, the investigator acknowledges that he/she has read and understands 
this protocol, and will comply with the requirements for obtaining informed consent from 
all study subjects prior to initiating any protocol-specific procedures, obtaining written 
initial and ongoing EC(s) protocol review and approval, understands and abides by the 
requirements for maintenance of source documentation, and provides assurance that this 
study will be conducted according to all requirements as defined in this protocol, clinical 
study agreement, ICH GCP guidelines, and all applicable regulatory requirements.
Signature of Principal Investigator
Date
Print Name of Principal Investigator
For n
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